Just The Beginning

Words from a practicing surgeon::

Truth cannot be legislated!

Good morning!

The sun came up this morning in upper Michigan.  The air is crisp and clean as usual and another beautiful day is beginning.  As always, I'm operating on Monday.  I saw my first patient, a middle aged man with a hernia.  He smiled at me, we shook hands and I answered his last minute questions.  Soon I'll be in the OR doing the same work that I still love.

My patient didn't watch the vote last night.  He wasn't aware of Pelosi's grand victory.  All that matters to him this morning is that I am his surgeon, he trusts me to do my job well, and I will.

What we saw last night was a political manipulation of history.  A re-write of law to move the money around and change some rules.  I don't agree with what was done.  My disagreement is the same this morning as it was last week, last year and 30 years ago.

Politicians are still trying, with complex systems and regulations, to change immutable facts.  It is a grand illusion that only will have a transient political benefit for them, if that.  No amount of ink on paper can change the fact that people cannot purchase services for nothing.

No amount of government regulation will change the science associated with the medical care that we provide.  No new ruling or designation will elevate unqualified individuals into the positions that we have worked so hard to attain.

The stroke of the President's pen won't do any of that.  Most of the nation knows this, even though they may not be able to articulate it easily.  But, those of us in medicine, the working physicians who care for patients everyday know this very well.

History takes a long time to play out.  We saw what happened in Massachusetts earlier this year.  People know a scam when they see it.  I am confident that we will weather this "storm".  But, don't be complacent.  Washington is once again messing with your freedom.  That is too important to ignore.

Personal Health Records

The personal health record is failing patients
By Kevin on emr


A personal health record (PHR) has been touted as a way for patients to better keep track of their health information. Google Health and Microsoft HealthVault lead the way.

But what happens if the company storing your data gets bought, goes bankrupt, or simply decides to discontinue their system?

Well, those who stored their data with Revolution Health are finding out first hand.


The troubled company, which started off with so much fanfare, yet died in a whimper, recently announced they’re shutting down their personal health record service.

According to American Medical News, “Industry insiders say Revolution joins a long list of vendors who launched PHRs with a big splash, only to find little interest from consumers.”

Leaving the data entry to the patient is inefficient, and a sure way to minimize the adoption rate. Indeed, “the most successful PHR-type systems have been created by health care organizations and have benefits to patients, he added, such as e-mailing with physicians, online appointment scheduling and the ability to look at information entered by their physicians.”

That means a successful personal health record have to be well-integrated with, or designed by, existing hospital and physician systems, making it harder for a third-party system, such as the defunct Revolution Health service, to gain traction.



Revolution Health, as you may remember was started by Steve Chase, the AOL whiz kid.Another boom to bust enterprise.

Do The Wrong Thing

Robert Laszweski tell us:

As the Democrats make their final push to pass their health care bill many of them, and most notably the President, are arguing that it should be passed because it is the “right thing to do whatever the polls say.”

Their argument is powerful: We will never get the perfect bill. If this fails who knows how long it will be before we have another big proposal up for a vote. There are millions of uninsured unable to get coverage because of preexisting conditions or the inability to pay the big premiums and this bill would help them.

Any big health care bill will be full of compromises—political or otherwise. But this bill doesn’t even come close to deserving to be called “health care reform.”

But as an unavoidable moral imperative, enacting this bill would fall way short:

1. It is unsustainable. Promises are being made that cannot be kept. As the President has said many times, we need fundamental health care system reform or the promises we have already made—the Medicare and Medicaid entitlements, for example—will bankrupt us. What few cost containment elements the Democrats seriously considered are now either gone from their final bill or hopelessly watered down—most notably the “Cadillac” tax on high cost benefits and the Medicare cost containment commission.

