Thursday, July 30, 2009

A Brief Blog Break

I'll be talking an extended weekend at a location with limited internet and almost no cell phone access. As a result, comment moderation might slow a bit.

See you Monday.


Wednesday, July 29, 2009

Health Bloggers Speak on Health Care Reform

The video from our recent trip to Washington hit YouTube tonight:


The Careful Exam

When looking for the cause of atrial fibrillation during a physical examination, not only can the doctor's olfactory bulb be helpful, but so can the examination of what gets brought into the exam room.

Patient: "Hey doc, it's just a Pepsi."

Doctor: "Really? Can I see?"

Nothing a good knife and a piece of scotch tape can't manufacture.

Case solved.


What Real Health Care Reform Would Require

... open health care markets:
While congressional reform efforts screech and shudder along, let's take a moment to dream: What would real reform look like? It would be consumer driven, transparent, and competitive.

Right now consumers are locked into the health insurance and health care plans that their employers choose, thanks to previous government meddling with the health care system and the tax code. Consequently, most consumers simply don't have a clue what their health insurance costs. They have no way to reduce those costs, and no incentive to do so, even if they could.

Harvard University business professor Regina Herzlinger is stuck in exactly the same place as most Americans—her employer, in this case, the president of Harvard, buys her health insurance for her. "I wouldn't permit him to buy my house or my clothing or my food for me. Yet as my employer, he could take up to $15,000 of my sala­ry each year and buy my health insurance for me, without knowing anything about my preferences or needs. It's ridiculous."
Read the whole thing.


Saving Costs in Cardiac Electrophysiology

If the government can manage to find $100 million dollars in government cost savings by realizing they can use both sides of a piece of paper, it's high time electrophsyiologists do their part to help our national fiscal crisis!


Cartoon courtesy Yahoo News with h/t to "Marco."

Tuesday, July 28, 2009

Mission Impossible

The elevator door opens, and a handsome man wearing dark glasses appears, looking something like a Gentleman's Quarterly magazine model. He makes this way to the swank hotel lobby front desk, and is immediately noticed by the young clerk with the French accent.

“Bon jour, monsieur. May I help syou?”

“I understand there might be a package for me here.” he asks in a hushed tone.

“Ze name?”


“Shust a moment, Monsieur Phelps.” She retreats behind the desk and returns, carrying a manilla envelope. “Here you are, monsieur.”

He walks quietly to a corner table at the hotel’s dining room, tipping the waiter to permit him some privacy for a few minutes. He sits, opens the envelope, and removes its contents. A small Bluetooth headset and latest Apple iPhone GS-99 XKE is removed. He deftly assembles them and finds the video play button. A man appears.
“Good morning, Dr. Phelps.”
He smiled slightly. He liked to hear that familiar introduction. The video continued:
“As you know, Sanofi-Aventis, makers of the new drug to treat atrial fibrillation, dronedarone (Multaq), have been actively recruiting doctors to serve as speakers to promote their drug. They are required to speak verbatim from slides housed on a central server using a protected link to the server's flash-player software. No anecdotes can be uttered lest they be terminated. Most remarkably, Interpol has discovered that when recent physician recruits inquired about the cost of the drug as it compares to its competitors, a lawyer stood and claimed that discussing price was illegal. He claimed that because the price would vary from location to location, to discuss price would put the company at liability risk for false advertising.

Your mission, Jim, should you decide to accept it, is to find the price of dronedarone that patients and pharmacy benefit managers will have to pay on the open market. Your unique status as a cardiac rhythm specialist, paired with your unique background, should make it easy to infiltrate the organization. As always, if you or any members of your team are caught and terminated, the Secretary will disavow any of your actions.

Good luck, Jim.

This video will self distruct in five seconds."
Seconds later: Shhhhhhhhhhhhhhhhhhh. Bbbbbzzzaaaappppppppppppp. The iPhone screen went black.

He pondered the mission as he glanced about making sure no one saw the phone screen.

Somehow, the French woman behind the counter seemed the simpler mission.


Addendum from Interpol: "Good work, Dr. Phelps."

Monday, July 27, 2009

You Get What You Don't Pay For

Like fewer cardiothoracic surgeons:
"The reasons for this declining interest appear to be multiple," according to the investigators. For one thing, they note, the number of coronary artery bypass graft operations, in which surgeons reroute blood flow around block arteries that supply the heart, and which account for a large part of the surgeons' income, fell by 28 percent between 1997 and 2004. Many of these operations were replaced by stents -- mesh tubes that prop blocked arteries open -- inserted by cardiologists, not heart surgeons.

Furthermore, Medicare reimbursements for bypass surgery have fallen by 38 percent. Finally, newly trained cardiothoracic surgeons have had trouble finding jobs.

For the supply of cardiothoracic surgeons to be adequate in the coming decade would require elimination of coronary artery bypass operations, and numbers of young surgeons entering the field must be as high as in the 1990s. Since these are both highly unlikely, the researchers continue, the number of surgeons entering training in cardiothoracic surgery will probably be "inadequate to care for the US population in the coming decades."
But then, this is what proponents of cutting specialists' income want: fewer costly specialists, all in the name of "cost savings."


Reference: "Shortage of Cardiothoracic Surgeons Is Likely by 2020" Circulation Published online before print July 27, 2009, doi: 10.1161/CIRCULATIONAHA.108.776278.

Friday, July 24, 2009

On MedPac and Robots

Yesterday in our cath conference, we discussed the substudy from the prospective randomized trial called PREVENT-IV just published in the New England Journal of Medicine. That study evaluated the major adverse cardiac event rates of minimally invasive vein harvesting compared to open vein harvesting prior to coronary bypass surgery.

