Why Is The NIH Funding Chelation Therapy?

Because politicians in high places say so. This is what happens when lawyers politicians interfere with scrupulous science. This is why you should be very afraid of government controlled health care. Politics will always trump science.

All evidence seems to suggest that political meddling managed to trump science in this case - putting the lives of 2000 study subjects at risk, without any likely benefit to them or medicine.

I had a patient once who sweared by chelation therapy for his coronary artery disease. All I could do was nod my head, uh huh uh huh, and smile. He couldn't understand why the clinic got shut down.

Are The Consequences of Drug Prohibition Worse Than The Drugs Themselves?

A great read over at Bad Science. I love the last paragraph.

Drugs instantiate the classic problem for evidence based social policy. It may well be that prohibition, and the inevitable distribution of drugs by criminals, gives worse results for all the outcomes we think are important, like harm to the user, harm to our communities through crime, and so on. But equally, it may well be that we will tolerate these worse outcomes, because we decide it is somehow more important that we publicly declare ourselves, as a culture, to be disapproving of drug use, and enshrine that principle in law. It’s okay to do that. You can have policies that go against your stated outcomes, for moral or political reasons: but that doesn’t mean you can hide the evidence, it simply means you must be clear that you don’t care about it.

So much of what government does follows blindly in the face of not caring about the evidence. For example the evidence suggests we are 99 trillion dollars in the hole, and yet we want to keep spending more. That's because the role of today's government has far exceeded its original necessity and it establishes laws often times solely to justify its own existence and to guarantee its own survival.

The amount of destructive pathology I see as a hospitalist physician due to alcohol and tobacco easily outnumbers the patients I see for illegal narcotic complications by 100 to one. And that's being generous. It's time for change and hope we hear so much about. It's time for less talk and more action. It's time for evidence to guide your policy, or at least admit you don't care about the evidence.

Is It OK For Hospitals To Pay Physicians To Be On Call?

An advisory opinion by the Department of Health and Human Services Office of Inspector General says yes.

In the May 21 opinion, OIG acknowledged that hospitals increasingly are compensating physicians for emergency coverage. "We are mindful that legitimate reasons exist for such arrangements in many circumstances," including a scarcity of available doctors in particular areas and compliance with the federal Emergency Medical Treatment and Active Labor Act.

Many hospitals already pay hospitalists subsidies for their inpatient duties, one of which is to take care of unassigned uninsured patients. Perhaps the AMA believes hospitalists have an ethical obligation to provide charity care to these patients.

I have a different suggestion. If it's OK for hospitals to pay physicians to be on call in order to maintain compliance with EMTALA rules, shouldn't it be the US government and not the hospitals who are fitting the bill for the uninsured being treated under EMTALA rules? Any lawyers out there want to take on the federal government? It could perhaps save your life one day when you need a doctor to care for you, but everyone is at home sleeping.

Which Medical Specialty Has The Highest Acceptance Of Credit Cards?

You probably guessed plastic surgery. You are correct, at 91%. Internists are just over 50% Pathologists round out the bottom at 21%. However, the trend is apparently less, not more acceptance. The interchange fees can run 3-4%, which cuts into the physician's bottom line. I find the lack of acceptance of credit cards hard to believe.

At a 4% fee, if you increased your collection rate by just one patient out of every 25, you would come out ahead, not even including the billing expenses incurred from unpaid balances. It takes increasing your collections on just one patient a day in a 25 patient per day clinic to come out ahead. And it's easier to collect a $100 "outstanding balance" on credit card than it is to ask for $100 in cash.

Do Physicians Have An Ethical Obligation To Provide Charity Care?

In interesting discussion in the AMA. It appears they feel physicians have an ethical obligation to provide care, regardless of the patient's ability to pay.

So long as it is fiscally sustainable for physicians, the policy says, doctors should accept uninsured patients and maintain relationships with patients who lose health coverage. Doctors should help patients access public programs and charitable sources. They should take part in the political process to cut financial obstacles to health care access, delegates said.

A very noble policy to institute. To bad nobody can define "fiscally sustainable". For some physicians that might mean $100K a year in income. For others that might mean $1 million. It is not for anyone to judge what is fiscally sustainable for a physician's lifestyle. That is a personal decision only the physician and their family can answer.

Of course all would be fine and dandy if the grocery store down the street accepted the smiley faces and fuzzy snuggles as payment in full that you receive from your ethical obligation to nonpaying patients.

The AMA has it all wrong. Physicians have always been a very charitable group of folk. Not because of an ethical obligation dictated by an organization that has lost its way through the years, but rather out of a self inflicted viral desire to help others, on their own terms. Mandating charity as an ethical obligation is the same as mandating all physicians accept Medicaid or Medicare. That makes you a slave of society.

As practicing physicians who operates under the US monetary system we are bound to play by capitalism's rules. Your landlord does not care about your ethical obligation to provide charity care. Your kid's dentist does not care about your ethical obligation to provide charity care. Your accountant and lawyer do not care about your ethical obligation to provide charity care.

Whether to be charitable or not is a very personal decision. One that cannot be codified into ethical mandates from aging institutions. If you as a physician lose your ability to provide free care on your own terms, based on your own value system, you become nothing more than a slave of society. An ethical mandate devalues your years of training to nothing more than a societal right. A right that places you in a position slavery and not one of free will to provide charity on your own terms. The fact that the AMA feels an obligation to codify the ethical obligation to charity says to me how out of touch they are with the realities of the economics of today's medicine.

The new policy comes when declining physician income appears to be affecting the amount of charity care doctors provide. A March 2008 Milbank Quarterly report found doctors' pay fell 7% from 1996 to 2005, when adjusted for inflation. In the same period, the proportion of doctors offering charity care dropped 10% to about two-thirds of physicians

Physicians are saying, that their ability and or desire to provide charity care is inversely proportional to the financial situation they find themselves in. It has nothing to do with ethical mandates and everything to do with personal financial decisions. If you want more physicians to provide more charity care, you're going to have to pay them more to do so. And that has nothing to do with ethics and everything to do with economic common sense.

What Are The 25 Top Priorities For Comparative Effectiveness Research?

The American Recovery and Reinvestment Act of 2009 called on the Institute of Medicine to recommend a list of priority topics to be the initial focus of a new national investment in comparative effectiveness research. The IOM’s recommendations are contained in the report, Initial National Priorities for Comparative Effectiveness Research. via (Kaiser Health News)

There are 100 priorities, divided into four quartiles. The first quartile carries the highest priorty. In no specific order, here are your top 25 priorities for CER.

1. Compare the effectiveness of treatment strategies for atrial fibrillation including surgery, catheter ablation, and pharmacologic treatment.

2. Compare the effectiveness of the different treatments (e.g., assistive listening devices, cochlear implants, electric-acoustic devices, habilitation and rehabilitation methods [auditory/oral, sign language, and total communication]) for hearing loss in children and adults, especially individuals with diverse cultural, language, medical, and developmental backgrounds.

3. Compare the effectiveness of primary prevention methods, such as exercise and balance training, versus clinical treatments in preventing falls in older adults at varying degrees of risk.

4. Compare the effectiveness of upper endoscopy utilization and frequency for patients with gastroesophageal reflux disease on morbidity, quality of life, and diagnosis of esophageal adenocarcinoma.

5. Compare the effectiveness of dissemination and translation techniques to facilitate the use of CER by patients, clinicians, payers, and others.

6. Compare the effectiveness of comprehensive care coordination programs, such as the medical home, and usual care in managing children and adults with severe chronic disease, especially in populations with known health disparities.

