Thursday, April 30, 2009

Rationing Health Care Brought to You by Obama

Once again, Charles has it right and states it so eloquently. His op-ed can be viewed many places including here. RealClearPolitics - Obama: The Grand Strategy.

If Obama gets his health care plan passed, it will mean rationing as I have stated in several other blogs and Government will decide on what is necessary for the individuals. Is that really what we want?

By Charles Krauthammer

WASHINGTON -- Unified theory of Obamaism, final installment:

In the service of his ultimate mission -- the leveling of social inequalities -- President Obama offers a tripartite social democratic agenda: nationalized health care, federalized education (ultimately guaranteed through college) and a cash-cow carbon tax (or its equivalent) to subsidize the other two.

Problem is, the math doesn't add up. Not even a carbon tax would pay for Obama's vastly expanded welfare state. Nor will Midwest Democrats stand for a tax that would devastate their already crumbling region.

What is obviously required is entitlement reform, meaning Social Security and Medicare/Medicaid. That's where the real money is -- trillions saved that could not only fund hugely expensive health and education programs but also restore budgetary balance.

Except that Obama has offered no real entitlement reform. His universal health care proposal would increase costs by perhaps $1 trillion. Medicare/Medicaid reform is supposed to decrease costs.

Obama's own budget projections show staggering budget deficits going out to 2019. If he knows his social agenda is going to drown us in debt, what's he up to?

He has an idea. But he dare not speak of it yet. He has only hinted. When asked in his March 24 news conference about the huge debt he's incurring, Obama spoke vaguely of "additional adjustments" that will be unfolding in future budgets.

Rarely have two more anodyne words carried such import. "Additional adjustments" equals major cuts in Social Security and Medicare/Medicaid.

Social Security is relatively easy. A bipartisan commission (like the 1983 Alan Greenspan commission) recommends some combination of means testing for richer people, increasing the retirement age, and a technical change in the inflation measure (indexing benefits to prices instead of wages). The proposal is brought to Congress for a no-amendment up-or-down vote. Done.

The hard part is Medicare and Medicaid. In an aging population, how do you keep them from blowing up the budget? There is only one answer: rationing.

Why do you think the stimulus package pours $1.1 billion into medical "comparative effectiveness research"? It is the perfect setup for rationing. Once you establish what is "best practice" for expensive operations, medical tests and aggressive therapies, you've laid the premise for funding some and denying others.

It is estimated that a third to a half of one's lifetime health costs are consumed in the last six months of life. Accordingly, Britain's National Health Service can deny treatments it deems not cost-effective -- and if you're old and infirm, the cost-effectiveness of treating you plummets. In Canada, they ration by queuing. You can wait forever for so-called elective procedures like hip replacements.

Rationing is not quite as alien to America as we think. We already ration kidneys and hearts for transplant according to survivability criteria as well as by queuing. A nationalized health insurance system would ration everything from MRIs to intensive care by a myriad of similar criteria.

The more acute thinkers on the left can see rationing coming, provoking Slate blogger Mickey Kaus to warn of the political danger. "Isn't it an epic mistake to try to sell Democratic health care reform on this basis? Possible sales pitch: 'Our plan will deny you unnecessary treatments!' ... Is that really why the middle class will sign on to a revolutionary multitrillion-dollar shift in spending -- so the government can decide their life or health 'is not worth the price'?"

My own preference is for a highly competitive, privatized health insurance system with a government-subsidized transition to portability, breaking the absurd and ruinous link between health insurance and employment. But if you believe that health care is a public good to be guaranteed by the state, then a single-payer system is the next best alternative. Unfortunately, it is fiscally unsustainable without rationing.

Social Security used to be the third rail of American politics. Not anymore. Health care rationing is taking its place -- which is why Obama, the consummate politician, knows to offer the candy (universality) today before serving the spinach (rationing) tomorrow.

Taken as a whole, Obama's social democratic agenda is breathtaking. And the rollout has thus far been brilliant. It follows Kaus' advice to "give pandering a chance" and adheres to the Democratic tradition of being the party that gives things away, while leaving the green-eyeshade stinginess to those heartless Republicans.

It will work for a while, but there is no escaping rationing. In the end, the spinach must be served.

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Wednesday, April 29, 2009

ICD-10 Delays

I blogged on the new ICD-10 coding changes which were to be implemented soon, but citing an outpouring of demand for more time, the U.S. Department of Health and Human Services earlier this month granted a two-year deadline extension to 2013 for the transition from ICD-9 codes to the greatly expanded ICD-10 codes.

