On Health Care Rationing

From Michael Kinsey at the Washington Post:

I suspect that what a billion-plus dollars' worth of (comparative effectiveness) research will find is that perhaps 30 percent of what we spend on health care is almost entirely worthless, or just barely better than a much cheaper alternative. Or it might be better and no one knows for sure. Denying someone these treatments or tests is rationing.

Similarly, when fear of malpractice lawsuits leads doctors to practice "defensive medicine" -- a legitimate complaint about current arrangements -- it doesn't mean that they order worthless tests. It means they order tests with only a very long-shot chance of finding something wrong.

Here is a handy-dandy way to determine whether the failure to order some exam or treatment constitutes rationing: If the patient were the president, would he get it? If he'd get it and you wouldn't, it's rationing.

I think he gets it.

-Wes

Is Scientific Publishing About to Be Disrupted?

A remarkable and thought-provoking essay by Michael Nielson. Read the whole thing.

-Wes

Grand Rounds: Advice to Residents

And it's a good one over at Edwin Leap on advice to residents:

1) It’s going to be hard. Deal with it. The less you whine, the more you will be loved and trusted. Learn to be strong, learn to power through your fatigue. And remember that it often takes more energy to avoid work than to just do it.

2) Do the right thing. Ethically, professionally, morally. Be the one everyone can count on to do the right thing; however hard it may be.

3) Humans, to paraphrase Blaise Pascal, are glorious and wretched. Capable of nearly angelic goodness and demonic evil, they will both thrill and disappoint you. Be neither too judgmental nor too naive. And remember that you, dear ones, are human as well.

Nice.

-Wes

Virtual Consultations

"I'll be damned."

They were the first words I heard after I was called to the Emergency Room to see this older woman in complete heart block with a wide-complex escape rhythm at 33 beats per minute.

"Could this be why I've been so exhausted any time I try to do anything?"

Her disbelief continued.

I turned to the medical record to document my findings, notify the personnel to stick around for another pacemaker, only to find that another cardiologist had been notified of the patient's admission, written a note, and made an assessment - all electronically.

No detailed history. No exam. No review of labs.

Just this praphrased note on the chart from a doctor at another facility:

"3 weeks of fatigue. EKG demonstrates complete heart block. Pacer to be placed in AM by Doctor Frigamafratz."

A virtual consultation from another hospital, courtesy of the Electronic Medical Record.

"I'll be damned," I echoed.

-Wes

Twittering Your Heart Rate

Developed by Japanese geek forum Koress Project, the Akiduki Pulse box does this by autonomously posting your heartbeat to Twitter. Once there, friends, family and enemies can all watch as your natural rhythms play out on the world stage in real time.

Although it might sound like a good idea at first, your relatives might become a bit upset when Twitter crashes.

-Wes

Having Some Technical Difficulties

It seems my e-mail provider decided to "upgrade" their service over the weekend. This "upgrade" (I say that with a few expletives under my breath) has resulted in my inability to receive messages on my mobile phone and greatly complicated my ability to retrieve my e-mail at work due to our workplace firewall. As a result, comment moderation and responses to posts my be delayed as I attempt to rectify the situation.

Thanks for your patience.

-Wes

Biasing the Argument Against Specialists

In an article originally published in the Washington Post on 20 Jun 2009 and republished in the Chicago Tribune today, the national shortage of primary care physicians is highlighted and serves as a significant problem for health care reform efforts underway. The systematic devaluation of primary care relative to "procedural-based" medicine is again addressed:

The disparity results from Medicare-driven compensation that pays more to doctors who do procedures than to those who diagnose illness and dispense prescriptions. In 2005, for example, Medicare paid $89.64 for a half-hour visit to a primary-care doctor in Chicago, according to a Government Accountability Office report. It paid $422.90 to a gastroenterologist who spent about the same amount of time performing a colonoscopy in a private office. The colonoscopy, specialists point out, requires more equipment, specialized skills and higher malpractice premiums.

But, as mentioned previously, we should realize that Congress made attempts to correct this disparity though "fudge factors" to the RVU payment formula before:

In 1993, Congress declared a redistribution of funds from proceduralists to primary care physicians. Initially there were 2 conversion factors—1 for medicine and 1 for surgery. The conversion factor, ie, the multiple of the RVU for payment, had the added advantage of demonstrating where costs were increasing. The 2 conversion factors demonstrated conclusively that surgeons did not increase their utilization when reimbursement decreased (because, for example, patients have only 1 gallbladder, and the indications for its removal remain constant). Other specialties increased their utilization, a process that continues to this day. In a refining effort to shift money to primary care, a third and separate conversion factor was developed in 1995. By 1997, it was clear that separate conversion factors were not controlling utilization of primary care and medicine services, causing these 2 conversion factors to decrease. The 3 separate conversion factors were eliminated in 1998, resulting in a decrease for surgery and an increase for medicine and primary care. In addition, more surgeons' practice expense reimbursements are included under the indirect category, now reimbursed at 35% of cost; internists and primary care physicians have a higher percentage included as direct expenses, which are reimbursed at 66%.

But few mention these facts. Further, when payment differentials are cited between primary care and specialists (whom have been conveniently reduced to "proceduralists"), the 90-day global period (the surgery and all care related to the procedure for 90-days afterward) is rarely, if ever, mentioned in the discussion. Follow-up visits, dressing changes, wound checks, and management of complications - all conveniently ignored pre-paid for three months.

Without a clear understanding of all of the issues related to physician compensation and the problems with government's prior attempts at meddling with the system to correct the disparity between primary care physicians and specialists, we should understand that simply cutting specialists' fees in favor of primary care physicians might lead to not only additional primary care shortages, but an even more acute shortage of specialists as well.

-Wes

Our Pill Culture

She sat at the dining room table, counting.

"Let's see, a pink one, the tiny one, a big blue one, another one of those other white ones, the yellow one... oh, I don't take THAT white one until noon ... then one of those and one of those. There. I think I've got it."

She scraped then all in a little pile on the table, then swept them in her hand and tossed to pill pile into her mouth as she chased them all down with a slosh of water, looking a bit like a pelican downing an oversized fish.

"Ahhhh," she said. "Now, how about breakfast?"