I was surprised to see that minimally-invasive vein harvesting had a higher combined complication rate of death, myocardial infarction (heart attack) and need for revascularization in the patients who received vein grafts harvested by the minimally-invasive technique. Following the presentation of the data, our surgeons were asked why this might be the case. While none knew for sure, they postulated that the art of harvesting vein-conduits using endovascular techniques might play a role (it's more difficult), or the effects of the thrombolytic state induced by on-pump bypass vs. off-pump bypass might create the discrepency in post-surgery vein survival, since patients are less likely to develop clinical thromboses in the post-open chest bypass population.

So this morning, I was surprised that President Obama toured Cleveland Clinic yesterday and had such an up-front experience with minimally-invasive robotic surgical techniques for mitral valve repair that hardly represents mainstream American health care. While the marvels of the technologyy cannot be disputed, like the endovascular vein harvesting study above, might we find that robotics could be as deliterious to patients compared to open chest techniques? After all, these techniques have yet to be compared in multicenter trials to more conventional open techniques for mitral valve repair. But more concerning as we move forward is this question: will academic centers be granted more funds to test comparative effectiveness research for robotics at the expense of front-line American health care? Surely, this won't be, will it?


But when I see pieces like this I wonder why the article does not question the cost and risks of this technique compared to conventional open-chest procedures, especially in this era of touting the need for health care cost containment. How much is this piece about the marketing of this technique to the community (for financial gain) or to the President (for obtaining grants or political favors)?

Perhaps we should ask ourselves how many of the physicians and surgeons at Cleveland Clinic stand to earn a seat on the proposed MEDPAC board that will determine if Congress will approve payment for robotic techniques even when few data exist to show their superiority over conventional techniques.

Now that might make for some really interesting reading.


Wednesday, July 22, 2009

President: Doctors Consult Fee Schedules First

It came at 47 minutes or so in the President's press conference last night (bold emphasis mine):
We wanted to make sure that doctors are making decisions based on evidence, based on what works. That's not how it's happening right now. Doctors are forced to make decisions based on a fee payment schedule that's out there. So they're looking... if you come in with a sore throat or your child comes in with a sore throat, has repeated sore throats, a doctor may look at the reimbursement system and say to himself, "I'd make a lot more money if I took this kids tonsils out." Now that might be the right thing to do, but I'd rather have that doctor making those decisions based on whether you need your kids tonsils out or whether it might make more sense to change, uh, maybe they have allergies or something else that would make a difference. So part of what we want to do is free doctors, patients, hospitals to make decisions based on what's best for patient care.
It is rare to see such hubris, such blatant disrespect of our profession by an individual on a national platform. It disregards the sacrifices doctors make every day on behalf of their patients. It speaks nothing to the requirements for learning our craft, the push to follow treatment guidelines crafted to improve care standards, about the recertification doctors must undergo every 10 years to remain credentialed and licensed, about the ever-present litigation risk that hovers over patient decisions and remains unscathed in the health care reform debate.

Now I admit, doctors have incentives to test, and test often, but that incentive is driven not by fee schedules, but assuring that no stone goes unturned and quality and comprehensive care assured. But more importantly, sometimes referring the patient for the expensive treatment is in the best interest of the patient: like referring a patient with three-vessel coronary disease for bypass surgery.

To think that the chief architech of health care reform in America feels this is how doctors make decisions is especially concerning. Now we know what we're up against.

But talking points aside, what is clear is that government officials have no place in attempting to proscribe the delivery of health care. With all due respect, politicians are not known for their honesty, humility, or trust-worthiness. Perhaps this colors their perception of another profession.

Mr. President, you owe America's doctors an apology.


EKG Du Jour #17 - The Seizure

Editors note: File this one under "Classics." Used with permission.

She was only six years old when she was diagnosed with a seizure disorder and placed on Dilantin (phenytoin). She did well for years with a normal physical and cognitive development. Many years after her initial seizure, it was elected to stop her Dilantin, since it was felt she might have outgrown her need for the medication. Unfortunately, not to long after while sitting in the passenger seat of the car, she suffered a cardiac arrest, and slumped forward. 911 was called and the paramedics found her to be in ventricular fibrillation. A single external cardioversion restored sinus rhythm. Gratefully, she recovered completely.

She eventually went on to get a defibrillator after her cardiovascular workup demonstrated no structural cardiac disease. Her dilantin was continued and she did well, until a cardiologist tried to stop her dilantin; she received a flurry of ICD shocks when that occurred. The dilantin was restarted and she has not had any ICD shocks or non-sustained VT detected on her subsequent defibrillator interrogations.

Oh, what does her EKG look like now, you ask?

Like this:

Click image to enlarge.

So while the general diagnosis might seem obvious to the skilled EKG reader (I'll let you figure out which specific type of disorder this represents), it is clear that her antiarrhythmic of choice for this patient is dilantin: it as been well-tolerated for years, highly effective, and safe for her for over twenty years.

I wonder what will happen the our comparative effectiveness research czars note that the treatment for cardiac arrhythmias with this drug is not labeled as indicated for this disorder. Will her prescription no longer be covered?


Tuesday, July 21, 2009

I'd Better Get Some Extra-Large Catheters

You've got to love health care marketing:
NorthShore University HealthSystem, a large hospital operator in the northern Chicago suburbs, said it has signed a three-year deal to be the health-care partner of the Chicago Bears.

The deal comes after the National Football League for the first time allowed NFL teams to display sponsorship logos on their practice jerseys, NorthShore and the Bears said.
Remember guys, overtime is okay, just no "sudden death," you know what I mean?


Lessons from a Wheelchair

Thanks to Medicare, a $348-dollar wheelchair costs taxpayers $1200.

Here's why.


The Push to Medical Practice Decentralization

The pager bleeped at 06:15 AM this morning.

