July 1st, 2009 by James Herndon, M.D. in Health Policy, Opinion
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[Dr. Jim Herndon is a past president of the American Academy of Orthopaedic Surgeons, and chair emeritus of the department of orthopaedic surgery at Partners Healthcare]
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The challenges of health care reform are enormous. To expect that the vast array of problems that exist today will be corrected or solved in a couple of months is totally unrealistic. Witness the moving target of announced changes and options occurring daily in the press and media in general. And add to the confusion…these changes are being developed at the top (Congress and the White House)…not from the bottom up (from doctors, nurses and other health care providers, and importantly, patients). In their place are the powerful lobbyists…the health insurance industry, the hospital industry, the drug industry and even organized medicine (AMA)…who wield their influence over our policy makers by all sorts of tangible (financial donations) and intangible (spouses of leaders on corporate boards) pressures.
I must admit, although occasionally said without real meaning…I don’t hear an outburst of support for the essential mission/purpose of health care…the health of our citizens…”the patient comes first”. Where is the patient…who is supposed to come first…in this national debate?
Everyone knows that health care is expensive. In 1970 health care spending consumed 7% of the Gross Domestic Product. In 2009 health care spending is consuming 16% or more of our Gross Domestic Product. It is increasing more rapidly than inflation. Yet, as a nation, we have not…in all these years…had a serious conversation about Americans’ health. Where is it in our list of priorities? I don’t think we know. From recent events we do know it is lower than the need to remove Saddam Hussein from power…it is lower than bailing out investment companies and banks…it is lower than stabilizing the mortgage market…and it is lower than bailing out two automobile manufacturers. I am not knowledgeable enough to question the priority of the bailouts of banks and financial institutions or the mortgage companies…but I do question the priority of removing another country’s dictator or bailing out two automobile manufacturers instead of allowing them to proceed through bankruptcy in our court system…over health care reform.
Too often in my lifetime I have seen the importance of health care reform pushed down the list of priorities over other needed programs…to wait for another day. How important is the patient, the health of Americans today? How far are we going to push the profession of medicine from “a calling”…a profession, as President Obama states to “a business”. It is known that patients trust their doctors, but not our health care system. When will patients begin to trust their own doctors less? It will happen if and when they believe doctors are more “concerned with the pulse of commerce” rather than the “pulse of their patients”. I submit we are getting very close to this tipping point…in losing the trust of our patients and society in general.
There is no unanimity of opinion regarding the health care reform debate…amongst Democrats, amongst Republication…amongst the public…amongst physicians in general…and orthopaedic surgeons specifically. I asked a few young physicians in an orthopaedic residency program their opinions about the health care reform debate. All believed that every American should have basic health care insurance coverage. Obvious to them, it would include coverage for care of patients with acute fractures or patients with severe pain or loss of function. They admit not knowing much about the “public option” and the swirling politics going on. They also were not comfortable with defining what situations or problems would not be covered by insurance…although they agreed that some restrictions above “basic care” would have to be implemented.
Their responses reminded me that in 1990, when I was in graduate school for an MBA…we had a class debate about whether health care was a right or not of all citizens? Although the discussion was lively and some felt health care was a privilege, the class conceded that health care was a right of all citizens…admitting historically it was considered a privilege for the few who could afford it, but then (1990 or earlier?) health care had become a right for all in the US. I then asked a few of my colleagues who enjoy leadership positions in the field of orthopaedic surgery their opinions regarding health care reform. They also could not agree on the issues of this debate.
One area where they did agree was that academic medical centers are not well positioned for the future…especially those that depend on state funding. We have already witnessed this in Massachusetts where apparently the state has decreased funding to some teaching hospitals that traditionally have cared for a large number of uninsured. Now that most citizens have insurance, they are seeking their care in other hospital emergency departments. My colleagues also agree that physicians will receive lower payments for specific treatments or participate in “bundled” payments to the entire healthcare team/facility for comprehensive care of the patient.
