John McCain gave some details regarding his healthcare plan at a speech in Iowa back in October. The entire speech can be read here. I didn't find a separate link on his website leading to a formal outline, so this is all we get.
Things I liked about McCain's "proposal"; coverage for all; tort reform; idea of coordinated care; emphasis on personal responsibility for our health and prevention of chronic diseases;
Things I didn't like; health benefits instead paid to employees as wages then give them a tax credit; emphasis on payment for "quality" without defining how to measure it or account for complications or comorbid diseases; almost no emphasis on reducing waste in government run programs; coordinated care(more detail for the contradiction below);
Overall, McCain's approach is from a conservative point of view that doesn't disrupt the "staus quo" very much. It seems to focus more on an oversight role to ensure the quality and accountability he repeats over and over again. Corporate greed and profit certainly aren't mentioned as places to trim fat from healthcare expenditures.
Notes;
1. Like Hillary, McCain is suggesting that instaed of employer funded insurance benefits, the employee should be paid wages, have the wages taxed and then get a tax credit from the government. For low wage earners this will seem like they hit the lottery. Receiving an additional 6-8K per year as wages, a low tax rate AND a tax credit, who wouldn't vote for that? As income increases, the tax rates increase and a smaller portion of those wages come to you. Don't forget that you also pay 7.625% (along with your employer's matching contribution) as Medicare and Social Security Tax. And you still have to buy your health insurance. Again the less you make the better off you are. Another form of redistributing income, except now the government wants it's share though increased taxation.
2. Paying for quality is not a new concept. As I mentioned in the Hillary post, Medicare 646 was designed to look into better ways to provide quality, explore the benefits of paying for chronic disease management and also, disease prevention. Insurance companies are doing this already. The government may be ready to participate AFTER they review the results of their 5 year study that won't conclude until 2012.
3. Coordinated care IS a great concept. Care must be taken to make sure that there can be some variability based on a patient's "severity of illness" and their complicating or comorbid conditions. For example, it would cost MUCH less to care for a 55 year old female, who only has high cholesterol and needs cardiac bypass surgery than it would be to take care of a frail, 68 year old male with high blood pressure, diabetes, high cholesterol, chronic kidney disease, anemia, tobacco use and emphysema, who needs the same bypass. It may sound extreme, but the male patient is pretty typical for someone with heart disease, more so than a 55 year old female.
4. Medicare has started looking at "severity of illness scores", physician's practice patterns in regards to specific diseases comparing them to their colleagues and resource utilization. The problem is that Medicare is only looking at the claims that come to them with specific diagnoses. They are not fully taking into account the patient's complicating and comorbid conditions. The Inspector General has recommended that Medicare use all of this data as a measure of quality and payment for that quality, but only after the data reports what it is supposed to. They aren't there yet.
5. Medicare, nor anyone else for that matter, should have to pay for medical errors, but at what point does an action constitute an "error"? And what is the definition of an error? In most people's minds an error is anything that doesn't go as expected. Dictionary.com also defines error as "a wrong action attributable to bad judgment or ignorance or inattention". I think this is the definition of error we should use for healthcare. If granny is in the hospital, gets out of bed to go to the bathroom, and in her usual, at home, confused state, falls and breaks a hip, does that constitute an error? Medicare thinks so and won't pay for the treatment of her broken hip. And Medicare won't allow granny to be restrained, even if it is for her protection. Perhaps the presidential candidates should all spend a week in a hospital watching all the grannies, then when they fall, the error can be theirs.
Overall I think McCain's healthcare plan is a less painful alternative to Hillary's. But McCain doesn't give us enough detail, isn't addressing government waste and inefficiency in the Medicare and Medicaid programs, neglected to speak to insurance company profiteering, forgot to tell you about the additional taxation and forgot to mention how much this thing will cost.
Sounded good in the speech though.
Doc B
My opinion is free.
Advice is worth exactly what you pay for it.
Thursday, January 31, 2008
Wednesday, January 30, 2008
Healthcare: Hilliary Clinton Style
I chose Hilliary as the first presidential candidate to review because she has tried and failed already during Bill's first term as president. Let's see if anything has really changed.
Hillary's Healthcare plan can be viewed here for the cliff note version and the entire plan here, in pdf format.
Things I like about Hillary's plan; guaranteed coverage, coverage for everyone and eliminating insurance company discrimination regarding whom to insure, whether to insure, and rate adjustments for higher risk patients.
Things I don't like; everything else.
The lengthly, and often redundant, pdf version of her health plan contains a lot of rhetoric aimed at appeasing and attracting the simple-minded potential voter. Some key points to ponder;
1. Eliminating the employer exclusion for health insurance means that your employer will no longer be able to write off their cost of your health insurance premium as a business expense. Instead it will be included as taxable income to YOU. Of course, they'll give a TAX CREDIT, to offset the extra tax you're paying already.
2. Medicare 646 is a study commissioned by CMS (Medicare) to find more efficient ways to provide care. Here is the link. What Hillary is proposing as HER idea was actually put into place in 2005. Final applications were accepted Sept of 2006. Implementation of the study was to begin in 2007 and continue for 5 years. The object of the study is improving efficiency in government funded programs, not private. Most private insurance companies and providers are already implementing many, if not ALL, of the recommendation made by Hillary and still under study by CMS.
3. Hillary claims significant savings from preventative services and chronic disease management. But, Medciare stops paying for annual pap smears and mammograms for eligible Medicare women because those women are "too old" to have breast or cervical cancer. Breast cancer is still the #2 killer for women behind lung cancer. Most insurance companies and hospitals have already instituted disease specific management protocols because they have realized their fianancial rewards. The government funded programs have not.
4. Health insurance choice? If I were to choose what plan to accept; mine, federal employees or Medicare, I'd choose federal. They have the best coverage at the lowest cost, and we, as taxpayers, are paying for EVERY penny of it, even the amount the members of Congress pay "out of pocket" (we pay their salries too). Here is a link to their plans and premiums. See how they compare to yours.