It was a nurse, calling me bright and early to ask a favor; her mother had an appointment in our office the following day, but my office was 20 minutes west of where she lived.

“Do you ever see patients in the office closer to me?”

I explained that I used to see patients in three offices, but found that no single office was adequately staffed and rather than spread ourselves too thin (not to mention save on costs), we consolidated our offices into one location.

The nurse capitulated and agreed to bring her mother to our more remote office.

I have been interested to see the commercialization of medical practice based on a corporate McDonalds-like philosophy of a medical office on every corner. Certainly access is key for primary care practices working to attract patients, and the competition engendered by doc-in-the-box services are real. After all, convenience and availability go a long way to improve patient satisfaction and the availability of the electronic medical record should make this possible, right?

But I wonder if such an approach is always so advantageous for specialists and their patients.

I find it funny that some well-to-do patients would travel to tertiary care centers outside of our state for the “finest” of care, yet gripe when they have to drive across town to a specialist’s office for follow-up pacemaker appointments.

The downsides of decentralizing office personnel for specialists are significant: more staff are generally required, more rent, phone lines, maintenance, etc. Highly trained technicians that are involved in performing in-office procedures (in our case, pacemaker and defibrillator follow-up) could perform procedures independently at more than one site, but the benefit of the availability of a second technician-colleague or a doctor that is always on-site to help trouble-shoot problems and speed patient management can’t be overestimated. Simply put, it's hard for one doctor to cover two clinics and far easier to supervise two technicians at one clinic. Further, there is benefit to patients if there’s “depth on the bench.” That is, if one technician goes on vacation, another technician can remain behind to assure continuity of care. To me, quality care should supersede convenience in this case.

But I find myself constantly beating back to “convenience” proponents, and so far, I'm winning. But as competition heats up between large behemoth health care organizations, I wonder how long I’ll be able to hold out.


More Reactions to Putting Patients First

Another compilation of the discussion and reactions to the Putting Patients First conference held in Washington, DC on 17 July 2009 is nicely summarized by Evan Falchuk (a lawyer of all things and remarkably nice fellow) over at See First blog.


Saturday, July 18, 2009

Washington Wrap-Up

Once again, I have to thank Dr. Val Jones for setting up the Putting Patients First event at the National Press Club in Washington DC on Friday. For a full summary of the pagentry, Dr. Rich does a much better job summarizing the whole event than I ever could, though I was uh, surprised about what he said of me (thanks, dude).

But one thing he forgot to mention was the moment when our moderator asked us what struck us most about what Congressman Paul Ryan had to say in his speech to us. I, being ever soft-spoken, piped up that I was struck that no one had read the bill and it was already on its way to the floor after being completely "marked up" early that very same morning.

So, while we might not have been chasing windmills at this event, I couldn't help but wonder if it might come to this (with appologies to GA Harker, whose illustration I couldn't help but Photoshop):

Click image to enlarge


My Comments At the National Press Club, Washington DC

For those interested in what I said at the National Press Club, in Washington DC on Friday, here's it is, though it was shortened due to time constraints:
Today, we come here not as experienced politicians, layers, policy pundits, big-money insurance or health care executives, but as doctors and nurses – just like one of those you want to see when you or a loved one is struggling with a complicated medical problem or lying awake at night wondering what to do. My face is the one you want to see – NOT a nurse coordinator.

And because I know you, because I have treated you, and have trained extensively and seen your problem before, seeing me can literally mean the difference between life and death.

I can be there for you because I still find enough reward in my job. I am still able to stay devoted to it, because I have professional freedom, because I love helping, and because I give my family a good living even as my kids see their Dad rushing off from dinner, a ball game, or holiday event that they will never remember.

And yet, some of us are watching the evolution of a health care delivery system that appears to care more about the system than the very patients it is supposed to treat. One only has to look at the diagram of the recently-proposed health care system interconnections, to realize that the health care providers and consumers are on opposite sides, separated by so much regulation and oversight, we wonder who stands to win.

It seems we are about to underwrite and unprecedented $1.6 trillion in government spending for a huge bureaucracy that piggybacks on two other government systems that are already nearly bankrupt: Medicare and Medicaid.

You may recall that we tried once to provide affordable housing for everyone at low cost or no cost through convenient government-run and regulated mortgage deals, only now we see the consequences of that effort to our economy. Make no mistake; we are now about to offer affordable health care to everyone through similar creative government-run insurance and oversight regulators. Like in the housing failure, do we really know what we’re up against? What happens when we realize that we can no longer afford our new plan? What cuts will make then?

Now many people have worked hard to develop a plan for health care system reform. People from all political persuasions, economists, scientists, and scholars have tried to create a new way of providing health care to every American. There is no denying this is a laudable goal.

But when it comes to health care, where should we invest the most? In the infrastructure or the caregivers? What will government-mandated cuts to the salaries of some of our best and brightest caregivers in an effort to balance the cost of such a system mean to our patients? We hear seemingly well-reasoned essays about how it’s the caregivers that are the problem because we order all of the expensive tests.

But why do we?

Is it to make a profit? Or might those tests be necessary to establish the cause of that lump you felt? While we certainly could go without some tests to save money, to doctors, the legal implications of doing so risks our very livelihood. Can we really continue to ignore the threat to your pocketbook that ever-rising malpractice premiums create?

Now the President has suggested that if I just use comparative effectiveness research to make my decisions and stay well within their recommendations, I will not get sued. But every patient walking through my door has the potential for virtually infinite constellations of diseases. Every one practicing medicine here today knows this. In the new era of health care delivery proposed, will my job be to parse these complexities into formulaic protocols in order to get paid and avoid litigation? Most patients don’t fit into these boxes. While treatment recommendations from such research are helpful, they can not take the place of personal and private discussions between the doctor and patient about their treatment. Simply put, coercive enforcement of this policy to mandate treatment by protocol is an assault on the doctor-patient relationship.

