June 24th, 2009 by RamonaBatesMD in Better Health Network, Health Policy
Tags: CMPI, Dr. Bob Goldberg, Dr. Val Jones, Government-run Healthcare, Healthcare reform, Public Plan
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I was in the “audience” of the phone conference today organized by Dr. Bob Goldberg, President, Center for Medicine in the Public Interest (CMPI). In addition to him, Dr. Val Jones (Founder and CEO of Better Health) and Dr Gary Puckrein (President, National Minority Quality Forum) were on the panel of speakers. The focus was to be on the risks of government-run healthcare.
It seemed to me that many good points were made, but the main one was that the focus of the healthcare discussion needs to be refocused on the patient and the care given rather than simply on the high cost of care/insurance and any cost savings to be gained short-term. As Dr Wes pointed out in his recent post (The $400 Billion Dollar Question), patients aren’t at the “table” of many of the discussions of healthcare reform that are taking place.
Should America understand precisely what is being cut when we see $400 billion suddenly disappear from the health care reform budget?
I would argue we must know.
After all, it’s we the patients who are not at the policy table, and you can bet that it’s the patients who will ultimately be paying the tab, be it directly through health care premiums, or indirectly by taxation or deficit spending.
There were two links given by the CMPI as sources for factual information on the healthcare discussion: publicplanfacts.org and biggovhealth.org.
I went to both, but in an effort to keep this post at a reasonable length will highlight only a few from the first link. First this one —
- Public plan proponents are advocating a $1.25 per hour per employee tax to pay for the public plan. The Commonwealth Fund, “The Path to a High Performance U.S. Health System”, p. 29, February 2009.
I won’t comment on that one, but will this next one:
- Under the public plan, doctors and hospitals would see their reimbursements for providing medical care cut by as much as 30%. The Commonwealth Fund , “The Path to a High Performance U.S. Health System”, p.33, February 2009.
This decrease in reimbursement troubles me as I have watched the struggles many hospitals have experienced over the past several years with the current reimbursements. I think this trend will only get worse. Check out Barbara Duck’s series at Medical Quack on desperate hospitals. Here’s an excerpt from the May 24, 2009 post:
In Chicago, Illinois
The Loyola University Health System in west suburban Maywood on Tuesday said it will eliminate more than 440 jobs, or about 8 percent of its workforce, amid the recession and an economic downturn causing an influx of patients who cannot pay their bills.
The cost of patients who cannot pay has increased 73 percent, to $31.3 million from $18.1 million, from a year earlier for the nine months ended March 31.
“We have been hit by a number of things,” Dr. Paul Whelton, chief executive of Loyola University Health System, said in an interview. “We are having more trouble with charity care, and the money we are getting [from patients] is more slow to come in. But we have a mission to provide care in our communities and we are going to stick to it.”
In all this talk on healthcare reform, it seems to me and others at the phone conference that the quality of patient care rather than simply cost containment needs to be put back at the front of the discussion. Healthcare should provide care without being hampered by more and more rules and regulations in an effort to contain costs. We don’t need more rules like the Medicare’s 75% rule.
Saving money by providing an inferior “product” isn’t what any of us want. Is it?
*This blog post was originally published at Suture for a Living*
June 24th, 2009 by EvanFalchukJD in Better Health Network
Tags: Cost, Doctor Patient Relationship, Finance, Money, Motivation, Physicians, Salary
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Steven Pearlstein actually wrote that in the Washington Post on Wednesday, right after (another) long rant against physicians. At the end, he offers doctors an olive branch. Or maybe its an offer he thinks doctors can’t refuse:
The choice for doctors now is quite clear: They can agree to give up a modest amount of autonomy and income, embrace more collaboration in the way they practice medicine and take their rightful place at the center of a reform effort that will allow them to focus more on patient care. Or they can continue to blame everyone else and remain — stubbornly — a part of the problem.
After reading Pearlstein’s columns, I’m still sure not why he has such a problem with doctors. I am beginning to think it’s because he just misunderstands them.
Pearlstein is convinced that doctors go into medicine for the same reasons investment bankers go to Wall Street: to make money.
Docs seem to take it as a given that physicians in the United States should earn twice as much as doctors in the rest of the world — and five times more than their patients, on average. Mention these facts and you are guaranteed to get a lecture about the crushing debt burden that young docs face upon completion of their medical training. Offer to trade free medical education for a 20 percent reduction in physician fees, and you won’t find many takers.