5. Why opt for the most expensive plans (see earlier post for cost per person comparison)?. Expanding the already expensive and inefficient Medicaid program is not the answer. Neither is choosing a Medicare-like insurance option.
Be careful what you ask for, you just might get it. But, don't let someone sell you a bill of goods just because it sounds good on the surface. There is no easy fix for any problem that consumes 16% of the US GDP. It'll take a lot of time, compromise, sacrifice and pain to create something we can all live with. Let's have the patience to tell all the candidates to look before we leap.
Doc B
My opinion is free.
Advice is worth exactly what you pay for it.
Hillary's Healthcare plan can be viewed here for the cliff note version and the entire plan here, in pdf format.
Things I like about Hillary's plan; guaranteed coverage, coverage for everyone and eliminating insurance company discrimination regarding whom to insure, whether to insure, and rate adjustments for higher risk patients.
Things I don't like; everything else.
The lengthly, and often redundant, pdf version of her health plan contains a lot of rhetoric aimed at appeasing and attracting the simple-minded potential voter. Some key points to ponder;
1. Eliminating the employer exclusion for health insurance means that your employer will no longer be able to write off their cost of your health insurance premium as a business expense. Instead it will be included as taxable income to YOU. Of course, they'll give a TAX CREDIT, to offset the extra tax you're paying already.
2. Medicare 646 is a study commissioned by CMS (Medicare) to find more efficient ways to provide care. Here is the link. What Hillary is proposing as HER idea was actually put into place in 2005. Final applications were accepted Sept of 2006. Implementation of the study was to begin in 2007 and continue for 5 years. The object of the study is improving efficiency in government funded programs, not private. Most private insurance companies and providers are already implementing many, if not ALL, of the recommendation made by Hillary and still under study by CMS.
3. Hillary claims significant savings from preventative services and chronic disease management. But, Medciare stops paying for annual pap smears and mammograms for eligible Medicare women because those women are "too old" to have breast or cervical cancer. Breast cancer is still the #2 killer for women behind lung cancer. Most insurance companies and hospitals have already instituted disease specific management protocols because they have realized their fianancial rewards. The government funded programs have not.
4. Health insurance choice? If I were to choose what plan to accept; mine, federal employees or Medicare, I'd choose federal. They have the best coverage at the lowest cost, and we, as taxpayers, are paying for EVERY penny of it, even the amount the members of Congress pay "out of pocket" (we pay their salries too). Here is a link to their plans and premiums. See how they compare to yours.
5. Why opt for the most expensive plans (see earlier post for cost per person comparison)?. Expanding the already expensive and inefficient Medicaid program is not the answer. Neither is choosing a Medicare-like insurance option.
Be careful what you ask for, you just might get it. But, don't let someone sell you a bill of goods just because it sounds good on the surface. There is no easy fix for any problem that consumes 16% of the US GDP. It'll take a lot of time, compromise, sacrifice and pain to create something we can all live with. Let's have the patience to tell all the candidates to look before we leap.
Doc B
My opinion is free.
Advice is worth exactly what you pay for it.
Saturday, January 26, 2008
Presidentail Candidates Healthcare Proposals; Baseline data
In order to make sure we're all playing on a level field and that none of the candidates try to play with the data, I am including the 2006 Census report for Historical Health Insurance Tables. This is the data that everyone is quoting that states 47 million Americans are without health insurance coverage. What no one is reporting is how our healthcare dollars are being consumed among the various groups. Let's see if we can shed a little light on the subject.
Everything I report here is available from the US Census Bureau website, the CIA Factbook and a link to an article by a Canadian physician with his views on Universal Healthcare run by the government.
Total dollars spent on healthcare for 2006 $2.105 TRILLION
Population of the US in 2006 296.8 Million
Average cost person for healthcare $6,700
Private Pay $1.1352 Trillion (51% of Total)
(private insurance, out of pocket, etc.)
Insurance costs $723.4 Billion
Out of Pocket expenses (consumer) $256.5 Billion
Other (non-government) $155.3 Billion
Population covered by Private monies 201.7 Million (67% of general pop)
Average cost per covered person $5,628
Government Pay $970.3 Billion (45% of total)
Medicare $401.3 Billion
Population covered by Medicare 40.3 Million (13.6% of pop)
Average cost per person Medicare $9,939
Medicaid (Federal, State and SCHIP) $569.1 Billion
Population covered by Medicaid 38.3 Million (12.9% of pop)
Average cost per person Medicaid $14,859
Notes:
If there are inefficiencies inherent in the "system", wouldn't it make sense to go after the apparently most inefficient one (cost/person) first?
The government programs spend much more per person than do any of the private programs, AND cover less people.
The uninsured are actually covered by the private sector because as they seek healthcare, they may receive a bill from a hospital or physician, but they won't or can't pay it, so it gets written off as bad debt. The government has a fixed payment system, there is NO WAY for private entities to recoup any of these costs except through private, paying customers (cost shifting).
If you recalculate the cost per person for the private sector and ADD in the uninsured, the actual cost per person is $4,564.
ALL government programs are paid for with your tax dollars. Expansion of any government program will simply increase taxes or decrease deductions.
An article by a Canadian physician, Dr. David Gratzer, looks at the Canadian style of National healthcare from his perspective as a patient and as a provider. I recommend it as required reading for anyone considering letting the government run anything. Find it here.
Doc B
My opinion is free.
Advice is worth exactly what you pay for it.
Total dollars spent on healthcare for 2006 $2.105 TRILLION
Population of the US in 2006 296.8 Million
Average cost person for healthcare $6,700
Private Pay $1.1352 Trillion (51% of Total)
(private insurance, out of pocket, etc.)
