Archive for the 'Health care reform' category

More Kafka-eque health care absurdities

May 26 2010 Published by under Health care reform, Medicine

As my regular readers know, I'm not a big fan of our current health care system. Our bloated, industry-driven system manages to deliver less effective care at a higher cost than most other industrialized nations. The system is Byzantine, unnavigable, and dangerous, and is kept that way in the name of the Holy Market. But health care can benefit from practices that are decidedly un-capitalist, at least in the Milton Friendman or Ron Paul sense.

Like aviation, health care must apply risky and expensive practices to large numbers of people in dangerous situations. This process is made safer by certain sorts of standardization, such as checklists. Data suggest we would also benefit from developing widely applied, evidence-based best practice guidelines, and from increasing the use and interoperability of electronic health systems. But that's not how we do things here.

Our culture is strongly biased against centralized anything, which is often a useful instinct. But in health care, the market does not necessarily drive best practices, but most profitable ones. One of the worst hybrids of the ultra-free market ideal and the more communitarian ideal is the HMO. It's not that the idea is inherently bad, but its implementation has often been problematic.

An HMO is an agreement between a patient, a physician, and an HMO. The patient pays a premium to the HMO, and co-pays to doctors and other providers.  These fees are usually significantly lower than in other types of plans. The HMO assigns them to a primary care physician and agrees to pay for care the PCP recommends, within the guidelines of the plan.  This puts the PCP in the position of "gatekeeper" for more complex medical care.  The doctor is often payed less to care for HMO patients, but in exchange the HMO sends them patients and keeps them busy. But this system is often a loss for both the doctor and the patient. 

A common way doctors get paid by HMOs is "capitation", that is, getting paid per head. An HMO will offer a doctor x dollars per month per patient.  This reduces the incentive for the doctor to provide unnecessary but potentially profitable care.  In fact the incentive is exactly the opposite: the more patients the doctor enrolls, and the fewer services she provides, the more she and the HMO will profit.  Basically, HMOs are designed (in their classic form) to give the appearance of providing efficient low cost care, while actually providing inefficient, low cost care that can be minimalist at best.

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21 responses so far

Health care reform---democracy in action

Mar 22 2010 Published by under Health care reform, Medicine

It's hard to imagine the that the hyperbolic rhetoric that characterized the health care reform debate could get any worse (death panels, etc.). But it will.  Representative John Boehner (Asshat-OH) started it of last night with what amounted to a call for the overthrow of our democracy.

"Today we stand here amidst the wreckage of what was once the respect and honor that this House was held in by our fellow citizens.

"And we all know why it is so.

"We have failed to listen to America.

"And we have failed to reflect the will of our constituents.

"And when we fail to reflect that will - we fail ourselves and we fail our country.

[...]

My colleagues, this is the People's House.

"When we came here, we each swore an oath to uphold and abide by the Constitution as representatives of the people.

"But the process here is broken.

"The institution is broken.

"And as a result, this bill is not what the American people need, nor what our constituents want.

"Americans are out there are making sacrifices and struggling to build a better future for their kids.

[...]

"And they are angry. They are angry that no matter how they engage in this debate, this body moves forward against their will.

"Shame on us.

"Shame on this body.

"Shame on each and every one of you who substitutes your will and your desires above those of your fellow countrymen.

[...]

"If we pass this bill, there will be no turning back.  It will be the last straw for the American people.

"And In a democracy, you can only ignore the will of the people for so long and get away with it.

"And if we defy the will of our fellow citizens and pass this bill, we are going to be held to account by those who have placed us in their trust.

"We will have shattered those bonds of trust.

I'm sure if asked he will say that "being held to account" means being voted out of office.  And that's fair.  If, as Boehner says, our representatives ignored the will or their constituents, then they will probably lose their seats.  My own rep voted exactly as I would have instructed him: "Yea." This will earn him my future vote.  The true subversion is Beohner's claim that his opinion is the majority opinion, and that those have fought for health care reform have subverted democracy.

I have news for Boehner.  His party lost the last election.  They may win the next one, but this one they lost.  That means they are in the minority, a word seemingly unfamiliar to him.  What "minority" means is that he represents the smaller part of the American public.  He cannot rightly claim to represent me or anyone else outside the 8th district of Ohio or the House republican delegation, a delegation that is currently in the minority.

This is how democracy works: if the voters like what you're doing, they vote for you.  If they don't, you're out.  Continuing calls for subverting the will of the people as expressed in last night's vote are immoral and antidemocratic. 

