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Saturday, January 30, 2010

Charitable Largesse

Bill Gates (former Microsoft CEO) announced a 10 billion dollar grant from the Bill and Melinda Gates Foundation for the development and distribution of vaccines to combat malaria. Vaccines against diarrhea, pneumonia and tuberculosis would save millions of children in developing world countries.


Mr Gates will go down in history as another Carnegie, Robert Woods Johnson, or Howard Hughes, Warren Buffet, George Soros, Li Ka- Shing.

Monday, January 18, 2010

Out of Office

I did not realize it's been ten days since I last posted here. Had to take an emergency trip to the 'left coast', but should be back in several days. Wouldn't you know it, I return to California not to sunshine but a big El Nino...5 days of pouring rain, mud watches and high winds.

Saturday, January 9, 2010

A Cents of Humor

One of my favorite bloggers is Placebo Journal.


This is borrowed from Dr. Douglas Farrago. Laugh on Dougie......Doug can be found on his own web site @    I laugh so hard my liver starts to ache !!  Doug is from Maine, so that explains much of his 'common cents".

Sound Familiar? by Michael Gorback MD

By (Placebo Journal Blog: Medical Humor with a Purpose!)

I don't know how many of you have heard the new buzz about ACO's -
accountable cost organizations. If you have been following discussions
about Massachusetts health care you have seen this suggested.
ACOs are groups of doctors that receive a fixed amount of money and then
provide all of a patient's health care needs. I guess they figure they
can glue together a pediatrician, a heart surgeon, a dermatologist, etc
and make a cohesive group that provides one-stop shopping for all health
care needs. If the patient needs an MRI, the ACO pays for it. Hip
replacement, same thing. Labs, xrays, the whole deal. Kind of like an
insurance company, except now the doctors are the insurance company
without having any insurance company experience. We take in fixed
premiums and pay out benefits.
Does this sound like back to the future?This is basically capitation
The geniuses in Washington, who think we are as corrupt as they are,
believe that instead of paying us to "do things" (which seems to be ok

The geniuses in Washington, who think we are as corrupt as they are,
believe that instead of paying us to "do things" (which seems to be ok
for everybody but doctors) they can control costs this way. After all,
you'll think twice before you rip out that kid's tonsils if you have to
pay for it. Considering deliberately mismanaging someone's diabetes so
you can get $50,000 for a BKA? Not if it comes out of your own hide.
I think it will succeed, because if you stop paying people to "do
things" they will pretty much stop doing things. In my specialty the
general goal for most of us is to get a patient's pain under control
with minimal reliance on pain meds. Some of these modalities are
expensive. A spinal cord stimulator lead costs $1500, and the battery
about 10x that. An intrathecal pump is about $10,000. These are hardware
prices. they don't include O.R., anesthesia, etc.
So here I am in my new ACO office and a patient comes in with horrible
pain from failed back surgery that has been refractory to just about
* I know a stim could potentially help a lot.
* However, I also know that if I go around putting $15-20,000 worth of
hardware into people my partners are not going to be happy.
* I also know that writing a prescription is far easier and much better
for my health than spending an hour in front of a c-arm wearing a lead
apron under hot lights. And I will make MORE money that way. Plus, you can't surf the Internet while scrubbed.
So what's going to happen? They gave me an incentive to not do things
and I will accommodate them. Here's your methadone. It's cheap. Try not
to let your QT intervals get too long. If it makes you sick I'll call in

and I will accommodate them. Here's your methadone. It's cheap. Try not
to let your QT intervals get too long. If it makes you sick I'll call in
some Phenergan for you. No wait -- that might drop your WBC. That means
paying for lab tests. Try some flat ginger ale. That's what my mother
gave me for a tummy ache. Excuse me, time to check my email.
This didn't work when it was called capitation. I don't see how it will
work this time, and I can't imagine how they plan to get doctors to join
into diversified groups without killing each other. Maybe it will be
assigned seating like high school. Maybe they have figured out how to
herd cats. Maybe the CIA has secret pheromones that will make us
cooperate like ants and bees.
I want to know what will happen when a patient hates the group's
endocrinologist and wants to go "out-of-ACO". Can you do that, or do you
send the doctor and the patient to counseling to work it out? What if
the cardiologist you want is in another group?
What if you are a very popular or famous doctor, in big demand? Can you
threaten to go to another ACO if they don't give you more money? Will
there be a draft for doctors coming out of residency? When can you
become a free agent?
The ACO's are also supposed to help "coordinate care". This is the new
buzz word. The old buzz word, "preventive care", turned out to be not so
good after the data showed that it actually costs more to do tests on asymptomatic people. Not to mention that a PAP smear or colonoscopy is not preventive so much as early detection. Smallpox vaccine is preventive. Tetanus shots are preventive. Colonoscopies find what's already there. Anyway, it's not like we have any control over whether or not you eat a large pepperoni pizza every night, washed down with a 6-pack of beer, and then a few relaxing smokes. Nor can we prevent gallstones, broken ankles, cerebral aneurysms