Insurance costs $723.4 Billion
Out of Pocket expenses (consumer) $256.5 Billion
Other (non-government) $155.3 Billion
Population covered by Private monies 201.7 Million (67% of general pop)
Average cost per covered person $5,628
Government Pay $970.3 Billion (45% of total)
Medicare $401.3 Billion
Population covered by Medicare 40.3 Million (13.6% of pop)
Average cost per person Medicare $9,939
Medicaid (Federal, State and SCHIP) $569.1 Billion
Population covered by Medicaid 38.3 Million (12.9% of pop)
Average cost per person Medicaid $14,859
Notes:
If there are inefficiencies inherent in the "system", wouldn't it make sense to go after the apparently most inefficient one (cost/person) first?
The government programs spend much more per person than do any of the private programs, AND cover less people.
The uninsured are actually covered by the private sector because as they seek healthcare, they may receive a bill from a hospital or physician, but they won't or can't pay it, so it gets written off as bad debt. The government has a fixed payment system, there is NO WAY for private entities to recoup any of these costs except through private, paying customers (cost shifting).
If you recalculate the cost per person for the private sector and ADD in the uninsured, the actual cost per person is $4,564.
ALL government programs are paid for with your tax dollars. Expansion of any government program will simply increase taxes or decrease deductions.
An article by a Canadian physician, Dr. David Gratzer, looks at the Canadian style of National healthcare from his perspective as a patient and as a provider. I recommend it as required reading for anyone considering letting the government run anything. Find it here.
Doc B
My opinion is free.
Advice is worth exactly what you pay for it.
Wednesday, January 23, 2008
Healthcare; The presidential candidate's proposals
Over the next several posts, I'll be reviewing and digesting the front runner's positions and proposals on healthcare. All of the candidates have one but the only ones discussed here will be those that are easily available to everyone on a particular candidates website.
Most of them have broached the idea of healthcare reform and at times have used it as a topic of debate. No one has given details, at least in the debates or press conferences, how it will be paid for. As I mentioned in an earlier post, any hybrid program is doomed to failure because of corporate greed on one hand vs government inefficiency on the other.
The only way a hybrid program would conceivably work is if there were strict regulation, much like there is in the utilities industry. Many of you may recall when the oil and airline industries were regulated and what happened to prices AFTER deregulation. The reason for the regulation in those industries at the time was because of a small number of corporation having control of a high demand product or service, an oligopoly.
The insurance industry is much like that today. While there are many smaller firms offering health insurance, the bigger players still have the lion's share of the market. The smaller outfits also can't offer comparable benefits to as many providers because many providers don't participate in smaller plans. It's simply not worth their time.
So, if the candidates are truly committed to healthcare reform that provides good benefits at a reasonable cost, I'm ready to listen. But, I want details.
Doc B
My opinion is free.
Advice is worth exactly what you pay for it.
Most of them have broached the idea of healthcare reform and at times have used it as a topic of debate. No one has given details, at least in the debates or press conferences, how it will be paid for. As I mentioned in an earlier post, any hybrid program is doomed to failure because of corporate greed on one hand vs government inefficiency on the other.
The only way a hybrid program would conceivably work is if there were strict regulation, much like there is in the utilities industry. Many of you may recall when the oil and airline industries were regulated and what happened to prices AFTER deregulation. The reason for the regulation in those industries at the time was because of a small number of corporation having control of a high demand product or service, an oligopoly.
The insurance industry is much like that today. While there are many smaller firms offering health insurance, the bigger players still have the lion's share of the market. The smaller outfits also can't offer comparable benefits to as many providers because many providers don't participate in smaller plans. It's simply not worth their time.
So, if the candidates are truly committed to healthcare reform that provides good benefits at a reasonable cost, I'm ready to listen. But, I want details.
Doc B
My opinion is free.
Advice is worth exactly what you pay for it.
Sunday, January 20, 2008
Your Doctor as Social Worker? Or "beam me up Scotty, there's no intelligent life here".
Most people assume that with the "MD" after your name it garners some form of respect, just because of the degree and expertise, the job you have to do. Maybe it did "in the day", but certainly no longer. Physicians are looked on with contempt; looked at as an easy target for a frivolous lawsuit; spends as much time pushing paper and doing social work as caring for patients. The social work aspect of practice is increasing at an alarming rate and is directly proportional to the change in the demographics of our hospital patient population. In other words, the poorer the patient, the more services have to be arranged for them after discharge.
Don't get me wrong. I don't mind helping people who need help, but the people who utilize these other services the most are the ones who "abuse" the services always. Take for example a member of the working poor who simply doesn't have health insurance. This type of patient worries about how long they will be in the hospital because of the hospital bill. They are anxious to get better so they can be discharged sooner. They are also the ones that ask "how much" their prescriptions cost and will ask if cheaper alternatives are available.
On the other hand we have the hard core professional patients. These are the ones with repeated admissions for the same problem. They hop from ED to ED and frequently get multiple prescriptions from several different doctors for, guess what, narcotics. They have developed their own specialized complaint that is difficult to disprove by exam or by laboratory study. If the ED doc believes the story or has never seen them before, they get admitted.
The admission isn't the bad part. It's the discharge. From the date they are admitted until discharge, and sometimes long afterward, they are consuming vast amounts of resources.
Here are some of my favorites;
A young woman admitted with stomach pain and maybe diarrhea, who likely has a mild case of stomach flu. Most of us would take care of it at home with fluids, acetaminophen and rest. She, of course needs large amounts of narcotics to control a pain we can't locate with any exam or test. No diarrhea during her stay in the hospital, either. Appetite seemed OK and she was out of her room smoking whenever someone was looking for her. After several days, she was discharged but refused to leave saying she had no where to go. We were amazed. She had a place when she was admitted.
The answer, of course, was simple but new to me. She and her mother lived together. During her hospital stay, the patient's boyfriend and mother decided to "hook up". Since mom thought it would create a problem with all of them living together, she decided to kick her daughter out, leaving her homeless. Needless to say, our social worker had to put her thinking cap on. Eventually the patient was given a cab voucher, a voucher for prescriptions and, with the assistance of the social worker, located a family member willing to take her in.