I sat in amazement as I looked at my mother-in-law's pill pile. It really wasn't anything over the top: the usual medications for coronary disease, hypertension, adult-onset diabetes - all things I've prescribed a thousand times. But I could not help but wonder how our patients keep all this stuff straight.

Most doctors don't think twice about adding another drug here and there. After all, we always seem to have such a good grasp of pharmacology that we're absolutely convinced, I mean CONVINCED, that our new drug is important for our patient's management. But recently in the hospital I've noticed a problem that seems to be becoming more common: drug-drug interactions, or more accurately: drug-drug-drug-drug-drug interactions that can lead to unintended or unsuspected side effects, especially (in my case) cardiac arrhythmias.

These interactions are becoming tougher to identify as polypharmacy increases in America. Which drug causes what effect can be particularly challenging when people take plenty of different medicines. Nowhere is this more common than with psychotropic medications, especially tricyclic and tetracyclic antidepresants which might be coupled with analgesics, antibiotics, antifungal agents or sleeping medications and the like. Often, these make the perfect cocktail for cardiac catastrophe. We see this on the ward (if we're lucky) as polymorphic ventricular tachycardia or "torsades de pointes" (so-called "twisting around the points") - a malignant heart rhythm disorder caused by excessive prolongation of a resetting current for cardiac contraction called "repolarization." With the right circumstances and when it occurs at the correct time, a single skipped heart beat can cause the heart rhythm to lose all coordination and just quiver, effectively stopping the flow of blood to the brain. Also, sedatives can exacerbate sleep apnea and its resultant hypoxia (low oxygen level). Hypoxia, if significant enough, can cause significant cardiac slowing or even complete heart block.

I wonder, in all the sadness and turmoil surrounding Michael Jackson's recent death, if this same problem might have led to this popular pop icons' demise as well. By now, we have "heard" that Mr. Jackson was given an injection of Demerol (propoxyphene meperidene) shortly before his death. If so, demerol is usually given intramuscularly. But it would not be too inconceivable that one shot might have accidentally been injected into the vascular system, causing rapid sedation and overwhelming his drive to breathe. Follow this respiratory suppression with a few other psychotropic, analgesic medications, antibiotics or sleep aides, and not only might additional sedation occur, but a lethal cardiac arrhythmia as well, even in someone with totally normal coronary arteries.

To me, this scenario seems a much more plausible cause for Mr. Jackson's death rather than a massive heart attack, but then, since I do not have the benefit of reviewing his autopsy results, my thoughts are really nothing more than an educated guess.

No doubt by now there are a multitude of other guesses out there, a million opinions, and even more possibilities regarding the cause of Mr. Jackson's death. Everyone wants and, probably, needs an answer. Unexpected death is like that. But whether a definitive answer is ever found or whether the world will be permitted to learn the true answer is unknown at this point. Family takes precedence, in my view. But maybe there's some other take-home messages we can gain from this sad circumstance.

For one, we have become a pill culture, reaching for pills to cure almost anything and everything. We gobble them down often with barely a thought about their side effects as we eagerly seek a simple fix for what is often very difficult problems. Certainly, there there are scores of miraculous agents out there that have improved the quality and quantity of life for millions of us. (I am not advocating anyone stop any meds as a result of this blog post!) But I have become jaded about psychotropic and sedative medications because of my vocation as a heart rhythm specialist, especially when they are used in combination with other medications that can potentiate their effects or alter cardiac activity. Although drug companies have excellent testing to assure new drugs' safety, they simply cannot test the multiple permutations and combinations of medications on the market with their drug. New interactions are found all the time. It is a little known fact that many of the drug combinations we use today have never been tested in man. Further, patients might not disclose the use of psychiatric medications because of social biases toward psychiatric illness, or physicians, in their hurry to complete their 7-minute office visit, might fail to ask about psychiatric problems and medications.

Secondly, doctors have become pill-obsessed, too. All too often we don't take the time to refer our patients to qualified psychiatric or psychologic specialists. Instead, we try to add these drugs ourselves in the genuine hope of helping our patients with a "quick fix," perhaps not realizing all the consequences of our choice.

So maybe, just maybe, each of us can take a lesson from Michael Jackson, his "cardiologist" doctor, and others in a similar circumstance (Anna Nicole Smith or Elvis Presley comes to mind). First, patients must disclose all of their medications to their doctors. Second, doctors need to exercise caution when any medication, especially psychotropic or sedative ones, are are added to our poly-pill-laden patients and consider the cardiovascular effects that could arise.

Doctors and patients who would like to know many of the medications suspected of causing cardiac arrhythmias, a relatively well-maintained list can be found from the University of Arizona at qtdrugs.org.

-Wes

What Does America Think About Health Care?

A new survey (pdf) from the Economist.com with the full data here (pdf). Regretably, I was unable to find the methodology for the poll other than "1000 General Population" respondents.

Another poll with lots of numbers that mean what ever you want them to mean.

-Wes

h/t: The Happy Hospitalist.

How to Fund Your Cardiovascular Company

... have a Texas governor pass a bill mandating insurers pay for cardiovascular screening. The conflicts of interests involved, as I've reviewed earlier here and here, are staggering, but hey, it's all about making sure more people are considered sick so we can make them better, right?

-Wes

h/t: Schwitzer Health News blog.

Michael Jackson Found Down

He's currently in a LA hospital.

-Wes

The $400 Billion Dollar Question

Max Baucus (D., Mont.), chairman of the Senate Finance Committee, said after meeting with top Republicans on the panel that "the mood and tone is positive" among those trying to forge a bipartisan deal. "Nobody said...I'm outta here," he said. "We're going to have a bipartisan bill."

In another sign of progress, Senate aides said the committee has managed to cut $400 billion from the estimated cost of the 10-year measure, bringing it to $1.2 trillion.

"Obama Open to Health Overhaul Without Public Plan", Wall Street Journal, 24 Jun 2009

In policy, it's the story behind the story that matters.

About a week or so ago, the Congressional Budget Office came out with their projections for the cost of health care reform, and tabbed the bill somewhere close to $1.6 trillion dollars. Congress gasped. The price tag was so steep that even more conservative Democrats took pause.