Moving on, I work in a hospital with one of the most comprehensive electronic medical record systems in the country. I have seen first-hand the potential benefits of such a system to provide world-class care to our patients and improve communication between doctors. It brings test results and images right to my desktop so I can explain results in real-time with my patients. But while these are some of the wonders of such a system, the information overload presents its own problems.

First, I must type and type really fast. As such, I look at monitors more and you less.

Second, our current billing system requires that I code every diagnosis you have, and place it in a computer form. Our current coding scheme, developed by our own American Medical Association, contains 17,000 non-descript codes that must be correctly entered or else you won’t receive your insurance payment, Insurers have used these for years to justify claim denials. Beginning 1 October 2011, these codes are set to balloon to some 155,000 codes. Tell me, how many computer programmers will be required to update our current systems and how many denials will you experience then, all in the name of cost savings?

Finally. all of that data that I enter is just too tempting for hospital leadership to ignore. “How do we do things better? Where can we cut?” they say. “Could we offer new goods and tests on your behalf in the name of ‘prevention’ and ‘wellness?’” We’re all about prevention to save money these days, after all.

But I have seen a different motive: the bottom line. Computers, you see, are as much business tools as they are medical tools, maybe more so. The rush to widespread implementation of the EMR without dealing with these conflicts is simply not in the interest of the doctor-patient relationship.

In hosptials, we rationalize the deployment of hoards of oversight bodies, government regulators, performance enhancement specialists, market researchers, safety monitors, and hall monitors - all to make sure that we have the safest, most cost-effective healthcare with glowing “quality scores” published on our websites. More recently, we have made this an economic necessity for our struggling hospitals. How cost-effective are these strategies? As doctors clear their desks once a year to get ready for inspections, do they truly make a difference? How many ward nurses have had to be let go to make way for these regulators?

I think most patients want their doctors to be happy, engaging, and happy with their vocation. After all, when they can stay focused, attentive, and engaged in their patient’s care, patients do better. But these are uncertain times. If a doctor dares to question the rush to government health care today, they are labeled as unsympathetic to the uninsured, unsympathetic to the unemployed, unsympathetic to the plight of the illegal aliens, unsympathetic to the chronically ill, or “you just don’t get it.” You see you just don’t have the right to have the common sense you have.

The honest truth is, if I could help the uninsured, and unemployed and chronically ill while preserving my relationship with you – I would. If I could solve these problems while preserving my love for medicine – and the devotion of my colleagues, I would.

Fortunately, I believe we can.

But we can’t do that and continue to fund the gravy train. And that gravy train is the multi-billion dollar health insurance industry with executives who made over $24M annually in 2007, the $800B pharmaceutical industry with executive compensations of over 25 million dollars the same year, the over $24 billion spent in one year in our country on new hospital construction, the nearly half a billion dollars in political campaign contributions from health care special interests a single year (2008), and the 55-80% increase in malpractice insurance premiums that your doctors have paid over the past 5 years.

Yes, there are problems with our current system, too many to describe in this brief press conference, but for the first time, a serious dialog about our problems and how to solve them is underway. How these reform ideas really translate into reality, how they look to those of us on the ground, has to be played out before our patients are put at risk. The only people who can play that out for you are the frontline caregivers. If we don’t have the time or patience to do that, we’ve got a problem.

There are creative ideas afloat, like insurance-free medical homes costing less than a dollar a day for unlimited access being test-run now to address many of the concerns of the lower income and chronically-ill in America that doesn’t involve a middleman, unless you want one. There is the idea of open source health information technology that would promise greater scalability, intercommunication between health care facilities, and cost transparency. Better still, billions of dollars of taxpayers’ money could be saved on drug and device costs tomorrow – that’s right, tomorrow - if we stopped wasting those dollars on direct-to-consumer advertisements on the Nightly News.

You see, there are real clinically-involved doctors and nurses eager to become part of the solution who refuse to believe that they are the problem.

And that’s why we’re here today. Not as a passive voice that bows to the whims of those who with much larger financial stakes in the industry or as someone who has no clue about health care delivery, but as concerned doctors, nurses, and nurse practitioners who are eager to propose real solutions for reform.

Wednesday, July 15, 2009

Medicine Soon to Be Low Touch or No Touch

Warning to medical receptionists: your days are numbered.

As medicine continues to go the "no touch" route, I wonder who will answer the phone? Seriously.

Oh, I forgot, it'll probably be someone overseas.

Yep, health care information technology at its finest.


Tuesday, July 14, 2009

Implications of Cutting Cardiologists' Payments

It's been interesting to hear my cardiology colleagues in the community discuss what the proposed CMS cuts might mean for their patients and the implications for therapy access for patients requiring cardiovascular services.

In one local group, 40% of the cardiologists are over age 55. Now imagine cutting their practice income between 11 and 42% this year, with the potential for additional cuts yearly afterward. Recall that payments collected must first pay for office overhead: staff, collection personnel, lease payments, rent or mortgage, taxes, etc. These expenses do not go down annually. Cardiologists' take-home pay will be the item ultimately affected by these cuts. If a cardiologist makes, say, an average of $350,000 and one assumes a 50% overhead cost for his practice before the cuts, then $175,000 must first go to support his overhead. If income to the cardiologist's office is reduced 20% (on average) in 2010, then of the total $525,000 that was collected last year will translate to only $420,000. Since the practice expenses remain (at best) constant, the cardiologist's salary will be $245,000. ($350,000-$105,000 = $245,000).

Most internists and primary care doctors are quietly smiling right now. "Serves 'em right!" they snicker under their breath.

