By BOB WACHTER, MD
A couple of months ago, a Baltimore reporter called to get my take on a scandal at St. Joseph’s Hospital in Towson, an upscale suburb. A rainmaker cardiologist there, Dr. Mark Midei, had been accused of placing more than 500 stents in patients who didn’t need them, justifying the procedures by purposely misreading cath films. In several of the cases, Midei allegedly read a 90 percent coronary stenosis when the actual blockage was trivial – more like 10 percent.
Disgusting, I thought… if the reports are true, they should lock this guy in jail and throw away the key. After all, the victims now have permanent foreign bodies in their vascular beds, and both the stent and the accompanying blood thinners confer a substantial lifetime risk of morbidity and mortality. As I felt my own blood beginning to boil, the reporter asked a question that threw me back on my heels.
“Why didn’t peer review catch this?” he asked.
Hospital peer review is getting better, partly driven by more aggressive accreditation standards for medical staff privileging. In my role as chief of the medical service at UCSF Medical Center, I’m now expected to monitor a series of signals looking for problem doctors: low procedural volumes, unusual numbers of complications, and frequent patient complaints, unexpected deaths, and malpractice suits. When a flashing red light goes off, my next step is to commission a focused review of the physician’s practice. The process remains far from perfect, but it is an improvement over the traditional system, in which docs tapped a couple of their golfing buddies to vouch for their competence.Continue reading…
I was talking to a fellow physician about a mutual patient. I had
information that would help him in their care and he was taking the
unusual step of asking me for my information. I was impressed.
“Could you fax me those documents?” he asked. ”Here’s my fax number.”
I scrambled to get a pen to write down his number. Then I had a
thought: “I could email you those documents much easier. Do you have
an email address?”
After a long pause, he hesitantly responded, “I would rather you just fax it.” He said no more.
This is a typical reaction I get from my colleagues when suggest
using the new-fangled communication tool called email. The palms
sweat, the speech stumbles, and the awkwardness is thick in the air.
It’s as if I am suggesting they join me in an evil conspiracy, or as
if I am asking them to join my technology nerd cult. There is a
culture of fear in our healthcare system; it’s a wall against change, a
current of stubbornness, a root of suspicion that looks at anything
from the outside as a danger. Instead of embracing technology, doctors
see it as a tool in the hands of others intent on controlling them.
They see it as a collar on their neck that they only wear because
others are stronger than them.
It’s the only reason I can see for the resistance of a transforming
technology. It’s the only way to explain how they would favor a
non-system that hurts their patients over a system that can improve
their care immensely. After all, what good is it to embrace a
technology – no matter how good – if it will take away their ability to
practice medicine? ”It’s good for you!” they hear from politicians and
academics, but they see it as a poison pill.
We once thought Democrats would accept tort reform to win Republicans’ support for national health care legislation. Now, however, Democrats have dispensed with bipartisanship. Perhaps they think they can ram health care legislation through without any Republican backing. Perhaps the price required to obtain even a few Republican votes was too high. Perhaps Democrats received too much pressure from the trial bar. Whatever the reason, neither the bill passed by the House nor the bill pending in the Senate contains any of the tort reform provisions Republicans want. To the contrary, the House health care bill is anti-tort reform.
Not only does it reject the entire slate of lawsuit restrictions Representative John Boehner put forward in the Republican alternative to the Democrats’ bill; it contains a provision that will reward states for scrapping damages caps and other tort reforms many already have in place. This provision flew beneath the radar during the House debate, but the editorial board of the Wall Street Journal condemned it after the vote took place. Describing the provision as a “hidden Pelosi tort bomb,” the Journal editors predicted that “[i]f it passes in anything like its current form, we are going to be cleaning up the mess for decades to come.”
Most predictions that the sky will fall are wrong. This one is wrong as well.
In trying to think about the future of health care, thoughtful, intelligent people often ask, “Why can’t we just let the free market operate in health care? That would drive down costs and drive up quality.” They point to the successes of competition in other industries. But their faith is misplaced, for economic reasons that are peculiar to health care.
More “free market” competition could definitely improve the future of health care in certain areas. But the problems of the sector as a whole will not yield to “free market” ideas – never will, never can – for reasons that are ineluctable, that derive from the core nature of the market. We might parse them out into three:
- True medical demand is wildly variable, random, and absolute. Some people get cancer, others don’t. Some keel over from a heart attack, get shot, or fall off a cliff, others are in and out of hospitals for years before they die. Aggregate risk varies by socioeconomic class and age – the older you are, the more likely you are to need medical attention; poor and uneducated people are more likely to get diabetes. Individual risk varies somewhat by lifestyle – people who eat better and exercise have lower risk of some diseases; people who sky dive, ski, or hang out in certain bars have higher risk of trauma. But crucially, risk has no relation to ability to pay. A poor person does not suddenly discover an absolute need to buy a new Jaguar, but may well suddenly discover an absolute need for the services of a neurosurgeon, an oncologist, a cancer center, and everything that goes with it. And the need is truly absolute. The demand is literally, “You obtain this or you die.” Continue reading…
Former Alaska Governor Sarah Palin’s widely publicized comments on death panels and rationing this August were among the opening shots of an unprecedented national fight over health care reform. At the time, few sober analysts would have predicted that Palin’s criticisms would gain traction. Yet, they found a receptive audience among conservative opponents of the Obama administration’s health care reform plans, triggering an ugly battle between supporters of reform and right wing opponents.This weekend, Gov. Palin returned to the healthcare debate with another post to her official Facebook page that touches on the talking points you’re likely to hear in the months to come from Republican critics of the Obama administration’s health care reform efforts. In the spirit of debate we are republishing the post in its entirety. — John Irvine
Now that the Senate Finance Committee has approved its health care bill, it’s a good time to step back and take a look at the long term consequences should its provisions be enacted into law.
The bill prohibits insurance companies from refusing coverage to people with pre-existing conditions and from charging sick people higher premiums.  It attempts to offset the costs this will impose on insurance companies by requiring everyone to purchase coverage, which in theory would expand the pool of paying policy holders.Continue reading…
…without Republican leadership.
I will suggest that there is an opportunity for the Republicans to
score a huge political and policy win. It can be done in a bipartisan
way and it can be done in a way that does not sell out the core
principles that either Republicans or Democrats believe in.It would require a new effort—a clean sheet—this time initiated by the Republicans.The
Republicans have won August. No doubt about it. But they have “won,”
not because they actually did anything to deserve the win—they pretty
much sat back and let political gravity do all of the work.Now what? Do Republicans really think they can sit back and do nothing for three or four more months and come out “winners?”At this rate, this health care debate is headed for a stalemate that will not do the country, nor either party, any good.
Sermo’s Daniel Palestrant got on TV with Howard Dean. It was an amusing (and short) little debate which you can find here.
The best moment was at the start when Dean claimed that Sermo was just a poll. Palestrant pointed out that Dean spent last week explaining how reflective online communities were about what their members thought. Given how Dean rose to national prominence I’m a little surprised that he’s trashing the Internet!Continue reading…