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Category: Physicians

BLOGS/PHYSICIANS: Enoch Choi in New Orleans

oDr. Enoch Choi, a medblogger (and OT but BTW a liberal evangelical Christian just so you know there is one!) has packed up his black bag and spent the week in New Orleans following his medical calling.  Go read his blog and scroll down to the October 1 entry — then read up. Doesn’t take too long as he’s posting via his Treo and he’s mighty mighty busy. It’s an amazing read.

It’s very clear that the return to New Orleans is fraught with similar perils to the evacuation. Plaudits to Enoch to heading out and putting his God-given talents to work in a crisis. They still need doctors desperately down there.

UPDATE:  Enoch writes direct (promoted from the comments). Please consider donating once more to the organizations that are sending committed volunteers like him onto the very front lines.

thanks for the props, Matthew. i’ve come to new orleans with City Team ministries and serving under the local authority of Pastors Resource Council PRC Compassion, invited by the local churches in St. Bernard. Menlo Park Presbyterian Church MPPC paid all of our flights, expenses, medicines and supplies.

Any of those organizations would be able to immediately deploy your donations to people we’re seeing every day. Yesterday, one of our nurses gave us $1000 from their Kansas Church… Their entire disposable cash. We spent it today on natural tears, sunblock, nasal saline, sudafed, lozenges, cough syrup, hydrocortisone. We gave it away in 2 hours. There’s immesurable need here, and whatever you give to MPPC would be immediately consumed by that need by our medical team.

to give to MPPC:

to give to City Team:

to give to PRC Compassion:

This is so different than giving to Red Cross, what you give to them will be spent on the next disaster. The Red Cross doesn’t have physicians down here. I don’t see any other medical teams down here other than ours. There are plenty of individual physicians that have come down, and they’re very important, but as an organized group, we’re it.

PHYSICIANS/POLICY: Malpractice explained

Susan Sheridan, whom I wrote about last month, is even more famous. She and her son Cal who has kernicterus syndrome are the hook for a piece in The New Republic by Robert Berenson. (You may only be able to get to the first page…) It largely tells the truth about malpractice, but just to reiterate, my reading of the data is that:

1) The tort system only picks up about half of malpractice2) The medical system barely ever apologizes (Susan never got an apology), but when it does law suits are much less likely3) Too much of the money goes to lawyers and expert witnesses, and lawyers and Democrats don’t want to change that, but as they don’t hold power–so what.4) Doctors, whose Republican allies now do hold power, are only interested in reducing caps on damages, which may reduce their rates a bit but does nothing to help severely injured victims of malpractice and more importantly nothing much to reduce medical costs for the rest of us. (I live in California where we have the MICRA caps and my insurance premiums ain’t going down — sufficient proof to me that the Republican talking points about this are bunk).5) Defensive medicine makes the system and the doctors more money and until they stop getting paid for it, the whole "8-10% savings" concept is a myth6) Special courts, non-binding arbitration, apologies, openness, and a near-miss reporting system are all good ideas and are the eventual solution, but the AMA won’t back them, and their Republican allies won’t either. Why not? For them tort reform has nothing to do with patients, and not much to do with doctors, but much, much more to do with stopping what are mostly legitimate lawsuits against malfeasant corporations — and it’s much better if that all gets mixed up with an evil lawyer suing Marcus Welby MD in their PR campaign.

So unless there is some real concession from organized medicine, we’ll keep what we’ve got and it doesn’t work.  The "good" news is that it’s only a minor issue compared to the complete morass of the rest of the health care system.

(Hat-tip to Brian Klepper for the article)

PHARMA/PHYSICIANS: Trying to stop the biting of the feeding hand

So there’s a bunch of rabble-rouser docs who are actually trying to enforce the often mouthed concept that doctors shouldn’t take freebies from pharma companies. They’re called No Free Lunch

And of course, given the actual views of mainstream doctors who believe that life was better when the pharma companies had no restrictions on the graft they could send their way, they are being banned by specialty societies from doing things like handing out the specialty societies own guidelines on gift-receiving to its members, and of course from buying a booth at the oh-so-well incorruptible AAFP’s convention. Jim Edwards at Brandweek has more. But let’s not be too surprised.

