"Thanks to modern medicine we are no longer forced to endure prolonged pain, disease, discomfort and wealth."
Robert Orben
Like A Chicken With Its Head Cut Off…Or Something
I start third year on Monday.
I knew I started with medicine, but until yesterday not where. I head on Monday to a military hospital. I’m actually looking forward to that. I’ve heard nothing but good things about going through there and I think it is something interesting to start with. I figure you’ll see a younger population and probably less of the same.
There is a little bump in the road, I only now know that I need my registration and inspection to be up to date in order to drive on base.
In a stunningly bad coincidence, my car’s inspection runs out at the end of this month (i.e. today). Trouble is, it is raining down here and I have a personal horror study of trying to get an inspection done while it’s raining. Long story, short: You can’t get it done (at least per the rules) because the slick pavement doesn’t allow effective testing of your car’s brakes.
It should dry up later today though. If not maybe I’ll be hitching a ride to my first day of my first rotation.
The AMA will now “actively oppose” some private P4P measures.
[A]fter five hours of debate — often over the addition or deletion of a single word — the AMA’s House of Delegates said that it will “actively oppose” any pay-for-performance programs that do not meet the AMA’s five pay-for-performance principles.
Adopted in 2005, those principles specify that programs should ensure quality of care, foster the patient/physician relationship, offer voluntary physician participation, use accurate data and fair reporting, and provide fair and equitable program incentives.
The number of pay-for-performance programs, which provide monetary bonuses to participating physicians who make progress in achieving specific quality or efficiency benchmarks, has increased significantly over the last four years — from 35 plans in 2003, to 130, for a growth rate of 271%, according to one report. By 2008, it’s estimated that there will be more than 160 pay-for-performance programs covering services provided to an estimated 85 million patients.
But this is minutiae.
The association was already on record as opposing plans that didn’t meet AMA criteria, but, said Dr. Rohack, by adding the word “actively” the delegates authorized the AMA to mount opposition against any plan, anywhere that did not meet the standards.
I’m about as involved in organized medicine as any student can be. And while I couldn’t stay for the big HOD meeting at Annual this year (which is where this resolution came from), I’ve been around the pay-for-performance debate.
And I’m not sure this adds anything to it. The battle really is between those who don’t want physicians to have anything to do with planning P4P and those who think P4P is coming no matter what physicians do, and so we better get to the bargaining table to make its implementation more…acceptable.
There was near disaster in Las Vegas at the AMA interim meeting last year when Secretary Mike Leavitt stumbled into the P4P bear trap during a speech to the physician HOD. In it he basically admitted that P4P was coming no matter what, and it was coming so that payers (Medicare) could save money.
Kind’ve a no duh, but even as his handlers used a sheep herding hook to drag him off the stage the outrage was blooming amongst the physicians. I think the argument on how to respond to those comments by the HHS Secretary was the best display of the schism in organized medicine (and amongst all physicians) over how to respond to pay-for-performance initiatives.
I’m not sure this new resolution does much to gap the divide.
I’m on the record for thinking that, if implemented properly, P4P can actually be a positive thing; not just something physician’s have to get used to. But even if I didn’t think that, it seems to me that P4P is coming no matter what.
It is. That is just reality.
And while there’s something valiant in being principled, the greater part of such is discretion. Choose your battles; go to the table on pay-for-performance in order to assure that at least it has physician input.
And, through all my meetings, that has been the consistent position of the AMA it seems. They’re willing to go to the table, but once there to only acquiesce to P4P plans under certain terms (such as guidelines being drawn up by physicians). Throwing in the word active changes this position, how? It opens up more options for the BOT? Small, small change. I’m not sure how many of the nay sayers such can bring over to the side of ‘compromise’.
That Medicare PMHQID program doesn’t have such amazing initial results. So says a JAMA study (H/T Kevin, MD).
Researchers looked at information from hospitals treating 105,383 patients over three years beginning in 2003. They evaluated such factors as whether the hospitals prescribed aspirin and widely accepted cardiac drugs called beta-blockers and ACE inhibitors, and whether patients were counseled to quit smoking.
Compliance rose to 94.2% from 87% at the pay-for-performance hospitals. At the others, compliance also rose, to 93.6% from 88%. Researchers found a “slightly higher rate of improvement for 2 of 6 targeted therapies” but concluded that “overall, there was no evidence that improvements in in-hospital mortality were incrementally greater at pay-for-performance sites.”
