I had the chance to speak with Jim Herndon recently about how the current healthcare climate is affecting orthopedic surgeons. He said that there are 3 things that worry orthopods:

1. Decreasing Medicare reimbursement. In 1990, reimbursement for a total hip procedure was $2,200. In 2007, the reimbursement is $1,190. Medicare is planning to further cut reimbursement 30% in the next 4-5 years.
2. Increasing malpractice insurance costs. Premiums are steadily increasing. In Boston, the average malpractice insurance is about $50,000/year. In Philadelphia, the cost is $150,000. And if you’re an orthopedic surgeon specializing in spinal surgery, malpractice insurance premiums can start at $250,000/year.
3. Pay for performance. No one really knows how this will be applied specifically to surgeons (other than the obvious infection rates), but fears are mounting regarding how to show the best possible performance in one’s practice.

Let’s say that a typical surgeon in Philadelphia pays 33% in overhead (the hospital facilities, staff, etc.). Let’s say that he is also taxed 33% on his income. That means that he’d have to perform 382 hip replacements per year, just to pay his malpractice insurance. That’s almost 2 surgeries/day, 5 days a week, 11 months/year.

So what are surgeons doing? They are reducing overhead by setting up outpatient surgery centers (Dr. Herndon estimates that 60% of orthopedic surgery can be performed in an outpatient setting), they are increasing the volume of surgeries they perform, they are buying radiology facilities where they send their patients for XRays, MRIs etc. (Dr. Herndon explains that Stark Laws don’t prohibit this, so long as the physician takes on the risk of the facility – i.e. that he can potentially make or lose money), and they are financing physical therapy practices that supply therapy to their patients.

Orthopedic surgeons in private practice have become very business savvy in order to survive in this climate. But somehow I feel saddened by all this – the business of medicine is a grim reality that can create a wedge between the physician-patient relationship. A patient is left to wonder about the motivations behind tests and therapies – and perhaps even behind recommendations for the surgery itself.

I guess the second opinion has become more important than ever before?

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

In my previous blog post, I summarized the arguments opposing health care as a “right” for all Americans. Now I will summarize some of the arguments FOR healthcare as a right:

First, a few words from the Center for Economic and Social Rights:

Healthcare policy needs to be about the right to health. The current debate over health care reform tends to bog down in ideological disputes and arguments over economic efficiency. In contrast, a human rights approach would focus on the underlying purpose of the health care system. The core human rights demand is for outcomes consistent with internationally-recognized standards – regardless of whether the health system is private or public. Framing health care reform as a matter of right establishes a mechanism for government accountability and encourages public participation in the decisions that affect our lives and well-being.

Health care must be universally available and accessible. Basic human rights principles hold that health care must be accessible and affordable to all, irrespective of race, gender, religion, geography, and income. The increasing costs of providing services combined with the waste and inefficiency apparent in the current system result in fewer and fewer people having access to basic health care. Policymakers must ask at the outset how well a given plan will work to cover all – not most, or more, but all – people in this country.

There is a commonly held belief that health care IS a right:

Fully, 89 percent of New Yorkers believe that health care should be a right for all New Yorkers.  Further, nearly 70 percent believe that government (federal, 41%; state and local, 28%) should be “mainly responsible for ensuring that everyone in New York gets the health care that they need.”

The strange irony is that some Americans do in fact have the right to health care now:

In respect to health care, the only two groups of Americans I know of that have a constitutional right to health care are adult and juvenile offenders who are incarcerated.  The rest of us get health care the same way we get housing or almost anything else in this society, we get what we can afford to pay for.  Those who can pay the most get the best and those that can pay the least get the minimum or less than the minimum in many cases unless they are able to access care through “charity” for lack of a better word.

Why should health care not be a right when women, minorities, and the disabled have been given special rights?

Even if we could convince everyone in the USA that “human rights” have always been expanding as civilizations progress and that even “civil rights” have been expanding continually throughout our nation’s history, there would likely still be many people resistant to this expansion in general and some who are opposed to the idea of health care, in particular, becoming a right in this country. They may say it just doesn’t look like the list of rights needs such expansion. How carefully, though, have they considered the issue? Did any of the other more recently recognized rights in the US look like they belonged on the list (say in the view of 90% of Americans, or in the view of the most powerful men of the era)? Consider the right of the disabled to be provided with comparable secondary education facilities, or the right of girls to have some reasonable funding for their athletic programs at public universities. Or consider broader rights such as that of African American children to attend the same schools as white children, or the right of any person in this country to be seen and medically stabilized in any Emergency Room in this country. How did these rights come to be accepted and formally established?