And so, the "Senate aides" went back to work and sharpened their pencils. Magically, in the space of about a week, $400 billion in "savings" were realized. The proposal is now "on track" again.

But what, exactly, was cut?

Was it the pharmaceutical profits? Probably not, since they've already "come to the table" with price concessions.

Was it fees to hospitals? Probably not, they're already struggling to stay afloat.

Was it concessions from the unions? Probably not, after all, cost-of-living increases need to continue.

Was it the health information technology budget? No, we need that to save money, and to collect co-pays.

Was it quality assurance budgets? Not sure. But wouldn't a cut there potentially harm patients?

Was it legal costs? No way. Who will write the legislation and draft the bills that go before the House and Senate and assure the rights of all Americans?

Was it the doctors' salaries? Probably not significantly. The policy pundits understand that someone has to deliver the care.

No doubt there are many others at the policy "table" that had their say.

But in the end, the one person not at the "table" are patients. Eventually, every dollar cut from the budget will be one less to trickle down to the people receiving the care.

This is no surprise to me, but we must realize that everyone of us are having compromises to care imposed upon us when the pencil sharpeners come out and $400 billion are magically shaved from the health care delivery budget.

Putting this in perspective, yesterday a well-done study came called MADIT-CRT demonstrated that the addition of biventricular pacing to a defibrillator significantly reduces the complication of heart failure to asymptomatic or event minimally symptomatic patients with heart failure. Such a device costs about $30,000. Admittedly, heart failure is an immensely expensive complication of weak heart muscles because of recurrent admissions to hospitals, need for frequent doctor evaluations, expensive implanted devices, ongoing testing, and the like. As a doctor, it's hard to argue that patients' lives will benefit from this technology.

Now to digress a moment, when I was in the US Navy many years ago, we had a $1.2 million-dollar a year budget for our cath lab. We struggled to stay within that budget as we treated our active duty servicemen and women, their dependents, and often retirees. As defibrillators came on the scene, it became abundantly apparent that they would completely disrupt our budget. But there was no denying the benefit that these devices provided to our personnel.

So what did we do when we overran our budget? Well, first we "borrowed" from other budgets. After all, our devices saved lives, plain and simple. But expenses quarter to quarter kept growing. Sometimes, we also found that we did not have the latest technologies for our active duty personnel and we always happy to farm them out to the local private heart center since those expenses didn't come out of our budget - it was Tricare's problem then. And so it went.

Now getting back to the present discussion, we have to ask ourselves what will be our fiscal pop-off valve as new technologies are invented and lives prolonged in our health care system going forward? In the case of heart failure, will the government limit the number of defibrillators available for us to implant, or will they not, in favor of "permitting" budget overruns in one area and take from some other less-apparent part of the health care system? Should America understand precisely what is being cut when we see $400 billion suddenly disappear from the health care reform budget?

I would argue we must know.

After all, it's we the patients who are not at the policy table, and you can bet that it's the patients who will untimately be paying the tab, be it directly through health care premiums, or indirectly by taxation or deficit spending.

-Wes

A Candid Discussion of End-of-Life Decisions

... show-cased vividly by Richard Knox at NPR:

If any situation kindles the impulse to be heroic, it's the threatened death of one's father, mother, spouse or child. The feeling is so primal that we are regularly warned against medical heroism these days, when every community hospital has its intensive care unit and somebody else is paying the bill. Don't, ethicists caution, yield to the temptation to keep your loved one alive beyond any rational purpose.

Among medical personnel the practice is called "flogging," as in, "Don't flog a dead horse."

Who can disagree? Apparently a shrinking American minority. A plethora of polls in recent years consistently shows that more than 4 out of 5 people approve of terminating "extraordinary" life-support measures if the patient has no hope of recovery. Recently the consensus seems to be broadening to not-so-extraordinary measures, such as "tube" feeding and intravenous fluids.

Most of these polls are couched in terms of life support for terminally ill patients. But a 1988 poll of Ohio residents found 88 percent would not want to be "kept alive by extraordinary means if there were only a small chance of living a normal life."

All well and good, but when it's your father-mother-wife-child, the question is no longer academic. Suddenly you need facts and explanations. What's wrong? Can it be treated? If he survives, will he be the same as before? Will he be normal?

I know from 20 years of writing about medicine that even the best physicians often can offer no immediate answers to questions like these. I also know that doctors and nurses vary enormously in their ability and willingness to communicate medical information.

But the next two weeks will teach me anew how hard it is to extract and assimilate the data families need to answer the awful question: "Do you want heroic measures?" I will also learn firsthand that the question is often far from cut-and-dried, as many thoughtful people imagine when they fill out living wills or declare, "I never want to be maintained on a machine."

Well done. Read the whole thing.

-Wes

MADIT-CRT Meets Primary Endpoint

From a press release, just released:

Boston Scientific Corporation (NYSE: BSX) and the University of Rochester Medical Center today announced that the landmark MADIT-CRT trial has met its primary endpoint. Preliminary results show Boston Scientific cardiac resynchronization therapy defibrillators (CRT-Ds) to be associated with a significant 29 percent reduction (p=0.003) in death or heart failure interventions when compared to traditional implantable cardioverter defibrillators (ICDs). High risk(1), asymptomatic or mildly symptomatic, New York Heart Association (NYHA) Class I and II(2) patients were enrolled in MADIT-CRT. The MADIT-CRT Executive Committee expects to present and publish the trial's full results later this year.


MADIT-CRT, sponsored exclusively by Boston Scientific, demonstrates that early intervention with cardiac resynchronization therapy can slow the progression of heart failure. It is the world's largest randomized NYHA Class I/II CRT-D trial, with more than 1,800 patients enrolled at 110 centers in 14 countries. The trial is being conducted under the leadership of Principal Investigator Arthur J. Moss, M.D., Professor of Medicine at the University of Rochester Medical Center.