My best stories are the alcoholics. They party 24/7 with reckless abandon. That is until they truly get sick or run out of money. One such person came to us after having a case of the stomach flu of the month. His routine was to drink 12-18 beers per day, a few Long Island Iced Teas, a bottle of wine and whatever else he could get his hands on. During sporting events, he would have 7-8 beers at the game PLUS his usual at home. Where the hell do these guys get the money?
His family brought him in because he wasn't acting right. After talking to the family, I knew right away the guy was going through withdrawal. To be perfectly honest, I wish they had brought him in sooner. It would have been easier and safer to give him a drink and send him home than to let him detox and go through DT's. But that wasn't to be. He did go through withdrawal and he did go through DT's; for three weeks. He laid in our ICU, nearly unconscious, for three weeks. All because of alcohol. We are not a detox or treatment facility.
When he woke up, we sent him home because he refused outpatient treatment and didn't even want any information for any treatment programs. He'll be back.
Another of our alcoholic friends comes in often. Sometimes for falling down, sometimes for pain and sometimes just because he' s drunk and has no where else to go. One such night he came in sooooo inebriated, that after several hours of "sleep" he was still too dunk to go home. So, the ED admitted him. When he finally woke up, I discharged him. But before he would leave, he wanted another meal, another shower, a new change of clothes and new shoes. The hospital gave it to him and then we gave him a a cab voucher to get home. Should've given him the cab voucher in the first place.
One of our most infamous frequent fliers is a diabetic aged 20 years. She's had her diabetes long enough to know how to take care of the basics. That means that she should be able to keep herself out of the hospital. She splits her time between us and another hospital across town. She'll spend a few days with us, stay out 1-2 days then spend a few days with them. The cycle repeats. She comes in with Diabetic Ketoacidosis, the most severe and critical illness a Type I diabetic can have next to acute hypoglycemia (low blood sugar). It is always serious and often life threatening. She knows full well that she isn't taking her insulin like she's supposed to. Soon she's going to push it too far and die. She doesn't seem to care.
She always does well while she's with us meaning she's not the "brittle" diabetic people hear of. We always go over her insulin regimen, what to do when her sugars are high and refill all of her medicines when she's discharged. She also gets vouchers to get her meds refilled at the pharmacy. As often as she's gotten vouchers from us, she'll accumulate a year's supply in about 3 months.
The best of all, and the predictor of things to come, was a young man who presented to the ED with belly pain. He had fever, white count (sign of infection), nausea and right lower quadrant pain. First thing we all think of is appendicitis.The ED physician ordered a CAT scan which the radiologist read as acute appendicitis. This is a surgical diagnosis and he needed an operation. The surgeon on call came in, examined the patient, looked at the CAT scan and then went to talk to the young man's mother.
He introduced himself, explained what his exam, blood work and CAT scan showed, then proceeded to explain that her son needed surgery, an appendectomy. Her response was "You're wrong and I'm going to sue you!"
That doctor finished the surgery then took himself off of the call schedule for the ED. Another pair of skilled hands has bitten the dust.
Their stories differ a little but the theme is the same. I did this to myself; yes I'm still going to smoke; no I'm not taking my meds like I'm supposed to; no I'm not going to see the doctor you found for me;I came by ambulance, can I have a ride home; can I get my meds for free; can I stay another day; no I want the stronger pain pills; well, Dr. X will give them to me, why won't you; I'm going to sue.
And you all wonder why healthcare is in crisis; why more and more doctors are looking for a way out; why there are fewer applicants to Medical School; why costs are skyrocketing; why liability insurance premiums are outrageous?
Take a good look around. The finger of responsibility needs to be pointing back at the person looking in the mirror. The gravy train needs to be stopped before the whole thing derails.
Doc B
My opinion is free.
Advice is worth exactly what you pay for it.
Don't get me wrong. I don't mind helping people who need help, but the people who utilize these other services the most are the ones who "abuse" the services always. Take for example a member of the working poor who simply doesn't have health insurance. This type of patient worries about how long they will be in the hospital because of the hospital bill. They are anxious to get better so they can be discharged sooner. They are also the ones that ask "how much" their prescriptions cost and will ask if cheaper alternatives are available.
On the other hand we have the hard core professional patients. These are the ones with repeated admissions for the same problem. They hop from ED to ED and frequently get multiple prescriptions from several different doctors for, guess what, narcotics. They have developed their own specialized complaint that is difficult to disprove by exam or by laboratory study. If the ED doc believes the story or has never seen them before, they get admitted.
The admission isn't the bad part. It's the discharge. From the date they are admitted until discharge, and sometimes long afterward, they are consuming vast amounts of resources.
Here are some of my favorites;
A young woman admitted with stomach pain and maybe diarrhea, who likely has a mild case of stomach flu. Most of us would take care of it at home with fluids, acetaminophen and rest. She, of course needs large amounts of narcotics to control a pain we can't locate with any exam or test. No diarrhea during her stay in the hospital, either. Appetite seemed OK and she was out of her room smoking whenever someone was looking for her. After several days, she was discharged but refused to leave saying she had no where to go. We were amazed. She had a place when she was admitted.
The answer, of course, was simple but new to me. She and her mother lived together. During her hospital stay, the patient's boyfriend and mother decided to "hook up". Since mom thought it would create a problem with all of them living together, she decided to kick her daughter out, leaving her homeless. Needless to say, our social worker had to put her thinking cap on. Eventually the patient was given a cab voucher, a voucher for prescriptions and, with the assistance of the social worker, located a family member willing to take her in.
My best stories are the alcoholics. They party 24/7 with reckless abandon. That is until they truly get sick or run out of money. One such person came to us after having a case of the stomach flu of the month. His routine was to drink 12-18 beers per day, a few Long Island Iced Teas, a bottle of wine and whatever else he could get his hands on. During sporting events, he would have 7-8 beers at the game PLUS his usual at home. Where the hell do these guys get the money?
