Mad About Medicine

Amende Honorable

2008-05-03T18:06:00.005-04:00

Formal apology for an injury to the reputation and honour of another.

In old French law the term was once used to describe a public confession made by persons guilty of crimes coming under the head of public scandals, and was accounted an infamous punishment.
The Free Dictionary by Farlex

AMENDE HONORABLE - Ob. English Law. A penalty imposed upon a person by way of disgrace or infamy, as a punishment for any offence, or for the purpose of making reparation for any injury done to another, as the walking into church in a white sheet, with a rope about the neck, and a torch in the hand, and begging the pardon of God, or the king, or any private individual, for some delinquency.
-The 'Lectric Law Library's Lexicon

I think it is about time to come clean. I am sorry. Since the entire medical establishment has failed to apologize to all of you patients I will take it on my shoulders and do it. Amende honorable.

I would add that I am not alone because we all are responsible for the colossal mess that health care is in- not only in America but in the world. We are seeing an unprecedented decline in integrity and respect for quality care. All we can do now is beg the pardon of whoever will listen. No one is actually listening to solutions offered so maybe an apology will get some attention. The crimes against medical humanity have been so egregious that there are no laws, no punishment strong enough- we must look to a higher power and simply grant forgiveness.

Forgive the insurance companies for:

Negatively affecting more people in a day than the Civil War did in 5 years by denying care to patients who needed it.
Delaying care through tedious and unnecessary barriers to care such as precertification of tests.
Calling regular treatments like bone marrow transplants "experimental" so they can just avoid payments.
Taking money from the health care system and calling it earned profits when the only thing that was earned was encouraging patients to purchase insurance policies.
Hiring executives with no hearts (a modern medical miracle I assume but I guess that a heart can be replaced by another body part and the organism can still live). Executives who make decisions like making chemicals for heparin in China where the FDA has no regulatory control and possibly causing the deaths of four Americans.

Forgive the drug companies and device manufacturers for:

Telling us we may be sicker than we are and might need all their products all the time.
Downplaying valuable medical data that is not supportive of their products
For not using some of their gargantuan profits to offset the price of medications for those who can’t afford them
Gross irresponsibility to the international community, especially Africa who needs their help in the worst way.

Forgive the government officials (President, VP, Senator, Congressmen, etc) for:

Being totally beholden to the insurance and drug company lobbies
For not having the guts to do meaningful malpractice reform
For not having the brains to develop meaningful healthcare insurance reform

But do not forgive the candidates yet. They have yet to wreak their havoc. Give them time. By the way, I think what they say in the campaigns about health care reform is an empty promise. They won’t do it. The smart money says no way.

Forgive the hospitals for:

Attracting the rich payers and clients and ignoring the time-honored tradition of caring for the poor
Hiding their errors and mistakes from public view
For not fixing their broken emergency rooms

Forgive the physicians for:

Not taking control of health care away from the government and the insurance companies. In our zest for profit and immediate gain we have lost our way. Starting with the early pay-for-service insurance plans the early Medicare program that made a generation of doctors wealthy and the next generation searching for the holy grail of greed we have gotten totally caught up in medicine for money
Advertising false claims of cures with all sorts of non-evidence based medicine
The ill-will that doctors have towards their colleagues and the negatives things they say about each other
Allowing the drug companies to infiltrate our offices and our minds and convince us to prescribe a billion dollars worth of medicines that are mostly unnecessary
Hopping on the bandwagon of every next great advance - not because it helps the patients but because it helps our pockets.
Prescribing unnecessary tests and treatments at facilities that we have ownership in like MRI facilities in our offices or physician-owned physical therapy.

Forgive the patients for:

Blindly getting their health information from the Internet with no regard for the source.
Doubting that the doctors actually do know better than their neighbor, friend, and especially their insurance company.
Thinking that it is the doctors and not the insurance companies that are to blame for our health crisis.

So we all must look to a higher power and ask forgiveness for this health care system we have.
To quote one of the greatest of philosophers:

"Well, here's another nice mess you've gotten me into"
-Oliver Hardy

Dr. K

Related Topics:

Crisis Ahead for Elderly Health Care?
How States Rank on Health Care

Technorati Tags: heathcare, reform

Doctors & Money: The Last Three Piggies

2007-12-26T04:13:00.000-05:00

Roast Beef, Bankruptcy, and Happiness

To round out our group of Piggies I thought that the last three sort of go together. These three Piggies may very well be at the center of how doctors are actually behaving and may give us all some insight into the future of how we will all get our healthcare in the coming years.

The Beef Eaters: Who really is the Piggy that had roast beef?

While much of the public tries to grasp onto the erroneous idea that all doctors do extraordinarily well financially this is clearly not the case. This I showed in the first Piggy that went to market. Read that. Twice. There are many doctors who do VERY well financially, though. We can define the financial winners (roast beef eaters) into three groups:

The doctors that work their butts off 90 hours a week and run efficient offices.

The doctors who are in specialties that are more involved in cosmetic aspects of medicine who built large factories of delivery of cosmetic care.

The doctors who decided to remove themselves from all insurance plans and charge high rates for their services.

I am sure there are more groups but these represent the majority. Please feel free to blog on some more.

Let's look at these three groups not as much to make value judgments but to see if we can learn something from their effects on health care in general and our own health in particular.

I know many doctors who work very long hours, take a healthy number of health plans to assure diversity in their patient population and commitment to their community, charge reasonable rates for patients in plans they choose not to take and run the best offices they can. Take pictures of these doctors the next time you see them. Put them in the next space capsule so that future generations will know who they were. They are dead and but they don't know it yet. They will not be coming back. Count on seeing a Tyrannosaurus Rex before you see one of these dudes walking down the hall.

The cosmetic doctors and surgeons are neither doctors nor surgeons IF they are practicing their craft for the sake of vanity. Don't even try to convince me that they are doing anything good in the world concerning the self-image of those they operate on. That motivation affects less than 5% of plastic surgeons. The other 95% are hairdressers with licenses to hold scalpels instead of barber shears. They will make a lot of money (and eat a lot of roast beef) because we are a society consumed by youth and beauty. They are not surgeons. They just don't count when discussing medicine. End discussion. I laugh when I hear of a prominent Hollywood Plastic Surgeon. What a joke. Prominent for what? Saving lives - NOT. Helping the health of others - NOT. Making some already fathead actress have even puffier lips. If we define prominence based on that we are surely are on the road to perdition.

There is a third group that is more controversial and represents those most difficult aspects of the money crisis facing doctors. These are doctors who truly do outstanding medicine and surgery and decide to be out of all insurance plans and charge what they feel they should get for their services. This is difficult in that on the one hand I highly support their personal choices to charge what they want for their services. The problem is that, over time, only a select few in the population will be able to afford them. This means the truly best and the brightest will be treating rich people from Beverly Hills and Park Avenue and no one else.

Let's make this clear. The fault is not in the talented doctors that want to charge what they choose to but rather in that we do not have an insurance system that can even pay a pediatrician for a flu vaccine in a timely manner let alone complex brain surgery. This third group is the one that is growing most rapidly.

As general physicians, specialists and surgeons get more in demand it is only natural they will leave the insurance plans that offer below market pay, extra paperwork, and interference with decision making. This group will continue to grow and what will be left you will not want to operate on your worst enemy. It is already happening. If you are a patient in one of these large multi-medical groups that mixes primary care doctors and surgeons and you think that the surgeon in the group is the best one in the community then wake up. Of course not - it is the surgeon that the medical doctors hired to make money from. The better doctors went off to eat roast beef and you are the meat that is left for the surgeons in the multispecialty groups. This would be a good time to eat cake.