The MADIT-CRT trial was designed to determine if combined implantable cardiac defibrillator (ICD)-cardiac resynchronization therapy (CRT-D) would reduce the risk of mortality and heart failure (HF) events by approximately 25%, in subjects who were in New York Heart Association (NYHA) functional Class II with non-ischemic or ischemic cardiomyopathy and subjects who are in NYHA functional Class I with ischemic cardiomyopathy, left ventricular dysfunction (ejection fraction [EF] < or = 0.30), and prolonged intraventricular conduction (QRS duration > or = 130 ms). 60% of patients were randomized to CRT-D and 40% to ICD only.

This news could not come sooner to the medical device industry, but the fiscal realities before us make me wonder if soon we will dealing with medical device benefits managers, just like we're dealing with pharmaceutical benefits managers.

-Wes

Leading By Example

While I support the President at signing tough new no-smoking legislation, shouldn't he lead by example?

There are fewer touchier questions inside the White House than this: Is Mr. Obama still smoking? One administration official declined to answer on Monday, but pointed out that the president spoke in the present tense, “I know how difficult it can be to break this habit,” as opposed to, “I know how difficult it was to break this habit.”

If we're going to make the case repeatedly for "prevention" as a cornerstone of health care reform (and supposed health care "savings"), I would suggest he practice what he preaches.

-Wes

Killing Me Softly

I filter through progress notes looking for the few sentences different from the day before, only to find them sandwiching pages and pages of electronically-produced babble dutifully and automatically mass-reproduced in every note. I wonder, has anyone ever looked retrospectively at the mess created by this process developed to assure doctors were doing what they said they were doing? Ironically, I find we're rarely reading most of what we re-create each day.

But we're sure good at following the rules.

Next.

I now see prescription refills for each and every bottle of prescriptions ever filled by a patient, the date a patient filled it, and how many pills they received with each prescription. I’m not sure why. I sat awestruck in clinic yesterday when the list extended 94 pages, double-spaced, since January, 2009. No one, and I mean no one, filled that many prescriptions, did they? Or did they? Am I supposed to correct that list? Oh, by the way dear referring doctor, my note’s at the bottom of that listing.

Next.

I get pre-surgical notifications, even though I was the one to notify everyone else about the need for admission, just so I can click on the patient’s name again, lest it not appear I’m not doing enough, I guess.

Next.

I get EKG results forwarded for me to sign electronically, even though I’ve already read them, and signed them, by hand, on the EKG. I get notified again that the order I entered for that EKG now has a result, and I have to click on that to tell the computer, “I know.” But that, you see, is not enough. I must also log in, review, and sign off on my EKG’s on the EKG server, too. After all, I’m responsible, and it’s all about quality.

Quality three times over.

Now, multiply that same process for each and every other test I have ordered.

Next.

I see orders for things I’m not sure I ordered, just to be sure I’m responsible, and watching, literally hundreds of times per day.

Next.

I get e-mails and electronic notifications, and electronic communications, as if I know the difference.

Next.

I bypass nursing notes that are mere QA checklists and say nothing about the patient, except that a nurse was there last night.

Next.

I feel guilty entering data as I talk to my patient while serving my electronic master. Yet I find the stakes are high to assure accuracy and timeliness in clinical electronic reporting. After all, you never hear the bullet that hits you.

Next.

I go home on call, am paged, and reprimanded by a patient who wonders why I can't look up their medication list on-line, even though I'm standing in the grocery store.

Next.

Worst of all, I find myself sending myself messages, just to make sure I do something tomorrow that I could not get done today.

Killing me softly …

… with information overload.

-Wes

The World's Smallest Pacemaker Recipient

Pretty amazing:

When she was fitted with the (external, temporary) pacemaker, nine hours after her premature birth three weeks ago, Taylor weighed only 541g and is believed to be the smallest baby to undergo such an operation. She is now a healthier 720 grams (19oz), but is still so small that the grey and green heart regulator appears bigger than she is.

The pacemaker is an external one for now and will be replaced by a much smaller internal device, once the the baby grows sufficiently.

-Wes

Picture reference: David Caird, Herald Sun.

Medicine: Too Big to Fail?

After reading this piece in the New York Times, we have to wonder if the health care will be the next Hindenburg to fail:



I think Abraham Verghese, MD said (subscription) it best this weekend in the Wall Street Journal:

My wife tried to tell me the other day that she had just ‘saved’ us money by buying on sale a couple of things for which we have no earthly use. She then proceeded to tote up all our ‘savings’ from said purchases and gave me a figure that represented the money we had generated, which we could now spend . . .she had me going for a minute.

I mention this because I have similar problems with the way President Obama hopes to pay for the huge and costly health reform package he has in mind that will cover all Americans; he is counting on the “savings” that will come as a result of investing in preventive care and investing in the electronic medical record among other things. It’s a dangerous and probably an incorrect projection.

Dangerous and probably incorrect, indeed.

-Wes

How A Lawyer Would Save Health Care Costs

A lawyer, of all things, at Supremacy Claus shares ideas to shave health care costs by getting rid of the "pestiliential land pirate."

-Wes

How Clever Are You?

Okay, medical blog-o-sphere, opportunities like this don't come along often:

LOS ANGELES - Reese Witherspoon is going into the pharmaceutical business with Universal Pictures.

The studio is developing "Pharm Girl," an aspirational comedy centering on one woman's odyssey through the drug industry.

...

The project concerns a woman who gets a job at a pharmaceutical powerhouse and begins to see the underbelly of the industry as she rises through the company's ranks.

Anyone up for writing the trailer for the movie?

-Wes

EPIC's Worst Nightmare

... are screens like this.

-Wes

An Open Letter To Patients Regarding Health Reform

Dear Mr. and Ms. Patient,

It has come to my attention that in order for you to enjoy success as patients in the new era of health care reform, you must start working now to prevent illnesses that might befall you. Do not, under any circumstances, eat or drink too much. Fast food might as well be considered illegal. Exercise three, four, five times a day, even if it means take time off from work. It goes without saying that you should not smoke. The government has data that demonstrates how you have become fat, lazy, and a huge burden on our health care system. Your non-compliance threatens the very fiber of our economy. Even employers realize this, and are using calculators to figure your financial burden to them.

Now, in the unfortunate circumstance where you might become sick, you will need to develop symptoms that follow a few simple rules. Do not, under any circumstances, develop symptoms that fall outside federal protocols developed based on comparative effectiveness research data. If you do, your doctors will face pay cuts, litigation, limited resources due to lack of funding for cost-ineffective technologies, and the scourge of discharge planners. Does the term "leper colony" mean anything to you?