His family brought him in because he wasn't acting right. After talking to the family, I knew right away the guy was going through withdrawal. To be perfectly honest, I wish they had brought him in sooner. It would have been easier and safer to give him a drink and send him home than to let him detox and go through DT's. But that wasn't to be. He did go through withdrawal and he did go through DT's; for three weeks. He laid in our ICU, nearly unconscious, for three weeks. All because of alcohol. We are not a detox or treatment facility.
When he woke up, we sent him home because he refused outpatient treatment and didn't even want any information for any treatment programs. He'll be back.
Another of our alcoholic friends comes in often. Sometimes for falling down, sometimes for pain and sometimes just because he' s drunk and has no where else to go. One such night he came in sooooo inebriated, that after several hours of "sleep" he was still too dunk to go home. So, the ED admitted him. When he finally woke up, I discharged him. But before he would leave, he wanted another meal, another shower, a new change of clothes and new shoes. The hospital gave it to him and then we gave him a a cab voucher to get home. Should've given him the cab voucher in the first place.
One of our most infamous frequent fliers is a diabetic aged 20 years. She's had her diabetes long enough to know how to take care of the basics. That means that she should be able to keep herself out of the hospital. She splits her time between us and another hospital across town. She'll spend a few days with us, stay out 1-2 days then spend a few days with them. The cycle repeats. She comes in with Diabetic Ketoacidosis, the most severe and critical illness a Type I diabetic can have next to acute hypoglycemia (low blood sugar). It is always serious and often life threatening. She knows full well that she isn't taking her insulin like she's supposed to. Soon she's going to push it too far and die. She doesn't seem to care.
She always does well while she's with us meaning she's not the "brittle" diabetic people hear of. We always go over her insulin regimen, what to do when her sugars are high and refill all of her medicines when she's discharged. She also gets vouchers to get her meds refilled at the pharmacy. As often as she's gotten vouchers from us, she'll accumulate a year's supply in about 3 months.
The best of all, and the predictor of things to come, was a young man who presented to the ED with belly pain. He had fever, white count (sign of infection), nausea and right lower quadrant pain. First thing we all think of is appendicitis.The ED physician ordered a CAT scan which the radiologist read as acute appendicitis. This is a surgical diagnosis and he needed an operation. The surgeon on call came in, examined the patient, looked at the CAT scan and then went to talk to the young man's mother.
He introduced himself, explained what his exam, blood work and CAT scan showed, then proceeded to explain that her son needed surgery, an appendectomy. Her response was "You're wrong and I'm going to sue you!"
That doctor finished the surgery then took himself off of the call schedule for the ED. Another pair of skilled hands has bitten the dust.
Their stories differ a little but the theme is the same. I did this to myself; yes I'm still going to smoke; no I'm not taking my meds like I'm supposed to; no I'm not going to see the doctor you found for me;I came by ambulance, can I have a ride home; can I get my meds for free; can I stay another day; no I want the stronger pain pills; well, Dr. X will give them to me, why won't you; I'm going to sue.
And you all wonder why healthcare is in crisis; why more and more doctors are looking for a way out; why there are fewer applicants to Medical School; why costs are skyrocketing; why liability insurance premiums are outrageous?
Take a good look around. The finger of responsibility needs to be pointing back at the person looking in the mirror. The gravy train needs to be stopped before the whole thing derails.
Doc B
My opinion is free.
Advice is worth exactly what you pay for it.
Friday, January 18, 2008
How do I fnd a good Family Doctor?
Working as a Hospitalist means that I have no outpatient practice. Many of my patients ask me near the end of their hospital stay if I can be their Family Doctor. Of course, I don't have that type of practice and it would be a conflict of interest if I did. My patients have had the opportunity to "try before you buy", although we'd all rather it not be under the circumstances of a needed hospitalization. Nonetheless, how do you find a good Family Physician? Or any physician for that matter?
I always encourage people to seek out a physician that friends or family are happy with or speak of highly. The best referral is one that comes from someone with personal experience. You are able to ask questions about the office staff, billing procedures, nurses, and better yet, can ask exactly what the person thinks and feels about their doctor. Don't underestimate the power of public opinion.
If the doctor you would like to see isn't accepting new patients, a personal referral from one of the doctor's existing patients is an excellent way to try to get your foot in the door. The longer the referral has been a member of the practice, the more likely you are to get an appointment. That's also a good indicator that the person referring the doctor to you is satisfied with with that particular doctor. If you do get an appointment, make sure you mention that you were able to get an appointment because "patient x spoke highly of you and referred me to you". Everyone likes to hear feedback about how they are doing.
As far as surgeons go, some of the same rules apply. Referrals from previous or existing patients is key. Satisfaction with the pre-surgical consultation, surgery, if needed, and post operative care are all things you want to know.
One of the best, but sometimes confusing, key elements of selecting a surgeon are their reluctance to operate. I would rather that my surgeon explain all of my options, including no surgery at all.
And always NEVER be afraid to ask for a second opinion. The doctor should be confident enough in his/her examination and diagnosis that he/she would feel another physician would agree with his/her assessment. If your doctor gets upset that you ask for a second opinion, get a new doctor! I also like a doctor who isn't afraid to say "I don't know", but finishes their statement with "but I'll find out". To me that means they can acknowledge their limitations AND are interested in you and learning more.
And finally, when you do find a doctor you are satisfied with, be sure to refer other patients to them. Return the favor someone else gave to you.
Doc B
My opinion is free.
Advice is worth exactly what you pay for it.
I always encourage people to seek out a physician that friends or family are happy with or speak of highly. The best referral is one that comes from someone with personal experience. You are able to ask questions about the office staff, billing procedures, nurses, and better yet, can ask exactly what the person thinks and feels about their doctor. Don't underestimate the power of public opinion.
If the doctor you would like to see isn't accepting new patients, a personal referral from one of the doctor's existing patients is an excellent way to try to get your foot in the door. The longer the referral has been a member of the practice, the more likely you are to get an appointment. That's also a good indicator that the person referring the doctor to you is satisfied with with that particular doctor. If you do get an appointment, make sure you mention that you were able to get an appointment because "patient x spoke highly of you and referred me to you". Everyone likes to hear feedback about how they are doing.
