Category: Uncategorized

The Original Individual Mandate, Circa 1792

Jul 23, 2010• 21

By BRADLEY LATINO

Regardless of one’s opinion on the Patient Protection and Affordable Care Act’s constitutionality, most commentators-and no less an authority than the Congressional Budget Office)-agree (or concede, as the case may be) that Congress has never required Americans to purchase a good or service from a private entity as a condition of citizenship. But, importantly, they are wrong. The ongoing debate over the mandate’s constitutionality has uncovered an unlikely precedent to the PPACA’s individual mandate to possess health coverage. I recently wrote about this overlooked original individual mandate in an article, “The First Individual Mandate: What the Uniform Militia Act of 1792 Tells Us about Fifth Amendment Challenges to Healthcare Reform.”

The Militia Acts of 1792, passed by the Second Congress and signed into law by President Washington, required every able-bodied white male citizen to enroll in his state’s militia and mandated that he “provide himself” with various goods for the common weal:

[E]ach and every free able-bodied white male citizen of the respective States . . . shall severally and respectively be enrolled in the militia . . . .provid[ing] himself with a good musket or firelock, a sufficient bayonet and belt, two spare flints, and a knapsack, a pouch, with a box therein . . . and shall appear so armed, accoutred and provided, when called out to exercise or into service

This was the law of the land until the establishment of the National Guard in 1903. For many American families, compliance meant purchasing-and eventually re-purchasing-multiple muskets from a private party.

This was no small thing. Although anywhere from 40 to 79% of American households owned a firearm of some kind, the Militia Act specifically required a military-grade musket. That particular kind of gun was useful for traditional, line-up-and-shoot 18th century warfare, but clumsy and inaccurate compared to the single-barrel shotguns and rifles Americans were using to hunt game. A new musket, alone, could cost anywhere from $250 to $500 in today’s money. Some congressmen estimated it would cost £20 to completely outfit a man for militia service-about $2,000 today.

What if All Americans Had at Least Catastrophic Health Care Coverage?

Jul 23, 2010• 31

By ED PULLEN, MD

I really dislike the term healthcare reform. I think our system needs to be changed not reformed. I assume that I am not the only person who suspects that the recent health care reform act is not going to be the final solution for America’shealth care problems. The cost of healthcare is not really addressed at all, and even if it works better than expected some Americans will not have even catastrophic health carecoverage.

This post is really just my first shot at suggesting a way I think makes sense to address the problem of the large number of uninsured people in America, while at the same time leaving lots of choice and personal responsibility that seems to be needed and a part of the American culture. I am certain that I have not thought through all of the gritty details, and really don’t profess to have the talent or knowledge to write legislation, but I think this basic tenant might be a starting point.First my assumptions:Continue reading…

My Side

Jul 22, 2010• 5

By ROB LAMBERTS, MD

I was planning on leaving behind the seriousness of the past few posts and going back to my usual inane writing, but some of the comments have made it too hard for me to keep quiet. The response has been largely positive, and overall it has been overwhelming. More people have read or commented on my letter to patients with chronic disease than any in recent history. I am grateful that it is circulating around the web for others to contemplate, perhaps understanding the intent of what I wrote and improving their relationship with their doctors in the process.

The purpose of the letter was to give some helpful insight into the emotion on the other side of the equation. I can’t understand what it is like to have a chronic illness without having the disease, but it is still fruitful for me to try to figure this out. In the same way, patients with chronic illnesses benefit from a better understanding of the doctors they see so frequently and depend on so greatly. I can sympathize, but I can’t feel the pain. Still, I do need to listen closely to patients so I can have the best relationship possible.

Some folks felt that I was saying that doctors need their egos stroked and to be treated special, but that is not what I meant to say. Each person needs to be understood and treated as their situation dictates. People with chronic illness want to be understood (as witnessed by the incredible response to my letter!) and treated based on that understanding. Doctors want to be understood as well. So let me tell you my side of the story. What is it like to sit in my chair? I don’t say this for sympathy or pats on the back, I say it to be understood. If I am better understood by my patients (and readers), my relationship with them is better, which is good for both of us. I think I represent a fair percentage of primary care docs in these ways.

1. I care about my patients – As hard as I try to “just do the job,” and not expend the emotion I do during the day, I couldn’t live with myself if I let my patients down. They depend on me for a lot, they pay for my service, and they deserve my best. I’ve been told I do this to a pathological degree (along with my llama obsession), but it is there. I want to help them. I get frustrated at my powerlessness and am genuinely happy when they do well.