PHYSICIANS/POLICY: Another Podcast with Eric Novack

So here’s another podcast recorded at the tail end of last week with me chatting with surgeon, talk radio host and "free-market" advocating surgeon Eric Novack. This one focuses on why health care costs so much and why we can’t stop physicians behaving badly. We discuss evidence-based medicine, managed care, capitation, end of life care, practice variation, and defensive medicine — and it’s still incredibly civilized. Don’t worry — we’ll keep having these talks until we really start laying into each other!

Here’s the MP3 to download (this one’s a little over 30 minutes listening time). Enjoy and please tell me what you think

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CONSUMERS: Trade up players, but maybe not enough of them

Once again there’s something very important in a WSJ/Harris poll which concentrates on the people that, when I was at Harris, were called the "Trade up players". These are the people with enough discretionary income to buy themselves a better class of service from their providers.  As I know many of you don’t have WSJ access, I’ve quoted most all of the results.

"Do you have health insurance? It could be from an employer, that you purchase yourself or from a government program like Medicare or Medicaid?"

Base: All Adults

Yes, have health insurance 87%
No, do not have health insurance 13

* * *

"Which one of these statements best describes you?"

Base: Adults with health insurance

Total
I only go to doctors that accept my health insurance 85%
I sometimes go to doctors who don’t accept my health insurance 15

* * *

"Whether or not you have done so in the past, how willing would you be to go to a doctor who doesn’t take your health insurance if he or she was highly recommended by a source that you trust?"

Chart1

"How willing would you be to pay the full cost of a doctor’s visit – rather than use your health insurance – if you . . .?"

Chart2

The important issue is that pretty uniformly, those with incomes over 50K, which is a little over average household income and around US median income, are willing to spend more money to get a better class of service. Obviously this means a couple of things

a) If you are marketing a health care service to wealthier Americans there is a willingness to pay for it. Of course that’s a well known fact to chiropractors, orthodontists, and cosmetic surgeons. But it might mean that other physicians and providers might start to think about providing better access and customer service, for a small fee (and I don’t mean insisting on $20,000 for concierge service). This is the Nordstroms approach, and one that health care providers should be thinking about emulating (and one that some are).

b) This willingness to pay is a minority effect — it’s a big minority and may be a majority in the case of referrals from someone the patient trusts.  But for most of these services more people are unwilling to pay extra, and of course large majorities of those with lower incomes, even those with health insurance, do not want to pay extra.

This tells me that continued bifurcation is likely to be the case when people seek health services that they have to pay out of pocket for, with roughly double the number who want to "trade up" skimping on "extras". Why does this matter?  Because in our brave new consumer world, cash may be an increasingly important way that patients pay for health care, especially for "minor" care out of their HSAs. So this correlates with much other data about user fees at the point of care–they tend to prevent lower income people from getting care (including often needed care).

Like it or not, we are slowly heading towards this future.  Unless, that is, you live in Rochester New York.

Meanwhile, (and this is a bit of a throwaway for Ron) the Kaiser Network Health Policy Report notes that the CBO is out with a study showing that "Uninsured workers are unlikely to purchase individual health insurance, regardless of whether they receive tax credits or other subsidies to help cover the cost of premiums, according to a report released on Friday by the Congressional Budget Office". Proving to my mind once again that high deductible health plans are not going to solve the uninsurance problem and that voluntary universal health care is a myth.

INTERNATIONAL/PHYSICIANS: Canadian doctors going home means the US sucks, n’est-ce pas?