As far as surgeons go, some of the same rules apply. Referrals from previous or existing patients is key. Satisfaction with the pre-surgical consultation, surgery, if needed, and post operative care are all things you want to know.
One of the best, but sometimes confusing, key elements of selecting a surgeon are their reluctance to operate. I would rather that my surgeon explain all of my options, including no surgery at all.
And always NEVER be afraid to ask for a second opinion. The doctor should be confident enough in his/her examination and diagnosis that he/she would feel another physician would agree with his/her assessment. If your doctor gets upset that you ask for a second opinion, get a new doctor! I also like a doctor who isn't afraid to say "I don't know", but finishes their statement with "but I'll find out". To me that means they can acknowledge their limitations AND are interested in you and learning more.
And finally, when you do find a doctor you are satisfied with, be sure to refer other patients to them. Return the favor someone else gave to you.
Doc B
My opinion is free.
Advice is worth exactly what you pay for it.
Wednesday, January 16, 2008
You expect your Doctor to feel your pain. Do you feel theirs?
When most people go to see the Doctor, it's because something is wrong. And when something is wrong, you expect the person you tell to have some compassion and empathy for your discomfort and vulnerability. You expect that from your Doctor and when you don't get it, you feel put off, upset and have no problem telling everyone "what a jerk" your Doctor is. Some may resort to going to someone else.
People admitted to the hospital are much more vulnerable. At times they may be so ill that they are unable to communicate or speak for themselves. If no family is available, your Doctor acts as your advocate, making potential life or death decisions for you. In situations like these your Doctor may make those decisions by imagining "What would I do if this were a member of my own family?" Your Doctor is feeling your pain. Who feels your Doctor's pain?
Contrary to popular belief, the traditional Hippocratic oath doesn't say "First, do no harm". The original oath can be read here; http://www.pbs.org/wgbh/nova/doctors/oath_classical.html. It also dosen't say that a Doctor cares for others at the expense of himself or his family. But in fact, many of us have done just that.
When inclement weather keeps other people from traveling, or a "snow emergency" looms at dawn, illness occurs in the family or work force, some still carry out their duties. Among them are paramedics, policemen, nurses and Doctors. I, myself, have gone to work with a 104 fever from flu to take care of people MUCH less ill than I was. But, I didn't give it a second thought. In over 20 years, I've only missed one day of work. We have become civil servants, expected to be at a certain place at a given time.
How many of you would have left your family during an emergency to go down the street to take care of your neighbor? And have that neighbor express no appreciation for the fact that you chose them over your own family? Patients don't think that way.
My family has sacrificed more than I can ever repay them for. I've missed my kid's birthdays, first steps, lost teeth, school dances and plays, family vacations, not been there to take care of them when they were sick. Left my wife by herself to deal with house and home, kids, family and urgent issues. There were times I was so detached, I didn't appreciate the fact that things were still running smoothly when I did get home. I don't have to deal with things that run "smooth" so that didn't catch my attention. My oldest son wouldn't give it a second thought if I said I had to go to take care of a patient while talking to him on the phone, even if he was talking to me about a concern with one of his children; my grandchildren. "I'll have to call you back". My wife isn't my wife anymore either.
How many of you get phone calls in the middle of the night that aren't a wrong number? How many times have you been out to a movie, tried to attend a dinner party, a picnic, a day at the pool, cutting your grass, planting flowers with your kids or spouse, etc., and had to stop (and possibly leave) because you were "on call"?
Can I or my colleagues regret the attention we have given to our patients? Do I regret the countless patient encounters, the lives I have literally saved myself? How much different would the world be today if we didn't do what we do?
I think most of us would just like to hear "thank you" a little more often. And maybe, not have to take care of sooooooo many people who are abusing the system and making us all way too cynical.
So the next time you visit your Doctor's office, they answer a call after hours or weekends, or you're looking up at them as you recover from an illness in the hospital, remember who and what they left behind to take care of you.
Thank YOU for listening.
Doc B
My opinion is free.
Advice is worth exactly what you pay for it.
People admitted to the hospital are much more vulnerable. At times they may be so ill that they are unable to communicate or speak for themselves. If no family is available, your Doctor acts as your advocate, making potential life or death decisions for you. In situations like these your Doctor may make those decisions by imagining "What would I do if this were a member of my own family?" Your Doctor is feeling your pain. Who feels your Doctor's pain?
Contrary to popular belief, the traditional Hippocratic oath doesn't say "First, do no harm". The original oath can be read here; http://www.pbs.org/wgbh/nova/doctors/oath_classical.html. It also dosen't say that a Doctor cares for others at the expense of himself or his family. But in fact, many of us have done just that.
When inclement weather keeps other people from traveling, or a "snow emergency" looms at dawn, illness occurs in the family or work force, some still carry out their duties. Among them are paramedics, policemen, nurses and Doctors. I, myself, have gone to work with a 104 fever from flu to take care of people MUCH less ill than I was. But, I didn't give it a second thought. In over 20 years, I've only missed one day of work. We have become civil servants, expected to be at a certain place at a given time.
How many of you would have left your family during an emergency to go down the street to take care of your neighbor? And have that neighbor express no appreciation for the fact that you chose them over your own family? Patients don't think that way.
My family has sacrificed more than I can ever repay them for. I've missed my kid's birthdays, first steps, lost teeth, school dances and plays, family vacations, not been there to take care of them when they were sick. Left my wife by herself to deal with house and home, kids, family and urgent issues. There were times I was so detached, I didn't appreciate the fact that things were still running smoothly when I did get home. I don't have to deal with things that run "smooth" so that didn't catch my attention. My oldest son wouldn't give it a second thought if I said I had to go to take care of a patient while talking to him on the phone, even if he was talking to me about a concern with one of his children; my grandchildren. "I'll have to call you back". My wife isn't my wife anymore either.