69 responses so far

Rush Limbaugh doesn't get it

Jan 01 2010 Published by under Health care reform, Medicine

Or if he does, he's even a worse person than I'd realized. After suffering chest pain in Hawaii he was evaluated in a hospital. When discharged today, he held a briefing in which he praised the U.S. health care system as being the best in the world and remarked that he sees nothing wrong with it at all. He also stated that he received no special treatment. (I don't have links yet, as it was just on TV.)
Such unmitigated arrogance. Such hateful, uncompassionate ignorance. Chest pain can be a useful example of how we approach health care in the U.S., so let's dig and see how spectacularly wrong Rush is.

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30 responses so far

The "R" word: why we shouldn't fear health care rationing

Nov 14 2009 Published by under Health care reform, Medicine

An easy way to kill a debate on health care policy is to use the "R" word. We saw this early in the HCR debate with overheated talk of "death panels" and other nonsense. But we ignore the real issue of rationing at our own peril. Those of us who favor real HCR must embrace rationing, coopt it, show our opponents how it is inevitable.
Nowhere is the the Right more hypocritical than the issue of health care rationing (OK, maybe with sex stuff, but...). Everyone who studies American health care knows that we already ration; we just do it irrationally. Current rationing allocates resources to the wealthy and those with good jobs, and when we do care for the uninsured, unevenly spreads that cost to some hospitals and taxpayers. Medical services are reimbursed in an unstable fashion, with some services reimbursed well one year, and poorly the next, making planning nearly impossible for doctors, hospitals, and patients. For example, there are currently large cuts planned for some cardiology services, cuts which I don't disagree with in theory but cardiologists cannot provide good service to their patients if one year they are encouraged to go out and buy lots of fancy equipment and the next year are told they can't use it.
Hospitals struggle from year to year as economic downturns change the payor mix driving down income. There is no stability in our current system. It is not robust, for providers or for patients.

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33 responses so far

Faith healing in health care reform---blogs had the story first

Nov 03 2009 Published by under Health care reform, Medicine

The mainstream media is finally catching on to a disturbing story--the insertion of faith-healing and other non-scientific practices into health care reform. Health bloggers have been on this story for a while, showing us that Senate Bill 1679 currently contains language that would require support for faith healing practices:

The essential benefits provided for in subparagraph (A) shall include a requirement that there be non-discrimination in health care in a manner that, with respect to an individual who is eligible for medical or surgical care under a qualified health plan offered through a Gateway, prohibits the Administrator of the Gateway, or a qualified health plan offered through the Gateway, from denying such individual benefits for religious or spiritual health care, except that such religious or spiritual health care shall be an expense eligible for deduction as a medical care expense as determined by Internal Revenue Service Rulings interpreting section 213(d) of the Internal Revenue Code of 1986 as of January 1, 2009.

This, and other language, would protect such services as Christian Science healing as valid, reimbursable medical practices. Why should anyone have a problem with that?
As I pointed out previously, it takes away important resources needed for real medical practices, and my violate the Constitution. But there are more important ethical reasons to be cautious about such language.
Religious healing practices are nonsense. They are not based on science but on mystical, vitalistic nonsense, and while one cannot object to people doing it on their own dime, to give these practices the same legitimacy as, say, blood pressure monitoring and treatment is unconscionable and immoral. When the government decides to require that faith healing be treated like any other modality, it lends legitimacy to useless and often harmful practices. How are we to protect children from their deluded parents if health insurance actually pays for neglect?
We cannot allow codification of faith healing and child neglect. This is a deal-breaker. It is not impossible to believe that if this language were retained, we could see homeopathic hospitals and Scientology psychiatry wards.

21 responses so far

Are you a 99214 with 250.02, 401.1, and 272.2?

Oct 26 2009 Published by under Health care reform, Medicine

When I see a patient at the office, I spend time developing trust, forming a therapeutic alliance, thinking through their physical complaints, examining them, and applying the best evidence to formulating a plan for maintaining their health. It's a lot of fun.
Less fun is the part where I try to get paid. To bill an insurance company, I must use numeric diagnostic codes that best fit what I'm seeing, and I must pick a code representing a level of service, that is, how hard I worked.
The diagnostic codes are referred to as ICD-9 codes, and the service codes are called E/M codes. Not all ICD-9 codes are easily billable. For example, if a patient comes to see me for anxiety or depression, I can't bill for it. I can bill for "malaise and fatigue" (780.7), but not for generalized anxiety disorder (300.02) (supposedly it's possible, but, like the Loch Ness monster, it's always a friend of a friend of a friend who saw it).

