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New Hospital Policy Leaves Cancer Patient In Tears

cryingpatientA dear friend of mine (let’s call her Amanda) has metastatic breast cancer. She’s far outlived her life expectancy, thanks to advances in targeted chemotherapy, but is beginning to need more medical care. She’s the divorced mom of two teens, with a loving extended family who keeps a close eye on her.

When Amanda was recently admitted to her local hospital with abdominal pain, a new policy resulted in some unintended consequences. While she was still in the Emergency Department, a nurse came by to ask if Amanda wanted to be an organ donor. The family members – keenly aware of her grave prognosis – assumed that the nurse knew about the cancer, and was asking this question because it had been determined that Amanda was about to die.

Tearful sobs ensued. Amanda’s sister called me the next day to tell me the news. Read more »

Healthcare Reform Views From A Flaming Moderate

I am a flaming moderate.  Yes, I know that is an oxymoron but the fact remains that I am both passionate and moderate in my political opinions.

And I am in the mood to rant, so beware.

Living in the deep south, I often seem like a radical communist to those I see.  I frequently get patients asking questions like “So what do you think about Obama’s plans to socialize medicine?”, or “I wanted to get in here before Obama-care comes and messes things up.”  I usually smile and nod, but find myself getting increasingly frustrated by this.

The house is burning down, folks.  Healthcare is a mess and desperately needs fixing.  How in the world can someone cling to old political yada-yaya-yada when people are dying?  I am not just talking about the conservatives here because to actually fix this problem we all have to somehow come together.  A solution that comes from a single political ideology will polarize the country and guarantee the “fix” to healthcare will be one constructed based on politics rather than common sense.

No, this doesn’t frustrate me; it infuriates me.  The healthcare system is going to be handed over to the political ideologues so they can use it as a canvas for their particular slant.  In the mean-time, people are going to be denied care, go bankrupt, and die.  Yes, my own livelihood is at stake, but I sit in the exam room with people all day and care for them.  I don’t want to be part of a system that puts ideology above their survival.

So here is what this radical moderate sees in our system:

  1. The payment system we have favors no one. Every single patient I see is unhappy with their health insurance to varying degrees.
  2. Stupid and wasteful procedures shouldn’t be reimbursed. This is business 101; if you don’t control spending, you will not be able to sustain your system.  This means that we have to stop paying for procedures that don’t do any good.  Some will scream “rationing” at this, but why should someone have the right to have a coronary stent placed  when this has never been shown to help?  Why should we allow people to gouge the system for personal gain in the name of “free market”?  I got a CT angiogram report on patient today who has fairly advanced Alzheimer’s disease.  I twittered it and the Twitter mob was not at all surprised.  These things happen all the time.  The procedures do no good and cost a bundle.  The procedure done today probably cost more than all of the care I have given this patient over the past 5 years combined!
  3. The government has to stop being stupid. Why can’t I give discount cards to Medicare patients?  Why can’t I post my charges, accept what Medicare pays me, and then bill the difference?  The absurdity within the system is probably the best argument against increased government involvement.  Who invented the “welcome to Medicare physical??”  I never do it because the rules are utterly complex and convoluted.  If the rules can be this crazy now, how much worse will it be when the government takes over?  If my medicare patients are confused now, how much more will we all be if the government grabs all of the strings?
  4. The money is going somewhere. In the past 10 years, my reimbursement has dropped while insurance premiums have skyrocketed.  There are more generic drugs than ever and I am no longer able to prescribe a bunch of things that didn’t get a second-thought 10 years ago.  Hospitals stays were longer and procedures were easier to get authorize.  So where is the money going?? We do know the answer to this question – there is no single culprit.  Drug companies were to blame for a while, but now they are going to the dogs; and yet the rates aren’t dropping.  The real problem is that there are far too many people trying to capitalize on the busload of money in healthcare.  Shareholders, CEO’s, and simple corporate greed has bled money out of the system like a cut to the jugular.
  5. Docs have to stop being idiots. We like our soap boxes to rant against EMR, malpractice lawyers, drug companies, and insurance companies.  We stand on different sides yelling our opinions but don’t come up with solutions.  Instead of doing what is right for our patients, we join the punching match of politics.  Is EMR implementation important?  Duh!  There is no way to fix healthcare without it.  But the systems out there are designed by engineers and administrators and don’t work in the real life.  So why can’t we computerize ourselves?  Every other industry did.  Why must we cling to the archaic paper chart because we don’t like the EMR’s out there?  Aren’t we smart people?  Aren’t we paid to solve problems?  Stop throwing darts and start finding solutions.  Med bloggers are terrible in this – they rant constantly against EMR, but don’t ever say what would work.  It’s fun to criticize, but nobody wants to propose an alternative.
  6. We need to get our priorities right. Healthcare is about the health of the patient.  Yes, it is a job for a lot of people.  Yes, it is an investment opportunity.  Yes, it is a good thing to argue about – whether it is a “right” or not.  Yes, it is a major political battleground.  But in the end, these things need to be put behind what is most important.  As it stands, we are more passionate about these other things than we are about the people who get the care.  In the end it is about making people well or keeping them that way.  It is about saving lives and letting people die when it is time.  If we were all half as passionate about what is good for patients (and we are all patients) as we are about these other issues, we wouldn’t have half of the problems we have.

As a flaming moderate I get to offend people on all sides.  We need to fix our system.  It is broken.  It is not a playground for those who like to argue.  It is not a place to be liberal or conservative.  This is our care we are talking about, not someone else’s.  The solution will only come when we all come to the table as potential patients and fix the system for ourselves.