It’s possible the financial penalties for not complying weren’t sufficient. “Those with the poorest performance risked future financial penalty,” researchers said, but didn’t actually pay such a penalty. Bonuses for complying with performance standards totaled $17.6 million to a total of 123 hospitals in the first year and 115 hospitals in the second year.
“One read on this is that the carrots have to be bigger,” Duke’s Dr. Peterson said. Hospital officials involved in the Medicare pilot project said this winter in a conference call with reporters that financial incentives were small relative to their budgets.
But seriously, this doesn’t tell us anything does it? This hospital program is counting on Medicare to punish hospitals and then hospitals to pass on the financial punishment to providers?
And as the study appears to admit, there’s a good chance there simply wasn’t enough incentive to promote…adequate change.
We All Know This Is Why P4P Is Coming
Pay-for-Performance is coming from CMS, in order to save some cash. But whatever their primary motives isn’t compensation being tied to performance - as long as it is implemented right - part of the same accountability and transparency physicians are calling for from all other players in the American health care system. I certainly know I think we need more transparency and accountability for payers and for pharma and others.
It isn’t like physicians are far and above better in those departments than insurance or drug companies. Let’s work towards it and some form of P4P can, and should, be part of that.
p.s.
Just kidding about the JAMA thing.
Away from New Orleans the memory of Katrina seems like it is already starting to fade. So you’re excused if you don’t remember the story of Dr. Anna Pou and co. who were accused of killing patients at Memorial in N.O. in order that they could you know…get out themself.
Despite the Coroner’s findings it is just short of a year since Dr. Pou was arrested and charged. Now it looks like the D.A. down there is really looking to string the Otolaryngologist up. There is immunity for nurses originally charged with Dr. Pou,
Two nurses accused in the post-Katrina deaths of four patients at New Orleans’ Memorial Medical Center have been offered immunity to testify before a special grand jury, sources close to the investigation tell CNN.
Sources close to the investigation told CNN the two nurses are expected to testify before the grand jury in the next two weeks, which could signal a possible wrapping up of the case. It could also signal the main target of the investigation is Pou, a physician who was under contract with Memorial Medical Center when Katrina struck.
I’ve been away from the blogosphere for a while, and I’m sure there’s been so chatter about this Grand Jury movement. Certainly Dr. Pou’s efforts have a strong internet presence. You can visit her defense fund page here.
Codeblog has Grand Rounds up for this week. Nearly forgot about it!
It’s All The System’s Fault!
Before I go off on my little tangent I’d like to admit (as I always do) that the U.S. has one of them least efficient health care systems the world over. It fails to value prevention, it fails to control costs, it fails to identify evidence based procedures.
It also allows the freest choice for those who can afford it and single handedly drives biomedical and pharma innovation.
All that aside, as I’ve made it clear over the years it really annoys me when people throw the cost of health care in this country out there and then really imprecise measures of quality - such as life expectancy - and pass it off like this country isn’t getting value for what it spends. Here’s the LAT article (via THCB) which has required this post.
Amid stacks of reports, all with wonky measures of access, equity, efficiency and medical outcomes, two statistics stand out. The U.S. spends more on medical care than any other nation, and gets far less for it than many countries. According to the 2006 analysis by the Organization for Economic Cooperation and Development, the U.S. spends an annual $6,102 per person — more than any other country and more than twice the average of $2,571. Yet Americans have the 22nd highest life expectancy among those nations at 77.2 years compared with the analysis’ average of 77.8 years. People in Japan, the world leader in longevity, live an average of 81.8 years.
Talk about me almost blowing my top.
Look, we’re only talking about magnitude here because all can admit the “faults” of the American health care system. But the magnitude; the degree to which blame can be heaped on the system itself is important because of the level of outrage that is building. Personally, I think it is insulting that groups like the Commonwealth Fund think they have to stay on message and dumb down the findings and explanations for the general consumer.
Because while I admit the comparative shortcomings of the American healthcare system a lot of these numbers owe something to the way this country lives. Ignoring that fact; continually marching out really multivariable figures as evidence of this country’s shortcomings is annoying.
Plenty of our health woes are on us as patients, not on faults of the system.
Americans in general lead some of the unhealthiest lives in the western world. Rightly throwing out those Pacific Island nations America is the second fattest country in the world, it has some of the highest rates of diabetes in the world, it has a higher mortality per 1000 females due to cardiovascular disease than any nation you’ll see held up as a glorious example of health care done right.
Get out of Dodge if you think much of that can be put on access issues or on a failure of American medicine to promote disease prevention. Us stuffing Big Mac’s down our faces (and importantly doing it longer and at a greater rate than other countries) isn’t a public health failure. That is a societal problem.