Otherwise my colleagues disagreed. On the one side some support the public option and universal coverage…although “the devil is in the details”. For this group they have become tired…like so many American physicians…with the convoluted way we finance health care and the associated paper trail/documentation overload. The system has made some patient conditions profitable and others not profitable…described by one as “perverted incentives”. These physicians (me included) are angry at the loss of our professionalism as hospitals and physicians chase dollars and not the health needs of each patient and the public. On the other side (against public option), my colleagues have some agreements…most orthopaedic surgeons are supportive of care of the uninsured and underinsured, especially for patients presenting with acute problems to hospitals’ emergency departments. Most also agree that there needs to be a serious realignment of incentives and improved collaboration of hospitals and doctors.
But they have many disagreements…including the provision of elective care. They argue…with good reasons…that with continued rising costs to practice medicine (rent, electronic records, employee wages and benefits, malpractice insurance, increased personnel requirements for the administration/paperwork overload) and continued reductions in reimbursement (Medicare, for example, pays an orthopaedic surgeon today approximately 50% of the reimbursement it paid for a total hip replacement in 1990)…it is becoming increasingly problematic to provide elective care for the underinsured and uninsured. They commonly ask…”How can you provide care that costs more than any receipts”?
Other disagreements include: the single payor system…they don’t believe it will work; although well-intended, they believe these reforms will result in overall lower quality of care for patients; that emergency departments will still be used by those with insurance because patients can see a physician at the patients’ convenience and avoid long delays to see a doctor in his/her office…for example there is a 40-day wait to see an orthopaedist in his/her office in Boston; the continued tremendous demands by American patients to have the latest technology, the latest treatment…even if evidence for its use is unknown; skepticism about the prevention of disorders that have a genetic basis, i.e. osteoarthritis…in the foreseeable future; the simple fact that to reduce errors and overuse/misuse of tests by an electronic medical record and computer physician-order system will cost enormous amounts of increased spending in the short term…before cost savings are eventually realized… and to draw attention to one specific unsolved problem area…Workers’ Compensation…where orthopaedists, daily, see ineffective treatments being used and large numbers of patients on disability.
Briefly, the follow are factors that have led to increased and inefficient health care in the US: high administrative costs; overuse of services and new technology; an increased prevalence of chronic disease; tremendous geographic variations in care; increased payments not resulting in improved quality; a continually high number of medical errors and complications; a broken professional liability system; a shift in costs from the uninsured to the insured; a predominant third-party payer system; overuse and misuse of care; focus changing from the patient to the pocketbook; insurance company abuses (cherry-picking healthy patients, denying care of patients with chronic disease, deliberately lowering the normal of “usual and customary” fees…to name a few); and continued issues of fraud and abuse, especially in the Medicare and Medicaid programs.
Finally I would like to close with the official position of the American Academy of Orthopaedic Surgeons (AAOS) on health care reform: “Any changes to the health care financing and delivery system…the well-being of the patient must be the highest priority. The AAOS strongly supports reform measures…that provide individuals with patient-centered, timely, unencumbered, affordable and appropriate health care and universal coverage while maintaining physicians as an integral component to providing the highest quality treatment”.
The AAOS is opposed to a single-payer health system or even a federal health care authority. The AAOS suggests “a number of tax initiatives…that will level the playing field and make health care coverage more affordable”. There should be “adoption of policies that restore equity and enhance market competition”. The AAOS also “strongly believes that patient empowerment and individual responsibility are necessary components of health care reform. Health choices should be recognized and preventive care should be promoted”.
July 1st, 2009 by Paul Auerbach, M.D. in Better Health Network, Health Tips
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“Community acquired” (that is, not acquired in the hospital, which would be “hospital acquired”) methicillin-resistant Staphylococcus aureus (MRSA) infections have not likely come about because germs that have evolved bacterial resistance by residing within hospitals have spread into the community. Rather, this bacterial resistance to methicillin appears to have arisen independently. The “community” now absolutely needs to be considered to include the outdoor community. Hikers, kayakers, divers, climbers and all other outdoors persons who share equipment or mingle with the general population are susceptible. From a reference entitled “Diagnosis MRSA – The Clinical Challenge of Multidrug-Resistant Infections,” authored by Peter DeBlieux and colleagues and published as a supplement to ACEP NEWS, comes some useful observations.