Pearlstein has no source for these claims, but let’s assume they’re true, and do the math. The government says that there are 633,000 doctors in the United States, and they earned median salaries between $135,000 and $320,000 a year. If we take a number in the middle — say $200,000 — that means that American doctors earn about $125 billion a year. A big number, but total health care expenses in the United States are over $2 trillion, which means doctors represent about 5% of the total. Can physician salaries really be driving our health care problems?
It seems unlikely. But Pearlstein is desperate for it to be true, so he keeps trying to discount all of the other possible causes of our problems as examples of conspiracies or arrogance or sloppiness:
For example, medical malpractice litigation is a problem…
But one of the reasons malpractice suits are still necessary is because doctors have transformed local professional review boards, which are supposed to protect patients, into nothing more than mutual protection societies
The “infelixible bureaucratic processes” that insurers impose are a problem….
But given that there is overwhelming evidence that doctors tend to order up tests, perform surgeries and prescribe treatments whose costs far outweigh the benefits, you can hardly blame the insurers.
We think it is good to have “clever and creative” doctors…..
but . . . we could all have better health at a lower cost if docs were less inclined toward the medical equivalent of the diving catch and simply were more disciplined about kneeling down for routine ground balls.
Doctors should be applauded for embracing evidence-based medicine…
however, practicing physicians still think that nothing should interfere with the sacred right of doctors and patients to make all medical decisions, even when they are wrong.
Pearlstein’s views on how doctors think are fundamentally flawed. He thinks of them like stock brokers, pushing questionable stock to make commissions for themselves. He’s thought of all the different ways doctors are abusing the system to their own advantage, but he doesn’t seem to have thought that maybe, possibly, he’s wrong.
So, yes, some doctors abuse the privilege of being asked to help their patients. But the overwhelming majority don’t. They want to spend as much time as they can with their patients, collecting information, thinking about their problem, and offering good, sound advice. They are bothered by the involvement of the insurance company or the government or the plaintiff’s lawyer not because they believe they have a “sacred right” to total independence. Or because they think the way to fix health care is to give them “free rein to treat their patients . . . run the hospitals and set their own fees.”
No, it is because these things actually interfere with the doctor’s ability to think, process and decide with their patient on the right things to do.
Pearlstein and other would-be reformers of our health care system need to reconsider their assumptions on what motivates doctors. Maybe it’s something Pearlstein should ask some of his friends about.
*This blog post was originally published at See First Blog*
June 23rd, 2009 by KerriSparling in Better Health Network, True Stories
Tags: Diabetes, Endocrinology, Pediatrics, Type 1 Diabetes
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I saw my niece over the weekend. She just turned seven. She had a bit of a fever and wasn’t feeling very well, so when I saw her snuggled up on the couch under a blanket, she looked every bit the little kid she is. Poor little peanut, hiding out until she felt better.
I remembered that I was about her age when I was diagnosed.
I found an old school photo from second grade, with me sitting next to my friend Bobby (who I still talk to, which is a very surreal experience, hanging out with someone I’ve known longer than I’ve known insulin injections). I was diagnosed in September, right as second grade started.
I’m in the blue dress, second row from the bottom, third from the left.
Swinging my feet. Not much for sitting still, even in second grade.
Over the last few days, I’ve been reading some emails from the CWD parents as they gear up for the Friends for Life conference in Orlando in a few weeks. These emails are sent out to a whole mailing list of attendees, and somehow I ended up on the list with all the parents. (Or maybe the list just happens to be mostly parents and I just happen to be an adult “kid” with diabetes.) These parents are comparing notes and reaching out to one another, looking forward to other parents who understand what they’re going through every day as they care for their kid with diabetes.
And I wish that my mother had this kind of support when she was dealing with my diagnosis over twenty years ago. My mom had a lackluster team of doctors at the Rhode Island Hospital (where I went for a few months before going to Joslin) and Eleanor (the only other mother of a diabetic kid that we knew of in our town and the woman who just happens to be my local Dexcom rep), leaving her with little to manage the enormous learning curve.
This weekend, I went on a bike ride with my sister-in-law, my father-in-law, and my husband. I had to remember to test beforehand, bring my meter, stash some glucose sources on several people, and monitor as re rode. A lot of thought for maybe an hour long bike ride. And it made me wonder what kind of preparation and worry my mother went through when she sent me out to play for a whole Saturday afternoon. Lot of work on my mom’s part just to keep things normal.