If you remember, the transition to ICD-10, which contains 155,000 codes compared to ICD-9 which has 17,000 was going to be a nightmare for offices, clearing houses and payers.

The regulators received more than 3,000 public comments, with a majority asking for a delay in the compliance dates citing implementation costs, the need to train healthcare personnel, and to ensure ample time for testing.

This change is going to be very expensive for providers and really provide them or their patients with no added benefit.

A recent study by Reistertown, Maryland-based research firm, Nachimson Advisors LLC reported the ICD-10 upgrade would cost a practice with three physicians about $83,290, and a practice of 10 physicians $285,195 to upgrade.

This is an unfunded mandate that will add more administrative hassles with no benefit to patient care. It will give insurance companies one more reason to deny a payment.

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Tuesday, April 28, 2009

New Flu Strain Notice

This notice was sent to physicians yesterday from Judy Monroe, MD (State Health Commissioner)

On Tuesday, April 21, the Centers for Disease Control and Prevention reported that two recent cases of febrile respiratory illness in children in southern California had been caused by a novel strain of influenza A (H1N1) which had not been reported in the United States or elsewhere previously. The novel virus contains genetic segments from N. American swine influenza A (H1N1), European/Asian swine influenza A (H1N1), N. American avian and human influenza viruses. By April 24, additional cases were being reported from southern California and Texas. At the same time health authorities in Mexico announced an influenza outbreak from this virus in southern and central Mexico. This message is to provide and update and provide guidance to health care workers in Indiana.

This outbreak is very fluid at the moment and changes are occurring daily. Interim guidance is available on the CDC Web site at
http://www.cdc.gov/swineflu/guidance/. The ISDH will be developing a page with information for Indiana health professionals and will provide you with the URL as soon as possible.

Current Situation
· World Health Organization reports that 1000+ cases and approximately 81 deaths have occurred in Mexico due to infection with a novel swine influenza virus twenty three cases have been confirmed as Swine Influenza (H1N1) genetically identical to the CA cases.
· In the US confirmed cases have been identified in CA (7), TX (2), Kansas (2) and suspect cases in NYC (8) and OH (4).
o One of the KS cases had a history of travel to Mexico and had transmitted the virus to a close family member
o Other cases, but not all, had travel history to Mexico
o None of the cases report exposure to swine
o No swine or avian outbreaks with this virus stain have been reported in the U.S. or elsewhere
o Transmission appears to be human-to-human.
· All US cases have been mild cases with one case requiring a brief hospitalization.
· The World Health Organization is meeting to determine if Pandemic Level should be changed
· Increased surveillance for influenza has been initiated by CDC, IN, and other states
· Current seasonal influenza vaccine may not provide protection.
Clinical Information
· Consider the possibility of swine influenza in patients who present with a febrile respiratory illness who:
o Live in an area where swine influenza cases have been confirmed.
o Have traveled to Mexico or areas were virus has been reported.
o Had contact in the past 7 days with ill individuals who had recent history of travel to Mexico, or States reporting swine influenza.
· Clinical symptoms of swine flu in people are similar to those of seasonal influenza and may include:
o Fever (greater than 100 degree F)
o Sore throat
o Cough
o Stuffy nose
o Chills
o Headache and body aches
o Fatigue
o Nausea and vomiting have also been reported
o Severe illness (respiratory distress and pneumonia) have been reported in people with this virus.


Treatment/Guidance
· The virus is sensitive to Tamiflu (oseltamivir) and Relenza (zanamivir) and guidance for the use of those drugs in ill individuals is presented at
http://www.cdc.gov/swineflu/recommendations.htm
· Isolation is recommended for those who are ill
· Quarantine for contacts of cases may be used in limited circumstances on a voluntary basis
· Infection control for care of patients confirmed or suspected of having an infection with Swine Influenza A (H1N1) in health care settings can be found at
http://www.cdc.gov/swineflu/guidelines_infection_control.htm
· Interim guidance on the use of facemask in community settings can be found at
http://www.cdc.gov/swineflu/masks.htm

Resources for Patient Education (some contain printable materials for patients)
· CDC Influenza page:
http://www.cdc.gov/flu/
· Taking Care of a Sick Person in Your Home
http://www.cdc.gov/swineflu/guidance_homecare.htm
· Seasonal Flu: what to do if you get sick: http://www.cdc.gov/flu/whattodo.htm
Preventing the Flu: Good Health Habits Can Help Stop Germs: http://www.cdc.gov/flu/protect/habits.htm

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Friday, April 24, 2009

The Next Generation

A self-important college freshman attending a recent football game took it upon himself to explain to a senior citizen sitting next to him why it was impossible for the older generation to understand his generation.


