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Latest Posts

Penalties Will Not Promote Participation In ACOs

As we get closer to January 2012, the originally scheduled implementation date for Accountable Care Organizations (ACOs), the time has come to reexamine the showpiece of President Obama’s Patient Protection and Affordable Care Act (PPACA) of 2010.

The final rules for ACO’s are now scheduled for release on January 2012. The implementation was originally scheduled for January 2012. As the original rules are being studied and interpreted the program for ACOs implementation became more confusing. Dr. Don Berwick (CMS Director) has refused to discuss the final rules until they have been published in the Federal Register.

“The ACO program is based on the hubristic assumption that the federal government can design the best organizational structure for the delivery of care, foster its development, and control its operation for the entire country.

The federal government has big-footed health system reform. Although there is no one right way to organize care, the federal government (Dr. Don Berwick and President Obama) thinks it has found one—and exerts top-down, bureaucratic control through PPACA to implement it.”

ACOs are supposed to be organizations that improve coordinated care. If an ACO decreases the cost of care Read more »

*This blog post was originally published at Repairing the Healthcare System*

Progressive Counter Point: The IPAB Could Be A Good Thing

I shouldn’t do this. It’s madness to try to delve into the minds of conspiracy theorists and try to make sense of their ravings. But I can’t help myself; I’m drawn like a moth to the flame. It never ends well. I only wind up with a horde of trolls in the comments telling me that I’m a glib supercilious idiot and should stick to medicine or go die in a fire or something.

Sometimes it’s too hard to stay away. Maybe it was the personal affront I felt in the false imputation of ill motives onto progressives. Maybe it was the gross errors in fact, sitting there ripe for the plucking. I don’t know, but I just can’t resist a rebuttal to Dr Rich at Covert Rationing, who weaves a technocratic cost control body into a paranoid web of fantasy, concluding that:

Progressives are dedicated to “progressing” to a perfect society, and they know just how to achieve it. … Specifically, the Progressive program requires individuals to subsume their own individual interests to the overriding interests of the collective – and human nature just doesn’t function that way. Thus, the Progressive program inevitably relies on a cadre of elites – those who have dedicated themselves to furthering the Progressive program – to set things up the right way for the rest of us, while manipulating we in the teeming masses to let them. And the rest of us, once the correct programs and systems are in place, will at last understand that it was all for our own good.

I suppose this paragraph tells you everything you need to know … about Dr Rich. Any supposition that he was approaching the view of policy with a fair mind or that he is willing to attribute anything but the worst motivations to those on the other side of the aisle is completely shredded by this paragraph. As rhetoric goes, it’s up there with “Conservatives want old people to die in pain.” So we can scratch Dr Rich off the list of people who are willing to discuss health care policy with a neutral mindset. He’s engaged in a holy war of ideology. Read more »

*This blog post was originally published at Movin' Meat*

Baby Boomers 2011: A “New Frontier” With Few Guideposts

This is a guest post by Dr. John Schumann.

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In 2011, the first wave of baby boomers will turn 65 years old. Sixty-five still has currency because that’s the age at which non-disabled Americans are eligible to be covered under the Medicare program (now itself having reached middle age).

As our economy continues to recover (hopefully) from the Great Recession, the entrance of millions of Americans to the Medicare rolls over the next decade and a half will be a formidable planning challenge. Look at this chart to see how the baby boomers population has surged:

So is the promise of healthcare reform (the “PPACA“), which will enlarge Medicaid by an additional 16 million Americans — about half of the projected growth in coverage for those currently uninsured.

A couple of recent patient encounters got me thinking about these phenomena, and how we are very much in historically uncharted territory. Never have we had so many living so well for so long. We have an entire generation of people reaching “seniority” who will continue to want the most out of life, without many guideposts on how to achieve it. Read more »

*This blog post was originally published at ACP Internist*

Know Thy Calories: Nutrition Labeling Guidelines For Restaurants

As part of the new healthcare legislation (Affordable Care Act), the FDA has now published its guidelines for restaurants to inform consumers of the calorie counts of food. It establishes requirements for nutrition labeling of standard menu items for chain restaurants and chain vending machine operators.

This is important because Americans now consume an estimated one-third of their total calories from foods prepared outside the home. Consumers are generally unaware of the number of calories they consume from these foods, and being overweight or obese increases the risk of a number of diseases including heart disease, type 2 diabetes, stroke, and cancer.

Here’s what the guidelines say:

– Restaurants with 20 or more locations must disclose the number of calories in each standard menu item on menus and menu boards (have 19 chain locations? You get a pass. Daily specials also get a pass.)

– Additional written nutrition information must be available to consumers upon request (total fat, saturated fat, cholesterol, sodium sugars, carbs, fiber, protein, etc.)

– The menu must say that the additional nutritional information is available. Read more »

*This blog post was originally published at EverythingHealth*

Rationed Care, Denied Treatment, And “Death Panels”

One of the canards slung at the Affordable Care Act is that it creates “death panels” that would allow the government to deny patients lifesaving treatments, even though two independent and non-partisan fact-checking organizations found it would do no such thing.

I don’t bring this up now to rehash the debate, but because the New York Times had a recent story on Arizona’s decision to deny certain transplants to Medicaid enrollees — “death by budget cuts” in the words of reporter Marc Lacey. His story profiles several patients who died when they were unable to raise money on their own to fund a transplant. Lacey quotes a physician expert on transplants who flatly states: “There’s no doubt that people aren’t going to make it because of this decision.”

Arizona Medicaid officials told the Times that they “recommended discontinuing some transplants only after assessing the success rates for previous patients. Among the discontinued procedures are lung transplants, liver transplants for hepatitis C patients and some bone marrow and pancreas transplants, which altogether would save the state about $4.5 million a year.” Read more »

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

Latest Interviews

How To Be A Successful Patient: Young Doctors Offer Some Advice

I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…

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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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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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