7. Compare the effectiveness of different strategies of introducing biologics into the treatment algorithm for inflammatory diseases, including Crohn’s disease, ulcerative colitis, rheumatoid arthritis, and psoriatic arthritis.

8. Compare the effectiveness of various screening, prophylaxis, and treatment interventions in eradicating methicillin resistant Staphylococcus aureus (MRSA) in communities, institutions, and hospitals.

9. Compare the effectiveness of strategies (e.g., bio-patches, reducing central line entry, chlorhexidine for all line entries, antibiotic impregnated catheters, treating all line entries via a sterile field) for reducing health care associated infections (HAI), including catheter-associated bloodstream infection, ventilator associated pneumonia, and surgical site infections in children and adults.

10. Compare the effectiveness of management strategies for localized prostate cancer (e.g., active surveillance, radical prostatectomy [conventional, robotic, and laparoscopic], and radiotherapy [conformal, brachytherapy, proton-beam, and intensity-modulated radiotherapy]) on survival, recurrence, side effects, quality of life, and costs.\

11. Establish a prospective registry to compare the effectiveness of treatment strategies for low back pain without neurological deficit or spinal deformity.

12. Compare the effectiveness and costs of alternative detection and management strategies (e.g., pharmacologic treatment, social/family support, combined pharmacologic and social/family support) for dementia in community-dwelling individuals and their caregivers.

13. Compare the effectiveness of pharmacologic and non-pharmacologic treatments in managing behavioral disorders in people with Alzheimer’s disease and other dementias in home and institutional settings.

14. Compare the effectiveness of school-based interventions involving meal programs, vending machines, and physical education, at different levels of intensity, in preventing and treating overweight and obesity in children and adolescents.

15. Compare the effectiveness of various strategies (e.g., clinical interventions, selected social interventions [such as improving the built environment in communities and making healthy foods more available], combined clinical and social interventions) to prevent obesity, hypertension, diabetes, and heart disease in at-risk populations such as the urban poor and American Indians.

16. Compare the effectiveness of management strategies for ductal carcinoma in situ (DCIS).

17. Compare the effectiveness of imaging technologies in diagnosing, staging, and monitoring patients with cancer including positron emission tomography (PET), magnetic resonance imaging (MRI), and computed tomography (CT).

18. Compare the effectiveness of genetic and biomarker testing and usual care in preventing and treating breast, colorectal, prostate, lung, and ovarian cancer, and possibly other clinical conditions for which promising biomarkers exist.

19. Compare the effectiveness of the various delivery models (e.g., primary care, dental offices, schools, mobile vans) in preventing dental caries in children.

20. Compare the effectiveness of various primary care treatment strategies (e.g., symptom management, cognitive behavior therapy, biofeedback, social skills, educator/teacher training, parent training, pharmacologic treatment) for attention deficit hyperactivity disorder (ADHD) in children.

21. Compare the effectiveness of wraparound home and community-based services and residential treatment in managing serious emotional disorders in children and adults.

22. Compare the effectiveness of interventions (e.g., community-based multi-level interventions, simple health education, usual care) to reduce health disparities in cardiovascular disease, diabetes, cancer, musculoskeletal diseases, and birth outcomes.

23. Compare the effectiveness of literacy-sensitive disease management programs and usual care in reducing disparities in children and adults with low literacy and chronic disease (e.g., heart disease).

24. Compare the effectiveness of clinical interventions (e.g., prenatal care, nutritional counseling, smoking cessation, substance abuse treatment, and combinations of these interventions) to reduce incidences of infant mortality, pre-term births, and low birth rates, especially among African American women.

25. Compare the effectiveness of innovative strategies for preventing unintended pregnancies (e.g., over-thecounter access to oral contraceptives or other hormonal methods, expanding access to long-acting methods for young women, providing free contraceptive methods at public clinics, pharmacies, or other locations).

Go check out the other 75.

Happy Fourth Of July

I heard a lady blew off half her face yesterday with a home made "firework".

Here's a safe way to celebrate.

via Carpe Diem

How Much Could A Private MRI Cost?

In Canada patients tired of waiting are going out of the government health care Q's and paying out of pocket. I blogged earlier about the truth about Canadian medicine.

As the Obama administration prepares to launch its legislative effort to create a national health care system, many experts on both sides of the debate site Canada as a successful model. But the Canadian system is not without its problems. Critics lament the shortage of doctors as patients flood the system, resulting in long waits for some treatment. "No question, it was worth the money," said Crossman, who paid several hundred dollars and waited just a few days.

Several hundred dollars cash? That's interesting. It'll cost you a at least a couple grand if you try to get one here. I wonder why that is. Perhaps there is no competition?

My Universal Access In A Market Based Health Care System

Obama admitted that government intervention into the pricing of health care is playing a huge role in the cost of care we are receiving.  I agree.  We are getting exactly what we pay for.  Third parties have tried, and failed, to price health care accordingly.  The unintended consequences has been a high cost, low value, do more mentality that his driven  up the overall cost of care.  The consequences of price control will always be to increase the volume of services, in a fee for service model, until the revenue recovers.  Health care will always be a growth industry.  The question is, how is our government going to fiscally survive the inevitable. We are 99 trillion dollars in the hole in unfunded entitlements.  

May I offer one suggestion that creates WIN-WIN while aligning all the forces:  A hybrid system that incorporates universality and personal financial responsibility and gives incentives to government, physician, patient and hospital alike to take care of patients for the right reasons, while making sure everyone has access to life saving health care.  It is a  common sense approach to health care financing.  And it is based on your adjusted gross income for the previous fiscal year ending April 15.  Happy's utopia for a hybrid universal market based health care finance system.

1. Determining Your Healthcare Tier:  The financial responsibility for you and your families health care will be determined by your adjusted gross income (AGI) for the fiscal year ending April 15th.  You and your dependents, as determined by your income tax filing, will receive a plastic ID card, indicating your tier of participation.  That tier, one of six, will be determined by your AGI above the federal poverty guidelines.    For example, the federal poverty level for a family of 4 is $22,050.  For every 100% above that income level, you achieve a higher tier. See the following example for AGI of a family of four:

Tier 1:     0-$22,000

Tier 2:  $22,001-$44,000 

Tier 3:  $44,001-$66,000 

Tier 4:  $66,001-$88,000 

Tier 5:  $88,001-$110,000

Tier 6:  $110,000+

   2.  Universal Access means the US government will pay a defined fee for every CPT code,or a defined fee for a bundled service.  It really doesn't matter if the payment if bundled or fee for service.  The government will  pay no more than its defined maximum for the year.    And every American receives the same benefit.   The US government will decide, based on its own solvency how much that fee is.  It is the ultimate capitated government health care system.  Think Medicaid for all.  If the pot of money decreases, the payment rates will  decrease as well.    That means it cannot go unfunded.  Base payment rates will rise and fall with the state of the economy.  It is an entitlement mentality, but one that will never bankrupt our country.  This sounds like a terrible idea (Medicaid for all) until you consider the rest of my proposal.

    3.   Market Prices.  The provider of service, (a physician, hospital, pharmacy, HHC agency etc...) are free to charge market prices in a bid to compete with our providers on quality and cost.  For example  Dr Smith, a cardiologist can charge $300 for a new office visit.  Dr Jones, a competing cardiologist can charge $400 if he feels he offers a greater service.  In either case, both physicians are competing on price.  The universal Medicaid for all government system may only pay $50 of that office visit.  So how does the physician collect what he feels his service is worth?  Well, how much you as a patient owe your physician (above what the government will pay) will depend on what tier you are in.  Here is my proposal on how much you would owe your physician.