This one I find hilarious and gives me great deal of personal satisfaction. The pro-American health care system, "it’s the finest on earth crowd" goes on and on about how terrible the Canadian system is and how all the doctors are leaving. In fact it was that sentiment especially from the wonderful, but confused, Sydney Smith over at Medpundit that inspired my "Oh Canada" tome.  (Actually I re-read "Oh Canada" the other day and it’s a pretty damn good piece of analysis if I say so myself).

Syd was basically saying that all the doctors were leaving cos they hated the clinical restrictions of the single payer system and wanted to move to the glorious homeland of free-choice medical practice and CABGs for 97 year olds. I showed pretty conclusively using actual real life data that a) very few doctors were leaving Canada for the US, and that b) if they were leaving it wasn’t that surprising as they get paid about twice as much by sneaking below the 49th parallel.

Well now we have more actual statistics and real data that shows that more Canadian doctors are heading back to Canada than are leaving — and this was in 2004 when hockey was on strike so there was no real reason to go to Canada! The numbers are:

Canada has seen more doctors returning than leaving for the first time in 30 years, a report by the Canadian Institute for Health Information (CIHI) shows. The report, released Wednesday, says that between 2000 and 2004,the number of physicians leaving Canada declined by 38 percent. In 2004, 317 physicians returned to Canada and 262 left. That was a drop from 2000, when 420 doctors left the country and a significant decrease from the peak of 771 physicians who moved abroad in 1994.

I’m looking forward to the barrage of articles from the know-it all alleged "free-market" crowd who get spoon-fed rubbish by Frasier, PRI, Manhattan et al offering their apologies to the Canadians and admitting that their system is better than the one down here.  After all the alleged rush of Canadian doctors to the US was absolute proof in their mind that the reverse was true.

I’m waiting, I’m waiting….

POLICY/PHYSICIANS: Is the Medicare reimbursement issue more serious this time?

This week things are starting to get a little serious regarding physicians’ Medicare reimbursement. The AMA is gearing up for a fight, trying to avoid a scheduled 4.3% cut in Medicare reimbursement. Meanwhile a survey of California doctors suggested that they would stop taking new patients at the lowered rates. Much of this is just bargaining rhetoric, but CMS is determined to start Medicare down the pay-for-performance road, and has already begun to initiate this process by paying hospitals for reporting quality measures (even though it’s less than 0.5% of their Medicare revenue).

Meanwhile Republican house rep Nancy Johnson is pushing a pay-for-performance bill which would change how physicians get paid. Anytime you put doctors, money, and quality and performance requirements in a sentence together, be prepared for at the least a vigorous debate. Medicare is still the big Kahuna, and where it goes other payers will follow — if they’re not moving there already.

PHYSICIANS: How to easily increase access to care, by Eric Novack

NovackEric Novack is an orthopedic surgeon who went to medical school in liberal San Francisco, but is now practicing in the red state of Arizona. Eric has been sparring with me and others in the comments on THCB, and also has his own weekly radio show. It’s on a station called "960 The Patriot" — and you can guess that it’s line up is a little different than San Francisco’s 960 The Quake, which is our local Air America affiliate. Eric’s weekly show is very well done, and I recommend that you head over there to take a listen to his archived shows. Some of you might perceive a bias in his guest line-up, and Eric has strong opinions on policy, many of which I do not share.  But I’m very hopeful that by encouraging Eric to write for the blog, (and we are also planning some podcast conversations in the near future), we can get to some of the heart of the issues about which we disagree. For his first post, Eric starts simply, with an idea to get physicians to provide more uncompensated care.
In what I hope is the first of many posts for THCB, I propose a simple step to increase access to care. The number of uninsured is large. Depending upon your perspective, the number can be as low as around 20 million Americans or as high as 45 million. Of course, you can find those who claim a number larger or smaller. It is a great bit of semantic legerdemain to equate lack of insurance with lack of access to health care. Stating "no access" implies that no care is available and that the government has "abandoned" this group. This is simply not true.