But if we consider this threat, is there an incentive to order fewer tests to offset their losses as they struggle to pay their kid's college educations?


Further, recall the fact those "rich" cardiologists do not finish their training until age 30, on average, and that about a third of them are over age 55. We have to wonder if many will opt for early retirement instead of tolerating the bureaucratic hassles and salary cuts. After all, the nice thing about an MD degree is there are plenty of other options besides clinical care.

Alternately, in exchange for the dramatic salary reductions, they might demand a better life-style with better hours. If so, 90-minute door-to-balloon times might not be so easy to come by for hospitals. ER's might not find cardiologists quite so available, too, since the added 8% added to E&M codes won't offset the economic losses enough to warrant this extra workload. Hospitals' quality ratings will likely fall as they fail to meet their benchmarks and Medicare payments will dwindle to them, too.

While these cuts might help the Medicare budget very slightly and look good to policy pundits who have never had to go to a hospital at 2AM for an acute MI (heart attack), it's an entirely different thing in real life. Regretably, it's often the patients that lose.

Is this the price our system is willing to pay?

Perhaps. These cuts are certainly on the table. (Warning: pdf, 1277 pages).

But one thing's for sure, with these cuts will come consequences. Given the fact that cardiovascular problems are one of the most common ailments in man and a large number of cardiologists are approaching retirement age, these are going to be every tough times for doctors, hospitals and patients alike.

Is this who should be affected most by our current reform plans?

I wonder.


Monday, July 13, 2009

The Same Old “Same Old”

Years ago I practiced cardiac electrophysiology in an “EP-only” practice in Cincinnati, Ohio. There were three of us in our practice at the time, providing EP services to cardiologists who were not part of the larger 50-man cardiology group. I was credentialed at 11 hospitals and worked out of three different hospitals’ EP labs. Needless to say, I tried to make it work, but found myself running between hospitals so often and being called back to hospitals where I had already been, that the practice model did not work for me. After trying to make the practice model work for three years (I was not very bright then and was SURE my challenges were because I was a neophyte to private practice medicine), I left.

From that experience, I learned what it took to be a private practice cardiac electrophysiologist and just how hard it was to generate revenue with only professional and technical revenues from EKG’s, event recorders, and Holters, and the evaluation and management (E&M) codes as we rounded on our patients at each of the hospitals each day. It was virtually impossible to run a viable practice, since paying the receptionist, the billing and collection clerk, the nurse or medical assistant and office overhead came well before our salaries. Only our professional fees collected from invasive electrophysiology procedures generated a high enough amount of cash flow to survive. These, I came to find, were one tenth of the amount that hospitals collected for the use of their lab facilities. This was almost 10 years ago and that practice no longer exists. It was eye-opening to say the least.

But was even more eye-opening was watching how prices were negotiated between hospitals, insurers, and employers. Hospitals had the facilities, insurers had the money, and employers had the potential patients. First came the negotiation between the insurers and the employers, as “products” with varying deductibles were offered to employers to garner their business and “trust.” To win those contracts, insurers commonly presented low-cost options attractive to employers. The insurer would then come to the hospital with a promise of 10,000 or more potential patients, but would want the lowest possible price, otherwise they’d take their patients to another hospital in the city. Hospitals, eager to grow their patient referral base, would bitch and barter, and finally a deal was struck. Only then did they report to the physician the deal that they had hatched and the amount the physicians could expect to see for each procedure. Doctors then had to decide if they were “all in” and willing to accept an individual carrier’s patient volume. If so, they would agree to see patients from that insurance panel at the negotiated rate. Usually, they had to accept a lower price for larger groups of patients without any ability to negotiate the terms agreed upon. The problem with Cincinnati was there were too many hospitals and too few big employers, so the negotiations were particularly challenging for insurers there: they had to offer really low prices. Suffice it to say, the intermediaries got theirs while doctors and patients were left to make due with the fees paid and the services paid for, often creating a vicious cycle with more patients seen in less time, higher patient deductibles and all-too-often patients that were unhappy with their patient care experience while paying more for the pleasure. Needless to say, Cincinnati has had trouble retaining doctors for this reason.

But this cycle is not unique to Cincinnati. The annual courtship between insurers hospitals and employers recurs countless times across the country. Insurers, hospitals, employers offering prices, patients, negotiation terms that doctors and patients have no hope of deciphering.

And now, to maintain their stronghold on the bureaucracy, we see the same negotiations going on at a national scale happening behind closed doors with our Congressional leadership.

No real change where patients and doctors know what’s going on.

Just the same old “same old.”


Sunday, July 12, 2009

Medicare's Mythical Cost Savings

Meghan McArtle makes some interesting observations in the Atlantic Monthly:
Monopolies, government or private, are risk averse, slow to innovate, and generally run things for the benefit of themselves rather than their customers. Hamstringing them with regulations can limit measurable outcomes, like excess profit-taking, but not unmeasurable ones, like the people who might have been cured by a drug the system didn't invent. And the political system introduces its own problems. As Robert Heinlein pointed out years ago, systems that have only positive feedback loops tend to fail catastrophically.

My critics will want me to explain why, then, Europe can do it cheaper. The answer is threefold. First, most European nations have better governance than we do--the American political system is a Public Choice disaster. Second, they pay people less money in a way that's hard to replicate here (and even if it wasn't, would be a one time savings that wouldn't check the rate of growth). Third, we're still driving quite a bit of product innovation. Our messy, organic, wasteful, unfair, irrational system allows experimentation, and they cherry pick the best results. If we stopped doing this, their system would stop looking so good.
The back and forth in the comments section are equally enlightening.