This brings us to our fourth Piggy: This Piggy Had None

In the war between insurers and insurers and insurers and more insurers with pharmaceutical and device manufacturers and politicians there will be casualties of this war. Patient health is one. For the purposes of this post the casualty will be good and well-meaning medical practices. They will not have roast beef. They will not even have liverwurst. They will have none. They will go bankrupt. They are the roadkill on the highway of health.

In the last five years alone I have seen countless 1-5 person medical groups close their doors for a variety of reasons. Some because they can't keep up with the expenses. Some because the paperwork and administrative time to practice is just not worth it. Others because the numbers don't add up after the 90th hour of work. Where did they go? Some joined multi-specialty groups for the "protection amongst the many" philosophy. I view this as temporary salvation as they are probably becoming medical refugees in large refugee camps until the insurance companies and politicians create havoc for these groups. Some have taken full-time salary positions for hospitals. This can be a great thing for a forward thinking hospital and a bonus to the physician but it does represent a change in the level of service and personalization. Others, if they are of a certain age, just decided to retire. The great sadness of the death of the smaller groups is that they were the backbone of service and dedication that made American medicine great. Without these groups we are becoming a bit more of an assembly line of medical practice.

So what will make doctors happy when it comes to payment and job dedication? Will we ever see the day when:

This Piggy cried wee, wee, wee all the way home.

Happiness is subjective. In this current medical environment represented by our five Piggies it is hard to determine what the mix should be. If money makes you happy then become a beef-eating plastic surgeon (medical beautician). If what you want is that amazing dedication type job but need to make more money and can't work 80 hours a week then you will surely stay home, work for a private equity firm, and cry wee, wee, wee for the rest of your days but you will not be a Dr. Piggy and the world will be without you as a talented Surgeon Piggy. If you are that good in medicine and charge a retail rate for your surgery you will be driving that great big car but all your patients will be industry fat cats. You will soon ask the question: Did I go into medicine to only treat the top 5% of the economic scale?

What will allow this Piggy to be happy and cry wee, wee, wee all the way home? From what I hear from my colleagues here are some of the major things that doctors would like to see happen in medicine:

When a patient comes to the office for a service and that service gets rendered then the service gets paid. There are no denials by the insurance company for any of their classically lame reasons like- "we want more documentation," or "we are sending the bill for medical review."

There absolutely needs to be serious reform of medical malpractice. I support caps on liability that have been in the State of Illinois for the past few years where the most a person can receive is 500K for an adult case and 1 million for a pediatric case. I also think there needs to be a state medical review that would allow a case to even go to a trial jury.

If we ever do get to a universal insurance model there should be two options of participation: (a) complete joining by the doctor with payment of medical malpractice for those that accept the universal insurance and (b) joining partially where the doctor gets the universal payment but is allowed to charge any amount over that (no payment of this doctor's medical malpractice). This may assure a wide range of providers. Possibly.

Allow doctors to partner with hospitals where hospitals can pick up certain costs like malpractice, office equipment and maybe even central scheduling or supplying of office workers. Currently these kinds of partnerships are illegal.

Dismantle the entire private insurance industry. It is a failed model. Notice how I just sort of snuck that last one in...

It is unlikely that any of the above recommendations will even be remotely followed because generally speaking the free market will determine what happens. Smart Piggies will find out they will not get their value in medicine; they will seek other fields leaving a certain lesser-quality pool behind. That pool will be further diluted because the smartest Piggies left will go for the roast beef medical jobs and careers leaving whomever is left to be your and my doctor. That person will be our doctor for 3-5 years and then starve from the lack of any roast beef at all as they are the Piggies who had none. They will leave for other types of pastures. The few good souls who remain will not cry wee, wee, wee all the way home. They will just be crying during the eulogy service for the death of American medicine.

Oink.

Doctor K.

Related Topics:

Technorati Tags: health care, health reform, medicine, medical practice, universal health care

Medical School - This Little Piggy Stayed Home

2007-12-06T13:18:00.000-05:00

Photo: Jim Champion

In my last post we delved into the idea of payment of doctors. A touchy subject for some reason. It is still remarkable to me that everyone in this country can earn a market rate for their services but everyone wants to control doctor salaries. Let's move on.

Now that we live in an uber-regulated world of medicine what has this produced? Nothing particular good for patients. The insurance companies continue to rape the American public and the pharmaceutical companies and other companies assure themselves of profit.

How does a person decide what to do for a career? I think we all have gone through this in any field of endeavor. Here is a partial list of things someone considers when looking for a career:

Is it interesting to me?
Will I be good at it?
Am I helping people?
Will I actually get a job?
How much will I make?
What will my lifestyle be?

This and many other questions arise whether you want to be a nuclear physicist, small business owner, or a doctor.

What is the career that looks like this?

It is interesting to me
I know I will be good at it
I will definitely be helping people
I may not get a job (at least in the geographic area I want)
I will not make nearly as much as I could in other fields open to me
My lifestyle in this field is overworked and over-regulated by politicians and lawyers

The above career is actually medicine for a lot of people. Talented people who have choices put all these things into a hat and a decision is made. For many talented youth, medicine is not coming up on the radar.

There are numerous studies predicting the shortage of physicians that we will be beginning to experience within the next ten years. This has prompted certifying organizations like the Association of American Medical Colleges (AAMC) to recommend increasing medical school spaces significantly. There are many studies and editorials as to whether this can practically be done. Issues related to the massive debt incurred by the cost of medical school with uncertainty of reimbursement in future years decrease the raw numbers of talented applicants. We are also seeing more students who went to off-shore medical schools or foreign-trained non-Americans who perceive the medical environment more favorable in this country than their own.

I am not completely sure whether these changes are good or bad. They may just be the factual state medicine and medical education that we will all need to adapt to. One can certainly argue that people who choose to go into medicine for the money may not be the doctors we want caring for us. Does this go against American nature, though? Money does seem to attract talent in many areas of the marketplace. On the other hand, a dedicated physician who has a reasonable balance of commitment and expectation of reasonable reimbursement would be a good model as well.

We will be running into problems though because there will certainly be many dedicated people who simply can't afford to go to medical school. The cost of medical education is so prohibitive (over $50,000/year) that a $200,000 debt upon leaving school is not possible for anyone except the children of the wealthy.

It seems that in this scenario, the Piggies will stay home. If you are in it for the money then medicine is not for you. If you are in it for the passion and to help mankind you are staying home unless you can afford to go.

I recall having a breakfast meeting with a dean of a major American medical school a short time ago and I asked him about the issue of funding for medical education. He told me that at his medical school (ranked in the top 15 in the nation), that 80% of the revenues came from government research grants, 10% from donations, and 10% medical school tuition. Then came from me the following obvious question- If only 10% of medical school revenue comes from tuition then why do you charge tuition at all? Why can't you make up the 10% in cost savings, more donations, or more grants? I told him to imagine the talent pool he would get by being a free medical school.

Here is the bottom line.

If we are going to force upon doctors regulations on how much they can earn with Universal Health Care and regulations restricting revenue from other sources it is clearly obvious that in exchange, medical education should be free and medical malpractice premiums should be paid by the insurers (government and private) and not the doctors. Then, and only then will we have a pure, dedicated talent pool to assure our health care for many generations and all the Piggies will not stay home from medical school.

~Dr. K.

Related Topics:

Technorati Tags: medical school, health care, doctors, money

Doctors and Money - This Little Piggy Goes to Market

2007-09-20T03:15:00.000-04:00

Photo by **Maurice**

Let's go to Market! What would happen to doctor payments if the free market was allowed to work? Let's begin.

A few postulates about the public:

The public has absolutely no clue how much their own doctor gets paid
The public has no clue how much the average doctor gets paid
The public has no clue how much even the wealthiest doctors make.