Rest assured, if you fall into one of the areas studied under the guise of comparative effectiveness research and I apply all of the 153 quality care measures deemed necessary, according to the President I will not receive a cut in pay and you will receive exemplary care. Further, my nurse coordinator will be more than happy to answer your calls, see you in the hospital, answer all your questions and service your symptoms. After all, Mr. Peter F. Orszag, an economist and Director of the Congressional Budget Office feels they are equivalent to my specialist care and will serve as "productivity enhancements," saving $110 billion. See how patriotic you'll be?

Also, do not be a surgical case that has any risk of failure. After all, "Complicated Patient" is the new scarlet letter as we work to cut even more costs. Fortunately, thanks to the new multitudes of guidelines for care that we must follow, I will be carefully interviewing you to assure that you fit into one of several pre-determined renumeration bins called "bundles." Please don't confuse me with more than one major disease since there is currently no way to handle this circumstance. I would suggest you pick the disease that bothers you most.

Unfortunately, after years of clinical practice I have observed several clever patient stunts, like failure to respond to medications, unusual unforeseen infections, having an rare disease, and the like. I strongly recommend against these shenanigans as we move forward. It is in your best interest to not require long hospital stays, dear patient, or else.

I wish you the best as we move forward in this exciting time. Please feel free to contact my automated pool of nurse coordinators if you have questions. They'll each open your message, play a little "hot potato" with each other, and then contact you as our information technology system streamlines communication.

Stay healthy!

Sincerely,

Dr. Wes

Who Needs a Public Plan When You Have Bundling?

We need to bundle payments so you aren’t paid for every single treatment you offer a patient with a chronic condition like diabetes, but instead are paid for how you treat the overall disease. We need to create incentives for physicians to team up – because we know that when that happens, it results in a healthier patient. We need to give doctors bonuses for good health outcomes – so that we are not promoting just more treatment, but better care.”

President Barack Obama's speech to the AMA, 15 Jun 2009

The public plan is likely to fail as intense competition against the proposal mounts, but given the relatively moot voice of physicians in the debate, bundled payment plans proposed by the President yesterday will be the hammer to drive cost savings.

An excellent article outlining the current limitations of any "bundling" proposal is published in HealthLeaders Magazine:

Essential to the administration's idea to reform healthcare payment is bundling, a way to reimburse disparate players in the healthcare marketplace for a basket of services provided to the beneficiary over a given time frame. In the proposal the president has floated in his budget, which is admittedly short on detail, a hospital might be responsible for a patient's welfare related to the procedure it performed for up to 30 days after discharge. If the patient requires rehospitalization during that time frame due to a condition related to the procedure, Medicare would not pay for it. Sounds good on paper, but implementing such a system is fraught with complexity. For example, if the patient's episode of care involves two, three, or more separate entities with no business relationships, how would one determine whose fault it is that the patient didn't do as well as expected and thus needed additional services? Is it any one provider's fault? Can blame be spread around? If so, how? What if a bad outcome is the patient's fault?

There are plenty of other problems they outline, too. Like when there's multiple comorbid conditions, which "bundle" will apply?

Or this quote: "The core issue is cash flow and how you divide the money."

Or how the patient cold become the bad guy in bundling schemes - even in ones that exist today:

Geisinger's guarantee is invalid if patients decide to use outside providers following discharge, for example. Certainly, Geisinger might have to change its model to reflect an "any willing provider" component to healthcare reform.

"If someone had their heart surgery here and developed a complication and then went to Philadelphia for care, that's not included in the bundle," says Paulus. "When people talk about accountable systems, it's not just the healthcare provider, it's the patient."

Hmmm. I wonder who pays in this circumstance?

Read the whole thing.

-Wes

Table Setting and The Scrum

I could never have said it better than David Brooks did this morning:

You want the scrum to be quick so that the bill is passed before some of the interests groups realize that they’ve been decapitated. You want the scrum to be frantic so you can tell your allies that their reservations might destroy the whole effort (this is how you are going to get the liberals to water down the public plan and the moderates to loosen their fiscal rectitude).

The scrum will be an ugly, all-out scramble for dough. You can probably get expanded coverage out of it. You can hammer the hospitals and get much of the $1.2 trillion to pay for the expansion. But you won’t be able to honestly address the toughest issues and still hold your coalition. You won’t get the kind of structural change that will bring down costs long-term. In the scrum, Congress will embrace the easy stuff and bury the hard stuff.

Which is why you have MedPAC. That’s the Medicare Payment Advisory Commission that you want to turn into a health care Federal Reserve Board — an aloof technocratic body of experts that will make tough decisions beyond the reach of politics. You can take every thorny issue, throw it to MedPac and consider it solved.

-Wes

A Cool Cat

I'm not really a huge cat-lover (though I have one), as a cardiologist, I might have to make an exception for this one.

Somehow, I bet he's related to this guy.

-Wes

Show Me The Money

Quote of the week from Tyler Cowan:

The demand for universal coverage sounds like a moral imperative to “take care of everybody,” but in reality it would make only a marginal difference when it comes to the overall health of the American population. The sober reality is that universal coverage is another way to spend money, which may or may not be a good idea.

The most likely possibility is that the government will spend more on health care today, promise to realize savings tomorrow and never succeed in lowering costs. It is rare that governments successfully cut costs by first spending more money.

No where is this better seen than in the case example of "prevention" being promoted in the most recent Time Magazine article, "This Doctor Does Not Want to See You." (Recall that Cleveland Clinic is one of those magic centers that provides Medicare care at less than the national norm):

The Cleveland Clinic and its 10 sister hospitals employ 40,000 people in Ohio, Florida, Canada and the United Arab Emirates. Cosgrove's idea is to turn those campuses into living laboratories, where healthy behavior is rewarded (with cash incentives if necessary) and people start thinking about health as an investment and a responsibility. In a demonstration of this commitment, Cosgrove even created new executive positions, including chief wellness officer, chief empathy officer (now changed to chief experience officer) and arts-program curator. These are not titles you're likely to find in any other organization.