Tier 1:  The patient owes nothing.  The government would pay both physicians $50.

Tier 2:  20% of market fee minus government rate.  For Dr Smith that means ($300-$50)*.2=$50 .  For Dr Jones that means ($400-$50)*.2=$70

Tier 3:  40% of market fee minus government fee.  For Dr Smith that means ($300-$50)*.4=$100.  For Dr Jones that means ($400-$50)*.4=$140

Tier 4:  60% of market fee minus government fee.  

Tier 5:  80% of market fee minus government fee.

Tier 6:  100% of market fee minus government fee. That means, what ever the government doesn't pay, the patient is responsible fully for the rest of the market based fee being charged by the physician.

What this does is encourage all providers, whether it's doctors or hospitals to compete on quality and price to drive patients to them rather than their competitors.  If you are a tier 3 patient and you had the choice between paying $100 or $140 it is up to you to decide whether you want to pay the extra dollars to keep Dr Jones rather than switching to Dr Smith.  If you feel Dr Jones is worth the extra $40, you may decide to pay the extra money and stay with him.

Some folks may suggest that having unlimited price potential is dangerous for patients.  And it potentially is, except when you consider my proposals further.

  4.  Automatic Deductible.  Every American has an automatic 4% withdrawn tax free from their paychecks and deposited into an account, to be used for all their health care needs.  Your deductible is determined by your tier, but shall remain at 4% for all tiers.  

Tier Deductible

Tier 1:  No deductible.  The government pays for everything

Tier 2: $880-$1,760 (this is 4% of your AGI)

Tier 3: $1,761-$2,640 (again 4% of your AGI)

Tier 4: $2,641-$3,520

Tier 5: $3,521-$4,400

Tier 6: $4,401- unlimited.

If you make 10 million dollars a year in AGI, your deductible for your family would be $400,000 a year.  I  suggest that 4% of AGI, tax free in and tax free out, is a reasonable contribution to ones own health care needs.  This takes FREE=MORE out of the equation and places some reasonable personal financial responsibility into the equation.  The contribution is required.  Everyone in this country with an AGI of greater than the poverty level is required to contribute to their own health care needs.  But what happens if you reach your deductible for the year?  Who pays then?

5.  Post Deductible Dollars.  All employers are required to purchase post deductible insurance for their employees.  If you are unemployed or retired disabled, the government will purchase the insurance for you on a prorated basis, based on your AGI.    How much the insurance company pays the providers of care will be determined by the patient's tier with the same percentages applying.  Let us imagine a hospital charging $20,000 for your hospital stay.  I would imagine a lot more transparency in pricing if hospitals were forced to compete on price and a lot of the ridiculous pricing would disappear.  How much would the private insurance company pay if you got a $20,000 hospital bill?  

Let's imagine Medicaid for all paid $3,000.  That leaves $16,000 to be paid for.

Tier 1:  The government would pay nothing more than $3,000.  Since there are no deductibles for the patient to pay, there is no private insurance payment.  Payment in full is $3,000

Tier 2:  The government would pay $3,000 (to guarantee universal access, it must be cheap), the patient would pay 20% of the remaining $17,000 up to a maximum $1,760.  That leaves $20,000-$3,000-$1,760=$15,240.  That means the private insurance company would be responsible for 20% of $15,240, or $3,048.  Total bill paid $7,808  on a $20,000 market price hospital stay.  

Tier 3:  The government would pay $3,000.  The patient would pay 40% of the remaining $17,000 up to a maximum of 4% of AGI ($1,761-$2,640).  That means the private insurance company would be responsible for 40% of $20,000-$3,000-$2,640, or $5,744.  The total bill paid would be $11,384.

Tier 4:  Government would pay $3,000.  The patient would pay 60% of $17,000 up to a maximum of $3,520.  The private insurance company would be responsible for 60% of $20,000-$3,000-$3,520, or $8,088.  Total bill paid to the hospital would be $14,608.

Tier 5:  Government would pay $3,000.  The patient would pay 80% of $17,000 up to a maximum of $4,400.  The private insurance company would be responsible for $10,080.  The total bill paid to the hospital would be $17,480

Tier 6:  Government would pay $3000.  The patient would pay 100% of $17,000 up to a maximum of 4% of their AGI.  Potentially the private insurance company would pay nothing, if the patients income was great enough.  Hospital collects $20,000

You might read this and suggest that hospitals and providers may simply build in rich areas or close down in poor areas, or doctors may turn away poor folk.  You'll have to read on to understand why that wouldn't happen.

6.  Earning Cash Back.  Since deductibles are determined yearly by your adjusted gross income and you are required to contribute 4% every year to your account and since your maximum out of pocket per year is 4%, what happens to your dollars if they are not spent?  Good question.  You cannot purchase other goods and services with your health care deductible dollars,  but you can sell them back to the private insurance market   These deductible vouchers (as good as cash to the insurance companies), sold to insurance companies (EBAY style auction) at discounted rates  can be used by private insurance companies to keep their costs down.  If you had $3,000 in unused pretax health care dollars, you may get $2,000 in cash by selling your health care dollars to your private insurance company, who can then use it to subsidize their premiums.  Once again, the healthy are subsidizing the unhealthy by helping to keep private premiums down.  And the money patients earn from selling their unused deductible dollars is tax free as well.  And can be used for anything.  Patients have an incentive to shop around for the lower priced physicians, the lower priced radiology suites, the lower priced hospitals to get their elective procedures.  They have an incentive to remain healthy, to stop smoking and exercise.  If they can prevent their own illness, they have an opportunity to recover a percentage of their  deductible dollars.  Private insurance companies may use their voucher money to offer lower cost premiums or to offer programs to keep their premium payers out of the hospital.  

7.  It pays to take care of poor people.  What's to keep hospitals from only building in rich neighborhoods.  What's to keep physicians from only filling their clinics with rich people?  Well, first of all,  if most of the population was rich, we wouldn't be having this discussion.  That's not to say there aren't rich and poor neighborhoods.  There are.  But as it stands now poor people don't pay anything and rich people don't pay their fair share.  That's why I would propose minimum standards for the number of Tier 1 or Tier 2 patients.  If these minimum standards were not met, no physician in that practice  (or hospital for that matter not seeing enough poor people) would receive any payment of any kind from the US government.  That would free up money to increase payments to other physicians and hospitals who do see a fair number of Tier 1 or Tier 2 patients.  And the higher your percentage of Tier 1 and Tier 2 patients in your practice, the more the government would give you for all your patients, including Tier 6 patients as well.  In other words, If Dr Jones had no Tier 1 patients in his clinic or if his hospital on the lake had  very few Tier 1 patients neither would get the $50 for the clinic visit or the $3,000 for the hospital stay, and that money would be used to increase payments to hospitals and doctors who were.  If you aren't going to see your fair share of patients with little or no money, then you shouldn't get any government payment.  Most physicians and hospitals I know would gladly see poor patients, I suspect even for free, if they knew they were receiving fair price from those who could afford it.

My scheme has it all.  A market based universal access approach that would distribute physicians into critical access areas by nature of the market based pricing principles.  If you are the only cardiologist in a 300 mile radius, you have every incentive to move to critical shortage areas because you can charge more.  If you are one of 300 cardiologists in a 10 mile radius, you have every incentive to move as well because your competition will be fierce.  It allows the government to provide payment for the poorest of the poor while allowing those with more financial means to subsidize the government's low price points.  It forces patients to make good choices on price through transparency and competition, knowing they may very well get some of their deductible dollars back if they stay healthy, don't smoke, and exercise.   