Saturday, July 11, 2009

Prasugrel and Dronedarone: Rough Roads to Approval

This past week or so was the week for the FDA to issue approvals of two drugs with tough paths to approval: prasugrel (marketed by Eli Lilly as "Effient®"), a potent platelet inhibitor used following acute coronary interventions and dronedarone (marketed by Sanofi-Aventis as "Multaq®"), an antiarrhythmic and cogener of amiodarone that does not contain Amiodarone's iodine molecule, which was approved for therapy of atrial flutter and atrial fibrillation is patients without severe congestive heart failure.

Prasugrel (Effient®)

Prasugrel is a thienopyridine — a prodrug that, like clopidogrel, requires conversion to an active metabolite before binding to the platelet P2Y12 receptor to confer antiplatelet activity. In the TRITON TIMI-38, prasugrel therapy was associated with significantly reduced rates of ischemic events, including stent thrombosis, but with an increased risk of major bleeding, including fatal bleeding while overall mortality did not differ significantly between treatment groups. The trial used a 60-mg loading dose, followed by a 10-mg maintenance dose administered after an acute coronary intervention. It seems that the concerns about bleeding did not escape the FDA's watchful eye, especially in lieu of the controversy surrounding the Cardiovascular and Renal Drugs Advisory Committee's decision to remove Sanjay Kaul, M.D., of Cedars-Sinai Medical Center in Los Angeles, an outspoken critic of the potential bleeding complications of the drug.

Dronedarone (Multaq®)

In 2006, the FDA shot down approval of dronedarone because of its limited effectiveness or safety, we weren't sure. In 2007 additional European data demonstrated efficacy and safety of the drug. In 2008 the drug was granted a reprieve by the FDA after the preliminary results of the Athena Trial that excluded patients with severe CHF were published and demonstrated a reduced incidence of hospitalization due to cardiovascular events or death in patients with atrial fibrillation administered 400 mg twice a day of the medication compared to placebo.

Precisely when these drugs will be available to the general market is uncertain, but I suspect you'll know when meals start showing up in cath labs and offices again.


Friday, July 10, 2009

A New iPhone App for CPR

Yeah, it's out. But $3.99? Hardly a way to promote wide distribution.

But then, I wonder if it plays "Stayin' Alive" for you, or lets you switch to "Another One Bites the Dust?"


The Biggest Threat to Health Care Reform: Physician Burnout

It was supposed to be delayed gratification.

After all, that's the American way: work hard, put your nose to the grindstone, get good grades, be obsessively perfectionistic, then you'll be rewarded if you just stay with it long enough. It's the myth that perpetuated through medical school, residency and fellowship. Our poor residents, purposefully shielded from the workload they're about to inherit, march on.

But then they graduate to find to find the population aging, chronic and infectious diseases are more challenging, and the number of complex health advances and therapies are exploding. Just then, we decide to launch a full scale attack on physicians and their patients with increased documentation requirements, call hours, larger geographic coverage of their specialties, reduced ancillary workforce, and shorter patient vists.

Physicians get it - burn out and dissatisfaction are higher now than ever before. This is probably the greatest real threat to the doctor-patient relationship and health care reform discussions don't even put it this on the table.

At the same time that we expect our doctors to be devoted, available, enthusiastic, meticulous and at the top of their game with perfect "quality" and "perfect performance," while simultaneously cutting their pay, increasing documentation reqirements and oversight, limiting independence, questioning their professional judgement, and extending their working hours. We must become more efficient!



Thursday, July 09, 2009

Why All Medical Students Should Go Into Nephrology

Because urine might just be our new fuel source.


h/t: Instapundit.

Why Do People Get 48-Hour Holter Monitors?

Look, if an arrhythmia doesn't show up in the first 24 hours, it's not that much more likely to show up in the following 24 hours. Although it's probably happened, I've never seen a "48-hour" Holter detect an arrhythmia better than a 24-hour Holter and all it ever does is increase costs (and torment the Holter reader).

If a patient has infrequent symptoms, consider an 30-day event (loop) recorder instead.

There. I feel better now.


Dr. Wes Goes to Washington

From Jessica, commenting on my "Are Doctors Sheeple?" post:
I for one want to hear what the physicians have to say and really, that's about the only group I want to hear from. It is beyond comprehension how people can condemn doctors/providers for health care costing too much. It makes me so mad - it is the best case of brainwashing I've ever seen and it would do us well to track that sentiment back to those who stand to gain the most from spreading such lies.

We are lucky to have the talented souls who go to work each and every day knowing the tape they have to work around and we need to stop now and listen to what they suggest. There is too many unnecessary layers between me and my providers, too much between me knowing how much something will cost so I can plan ahead, too many back room deals between unaffected players that help those who don't need it and hurt the ones that are dying for help.

While reading your post, I got this picture in my mind of like, all the great doctors in our country with their nose to the grindstone, doin' their thing, working their magic, not having the time to 'make deals' like power groups have time to - like you said, they are being the entrepreneurs, the innovators, the individuals who are healers and kind souls who set out on a mission to help people live their lives a little better than the day before. All the while, those who are not intrinsic to the provider/patient relationship are spending their time buying political capital. The individual-ness of doctors is what makes medicine in our country so great - your minds are free to work! No associations required, just more volume please!
Jessica, now's your chance to hear some doctors.

Dr. Wes will stop blogging briefly to participate in a press conference next week entitled "Putting Patients First", to be held at the National Press Club in Washington on 17 July 2009 from 9AM-12 noon EST.

Dr. Val Jones (of the blog "Better Health") has graciously invited me to participate along with other nurse, nurse practitioner and physician bloggers to discuss issues of health care reform that directly affect doctor/patient relationship from an "Outside the Beltway" perspective. The keynote speaker for the event will be Congressman Paul Ryan, (R-Wisconsin), ranking member, House Budget Committee and the moderator will be Rea Blakey, Emmy award-winning health reporter and news anchor, previously with ABC, CNN, and now with Discovery Health.