A few postulates about doctors:

Doctors have no clue how much the doctor across town is making ( or how much their patients make for their jobs)
Doctors have no clue what their services are actually worth in a free market
Doctors have no clue what their worth is as compared to other professions

But wait, there's more...

The public thinks that doctors are grossly overpaid.
Doctors think they are grossly underpaid.

Now let's look at cost:

The public has no idea how much it costs to support and run a medical office
The public has no idea of the cost of training a doctor
The public has no idea of the amount of time their own doctor spends treating patients

Of course, the other side:

Doctors are not the most savvy businessmen and have no idea how to efficiently run a service company
Doctors think the world owes them forever for the financial and personal sacrifice they made to go to medical school
Doctors think that they are entitled to a huge amount of money for every service they do with the patient.

I hope that at least some of the above completely annoys both patients and doctors. The patients reading this will be saying to themselves that I am wrong about the things I say about the public perceptions of doctors and the doctors will say I am totally on drugs (a charge often made on this site after one reads what I write. Some may even call me a traitor. I am none of those, but I'm not afraid to air the dirty laundry, either.)

The Experiment

by BeeldenZeggenMeer

If the public think doctors are pigs let's send the piggies to market and see what we are worth. BTW, I think pigs are pretty cute, very smart, and quite tasty.

At least the last time I looked, the United States was a free democracy that allowed capitalism to thrive. Every kid can grow up to be President, and that the free market rules in business. The law of supply and demand. The more people that want your service, the more you will get paid. If no one can afford your service, you will be forced to lower the price of your service. The free market. It actually works. It may explain why a majority of people in this country sleep in beds rather than caves.

To look carefully at this issue I devised the following thought experiment. I actually did real research for this article. I talked to other people. Colleagues, friends, and patients. This is how is all went.

Here are the assumptions I made:

I invented a sample practice based on real numbers after interviewing a number of colleagues in the practice of Orthopaedic Surgery. This model is based on Orthopaedic Surgery because it is the world I know. I kind of like to write on something I at least know something about. The conclusions drawn from this informal study probably applies to all medical practices, but you make your own decision on that.

Based on real information this is what our "WebMD - Get a Medical Life" practice looks like:

The practice has three surgeons
The gross revenue collected from patient fees is 3.6 million dollars
The overhead of the practice which includes everything except salaries is 60% of revenue (believe me this is a real number!). In actual dollars for our thought experiment this is 2.16 million dollars
Each doctor works an average of 70 hours a week, not including being available for phone calls or visits to the emergency room on off-hours every other day = another real number.
The practice is in a community where there is a normal mix of insurance companies and Medicare.
The practice is on the panel of every insurance company that exists in their area. This goes by other common terms: The doctor accepts the patient's insurance, the doctor is par with the insurance... I think you get it.
Each surgeon in this busy practice sees an average of 4,000 office visits a year. This is a lot of visits. Needless to say, they probably don't spend a ton of time with each patient.
The practice philosophy is based on excellent surgery, commitment to proper diagnosis and treatment, and making money, which is why this group chooses to work longer hours and see more patients.
The group is a respected group in its community from the point of view of patient satisfaction and the perception that if you need surgery this is a group to have it with. A "Go To" group.
In the town next to this group is a group from a prestigious university clinic that chooses to accept no insurance. They charge what they consider the rates they feel they are deserved. For the purposes of this thought experiment, assume that the quality of the surgery and the diagnosis and treatment as compared to our hypothetical practice are completely equal.
One major procedure that this group does is a hip replacement. They do a full range of Orthopaedic procedures, though.
The surgeon you go to is Dr. SmithJones. You are going for a hip replacement.

Here is the experiment -- a survey which I want all of you to take. Answer the questions in order. At the end of the question group are the real answers and then we let the sparks fly.

Questions:

How much to you think Dr. SmithJones receives from Medicare/HMO to perform a total hip replacement? This fee includes the pre-operative evaluation and ninety (90) days of post-operative care rolled into a single fee.
Dr. SmithJones has another surgeon there as a first assistant (assume this is a required and important role). How much does the assistant surgeon, Dr. Surgical Assistant, receive to assist a total hip replacement?
Dr. SmithJones has an assistant, Dr. Patient Assistant, who shares in daily visits to the patients every other day. How much does Dr. Patient Assistant receive for this service each time he visits the patient?

(Theme from Jeopardy... Da da da da da da da, da da da da DA da da da da da, da da da da da da da, da da da da da da da.)

Write your answers on a paper. No cheating, now!

Here are the results of my straw poll when I asked a bunch of people the answers to this question. See if your answers compare to what the people I asked told me what they thought. Compare what you wrote to what people I asked told me. They probably are quite similar.

In answer to the question: How much do you think Dr. SmithJones actually receives for the surgery? One person came in with the lowest number at $3,000.00. The next lowest was $5,000.00. The majority had numbers ranging from $8,000.00 to $12,000.00.
In answer to the question: How much do you think Dr. Surgical Assistant receives for assisting in the surgery? The numbers ranged from $500.00 to $2,000.00
In answer to the question: How much do you think Dr. Patient Assistant gets for seeing the patient in the hospital after the surgery (per day/per visit). The numbers ranged from $50.00 to $150.00.

Okay. Now answer the following multiple choice questions.

I will give you an answer (not necessarily the real answer) to the above questions. You answer each with one of the following choices:

That amount is too little
That amount is too much
That amount is just right

Answer the following three questions:

Dr. SmithJones received $3,000.00 from Medicare/HMOs to perform a total hip replacement. This fee includes the pre-operative evaluation and ninety (90) days of post-operative care rolled into a single fee.
1. That amount is too little
2. That amount is too much
3. That amount is just right
2. Dr. Surgical Assistant receives $500.00 to assist in the hip replacement surgery.

That amount is too little
That amount is too much
That amount is just right

Dr. Patient Assistant receives $50.00 for each day he visits the patient in the hospital after surgery.

That amount is too little
That amount is too much
That amount is just right

Write your answers down. I will give you some time.

Da da da da da da da, da da da da DA da da da da da, da da da da da da da, da da da da da da da. Repeat once. Extra credit fill-in: I am singing the ??????? Theme?

Based on what you wrote and what I supplied you from my survey, you have an idea of not only what the public perceives what Dr. SmithJones gets for the hip replacement but also, based on the lowest amount mentioned on the first survey you learned whether you thought this was too low, high, or just right. Pretty good information. Remember, this is the free market in action.

One last question and then we put it all together.

Make the following assumption: There is some type of insurance plan that pays 100% for the hospital, hospital physicians like anesthesiologists and pathologists, equipment, blood transfusions and all other institutional type services (often as high as $25,000.00). You, therefore, pay none of these pills under the DRK Universal Health Plan (DRK- Doctor K). You are, though, responsible to pay only for the doctor's fee (like you may pay for a plumber, for example).

Answer the following questions:

I need to pay Dr. SmithJones $3,000.00 for the hip replacement. I can pay in a single payment or over a one-year period at 0% interest. This would work out to $250.00/month for 12 months. The payments are fully tax-deductible.
1. I think this is fair and reasonable and I would pay this.
2. I think this is too high for this service.
I need to pay Dr. Surgical Assistant $500.00 for his role in assisting Dr. SmithJones for the hip replacement. I can pay this in a single payment or over a one year period at 0% interest. This would work out to $41.67/month for 12 months. The payments are fully tax-deductible.
1. I think this is fair and reasonable and I would pay this.
2. I think this is too high for this service.
I need to pay Dr. Patient Assistant $150.00 ($50.00/day for three days) for his role in seeing me in the hospital after the surgery. I can pay this in a single payment or over a one year period at 0% interest This would work out to $12.50/month for 12 months. The payments are fully tax-deductible.
1. I think this is fair and reasonable and I would pay this.
2. I think this is too high for this service.