2. I am tired – Each day demands an emotional price. Some days the demand is not so high, others suck the life out of me. Being “needed” cuts two ways; on one side it is nice to truly help people when they need the most help, it’s satisfying to see your life making a difference. On the other side, it is a never-ending river of need, pain, and crises to be handled. Being patted on the back (or patting myself) is nice, but it doesn’t mean anything for the future. Each day brings new hands to hold, needs to meet, problems to be solved. Each day is as much a burden as it is an opportunity. That burden won’t leave me until I take down my shingle, yet the opportunities to make a difference will make it hard to take that shingle down.

3. I also run a business – In terms of priorities, I need to pay my staff, pay the rent, and pay my personal bills to even have the chance to take care of patients. I get frustrated when patients insinuate that I value money too much. I get very frustrated by that, actually. People seem more willing to pay for cable TV, cigarettes, or eating out than to pay me for what I do. I earn less than most other medical specialists, yet some people resent my income. The mess of a system we have works against primary care and works against complex patients. If I spend 30 minutes with a complex patients (I do spend 30 minutes with people regularly), I am paid about 50% more than if I see a 5 minute ear infection visit. Doing the math says that my mind is not valued and that I should see more ear infections and less chronic patients. All of this adds to my daily stress.

4. I am actually a person, not just a doctor – I have four children and a wife, and being a dad and a husband isn’t easy when I come from work with the emotional life sucked out of me. I struggle with my own emotions and I get sick. I worry a lot about money, and I feel insecure about the fact that despite being a doctor, I am not saving enough. Hence I also struggle with working too much. Life’s not easy for anyone, and despite my title I am not exempt.

5. I hate bad doctors – Many of the comments to the letter I wrote were lamentations about doctors who suck. Unfortunately, doctors who take bad care of their patients make my life miserable too. I have to clean up their messes, I have to re-teach their patients on what medicine should look like. I have to wean their patients off of addictive drugs that they didn’t have the guts to deny. I am personally frustrated when I send a person to a specialist and they don’t do anything or upset my patient, and I hate the fact that they almost never communicate with me. It makes my already hard job even harder.

6. My blog is a refuge and a tool – I am thankful that I have this blog as a means to vent, to use another part of my brain (some may argue that point on some of my posts), and to make a difference. I actually have a voice in the whole healthcare reform debate. I actually can reach a large number of people and make their medical experience better (which was the most gratifying thing to hear in the comments to my letter). I’ve made practically no money doing this, but I’ve gotten a whole lot out of it.

That’s my story. Like it or not, it is what it is. I am just a guy who happens to be a doctor – the same as the rest of the doctors out there. There will always be angry people and idiots on both sides of the doctor/patient relationship, but no matter what, the doctor-patient encounter is a human thing. Love is human, war is human, murder is human, and so is childbirth. You can’t put humanity into a bottle, you can’t throw a single label on it. The highest calling is to enter into another’s life, to see things from their perspective, and to add good to it.

That goes for all of us, regardless of letters behind our names.

Thanks for listening.
Rob Lamberts, MD, is a primary care physician practicing somewhere in the southeastern United States. He blogs regularly at Musings of a Distractible Mind, where this post first appeared. For some strange reason, he is often stopped by strangers on the street who mistake him for former Atlanta Braves star John Smoltz and ask “Hey, are you John Smoltz?” He is not John Smoltz. He is not a former major league baseball player. He is a primary care physician.

Microsoft talks health plans

Jul 21, 2010• 2

By Ida Strom Seljeseth

Microsoft talks health plans from Health 2.0 on Vimeo.

At the AHIP conference in Las Vegas in June 2010, Matthew Holt sat down with two leaders in Microsoft’s health plan practice: Dennis Schmuland, Director οf U.S. Health Plans Industry Solutions and Hector Rodriguez, Industry Technology Strategist for Health Plans. They talked about health plans and the consumer market, where health plans are today and the future technological development of health plans. Oh…and how Microsoft can help.

WEGOHealth provides solution for that Ning premium charge

Jul 20, 2010• 1

By Matthew Holt

Ever since the “build your own network” company Ning moved to a pay model for its networks, there’s been some browbeating on the blogosphere about what to do with those communities which had created traction on Ning, but didn’t have a way to pay.

For the next year at least that little problem is over. The sugar daddy here is WEGOhealth, which has positioned itself in an unusual niche—the place where people leading online patient communities can go to learn from each other. WEGOHealth is run by former Yahoo Health leader (from a few years back) Jack Barrette. Jack is a hell of a nice guy but I suspect that this deal wasn’t just about being nice. The WEGOhealth business model is about convincing advertisers that they can get in front of influential patients, and anyone running a Ning network for a health condition is likely to be (as Edelman call it) a health infoential.