My market based approach to universal access in our health care system.  A way to subsidize the care of inconvenient patients who can't pay from those who can.  

A Market Solution To Controlling Health Care Costs

If you've been reading anything I have written, you won't be surprised that it involves putting skin in the game. That's exactly what Safeway did. And they're winning while the rest of America heads for bankruptcy. It's also a cornerstone concept of my proposed market based universal access for health care delivery that gives everyone skin in the game.

Today, Safeway has accomplished what Washington claims is the goal: The company's per-capita health-care expenses have remained flat, compared to the near 40% increase experienced by the rest of corporate America over the past four years. This has not been done by cutting care or shifting costs to employees. Nearly 80% of the 30,000 nonunion Safeway workers who take part in the program rate it good, very good, or excellent.

via AllFinancialMatters

An Inconvenient Patient

Tis better to just stop accepting insurance that pays you 13 cents on the dollar than it is to not make a patient your priority.  If you can't give your patient your all, you should not be seeing them at all.  Thanks to a reader for finding this story about an inconvenient patient.

MediCal cancelled me three times over the next year or so, and then denied me approval for an MRI, which my Doctor told me I needed before seeing a neurologist. Expecting the Doctor to call me when it was cancelled, I didn't find out for two months. When I asked what took so long to tell me, I was told (in front of my wife and kids) "You're a MediCal patient. I make thirteen cents on the dollar to see you. You just aren't one of my priorities". 

What's Your Strangest Insult From a Patient?

Mine is from a drug addict when I wouldn't give him his fix:

"I beat up people like you in high school"

What's yours?

Storms On The Horizon

Out of the Federal Reserve Bank of Dallas, comes this excellent presentation by its President and CEO, Richard Fisher about the fiscal disaster we currently find ourselves living in. Found  (Via Grand Rants)

Happy's  summary.  We are all screwed.  Every last one of us.  Unless a massive shift of policy is instituted today, we leave no future for ourselves or our children.  The entitlements we currently support are ponzi schemes a thousand times larger than Madoff and his thieves.

Tonight, I want to talk about a different matter. In keeping with Bill Martin’s advice, I have been scanning the horizon for danger signals even as we continue working to recover from the recent turmoil. In the distance, I see a frightful storm brewing in the form of untethered government debt. I choose the words—“frightful storm”—deliberately to avoid hyperbole. Unless we take steps to deal with it, the long-term fiscal situation of the federal government will be unimaginably more devastating to our economic prosperity than the subprime debacle and the recent debauching of credit markets that we are now working so hard to correct.

Stating the obvious, we are screwed.  But how is Social Security you ask?

Now, fast forward 70 or so years and ask this question: What is the mathematical predicament of Social Security today? Answer: The amount of money the Social Security system would need today to cover all unfunded liabilities from now on—what fiscal economists call the “infinite horizon discounted value” of what has already been promised recipients but has no funding mechanism currently in place—is $13.6 trillion, an amount slightly less than the annual gross domestic product of the United States.

Sounds like a lot of money, but that's the good news.  Read on:  

The good news is this Social Security shortfall might be manageable. While the issues regarding Social Security reform are complex, it is at least possible to imagine how Congress might find, within a $14 trillion economy, ways to wrestle with a $13 trillion unfunded liability. The bad news is that Social Security is the lesser of our entitlement worries. It is but the tip of the unfunded liability iceberg. The much bigger concern is Medicare, a program established in 1965, the same prosperous year that Bill Martin cautioned his Columbia University audience to be wary of complacency and storms on the horizon.

You should be afraid, very afraid of where we are heading.

Please sit tight while I walk you through the math of Medicare. As you may know, the program comes in three parts: Medicare Part A, which covers hospital stays; Medicare B, which covers doctor visits; and Medicare D, the drug benefit that went into effect just 29 months ago. The infinite-horizon present discounted value of the unfunded liability for Medicare A is $34.4 trillion. The unfunded liability of Medicare B is an additional $34 trillion. The shortfall for Medicare D adds another $17.2 trillion. The total? If you wanted to cover the unfunded liability of all three programs today, you would be stuck with an $85.6 trillion bill. That is more than six times as large as the bill for Social Security. It is more than six times the annual output of the entire U.S. economy.

And how much is that for you and me?

Let’s say you and I and Bruce Ericson and every U.S. citizen who is alive today decided to fully address this unfunded liability through lump-sum payments from our own pocketbooks, so that all of us and all future generations could be secure in the knowledge that we and they would receive promised benefits in perpetuity. How much would we have to pay if we split the tab? Again, the math is painful. With a total population of 304 million, from infants to the elderly, the per-person payment to the federal treasury would come to $330,000. This comes to $1.3 million per family of four—over 25 times the average household’s income.

What would you have to do to get make the unfunded mandates funded? 

1. Either increase federal tax revenue 68% starting today, and continue it forever.    Good luck with that.  When you tax something, anything, you will get less of it.  Nobody knows what tax rate could support that without destroying the economy in the process.
2. Or cut discretionary spending 97% (that includes defense, education, environment and everything else under the sun), forever.  

The issue isn't not enough taxes.  The issue is a government that can not say no to its constituents.  Now, I know some of you view Obama as your messiah, but I'm sure even he knows he can't generated 99 trillion dollars on the backs of the rich.   So the question is, does he have the guts to tell you no before it's too late? It takes a real leader to tell his followers no.  Right now, our leaders are promising everything and they will ultimately be able to deliver on nothing.

Is Percocet And Vicoden Going To Be Banned?

If the FDA follows the recommendations from a federal advisory board, the answer is yes. While I understand the logic, I fear for specialists everywhere who have never been trained to write for anything other.  I fear all their patients will go without pain medicine or get a "hospitalist consult for pain managment" 

FridaWrites, a patient with chronic pain gives her take on it all.  

Are Consultation Codes Going Away?

CMS dropped a doozy on the health care profession yesterday.  If they have their way, the answer is yes.  Their news room had lots of goodies to ponder.  You should go read the whole article when you're done reading this.

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.  

I have previously stated that the payment differences between consultation codes and admission codes are irrational.  As a hospitalist, if I am asked to consult on a patient, the time commitment can be 1/2 or less.  Most of the history can be "ripped off" from other physician records available in the chart (most notably the admission physician), which is exactly what many physician consultants do.  

Consultants do not get bothered with house keeping hospital orders.  Consultants can write their recommendations and quickly move on to the next patient.  All in all, in my experience, a consult note can take 1/2 as long, or less, has fewer headaches, has less paperwork, AND, get this, pays more than the equivalent level admission note.  It is no wonder why no physician wishes to be the admitting doctor these days and why hospitalists, me included, are being asked to admit healthy 45 year olds no medical problems, except that which requires subspecialist intervention.  

There is no clarification on what this means for "use existing E/M codes".  Does that mean consultants would submit admission codes (99221-99223) or does it mean consultants will only submit hospital follow up codes (99231-99233).  I would be interested to know how CMS clarifies this rule.  

It also looks like facility fees are going to take a hit as well.

