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Health Care’s Tragedy Of The Commons

There are at least two conversations going on in the health care marketplace today, each focused on one of two key questions. One is: How can we achieve the Triple Aim? The other is: Why do they get to do that?  (It’s not fair! I want more!)

Until we stop asking the second question, we can’t answer the first question. Why? Because all too often the answer to the second question is the equivalent of: It’s OK, Timmy, I’ll buy you TWO lollipops; pick whichever ones you want.

It’s the tragedy of the commons, transposed to the health care marketplace.

Recent cases in point:

  • Avastin
  • Tufts Medical Center – Blue Cross Blue Shield of Massachusetts grudge match
  • Mammography and PSA guidelines

1.    Avastin.  Late last year, Read more »

*This blog post was originally published at HealthBlawg :: David Harlow's Health Care Law Blog*

Boehner’s Announcement Means An Extension Of Current Medicare Payment Rates

Last week, Speaker Boehner announced that the House and Senate have agreed on a two month extension of current Medicare payment rates, the payroll tax cut, and unemployment benefits.

My understanding is that the agreement has the House accepting the Senate’s proposal to extend the payroll tax break, unemployment insurance benefits, and current Medicare payment rates through the end of February, along with an agreement with the Senate to appoint a House-Senate conference committee to begin negotiations on a longer-term extension. It remains unclear exactly when the votes in the House and Senate will take place, and at least in the Senate, it will require unanimous consent by all Senators. If it passes both the House and Senate, Read more »

*This blog post was originally published at The ACP Advocate Blog by Bob Doherty*

The Rising Price Of Health Care: How Are People Dealing With The Expense?

A couple of weeks ago, I was asked to speak as a patient about “consumers and cost information” while being videotaped for use in the annual meeting of the Aligning Forces for Quality initiative funded by the Robert Wood Johnson Foundation.

RWJF Video - This Costs How Much?

I admire the aims of this initiative – “to lift the overall quality of health care in targeted communities, reduce racial and ethnic disparities and provide models for national reform” – and I think it has taught us some valuable lessons about what it takes to make even slight course corrections in the trajectory of the huge aircraft carrier that is health care.

Plus, I have listened to hundreds of people talk about their experiences with the rising price of health care: who thinks about it when and why, what individuals do to cut back on the expense, where they have been successful and where not. I’ve heard lots of stories, most of them involving Read more »

*This blog post was originally published at Prepared Patient Forum: What It Takes Blog*

Should Insurers Contribute To Graduate Medical Education Funding?

Graduate Medical Education has for the most part escaped big budget cuts in the past, mainly because powerful lawmakers have aligned to protect funding for teaching hospitals in their own states and districts. Plus, the Association of American Medical Colleges, the American College of Physicians, hospital organizations, and many others long have made funding for GME a top legislative priority.

GME, though, could be on the chopping block as Congress’s new “Super Committee” comes up with recommendations to reduce the deficit by at least $1.2 trillion over the next decade. A report from the Congressional Budget Office of options to reduce the deficit to suggests that $69.4 billion could be saved over the next decade by consolidating and reducing GME payments. Earlier this year, the bipartisan Fiscal Commission on Fiscal Responsibility and Reform also proposed trimming GME payments.

How then should those who believe that GME is a public good respond? One way is to circle the wagons and just fight like heck to stop the cuts. But that raises a basic question: is GME so sacrosanct that there shouldn’t be any discussion of its value and whether the current financing structure is effective and sustainable?

Another approach, the one taken by the ACP in a position paper released last week, is to Read more »

*This blog post was originally published at The ACP Advocate Blog by Bob Doherty*

Does Your Doctor Look Up Information Online In Front Of You?

Nearly three-quarters of survey respondents said they look up information online in front of a patient sometimes or often, and another 11% said they do when absolutely needed. Only 13% deliberately avoid it.

ACP Internist polled its readers in relation to its story on computers in medicine, in which it focused on whether doctors should look up information in front of a patient. From this, 362 readers responded in August that: Read more »

*This blog post was originally published at ACP Internist*

Latest Interviews

How To Make Inpatient Medical Practice Fun Again: Try Locum Tenens Work

It s no secret that most physicians are unhappy with the way things are going in healthcare. Surveys report high levels of job dissatisfaction burn out and even suicide. In fact some believe that up to a third of the US physician work force is planning to leave the profession…

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Caring For Winter Olympians In Sochi: An Interview With Team USA’s Chief Medical Officer Dr. Gloria Beim

I am a huge fan of the winter Olympics partly because I grew up in Canada where most kids can ski and skate before they can run and partly because I used to participate in Downhill ski racing. Now that I m a rehab physician with a reconstructed knee I…

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Latest Cartoon

Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.

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Click here for a musical take on over-testing.

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Latest Book Reviews

The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

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Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

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Unaccountable: A Book About The Underbelly Of Hospital Care

I met Dr. Marty Makary over lunch at Founding Farmers restaurant in DC about three years ago. We had an animated conversation about hospital safety the potential contribution of checklists to reducing medical errors and his upcoming book about the need for more transparency in the healthcare system. Marty was…

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