Grand Rounds Is Up

Dr. Deb, my favorite blogging psychologist, hosts this week's best of the medical blog-o-sphere with an iPod theme, tho' there were no podcasts that I could find...

-Wes

Where Has All the Money Gone?

I heard this on the radio this morning:

On the 10th anniversary of the $246 billion settlement, the Campaign for Tobacco Free Kids has done an analysis of where the money's been going.

The group's Danny McGoldrick says only 9 states are funding tobacco prevention programs at even half the recommended federal level.

Illinois, he says, is near the bottom of the list. It ranks 43rd, spending just $9.5 million dollars of its $900 million share of the settlement on smoking prevention programs this year.

Seems we know the answer:

"...the states are expected to face significant budget shortfalls in the coming year as a result of the weak economy. The last time the states faced budget shortfalls, they cut funding for tobacco prevention programs by 28 percent between 2002 and 2005. The cutbacks are a major reason why smoking declines subsequently stalled..."

Talk about "spreading the wealth." I just hope it's not short-sighted.

-Wes

Reference: See the full report (pdf).

First Snow

Click to enlarge

The first dusting came last night, much too early in my book.

-Wes

Proof that Cardiologists Are Under Pressure

Some are resorting to selling vitamins:

(Medscape - subscription required) "As cardiologists' income has been declining, we've seen a trend toward adding ancillary services," says Patrick White, president of MedAxiom, a cardiology practice management and information services firm in Neptune Beach, Florida. "I've seen cardiologists starting to do laser vein therapy and selling vitamins," says White. "But these are likely to divert their energies. Instead, they should focus on their core mission."

In 2007, the median total medical revenue for cardiology practices decreased 0.61%, while median operating costs increased 6.3%, according to the Medical Group Management Association's (MGMA) 2008 Cost Survey Report."

-Wes

MRI-safe Pacemakers Are Coming

Really. But not quite yet in the US.

-Wes

Why Hospitals Like Robin Hood Economics

As specialists are threatened with declining revenue streams as our government Robin Hood compadres shift payments from specialists to primary care in the interest of "lowering costs," why aren't hospitals who have profitted handsomely from the high-tech procedures performed by specialists stepping up to stem the bloodletting?

I believe it's because the model for primary care medicine has changed dramatically over the last five to ten years. Primary care, as we know it now, isn't the all-encompassing primary care model that it once was in years gone by. No longer is it the norm for a primary care doctor to follow their patients in the hospital. Regretfully, the payments to doctors for the time spent have dwindled to the point where doctors have to stay in their offices to treat more and more patients in less and less time and resort to turning over their soon-to-be inpatients to "hospitalists" to manage them in the hospital.

They are turned over today to young, eager, relatively cheap hospitalists fresh out of their internal medicine residency. The same hospitalists who are often hired by hospitals because they order lots of tests and decrease the patient's length of stay. The same hospitalists whose salaries are typically subsidized by the hospitals. And the hospitals are eager to keep their hospitalists happy because they need even more consults and tests performed whose technical revenues exceed professional revenues by about ten to one.

Physician salaries are a relatively small piece of the health care cost pie.

So shifting payments might be a pretty good return on investment for hospitals: watch the specialists' salaries decline and shift funds to the hospitalists (your employees or employees in proxy) as you earn more for them and lots more for you.

I guess that's why they're in business and I'm in medicine and hospital leadership can gloat over a $2.25 million a year in a place with relatively low cost of living, justifying that income because "I'm a poor kid from a mill town. My father graduated from high school, and my mother didn't. And so it is a lot."

Wow.

-Wes

Overvalued

"The Baucus plan would seek a continued focus on the high value of primary care-related services, with corresponding reductions in relative values for overvalued services."

"To avoid cost inflation, this proposal should be made budget-neutral. Budget-neutral changes to Medicare payments mean that any increase to primary care providers requires a corresponding cut to specialist services. This approach has the potential to create significant controversy among physicians, however. Any reforms along these lines must be crafted in collaboration with the entire physician community and other practitioners to ensure appropriate valuation of, and access to, primary care services."

- White paper from the Chairman of the Senate Finance Committee, Senator Max Baucus (D. Mont)

Any appreciation for one's skill level and years of experience: overvalued.

Requiring five additional years of subspeciality training: overvalued.

Being paid well below what generalists were making during those five additional years of training: overvalued.

Requiring two more recertifications every 10 years and the expenses incurred for continuing medical education credits to permit sitting for those boards: overvalued.

Performing truly curative procedures, rather than palliating them with medications for a person's lifetime: overvalued.

Being paid the same for a four to five hour case as a two-hour case: overvalued.

Focusing on the already-failed experiments of PQRI and "wellness" and "preventative" initiatives that have bloated our bureaucracy and failed to have any positive return on investment: undervalued, so please, let's do more.

Yeah, I see where this is going...

-Wes

P.S.: Could someone explain to me why the good Senator's white paper sounded so much like the one from these guys?

Nerds Are Hip Now

Thanks to the crash of Wall Street recently, it seems it's becoming hip to be an engineer:

As the financial crisis deepens, science and math graduates of top colleges and universities who once flocked to investment banking are now looking to jobs in engineering and technology.

Maybe. But having taken a biomedical engineering tract before medical school, I can attest that my lab partners NEVER looked like that...

-Wes

Colbert and Jupiter

If you haven't seen this spoof by Stephen Colbert, D.F.A. (Doctor of Fine Arts) regarding the latest cardiovascular news concerning issues related to women's health, CPR, and the Jupiter trial, trust me, it's worth it:



Hilarious.

-Wes

h/t: Kevin MD

Who's More Important?

What do you think: who's more important, trial lawyers or doctors?

I think I know who's more narcissistic.