CMS is proposing two changes to address concerns from the Medicare Payment Advisory Commission (MedPAC) and the U.S. Government Accountability Office (GAO) about rapid growth in high cost imaging services.  First, CMS is proposing to reduce payment for services that require the use of expensive equipment which would produce a redistribution of the resulting savings to increase payments for other services, including primary care services.  The current payment rates assume that a physician who owns this type of equipment will use it about 50 percent of the time, but recent survey data suggest this expensive equipment is being used more frequently.  As the use of this type of equipment increases, the per-treatment costs for purchasing, maintaining and operating the expensive equipment declines, making a reduction in payment appropriate.

It looks like primary care is starting to gain some respect, outside of the RUC committee.  Now the question is, will it be enough and will it be quick enough.

Oh, and one more thing,  E/M codes, are inherently flawed in general.  The rules required to meet their standards create an incredible inefficiency in cognitive based medicine.  I often blog that I could triple or quadruple the number of patients I see in a day if I wasn't required to document what I needed to document in order to get paid  and not be accused of fraud.  Perhaps the removal of the consult codes is one step closer to abandoning the E/M a coding system (HURRAY!) that adds nothing of value to patient care, but has guaranteed entire cottage industries and billing support systems, who's expense will be paid for in one way or another in higher health care costs for you, the patient.

Obama Seems To Understand The Fault Of Government In Creating The Health Care Crises

I applaud him for admitting that the destructive incentives embedded in the payment models, and codified by the Medicare National Bank, are to blame for the out of control health care spending in this country.  As he states:

Obama said the best way to drive down health care costs is to persuade doctors and hospitals to emphasize quality of care over the quantity of procedures.

Health experts have long criticized formulas that tie Medicare payments to tests and other services that may not always be the best way to treat a patient. Obama said the formulas must change as part of his bid to overhaul U.S. health care delivery.

You see, we are getting exactly the kind of health care the payment models are set up to pay for.  There is no such thing as an unnecessary boob job.  If the patient is willing to pay for it, and the surgeon is willing to perform it, the result is the right care at the right place for the right price at the right time.  

As it stands now, the Medicare National Bank is being bankrupted by an irrational payment model (the RVU system)  that is entirely built upon the back door secretive politics heavily controlled by specialty medical societies that try to protect each others own special interest in the revenue neutral,  irrational economics of RVU/RUC/SGR/Medicare Part B.

The whole thing is a sham.  It is impossible to get to WIN-WIN when the only possible outcome for every winner is a loser.   

This is why any government that attempts to set prices on goods and services, including health care, is doomed to fail.  While I applaud Obama for realizing the failed economies and all the irrational, yet so rational, consequences of government intervention on price, I fear his solution, which he has yet to provide, will offer nothing more than a different set unintended consequences.  No centralized agency will ever price a product better than 300 million Americans can.  With that, I have another proposal to consider in the financing of American health care.  You'll have to read my next post to understand how simple this could be.

Does An Elevated CRP Cause Heart Disease?

I remember a few years ago a prominent study (I can't remember the source) suggested an elevated CRP had a more profound effect on the development of heart disease than did an elevated LDL.

And now JAMA reports that causal relationship doesn't exist.   

Save The Hungry Calves Act of 2009

(click image to enlarge)  

When the baby realized that her skinny mama wasn't making enough milk for its hungry belly, it petitioned the Yellowstone Commission for a trillion gallon milk stimulus plan, and demanded that free milk be shipped in, taken by force from the larger buffalo on the plains.   Equal milk supplies for all the calf argued, stating that no calf should go hungry, while other calves basked in an endless supply of free milk.  

As the Save the Hungry Calves Act of 2009 swept through the wilderness, hard working mother buffalo after mother buffalo from the  plains stopped spending endless days eating to support her milk supplies.  Instead, she would just lay there and sunbath, hour after hour of glorious sun.  

Once a proud provider of milk for her baby calf through hours upon hours of endless feeding, she no longer felt the desire to work so hard.  Instead she took to the hills to lay.  And lay she did.  While she lay, she waited.  And she waited and waited and waited for the Yellowstone Commission to ship her the milk for her calf, the calf she once proudly supported on her own through her own endless hours of sacrifice in the fields.  The same milk  the calves in Yellowstone were getting for free.  The same right to free milk mandated by the Yellowstone Commission.  

But no one ever brought her the free milk.   Why should every other mother buffalo but her get to stop eating and just lazy around in the sun waiting for the free milk to arrive by virtue of free milk declaration from the Yellowstone Commission?  

It turns out she herself used to be the unending supply of free milk that the other lazy buffalo depended on.  When she too decided to stop working so hard, there was no longer any free milk left for all.  Now so lazy from doing nothing, their knees could not support their own weight.  They couldn't stand long enough to eat enough grass to make enough milk to feed their own calves.  None of them.  And as a result, a mass extinction of buffalos swept this land.  The very act, the Save The Hungry Calves Act of 2009, that was supposed to save the hungry calves, killed them all.  

And, that folks, is a lesson on how to create policies that force a race to the end.  That's exactly what we have going on today.  Every dollar our government collects in a  tax the rich and give to the poor mentality, is one less dollar they will eventually collect when the rich decide to stop making milk and start collecting free milk vouchers like everyone else.  And when that happens, and it will, nobody will be left to make the milk.   And the government, which promises everything, will be able to deliver on nothing.

The Importance Of Hospital Culture, And How Much More Likely Are You To Survive As Happy's Patient?

Aggravated DocSurg explains the importance of hospital culture as he disects data from the ACS Surgery News

To draw on the current phraseology of hospital management-types, it boils down to culture. Hospitals with lower mortality rates, I suspect, aggressively engender a culture of high expectations, where everyone down the line understands how important of a role they play on the team. High expectations come with accountability, and the squishiness of some administrators when it comes to meting out that accountability can lead to poor outcomes. That accountability must also apply to the physicians, and a physician culture that demands the best for our patients in our hospitals --- from the physicians and staff alike --- pays big dividends.

When you expect little, you get little in return.  I have full faith in the abilities of most folks at Happy's hospital that come in contact with patients in one way or another.  That which I am not trained to handle, I leave for others more educated than I.  As an internist trained hospitalist, the volume of disease I am capable of handling is immense.  My limits are well known to me.  And when they are met, I act accordingly.

Physicians also play an important role in following  protocols designed for patient safety.  If you have infection control policies in place that require full shield protection while placing central lines, the policies do no good if the physicians do not follow them.  If you have good policies in place to prevent venous thromboembolism (VTE), they do no good if the physicians are not active participants.   Physicians must be willing participants, along with everyone else, in a culture of excellence.

I can say, without a doubt, there are some physicians that don't want to do the right thing for patient care.  Eventually, those physicians will be found out.  If they don't want to prevent  VTE in their patients, their numbers will eventually prove their failure.  If they don't want to barrier protect their patients from infection, their numbers will eventually prove their failure.

On a personal note, I am happy to report that my data is exceptional.  If you were taken care of by me, you were 50% less likely to die than your severity of illness adjusted expected mortality would have suggested.  Every year I get a report indicating my actual mortality % vs expected mortality %.   Some of this can be manipulated by how well I document, compared to the rest of the physician universe.  I understand the documentation rules very well.  That may, to some degree, skew my data when compared with the physician universe.  But so what.  It's accurate data.  And it's accurate when comparing me against my own data.  If my patient is sick, I document exactly how sick they are.  

So how do my numbers look?  Well,  in 2008, 355 cases were evaluated.   The severity of illness adjusted expected mortality for my patients was 5.7%.   This compared with the national database numbers of 5.1%.  But how often did my patients die?  5%?  4%?  3%?  None of the above.

