Hey Doc, Please go Away

Aaron Carroll,  over at The Incidental Economist,summarizes a study suggesting that patients do better when cardiologists are away at academic meetings.

High risk patients admitted with heart failure during meetings had a 30-day mortality rate of 17.5%, compared to 24.8% when more cardiologists were there. Cardiac arrest 30-day mortality was 59% during meetings and 69.4% at other times. 

Why is this?

There are a number of ways to interpret this. Maybe the best cardiologists were the ones who stayed home. Maybe with fewer cardiologists available, fewer invasive procedures get done, and that leads to better outcomes. Maybe they tell more low-risk patients to wait when fewer cardiologists are available, which gets the higher risk patients more attention and better outcomes. Maybe it’s something else.

I favor the second explanation and am reminded of the excellent judgment of my PCP back in 2007 when I was asked by the touring company to take a stress test before a two-week long kayaking trip to Patagonia.

She says, “No. I refuse to order a stress test for you.”

“Huh?” I reply intelligently.

“Here’s the deal,” she says. “If I order the stress test, our especially attentive (knowing who you are) cardiologist will note some odd peculiarity about your heartbeat.

 He will then feel the need, because you are president of the hospital, to do a diagnostic catheterization. Then, there will be some kind of complication during the catheterization, and you will end up being harmed by the experience.”

Minor ST segment changes, may be non-specific.

” I will not authorize a stress test.”

Health Reform: A Play in Multiple Acts

It is a very exciting and troubling time  for health care in the United States.  The stage is set for multiple acts occurring simultaneously.

For those who have boots on the ground with financial commitments and assets the changing landscape means unknown profits (if any) or losses.  Health institutions and providers charged with improved outcomes and 'less cost' are facing the conundrum of supplying more care with less money.

Leonard Zwelling M.D., a Houston physician who was a congressional staffer during the writing of the affordable care act puts it this way, as he discusses a statement made by

Norman Ornstein, a scholar at the American Enterprise Institute, one of the leading experts on the workings of Congress, summed it up in one sentence during a briefing for the press and politicos in November 2008. He said:

"Every one's idea of health care reform is the same: I pay less."

Where I was trying to get my head around a solution to the three tenets of my idea of health care reform, everyone around me was trying to preserve or increase his piece of the health care payoff pie. I was looking for a legislative solution to assist the country in arriving at the place where the rest of the civilized world was - the provision of some form of universal health care as a right of citizenship. Everyone else was looking to cut a deal that preserved his place at the trough of health care profiteering. Guess who won?

With the full cooperation of the Congress and the White House, health care was not even remotely reformed. The Affordable Care Act is not about health care reform. It is about money, particularly preserving the insurance industry's hold over how health care dollars are spent.

Hospitals and providers had little to do with the Affordable Care Act.

"The Affordable Care Act continued to allow hospitals to jack up prices with no relation to actual costs. Only the doctors gave up something because, unlike the insurance industry and the pharmaceutical industry, medicine did not speak with one voice when lobbying on Capitol Hill and thus could largely be ignored. This is health care reform? I don't think so.

The reason the Affordable Care Act did what it did is because that's what it aimed to do - increase access to insurance for the uninsured, get everyone else to pay for it, and make sure no one currently in the health care business loses a dollar from the amounts they are already extracting from patients and doctors alike.

Complicating Ornstein's comments are the multiple scenes ongoing in the 'reform' efforts

Technological advancements such as

Health information technology which includes electronic health records, health information exchanges, the proposed upgrading of the ICD - 9 to ICD -10, the advances in mobile health, telemedicine and more.......

The increased regulatory arm with meaningful use in 3 steps.  MU is linked with financial  incentives from CMS to offset the expense of providers and hospital acquisition of electronic medical records.

The challenging role of an unproven health benefit exchange system, with an incomplete back end disconnecting the actual payment to insurers.





The details of connecting the dots are only now coming into focus for bureaucrats and congress who badly underestimated the complexity of health care delivery.  The turmoil is clearly more evident among providers, hospitals and the patients who are the "guinea pigs"

During the next 12 to 24 months the 'symphony" will unfold.  Will it be harmonious or an unfinished symphony?

CMS AND ONC ACT TO SLOW DOWN THE HEALTH TRAIN EXPRESS

The Center for Medicare Services and the Office of the National Coordinator are responding to the intense "push back' from providers, insurance companies, health consultants and others. Realizing the debacle of  Healthcare.gov may be a tremor of impending catastrophic health reform failure they have chosen to 'back off' and delay several major milestones for HIT.

Numerous mandates for the Affordable Care Act have been delayed due to what seems to be a systemic overload of HHS and other regulatory agencies that go beyond the Affordable Care Act.

1. Individual Mandate
2. Last date of enrollment on Healthcare.gov pushed back to December 23rd for a January 1 2014 enrollment. (Is this another pipe dream?  7 days from enrollment to eligibility with authentication of finances?..Another example of fantasy planning by Obama and his administration..

These delays are only the tip of an iceberg upon which the Titanic Obamacare ship founders.

Early on in 2010 shortly after the Affordable Care Act became law, the DOJ warned about employer sponsored health plans.  Rather than the Health Benefit Exchange impacting on only five percent of the population, the actual numbers willl be much greater perhaps as great as 80% excluding public programs.

What's New??

Okay, I have submitted to my urge to upgrade the RHIO blog to something a bit more diverse and expand the scope of it to include other interesting health related information. With this transition to ver 2.0 of blogger.com, comes the ability to do some fancier things such as RSS feeds and other techno-marvels I can name but clearly go beyond the capability of my 1943 CPU. This is merely a test posting you have found after being referred from the old blog site.
All future posts will be made to "Health Train Express".