When I conducted the survey, a near 100% answered section 2 either that the made up numbers (for example $3000.00 for the hip replacement) was either "Just Right" or "Low." No one thought the amount was too much. Needless to say, considering one does not get a hip replacement often, the yearly pay-off of this reasonable fee seemed to all an interesting and realistic idea.

What are the real numbers?

Doctor Procedure Minimum - Acceptable Free-Market Fee - Actual reimbursement

Dr. SmithJones Total Hip Replacement $3000.00 - $1347.86 - 42%
Dr. Surgical Assistant Assisting Surgery 500.00 - $183.31 - 37%
Dr. Patient Assistant 3 days of post-op visits $150.00 - $00.00 - 0%

The current reimbursement going to this group of 3 surgeons is severely and artificially depressed as compared to lowest the free market would accept to pay. Based on the lowest the public would be willing to pay a doctor for services, doctors are receiving less than 50%.

What happened to the free market?

After all, there are few industries in which people choose to work where the salaries are artificially depressed to below-market rates.

Keep in mind that doctors are not a single group of workers. Each doctor or doctor group is an independent business so medicine as an industry cannot be viewed as though the doctors are employed by others. If that was the case, then doctors would legally be allowed to unionize and act in concert in negotiations with insurance companies. Currently, even this is illegal.

It is illegal for physicians to collectively bargain or organize as any single group because the government views them as separate businesses organizing to influence the market and this is considered against antitrust statutes. It is amazing that the government uses one law that tries to assure free trade and protect a fair market while the same law actually prevents competition with the insurance companies and inhibits the free market!

The artificial depression and selective destruction of free markets in medicine continues in medical programs like Medicare. Many patients are unaware of the gross inconsistency of Medicare regulations as compared with regulations in other industries. For example, if a physician chooses to be part of the Medicare program, that physician cannot charge higher than allowable Medicare rates. That, of course, I believe, is fair. If you choose to be part of a program then you need to accept the provisions.

Did you know, though, that if a physician chooses NOT to be part of the Medicare program, the physician is legally not allowed to charge the more than the allowable Medicare rate? This means that when Bill Gates turns 65 and has Medicare for insurance the doctor can only charge him 15% above the allowable $33.10 for that follow-up visit for his high blood pressure visit.

When did we give the government permission to dictate the amount of money a person in private business is allowed to charge? Are there national dry cleaner rates for people over 65? Are there national designer clothing rates that a department store must charge? The only industry I know of that does anything close to this are gas and electric utilities.

Medicine is not a public utility -- yet. Whether it becomes one is neither the issue nor scope of this entry. This issue is that in when physicians pay vendors for services such as supplies and employee wages, they live in the free market. When it comes to reimbursement, current government programs coupled with the inconsistent regulation of the industry prevents doctors from living in a free market.

Here's what a true free market would be like: Dr. SmithJones would earn anywhere from twice to six times what he currently earns. The reason for the large range is because if the reimbursement will be increased and expenses will remain fixed.

Once Dr. SmithJones starts getting paid even the lowest market rate he will probably stop trying to squeeze in 100 patients a day in the office, spend more time with each patient. This will lower the raw number of patients he sees and possibly improve patient satisfaction and treatment which is yet another benefit of following the free market.

Is the fair-market price too high or too low?

Wrong question. This is the real life answer representing the free market for services rendered. The free market does not lie. The free market is not emotional. Is $25,000 too high or too low for a new car? Also wrong question - the cost is based on the free market. The rest of the country functions on free market principles; your business probably does as well. Pharmaceutical companies and insurance certainly do. If the doctor went to market, the numbers presented show what he would get.

Health care in the United States is reimbursed at below-bargain basement rates. In businesses in this country where you pay bargain basement prices you get bargain basement quality and service. It is only through the ethical nature and dedication of a majority of doctors in this country, who choose to practice blind to the reimbursement and treat individual patients equally and fairly, that this does not happen and medical delivery remains of the highest quality.

Unlike a piggy going to market, doctors are lambs to the slaughter of the business and political agendas at work in this country.

I will see you later; I have an errand to run. I am definitely going to the market...how about you?

QED

Next installment: This Piggy Stayed Home- What happens to the future of health care when the best and the brightest choose not to go into health care but into corporate Wall Street type jobs?

Related Topics:

Technorati Tags: health care, doctors, money, medicare

Doctors, Money, Salaries, and Similar Unspoken Topics

2007-09-19T23:57:00.000-04:00

This little piggy went to market.
This little piggy stayed home.
This little piggy had roast beef.
This little piggy had none.
This little piggy cried "Wee! Wee! Wee!" all the way home.

I sat here listening to the Fourth movement of Beethoven's 9th Symphony in attempt to see if I can muster the energy to even start this highly charged topic. It didn't help but the music is great anyway. Probably more inspiration from Eminem on the topic of doctors and money..

There is probably no topic I know of that brings more spirited discussion than the payment of doctors. I tried to figure this out. It seems, first of all that insurance companies are really not people, they are nameless and faceless companies. At least a doctor is someone you can actually touch (even though we are God-like :-))

I know no better way to understand the complex economics of doctor reimbursement than the statistically significant analysis using the above nursery rhyme.

This is the first blog entry in the series The Piggy and Medical Reimbursement. The five parts are:

This Piggy Went to Market: What doctors would make of market forces-determined doctor payment

This Piggy Stayed Home: The consequences to medicine when talented men and women choose not to go into medicine due to financial and lifestyle problems in the profession.

This Piggy Had Roast Beef: The private world of high-priced fee-for service medicine with "doctors to the stars" and others who charge huge fees for even the simplest procedure.

This Piggy Had None: The problems of practices going out of business or being forced to join large impersonal medical groups that supply cookbook medicine because they economically can't make it in this environment or simply leave a town leaving it without medical care.

This Piggy Cried "Wee! Wee! Wee!" All the Way Home: Recommendations for a health care payment system that properly rewards doctors for doing the right thing for patients that makes us all happy.

The One-Paragraph First Step to Solving the Health Care Crisis

2007-08-31T13:43:00.000-04:00

Health care is a mess because the insurance companies are interfering with the clinical decision-making process. They have so many rules so that they do not pay in that they deny many legitimate claims over and over again. It should be the law of the land that to be allowed the privilege of offering insurance in the country, all insurers, HMOs, PPOs, etc. must have the same rules and regulations concerning payment and clinical decision making as the Medicare system. If they would like to offer a more robust coverage product on top of that foundation, they can do so but no added benefit can in any way change any aspect of the basic Medicare benefits structure.

In other words, the first step should be to standardize claims review and criteria, based on current Medicare standards. What's the next one?

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CEO Compensation: Who Said Health Care is in a Financial Crisis?

2007-08-23T15:45:00.000-04:00

Those of you who are struggling to pay for your generic medicines or wondering why the doctor is charging you a $5.00 co-pay, give some thought to these facts about how our health care dollars are allocated. At the end of this post, there is a list of 23 health companies I found on Forbes.com, what the CEO was paid in 2005, and the average paid to the CEO in the past five years.

Imagine adding vice presidents, Board of Directors, stock holders and the other 200-300 other companies all cashing in on your health to that total at the bottom.

Based on this, the next time you want to argue with your Primary Care doctor's front desk about a $5.00 co-pay, remember that he makes an average of $149,000.00 per year. On the other hand -- using United Healthcare as an example -- your insurance company paid their CEO -- one man -- $324,000,000 over a recent five year period.

