June 25th, 2009 by DrRob in Better Health Network, Opinion
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I was looking through an article in Time Magazine recently and came across an article about healthcare reform. It spoke of the daunting task ahead and went through a list of the people at the table in the process of creating change. The list included politicians, hospital corporations, pharmaceutical companies, insurance companies, and lobbyists from certain large special-interest groups. Notably absent from the list was physicians and “normal” patients. I commented about this in a conversation with Val Jones, MD, and she said: “If you aren’t at the table, then you’re on the menu.”
She’s right. Up to now, the interests of the people who matter most – the doctor and patient in the exam room – were largely unheard. Folks said they knew our needs, but they all had their own agendas and so often got it wrong (either out of ignorance or out of self-interest). Even the organizations that are supposed to represent my needs, the AMA and the specialty societies to which I belong, are not composed of folks who spend most of their time in the exam room; they are people who have either retired to spend their time in Washington, or are full-time smart people (they know lots about other people’s business). There are very few people at the table who regularly see patients. There are also very few who represent patients without a particular axe to grind (elderly, people with chronic disease or disabilities).
But healthcare is about what goes on in the exam room. The entire point of healthcare is health care; it is about the care of the patient. It isn’t about the business, the drugs, the delivery system, or the insurance industry; it’s about optimizing how the system makes sick people better and keeps better people from becoming sick. Everything else is a means, not an end.
But those of use who are in the exam room are soon to be served up on the menu for the sake of political gain and special interest clout. They may or may not have a good plan, and they may or may not have good intentions. But they definitely do not have an understanding of what really goes on and won’t be affected much by the decisions they make. They are serving up a dinner of food they don’t know about and they won’t have to eat what they cook. How can they make good decisions?
A step in the right direction would be to listen to bloggers. As opposed to the lobbyists and pundits inundating Washington, we actually do healthcare. The doctor and patient blogs on the web represent the interests of the people who are in the middle of the healthcare universe. This universe doesn’t have Washington DC at its center, it has the patient and those who care for him or her.
A good parallel is the crisis in Iran. There are reporters and politicians who say they know what it’s all about – and in some ways they do – but the voice of the people living in Iran are crucial to understanding what is going on. Why are there riots? Ask a rioter. Was there rigging of the election? Ask someone who was there to witness the process. The people who are on the ground should always be listened to. They don’t give the entire perspective, but getting a true perspective is impossible without talking to them.
Don’t just listen to me; I represent a specific point of view, and don’t represent that of patients or specialists fully. Don’t just listen to patient blogs, as they often don’t have a clear understanding of the business of medicine or the complex medical realities (although I know some of them do know an awful lot). We need to force ourselves to the table. We need to give perspective that has previously been invisible.
Blogging matters because it gives perspective that could never come from anywhere else. Blogging is the journalistic equivalent of democracy, giving the average person a chance to make their voice heard.
In July, a group of us medical bloggers will be going to Washington to do what we can to make our voice heard (thanks to Val Jones’ hard work). Maybe it won’t make a difference; but at least we won’t be invisible any more.
*This blog post was originally published at Musings of a Distractible Mind*
June 24th, 2009 by KevinMD in Better Health Network, Health Policy
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It’s not because of what you think.
The common thought is that health insurers will quiver at the sight of a government plan, with the public option offering lower premiums to patients due to leaner administrative burdens.
But Charlie Baker, CEO of Massachusetts’ Harvard Pilgrim Health Care, isn’t so worried about that. Instead, he first wonders about the government’s competence in handling another large bureaucratic program:
I worry less about the impact of having the federal government writing the rules and competing directly with plans like Harvard Pilgrim for business, and more about the federal government’s ability to do this at all, much less do it well. Merely coordinating basic demographic information between Social Security, Medicare and Medicaid – three big federal programs that millions of Americans belong to – can be a chore for beneficiaries, their children, and their health plans. It’s not unusual for our members to spend six months or so trying to get this stuff corrected before they call us and ask us to step in on their behalf.
And next, he has zero confidence that the government will be fiscally disciplined administering such a plan. With how it handled the General Motors fiasco as an example, Mr. Baker wonders how any proposed public plan “will negotiate with providers for a mutually agreeable fee . . . will balance its books every year . . . will have to cover its costs of doing business – just like the private plans do – [but] won’t add to the federal deficit.”
Is that even possible?
*This blog post was originally published at KevinMD.com*
June 24th, 2009 by RamonaBatesMD in Better Health Network, Health Policy
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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 23rd, 2009 by Shadowfax in Better Health Network, Health Policy, Opinion
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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
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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*