And for good reason. "Chief Wellness Officer?" "Chief Empathy Experience Officer?" "Arts-program Curator?" Who are they kidding? Are these positions going to save money or merely blow through precious resources in the name of a political self-service?

When the government can show me they can balance the budget for our existing Medicare or Medicaid programs (the larger of which still only pays eighty percent of health care costs, by the way), then I'll start believing that they might be capable of handling the much ballyhooed $1.5 trillion dollar reform package soon-to-be presented before Congress responsibly.

-Wes

Why US Healthcare Is Expensive

It's not because we're inefficient.

Despite what others may say, it's not because we provide poor care and have high infant mortality.

It's not because we don't emphasize preventative care.

And believe it or not, it's not because most doctors are greedy and overtest for profit.

Oh sure, there are stories like this, where pre-terminal care lends itself to over-consulting and over-testing, in part because patients and their families have little financial stake in the game and, in part, because of the looming malpractice concerns for physicians. While important, the reality is that these concerns represent a mere 29 cents of the health care dollar.

And yes, there are the intermediaries: the insurers, the coding and compliance officers, the medical device companies and the pharmaceutical companies getting their piece.

But these patient care issues are minor weather disturbances compared to the health care cost jet stream that rises above all others: politics and the need for jobs.

Health care, after all, has become our economy.

If there is any question about this, look to down-state Illinois in the city of Springfield that serves as the capital of our president's home state. Look to city that has two main acute care hospitals, some of whom have entire wards that stand empty, feverishly competing with each other. Look for the new SimmonsCooper cancer care center, built on the backs of a wink and a nod to contractors and state regulators, yet remains shuttered.

Yet this does not thwart the director of this center. No, in his Spring newsletter he criticises the lack of coordination he observed in cancer care on a junket to King Hussein Royal Military Hospital in Amman, Jordan, while not even acknowledging that his own care center remains closed. He concludes:

"Let's hope that our efforts to educate our state government representatives on how we are helping to lessen the terrible burden of cancer in downstate Illinois will convince them to provide the necessary funding to occupy our new center this coming summer."

Earmarks. Waste. Inside deals. Hidden spending.

How do we make this part of health care reform?

-Wes

Pajamas Medicine

Wow, online consultations for $25 every 10 minutes! Compudocs for $150/hour.

Not bad, I guess, and it's the new rage with insurers. But "compudoc" sounds so boring. I want to coin a new name. Call it "pajamas medicine." After all, PJ medicine can be performed from the comfort of your own living room, any time of the day or night.

So here's a question: why not open pajamas medicine up to the rest of the world? I mean, think of where those prices might go! Maybe we'll be working for under $20 and hour soon! Wooooo hooooo! No fuss, no mess. No chance for the spread of swine flu because you don't even have to touch a patient!

And liability coverage? Well, that might be a little sticky...

But hey, let's not ask the tough questions. After all, it's medicine as a commodity coming to a computer terminal near you.

Oh, and that sentinal node? I'm sure it'll be the first thing they tell you about online.

Really.

-Wes

h/t BNET Healthcare.

How to Promote Heart Disease Awareness

I'm not making this up: Pole dancing.

Sounds like a good idea to me.

-Wes

Change of Shift is Up

Change of Shift, this week's best of nursing blogs, is up over at Florence dot com.

-Wes

The New Outback of Medicine

It's 4AM at one of the tens of thousands of long-term care facilities (sometimes euphemistically called "rehab centers") that dot the country. The silence is punctuated by a cryptic announcement from the public address system:

"Nurses, it's time to look out the window."

At 6AM, another announcement:

"Nurses, it's time to look at the ceiling."

Later, another:

"Nurses, it's time to look out the door."

All day, all night, 24-7-365.

This is not a reference to psychological wellness for nurses, but rather state-regulated instructions for pressure sore care that are happening now in the new outback of medicine: long term care facilities.

One of the key strategies of current health care reform to control costs are "bundled payments:" a single payment to hospital systems based on national norms for treatment that place the onus to save costs on the facilities and physicians. Through "comparative effectiveness research" strategies it is argued, "best practices" for care can be developed and disseminated to reduce costs. As these under-funded "bundles" are deployed, hospital systems will increasingly look to ways to shorten length of stays to remain fiscally solvent. As a result, patient census at long-term care facilities will only grow.

And from this group research strategy, comes group care.

Just like it's happening now.

"Nurses, it's time to look out the window."

-Wes

Rock On!

Thanks to Scott Hensley for pointing me to this article in New York Magazine about the rock band Giraffes’ Aaron Lazar who received an implantable cardiac defibrillator (ICD) in 2005 after an episode of aborted sudden death.

The best part? When he haggles about the device's settings:

Lazar returned to New York and met with his doctors and a rep from the ICD manufacturer. One doctor confronted him directly. “She said, ‘You really should not be doing what you’re doing,’” Lazar says. “And I said, ‘This is what I do.’” He then literally haggled with them over a new ICD trigger. “The doctor’s like, ‘Okay, let’s make it 195 for two and a half minutes,’” remembers Lazar. “And I was like, ‘Couldn’t you make it 200 for five minutes?’ It was like buying a mattress from Russians.”

Heh. Rock on!

-Wes

A Defibrillator In Action

If you ever wonder why I do what I do, there's probably no better example than to see 20 year old Belgian soccer player Anthony Van Loo saved by his implantable cardiac defibrillator (ICD):



In this video, Van Loo is seen walking from the field and then collapsing at 7 seconds, his legs are seen twitching at 15 seconds as his automatic defibrillator fires to restore his heart rhythm to normal, and then by 21 seconds after the event he regains conciousness and sits up. According to some reports, Van Loo was not allowed to return to soccer unless he had an ICD implanted due to his known cardiac disorder.

Despite all of the press out there, this is NOT a heart attack, but rather the result of a life-threatenting heart rhythm disorder like ventricular fibrillation or ventricular tachycardia. In young people, the cause of these life-threatening arrhythmias include right ventricular dysplasia, catecholamine-induced ventricular tachycardia, idiopathic cardiomyopathy, and long QT syndrome (to name just a few). At maximum output, a defibrillator can deliver about 830 volts in a tenth of a second to restore the heart rhythm back to normal.