If you are uninsured, try calling any one of these 23 CEOs and see if they will give you free insurance.

BTW: 10% of 14.9 billion is 1.4 billion. If basic insurance costs $8,000/year for a family then taking 10% from just these CEO salaries would insure 35,000 Americans a year for five years. That is a lot of people that can be helped just by 23 men. Looking at the companies as a whole that profit from health care, we can probably pay for every uninsured person in this country for decades to come.

The numbers are numbing, which is why we should do something about this.

United Health Group
CEO: William W McGuire
2005: 124.8 mil
5-year: 342 mil

Forest Labs
CEO: Howard Solomon
2005: 92.1 mil
5-year: 295 mil

Caremark Rx
CEO: Edwin M Crawford
2005: 77.9 mil
5-year: 93.6 mil

Abbott Lab
CEO: Miles White
2005: 26.2 mil
5-year: 25.8 mil

Aetna
CEO: John Rowe
2005: 22.1 mil
5-year:57.8 mil

Amgen
CEO: Kevin Sharer
2005:5.7 mil
5-year:59.5 mil

Bectin-Dickinson
CEO: Edwin Ludwig
2005: 10 mil
5-year:18 mil

Boston Scientific
CEO:
2005:38.1 mil
5-year:45 mil

Cardinal Health
CEO: James Tobin
2005:1.1 mil
5-year:33.5 mil

Cigna
CEO: H. Edward Hanway
2005:13.3 mil
5-year:62.8 mil

Genzyme
CEO: Henri Termeer
2005: 19 mil
5-year:60.7 mil

Humana
CEO: Michael McAllister
2005:2.3 mil
5-year:12.9 mil

Johnson & Johnson
CEO: William Weldon
2005:6.1 mil
5-year:19.7 mil

Laboratory Corp America
CEO: Thomas MacMahon
2005:7.9 mil
5-year:41.8 mil

Eli Lilly
CEO: Sidney Taurel
2005:7.2 mil
5-year:37.9 mil

McKesson
CEO: John Hammergen
2005: 13.4 mil
5-year:31.2 mil

Medtronic
CEO: Arthur Collins
2005: 4.7 mil
5-year:39 mil

Merck Raymond Gilmartin
CEO:
2005: 37.8 mil
5-year:49.6 mil

PacifiCare Health
CEO: Howard Phanstiel
2005: 3.4 mil
5-year: 8.5 mil

Pfizer
CEO: Henry McKinnell
2005: 14 mil
5-year: 74 mil

Well Choice
CEO: Michael Stocker
2005: 3.2 mil
5-year: 10.7 mil

WellPoint
CEO: Larry Glasscock
2005: 23 mil
5-year: 46.8 mil

Wyeth
CEO: Robert Essner
2005:6.5 mil
5-year: 28.9 mil

TOTAL 2005: 559.8 mil

TOTAL 5-Year: 14.9 billion

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The opinions expressed in the WebMD Blogs are of the author and the author alone. WebMD does not endorse any specific product, service, treatment or political point of view.

Health Insurance: SiCKO Has the Right Idea

2007-07-30T13:19:00.000-04:00

I had the chance to see Michael Moore's new documentary: SiCKO. I did not read any reviews before going in and did not go on his website before seeing the movie.

See this movie.

Getting an education in the mess we call health care is more complex than a degree in astrophysics from MIT but we all have to get it and we have to start somewhere. Whether you agree with Moore or not, see the movie. He is right about the one thing that a vast majority of readers of this blog were right about: The insurance companies are THE MAJOR reason we are in the mess we are in.

Since the movie came out there are a number of critics out there who have been trying to bring up all the accessory problems that health care has. Many, if not all of these are true. The problem is that whenever someone waters the arguments down with a claim about the quality of hospitals, the amount of money paid to hospitals and doctors, the grading of performance, the useless tests ordered, or medical malpractice is a problem one fact always will emerge. No problem in health care can be fixed without first a massive restructuring of the system with which we pay - the insurance system.

OK. We now know the problems. What are we going to do? It is about time the biggest lobby in the country - the American People - got it together to put an end to the insurance abuses. If you have been under a rock for the last 30 years here is what happens:

Insurance companies take your monthly premium payment. If you do not pay immediately, you are quickly canceled.
Insurance companies decide on the premium based on the profit they want to obtain.
Any profits from the system go to executives and shareholders and not back into health care.
Insurance companies routinely and arbitrarily deny approval for necessary tests for patients.
Insurance companies routinely and artificially deny payments to doctors and hospitals for services already approved and performed.
Insurance companies have the goal to NOT PAY a claim.
Insurance companies interfere with clinical decision making of physicians.
Insurance companies have lobbyists that have heavily influence your Congressman and Senator.
Insurance companies have no interest in "maintaining" your health. HMO's are designed for profit even when they call themselves non-profit.
Insurance companies abide by their own rules of behavior.

There is really only one solution. Reform the health insurance industry as we know it. Make it illegal to sell health insurance in America until every American is covered with a basic universal plan and then, and only then, insurance companies can sell gap-type insurance.

Here is the bottom line. There are a ton of real problems in health care. If you want to get a good idea of some of the issues I recommend you read the book Better by Atul Gawande. It is an excellent balanced view of how we can hope to improve American health care.

In the meantime, while we are looking for balanced solutions get your Congressman, Senator, or Presidential Hopeful to outline a plan for meaningful regulatory controls over the insurance industry and start working on a fair and open universal health care system that covers all Americans, allows doctors to opt out, but assures an acceptable quality of care for every citizen.

Doctor K

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Hospitals: The Good, the Bad and the Ugly

2007-06-19T20:47:00.000-04:00

Wikimedia Commons

I recall the hospital in my small town during the time I was growing up. It was St. Joseph's Hospital. The nurses were nuns and from what I could tell in the short time I stayed there after my double hernia operation, they were close to God.

St. Joe's (local name), like all the hospitals of its time, had a unique smell. The hospitals always had a smell that separated them from the real world that I lived in. Back then it was the smell that only comes from something that emits its character in an odor. It was an antiseptic smell. It was a quiet smell. It was a smell of respect in the neighborhood of disease. The focus of the hospital was the care of the patient at all cost. A unique focus. A focus that emitted a unique smell.

The smell of hospitals today is indistinguishable from any strip mall located on a turnpike in New Jersey, Illinois, or California. I've tried to figure this out over this past year in my travels. Not only do I admit patients to my own hospital, but because some people think I have some interesting things to say (fools are everywhere), I get to travel and visit a number of hospitals across the country.

At first, hospitals appear to have no smell at all because there are thousands of special interests within a hospital that emit so many odors that they cancel each other out. By the end of last year, they just smelled like crap to me. Hospitals spend their waking days preparing for yearly inspections from agencies created to survey, approve and accredit hospitals. Unfortunately, dotting the i's and crossing the t's on all the survey points has little to do with patient care.

What I See

Hospitals seem to only care about profitable diseases. One would think that this entire country is filled with only three types of people:

Very healthy women having babies

People with cancer that need chemotherapy or radiotherapy

People with heart disease that need a stent procedure.

I say this because in every hospital I go to, the obstetrics floor, the "I am a Person With Money" Cancer Center and the Invasive Cardiology Wing look like a Ritz-Carlton hotel. When I tour a hospital and the administrator proudly displays these freaks of medical construction, I usually drop out of these tours and check out the rest of the hospital.

Mitch Featherston

First, I look for what is called the Med-Surg floor. This is the floor where people with all kinds of other diseases go. What I usually find are dirty floors, linens piled outside rooms in overflowing bins, nurses who are tired and ignored and patient-to-doctor nursing ratios that approach the population base in the largest province in China.