How many of you get phone calls in the middle of the night that aren't a wrong number? How many times have you been out to a movie, tried to attend a dinner party, a picnic, a day at the pool, cutting your grass, planting flowers with your kids or spouse, etc., and had to stop (and possibly leave) because you were "on call"?
Can I or my colleagues regret the attention we have given to our patients? Do I regret the countless patient encounters, the lives I have literally saved myself? How much different would the world be today if we didn't do what we do?
I think most of us would just like to hear "thank you" a little more often. And maybe, not have to take care of sooooooo many people who are abusing the system and making us all way too cynical.
So the next time you visit your Doctor's office, they answer a call after hours or weekends, or you're looking up at them as you recover from an illness in the hospital, remember who and what they left behind to take care of you.
Thank YOU for listening.
Doc B
My opinion is free.
Advice is worth exactly what you pay for it.
Saturday, January 12, 2008
Universal Healthcare? We already have it!
The hot topic in the last several presidential elections has always centered around the same or similar issues; the economy, international affairs/terrorism and healthcare. The Clintons made healthcare such a large issue that Hilliary had to take that bull by the horns herself. Unfortunately, the bull drug her into the dirt. That's a beast that needs Paul Bunyan to bring it down.
Now more than ever before, the issue of healthcare, specifically "universal healthcare", is one of the most discussed topics. The news is rife with stories about the increasing number of uninsured who have no access to healthcare. More and more corporations that used to provide health insurance benefits to their employees, are more often opting for insurance plans that offer fewer benefits with larger deductibles and copays. The employees are paying more for their coverage than ever before. Medicare recipients have also seen their deductibles and copays increase. The bottom line is that the patient is becoming responsible for their own healthcare.
The government has already enacted legislation that insures that everyone has access. It may not be cheap, efficient or cost-effective, but it is access just the same. From Medicare to Medicaid and "anti-dumping" laws, the government has assured you of access.
Take for example a person who works at a fast food restaurant, has no employer sponsored health insurance and can barely afford to live from paycheck to paycheck. What do these people do when they need care? They visit their local Emergency Room (ER). Because of government legislation initially designed to address patient "dumping" (sending a patient away that may not have had the ability to pay, to a public hospital), we now have created the largest, most inefficient and expensive clinic system in the US. No one who presents themselves to the Emergency Room can be turned away. The ER is required by law, to "evaluate and stabilize" that patient, regardless of the trivial nature of their complaint.
In my own personal experience, a typical day in the ER consists of truly ill people needing emergency care. But intermixed in this group are a large number of patients with these bullsh*t conditions; overdose on illegal street drugs; an alcoholic, currently intoxicated, who ran out of money and is afraid of going into withdrawal; a woman and ALL of her family who have a cold, called 911 and came by ambulance; a return visit for another STD; drug seekers who go from hospital to hospital looking for narcotics; a felon trying to get admitted to the hospital to keep from going to jail; "I ran out of my meds and I need a refill"; "I didn't get my prescription filled that you gave me two days ago and now I'm worse"; alcoholics who develop pancreatitis because they drink too much; illegal aliens; etc.
Guess what? NONE of those people have insurance and NONE of them will pay their bill. This is what happens every day in every ER in the country. The numbers of these patients increases every year. They have free access and so does everyone else. So why is everyone complaining? The government isn't paying for them. The insurance companies aren't paying for them. The politicians aren't paying for them. Do you know who IS paying for them? You are. The hospitals are. The doctors are.
The government doesn't pay. The budget reconciliation act demands that Medicare payments be frozen. All they do now is change the slices of the pie, the pie stays the same size. The insurance companies simply increase premiums and decrease your benefits while they decrease payments to doctors and hospitals. When was the last time a health insurance company went bankrupt, didn't show a profit or didn't pay a bonus to their executives (I buy stock in insurance companies as a way to get some of my money back)? The politicians in Washington certainly aren't paying for it. We pay their salaries, staff and benefits with our taxes. They have one of the richest benefit plans (including health insurance) that you could imagine.
You pay for it by paying higher premiums, deductibles and copays. Hospitals have no choice but to pass those expenses on to the paying patients. Doctors pay because they are providing free care. They also have to have health insurance just like everyone else. And believe it or not, the lovely patients I described above are also more likely to file a frivolous lawsuit. Can anyone say "lottery"?
Everyone has access to healthcare, if they need it. Unfortunately, the people who routinely take advantage of that privilege are the ones who have learned to manipulate the system with petty, self-abusive, self-inflicted diseases and not the working stiff who deserves a break.
What a shame.
Doc B
My opinion is free.
Advice is worth exactly what you pay for it.
Now more than ever before, the issue of healthcare, specifically "universal healthcare", is one of the most discussed topics. The news is rife with stories about the increasing number of uninsured who have no access to healthcare. More and more corporations that used to provide health insurance benefits to their employees, are more often opting for insurance plans that offer fewer benefits with larger deductibles and copays. The employees are paying more for their coverage than ever before. Medicare recipients have also seen their deductibles and copays increase. The bottom line is that the patient is becoming responsible for their own healthcare.
The government has already enacted legislation that insures that everyone has access. It may not be cheap, efficient or cost-effective, but it is access just the same. From Medicare to Medicaid and "anti-dumping" laws, the government has assured you of access.
Take for example a person who works at a fast food restaurant, has no employer sponsored health insurance and can barely afford to live from paycheck to paycheck. What do these people do when they need care? They visit their local Emergency Room (ER). Because of government legislation initially designed to address patient "dumping" (sending a patient away that may not have had the ability to pay, to a public hospital), we now have created the largest, most inefficient and expensive clinic system in the US. No one who presents themselves to the Emergency Room can be turned away. The ER is required by law, to "evaluate and stabilize" that patient, regardless of the trivial nature of their complaint.