So if you have a NING network that might qualify, here’s how to apply. And I suspect that Jack would appreciate it if you also paid a visit or two to WEGOhealth as well.

Guidelines for the Perplexed

Jul 20, 2010• 5

By NORTIN HADLER, MD

There has been much progress in the understanding of the biology of Alzheimer’s disease. Chemicals detected in the blood and spinal fluid of patients with Alzheimer’s and findings with new brain imaging techniques are the long sought after “biomarkers” of the disease. They are clues to its cause that are already targets for drug development. But there is a great public health danger in jumping the gun and prematurely using biomarkers in clinical practice for diagnosis or prognosis. It is for this reason that I have serious reservations about the new diagnostic guidelines proposed for the diagnosis of Alzheimer’s disease.

The current guidelines, which have served as well as possible for 26 years are based entirely on the patient’s narrative. The diagnostic label is applied when there is no better explanation for a severe and global compromise in cognition that developed insidiously. The diagnosis of Alzheimer’s when it is full blown is not a challenge. The challenge is in making the diagnosis when it is less obvious, when it is but “Possible” or “Probable.” These categories are confronted in the old criteria by considering the degree to which elements of cognition are compromised. The application of these qualified diagnostic labels provokes as much anxiety in the clinician as it does angst in the patient and foreboding in the patient’s intimate community. Maybe the fact that grandpa occasionally forgets his keys or his neighbor’s name is all there is to it; “grandpa’s losing it” or has a touch of “senility”. That would call for a supportive community, and not the specter of a slide to a dreadful fate denoted by Alzheimer’s.

Failure

Jul 20, 2010• 2

By ROB LAMBERTS, MD

I went to a patient’s funeral this past weekend. I generally don’t do that for people whose relationship I’ve built in the exam room. It’s a complex set of emotions, but invariably some family member will start telling others what a nice doctor I am and how much the person had liked me as a doctor. It’s awkward getting a eulogy (literally: good words) spoken about me at someone else’s funeral. This patient I had known prior to them becoming my patient, and his wife had been very nice to us when we first moved here from up north.

But that’s not why I am writing this. As I was sitting in the service, the thought occurred to me that a patient’s funeral would be considered by many to be a failure for a doctor. Certainly there are times when that is the case – when the doctor could have intervened and didn’t, or intervened incorrectly, causing the person to die earlier than they could have. Every doctor has some moments where regrets over missed or incorrect diagnosis take their toll. We are imperfect humans, we have bad days, and we don’t always give our patients our best. We have limits.

Sermo: The latest from Dan Palestrant

Jul 20, 2010• 1

By Matthew Holt

Over the weekend I caught up with Dan Palestrant, the CEO of Sermo–still the largest US based physician online community. Sermo opted not to raise new VC recently (unlike say Phreesia and ZocDoc) and actually reduced headcount in early 2009. Meanwhile during 2009 Daniel got his 15 minutes of fame debating the likes of Howard Dean on cable news and the site became a haven for lots of (grumpy) political talk, But while that may have captured the headlines, Sermo has done a major technology upgrade and redesigned both its user and its client interface. That re-design went live last week and Daniel spoke to me about what they did, what the discussion on the site is about (think clinical and business, less politics than last year), which clients they’re working with (think big Pharma) and how they’re doing financially and business-wise (better than you might have heard).

Here’s the apprx.10 minunte interview: Dan Palestrant

Interview with Farzad Mosashari

Jul 19, 2010

By Matthew Holt

On June 7, 2010 senior advisor at the Office of the National Coordinator, Farzad Mosashari, gave an interview at the Health 2.0 Goes to Washington conference. These are his thoughts on the conference, meaningful use and the focus his office has on watching out for the little guy.

Beacon Communities: Webinar with EVERYTHING You Ever Wanted to Know!

Jul 19, 2010

HIE, SHARP, RECs, and now… Beacons?

What does it all mean?

With the passage of HITECH in 2009, we’ve seen a series of coordinated grant programs from HHS – and if you’re not confused with all of the acronyms, you’re probably not paying attention. But never fear, in the latest of our series of FREE webinars, Health 2.0 has teamed up with the Health 2.0 Accelerator to bring you a conversation with Aaron McKethan, Program Director for the Beacon Communities Program in ONC to explain what the Beacon communities are, give some details about the types of programs and opportunities that they are providing, and to help answer all of your questions!

Wednesday, July 21, 2010

1pm ET / 10am PT