Skin and soft tissue infections are among the most common infections caused by bacteria that can develop resistance to bacteria. Persons at particular risk for such infections include males, certain geographies, time of year (during warmer months), and affliction with diabetes. Many of the infections are abscesses, in which there is a pus pocket that can be drained by making an incision. Such treatment is in fact important to help control the spread of MRSA infections, presumably by helping to cure the abscess(es).
The current thinking is that in the setting of an “uncomplicated” skin and soft tissue infection (e.g., no involvement of deep tissues, minor clinically: simple abscess, impetigo, pimple, or superficial cellulitis), incision and drainage of small, localized abscesses can be curative. However, this is not an absolute, so many physicians are of the opinion that adding an effective antibiotic is useful. Until we have more information, it remains the clinical judgment of the treating physician about whether or not to prescribe an effective antibiotic, such as trimethoprim-sulfamethoxazole.
In complicated infections, which involve deeper skin structures (such as infected tissue ulcers, rapidly progressive infections, diabetic foot infections involving MRSA), antibiotics are deemed to be essential. The oral antibiotics that are felt to be effective against MRSA are clindamycin, trimethoprim-sulfamethoxazole, doxycycline, minocycline, linezolid, and rifampin. The injectable antibiotics that are felt to be effective against MRSA are vancomycin, clindamycin, daptomycin, tigecycline, linezolid, and quinupristin-dalfopristin. Notably, the fluroquinolone category of drugs, which includes ciprofloxacin, is not recommended as an effective treatment for community acquired MRSA infection. The same holds true for the macrolide category, which includes erythromycin, as well as cephalexin, penicillin, and dicloxacillin.
To prevent the spread of MRSA, wounds should be kept covered with clean, dry bandages; hands washed with soap and water or an effective hand sanitizer after each dressing change; close contacts instructed to bathe regularly; no sharing be allowed of bedding, towels, washcloths, bar soap, razors, and so forth.
image courtesy of www.mrsatreatments.com
This post, Watch Out For MRSA In Your Community, was originally published on
Healthine.com by Paul Auerbach, M.D..
July 1st, 2009 by Dr. Val Jones in Announcements, News
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Canadians and their fans celebrated a great Canada Day (Fête Du Canada) at the Washington, DC embassy, July 1, 2009. Canada Day is America’s Fourth of July equivalent.
I enjoyed the barbeque, air puppets, kiddie tattoos, and a photo op with the RCMP (aka the “Mounties”).
God bless Canada… but please don’t bring their healthcare system here. 🙂
If you’re a Canadian (or someone who loves ’em) check out the Canada Day party finder here.
Addendum: just added a bonus photo taken with a Blackberry – me horsing around.
July 1st, 2009 by KevinMD in Better Health Network, Opinion
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Apparently, there are some legitimate reasons why a patient may lie to their physicians.
A recent article in the Los Angeles Times discusses the phenomenon, which as Dr. Gregory House would aptly summarize as, “Everyone lies.”
In fact, a recent survey suggests that “38% of respondents said they lied about following doctors’ orders and 32% about diet or exercise.”
One interesting reason is that patients are wary disclosing potentially damaging information to health insurance companies. Indeed, when patients apply for individual health insurance, their medical record is pulled up. And since trivial details can cause insurance companies to deny health coverage, patients certainly may have second thoughts about giving an accurate history.
Furthermore, “when processing a claim, the insurance company finds something in a patient’s records that contradicts something the patient said when purchasing the policy, the company can retroactively cancel the policy.”
That’s pretty harsh.
But making medical decisions on inaccurate information has consequences as well, including providing poor patient care.
One suggested option would be to maintain two sets of medical records, one that is shared with the insurance companies, and a private one that is not released to third parties. Some patient advocacy groups even go as far as saying, “If your physician won’t do that, it’s reason enough to leave the physician.”
I currently don’t offer such an option. I wonder how many other practices do.
*This blog post was originally published at KevinMD.com*
July 1st, 2009 by SteveSimmonsMD in Better Health Network, Primary Care Wednesdays
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When my six-year-old daughter heard that I was going to write about President Obama’s speech to the American Medical Association in Chicago, she offered me this insight: “He’s not a doctor! He isn’t supposed to tell people what to do when they’re sick; he’s supposed to rule the world.” Yet, regrettably, doctors do need his help and it was with great interest that on June 15, the medical community listened.