-Wes

h/t: Overlawyered.com

The Harsh Reality

Daniel Callahan explains his position on rationing health care for the elderly: is 80 years of age where we draw the line?

There are in the end only two decisive ways to control Medicare costs: raise taxes, cut benefits, or both. Neither political party is game to raise taxes, for Medicare or anything else. As for cutting benefits, Congress this year voted for $20 billion in new expenditures, ignoring the need for frugality.

Yet there is nothing of importance left to do other than to reduce benefits. That move would mean denying elderly patients both what they might want and need. Or are there some less draconian alternatives? A long-standing refrain of many older people is that much money could be saved if they were more easily free — by living wills or the appointment of surrogates — to turn down expensive life-prolonging measures of dubious benefit. Maybe so, but some studies have shown that would not make much economic difference in an overall Medicare budget of hundreds of billions.

More important, despite what they say in advance, many elderly people will in fact choose to be aggressively treated for a critical illness even when there is a good chance it will not save them — but just might. Doctors endlessly complain to me that excessive patient expectations of medical miracles, or those of their family members, make it harder, not easier, these days to curtail aggressive treatment. Not all of us can resist the lure of a slightly longer life, despite what we may have said in advance.

Ninety seems like a safer bet to be palatable right now than eight as an age limit, but his points are worth pondering.

-Wes

Who Knew? History's Important

I am shocked, SHOCKED I tell you, to find that taking a history from a patient is important:

However, almost half of all coronary "events", such as heart attacks, that happened during this period, happened in patients whose ECG results had not shown any sign of problems.

A routine clinical assessment, which involved taking a detailed "history" from the patient, and examining them thoroughly, was almost as good in predicting future heart disease as the exercise ECG.

The researchers concluded that the tests were "of limited value" to doctors faced by patients with no prior heart disease.

Dr Mike Knapton, from the British Heart Foundation said that while early diagnosis of angina was important, the study showed that the best way to achieve that was to talk to the patient.

Who knew?

-Wes

Talking Sense

Ben Brewer, MD lays out his proposal to treat our health care crisis:

Looking at the way the government is doling out money these days, I have a proposal to help improve people's health and our system of care. What if the government gave each person $365 of their tax money back to be spent on primary health care?

That amount could be paid directly to each person's primary care doctor for a year's worth of services. Imagine if everyone in America could contract privately for medical care for themselves with a primary care doctor without government or insurance company red tape.

The patient would choose the doctor. The basket of services would be predefined, and the price would be locked in for a year, paid as a monthly subscription like cellphone service or movie rentals.

Money spent that way would cover a lot of preventive health, office visits, management of chronic diseases, email contact with the doctor, and after-hours advice. Make it tax deductible for individuals as well as businesses.

Doctors like the idea of universal coverage, but don't like the idea of unfunded mandates, like some programs to improve quality that cost physicians more to implement than can ever be recouped.

They don't want to be conscripted into a national program that pays them less than their costs. They don't see Medicaid or Medicare for all as solutions because those systems skimp on primary care and impose crushing paperwork and regulation.

But it seems to me that it is time to get beyond the argument of whether health care is a right or a privilege. We need to do something practical to bring affordable, basic health care to working people. Primary care isn't cheap, but it's less expensive than any other option.

We have had a financial stimulus package. My patients spent their $600 checks on $4 gas to get to work. A better and longer-lasting use of the money would be a health-care stimulus package.

The attraction for the doctor would be no billing hassles, no massive insurance coding system, no extensive overhead, and no bogus pay-for-performance schemes that cost more than they save. The infusion of money would also bolster primary care and might make it more attractive to new doctors over the long haul.

For primary care doctors, a $1 per patient per day would make for reasonable income from a smaller group of patients than most of see now. Patients would get more time with their doctor when they need it. There would be fewer office visits just so the doctor can get paid for giving advice.

Is his idea so far fetched?

I don't think so.

And yet, make no mistake, the push back will be substantial from those who benefit from the bureaucracy.

I am aware that even large physician groups such as ours, already equipped with the latest electronic gadgetry to track pay-for-performance initiatives, in their zest to go "all in" on the concept to earn their "gold stars" on the government's pitiful quality website (which is rarely consulted by patients, by the way), failed to cover the cost of implementing the initiative its first year. It's been just too many personnel, spending too many precious resources to gather data of limited value, rather than applied to the delivery of health care. (If you want to see just how bad it's become, check out the specifics over at the Happy Hospitalist.) This initiative has been a colossal failure in my book, but sold lock, stock and barrel to the populous by the policy wonks on Capital Hill.

So I can hear it now: "What will happen to all of those people paid to collect the data? They might become unemployed at this time of our colossal economic downturn! Our unemployment numbers will go up! We can't have that!"

Please.

We cannot afford NOT to make a significant change to the way we do health care today. I am convinced as Americans consider the options ahead of them, that they'll make the right choice and realize the consequences if they don't. Dr. Brewer's proposal makes a lot of sense.

After all, managing our own cash is looking pretty good right now.

-Wes

Vasectomy Zoning

No wonder public schools like it:

But the popularity of "kids-free" communities also adds an interesting wrinkle to the debate over Illinois' school-aid formula.

Recent protests at two North Shore schools spotlighted the high property tax price that residents of some suburbs pay per student.

The housing shift is not confined to the Chicago area. A few years ago, officials in suburban Boston approved so many age-restricted developments that a state legislator decried the practice as "vasectomy zoning."

(Sorry, couldn't resist linking to this, but it's an interesting use of a medical term...)

-Wes

Here It Comes

My favorite line in this New York Times article on the proposal being placed before Congress to guarantee health care for all:

"Other Democrats with deep experience in health care are also drafting proposals to expand coverage and slow the growth of health costs."

Does anyone else find that line as ridiculous as I do?

-Wes