Universal Debt

I have not been posting as regularly as I would like to. I've been busy working and spending whatever leftover time reading about proposed health care reform....The townhall meetings have raised a lot of questions and questionable answers.  Legislators admit, there is no bill.  (How could President Obama even suggest it could be decided an passed before the August recess?)

One has to learn to read between the lines and hear what is not being said during these townhalls.

A disturbing trend is how the media develops opinions and offers criticisms regarding the proposals.  I've taken some time to read parts of the drafts and read some analysis by those who have a lot more time than I do.

There is a high interest and    opinions in the blogosphere as well. I check on that daily to find bloggers have a lot of  'sechel', a yiddish term for common sense and smarts.

To keep my brain from rotting out as I approach retirement I have  contracted with the --------- (at an undisclosed location). After a long and busy professional life in private practice I am now a 'humble" worker in a defense installation. I've been here about a year and as I have always suspected that this is how socialized medicine would be.

I see 14 patients a day, spend about half of my day entering histories and finding into the EMR.  Sometimes I have a technician, and rarely have an assistant with me at surgery. In private practice most eye surgeons will do 4 cases/hour, here it's about one and maybe 2 cases/hour.  No ASC or surgery center could make it on that volume.  In a socialized system, it would not matter....in fact it would be a good thing.  I do my own clerical work, phone calls, chase down small things (much like an intern). I have volunteer workers who come to my office and open my cabinets, to explore and see if I have any 'unauthorized and/or expired bottles of drops in my cabinets. If so, they disappear without any communication with me.  I am not allowed to keep things like 1% Atropine in my lane, for fear I might use it to dilate a general by mistake for over a week. 

Surprisingly coding is a big issue....and I spend at least half of my documentation with CPT and ICD coding.  The  ----- does use an accountability system based on RVUs and each doctor is audited, so that the budget can be justified.  The system however is a bit unique and allows 'up-coding' generously, in that bilateral procedures are coded for twice the RVUs.

On the up side,as I head closer to retirement, this phase of my career allows me to continue caring for patients...the reason I went into medicine in the first place...We all know how much commitment, dedication and sheer will power and energy is required to practice medicine either solo or in a group setting.

Interspersed with all of this  is the necessary day to day family and individual personal and financial commitments.

Unless you have walked in my shoes....don't criticize, or give me unneeded advise, unless I ask.  I am not bashful about telling some pundits and 'reformers' to "buzz off"

HR 3200--The not so Fine Print

Congressman Mike Rogers, Michigan speaks about HR 3200.

 

Pass this along to your colleagues, and  your patients.....

Perverse incentives:::

Don't Leave Us Behind

KEVINMD always finds these 'neat programs'.

The AMA has a Blog

The AMA has a blog (no comments allowed, yet), and a VISION for Health Reform. It all sounds so wonderful and idyllic. Some of us bought into this mindset decades ago with good intentions, only to be used, abused, and betrayed by many who we thought were on the same road to provide care to our patients. The AMA still has good intentions, but it may be warped into positions which are not intended by the membership, (and non-membership). These physicians have little to say in the organization, if they continue voting with their feet.

del.icio.us Tags: ama,blog,social media,health reform

Travel Subsidy on the Health Train Express

The real 'deal'

The American Medical Association came out in favor of the House Democratic health care bill when the House Democratic leadership promised the doctors $230 billion in new spending to cancel out any future Medicare physician cuts (which are scheduled under an existing law called the Medicare Sustainable Growth Rate Formula). As a result, the doctors don’t have to give up anything under the health bills, and would actually pick up $230 billion under the House bill over 10 years.

Hundreds of 'sound bytes' and snippetes of highly charged statements are read daily by patients, providers and decision makers. Unfortunately for the uninformed (and even the informed) ferreting out the 'truth' is very difficult.

Both Republicans and Democrats seek the position to regain p ower, or retain power.  One has to take with a grain of salt, analysis from either side of the aisle.

It's up to we the people to analyze and make your own decision regarding health issues, and be certain your opinion reaches your representatives.  Avoid being a leftist or a right winger.