I forget this sometimes, how many people are really involved in keeping me healthy.
I need to call my mom.
(Granted, my diabetes diagnosis hasn’t kept me from doing much at all. And it definitely didn’t keep me from being … um, a bit of a goofball.)
*This blog post was originally published at Six Until Me.*
June 23rd, 2009 by Shadowfax in Better Health Network, Health Policy, Opinion
Tags: Baucus, Costs, Featured, Healthcare reform, Malpractice Reform, Medical Malpractice, Obama
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What a welcome headline to see in the New York Times:
Obama Open to Reining in Medical Suits
In closed-door talks, Mr. Obama has been making the case that reducing malpractice lawsuits — a goal of many doctors and Republicans — can help drive down health care costs, and should be considered as part of any health care overhaul, according to lawmakers of both parties, as well as A.M.A. officials.
Wow. Yay. Crisis over, let’s move on to something else now.
Or maybe not.
Senator Max Baucus of Montana, the chairman of the Senate Finance Committee, is expected to outline his proposal for a health care overhaul this week, and aides said liability protection for doctors is not part of the plan.
So, I’m guessing that Obama’s talk about supporting med mal reform runs about as deep as his comitment to gay rights. Which is to say that he’ll put out some happy talk about it to appease a necessary constituency but won’t twist any arms or spend any capital in Congress to actually make it happen.
Worse, the semi-concrete proposals I have seen don’t look like they’ll offer much protection. Jon Cohn at TNR links to a summary of a few options:
Win-Win-Win on Malpractice Reform? – The Treatment
Disclosure-and-offer programs, in which health care providers disclose unanticipated outcomes of care to patients and make prompt offers of compensation. Patients do not waive their right to sue by accepting the offer, but reportedly, few go on to file lawsuits.
It’s hard to see this as reform at all. Disclosures are nothing new any more, and it’s always been good tactics to make an offer of compensation if there actually was substandard care. I doubt this will be embraced by the medical community, since when you do a disclosure you’re basically giving a potential plaintiff a roadmap for their future lawsuit. You’re basically relying on their sense of decency to avert a suit, and how that fact can be altered I cannot imagine. Another commonly cited option would be to:
create a federal “safe harbor,” retaining the current process of adjudication but insulating physicians from liability if they adhered to evidence-based medical practices. For example, legislation introduced by Senator Ron Wyden (D-OR) in February would create a rebuttable presumption that care was not negligent if the physician followed accepted clinical practice guidelines.
Sound great, but good luck applying that standard. Consider Whitecoat’s trial, in which the case seems to be hinging on the fact that the got the right diagnosis and performed the right treatment, but he may or may not have done so in a timely fashion. Presuming there even exist “guidelines” for a particular condition or presentation, there are so many technical variables in the execution of the care under these guidelines that I don’t see how juries could be expected to put this into practice.
Consider a child with meningococcemia. It’s a no-brainer that a child with this deadly infection needs to be given antibiotics as soon as possible to have a chance to survive, and there’s probably a guideline out there that makes reference to “urgent” or “timely” administration of antibiotics. So, if a kid comes into my ER with a fever and petechiae and I don’t get the Rocephin in for, say ninety minutes, was that timely enough? Or maybe the kid didn’t have the rash on presentation, but at hour three of an extended ER work-up the rash is noted and then antibiotics are given? Or maybe I was too rushed, stupid or negligent to notice the rash and didn’t give antibiotics till hour three. My point is that it’s meaningless to say that “guidelines were followed” when it’s impossible to write guidelines that cover every clinical circumstance. Worse, if implemented narrowly, the “safe harbor” would offer very very little protection, and if construed broadly, it would make it very difficult to actually distinguish negligent care from good care.
The reason I’m spending so much time on this point is that this proposal has had explicit endorsement from Obama himself, his Chief of Staff Rahm Emanuel and his physician brother, Ezekiel Emanuel, and key legislators like Senator Ron Wyden. It sounds great, but it too is just “Happy Talk.”
The last option cited is the classic option of moving med mal cases to specialized health care courts of some variety. I’ve always thought this had great potential, but there doesn’t seem to be any political support for it and it would certainly be fought tooth and nail by the trial lawyer’s association.