Participants will include:

Primary Care Panelists:
Kevin Pho, M.D., Internist and author of the popular blog

Rob Lamberts, M.D., Med/Peds specialist and author of Musings of a Distractible Mind

Alan Dappen, M.D., Family Physician and Better Health contributor

Valerie Tinley, N.P., Nurse Practitioner and Better Health contributor

Specialty Care Panelists:

Kim McAllister, R.N., Emergency Medicine nurse and author of Emergiblog

Westby Fisher, M.D., Cardiac Electrophysiologist and author of Dr. Wes

Rich Fogoros, M.D., Cardiologist (and yes, another Cardiac Electrophysiologist) and author of The Covert Rationing Blog And Fixing American Healthcare

Jim Herndon, M.D.,
past president of the American Academy of Orthopaedic Surgeons and Better Health contributor
Better yet, you're also welcome to attend in-person. (Contact if they'd like to be in the audience. Seating is limited in the broadcast studio.) A video of highlights from the event will be created that I hope to embed in this blog or will link to after the event.

Got something you want said? Let me know.

- Wes

Wednesday, July 08, 2009

You Know Primary Care is Bad When

... you hear one of your more senior family practice physicians say:
"I now what I'll be doing soon: morphing into a practice manager supervising four or five nurse practitioners."
Thing is, he's probably right.


Tuesday, July 07, 2009

Are Doctors Sheeple?

Imagine a couple caught up in arguing about who should take out the garbage while there's a fire on the stove. The garbage may be a real source of conflict, but bickering about who's turn it is risks the house being engulfed in flames.

Such it was this past week when Daniel Palestrant, MD, Founder & CEO of the physician online forum Sermo, Inc., took a step in the wrong direction by deciding to stand in opposition (subscription) to the AMA:
As physicians, our first step in the healthcare debate needs to be clearing the air about who speaks for us on what topics. Today, I am joining the increasing waves of physicians who believe that the AMA no longer speaks for us. As the founder and CEO of Sermo, this is a considerable change of heart, given the high hopes that I had when we first partnered with the AMA over two years ago. The sad fact is that the AMA membership has now shrunk to the point where the organization should no longer claim that it represents physicians in this country.
While some of his points might be perfectly valid, we wonder how further division amongst our ranks will affect our ability to lobby effectively for the doctors and patients in the current era of health care reform. Do we have the time for such pissing matches? I understand the inherent opportunity for Dr. Palestrant to mobilize the online physician community, but how do we mobilize the majority of physicians and break out of our specialty silos to develop points of consensus? Needless to say, the other partner, the AMA, was none too pleased and shot back:
The AMA has decided not to continue its business relationship with Sermo.

The AMA is always looking for effective ways to communicate with physicians. After an evaluation of the initial relationship with Sermo, we have decided that the value was not there to justify the investment of AMA members’ dues dollars. We continue to explore ways to communicate more effectively with all physicians.
Meanwhile, the politicians and lawyers smile.

This is not about "he said, she said." While Sermo boasts over 100,000 physician registrants, neither organization can say it represents the majority of doctors. Further, to suggest Sermo is any less conflicted than the AMA when it comes to revenue generation is misinformation. But all doctors are keenly aware of the bureaucracy, the middle men, the excess, cover-your-butt tactics needed to shelter them from litigation, their increasingly demanding work hours, frenetic patient visits and diminishing professional payments despite all of their work.

But now, all the politicos see is this: "Look Joe: Sermo guys ain't talking to the AMA and the AMA ain't talkin' to Sermo! Poor bastards. Guess we don't have to worry about them if they can't even agree with each other."

We are, after all, surrounded by professional organizations that have not permitted themselves to devolve into silos. The American Bar Association. The pharmaceutical lobby. The medical device industries. The American Hospital Association, etc. They have political clout. They have a powerful voice on the Hill. They know how to play the game. They have differences in political bents (trial lawyers typically democratic and corporate lawyers typically republican, for instance), but they know how to minimize their internal differences to maintain political bargaining power.

We, on the other hand, are fiercely independent, entrepreneurial, and schizoid: conveniently parsed into our narcissistic silos of primary care, hospitalists, nocturnists, specialists and subspecialists. Some are hospital-employed and others in private practice, some are academic and others fiercely clinical, some are deeply conservative and others even more liberal.

I have to admit I'm still miffed at the CMS proposal to cut cardiologists' fees and shift funds to primary care. I'm miffed at the AMA, too: where was their condemnation of the proposal?

But is this the big issue? To pretend that the cost of doctors' services are the reason for excessive health care costs is a chimera. Look on your latest hospital bill at the exact line items for a health care charge. Look at the "adjustments." Look at what the doctor ends up clearing for that bill. And that's all they can think of to cut?

Enough said.

On the other hand, as one commenter mentioned at the Happy Hospitalist blog in a post on why doctors' salaries are so high:
Take, for example, the Navy SEALS. As an elite unit, their work demands nothing but the absolute best of the best soldiers. In the midst of a shortage and recruiting crisis, the last thing the Navy should do is lower its standards in BUD/S to get more graduates to fill the demand. Lives are dependent upon the quality of the work that the SEALS do. In order to meet the growing demand for the SEAL ranks, the Navy has gone to ultra-marathons, 24 hour adventure races, and Ironman-type competitions to recruit the kinds of people who can hack it as a SEAL.