or about 99% of the things that afflict people even if they all live like Dean Ornish in an isolation bubble. Healthy diet, a good night's sleep, exercise, don't smoke, watch your weight, and get lung cancer like non-smoker-vegetarian-yoga-enthusiast-transcendental-meditation-teacher-and-successful-actor/comedian Andy Kaufman, dead at age 35.
Do they think this will be like Boston Legal, where all the partners sit
around a conference table and discuss each case? How many of us call our
colleagues after every visit to discuss the patient? "I'm sorry, Dr.
Futznagle can't come to the phone to discuss Mrs. Balderdash. He's
already on the phone talking to Dr. Squigglemeyer and then he has to
return a call from Dr. Fussypants. Can he call you back next week after
he finishes returning last week's calls?"
Even the Europeans aren't that stupid. To really screw things up you
need the United States Congress, which seems to think that reinventing
the wheel by making a square wheel with a broken axle is the way to
decrease gas consumption.
Yes indeed, that's one way to do it.

Wednesday, January 6, 2010

Back to the Future??

Samll Chart

(figure 1):  Short list of small ambulatory practices EHR.


I thought I would take a step back in time to when I was writing about EMRs, RHIOs and interoperability.  The roots of this blog were in the Riverside Health Information Organization. 

Time has evolved EMRs from a primitive form of data collection and storage to a more sophisticated form of data storage and collection.

EHRs now have had the benefit of time, and some longevity to develop and critique their short comings.  The results thus far show the front runners in the great race to automate and interoperate.  The above figure is from an "independent study" of Group One Health Source, sent to me in a private emailing by Andrea Biddle. 

Large Practice Chart

(figure 2) Short list of large ambulatory practices.

The differences in these two charts is small and probably represents the different markets that vendors have chosen to target with their offerings.

Tuesday, January 5, 2010

What's in a Number??

Health Train Express January 5 2009

In which direction are we headed?  The WSJ reported that health care spending growth had diminished to 4.2%  in 2008.  the slowest rate of growth over the past forty-eight years.
Despite the slowdown, national health spending reached $2.3 trillion, or $7,681 per person, and the health care portion of gross domestic product (GDP) grew from 15.9 percent in 2007 to 16.2 percent in 2008. These developments reflect the general pattern that larger increases in the health spending share of GDP generally occur during or just after periods of economic recession.
This makes logical sense, since health needs never go into a recession….they continue no matter what the economy is. If the general economy outside of medicine contracts then health care expenses would represent a greater portion of the GDP.  What is critical here is that for the first time in 48 years the growth rate diminished from near  16.2% to 4.2%.  Let’s see how that sounds on  CNN, MSNBC and/or FOX News.

Sunday, January 3, 2010

2010 + 5

It was a very nice quiet  New Years on the Health Train Express. Fill in anchors on the networks and cable 24 hour media events, and less about healthcare.

Congress will be back in  session very shortly and the fires will be stoked up.

A colleague of mine sent this to me. Common sense, common values, and a real friend to physicians. 

Mike Huckabee (click to go to media)

If this doesn't warm  your heart in this cold January week perhaps a raise in our reimbursements would.  We are in a world of negative reward.  We feel good if we stop the cuts, we think we have won a battle.

We all need to take the Mayo Clinic route.  Give up  Medicare.

Tomorrow I return to what I like most about medicine, Patient care.  The rest of it is there supposedly to help me do that  better. (not a reality)

Friday, January 1, 2010


A place where no man has gone before.


This might be a timely metaphor from Star Trek.

A 'crack in the wall' as a result of proposed  health reform has already begun to form.  As reported in the Arizona Republic, Bloomberg News, and  The Health Care Blog, The well known and venerated name "MAYO CLINIC' in Glendale Arizona has announced that effective today, Januray 1, 2010 they will no longer accept Medicare for Primary care (formerly known as your family doctor).  While this only affects five physicians at that facility, Medicare reimbursement  for specialty care and hospitalization will continue to be accepted.


The amount patients will now have to pay for primary care will be about 1500 dollars/year.

Whether or not this is a 'trial balloon for Mayo will remain to be seen. 

This does not apply to private or employer based insurance plans.    It may also open a new market for private insurance plans to offer an option for primary care only coverage.

This of course radically affects the referrals to Mayo Clinic specialty care. It also shifts a considrable load to area doctors for primary care. It is not clear whether those patients who chose to go elsewhere will be able to be referred to Mayo for specialty care. Given the reputation of Mayo Clinic for "specialized care", this will  probably be the case.

My head hurts. Maybe it's my hangover???

HAPPY NEW YEAR from Health Train.