2. It is paying off the people already profiting the most from the status quo. Many of the big special interests, that will have to change their ways if we are really going to improve the system, are simply being paid off for their support. The drug deal, the hospital deal, promises not to cut or change the way physicians are paid, all add up to more guaranteeing the status quo rather than doing anything that will bring about the systemic change everyone knows is needed.....more:

 

THE TOP TEN BENEFITS AMERICANS WILL RECEIVE IF (WHEN)THE HEALTHCARE BILL PASSES: 

 

The legislation would:       (Maggie Mahar)

Prohibit pre-existing condition exclusions for children in all new plans

1. Provide immediate access to insurance for uninsured Americans who are uninsured because of a pre-existing condition through a temporary high-risk pool;
2. Prohibit dropping people from coverage when they get sick in all individual plans
3. Lower seniors prescription drug prices by beginning to close the donut hole
4. Offer tax credits to small businesses to purchase coverage
5. Eliminate lifetime limits and restrictive annual limits on benefits in all plans
6. Require plans to cover an enrollee’s dependent children until age 
7. Require new plans to cover preventive services and immunization without cost-sharing
8. Ensure consumers have access to an effective internal and external appeals process to appeal new insurance plan decisions
9. Require premium rebates to enrollees from insurers with high administrative expenditures and require public disclosure of the percent of premiums applied to overhead costs. “By enacting these provisions right away, and others over time” the Caucus declares, “we will be able to lower costs for everyone and give all Americans and small businesses more control over their health care choice

It makes me sick, I see a lot of that

Distractible MD says it so eloquently and simply: Just ask your doctor what he is “sick of”.

Doctors in training are flooding away from general Internal Medicine, Pediatrics and Family Medicine in droves. Only 2% of medical students plan to go into primary care. It used to be over 50%. A recent Jim Lehrer report discussed the reasons. We’ve been talking about it for years but things have only gotten worse, not better.

The whole premise of health care reform ensures that everyone has access to good quality care. Every nation that provides good, quality access has a strong primary care base that is the foundation. Primary care is valued by the government, the payers, the population and even by the physicians.
We have it all backward. It is time to revamp the system from the bottom up. Frankly I don’t care if we get one more multimillion dollar robot to assist in a rare surgical procedure or one more new “next generation” imaging scanner until we can rationalize how we pay for care.
We have not yet begun the hard work to bring costs under control because there are too many pigs at the trough. One of my favorite teachers said “you can’t clear the swamp until you get the pigs out of the way”.
We have a lot of pigs to move aside so more people can get to the water.

I saw a patient today and looked back at a previous note, which said the following: “stressed out due to insurance.” It didn’t surprise me, and I didn’t find it funny; I see a lot of this.

My very next patient started was a gentleman who has fairly good insurance who I had not seen for a long time. He was not taking his medications as directed, and when asked why he had not come in recently he replied, “I can’t afford to see you, doc. You’re expensive.”

Finally, I saw a patient who told me about a prescription she had filled at one pharmacy for $6. She went to another pharmacy (for reasons of convenience) to get the medication filled, and the charge was $108. I could see the frustration and anger in her eyes. ”How do I know I am not getting the shaft on other medications?” she lamented. I told her that I see a lot of this.

What is the toll that simply having an insane system that demands huge sums of cash, yet does not give back a product worthy of that cost? What is the toll of people suspicious that they are being gouged at the pharmacy, hospital, or doctor’s office? What is the cost of having a healthcare workforce that goes home more consumed by frustration about the system than by the fact that people are sick and suffering?
Our system is very sick, and the fact that it is so sick makes me sick. It makes a lot of us sick.
I see a lot of that.

Last Helicopter out of Saigon

Plagiarized from The Health Care Blog

Last Helicopter Out of Saigon!
By JEFF GOLDSMITH
In popular psychiatry, a classic passive aggressive gambit is “malicious compliance”- intentionally inflicting harm on someone by strictly following a directive, even though the person knows that they are damaging someone by doing so. In Washington, the most skilled practitioner of this dark art is Speaker Nancy Pelosi If health reform craters, Pelosi will disingenuously claim that she did precisely what the President asked of her, and blame the Senate and the President for its failure.
In reality, Pelosi’s “leadership” almost fatally wounded health reform last summer. If the process does collapse, the blame should fall squarely on her shoulders. Her poor political judgment led directly not only to squandering a nearly 80 vote majority, but also exposed embarrassing and ill-timed disunity among Democrats on a signature domestic policy issue. It won’t be the Republicans that killed health reform, but incompetent Democratic Congressional leadership.
PLAGIARIZED FROM KEVIN MD
Electronic medical records need to better focus on patients
By Kevin on emr

The biggest problem with today’s push for electronic medical records is an archaic user interface.
Physician Alexander Friedman, writing a scathing essay in The Wall Street Journal, agrees.
Today’s electronic medical records are written for the benefit of insurance companies, which scrutinize each doctor’s note carefully for billing purposes. But, as Dr. Friedman astutely points out, “thorough, efficient billing doesn’t translate to better care.”
It’s gotten to a point where some doctors print out pages of data to bring to a patient encounter, or scan in dictated notes; both of which defeat the purpose of digital records in the first place.
There are scores of electronic medical records competing the gain market share — but each fails to communicate with one another, and all are burdened with a user interface circa Windows 95 that impedes clinical care.
It’s imperative that we divorce charting from medical billing, update interfaces to today’s standards, and return to why doctors write in the medical chart in the first place — to easier treat and benefit the patient

Reform ? or Revolution !