My patients died only 2.8% of the time.  Less than half my patients who were expected to die, did.   How did I compare with the rest of Happy's hospitalist group?  Despite having a higher severity of illness (which may be due to better documentation), I beat them out too with an actual mortality of 2.8% vs 4.5% for Happy's entire hospitalist group.  So not only are my patients dying 50% less often than would be expected, patients in my entire hospitalist group are dying 12% less often than would be expected when compared with national statistics.

Hospitals with strong safety initiatives and a culture of compliance with those initiatives from all players, including physicians, separate good hospitals from great ones.  And physicians that practice sound clinical medicine can expect more of their patients to survive their acute illness, despite all the barriers to their survival.  Quality will come from within, not from the government.  How many bad mothers do you know out there on welfare?  How many bad mothers do you know not on welfare?  What makes a good mother is the mother, not the government.

So what does it all mean?  If you should ever find yourself as a patient on my service, you can sleep well at night knowing that your chance of dying is 50% less than if the average physician in this country cared for you.  And should you ever find yourself admitted to Happy's hospitalist service , you can sleep well at night knowing that if you don't get me as your physician, at the least, you have a 12% less chance of dying during your stay than the average patient in the average hospital being taken care of by the average physician in this soon to be average country.

How Fast Can A Bear Run?

I was told by several bystanders, the bear can run up to 35 miles per hour.  A good reason why the laws in the Yellowstone are post 100 yards as the closest allowable distance to approach a bear.  On several occasions whole herds of wild humans would congregate on the side of the road to view the bears in action.    And everyone kept their distance.  At least 100 yards.  

Except this guy, Mr. Bear Food.

Here we all were. About 50 of us all standing back, well over 100 yards, with our cameras at maximum zoom. And Mr. Bear Food walks farther and farther and farther, finally resting up against a tree no more than 30 yards from the hungry bear. Everyone is yelling at him to get back. He's just smiling away. Mr. Bear Food had no idea how many people had their video camera on trigger waiting for a chance to get a real life bear attack in action. Whom ever you are Mr Bear Food,



today was your lucky day.

Is It Time To Shut Down Medical Schools In Favor of Nursing School?

Dr Rich gives his in depth analysis of the news behind the AMNews.

While apparently Mary Mundinger (DrPH, RN, dean of the Columbia University School of Nursing, President of CACC, and bugaboo of physicians everywhere) did not make herself available to the AMANews for a direct response, she was quoted in an earlier article as saying, “If nurses can show they can pass the same test at the same level of competency, there’s no rational argument for reimbursing them at a lower rate or giving them less authority in caring for patients.”

If students of nursing can pass the same competencies, in their entirety, as their MD  counter parts, they should receive the same rights as physicians to practice in equivalent scopes of practice.  Which means they should take the certification presented by the  American Board of Internal Medicine.  And if the ABIM is shown to be too difficult, physicians should certify by the standards established by their counterpart nursing boards.    

Having  two different certification standard to practice in the same scope of practice is simply irrational.  

With equality defined in internal medicine, DNPs should also be allowed to pursue specialized training, should they desire, in new specialized tracks of training, called Doctor of Nursing Cardiology, Doctor of Nursing Gastroenterology, Doctor of Nursing Endocrinology, Doctor of Nursing Nephrology ( you get the point).  And once complete with their training, they should be allowed to sit for the certification exams presented by the American College of Cardiology, Gastroenterology, Endocrinology, Nephrology and on and on.  If these exams are shown to be too difficult for doctor nurses,  medical doctors of cardiology, gastroenterology, endocrinology and nephrology should be allowed to certify by the standards established by the doctor of nursing specialty societies in order to allow doctor nurses equality of standards. 

Given the mantra of equal training,  and showing that nurse training is equivalent in scope and practice to the specialty of internal medicine, cardiology, gastroenterology, endocrinology and nephrology, nurses  should also be allowed to pursue a new doctor of surgical nursing degree.   Proving once again that a higher nursing education is equivalent to medical education, they should be allowed to prove competency by sitting for board certification presented by the  American College of Surgeons, becoming equals with their MD surgical counterparts.

You see, there is nothing inherently different between the American College of Cardiology, the American College of Surgery and the American Board of Internal Medicine.  They are all certifiers of physicians in their field of expertise.   Each a speciality in their own right.   If nurses believe they can practice internal medicine in its entirety with their nursing degree, there is no reason for me to believe they don't also believe they can also practice cardiology and surgery, in its entirety with their nursing equivalent degree.    

Whether they choose to or not is irrelevant.  Should a nurse wish to pursue specialized training in cardiology or surgery and become certified as equals as their MD counter parts, I believe America owes it to patients and nurses alike to offer them this opportunity.  

Which is why I favor closing all medical schools immediately and broadly expanding nursing admissions to provide for the new wave of doctor nurses who can provide full scopes of internal medicine, cardiology, gastroenterology, endocrinology, nephrology and surgery.  To deny doctor nurses the opportunity to certify as equals in all these fields would be denying patients and doctor nurses alike the rights earned by nature of their training to practice in scopes determined to be equal as their MD counterparts.

If the educational outcome is the same, then as a country, we should be paying for the cheaper education.  That means it's time to shut down all medical schools for good and use the nursing model of care as the only model of care to evaluate and manage patient illness.

How Does A 98 Year Old Present To The ED?

I snapped this picture in a public ED.  I could hear the lady checking in.  She's 98 year's old.  And she presented to the ED by private auto.  Wheeled up to the front desk.  Checked in.  And waited her turn in line.

It's not every day you make it to 98 and you're not coming cutting in line by way of ambulance.  

The Supreme Court Rules It's Illegal To Discriminate Against Whites

Why did it take the Supreme Court to decide discrimination against whites was illegal?

The Supreme Court ruled Monday that white firefighters in New Haven, Conn., were unfairly denied promotions because of their race, reversing a decision that high court nominee Sonia Sotomayor endorsed as an appeals court judge.

New Haven was wrong to scrap a promotion exam because no African-Americans and only two Hispanic firefighters were likely to be made lieutenants or captains based on the results, the court said Monday in a 5-4 decision. The city said that it had acted to avoid a lawsuit from minorities.

Punishing whites because minorities failed to meet the standards of the job is a form of racism.  We can argue till the cows come how about the disparities in minority opportunity.  But it doesn't change the fact that standards are in place for a reason.  Is it acceptable to lower the standards for a defined  job for the sole purpose of increasing minority participation?  By doing so, you are making the presumption that minorities are by default less capable.  That in itself is a racist idea and lowers the standards for all to participate.  This mentality is a race to the bottom.

Let's take medical school for example.  If the minimum requirement at Harvard  was a 30 on your MCAT and a 3.5 GPA, would you keep out a white student with a 4.0 GPA and a 35 on their MCAT because not enough blacks meet the standard admission criteria?  Of course not.  If there cannot be equal standards for all, there should not be any standards at all. Setting different standards based on race is in itself racism.  Punishing one race for their success because another race failed to meet the required standards is racism.  

And the Supreme Court got it right.  It's just too bad it took the High Court to see that.

Cooper's First Buffalo

click image to enlarge

Should Emergency Physicians Be Given Immunity From Lawsuits?

Chris Seper over at Medcity News discusses effort underway in his own backyard to do just that.

Ohio is the latest state to introduce new legislation that would dramatically increase the legal standard to win a civil suit against a doctor working at an emergency department. It also offers the same protection for doctors helping after floods, tornadoes or other disasters.

The bill says physicians would have qualified civil immunity while working in emergency rooms and be subject only to lawsuits if they showed “willful or wanton misconduct” — a high standard for liability usually reserved to determine punitive damages.