In one hospital I recently went into, the Orthopaedic Floor had an inadequate number of pain pumps, older continuous passive motion machines, and an anemic physical therapy section that looked like a public toilet in a NYC subway.

In college sports there is a program called Title IX - this means that men's sports cannot get more funding that women's sports. We should have this in hospitals. If funding is given for a particular disease then a percentage must go to the rest of the hospital as well.

Medicine is not a business; Hospitals are.

Hospitals are run by Boards, administrators, and professional businesspeople. Doctors are not businessmen. We all seem to know this. Here's the 411 on something you don't know - medicine is not a business. That's right. You will probably hear every freaking "expert" in the country banter all day long that medicine is a business. No way.

Hospitals are businesses; medicine is a calling. Medicine - which includes doctors, nurses, respiratory therapists, physical therapists, unit clerks, radiology technicians and more - is a world that defies all the rules of economics. Applying the rules of economics to medicine leads to "acceptable" loss of life.

I recall that a number of military strategists used to talk about "acceptable" losses in nuclear warfare. What a concept. Businesses like Pepsi and Microsoft understand acceptable losses. If Pepsi has a division that they spent a lot of money on but is not working, they will sell or close the division. An acceptable loss. In medicine, the acceptable loss rate is zero. The acceptable complication rate is zero. The acceptable death rate is zero.

This does not mean that these things don't occur. It means that, as medical people, we refuse to accept it as a way of life and work to the end to prevent these things from happening.

Businessmen running hospitals accept complication rates. They accept infection rates. They accept death rates. Most of the time it happens way before anyone can figure out it was their doing.

A True Story

I was called recently about a problem in a mid-sized community hospital and asked to give an opinion on the situation. It appears that in this hospital there was a growing joint replacement program and the surgeons were concerned about a large transfusion rate as compared to a neighboring hospital.

After some simple research they found that the other hospital had implemented a product called an OrthoPat. This is a product that allows for the salvage of blood during the hip replacement operation and after hip and knee replacements. This meant that during a hip replacement case blood lost during that surgery was able to be put back into the patient. Over the course of a year this product would save almost 150 blood transfusions over the previous system.

What Happened?

The surgeon presented the product with all the data to a committee made up of a general surgeon a nurse, and three hospital administrators

The committee approved the product

The Chief Financial Officer of the hospital unilaterally vetoed the purchase of this even though he did not have the authority to do so.

The surgeon spent 3 months complaining to administration about this situation.

Finally the system was reapproved.

Two weeks before implementation of the system the surgeon got a call the system could not be implemented.

The reason for not implementing the system was that the hospital across town that used the system had hospital-based nurse practitioners manage the tubing on the ward.

Even though this surgeon's hospital has nurse practitioners on staff in multiple capacities in the hospital the Executive Vice President of the hospital, actually an MD at one point in his life, refused to assign this responsibility to one of these nurse practitioners.

When the surgeon inquired why this could not happen, he only received an e-mail reply saying "this service is not available at this time."

The product designed to save unnecessary transfusion was stopped from being implemented - again by an administrator.

This is remarkable. A product, known to prevent the need for unnecessary transfusions, was simply not implemented because a single hospital administrator did not want to assign one of the nurse practitioners in the hospital to manage the tubing. I can only assume that he felt that the potential disease transmission that could occur from 150 unnecessary transfusions a year was an acceptable loss. It was acceptable only because it was not in his own operation or in his own family.

I am sure someone who contracted Hepatitis C from one of these transfusions wouldn't think it is very acceptable. I wonder what the hospital will say when a patient who gets sick from one of these unnecessary transfusions, gets an attorney, and sues all of them for this grossly irresponsible behavior.

Not convinced yet?

Hospitals are owned by stockholders.

Hospitals judge their quality by standards that have nothing to do with health.

Many hospitals no longer care for the poor and the underprivileged.

Hospitals reward physicians that save money at the expense of patient care.

Hospital administrators have no clue concerning their infection rate.

Hospitals only order equipment if they either need to market a procedure or are embarrassed into it.

Hospitals are political in the way they deal with staff. Congress is political. Need I say more?

Doctors within a hospital have little say or power to bring about change. Patients have no say.

Is there another side? I am sure there is. I am sure across this extraordinarily large country there are hospitals driven to the care of their patients and the communities they serve. Unfortunately, you don't get recognition for doing something right unless you also have an extraordinary Public Relations department.

Hospitals will go out of their way to pass all kinds of state regulatory surveys and parade around their success. All they did in these surveys was dot the "i's" and cross the "t's." Stay out of hospitals if you can. You will probably live longer.

Dr. K.

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Cancer Treatment: Who Profits?

2007-06-14T13:21:00.000-04:00

Jamie Beverly

I just finished reading a report published in the NY Times on June 12, 2007 entitled Incentives Limit Any Savings in Treating Cancer by Alex Berenson. When you read things like this you really can get mad about what is going on in American medicine.

There will always be the good, the bad, and the ugly. The biggest problem we have in medicine is figuring out which is which. You are welcome to read this brief article but here is the summary: Boy meets girl, boy marries girl, and they live happily ever after. Oh, I'm sorry, that was the government's view on the state of health care.

The summary is actually the following: You are going to die. You are going to die with no money. Along the way a lot of people already way richer than you will get even more richerer (new word I made up...). What is even more interesting is that since you are going to die relatively quickly, these greedmeisters get to repeat it all over again, and again.

I recall in political science courses in college a phrase "Hard cases make bad law." What I learned was that a legal case presented before the Supreme Court that was difficult to decide and had many twists to it eventually led to a decision by the court that produced bad policy or generated reactive law making in response. No one really wants a hard case to determine policy.

In the same sense, difficult medical conditions make for bad public health policy-making. Let me give you examples. A simple case: If an otherwise healthy person is just starting to get a heart attack and you can give them a medication that prevents the heart attack from getting worse and saves their life then that drug should be approved for use to be given in all these situations regardless of price. Easy Case. Good Policy.

Here is a different one: A patient who is 87 with terminal cancer ("C" word) with a life expectancy of six months can be given a $75,000 drug that has a 30% chance of extending their life expectancy an average of three months. That's a hard case. That's a really hard case. What kind of policy can we make from this? Do we treat or not treat based on age? Should $75,000 of Medicare dollars be spent on an 87 year old for a "chance" to live three months?

More importantly, who makes that decision? If you had the money and it was your mother or grandmother, do you buy the drug? Why does it cost that much anyway?

Unfortunately, in the world of cancer treatment, it is these difficult decisions that are more common than the easy ones. This does not mean we can't weed out the rats from basement of cancer care though. Let's go back to the article in the NY Times and look at some issues.

The general thrust of the article was that since Medicare has cut back on the reimbursement to oncologists (non-surgical cancer specialists) then the treatment of these patients was being moved from the comfort and quality of these offices to hospital settings (presumably less personal and caring) as the doctors were claiming that they either broke even or lost money on the treatment of these patients.

The article points out that before the Medicare reimbursement decreased, doctors were making huge profits for giving chemotherapy to anyone at all cost and the financial incentives pushed more chemotherapy treatment.

On one side: This is obviously true. If there is a built-in profit to chemotherapy one time then you double your profit giving it a second time. I can do more math on this but the point is clear. There is no bonus put on spending time with the patient or thinking about their care - only in running more patients through the door.

On the other side, the article refers to the differential between the cost of the drug to the doctor's office and the price that Medicare reimbursed as "profit." I think the NY Times needs a basic lesson in economics.

The money the doctors collected from Medicare is called the gross revenue. The cost of the drug is referred to as a direct cost. The doctor has a ton of other costs to deliver the drug. These include the intravenous, the salary for the chemotherapy nurse, the furniture, the electricity, the malpractice, the receptionist, and the phone bills - the list goes on and on. If you are in a really caring cancer center that also has psychiatric social workers to help you and nurse educators on staff, the costs increase.