From my post here you may discern that I was in the 'self pity' mode, last week, something which I like to do once in awhile...'why me?"

Well, I am over that now and into:

'I am mad as hell, and I am not going to take it anymore"  My next swing will be into "charge ahead...Don't look back".  I am sure (or at least hope) most of your can identify with this evolution of mood.

For the past 14 months I have been a civilian contractor for the U.S. Army...I have been 'laid off'....A consequence of the financial crunch facing state and federal governments. Unfortunately I was not the beneficiary of all that "stimulus' money". 

The health reform debate, continues in D.C., in the media, and around town. 

I could 'pull a week's worth of all nighters studying the bills and come away not knowing much more about what would work, and what would not work. 

Frankly as any working physician knows this is very complicated, and in a tight balance financially....changing one aspect would create ripples in the health care economy. 

Promoting the enormous changes in our present Health REFORM  bill would be 'revolutionary, probably counterproductive, and even REVOLUTIONARY.  Not bad, if it brings more freedom, more incentives, and rewards for efficiency.  Measuring outcomes is a slippery slope.  With rapidly evolving medical technology where do we set the bar? 

Health Train Slows Down

Things are a bit slow this morning. A welcome respite. I spoke to wifey, who is still on the "left coast' tending to our adult children, who seem a bit reticent to step off into the world we are leaving them. I thought I would be retired by now, or at least tending to an alternate career, reading, writing, sitting on the park bench playing chess....or on the beach....not so. At times I thought I had my whole life well planned and structured, fool me!!!.
This post is going to be mostly a long ramble...that's what happens when I have a few unstructured moments. For five years or more I have blogged on a variety of subjects, ranging from health information exchanges, EMRs, health reform, generalized sarcasm and humor as well as commentary on my fellow bloggers meanderings.
I often wonder how some of these "overworked" and underpaid younger brethren' have time to write so many blogs. (Do they have 'ghost bloggers' ??).
Some of my favorite medical social media sites are KevinMD,DrWes,Medinnovationblog,The Health Care Blog, WSJ Health Blog, Cutting Through the Crap (written by the former publisher of Surgeon's Blog), Buckeye Surgeon, DistractibleMD, and more.
My guiding light platform is bloglines.com

Like my blog ramble today, things turn on a dime. Just found out I will be 'retiring' on April 2, 2010....that will give me a lot more time to blog. Happy Hospitalist, watch out....you too DistractibleMD.

Hal Scherz will be happy that I have more time to dedicate to Doctors 4 Patient Care.

Perhaps I can find a position in government (I hear they are hiring with all the stimulus money)...

Anyone need an ophthalmologist? ....will work for food !! Pity

Health Train at Blair House

 

Between patients yesterday I managed to watch the health reform forum at Blair House.  Thanks to the power of video streaming I was able to follow most of it.

The conversation seemed to present most of the issues, and even malpractice reform was brought up (at a late hour).  President Obama did not respond directly to that issue but it was estimated that the savings would run into billions of dollars, not from premium reductions, but the secondary effects of  'defensive medicine'...This brought no response from President Obama. He seemed more intent upon pushing his own vision of health care.

There were some central core issues that  both sides seem to agree upon.

1. Elimination of exclusions for insurance coverage (Universal coveragw)

2. Expanding medicaid would be very foolish, since it is a system that does not work, and not credible for quality care.

3. DEms want to push on with this bill, Republicans want to start over. 

Stay tuned...

Meaningful Use of EMRs

Many physicians are wondering what that means, in the context of their clinical practice.

 

Here's my 'take' on the situation. 'It depends"  on:

1. The day of the month.

2..What the feds and payors want to extract from your medical records.

It has nothing to do with your needs, or affordability

The latest insider information this week is posted by the HIT Policy Committee

So we have a moving target....and so do the software vendors.