So it’s looking more and more like health care reform, if enacted at all, will probably not include any meaningful or effective national solution to the ongoing malpractice crisis. Plenty of “Happy Talk,” but no action and no solutions. Not that I really expected any, coming from a Democratic President and a Democratic Congress, but hope does spring eternal.
*This blog post was originally published at Movin' Meat*
June 23rd, 2009 by Gwenn Schurgin O'Keeffe, M.D. in Better Health Network, Opinion
Tags: Healthcare reform, Lifestyle, Medical Education, Pediatrics, Pregnancy
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With health care reform being the talk of the week – a top priority for President Obama and for the AMA, who wants to be sure that America’s physicians are not just talked about in the reform process but included – I can’t help but wonder if the entire system will be reevaluated or if we will end up with just another band aid.
What worries me is that it’s not just the practical end of medicine that is broken. It is not just the billing end that is unhealthy. It’s not just the reimbursement and billing end that is broken. The overall culture of how we practice medicine is broken as well as the educational system in which and through which our next generation of physicians are being trained.
In this Spring’s issue of the Tufts University Medical School Alumni Magazine, my medical school Alma Mater, resident life style issues were at the core of their headline article. Reading the article, Pressure Drop, by Susan Clinton Martin, M.D., M.P.H, ’04, a pediatrics resident, I was at times propelled back in time to my pediatrics residency at the same institution in the early 1990’s have discussions with my adviser and residency director about whether I wanted to go part time. As I was in my junior year of my pediatrics’ residency and expecting my first child, this was not an easy decision to make and I had seen mixed results with other residents who had attempted this path before me.
In the end, I opted to not go part-time and for the reasons stated in the article for most residents not opting for this path:
1. longer length of overall residency
2. decreased pay and benefits (not ideal with a baby at home!)
3. resentment of colleagues for fear of extra work on their plates
4. lack of support of the program
The honest truth is all of these issues were at play back in the 90’s with me and my colleagues and still exist today. I opted to just forge ahead and deal with having a baby and being a full time resident. I don’t regret that decision. I had the support of some attending physicians and colleagues, friends, my husband and a wonderful nanny who a PICU (Pediatric Intensive Care Unit) Attending introduced me to. It wasn’t easy but is there ever a great time to have a baby in the medical profession? Let’s be honest – residency is one of the most challenging times for a physician and adding any stress to the plate makes it worse.
Balancing work and family is never easy for any career but particularly challenging as a doctor and incredibly challenging as a resident physician where you don’t control your time. Residency programs have rather rigid schedules and even the most thought through back up systems don’t accommodate the last minute life issues that can occur unexpectedly when you are a new parent and have a new baby at home. Residencies try to be reasonable when life issues emerge but it isn’t always easy and there is always some sort of “pay back”. Even when unexpected life issues emerge – daycare crises, infant illness, or a family crisis, it’s almost easier to find a way to get to your shift. That’s how intense the pressure is on you at the time. I recall seeing an Attending pregnant with her 3rd child in tears one day because some small issue had unraveled at home. I asked a mentor about it and she told me “You’ll see when your baby comes. Some days the pressure just gets to you. Just come talk to one of us. There are a few who understand and can help.”
Reading that Dr. Martin was brave enough to go part time was like seeing a rose among weeds. The benefit to her and her family was enormous. When working her “on” months, she can focus and feel less guilty, knowing her time with her family is coming. When she has her “off” months, she’s refreshed “emotionally accessible” to her family.
A recent study by Martin’s program director Dr. Robert Vinci showed that today’s medical students value part time options in residency programs, yet few residents are utilizing those options when they do exist and the majority of programs are still very traditional. According to the article, only 25% of US residencies have part time options with only 10% of residents in those programs utilizing the part time paths.
So, there’s a big disconnect in medical education between desire for better lifestyle and what is available, no different than what those of us who have completed our education and training have experienced within the health care system for years. While it’s discouraging that our caring profession doesn’t have a system that allows us to care for ourselves and our families, it’s encouraging that we are all finally speaking up that balance between work and home isn’t a frill but a necessity – even for physicians.
This is why it is so crucial that doctors at every level of today’s health care system not only have a voice in the health care system discussions under way but be the key players in crafting the new system. This is our career, our life’s work. We would never tell the Government how to do their jobs…what makes them think they call tell us how to do ours?
*This blog post was originally published at Dr. Gwenn Is In*