'You grew up in a different world, actually an almost primitive one', the student said, loud enough for many of those nearby to hear. 'The young people of today grew up with television, jet planes, space travel, man walking on the moon.. Our space probes have visited Mars. We have nuclear energy, ships and electric and hydrogen cars, cell phones, computers with light-speed processing....and more.'


After a brief silence, the senior citizen responded as follows:


'You're right, son.. We didn't have those things when we were young........ so we invented them. Now, you arrogant little sh-t, what are you doing for the next generation?'

The applause was amazing.......

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Thursday, April 23, 2009

The Newest Global Warning Concern

In a new study published in the International Journal of Epidemiology, scientists including Dr Phil Edwards, of the London School of Hygiene and Tropical Medicine, reported that the rising number of fat people is contributing to global warming.

The scientists warned that the increase in big-eaters means more food production which is a major contributor of CO2 gas emissions warming the planet.

In addition, they report that overweight people are also more likely to drive further adding to environmental damage.

They stated that each fat person is said to be responsible for emitting a ton more of climate-warming carbon dioxide per year than a thin one.

Dr. Edwards stated that “Moving about in a heavy body is like driving in a gas guzzler.” (You know the “Hummer” types)

According to World Health Organization these overweight individuals produce an extra billion ton of CO2 a year.

The scientists say providing extra grub for them to guzzle adds to carbon emissions that heat up the world, melting polar ice caps, raising sea levels and killing rain forests.

These researchers at the London School of Hygiene and Tropical Medicine say wealthy nations like the US and Britain are getting fatter by the decade and Dr Edwards made the following statements: “Food production accounts for about one fifth of greenhouse gases. We need to do a lot more to reverse the global trend towards fatness. It is a key factor in the battle to reduce carbon emissions and slow climate change. It is time we took account of the amount we are eating. This is about over-consumption by the wealthy countries. And the world demand for meat is increasing to match that of Britain and America. It is also much easier to get in your car and pick up a pint of milk than to take a walk.”

Dr Edwards went on: “We are not just pointing the finger at fat people. All populations are getting fatter and it has an impact on the environment. UK health surveys estimate fatness has increased from an average body mass index of 26 to 27 in the last ten years. That’s equivalent to about half a stone for every person.”

Current classification is that anyone with a BMI above 25 is overweight, while more than 30 is obese and a staggering 40 per cent of Americans are obese, among 300 million worldwide.

Sun doctor Carol Cooper said last night: “I’m not sure which came first, people getting fat and driving or the other way around. It is true fat people eat more food than average. A few obese people have a hormone problem, although most simply don’t use enough calories and eat too many. But making them feel guilty antagonizes them and may not help.”

Along with this study, we heard last week, the news that United was going to charge their fattest passengers double so they didn't ooze into the laps of skinny passengers and this news got people pretty riled up.

So according to this study, not only do fat people take up all of your plane seat, smell bad, and ruin your otherwise stellar plane experience, they are now also ruining the world by causing the global warming problem

The UK's Sun came out with a report that said just that: "Fatties cause global warming".The scientists of this study are now directly blaming fat people for melting icecaps, disappearing rain forests and the extinction of some animals.

There have already been reports on another important global warming issue: cow farts.

We’ll see how far the progressives are willing to take this. Let the comments begin!

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Wednesday, April 22, 2009

Medicaid Cuts

Early in April, David Welsh, M.D., president, Indiana State Medical Association, and Douglas Leonard, president of the Indiana Hospital Association sent the following notice to the legislators of Indiana:

Time to improve access by properly funding Medicaid

In these uncertain times, it is paramount that Indiana’s lawmakers commit to properly fund the Medicaid program in the next state budget. The number of Hoosiers for whom Medicaid is the sole source of health care coverage is growing rapidly, and the current economic downturn will accelerate this trend. The level at which doctors, hospitals and other health providers are paid under Indiana’s Medicaid program has been inadequate for many years, and cuts would impair our ability to deliver high-quality health care to all Hoosiers, including our most vulnerable citizens. Our associations and the thousands of members we represent urge the General Assembly to adequately fund the Medicaid budget in the 2009 session and prevent any provider cuts.

Almost 800,000 people in Indiana receive health care under the Medicaid program, and it pays for almost one-half of all babies delivered in our state. Unlike Medicare, Medicaid is a joint state-federal program. State governments contribute funding and have some flexibility in determining who is eligible, what services are offered, and the level at which health care providers are reimbursed.