For some specialties the term meaningful use is meaningless.

The Circus

 

Four days from now the three ring circus begins (Dems, Repubs,and Obama) on Thursday and Blair House in Washington, D.C.

Finally (maybe)an attempt at transparency will take place. It's been over a year since these plans for health reform were 'reconciled' in closed room, with secret deals, and legislative trade offs.

I am sure it makes us all feel good to know our health  care is now legislated in a back room.

I  belong to several specialty group listservs and professional health care blogs.  The tone on these forums has changed radically.  One of these groups is an ophthalmology forum.

Many on this forum plan to announce this coming week they will no longer be accepting medicare patients in their practices. This, because of the March 1 deadline for a 21% cut in Medicare reimbursement. This figure is an accumulation of about 5%/ year which is the sum of the number of times this cut was delayed by last minute tack ons to legislation delaying the reductions.

Undoubtedly this will occur again, but only by an uprising of protest by physicians  and patients.

They will all downsize, and shift their professional efforts toward elective non medicare reimbursements.  Those who still have choices will make them according to responsible measures and 'balanced budgets.    Unlike our federal government we cannot print money.

Bi-Partisan???

If you are like me, then you are fed up with hearing about “bipartisan support” for health care reform. Most of us would like to see non-partisan health reform. The recent pronouncement from on high is about the coming conference between Dems and Repubs regarding health care reform.  A dollar late and a dollar short.
Most interested parties could  care less about ‘bipartisan support’.   This wraps the process in a shroud of chaos and cloaks what the people really want and that is  MEANINGFUL change in our health system, not just another step in the path to federalized and/or socialized medicine. The TEA (party), which is not  a political party, but a movement amongst both Democrats and Republicans who agree that our federal government is out of control, not just in health care matters, and also violating constitutional guarantees regarding the limits of federal power as conceived by some very smart folks such as Thomas Jefferson, Ben Franklin and others.

Case in point:  The recent election of Scott Brown in Massachussetts surprised most dyed in the wool Democrats, however it bespeaks the deep distrust of politics as usual in the “Cradle of Liberty”, now an oxymoron.  The citizens of Massachussetts are burdened with their “socialized medical system”, in a state where the longest wait times occur for primary care (over 50 days).  It’s not hard to believe that now, a  heavily Democratic stronghold given what the ‘people’ really think about government health care, and it’s intrusion into medical care. 

Parachutes (and balloons)

Do you have your parachute on?

 

No, I am not speaking about the ‘golden one’ that many CEOs and financial wizards seem to deserve for their “financial wizardry”.
I mean the one that you will need when you are swept off the cliff by the ‘lemings’ cascading before the onslaught of insurance companies, Medicare, software vendors, EMRs, RHIOs, P4P, QA and hundreds of other eponyms.  Even as I back-pedal my feet slip closer and closer to the cliff of doom.
Sid Schwab in his most recent blog post of Cutting through the Crap seems to nail the problem on it’s head. (posted February 11, 2010…UNWORKABLE). It goes far beyond healthcare and medicine. It is a problem we physicians have recognized two or more decades ago.   Perhaps it is not because we are smarter or more intelligent than other citizens, but we do seem to be exposed to more human suffering and tragedy as well as a cornucopia of human experience, both good and bad.  For the longest time we were privileged to be able to rise above the morass and observe, without personal threat or financial anxiety.  It gave us the benefit of a certain altruism and privilege of caring for people, not out of financial necessity, but of moral compass and humanity.

How Much is a Trillion Dollars

A trillion here, a trillion there. In the words of Governor Bobby Jindall of Louisiana fame, “This here is a fine pot of gumbo”. 

He continues in his comments for the WSJ “I honestly do not know one single individual who is happy with this situation. Not one. Not a Republican, a Democrat or an independent. These actions are all problematic individually, but taken as a whole, they are devastating. So against that backdrop, we enter the health care reform debate. I honestly do not know one single individual who is happy with this situation. Not one. Not a Republican, a Democrat or an independent. These actions are all problematic individually, but taken as a whole, they are devastating. So against that backdrop, we enter the health care reform debate. I know a little something about health care policy, and I can tell you exactly the game that is currently afoot. If the House Democrats’ plan were to become law, the president’s statement that “if you like your health care now, you can keep it” will not be true. This is not an opinion, this is a fact.”