The best evidence says Americans are sicker than their Canadian counterparts, sicker than their British counterparts, independent of their access to care or the quality of care they receive.
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This is ambitious, as WaPo describes it.
The federal government is undertaking the most ambitious set of studies ever mounted under a controversial arrangement that allows researchers to conduct some kinds of medical experiments without first getting the patients’ permission.
The $50 million, five-year project, which will involve more than 20,000 patients in 11 sites in the United States and Canada, is designed to improve treatment after car accidents, shootings, cardiac arrest and other emergencies.
About 40,000 such patients show up at hospitals each year, and the standard practice is to give them saline infusions to stabilize their blood pressure. For the study, emergency medical workers are randomly infusing some patients with “hypertonic” solutions containing much higher levels of sodium, with or without a drug called dextran. Animal research and small studies involving people have indicated that hypertonic solutions could save more lives and minimize brain damage.
You don’t give give your consent for standard of care procedures in these kind’ve trauma situations anyway. How far do trauma care practices have to be vetted for research like this to be run?
Before starting the research at each site, researchers complete a “community consultation” process. Local organizers try to notify the public about the study and gauge the reaction through public meetings, telephone surveys, Internet postings and advertisements and through stories in local media. Anyone who objects can get a special bracelet to alert medical workers that they refuse to participate.
Trauma research like this has sparked interest before. We all remember some of these blood substitutes over the past several decades. Personally I think, just from this short story, these studies seem pretty within bounds.
Just a weird story from Kevin, MD wherein a patient doesn’t get a kidney because the unrelated donor might have been coerced into donation by a cult. Here’s the Toronto Globe & Mail story,
Kate and Nick Croft, Falkingham’s mother and stepfather, allege that the leader of the Jesus Christians, David McKay, coerces his followers into donating kidneys in an effort to garner media attention. The couple said they sent several e-mails to the Ontario Ministry of Health and Toronto General, pleading with them not to go through with the transplant, arguing that their son was not acting under his own free will. A spokesman for the Ontario Ministry of Health declined to comment, citing privacy concerns.
[The potential recipient] Sabloff summarily dismisses the Crofts’ brainwashing allegations. She said Falkingham was acting under his own free will and was only following his heart.
Here’s the Jesus Christians own webpage and the Wikipedia write up on the cult.
Let’s Hope Barney Never Needs A New Hip
The NHS reiterates - if you keep smoking, it’s going to take you longer to get that surgery.
The ruling applies to routine operations such as hip replacements and heart surgery for conditions that are not immediately life-threatening.
If smokers refuse to give up, they are still likely to be treated but may have to wait longer.
Leicester City Primary Care Trust will become the first health authority to introduce the “quit or wait” rule this summer. Other health trusts are consulting on the idea.
Rod Moore, the trust’s assistant director of public health, said: “If people give up smoking prior to planned operations it will improve their recovery. It would reduce heart and lung complications and wounds would heal faster.
“Our purpose is not to deny patients access to operations but to see if the outcomes can be improved.”
However patients’ groups argue that the move is about the NHS saving money rather than improving patient care.
You think Sherlock?
Seriously I wouldn’t have a problem with this if socialized medicine in the UK wasn’t surprising private options. Then they could just refuse to quit and have a legitimate avenue of paying for the operation themselves. But as it stands right now, this is only another example of the access to care issues raised by health care systems with bureaucraticly managed global budgets.
President Bush has nominated Dr. James Holsinger for Surgeon General. He appears more than qualified with his public and academic service.
Holsinger served as Kentucky’s health secretary and chancellor of the University of Kentucky’s medical center. He taught at several medical schools and spent more than three decades in the Army Reserve, retiring in 1993 as a major general.
But his position on homosexuality, especially voiced in roles in service to his church, is drawing much ire. In 1991 for a committee of the United Methodist Church, Dr. Holsinger published “The Pathophysiology of Male Homosexuality.”
I guess the question is: Do these views really speak to his ability in this job considering their age and the context in which they have been made? At the least the entire thing is a mess and unfortunate, considering the acting Surgeon General was such a friendly, easy going, competent guy when I met him last year. Sad to pass over Dr. Moritsugu for this big stinking mess.
I’m done with USMLE Step 1! Maybe I should leave off the exclamation point. The entire ordeal has been kind’ve anticlimactic.
What?! No Fireworks?
