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Why “The End Of Internal Medicine As We Know It” Might Be A Good Thing

A recent post on the Health Affairs blog proclaimed “The End of Internal Medicine As We Know It.” What the post is really asking about is the future of primary care in the world of healthcare reform and the creation of accountable care organizations (ACOs). While doctors should be naturally concerned about change, I don’t completely agree with this article.

ACOs are organizations that are integrated and accountable for the health and well-being of a patient and also have joint responsibilities on how to thoughtfully use a patient’s or employer’s health insurance premium, something that is sorely lacking in the current health care structure. These were recently created and defined in the healthcare reform bill.

Yet the author seems to suggest that this is a step backwards:

Modern industry abandoned command-and-control style vertical integration decades ago in favor of flatter, more nimble institutions.

Not true. Successful organizations are ones that are tightly integrated, like Apple, FedEx, Wal-Mart, and Disney.

The author talks briefly about how Europe in general does better than the U.S. in terms of outcomes and costs and has a decentralized system. All true. However, contrasting Europe and America isn’t relevant. After all, who isn’t still using the metric system? Therefore solutions found outside the U.S. probably aren’t applicable due to a variety of reasons. Americans like to do things our way.

What I do agree on is that doctors need to be part of the solution and ensure that the disasters of decades ago — like labeling primary care doctors (internists and family physicians) as “gatekeepers” rather than what we really do — never happen. Read more »

*This blog post was originally published at Saving Money and Surviving the Healthcare Crisis*

Should Doctors Be Allowed To Self-Refer?

Federal law generally prohibits physicians from referring their own patients to a diagnostic facility in which they have an ownership issue — a practice called “self-referral” — unless the facility is located in their own practice. This exemption exists to allow patients with access to a laboratory test, X-ray, or other imaging test at the same time and place as when patients are seeing their physician for an office visit. Less inconvenience and speeder diagnosis and treatment — what could be wrong with that?

Much, say the critics, if it leads to overutilization and higher costs and doesn’t really represent a convenience to patients. This is the gist of two studies by staff employed by the American College of Radiology, published in the December issue of Health Affairs.

One study analyzes Medicare claims data and concludes that patients aren’t really getting “one-stop-shopping” convenience when their physician refers them to an imaging facility that qualifies for the “in-office” exemption.

“Specifically, same-day imaging was the exception, other than for the most straightforward types of X-rays. Overall, less than one-fourth of imaging other than these types of X-rays was accompanied by a same-day office visit. The fraction for high-tech imaging was even lower — approximately 15 percent.” Read more »

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

Death: Why Are We So Afraid Of It?

My cousin’s mother-in-law is in her late 90s. She had horrible osteoporosis and can barely move. She has little cognitive function left. She requires nearly 24-hour care and no one would even attempt to say she has any quality of life left. She told her son years ago that she was “ready to go,” and had had enough.

And yet when I asked my cousin’s husband if his mother had any do-not-resuscitate orders, or had ever completed an advanced director  outlining her wishes of what kind of end-of-life care she wanted, he said no. His sister, he said, just wasn’t ready for that yet. So what, I asked, will you do when/if your mother gets pneumonia? Will you treat it with antibiotics? Will you put her on a respirator? If she is no longer able to eat, will you feed her through a tube?

He couldn’t answer. And he was clearly uncomfortable with the questions. Read more »

*This blog post was originally published at A Medical Writer's Musings on Medicine, Health Care, and the Writing Life*

Healthcare Spending: Slowest Growth Since The Great Depression

Healthcare spending grew in 2009 at its slowest rate since 1938, according to a report published in Health Affairs.

The last time America saw such a slow growth rate on health spending it was still emerging from the Great Depression and hadn’t yet entered World War II. The most recent recession is also the cause for the health spending figures, according to the annual report, released by the Centers for Medicare and Medicaid Services.

The report shows that the recession left a deeper impact than previous ones.

Healthcare spending grew 4 percent to $2.5 trillion, outpacing the rest of the still recovering economy. Authors wrote that the recession contributed to slower growth in private health insurance spending and out-of-pocket spending by consumers, as well as a reduction in capital investments by health care providers. Enrollment in private health insurance fell by 6.3 million people.

That’s still 17.6 percent of the U.S. economy in 2009, which reflects the effects of the recession on the economy and the effects of more Medicaid spending, which rose nearly 22 percent last year as part of the economic stimulus and to cover state deficits. (Health Affairs, Washington Post, New York Times, Wall Street Journal)

*This blog post was originally published at ACP Internist*

A Model Medical Community For The Nation?

In a high-profile paper in the September issue of Health Affairs, Thorson and coworkers showed that the care at St. Mary’s Hospital in Grand Junction, CO was superior to that of 20 other unnamed hospitals. Grand Junction is, of course the smal town in SW Colorado that became famous when President Obama visited there during the health care reform debates during the summer of 2009, and here’s what he said:

“Hello, Grand Junction! It’s great to be back in Southwest Colorado. Here in Grand Junction, you know that lowering costs is possible if you put in place smarter incentives; if you think about how to treat people, not just illnesses. That’s what the medical community in this city did; now you are getting better results while wasting less money.”

So, Grand Junction, a town of 58,000 people located  in SE Colorado, where there are virtually no blacks and fewer Native Americans but where family practice rules, is supposed to be the model for the nation. Read more »

*This blog post was originally published at PHYSICIANS and HEALTH CARE REFORM Commentaries and Controversies*

Latest Interviews

IDEA Labs: Medical Students Take The Lead In Healthcare Innovation

It’s no secret that doctors are disappointed with the way that the U.S. healthcare system is evolving. Most feel helpless about improving their work conditions or solving technical problems in patient care. Fortunately one young medical student was undeterred by the mountain of disappointment carried by his senior clinician mentors…

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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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Latest Book Reviews

Book Review: Is Empathy Learned By Faking It Till It’s Real?

I m often asked to do book reviews on my blog and I rarely agree to them. This is because it takes me a long time to read a book and then if I don t enjoy it I figure the author would rather me remain silent than publish my…

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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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