Is there something special about this point in history? So that it is reasonable to expect that expansion will now cease and the list will be considered complete for decades to come? Or such that the “Right to Education” belongs on the list, but the “Right to Health Care” does not?

The problem with a market-driven system – the poor suffer the most?

In our market-driven system, investor-owned firms compete not so much by increasing quality or lowering costs, but by avoiding unprofitable patients and shifting costs back to patients or to other payers. This creates the paradox of a health care system based on avoiding the sick. It generates huge administrative costs, which, along with profits, divert resources from clinical care to the demands of business. In addition, burgeoning satellite businesses, such as consulting firms and marketing companies, consume an increasing fraction of the health care dollar.

So should health care be a right or a privilege? You’ve heard both sides, now let me know what you think!This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

There is an old question still sparking debate in the blogosphere (see Kevin MD’s links): is health care a right or a privilege? I think it’s worthwhile to consider both sides of the argument, as one’s position on this issue actually provides the foundation for how one proposes to “fix” this broken health care system.

I have searched the Internet for some of the best quotes on the subject (and I’m sure I have missed most of them) to frame the debate. Today’s post is devoted to the “health care is NOT a right” position. My next post will provide quotes from the “health care IS a right” camp. I hope that you will provide your own views pro or con as comments.

Mr. Robinson wonders if (based on the US Constitution) one can classify health care as a “right:”

By definition, rights can not extend past the boundaries of one’s own person.  One can not, for instance, exercise one’s right to free speech by demanding that one’s neighbor cease speaking, for by doing so, one would deny the neighbor’s right to free speech.  Given that healthcare, for the most part, is the product of someone else’s knowledge, labor, capital, and equipment, it is not within the boundaries on one’s own person.  Healthcare can not be a right because it makes demands on other people.

This analogy by Dr. Peikoff sheds some light on what would happen if healthcare were treated as “a right” by the government:

Take the simplest case: you are born with a moral right to hair care, let us say, provided by a loving government free of charge to all who want or need it. What would happen under such a moral theory?

Haircuts are free, like the air we breathe, so some people show up every day for an expensive new styling, the government pays out more and more, barbers revel in their huge new incomes, and the profession starts to grow ravenously, bald men start to come in droves for free hair implantations, a school of fancy, specialized eyebrow pluckers develops — it’s all free, the government pays. The dishonest barbers are having a field day, of course — but so are the honest ones; they are working and spending like mad, trying to give every customer his heart’s desire, which is a millionaire’s worth of special hair care and services — the government starts to scream, the budget is out of control. Suddenly directives erupt: we must limit the number of barbers, we must limit the time spent on haircuts, we must limit the permissible type of hair styles; bureaucrats begin to split hairs about how many hairs a barber should be allowed to split. A new computerized office of records filled with inspectors and red tape shoots up; some barbers, it seems, are still getting too rich, they must be getting more than their fair share of the national hair, so barbers have to start applying for Certificates of Need in order to buy razors, while peer review boards are established to assess every stylist’s work, both the dishonest and the overly honest alike, to make sure that no one is too bad or too good or too busy or too unbusy. Etc. In the end, there are lines of wretched customers waiting for their chance to be routinely scalped by bored, hog-tied haircutters some of whom remember dreamily the old days when somehow everything was so much better.

This attorney wonders where the “rights” begin and end in the health care environment:

If we speak of a right to healthcare, we need to ask: What kind of healthcare? Perfectly healthy people seek healthcare simply to confirm that they are healthy. Some people seek treatments—vaccines, nutritional and hormonal supplements, surgery to eliminate genetic cancer risks—as preventive measures in order to preserve their health. Some people seek healthcare for conditions that others would not, such as minor colds, common balding, or sports performance enhancement. Few of us would be willing to recognize, or finance, a “right” to whatever kind of healthcare a person might think desirable.

A physician gives an example of what can happen when consumers demand their “rights” to health care:

“Doctor, this guy states he has a bleeding brain tumor and wants a CT scan of his head,” the emergency department registration clerk announced as I entered his room. He looked me in the eye and intoned, ” I want a CT scan of my brain. I have a bleeding brain tumor.” “Do you have a headache, neck stiffness, loss of strength?” “No,” he responded. I proceeded to examine and finding no neurological deficit I inquired why he thought a CT scan was needed. He informed me that a relative had suggested that the numbness he felt in his scalp might have been a sign of a tumor. He was furious when I told him a CT scan was unnecessary and indignantly took my name to make a complaint to the administrator. I had denied him his right.