Perhaps we should not make any decision this year in the midst of economic upheaval from which we have not yet recovered.

Bailing out banks, financial institutions, automobile industry have left us all a bit depleted and in no position to make such a critical decision.

Professionals cast a jaundiced eye upon statistics and projections of healthcare financing.  In reality it is difficult to imagine health care costs in 2016, while dealing at the present moment with a diffiicult system that is challenging to navigate for providers and patients alike.

I like to compare health reform to  the end goal of  orbiting  a satellite. The most effective means of accomplishing this task is by 'staging' a rocket with three booster segments.

It would be almost impossible to accomplish this task with a 'one stage rocket'. This is also true of health reform. 

One Small Step

Gravity acts to keep objects on earth and our present health system also retards change with inertia.

Here is some of the last weeks analysis.

WSJ's blog on health and the business of health.

Claims that health reform will be disastrous for businesses and government are wrong, writes Gary Locke, the U.S. secretary of commerce in an op-ed in the WSJ. Making his case for reform, Locke says that climbing health care costs already cost American businesses jobs and revenue, as well as entrepreneurship, and that isn’t sustainable. “In the short term, health-care costs pose a major problem for companies and their employees,” writes Locke. “In the medium and long-term, these costs pose serious challenges to our economy.”

Fixing Health Care will be good for the Economy

How Hospitals Could Profit from Health Reform

Rick Peters writes in The Health Care Blog

del.icio.us Tags: health reform,health train express,bailout plans

A Missing Passenger of the Health Train

Edward (Ted) Kennedy, D, Mass, departed from the Health Train yesterday. A significant voice in health affairs has left the stage. Not much more can be said by me when others have so elequantly described his life, and times.  Health Train Express offers condolences to his family and constituents.

A moment of silence.....

Ramblings on the Health Train

 

My day here at the government run undisclosed location started off with my morning read of health related blogs, pundits, and rumor mongers.

Buckeye Surgeon from Ohio presents a personal interview with two of his medical school chums, one in private practice and the other who is employed by the Cleveland Clinic. Rather than trusting media sources and medical management statistics, Buckeye decided to do his highly statistically significant study with a cohort of two…..My take on the interview is that some doctors like to work in a group practice, while others are individualists, and like to work alone or in a smaller controllable environment, where you have a choice of wallpaper color, who you hire and fire, and are accountable for just about all you need to practice medicine, and all that you perform. That is what is so unique and vibrant about our health care system….choices for physicians and patients.

Over at MedPolitics , and RealClear Politics The discussion turns to the uninsured.

Here is the “scoop” from t he CATO Institute regarding the uninsured, and who they really are.

 

del.icio.us Tags: uninsured,medpolitics,health train express,buckeye surgeon

Lieberman--A Voice in the Wildness

Joseph Lieberman, (IDem) Senator from the nutmeg state, CT boldly goes where no man goes before...a voice of reason, perspective and quiet reasoning. (typical of Lieberman).

One of the Senate's most powerful Democrats, Joseph Lieberman  said  Sunday that President Obama should take an "incremental" approach to fixing health care and argued that the country should postpone adding nearly 50 million new patients to the government system until after the recession is over.

"We morally, every one of us, would like to cover every American with health insurance," Sen. Joseph Lieberman of Connecticut, told CNN's John King on the "State of the Union" program.

One of the Senate's most powerful Democrats said Sunday that President Obama should take an "incremental" approach to fixing health care and argued that the country should postpone adding nearly 50 million new patients to the government system until after the recession is over.

"We morally, every one of us, would like to cover every American with health insurance," Sen. Joseph Lieberman of Connecticut, told CNN's John King on the "State of the Union" program.

"I'm afraid we've got to think about putting a lot of that off until the economy's out of recession," he added.

"There's no reason we have to do it all now, but we do have to get started. And I think the place to start is health delivery reform and insurance market reforms."

 

 

Although we physicians recognize perhaps more than most that out health system is flawed, most know that this must be accomplished in small steps, focusing first on defects in our insurance system, which lead to the increasing numbers of insured, and increasing overhead to physicians and our society in general.