It’s a giant relief to have that behind me and yet, disappointing that it is over. Mostly because the only things I can remember are the questions I had trouble with…so I sat there Wednesday after the test frustrated over things I could’ve done better.
It’s annoying when you get halfway to a question. For instance, the best case scenario would for me to have a memorized list in my head of vaccines contraindicated in HIV…but I don’t. Instead, trying to reason it out, I can call up the fact that MMR is a live attenuated vaccine. Seems a reasonable thing to figure not to give to someone facing immunocompromise.
Last night, as I did my after the fact research (with a beer in my hand) I couldn’t help but be a little annoyed. Of course, that question is just an example of many that are tugging at me.
Oh well, you only remember the iffy/tough questions. Not exactly a balanced way to estimate your performance.
Third year didactics are less than five days away. I plan to get back to regular posting before then.
Optimism is good for the soul most of the time.
Take a look: Forbes’ survey of the Top 25 highest earning jobs.
The survey is a gross generalization, true. Grouping all surgeons together, having categories like Physicians - NOS shows how “for the public” the survey is. I’m sure other professions on the list are likewise generalized. Physicians and surgeons obviously have a wide range of incomes. Take a look at this average physician salary survey to get a feel for the disparities.
That aside, the Forbes piece is still a reminder of how lucky I will be.
I love it when people say if you want to make money don’t go into medicine. While true in a way…
No One Aspires To Bill Gates-esque Wealth As A Physician
…I think it still grossly fails to appreciate the lifestyle most physicians enjoy. There is a real debate about the undervaluing of physicians. Merely looking at income levels fails to weigh things like years in training or education and business debt. And the reimbursement pressures are very real and I imagine very stressful.
But that isn’t what you hear out here as a physician-in-training or potential physician-in-training. I hear over and over, “If you want to make money go into business or become a lawyer or whatever.”
But really? The implication is there are guaranteed greener pastures elsewhere. It certainly doesn’t seem like that is the case when you step back and take a look.
Sure, there are some personal injury attorneys who earn millions and do better than the docs they’re suing. There are personal injury attorneys who can’t pay the rent on their office space.
Sure there are your friends with the bachelor degrees in finance who are pulling in the dough working their way up in some I-Banking job. There are your college friends trying to figure out how to earn with an English degree as well.
Anecdotes.
In reality even by the hourly pay (also see here), many if not most specialties (my apologies to PCPs), do really, really well. And yet I hear advice to stay away from medicine from ophthalmologists and ortho spine docs. That doesn’t seem right.
Being a doctor may not mean the relative wealth it did at its peak, but my God, for a profession that offers so much else, the earning potential is still pretty remarkable.
That said, by no means are physicians overpaid. Not here and not elsewhere. Far, far from it.
There’s a reasonable argument that physicians should be amongst society’s highest paid individuals. I think most of the public, realizing the relative value of health, buy that argument.
But whether physicians earn their true weight, it is worth stepping back and realizing how comparatively blessed this profession is. Even as students accumulate debt, even as payments fall and practice costs rise. Because while I could be earning more in some other profession, it is much more likely that my lifetime earning power would be less.
Plus, it’s just good for the soul to see the glass as half full.
She Is A UCLA Bruin Though
There’s an LA Times story floating around about a pretty remarkable UCLA medical student. Well, not medical student anymore, she’s probably Dr. Lim by now considering UCLA’s graduation/Hippocratic Oath ceremony has come and gone.
But whatever her title her’s is a truly encouraging story.
Struck with a ravaging bacterial infection that destroys limbs, she became a triple amputee at age 8 and soon faced a life of prosthetics, wheelchairs and often-painful rehabilitation.
But from that suffering, Lim forged a life of achievement. On Friday, she will graduate from UCLA’s medical school and then will begin a residency program at the medical center there.
Her chosen specialty? Pediatrics, with a possible concentration later on childhood allergies and infectious diseases.
Colleagues say Lim’s calmness in a hospital’s hectic environment puts others at ease.
“With Kellie, at first you notice her hand is not there. But after about five minutes, she is so comfortable and so competent that you take her at face value and don’t ask questions so much. She has an aura of competence about her that you don’t worry,” said Dr. Elijah Wasson, who supervised Lim during a rotation in internal medicine at Olive View-UCLA Medical Center in Sylmar.
The same old question: how do drug companies influence physician prescribing habits? The New York Times looks at “payments” for anemia drugs.