In my own personal experience, a typical day in the ER consists of truly ill people needing emergency care. But intermixed in this group are a large number of patients with these bullsh*t conditions; overdose on illegal street drugs; an alcoholic, currently intoxicated, who ran out of money and is afraid of going into withdrawal; a woman and ALL of her family who have a cold, called 911 and came by ambulance; a return visit for another STD; drug seekers who go from hospital to hospital looking for narcotics; a felon trying to get admitted to the hospital to keep from going to jail; "I ran out of my meds and I need a refill"; "I didn't get my prescription filled that you gave me two days ago and now I'm worse"; alcoholics who develop pancreatitis because they drink too much; illegal aliens; etc.
Guess what? NONE of those people have insurance and NONE of them will pay their bill. This is what happens every day in every ER in the country. The numbers of these patients increases every year. They have free access and so does everyone else. So why is everyone complaining? The government isn't paying for them. The insurance companies aren't paying for them. The politicians aren't paying for them. Do you know who IS paying for them? You are. The hospitals are. The doctors are.
The government doesn't pay. The budget reconciliation act demands that Medicare payments be frozen. All they do now is change the slices of the pie, the pie stays the same size. The insurance companies simply increase premiums and decrease your benefits while they decrease payments to doctors and hospitals. When was the last time a health insurance company went bankrupt, didn't show a profit or didn't pay a bonus to their executives (I buy stock in insurance companies as a way to get some of my money back)? The politicians in Washington certainly aren't paying for it. We pay their salaries, staff and benefits with our taxes. They have one of the richest benefit plans (including health insurance) that you could imagine.
You pay for it by paying higher premiums, deductibles and copays. Hospitals have no choice but to pass those expenses on to the paying patients. Doctors pay because they are providing free care. They also have to have health insurance just like everyone else. And believe it or not, the lovely patients I described above are also more likely to file a frivolous lawsuit. Can anyone say "lottery"?
Everyone has access to healthcare, if they need it. Unfortunately, the people who routinely take advantage of that privilege are the ones who have learned to manipulate the system with petty, self-abusive, self-inflicted diseases and not the working stiff who deserves a break.
What a shame.
Doc B
My opinion is free.
Advice is worth exactly what you pay for it.
Thursday, January 10, 2008
THE DOCTOR IS IN
Hi and welcome. First , as an introduction, I'm a practicing physician in the Midwest. I considered doing this blog as a way to vent, and as away to give my opinion on a variety of subjects related to medicine. They are many and varied. Whether it is the uninsured, the use of our Emergency Departments as clinics, illegal aliens using our limited healthcare resources, socialized medicine, managed Medicaid, Medicare, commercial health insurers, choosing a family doctor, second opinions, etc. You name it, I've either seen it, been involved in it or know someone who has.
I also want to make it clear from the beginning that this blog IS NOT intended to give anyone medical advice. What you will see is my personal opinion on whatever subject I happen to be writing about. I may address the flu for example, but I will not tell anyone how to treat it. I will tell you how I treat myself and my family. You can do with it what ever you choose.
Most topics in medicine, like religion and politics, generate great debate and emotional response. The reason is that medicine and medical care are so personal to so many people. We all know someone who has been ill, is ill, died after an encounter with the health care system, or heard about someone who can't get the care they need. The cost of health care continues to rise, our deductibles and copays continue to increase but our benefits are withering away. What is the answer?
A growing number of people, common folk and politicians, are leaning toward socialized medicine. That mean that the government would be responsible for funding healthcare for the entire populous of the US. The government has done such a great job with Medicare, right?
I was always opposed to socialized medicine, not because of an issue of my personal income, but because of the government's record for waste and inefficiency. Now, things are getting so bad that I would consider supporting some form of socialized medicine, if it could be operated efficiently, cost-effectively and truly takes care of the people who depend on it; the patients.
My greatest concern is that the healthcare lobby in Washington is soooooo strong that Congress will bastardize any true attempt at socializing medicine and continue to allow the greedy SOB insurers to operate "business as usual". You can't have it both ways. Insurers are too greedy to have their cash cows taken from them. The government can't socialize medicine UNLESS the insurers relinquish their control over the lives they insure, their bread and butter. It won't happen in my lifetime, so that means a "hybrid" system that will be expensive, inefficient and of NO additional benefit to patients.
Great ready. Things are not going to get better any time soon.
Doc B
My opinion is free.
Advice is worth exactly what you pay for it.
I also want to make it clear from the beginning that this blog IS NOT intended to give anyone medical advice. What you will see is my personal opinion on whatever subject I happen to be writing about. I may address the flu for example, but I will not tell anyone how to treat it. I will tell you how I treat myself and my family. You can do with it what ever you choose.
Most topics in medicine, like religion and politics, generate great debate and emotional response. The reason is that medicine and medical care are so personal to so many people. We all know someone who has been ill, is ill, died after an encounter with the health care system, or heard about someone who can't get the care they need. The cost of health care continues to rise, our deductibles and copays continue to increase but our benefits are withering away. What is the answer?
A growing number of people, common folk and politicians, are leaning toward socialized medicine. That mean that the government would be responsible for funding healthcare for the entire populous of the US. The government has done such a great job with Medicare, right?
I was always opposed to socialized medicine, not because of an issue of my personal income, but because of the government's record for waste and inefficiency. Now, things are getting so bad that I would consider supporting some form of socialized medicine, if it could be operated efficiently, cost-effectively and truly takes care of the people who depend on it; the patients.
My greatest concern is that the healthcare lobby in Washington is soooooo strong that Congress will bastardize any true attempt at socializing medicine and continue to allow the greedy SOB insurers to operate "business as usual". You can't have it both ways. Insurers are too greedy to have their cash cows taken from them. The government can't socialize medicine UNLESS the insurers relinquish their control over the lives they insure, their bread and butter. It won't happen in my lifetime, so that means a "hybrid" system that will be expensive, inefficient and of NO additional benefit to patients.
Great ready. Things are not going to get better any time soon.
Doc B
My opinion is free.
Advice is worth exactly what you pay for it.
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