Under the federal stimulus legislation, Indiana may receive as much as $1.3 billion for its Medicaid program. This is welcome news and it will help fund this social safety net at time when the need is great. While Congress intended these funds to provide a temporary boost in the federal government’s share of the cost of the Medicaid program, some states are already threatening to slash their Medicaid funding in an effort to balance their budgets. Fortunately, Indiana is much better positioned than other states, and we hope we can avoid such a scenario here.

The gap between the cost of providing care and payments received is widening. Squeezed by reimbursement far below the cost of delivering care, doctors have been forced to consider dropping out of the program or limiting their treatment of Medicaid patients. In a recent national survey, a mere 17 percent of doctors said the financial performance of their practice was “healthy,” and 53 percent already have closed their practices to certain patients based on payment source.

Hospitals are also grappling with government payment shortfalls. Medicaid rates for hospitals’ services under Indiana’s Medicaid program often amount to less than 50 cents for every dollar of cost. Additionally, some hospitals provide financial support to physicians rather than see Medicaid patients go without care. Such shortfalls invariably lead to cost-shifting to those with private health insurance. A 2008 study by the independent consulting firm Milliman

estimated that the total annual cost shifted to commercial payers in the U.S. from Medicare and Medicaid underpayments to physicians and hospitals is approximately $88.8 billion.

In the near future, policymakers must address these serious issues created by inadequate reimbursement to physicians, hospitals, and all other providers under Indiana’s Medicaid program. Raising rates to levels more like commercial insurance would be a welcome development. While the current economic situation makes that unlikely in 2009, let’s first resolve to prevent any form of Medicaid cut in the next state budget.


Since that time we have learned that the FSSA has recalled its notice of intent to adopt the rule that would have imposed up to a 5 percent cut in your Medicaid reimbursements.
There has been notable support from members of the Indiana General Assembly expressing their support in blocking the cuts and this will minimize the risk of more physicians dropping Medicaid patients.

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Tuesday, April 21, 2009

Methadone Risks

Narcotic (Opioid) treatment programs are very common in the United States and methadone clinics seem to be popping up more frequently.

There is mounting evidence that methadone is associated with serious heart problems and a multidisciplinary team has recently made new recommendations for practitioners and patients.

There are an estimated 250,000 patients receiving methadone in opioid treatment programs as well as the nearly 720,000 patients receiving methadone for chronic pain through U.S. retail pharmacies by private physicians.

This review of the evidence suggested that methadone, both oral and intravenous, is associated with a heart condition called prolonged QT syndrome. This can lead to a life threatening arrhythmia referred to as torsade de pointes.

The panel issued the following specific recommendations in 5 key clinical areas:

Recommendation 1 (Disclosure): When clinicians prescribe methadone, they should inform patients about arrhythmia risk.

Recommendation 2 (Clinical History): Clinicians should ask patients about any history of structural heart disease, arrhythmia, or syncope.

Recommendation 3 (Screening): All patients should have a pretreatment electrocardiogram (ECG) to measure QTc interval and a follow-up ECG within 30 days and each year. If the methadone dosage is greater than 100 mg/day, or if patients have unexplained syncope or seizures, additional ECG is recommended.

Screening with ECG may also be done as indicated for patients receiving methadone who have multiple risk factors for QTc interval prolongation, such as a family history of long QT syndrome or early sudden cardiac death or electrolyte depletion. Screening is also recommended when a cytochrome P450 inhibitor or other QTc interval–prolonging drug, including cocaine, is started.

Recommendation 4 (Risk Stratification): For patients in whom the QTc interval is between 450 and 500 milliseconds, the potential risks and benefits should be discussed, and they should be monitored more frequently.

If the QTc interval is greater than 500 milliseconds, discontinuing or decreasing the methadone dose should be considered, as well as eliminating other contributing factors such as drugs that cause hypokalemia. Use of an alternative therapy may be indicated.

Recommendation 5 (Drug Interactions): Clinicians should be knowledgeable concerning interactions between methadone and other drugs that tend to prolong the QT interval or to slow the elimination of methadone.

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Monday, April 20, 2009

New Director of the CDC

According to a Reuters report, Obama has designated Dr. Richard Besser as acting director of the CDC.

Dr. Besser was originally trained as a pediatrician and infectious diseases expert and will be replacing Dr. Julie Gerberding, the high-profile CDC head who announced her resignation quietly last week. Dr. Gerberding was known as an effective communicator but she fought many controversies during her six years as CDC head. She led an unpopular restructuring of the Atlanta-based agency and was accused of acting too slowly to protect people housed in trailers after the 2005 hurricanes from chemical fumes.