Industry analysts estimate that…payments — to cancer doctors and the other big users of the drugs, kidney dialysis centers — total hundreds of millions of dollars a year and are an important source of profit for doctors and the centers. The payments have risen over the last several years, as the makers of the drugs, Amgen and Johnson & Johnson, compete for market share and try to expand the overall business.
Let’s be clear what we’re talking about here. The physician practices aren’t getting a big check with you know, the word “Commission” on the Re: line.
Federal laws bar drug companies from paying doctors to prescribe medicines that are given in pill form and purchased by patients from pharmacies. But companies can rebate part of the price that doctors pay for drugs, like the anemia medicines, which they dispense in their offices as part of treatment. The anemia drugs are injected or given intravenously in physicians’ offices or dialysis centers. Doctors receive the rebates after they buy the drugs from the companies. But they also receive reimbursement from Medicare or private insurers for the drugs, often at a markup over the doctors’ purchase price.
Medicare has changed its payment structure since 2003 to reduce the markup, but private insurers still often pay more. Combined with those insurance reimbursements, the rebates enable many doctors to profit substantially on the medicines they buy and then give to patients.
No matter how they’re earning profit off these deals, you imagine it provides a pressure to overuse the drug. But I think there is a functional difference in between getting discounts on the drugs and…getting paid to use them.
Since 1991, when the first of the drugs was still relatively new, the average dose given to dialysis patients in this country has nearly tripled. About 50 percent of dialysis patients now receive enough of the drugs to raise their red blood cell counts above the level considered risky by the F.D.A.
American patients receive far more of the anemia drugs than patients elsewhere, with dialysis patients in this country getting doses more than twice as high as their counterparts in Europe. Cancer care shows a similar pattern. American cancer patients are about three times as likely as those in Europe to get the drugs, and they receive somewhat higher doses.
The fact not addressed adequately by the NYT’s article is that for smaller practitioners Medicare’s reimbursement scheme for these drugs mean they lose money on them. Much like the complaints PCPs have about some vaccines - it simply is not profitable for some smaller hem/onc and nephrology practices to stock and dose these synthetic erythropoietins. Yet they have to for their patients.
It is for those practices that the rebates are defended.
The biggest problem in the abuse of these drugs may lie with the big boys:
DaVita, one of the two large dialysis chains, and the most aggressive user of epoetin, gets 25 percent of its revenue from the anemia drugs — and even more of its profit, according to some analysts.
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Mexican Consulates “do their job” and help those Mexican citizens here illegally.
A program called Ventanillas de Salud, or Health Windows, aims to provide Mexican immigrants with basic health information, cholesterol checks and other preventive tests. It also makes referrals to U.S. hospitals, health centers and government programs where patients can get care without fear of being turned over to immigration authorities.
Launched in 2003 in Los Angeles and San Diego, the Ventanillas program is currently operating in 11 cities, including Chicago and Houston, and the goal is to have a version in all 47 Mexican consulates around the country.
“Health-related issues are a very important absent piece of information,” said Ruben Beltran, Mexican consul general in Los Angeles. “We’re filling the blanks…. The consulate is the prime location to disseminate that information to the Mexican community.”
But critics say that illegal immigrants are already an unchecked drain on the public healthcare system and that such programs will only allow them to reap even more benefits.
Putting aside my belief in more open borders and general support for the amnesty bill moving through Washington, I’m pretty unnerved by things like this.
The Mexican government has huge motives to promote illegal immigration and keep its citizens here in the U.S. It is stunning that Mexico’s prime export is workers. More than 20 billion dollars flows back into Mexico each year as remittances. And I guarantee as long as the Mexican government continues to promote the exportation of its citizens, their economy will never become self sustainable. These remittances aren’t a stepping stone. They’re a crutch Mexico is going to take a long time to get itself off of.
The Mexican government has screwed over their own people and the United States by setting up this sort of cycle.
A Mexican Government Brochure On How To Sneak Into The U.S.
I don’t think there is any argument to be made that - well, they’re going to do it anyway, might as well make it safe for them. Baloney
Helping illegals sneak into the U.S., handing them ID cards to help them find illegal work, and more. This basic circumventing and flouting of American law is acceptable, how? I know the Mexico - U.S. relationship is a little unique, but where else in the industrialized world would this stand? The Mexican government has basically decided its best export is its own citizens and be damned if the U.S. wants to buy that or not.
I’m all for expanding legal immigration, but the U.S. has the right to control its own borders and has a right for other countries to respect that.
No matter how insignificant you think the strain on public services is, clearly illegals use resources here. Including health care resources. They absolutely contribute to the cost of health care in this country. And now they’ll use even more under this plan.