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25 responses so far

When there's no place to go

Oct 19 2009 Published by under Health care reform, Medicine

A few weeks ago, I wrote a little about hospitals "dumping" patients. At least around here, it's a rare problem. But what about people who don't get dumped but have no place to go?
Let's take "Mrs. Anton". She's 68 years old and has metastatic breast cancer. She's going to die of the disease, but probably not this week or next. She is admitted to the hospital for a fall, but nothing is broken and there's no reason to keep her. Her husband has been caring for her, but he's a little guy and can't handle the day-to-day care which includes cleaning her, changing her diaper (she can't get to the bathroom quickly enough most of the time), and turning her in bed so that she doesn't develop painful bed sores.

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14 responses so far

Bad idea department: tax doctors to pay for health care for the poor

Sep 30 2009 Published by under Health care reform, Medicine

The state of Michigan is facing massive budget cuts which will further eviscerate the Medicaid program. If the legislature passes it's budget as planned, massive cuts to Medicaid will reduce federal matching funds further limiting access to health care for the state's many uninsured. It's not clear if there is a way out of this, other than a massive overhaul of the nation's health care system.
But lawmakers are looking for termporizing measures. One of these is to levy a tax on doctors. This is insane.
Medicaid pays pennies on the dollar so many physicians (my practice included) cannot afford to participate. This means that our already narrow-margin business would be assessed an additional 4% tax on our gross receipts (in addition to income and small business taxes).
There is already a shortage of primary care physicians, and if health care reform passes, more people will have insurance and seek our care. If we tax doctors to provide care, we are shooting ourselves in the neck.
This is not simply a self-preservation issue for me---the abject stupidity of a narrowly-applied tax for a societal benefit is odd, and to apply it to the people trying to provide the service is even crazier. Providers who already take care of Medicaid patients will still pay the tax, but may see a rise in compensation (although I doubt that it will make it profitable to care for these patients).
If this goes through, may practices are going to be in trouble. In addition to cutting our own pay, we will probably have to implement draconian measures such as dropping health care for our employees and probably laying off at least one worker (out of five).
This is a monumentally stupid idea. If you live in Michigan or in any other state where there are such proposals, make some noise.

14 responses so far

Health care---an obvious moral imperative

Sep 14 2009 Published by under Health care reform, Medicine

I got a little cranky earlier during a facebook discussion, then heard the voice of a friend in the back of my head saying, "Blog it! Blog that shit!"
And I was about to, when the hospital called with a minor crisis, and then I realized it was the probably one of the last nice days of they year, so I went to the pool with the family, then my wife made a yummy dinner...you get the idea. Anyway, here's the deal. I was reading this piece in the Times about a woman with a complex disease who died at least in part because of our Byzantine health care system. It was a familiar story.
And it's not just a compelling anecdote---this is every day. I'm just one physician and I regularly see horrors like this. The conservative/libertarian philosophy that encourages this sort of system is sick---immoral, unjust, and sick. It's hard for me to understand how otherwise moral-appearing people cannot see that medical care, like air, food, water, roads, and schools is not "just another commodity". I admit I just don't get it. This ultra-libertarian view of health care is a form of social insanity.
There is no justification for failing to create a just system--none. The cost is trivial compared to the cost of doing nothing. Ours current system is rife with irrational rationing and wasteful spending on profit-driven middle-men.
Health care is not just another industry where unfettered competition and "red in tooth and claw" capitalism benefits all. The profit motive kills. It kills trust, it kills people.
Ultimately, all the bluster and hot air expended defending the status quo because of cost, ideology, or whatever is immoral bullshit.

17 responses so far

Health care rationing vs. freedom to go broke

Sep 11 2009 Published by under Health care reform, Medicine

In the current debate over health care, the Right is pissing me off. They are whining about a "government takeover" that will lead to rationing and death panels, but also about runaway costs. Guess what?
You can't have it both ways.
I just got off the phone with a Major Private Insurance Company. In order to save costs, certain tests must be pre-approved. In this case, I spent about twenty minutes on the phone, first with a clerk, then with a nurse (interspersed with a number of long hold periods). In the end, the study was approved. (I've never made such a call for a Medicare patient.)
This kind of prior authorization is a bureaucratic nightmare---I could have seen two patients in the time it took to get this done. On the other hand, unnecessary tests are a big waste of money, so the private insurance company would be crazy not to throw up a speed bump.
We already ration care. The question is not whether to ration care, but how. Currently it's done by the faceless bureaucrats so feared by the right----they just happen to be private faceless bureaucrats.
The Right needs to reassess its values---do they value cost containment, absolute health care freedom, or a libertarian dystopia where the rich get whatever they want and everyone else can fuck off?

24 responses so far

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