Congress passed a law in 1986 called Emergency Medical Treatment and Active Labor Act" or EMTALA. EMTALA has a variety of provisions but can be simply stated that persons who come to emergency departments cannot be turned away because of an inability to pay. This applies to the hospital emergency department (ED), the emergency room physicians, and the specialists and internal medicine doctors "on-call" for the emergency department. "Emergency" for the purposes of the emergency room is anyone who comes to the hospital– the hospital cannot say– "it is just a cold, so we will not treat you". If someone breaks a leg and an orthopedic surgeon is on call to cover the ED, the surgeon must take care of the problem and the patient including the operation and all appropriate follow-up care.

One of the many problems is that all of this uncompensated care falls back on the doctors– remember that many hospitals are non-profit or have received federal funds that require them to provide a certain amount of uncompensated care.

Let me give an example, (any similarity to any real patient of mine is coincidental…). I am on call for "Arizona Hospital". Bill Jones is brought to the hospital after a fall from his ladder at home, where he was taking down his Christmas lights (it is never too late, is it?). I am called by the ED because Mr. Jones has broken his femur (thigh bone). I see the patient in the ED, he is admitted, and I operate on him at midnight. I finish surgery, the paperwork, and head home around 2:30 AM.  I then see Mr. J for the next 3 days after clinic. After discharge, Mr. J comes to the clinic regularly over the next several months for checks and x-rays and advice and guidance. Total charges for all the work, time, expertise, and liability risk is $5000.

Mr. Jones has his own landscaping business.  He has no insurance.  He never pays a bill.  I cannot abandon his care– it is unethical and against the law (abandonment). I get tired of this happening and stop taking call at the hospital. Losers in this scenario–the physician, the hospital (less coverage), and future patients–insured or not- who would benefit from my expertise.

Here is a partial solution– but first, a brief preamble. Health care system transformation will need to be incremental, not revolutionary– otherwise, the kind of horse-trading and compromises that resulted in the bloated, inefficient, restrictive system of Medicare result.

Here’s the partial solution. Guess what happens at the end of the year when I file my taxes?  Can I deduct the $5000 in bad debt as a "business loss"?  No. By simply allowing physicians to credit bad medical debt from their income (like other businesses can with losses related to products, etc.), physicians would be have a huge incentive to provide a certain amount of care to the poor. It needs to be a credit and not a deduction as a deduction would return only 35 cents on the dollar at best. So, there it is– tax relief to the providers of care for the amount of "free care" provided. 

No new bureaucracy.  Incentives, not punishment

For some more info on EMTALA see this lawyer’s site.

PHYSICIANS: Physician entrepreneurship

And in just one tiny example of physician entrepreneurship, the LA Times reports on a new bill to close a loophole in California Workers’ Comp law. The Workers Comp problem is one of those perennial problems here in California, where we have too many doctors and too many lawyers, and they are able to hone their skills in separating the insurers from their money. It was "fixed" by Pete Wilson in the early 1990s, and then "fixed" again last year by Arnie. The latest round seems to have done some good, but one little loophole has been exploited allegedly to the tune of $250m.

The loophole is that pharmacy prices for drugs were capped in the law, but prices for those drugs dispensed directly by doctors were not. Well you know what’s coming next. Physicians were enticed by some wholesalers to start prescribing and dispensing drugs, and their mark-ups are a factor of three to ten what the pharmacies can charge. And it’s all paid for by the insurers. Here are some pricing examples from a Rand study quoted in the LA Times.

Pharmacy price vs. Doctor’s office priceSoma $44.68 vs $396.98Prozac $14.81  vs $131.82Darvocet  $12.65 vs $58.31Acetaminophen/Hydrocodone  $12.81 vs $58.31

Even the unions are opposed to this, as they correctly see this type of lilly-gilding as being the kind of thing that might lead to another round of attacks on employee benefits. The employers are of course siding with them.

But it does just show you that in American health care, if there’s a way to bill an extra buck or two, physicians are as quick as anyone else to figure out how. I don’t need to tell you the California Medical Association’s position on the bill…..

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