A patient continues the refrain:

What’s so special about health care? Why not rights to higher education, job training, clothing, computers, child care, cars, etc.? There are a lot of things that will improve a society if everyone had them. This doesn’t mean that we should establish positive rights to provide all these things for those who can’t afford them. We need to keep incentives in place (and perhaps provide education) to encourage people to spend and save their money wisely and to nurture a solid work ethic. Encouraging people to help themselves seems to be a solution for the long-term, not trying to get everyone else to buy the necessities for them.

Do you think that health care is a right? 

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

I’ve been thinking a lot lately about the plight of family physicians – reimbursal for their services continues to decline, overhead steadily increases, and pressure to see a minimum of 30 patients a day can drive them to near despair. Family physicians want to provide quality care for their patients, but are exhausted by volume demands and paperwork.

If you missed this article about the primary care crisis in America in the New England Journal of Medicine, it’s an excellent read. Here are some excerpts:

Excessive demands contribute to long waiting times and inadequate quality of care for patients. A growing proportion of patients report that they cannot schedule timely appointments with their physician. Emergency departments are overflowing with patients who do not have access to primary care. The majority of patients with diabetes, hypertension, and other chronic conditions do not receive adequate clinical care, partly because half of all patients leave their office visits without having understood what the physician said.

These problems are exacerbated by the system of physician payment. Thirty minutes spent performing a diagnostic, surgical, or imaging procedure often pays three times as much as a 30-minute visit with a patient with diabetes, heart failure, headache, and depression…

These factors add up to an unsurprising result: fewer U.S. medical students are choosing careers in primary care. Between 1997 and 2005, the number of U.S. graduates entering family practice residencies dropped by 50 percent…

Who might support a national policy to rescue primary care? Employers and insurers, public and private, may reap a return on investment by fostering a more effective primary care sector that will reduce health care costs… Whoever takes up the cause of primary care, one thing is clear: action is needed to calm the brewing storm before the levees break.

A recent article in the Wall Street Journal sent ripples through the blogosphere. It was about how a few family physicians found a way to drastically reduce overhead – by being a solo practitioner and using technology to replace office staff and automate billing as much as possible.

Drs. Charlie Smith and Joe Scherger are family physicians here at Revolution Health who are leading the charge towards high tech solutions for family physicians. Charlie explains his philosophy in his recent blog post:

Having practiced primary care for over 30 years, I’m convinced the model of receiving in office care for every problem is not working well. I really like the ideas espoused by Don Berwick in changing the model of care in the doctor’s office to that of seeing patients in groups, treating them by phone or by e mail, rather than in the office. Using phone calls or e mails to sort through the patient issues, the doctor can decide to see the ones who really need to come into the office and the others can be taken care of without an office visit. This is a MUCH more efficient method, allows you to take care of many more people that need care, and gets people the care when they need it, rather than forcing them to wait until they can fit into a slot in your office.

The ideal way to partner with your doctor to use the health care system in the most effective way possible is to call or e mail him whenever possible, use the internet to research all of your health conditions, and only go into the office when you require in office care, such as exams, procedures, lab tests or x rays. Become an e patient!

I personally believe that Revolution Health can substantially improve the life of family physicians through innovative technologies designed to automate their practices as much as possible (thus reducing overhead and time spent on paperwork), as well as educating patients about the management of their diseases and conditions, (thus improving outcomes and increasing pay for performance bonuses), and triaging low acuity issues through online physician emailing services and retail clinics (thus helping patients receive the care they need without excessive use of office time).

Who will take up the cause of primary care (asks the NEJM)? Revolution Health will. Let’s work together to improve the quality of life for physicians and patients alike.

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Recent research suggested that circumcision may reduce the rate of HIV transmission by 50% (foreskin cells are particularly vulnerable to infection with the virus). In response to this news, adult men in Uganda and Kenya have been undergoing the procedure in the hope of reducing their risk of HIV infection.

Some young boys in Kenya were actually expelled from school for not being circumcised. Their parents were asked to bring them back to school once the deed was done.

HIV rates have decreased in Uganda from 15% to 5% after aggressive public health initiatives raised awareness of the importance of safe sexual practices. This is an incredibly positive achievement.

One would hope, however, that circumcision in infancy would become the preferred target age for future procedures.

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.