The Ohio bill would specifically apply to services being provided under EMTALA regulations. I would interpret that to mean any physician taking care of a patient that was seen or admitted to the hospital through the emergency room would be protected by this higher standard.  That includes hospitalists and all other subspecialists that care for hospitalized patients admitted through the emergency room.  I can't recommend admission on an ED patient and then sign off.  By default, that makes me fall under the same rules as an ED doc.  

And how does the lawyer respond?

Emergency room physicians are protected already, as long as they act within the concept of the standard of care, and don’t deserve an exception beyond what other physicians receive, Lansdowne said. “They can be wrong, and as long as they act in accordance with standard of care, they are not liable,” he said.

The only problem I see in today's malpractice environment is the irrational standard of care that has been established, not by science, but rather by the fear of the lawsuit itself.  Everyday of my life I see head CTs ordered on patients with drug overdoses because they are acting funny.  Should that be the standard of care?  Of course not.  Is it?  Yes.  Because just one of those patients may have fallen or bumped their head and experienced a subdural hematoma.  In the six years I've been practicing as a hospitalist, most of my patients who  have been admitted to my service with altered mental status and a drug overdose have had a CT scan.  A normal CT scan.  Now, I fear the doctor who doesn't order one on that one patient who has a bleed AND a drug overdose.  They're toast.  And because they're toast, everyone gets a CT scan.  That's the standard.   But it shouldn't be.  And it's a legally driven mentality that feeds on itself.  All us docs know the likelihood of having a drug overdose AND a head bleed as the cause of the altered mental status is minuscule.  But none of us are willing to be the doc who doesn't order it just that once and be wrong.  

When the standard of care in a community is the wrong standard;  when it's based on fear rather than science, everyone loses, except the lawyers.  It's time to discard standard of care as the legal basis for malpractice in this country.  And find something that isn't bankrupting our country.  What's the answer?  You tell me.

How To Survive In Primary Care And It's Not By Playing Doctor

It is kind of sad that taking care of the whole patient and serving as a well trained comprehensive doctor is at the bottom of the desirability food chain of medicine. Hospitals and multi-specialty medical groups see primary care physicians as "lost leaders". We have become the "oil change" of medicine, so the big ticket "engine overhaul" can be captured by the high dollar procedures.

Dr Brayer describes how to survive primary care.  And it's not by doing playing doctor.  That's really sad.  

I Can Do CPR With One Hand Tied Behind My Back

Strange indeed

I've done CPR on some pretty frail elderly.  I can't say I've ever seen it done one handed.  

A Reanalysis Of Gawande's Research

McAllen, Texas is the mother ship for the Medicare National Bank. A culture of care that is bankrupting our country. Or so we think. The ladies and gents over at the Health Care Blog analyzed the data. And came to a very different conclusion.

McAllen is different from many areas of the United States: it is sicker and poorer. The observed differences in the rates of chronic disease are highest for those conditions rampant in low income American populations: diabetes and heart disease. Further, Medicare beneficiaries in McAllen have significantly higher rates of co-occurring chronic conditions. As a result the costs of caring for McAllen Medicare population appears high in comparison to other areas but not abnormally so. McAllen suffers from a tremendous burden, but it not caused by its physicians: the care they provide leads to costs that are substantially comparable to the other counties in the article once adjustments are made for the magnitude of the health problems they face. The disturbing pattern of physician practices uncovered by Dr. Gawande sounds a warning not because it foretells a McAllen-like future but because it portrays the on-going crisis that affects both McAllen and Grand Junction and it is national in scope. Physician culture is only part of the McAllen story.

They did some great analysis of the data to come to these conclusions. They showed that the expenditures out of McAllen in patients without diabetes, heart disease or heart failure was not out of the ordinary.

My own analysis? Before I could conclude that an over treat culture of care in McAllen doesn't exist, I would like to see the data, not on patients without these three diseases, but rather expenditure data on patients WITH diabetes, heart failure and heart disease and corrected for poor status (who's poor health is directly related to smoking status). These are the patients for which medical care is expensive. These are the proceduralized patients. Telling me that healthy folks in McAllen cost no more than healthy folks in Colorado doesn't mean anything. Tell me a rich diabetic with heart failure and a history of MI costs more in McAllen than in Colorado. Now, that's meaningful information.

Bizarre Brain Research: Optogenetics

I reader pointed me to some crazy brain research. Optogenetics.

Optogenetics uses a brain cell switch with two genetic parts. The first is a gene taken from an algae that activates the cell in the presence of blue light in order to turn towards the light and photosynthesis. In a neuron, that activation fires the cell. The second is from an archaeon, a salt-based extremophile, which responds to yellow light by pumping chlorideions. In a brain cell, that means not firing at all.

I wonder how many RVU's that would pay?

What's It Like To Be A Nurse?

A nurse tells it like it is

My name is not Catharine. My name is "Nurse!" Not "Nurse?" Or "Nurse." But "Nurse!" Sometimes "Nuuurrrrsssse!!!!" That is what I'm called by the patients (if they can talk), their families, the doctors, social workers, dietitians, respiratory therapists, chaplains, visitors, physical therapists, everybody calls me "Nurse!" I'd sooner be called c*nt, b*tch, f*ckface or wh*re because calling me "Nurse!" amounts to a Master calling a slave. And slave I am.

And no one is just a nurse. For all the nurses out there, I respect the nursing work you do. It's one of the toughest jobs in health care. I for one could never do it.

I Got Offered $1000...

to give a "lecture" on Invanz. I was told I would be given the slides to do the lecture AND it would only take about 15 minutes.

It's not OK to give a doctor a pen, but it is OK to pay them a $1000 in consulting fees. I find this whole thing preposterous.

I turned them down due to my busy schedule. The question is, would you?

Caption Contest

Keep Coming Back For More

I'd like to thank my loyal readers for tuning in on all of my daily offerings. According to Google Analytics you keep coming back for more. In the last 30 days

15% of you have visited more than 100 times
17% of you have visited 25-100 times
13% of you have visited 5-25 times

In other words almost 1/2 of you keep coming back over and over again. Of the remaining 1/2, 30% of you have visited just once. All those poor people missing out on the truth...

100,000 Patients A Year Are Killed By Lack Of Ambu Access

Michael Jackson is dead. In a follow up post I discussed the dangers of IV narcotics, praised nurses for preventing more deaths than I would expect with its use, discussed my own experience with the dangers of IV narcotics, and reported on my nurse coordinator's suspicion that MJ died at the hands of fibromyalgia.

In a follow up post, after an N=12 trial at Happy's hospital, I discussed the lack of critical access to life saving Ambu bags in patient rooms. I suggested that having Ambu bags in every room was not a standard practice in hospitals all across this bankrupt country of ours. The response has been overwhelmingly one of concern for the safety of patients at Happy's hospital. Concern that life saving access to Ambu bags is being compromised in favor of profit.

I took these concerns to heart. I spent all day yesterday researching outcomes data as it relates to having Ambu bags in patient rooms. What I found was shocking (like Dateline shocking). I am now a converted believer. I want to thank all my readers for my new crusade in life.

What I found was unacceptable in the magic of American health care. Study after study points to an epidemic of hospital acquired Ambu death. The literature suggested 125 randomized controlled trials comparing Ambu bags in the mop closet vs Ambu bags in every patient room. A meta-analysis of all trials, suggested that 100,000 hospitalized patients a year are dying due to lack of Ambu access.