The difference between the gross revenues collected from Medicare and ALL these costs is called profit. The article points out that the current Medicare fee schedule pays for 6% above the cost of the drug. I would have to assume that a plate of Twinkies cost more than 6%, let alone all those other services.

Analysis: Somewhere between both sides a negotiated agreement may be possible. A reasonable amount of built-in revenue must be built in but again - who decides what is reasonable? We have serious problems in this situation because we have a lot of difficulty with a multi-tier healthcare system where the rich can get all the cool services and the poor get treated in a dungeon.

This causes doctors to be pitted against patients. While some suggest that we can actually determine a fair market rate or that we need to change the financial incentives there are some pretty darn obvious questions staring right at us: Why in the world do these drugs cost so much, why do we allow the pharmaceutical companies to set ridiculously exhorbitant prices and reap absurdly exhorbitant profits, and why do we allow the insurance companies to dictate who gets treatment?

Forget about pointing to doctors and clinics that make money. Forget about pointing to patients who think they want everything for free because they think it's a right. Try this on for size. The doctors should make money because they are being entrusted with serious questions and issues and the patients should get treated for a heckuva a lot less than they are paying now.

Try some basic arithmetic. I am too busy ranting about this crazy drug-and-insurance-company-controlled system to do it but can someone out there compute this? Add up the yearly gross revenues of the top fifty pharmaceutical companies and top fifty insurance companies in America. Take 10% of that revenue (for example a direct tax on gross revenues of pharmaceuticals and insurance companies) and apply it to a national insurance fund. Would that make a dent in getting the millions of Americans with no health care coverage the proper care they need? Will 15% do it? Will 20% do it?

If we really care about the uninsured or those who do not have proper access to cancer care and all medical care why are we wasting time trying to save nickels with decreased reimbursement to doctors or denying coverage to patients? The drug and insurance companies have been given governmental license to print money at our expense. Isn't it about time we got it back from them?

Get out your calculators.

Dr. K.

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Health Care: What Single Thing Would You Change?

2007-05-30T17:11:00.000-04:00

From the vantage point of this Blog, the state of our health care system ranges from the totally remarkable (advances in body imaging and cancer therapies) to more evil than the drug-lord tactics of nearly every insurance company and pharmaceutical company that make the Columbian Cartel look like the Vienna Boys Choir.

What do you do when nearly every aspect appears to require a major overhauling? Do you scrap the system? Do you make small changes? Do you have a philosophy of building or do you overlay a regulatory estate on the system -- sort of like "Big Brother meets your local doctor or hospital"?

As with many things in our daily lives that seem too complex to take on there are times when the adoption of a single event places us on the road to recovery. On a personal level it can be leaving that dead-end job you had and starting over. Maybe it's something as simple as cleaning off your desk. Whatever it is, the road to success starts not with a single step, but with an index moment. What is an index moment? It is a behavior or event that as time marches on you look back to the index of your life and see that event as a critical juncture where significant change began.

What Will be Our Index Event for Health Care?

Here is the challenge. There are a lot of smart people out there. Actually there are too many smart people out there. There are too few people with common sense. But a helluva lot of freaking smart people. The smart people outline, in article after article, ALL the problems with our health care system. The problem is that they are right. Every one of those articles has important points for us to ponder.

It really doesn't matter since we all have so much time to ponder health care anyway - the wait to get precertification for 4 extra physical therapy visits from our insurance company can take weeks, approval for surgery from the Worker's Compensation Board takes months, and doctor office waits, maybe longer.

Boy, do we have a lot of time to ponder these questions. That is why doctors' offices have so many magazines - to feed into our need to ponder these great dilemmas. The reason we need to ponder these is because since no one has the courage to DO a single thing to effect change (writing is not doing by the way) we are left with pondering. Let's ease off on pounding the pondering and figure out what we can do.

Is it Just One Thing? Maybe...

I think we all believe in the following statement:

If this one thing just changed in health care then we would be significantly better and on the road to recovery.

What is that "one thing"?

I asked a colleague this question recently. She was trained as a radiologist and ranks as one of the smartest doctors I ever met. She felt that if she had to change just one thing in medicine she would improve the environment for medical students coming out of medical school so that it would be more attractive to want to be a doctor. She feels that many of the best and brightest of our college graduates are not going into medicine because of the problems in the system and that any solution to health care must make sure that it is an attractive enough field to bring those people back in.

I agree with her, although the definition of "attractive" can be complex. Does this mean more money? More jobs offers? Tort reform (the changing of the medical malpractice system)? Either way, her point is that the destruction of the health care system will really be felt in twenty years when the current group of doctors will have some voids of talented people who went to other endeavors.

Recently I read a few articles by Atul Gawande, the respected health writer and author of the recent book Better. Since the end of April, Dr. Gawande, who is also a surgeon who practices in what appears to be an academic-based practice through a hospital system, wrote fourteen columns or reviews in the New York Times alone. All of them excellent and insightful. Dr. Gawande writes in other venues as well, so in a year he produces for us an encyclopedia of the issues that are presented to us in health care today. Read what he writes. You may or may not agree but it will clearly bring you up to speed on the major issues in front of us.

If reading Dr. Gawande's work was enough then we can stop there. No way, Jose. It is not that simple. The range of Dr. Gawande's work is massive, covering topics from access to HIV drugs to problems in the elderly related to nursing homes to hand-washing in hospitals; almost like a medical Wikipedia in action.

Unfortunately, like the movie said "there are a thousand stories in the Naked City...this is one of them..." applies to the American health care system. We are a complex melting pot of needs, special needs and special interests. We are a country with a deep attachment to civil liberties and the needs of the individual. That is not necessarily the case around the world.

In a recent NY Times article Dr Gawande makes reference to an important study performed by The Commonwealth Fund that showed our health care system is the most expensive but our life expectancy is the same as Australia, Canada, New Zealand, Germany, and Britain. While we don't appear to fare well against these countries in some areas, we excel in others. The take-home lesson is that what is important to Americans may not be as important to citizens of these other countries or to the authors of these studies.

That leaves us here, on this blog with one goal.

If you can do JUST ONE THING to change health care, what would it be? Just one thing. Not two, not three, not 28 million. One thing.

Here are a couple of ideas (not necessarily mine but ones that have floated through this Blog over the past year) but there are obviously more:

Universal health care insurance supplied by the government
Complete restructuring of medical malpractice
Nationalize the drug companies (treat pharmaceuticals like natural resources such as oil from the Alaska pipeline)

Let's see how far we are from each other...

Post away, baby....

Dr. K.

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What's in a Name? Everything.

2007-03-22T09:22:00.000-04:00

"A rose by another name would smell as sweet." - Shakespeare

What is the purpose of a rose? Is there just to smell? Is it there to look at? Would a rose by a different name and a different look smell as sweet? Let's rename a rose to a "Rat's Armpit." I am not sure that Rat's Armpit Gardens would be springing up in gardens in places like Greenwich, CT, and Bellevue, Washington. There is a lot in a name.

I was fortunate to get into medical school in 1979. I was also fortunate to attend the Albert Einstein College of Medicine of Yeshiva University in New York. Besides all the academic reasons I felt fortunate to be there, Albert Einstein was also a personal hero of mine.