-Wes

h/t: JC - A faithful reader.

Addendum: Video - Van Loo describes what he felt.

EKG Du Jour #16: Pacer, Pacer Everywhere

Yep, it's time for another in the series.

A 74 year old man with a biventricular pacemaker placed for a history of congestive heart failure is placed on telemetry following a total hip replacement. The "low rate alarm" on telemetry sounds, the nurses look, and note pacemaker spikes "everywhere" and want to transfer the patient to the ICU. You are called and review the strips:

Click image to enlarge

Should the patient transfer? What's going on?

-Wes

On Coping With an ICD

Nothing like a little barbeque to help implantable cardiac defibrillator (ICD) patients convert from victim to survivor!

Heh.

-Wes

Making the Best Out of a Tough Situation

A hospital administrator tries to look a the up-side of being laid off from his job. Not surprisingly, his blog might have been his salvation:

I feel very fortunate to have met so many people through this blog, and it has definitely helped me transition into the next chapter (more on that soon). Nonetheless, 100 percent of professionals know that they need to network. My advice: Be in the 5 percent that actually do it. And do it before you need it. If you wait until you need to do it, it'll be too late. All of my leads were with people who already knew me well.

-Wes

Rounds - Then and Now

Daily rounds - when doctors go to check on their patients and develop a therapeutic plan - have changed. A few short years ago, your list was developed containing the room room number, patient's name, diagnosis and looked something like this:

Room 2300 - Smith, Tom - CHF, Aortic stenosis
Room 2304 - Jones, Rhonda - s/p Acute MI, PCI
Room 4023 - Callahan, Robert - Atrial fibrillation
... and so on.

But now, our rounds have changed. We get to work, log on to the computer, and are greeted to this:

Addendum Notification Copy (1)
CC'd Charts (5)
Open Charts
Letters (1)
Covered Work
ED Follow-up (2)
Hospital ADT (4)
Incomplete Notes
Medication Cosign (15)
My Open Encounters (3)
Letters - Unsent (2)
Order Cosign (55)
Overdue Results (20)
Patient Call (3)
Patient Message
Phone Calls
Pre-Surgery Notification (12)
Result Notes (3)
Results (55)
Review Reports (4)
Staff Message (4)
Transcription Copy
Verbal Order Cosign (2)
Deficiency Letters (1)
Chart Deficiencies (1)

So if inpatients ever wonder where their doctors are, they should probably check one of the computer terminals.

After all, we're making rounds, 2009-style.

-Wes

Should We Be Fixing Medicare First?

Virginia Postrel sounds off on the Council of Economic Advisers "disingenuous" report claiming easily-reduced health care costs:

Think about this for a moment. Medicare is a huge, single-payer, government-run program. It ought to provide the perfect environment for experimentation. If more-efficient government management can slash health-care costs by addressing all these problems, why not start with Medicare? Let's see what "better management" looks like applied to Medicare before we roll it out to the rest of the country.

This is not a completely cynical suggestion. Medicare is, for instance, a logical place to start to design better electronic records systems and the incentives to use them. But you do have to wonder why a report that claims that Medicare is wasting 30 percent of its spending thinks it's making a case for making the rest of the health care system more like Medicare.

-Wes

h/t: Instapundit.

Repopulating Collagen Heart Shells to Make New Hearts?

Medgadget has the details. Although it's been done in rat hearts, there's plenty more to do before we see this in a human heart. Still, the potential is intriguing.

-Wes

Walgreens: Baking the Cake and Eating It Too

Why sustainable, affordable health care will not be feasible: when the CEO of Walgreens says stuff like this:

With more than 25,000 pharmacists at Walgreens stores alone, the chief executive of the nation's largest pharmacy chain sees his company's efforts go beyond just filling prescriptions as part of a solution he calls medication therapy management.

By helping patients stick to taking their medications and making better and more cost-effective choices, Wasson believes the country's pharmacists could help save billions of dollars in medical-care costs. That money could be used to provide benefits to more people.

But how to do this?

To make medication therapy management work, Wasson said, pharmacies would need to be paid more (my emphasis). Drugstores have long complained about the fees they are paid to dispense drugs, typically from $2 to $4 per dispensed prescription; Walgreens says costs are more than $10 per prescription.

Payments to pharmacies also would need to include the time to provide patient consultations, plus wellness advice and other tips.

"Wellness advice?" Everyone knows that Walgreens gets plenty of money from their convenience store model (pick up other goodies when you get your prescription).

Any health reform proposal asking to increase costs now in hopes of saving money later should be summarily shot down in these days of irrational health care reform spending exhubernance. (I have to wonder if the sudden added cost of prescriptions might be from their "buggy" e-prescribing system, but I digress.) The real question: where's the money going to come from for his "medication therapy management?"

Oh, I forgot, probably the Chinese.

-Wes

AMA

Note to reader: From another hospital years ago. Really.

She was older, frightened, and anxious about her racing heartbeat which woke her from sleep. She had come to the ER at about 2AM by ambulance after she noted considerable lightheadedness and some shortness of breath. Her initial EKG disclosed a heart rate of 200 b/min:

Click image to enlarge

The capable, bleary-eyed ER staff performed their magic: vitals, oxygen, blood pressure, telemetry and six- and then twelve-milligrams of adenosine:

Click image to enlarge

Ahhh. Her EKG a bit later looked pretty good:

Click image to enlarge

But it was late and the doctor thought she should be admitted. Fast heart rhythms like that might be a real problem, after all. The only problem was, she didn't want to be admitted.

"Really, I'm fine. I'll be just fine. Let me go home."

ER Doctor: "No ma'am. You need to be admitted. You had a heart rate of 200! I think you should be admitted, seen by our cardiologist in the morning and make sure you're going to be okay. Besides, it's awfully late. What will you do if it comes back?"

She pondered this a moment, looked at the circles under the doctor's eyes, and decided to go with the flow. She was admitted, taken upstairs and tucked in for the night.