In the back of each our minds are the millions of uninsured who present in our offices, on an hourly basis,  in the emergency department and public health clinics. 

The term "The Public Option" thus far remains clouded in hyperbole, sounds good or bad, depending  if your leaning is to the left, or to the right.

For many "The Public Option" remains a poorly disguised euphemism for Socialized Medicine.

del.icio.us Tags: lieberman,public option,recession

Value, Security, Beauty and Elegance

Mark Smith, CEO California Health Care Foundation, (video link)  spoke at the Microsoft Connected Health Conference meeting in June.

Comparisons between Richard Nixon’s Health Reform Proposals and Obama’s proposals..as described by Mark Smith, illuminate the similarities and differences. Read what a staunch conservative Republican proposed for a national health universal payor program.

Mark Smith and the things to get ‘right’

1. Standards
2. How will we wire doctors …nagging fear
3. Attributes for providers:
   1. Simplicity, Adaptability, Functionality
4. Attributes for “patients”
   1. Value (for the patient) solve the patients perceived needs.
   2. Security and privacy issues
   3. Beauty, elegance (something ‘they want’)

Dr Smith presented what doctors and patients would like from health IT developers.

K.I.S.S.

Health care financing in itself is a morass of complicated systems. Those who wish to make it as simple as possible, are mistakenly driven toward a universal payor model. What lurks behind the scene with that model is unknown and unintended levels of bureaucracy and the considerable expense of reorganization of the entire system.

It seems public opinion is focusing on these elements:

1. Eliminate cherry picking by private payers, elimination of exclusionary policies and waivers as well as predatory premiums.

2. A public option (which could be temporary) for lapses in employment, and/or insurability, or disability

3. Developing an actuarial insurance base that includes all citizens of the United States.

4. Elimination of free care for undocumented aliens.

5. Elimination of reimbursements based upon procedural coding.

6. Transparency and private oversight of government insurance plans and development of health IT.

7. Improve physician availablity for both primary care and specialty physicians by ''federalizing' medical licensure. Present state regulations amount to restraint of free trade. State licensing largely depends upon national testing standards.

K.I.S.S.  Keep it Simple, Stupid !

The SERMO-AMA Disconnect

Kevin MD today makes some keen observations about the recent dissolution of the AMA – SERMO connection. The sad fact is the outcome weakens the credibility of both organizations. No one knows what the ‘pre-nuptial agreement’, nor what investment in hard cash we as physicians made in SERMO. It would be nice if there were some transparency, other t han the posturing of either side.

My view is that we as physicians were hurt by these events. Neither side seems to want to own accountability for the rupture in the partnership. My guess is that The American Medical Association reacted like a ‘hurt parent’ when confronted by SERMO with the ‘truth’. The AMA and it’s board obviously did not see the relationship as mutually beneficial. The American Medical Association seems to have treated SERMO as a mere ‘marketing opportunity” for the AMA. They never really saw this relationship as a true “partnership.” Partnerships require trust, and trust requires time and actions to prove it’s worth. The AMA lost the opportunity to hear from the disenchanted physicians who no longer belong to the AMA. Perhaps the AMA thinks that by withdrawing its support for SERMO, it will wither and die. SERMO will find a number of other suitors. Mere numbers do not make any organization strong. Many ordinary decision makers and the general public no longer see the AMA as representative of doctors, and the AMA now shares the stereotyping as just one more special interest lobbying group.

Even as an early supporter of SERMO, and Dr. Palestrant’s meteoric rise in medical social networking, as well as major media, I feel somewhat chagrined, and can feel the angst of Dr. Palestrant….

I do not know the inner workings or the need for capital that SERMO required when the partnership was formed. The AMA is a much more mature and well structured organization, not dependent on the actions of one man. Dr. Palestrant seems to act alone, however I do know that I once served on an advisory council. I haven’t heard anything about that council for several years.

The fact that so few replied to the survey about the AMA is not surprising, given that most surveys have a very low yield . Also, given the fact that most doctors only occasionally sign into SERMO occasionally most missed the actual survey itself.