Starting monday, I will be contacting all appropriate government agencies and major news organizations to let them know of this hospital crises sweeping America. And I will be starting my own organization, paid for with Ambu advertising, to push for a national quality initiative to put Ambus in every patient room in America.

And I shall call it Happy's Attempt At Helping Ambu Access

Is It Reasonable To Stock Every Hospital Room With Emergency Rescusitation Supplies

A post I wrote yesterday touched a nerve with many ghosts of the night. Many suggested I was failing my duties as a physician for leaving the bedside of a patient to gather the support team for resuscitation efforts, suggesting instead I should have started bagging the patient myself, while I yell outside for help. Or, (as I suggested a once in a lifetime experience)to pull the code blue chord myself.

So I took a little survey on my rounds today. I rounded on 15 patients today. Excluding my ICU patients, I counted the number of Ambu bags that were stocked in my other 12 patient rooms . I searched high and low. Room after room. I opened closets. I opened drawers. I searched every where. Guess how many I found.

Zero. Zip. Nadda. Zilch. Nul.

I talked with a respiratory therapist and asked him where they are. He said they are stocked in one supply closet on every floor. The only places they are stocked in every room are the ICU and the ED.

One reader suggested this was unacceptable hospital policy. That I should contact the "Vice President of Patient Care" to change such as dastardly policy as it represented a patient safety issue. I would suggest this reader has minimal exposure to inpatient medicine and the economics of inpatient medicine.

Stocking an Ambu bag in every room ain't gonna happen. It ain't gonna happen in just about every hospital in this country, except the really rich ones. It is not reasonable, nor rational to have a fully stocked ICU in every patient room of a hospital, in spite of what some wish to believe. I might also add that Happy's Hospital is a level one trauma center, cardiac center, cancer center, neurosurgical center, whatever center. You can get everything at Happy's hospital. I do not work at a rinky dink hospital in the middle of no where with one ventilator and a part time physician that only works M-F from 8am to noon. We have it all, and we don't stock Ambu bags. That is a reality. Because it is the right reality.

It's hard to bag someone without a bag. I'm ready to accept y'all apologies at any time. Those angry at me for not bagging the patient, have been lead astray by forces not familiar with inpatient medicine. If you want the truth on inpatient medicine, stick with me. If you want outsiders opinions on inpatient medicine, go somewhere else.

As for the nursing staff, Happy's nursing team did an excellent job that day saving that patient's life. I take great pleasure in knowing that many of them excel in their duties and responsibilities on their floor duties as a nurse, a job harder than just about every other field of medicine. I have great confidence in many of them for the expertise in nursing related patient care issues and I would trust most of them with my life.

Do You Treat Lawyer Patients Differently?

If a patient tells you they are a lawyer, how does that affect your evaluation process?

Be honest.

The Four Most Expensive Words In The Goat Rodeo Known As American Healthcare

Why does a 92-year-old man with less than a fifty-fifty chance of living another year get an expensive colonoscopy?  I mean, it had better be a good reason.  Rectal bleeding.  Something like that.

“It was a screening colonoscopy,” said the consultant, “We removed a polyp.”

According to Panda Bear the four most expensive words in all of American health care are "Just to be safe".

I have used that line frequently.  And each time I do, I internally rationalize whether the tests I am recommending will ultimately affect my management decisions for my patients and whether those decisions have the ability to change the outcomes of my patient.  If we physicians cannot defend our medical decisions based on sound scientific principles, in the correct clinical scenario, we are part of the problem.    

The more we screw America, the more we screw ourselves.  If we are going to stick an endoscope in a 92 year old,  we are part of the problem.  

Michael Jackson May Have Died From Fibromyalgia

Dr Kevin is reporting that Michael Jackson may have died after receiving a dose of Demerol (generic meperidine). Demerol has all but been banned from Happy's Hospital. If any patient comes in on it our pharmacists are on me like a hawk to change it to something else, especially in our elderly population. It has metabolites that hang around and can cause bad side effects. It is also used by many folks to get high (apparently to a different degree than other narcs).

As I mentioned in my post on Michael's death, I'm not convinced it was a "heart attack" as some news outlets are reporting. He just doesn't fit the profile for coronary artery disease. With that said narcotic drug overdose is certainly a plausible explanation for his death.

Let me give you a story. I was doing my normal daily rounds on a patient when I walked in and just stopped. I stopped and I listened. I looked for signs of life in my 67 year old man who was admitted with abdominal pain. I stood there. Watching. Calmly observing.

It struck me as odd. For a full thirty seconds I saw my patient breath exactly one time. I turned on the lights and noted a remarkable physical finding (another reason to always turn on the lights). Cyanosis. A physical finding in which the skin turns purple due to an increase in deoxyhemoglobin in the capillaries (I will never forget the cause of cyanosis due to my exposure to one of the greatest pimping attendings of all times).

So I calmly walked out of the room, walked to the nurses station and stated calmly:

"One of my patients is about to code. What would you like me to do?"

This is probably the quickest way to get a nurse to jump out of their chair and come bedside to your assistance. I think in retrospect I lost the golden opportunity of a lifetime to pull the code chord and watch every nurse on that floor flock to my room with me standing there saying

"What would you ladies and gentleman like to do about my dying patient?"

This patient, perhaps just like Michael Jackson, was heading to Heaven at the hands of IV morphine, being used to treat an abdominal pain which certainly would not take his life. It was nurse administered, not patient controlled analgesia (the pain pump or better known as the PCA). Not every patient will respond equally to the same dose of medication. No matter how many protocols or protections are in place, we can not prevent 100% of our patients from not experiencing an adverse event. This is one such example. The fact that only a handful of my patients a year experience a complication from IV narcotics is a pat on the back to Happy's Hospital for getting rigorous safety protocols in place.

A PCA is a pump filled with narcotic, set to only deliver a maximum amount of medicine every defined period of time, which is activated by a button the patient carries near them. If the machine is set to only allow one dose every eight minutes, pushing the button a hundred times in eight minutes will only deliver one dose in eight minutes. The beauty of the PCA is that as the patient gets sleepy, the patient stops pushing the button. This is why family should NEVER EVER EVER nor should nurses NEVER EVER EVER push the PCA button for the patient. If they cannot push their own button, they should not have a PCA and nurse administered narcotics should be the route of choice.

My patient had nurse administered narcotics. Several times a year, for just me, I will have patients who experience life threatening respiratory depression from intravenous (and sometimes even oral) doses of narcotics. They are not to be taken lightly. The antagonist for narcotic overdose is Narcan. Sometimes multiple doses must be administered as it gets "consumed". Most patients will wake up very quickly, often in a fit of rage and delirium and no long standing side effects are experienced.

However, sometimes if the respiratory depression consumes the patient, irreversible cardiac ischemia or deadly arrythmias may present themselves, leading to the patient's death. It's the same reason heroin addicts die. They suppress the breathing centers of their brain and they stop breathing. A heroin overdose, is in fact quite a peaceful way to die.

I think I've delved into my hospitalist experience with IV narcotics enough. I think the real question needs to be asked. Why is any doctor prescribing and administering daily Demerol to any one, Michael Jackson or otherwise. Happy's nurse coordinator believes he may have had fibromylagia.

How's that for the official cause of death. Michael Jackson, dead at the age of 50, from fibromyalgia.

Yellowstone In Spring

A mama and her calf own the road.  A beautiful sight to see. (click image to enlarge)

The Doctish English Phrase Book

Dr Hal Dal brings us an up to date explanation of what doctors really mean when they open their mouths.

My favorite You will experience some discomfort. (really means) This will hurt a lot.