But they forgot to connect her telemetry. All the stickers and heplock were in place, but the monitor was not connected. Seizing the opportunity, she acted. She quietly removed her hospital gown, donned her clothes and laid the monitor in a neatly wrapped pile beside her bed. She put on her shoes, went into the bathroom and adjusted her hair. She approached her door and peered left and then right. No one was in view. The light was turned off and she walked out. On the way to the main lobby, she called a taxi from the house phone and waited for it to arrive.

Then she was gone.

She proceeded home and slept in her own bed, EKG stickers, heplock, and all. She woke around 10:30 AM and realized she better get back to the hospital. She changed her clothes, brushed her teeth, ate a quick breakfast, and returned. She parked her car, went back to her room, and saw that a food tray had been left at her beside next to the monitor cables. She changed back in to her hospital gown, smiling as she thought about her evening. A few moments later a man in a white coat appeared:

"Hello ma'am, are you Mrs. Smith?"

"Yes"

"I'm sorry, I must have missed you earlier, I'm Dr. Frigamafratz, the cardiologist sent to see you..."

She snarled: "Where have you been?"

-Wes

Achieving Linearity in a Non-Linear World

Harlan Krumholz, cardiologist and professor of Medicine at Yale University, wants better doctor ratings:

For most patients, the decision of where to seek care comes down to a recommendation based on hearsay. Good reputation plays a role, but unfortunately studies show that just because you have a famous name doesn't mean that you're good.

Even doctors don't know what to do. I broke my collarbone in a bicycle accident a few years ago and had no good way of selecting a surgeon. I picked someone based on advice from colleagues, but neither they nor I had any way of knowing what his past results for this operation — or any operation — had been.

Our health care system has a grasp of the astronomical amounts spent on care, but we have little information about the overall results that we achieve. We lack a trustworthy source of information in most areas of medicine to guide this most critical choice. We don't have a Consumer Reports for doctors and hospitals — at least not yet. For-profit ranking systems, such as the 100-best-doctors-in-your-area feature found in glossy magazines or online, often do not fully reveal their methods or submit their measures to independent peer review. Patients almost always have to make blind choices about where to receive elective care.

The paucity of information about medical performance not only makes it hard for patients to choose care. It also impairs our ability to improve care. If we in the medical profession could measure results, we could weed out bad practices and nurture the good ones — and save more money and lives than we could with virtually any breakthrough procedure or medication we are likely to see in the near future.

I completely agree that even doctors can't figure out who to go to when problems arise. But to suggest this is a simple, resolvable issue that can be posted online misses the point. The issue is not just how many complications a doctor has, but how many procedures has that individual done in their lifetime, what is their diagnostic acumen, interpersonal skills, eye-hand coordination, fund of knowledge based not only on standardized tests, but clinical experience. Are these things simply quantifiable? Furthermore, none of these measures disclose a doctor's availability clinically, or their personality and compatibility with a particular patient. You can have the world's expert in anything, but his clinic is full, then whom do you go to?

Presently, board certification, years of experience, and legal history might be quantifiable entities to use to roughly assess doctors' capabilities. TO some, low complications might be most important, to others, an affable personality. But to suggest that this will EVER be a simple assessment that can be placed online seems ill-conceived since we're attempting to make linear a non-linear algorithm.

To me, it's still better to ask a good nurse you trust whom to see. They've not let me down yet.

-Wes

Looks Like a Pulse Oximeter to Me

Nintendo's "new" heart rate monitor peripheral for their new (as yet unannounced) Wii game:

The device – a pulse sensor that clips on to the player’s finger and connects to the Nintendo Wii controller – measures heart rate to determine levels of excitement, nervousness and even concentration.

Mr Iwata said he believed gadgets like the Wii Vitality Sensor would help to tap in to a new audience of gamers. “Traditionally, video games have been used to create excitement, but it may not be long before games help people unwind or even fall asleep,” he told the audience at the E3 video games expo in Los Angeles.

Man, think of the fun they could have with end-tidal CO2 monitors, esophageal and rectal temperature probes!

Now THAT would be exciting!

-Wes

Jackpot

Want to earn lots of money for your cardiology department? Just place an online "heart risk" assessment on your hospital's website and label 37.4% of the respondents "at risk:"

Since going live in late January, 7,072 people had completed the HeartAware assessment through early May, and 2,645 have been labeled "at risk."

"There's an awful lot of people who develop a bad event from heart disease on a yearly basis, not to mention the 8 or 9 million folks walking around with some form of blocked arteries and abnormal functions," said Dr. Vince Bufalino, medical director of cardiovascular services at Edward Heart Hospital.

"But when you look at the random public you wouldn't predict [these HeartAware at-risk numbers] up front," said Bufalino.

More than half of the at-risk test takers (1,597) accepted Edward's offer for follow-up services.

Wow. Think of all that testing, office visits and the like. Who knew?

Well someone did. Because with the stroke of a little logo change and voilà - another hospital in Maryland or Ohio or anywhere else you please can have the same assessment.

This is a program started by the HeartAware organization, a program of the National Heart Association. So who is the National Heart Association?

Well, I'm not sure. I'm not sure it's a real organization, but rather a front.

What I can tell you is that HeartAware is a product of Byrne Healthcare who labels this program as a "strategic marketing program for healthcare providers that identifies undiagnosed and at-risk individuals in their community that have disease and mobilizes them into their hospital or clinic." So it seems to me that the National Heart Association is really a marketing firm, and has nothing to do with heart health, other than to do marketing for hospital systems.

More impressive, they also have a whole line similar risk assessment tools for orthopedics, diabetes, stroke, sleep disorders, lung disease and cancer!

Now there certainly is nothing wrong with people being empowered with performing their tests online and seeing how their "risk bars" turn from "healthy green" to "threateningly red." But when Congress wants to look for ways to trim costs, maybe they should look at the fact that over 1/3rd of on-line people are found "at-risk" and a remarkably high number are undergoing testing that is likely to be of very low yield, moderate cost, has a real and significant false-positive rate to every test done that might incur more costs and more testing, and some of which might be quite invasive and carry significant risks.

But it's all about awareness, right?

Well, now you're aware that the so-called National Heart Association does not exist and maybe this prevention thing promoted by our President and government organizations to save costs in health care might just be doing the opposite.

-Wes