I suspect that my colleagues in Chicago are the only crowd to boo the President during a speech since his election, and I think that much can be learned by examining why this occurred. Just moments before being booed, Obama received raucous applause when he acknowledged, “that some doctors may feel the need to order more tests and treatments to avoid being legally vulnerable. That’s a real issue.” Physicians in the audience then booed the next line, “I’m not advocating caps on malpractice awards which I believe can be unfair to people who’ve been wrongfully harmed.” The President went on to offer a plan to help physicians avoid practicing expensive defensive medicine. “We need to explore a range of ideas about how to put patient safety first, let doctor’s focus on practicing medicine, and encourage broader use of evidence based guidelines.”
I do not object to President Obama’s sincere and well delivered remarks to the AMA, but found some of them to contain trite platitudes. Encouraging physicians to “put patient safety first, focus on practicing medicine and follow evidence-based guidelines” is like asking airline pilots to pay attention to safety gauges, fly their planes, and respect passengers. I found the admonition to follow evidence-based guidelines as a means to avoid medical malpractice claims a particularly naïve statement. I’m not arguing against using guidelines, I just don’t see how guidelines will protect me from a lawsuit any more than the currently used standard-of-care.
I share the President’s opinion that any individual should have the option of remediation through the court system when wronged but large, punitive settlements change the way hospitals and physicians practice medicine and have resulted in an untold number of unnecessary surgeries as well as causing the actual death of many who never had their day in court. Unreasonably large medical malpractice settlements often have consequences that reach far beyond the parties involved in the original suit. Follow the relationship between cerebral palsy and C-sections and you will understand my assertion. In 1985, then trial lawyer John Edwards won a settlement of 6.5 million dollars against a hospital and 1.5 million dollars from an OB/GYN doctor arguing that if a C-section had only been done for an unfortunate child she would have been born without cerebral palsy. This case set off a chain reaction of suits throughout the country, leading obstetricians to practice defensive c-sections. The United States currently has the highest rate of C-sections in the world, the most expensive obstetrical costs per birth, and when measuring infant mortality ranks 42nd out of 43 industrialized nations.
In 1970, six percent of births in the U.S. were done by C-section; today that number has risen to over 30% while the WHO recommended, in 2006, that the actual rate should be no higher than 15%. Yet, the last four decades have seen the cerebral palsy birth rates remain close to 2 per 1000 live births in the U.S. without change. Considering that women are 4 times more likely to die during a C section than during a vaginal birth it becomes a simple and tragic mathematical exercise. Consider that in Scandinavia the maternal death rate is 3 per 100,000 births while 13 mothers die per 100,000 births in the United States; unless you’re African American–then you count an appalling 34 dead for every 100,000 births. Furthermore, once you have had a C-section there is a very good chance that all future births will be done the same way with an increased rate of hysterectomies, post-operative infections, blood clots, drug reactions, etc.
On the other hand, tort reform has resulted in major shifts in the physician workforce. In 2003 Texas put a cap of a quarter million dollars on malpractice settlements for pain and suffering but did not place a limit on the actual economic loss suffered by a plaintiff. The limit for a wrongful death case was set at 1.6 million dollars. Since 2003 Texas has seen 18% more doctors filing for new medical licenses per year (30% in 2007) and by the end of 2007 there was a 6 month backlog for the medical board to begin processing new license requests. The increased number of physicians has helped to improve access to care. Medical malpractice reform is necessary to avoid the kind of collective defensive behaviors that, ironically, may not be in the best interests of patients.
In my next few posts, I plan to discuss various aspects of our broken healthcare system. It is imperative that we understand all of these problems to avoid making things worse. This will require a probing and honest evaluation of what is wrong today. I also intend to discuss the President’s plans for reform and while I don’t agree with all of his plans, he has put forth many ideas that I do agree with. The time for reform is here, action appears inevitable, and the moment to speak out is now.
Until next week, I remain yours in primary care,
Steve Simmons, MD