Is it easy?  Heck no.  This rant is not meant to show I am smarter than the rest of you; it is meant to get all of us away from the other issues that make any hope of actually fixing our problem remote.  Given the fact that we all are eventually patients, our political posturing and plain stupidity may come back to haunt us.  No, it may come back to kill us.

*This blog post was originally published at Musings of a Distractible Mind*

Ezra Klein: Missing The Point

Ezra opines a bit on the role of doctors in health care with the strangely misleading headline: Listen to Atul Gawande: Insurers Aren’t the Problem in Health Care

This wasn’t Gawande’s point at all, and is something quite tangential to Klein’s point:

The reason most Americans hate insurers is because they say “no” to things. “No” to insurance coverage, “no” to a test, “no” to a treatment.   But whatever the problems with saying “no,” what makes our health-care system costly is all the times when we say “yes.” And insurers are virtually never the ones behind a “yes.” They don’t prescribe you treatments. They don’t push you towards MRIs or angioplasties. Doctors are behind those questions, and if you want a cheaper health-care system, you’re going to have to focus on their behavior.

Yes, doctors are a driver — one of many — in the exponentially increasing cost of health care.  Utilization is uneven, not linked to quality or outcomes in many cases, and may often be driven by physicians’ personal economic interests.  All of this is not news, though certainly Atul Gawande wove it together masterfully in his recent New Yorker article.  (I’m assuming you’ve all read it — If not, then stop reading this drivel and go read it immediately.) Nobody disputes that doctors’ behavior (and ideally their reimbursement formula) need to change if effective cost control will be brought to bear on the system.

But it’s completely off-base to claim that insurers aren’t one of the problems in the current system.  There are two crises unfolding in American health care — a fiscal crisis and an access crisis.  I would argue that insurers are less significant as a driver of cost than they are as a barrier to access.  Overall, insurers have, I think, only a marginal effect on cost growth, largely due to the friction they introduce to the system — paperwork, hassles & redundancy and internal costs such as executive compensation, advertising and profits.  It would be great if this could be reduced, but it wouldn’t fix the escalation in costs, only defer the crisis for a few years until cost growth caught up to today’s level.  In the wonk parlance, it wouldn’t “bend the cost curve,” just step it down a bit.

But as for access to care, insurers are the biggest problem.  It’s not their “fault” per se in that they are simply rational actors in the system as it’s currently designed.  Denying care, rescinding policies, aggressive underwriting and cost-shifting are the logical responses of profit-making organizations to the market and its regulatory structure. Fixing this broken insurance system will not contain costs, but it will begin to address the human cost of the 47 million people whose only access to health care is to come to see me in the ER.

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

Patients Do Not Want Their Doctors Paid On Salary

One question that occasionally comes up is whether doctors should be paid a flat salary or not.

Currently, the majority of physicians are paid fee-for-service, meaning that the more procedures or office visits they do, the better they are reimbursed. This, of course, gives a financial incentive to do more, without regard to quality or patient outcomes.

One proposed solution is simply to pay doctors a flat salary, with bonuses for better patient outcomes.

Well, according to a recent Kaiser/NPR poll, that idea is a no-go for patients. 70 percent of patients think its better that a “doctor gets paid each time they see you,” while only 25 percent think a yearly salary is better.

As an aside, I find it interesting that any public poll result that goes against the progressive health policy agenda is considered a “weak opinion,” but really, this isn’t a surprising result.

Economist Uwe Reinhardt hinted at the cause when he said that most Americans believe “that they have a perfect right to highly expensive, critically needed health care, even when they cannot pay for it.”

Perhaps the public believes that a salary is similar to the capitation debacle in the 1990s, where doctors were paid a fixed fee, which gave them an incentive to deny care. And any perceived attempt to restrict care will be met with visceral opposition by the American public.

Which again shows how difficult it will be to engage patients with any dialogue that involves cost control.

*This blog post was originally published at - Medical Weblog*

Five Things That Employers Want To Stop Doing

Our survey of employer attitudes about health benefits told us a lot about what employers are doing, and what they want to stop doing.  Here are 5 things employers want to stop doing:

1. Stop paying for bad employee lifestyles. Bad lifestyle choices are big drivers of expense.  Our study shows that employers want to stop being solely responsible for those costs.  More than half (54%) are adopting programs that use incentives — and penalties — to encourage employees to take responsibility for their health.  A study released last week by Watson Wyatt showed similar results.

2. Stop expecting health plans to deliver customized programs. Health plan offerings are popular — there is a nearly 90% adoption rate for core health plan services.  But employers increasingly turn to outside vendors for customized programs to fix bad employee health habits.  Health plans are looked to for value-based insurance designs, with 40% of employers looking to implement VBID or similar programs.

3. Stop paying for programs that don’t work. Fifty-five percent of employers said they were reducing the number of health benefits they offer or focusing on those with a proven ROI.  With 59% saying cost savings are their top priority, it makes sense that they cut costs where they don’t see savings.

4.  Stop confusing employees with too many benefit offerings. Employers have in place 10 or more distinct health benefits, with 60% identifying at least five major programs (EAPs, nurse help lines, health coaching, wellness, etc).  Employers want to implement a single point of contact to navigate their programs, with adoption rates of these services expected to triple in the next 2 years.

5.  Stop thinking bad medical outcomes are because of bad luck. Sixty-five percent of employers said their employees struggle with making the right treatment decisions when sick.  Thirty-five percent said making sure their employees have better quality care was a high priority, with 38% saying they wanted to do more to empower employees to make good health care decisions.

*This blog post was originally published at the See First blog.*

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