The fact is that doctors need the AMA, and also need organizations such as SERMO.

Other organizations have made the same observations

Daniel Palestrant, MD

Dan Palestrant, CEO and founder of Sermo.com has made the rounds of three media giants CNN,  MSNBC,  & CNBC.

In a friendly face-off with the AMA and other organized medical groups, Dr. Palestrant ably demonstrates that the AMA does not accurately represent many physicians. Of the 800,000 physicians less than 250,00 are AMA members.

What is fascinating to me is that SERMO began only three years ago as a meeting place for grand rounds, and physician to physician interaction regarding interesting clinical cases and treatments.  Members must be authenticated as duly licensed and credentialled MDs or DOs.  Sermo's 110,000 members represent all specialties of medicine from family practice to all specialties.

Members communicate almost in real time posting in different categories of interest, ranging from business, politics, practice management to each specialty. SERMO also surveys it's membership regarding clinical issues and treatment. The high interest in health reform and AMA positions on health reform stimulated active discussions on the SERMO boards, and it became apparent that 90% of participants did not support AMA positions.  Dr. Palestrant decided to provide a more formal poll of issues. In the limited time available for sound bytes he was unable to elaborate on all the other issues of concern to physicians.

Sermo has unexpectedly developed into a sounding board for previously  alienated physicians, not it's original intent.

SERMO has only been in existence less than three years.

Not only will SERMO continue to play an important part in health reform discussions, but it will also have a moderating effect on the AMA from a formerly silent minority (majority) of physicians.

Hat's off to Daniel Palestrant MD  another courageous physician and true visionary.

del.icio.us Tags: SERMO,Daniel Palestrant,AMA,Lou Dobbs,Wolf Blitzer,SERMO survey,CNBC,CNN,MSNBC

Mr. President: 'Shut up!'

The above title is my own..GML

The $50,000 Gangrenous Foot

By Buckeye Surgeon

"This one just takes the cake. We're definitely going to need another Beer Summit after President Obama's latest gaffe:

"If a family care physician works with his or her patient to help them lose weight, modify diet, monitors whether they're taking their medications in a timely fashion, they might get reimbursed a pittance. But if that same diabetic ends up getting their foot amputated, that's 30,000, 40, $50,000 immediately the surgeon is reimbursed. But why not make sure that we're also reimbursing the care that prevents the amputation? Right? That will save us money."

The ignorant arrogance, it just oozes. Vascular surgeons are getting 50 grand to lop off legs? Interesting. I surely would have done a vascular fellowship if that were the case. Sounds like a gravy train. Sit around, wait for poorly remunerated, overworked primary care docs to neglect the diabetic care of their patients, and boom, one day six of them show up in the office with gangrenous feet. Jackpot!
Listen, amputation is the procedure of last resort. And generally patients don't get referred to vascular surgeons needing amputations. They get referred with rest pain or with ischemic/diabetic ulcers. And then it's a progression of intervention. Conservative care. Stenting. Fem-pop bypass. Revision bypass. Fem-distal bypass. And then, finally, when all else has failed, the patient may need an amputation. And this process is generally managed entirely by the vascular surgeon!
There are those who would say (my least favorite Obama phrase) that our President "simply misspoke". But in the context of his recent remarks on ENT docs whacking out tonsils for financial gain, I tend to think that we're starting to see a pattern. The American College of Surgeons does as well. Once again, we see the President attacking the fragmented physician faction, demonizing us as the primary source of our health care woes. And the way he opted to use leg amputation as an example; chosen randomly out of thin air or a deliberate ploy? There is no more gruesome procedure in surgery than an elective amputation. The imagery and connotation it evokes is powerfully negative--- rich proceduralists hacking off your leg for a cash bonanza. Again, this man does not speak flippantly or off the cuff. Everything is purposeful.
I eagerly await the Great One's clarification of any "misrepresentations".

Mr. Obama's speech writers and advisors on health care are more than misinformed.  They ignore (?purposefully?) the real facts, substitute platitudes and offer politically correct lies to bolster their reform proposals.   GML