When we first got there we were shown a brief newsreel clip of a press conference with Albert Einstein where he proclaimed that he was proud to offer his name to a medical institution. Einstein was truly a great person. With Newton, he shares the podium as the greatest geniuses of the last two millennia. He wrote extensively on world issues related to peace and the human condition. Paraphrasing the famous science writer CP Snow, commenting on Einstein's General Theory of Relativity proclaimed that while many of Einstein's great discoveries world have eventually been found by others, this particular advance would never have been conceived by any human for eternity. Pretty good stuff. It gives you a good feeling to be educated in his house.

Let's fast forward to our current times. Alumni and students at two venerable institutions of higher learning - Cornell University Medical School and Brown University Medical School- essentially found that their institutions renamed their medical schools.

When I heard the medical schools were to be renamed I was excited. I thought of all the amazing people in the past half century that could have qualified for such a high honor from two Ivy League institutions. There was Martin Luther King, John Kennedy, Richard Feynman, The Dalai Lama, Mother Theresa, Jonas Salk, Eleanor and Franklin Delano Roosevelt, Harry Truman, and countless others of recent heroes not to mention historical figures like George Washington Carver, Robert Oppenheimer, Woodrow Wilson, Harriet Tubman, Sojourner Truth, Abraham Lincoln, and others.

It was not meant to be.

Cornell renamed its medical school for Sanford Weill, the CEO of Citibank, and Brown renamed its medical school for Warren Alpert, a billionaire who made most of his fortune developing selling fuel and groceries through Xtra Mart stores in gasoline stations across the country. Wow. Free checking and chili dogs for all incoming first year medical students.

Don't get me wrong. This is not about Mr. Weill or Mr. Alpert who by all accounts are deeply generous and good people. They gave a lot of money. A lot of money. I mean a real lot of money. For that something should be named for them - a building, a division of the school (The Weill Division of Cardiology at Cornell, for example) - but the entire medical school? What was Ezra Cornell, chopped liver? The naming of something as precious as one of our 80 medical schools in this country should be reserved to remind the public of the truly great figures in our country's history and not the fattest wallets.

In my living room there is a unique black and white photograph hanging over the fireplace. It is a photo of Albert Einstein taken at Princeton University (will that soon become Sam Walton College?) in 1948. The photograph was taken by the great jazz photographer Hermann Leonard who was an apprentice at the time with the great portrait photographer Yusef Karsch. Mr. Leonard was a young kid at the time and Mr. Karsch gave him permission to take shots of Einstein on the set that Karsch set up.

A few years ago I was in Herman's house in New Orleans and saw this photo in a stack of long-forgotten images in a career known for capturing the essence of Billie Holliday, Ella Fitzgerald, Louis Armstrong and others. I acquired this rare print from Herman who signed it: Albert Einstein, Princeton 1948 on the Karsch Set, Herman Leonard.

My hero, the namesake of my medical school is in a proud location in my living room. I wonder if graduates from the Weill school are so proud of their alma mater's namesake to have him (probably on the 9th hole at an exclusive golf club) smiling at them from their mantle? Don't even go there with Brown's Alpert School of Medicine. Do they distribute cardboard Warren Alpert-shaped scents to hang from their mirrors in their cars? Give me a freakin' break.

Now I know what a few of the yo-yo heads out there will say. These men are great philanthropists. Mr. Alpert started the Alpert Award in medicine 14 years ago recognizing and funding important medical research. Sanford Weill is also a supreme philanthropist.

Philanthropy is not a profession. You can't be a "great" philanthropist. You can be a generous one, but greatness? Hey, it is the giving of money. It is not discovering a cure, a planet, and solution for peace. There are many generous philanthropists. I have an aunt who gives a hundred dollars every year to her favorite charity. There are countless who give weekly to their church when they pass around the basket. I don't see any medical schools named after them.

Is it volume or frequency that makes a philanthropist generous? Well, I guess in the naming of medical schools size matters. That's all that seems to matter.

Giving to others should be the ordinary, not the extraordinary. Naming a medical school should be reserved for the extraordinary. There is nothing extraordinary about amassing money. These two schools passed over countless of extraordinary Americans and Internationals and moved their school names into the realm of the deeply ordinary.

I am waiting for Harvard to change its name to R. A. Pit School of Medicine. I am sure Mr. Rats Arm Pit gave a ton of dough. I am sure it will be the same prestigious school.

A rose by any other name...

Dr. K.

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Walter Reed: Dot the "i"s, Cross the "t"s, and Dig the Graves

2007-03-14T09:42:00.000-04:00

Unless you have been living in a foxhole off the coast of a small island in the Pacific for the past sixty years you must know what has been going on at Walter Reed Army Hospital. What is coming out is a story of neglect of patients and the physical plant. A crime of monstrous proportions committed by hospital bureaucrats- these happen to be in the Army. For excerpts on the atrocities perpetrated on our wounded citizens you can go to this article. After you read it, you will probably want to declare war on the United States Army Medical Corps.

Why are we surprised at the substandard care at Walter Reed? Who has been watching them? Unfortunately this issue has not been covered by the media yet but the answer is even more troubling. The answer unfortunately has consequences for the care we receive at our own local hospitals where many hospital administrators spend most of their days filling out paperwork and glossing over inefficiencies to pass inspections from an agency called the Joint Commission on Accreditation of Healthcare (now referred as the Joint Commission). Every "i" is dotted and every "t" is crossed. Unfortunately, at the same time, every grave is being dug.

It appears that the the Joint Commission which accredits hospitals signed off on Walter Reed. Follow this quote:

"We're fully accredited by the Joint Commission on Accreditation of Healthcare Organizations, which awarded us a final score of 97 out of 100 during their regular inspection..."

Walter Reed Army Medical Center Web Site

I wonder what a score of 90 out of 100 gets you - cyanide PEZ dispensers?

In interviewing many doctors around the hospital, it seems that their own hospital administrators tout their Joint Commission stature but at the same time here are a few horror stories:

A patient requiring intravenous antibiotics for six weeks was sent home on antibiotics by mouth so the hospital can save the nearly $800/day antibiotic dose. The patient was soon readmitted to another hospital after the life-threatening infection came back.

A hospital had the opportunity to obtain a special blood salvage unit called an OrthoPat that would save hundreds of transfusions a year but chose not to get this because the administrator refused to make available the hospital nurse practitioner to start the unit the first day after surgery. I assume that contracting hepatitis is OK with this hospital administrator.

After repeated requests a hospital administrator refused to allow the stocking of premium antibiotic bone cement once the supply from a previous "cheaper" vendor was found to be defective and at risk to the patients. Now the surgeons do not put the same antibiotics in to prevent infections.

None of the above breaks any Joint Commission rules but clearly break rules of a higher moral code. A code that many hospital administrators do not abide by. Their code is saving money at acceptable harm rates to patients...and of course, pass Joint Commission surveys.

Apparently, just recently the Joint Commission pulled a surprise two-day inspection at Walter Reed. Wow, what a surprise. Where I come from it is called trying to cover your rear end after the fact. Where was this commission before the surprise inspection? Shame on them.

Years ago, hospitals were run by doctors and nurses that actually cared for the patients and made all decisions in the patients' best interests. Now many hospital administrators make bottom-line decisions without patient care and safety being their most optimal concern. They don't make decisions by moral reason but rather on the selective and arbitrary enforcement of hospital rules and by-laws. Anything to save money and pass those accreditation surveys. They will need all the help they can get because if Walter Reed scored 97 out of 100, your hospital will need to score 1000 out of 100 just to prevent killing a healthy patient. That ain't happening on this planet.

Now I know that when a hospital has a ground breaking ceremony they have a photo of the administrators and Board of the hospital digging the ceremonial first holes with a shovel. After the building is built they will need those shovels to dig the graves of those patients who died due to their bonehead decisions once the building started taking patients. At least they saved some money on extra shovels. I bet these shovels are accredited by the Joint Commission as well.

Dr. K.

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