Medicine is no different. At a time when there are shortages across the board, why does it seem like the government and the industry have created less and less incentive for the best and the brightest to join our ranks? Arduous paperwork, debt, lawsuits, lack of emotional reward due to minimal patient contact, and the ever increasing leftist drone to decrease our income are some extremely powerful motivators to keep the best of the best looking somewhere else for satisfaction in life.
Getting doctors to argue about which among us should get the fee cuts buys into a myth that doctors' fees are the first and foremost reason health care costs are so high. Have doctors insisted on an intelligent discussion about true health care costs in Washington? Why not? Why are we being such sheep buying into the premise that doctors are the problem? Don't tell me that a doctor's pen is the single most expensive piece of medical equipment. Did my pen charge a patient a ridiculous $179,000 gross charge with a $43,000 "credit" seen on a recent 23-hour admission for a biventricular defibrillator implant?

No way. That's because the doctor's fee wasn't even included in the bill.

And what about the "Just To Be Sure" mentality that pervades medicine today? You know the one: "Mrs. Jones, I know you feel fine, but I think we should order another echo this year just to be sure your aortic insufficiency isn't any worse" or "Mr. Jones, we'd better check those liver function tests just to be sure your statin isn't somehow affecting your liver, even though we checked that test 6 months ago." Does the lack of liability reform and exorbitant malpractice awards force this line of reasoning? Dare we hold the politician's feet to the fire on this issue or do we just let the legal status quo with its ridiculous malpractice premiums continue?

I do not know what critical line was crossed that spurred Dr. Palestrant to sever his relationship with the AMA. Perhaps the damage is done. If so, God help us. But at this exact point in time, perhaps reevaluating and reconsidering the potential for reuniting the power of his forum with the established political standing of the AMA might be in the best interest to our profession, however staid the AMA might seem to him. With vigorous effort and collaboration, doctors might then have the ability to collectively voice their concerns to our political establishment and force policies beneficial to all physicians and their patients, rather than splintering our collective voice into impotent fractals of discontent.

Can physicians move out of their silos and develop consensus points we all agree upon?

The house is burning.


Monday, July 06, 2009

Insuring the Sudden Death Survivor

I had to stop and ask again:
"What is your annual insurance premium?"

His answer: "$24,000.00 per year."

His wife chimed in, "And that doesn't include about $20,000 of denied payments we have to pay annually as well."
No wonder he needs a defibrillator.


Spending More, Paying More and Getting Less

As spending accelerates to "stimulate" health care reform, hospitals are taking steps to cut back to promote "efficiency" while limiting patient access. Meanwhile, the "bluest" of Democratic states look like they'll be funding more of the health care tab through higher-than average tax increases.
Illinois ranks among the top 10 states with residents most likely to pay more in taxes if deductions were limited, with 1.7 percent of taxpayers possibly vulnerable to higher taxes, Citizens for Tax Justice data show.

The state also ranks above the national average in the cost of its employer-provided health care plans. Nearly 47 percent of people with family plans would face taxes under an Economic Policy Institute study, compared to 41 percent in the nation overall.

So Illinois residents as a whole might be expected to pay more in taxes under a Democratic health-care plan. About 13.7 percent of Illinois residents lack health insurance, compared to 15.3 percent nationally, according to data compiled by the Henry J. Kaiser Family Foundation, which studies health insurance trends.
Me thinks the divide in the Democratic Congress is about to grow more contentious.


Saturday, July 04, 2009

Wednesday, July 01, 2009

The Medicare Hatchet Begins

How's an 11% cut in a single year for cardiovascular services grab ya?

From CMS:
CMS is also proposing to stop making payment for consultation codes, which are typically billed by specialists and are paid at a higher rate than equivalent evaluation and management (E/M) services. Practitioners will use existing E/M service codes when providing these services instead. Resulting savings would be redistributed to increase payments for the existing E/M services.
And that's just the start.


Reference: CMS Press Release.

More from BNET Healthcare.

President Obama Talks About Pacemakers

I was one of those who missed the "town hall" meeting aired by ABC on the 24th of June, but was nicely pointed to this video where President Obama speaks about placing pacemakers in 100-year olds by a loyal follower:

The video is remarkable on several fronts.

First, I was impressed with the remarkable footage that suddenly appears of the caretaker with her mother, demonstrating the staged nature of this "spontaneous" town-hall interview. No doubt, this question was asked to reassure our seniors about the choices that will soon be made by Washington.

Second, the number of times the elder woman presented to the Emergency Room for care. We are left wondering, did she have a primary care doctor? What were the other discussions that took place before?

Third, the issue of placing pacers in 100-year olds and the new, proposed reliance on bureaucratic "experts" in Washington that will tell the local doctors what the best course of therapy should be based on "research" (a reference to the 1 billion dollar research boondoggle that is comparative effectiveness research). To think that any research will occur on patients of this age is ridiculous. (I'll let others decide what this means for our elderly).

But this is not to say that we should not make choices in this instance. The issue of "cognitive ability" of the elderly, however, was conveniently dodged, and there was never a discussion about the centurion woman paying for her own pacemaker (seems in this case it would be less than a new car).

But whatever you think, these are choices doctors and patients will have to make head-on in the days of increased pressure on Washington to cut costs. The thought of unknown and poorly-defined "experts" (MedPAC?) making these decisions based on non-existent data, rather than the frank discussions between the doctor and their patients and their families, is what really concerns me.


Goodbye Northwestern. Hello University of Chicago

Today's the day I magically lose my appointment at Northwestern University and transition to the University of Chicago's Pritzker School of Medicine. As of 1 July 2009, NorthShore University HealthSystem changes it's medical school affiliation, so I changed the "About Me" section on my sidebar.

For patients and collegues alike, I really don't expect much change, except for the logos worn by the medical students and residents.

But as we change affiliations, I'd like to thank all the residents from Northwestern with whom I have had the pleasure to work with and learn from over the years. I wish you all the best as you transition to the real world.

Now, Univeristy of Chicago, it's your turn.... (heh, heh).