Dr. Besser has been director of the Coordinating Office for Terrorism Preparedness and Emergency Response, which is responsible for public health emergency preparedness and emergency response and he helped coordinate the agency's response to Hurricanes Katrina and Rita in 2005.

The CDC has recently been helping other agencies, notably the U.S. Food and Drug Administration track a series of outbreaks of food poisoning, most recently involving salmonella in peanut products that has made nearly 500 people ill in 43 states.

The Director of the CDC is an important job and we hope he is up to the challenge.

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Friday, April 17, 2009

Quick Wit of the Old Man

An elderly man in Louisiana had owned a large farm for several years.

He had a large pond in the back.

It was properly shaped for swimming, so he fixed it up nice with picnic tables, horseshoe courts, and some apple, and peach trees.

One evening the old farmer decided to go down to the pond, as he hadn't been there for a while, and look it over.

He grabbed a five- gallon bucket to bring back some fruit.

As he neared the pond, he heard voices shouting and laughing with glee.

As he came closer, he saw it was a bunch of young women skinny-dipping in his pond.

He made the women aware of his presence and they all went to the deep end.

One of the women shouted to him, "we're not coming out until you leave!"

The old man frowned, "I didn't come down here to watch you ladies swim naked or make you get out of the pond naked."

Holding the bucket up he said, "I'm here to feed the alligator."

Some old men can still think fast.

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Thursday, April 16, 2009

Smoking Bill Dead

It would appear that the smoking bill, House Bill HB 1213, is dead for this year. The bill did not receive a hearing in the Senate Committee on Commerce, Public Policy, and Interstate Cooperation before the committee deadline. It was reported that the committee chairman hoped to find at least six votes to return the bill to a comprehensive form, but at last count, only five members of the committee were willing to commit to supporting a comprehensive smoke-free air law.

The ISMA has always supported legislation that would create a comprehensive statewide smoke-free workplace law. This bill originally would have prohibited smoking in any workplace throughout the state – including restaurants, bars and casinos.

The slow process of government.

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Wednesday, April 15, 2009

New Driving Bill for Teenagers

The following Senators here in Indiana (Sen. Travis Holdman, R-Markle; Sen. Tom Wyss, R-Fort Wayne; and Sen. Karen Tallian, D-Portage) have authored the bill SB 16 for changes in the teenage driving laws.

The bill was recommitted to the House Committee on Ways and Means and it was passed and now moves to the House for amendments and final passage.

Several amendments were added to this bill since its first introduction including one changing the entrance age for the classroom portion of driver education instruction from 15 to 15 ½ years of age.

Amendments also removed language requiring probationary drivers to display indicators for the first 180 days, signifying they are newly licensed drivers and another amendment added language specifying that an individual who holds a probationary license may not operate a motor vehicle while using a telecommunications device — unless that device is being used to make a 911 emergency call.

This bill has an excellent chance of passing and should help minimize teenage accidents. How to police for cell phone use, texting etc. will be more difficult, but more attorneys are pulling cell phone records for accident investigations.

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Tuesday, April 14, 2009

A Sad Day

It is a sad time in our wonderful country to witness such an obnoxious attack on an individual that simply asked a fair question of an elected representative and wanted nothing more than a simple answer. YouTube - Harvard Student Takes On Rep. Barney Frank (D-Mass)

The leaders of the Democratic Party, as represented by Barney Frank, should be ashamed at how Mr. Frank responded to this question. Other democrats should ask if Frank really represents the views of his constituency and why he is one of the major voices of the Democratic Party.

This law student was respectful and polite and Frank responded with hatred and accusations and continued to blame everyone but himself or his colleagues.

This typical response of the current Democratic leaderships continues with Obama to Pelosi to Frank and Reid.

It truly is a sad day in our history.

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Monday, April 13, 2009

Dangerous Care


The following article from the Wall Street Journal (Why 'Quality' Care Is Dangerous - WSJ.com) could not define the problem of “cookbook” medicine any better. Strict adherence to rules that change is detrimental to the health of patients and is not something we should strive for.

Good physicians will use all available clinical guidelines and current research but they understand the importance of making decisions based on the individual patient. Placing barriers on them is not beneficial

The Obama administration is working with Congress to mandate that all Medicare payments be tied to "quality metrics." But an analysis of this drive for better health care reveals a fundamental flaw in how quality is defined and metrics applied. In too many cases, the quality measures have been hastily adopted, only to be proven wrong and even potentially dangerous to patients.

Health-policy planners define quality as clinical practice that conforms to consensus guidelines written by experts. The guidelines present specific metrics for physicians to meet, thus "quality metrics." Since 2003, the federal government has piloted Medicare projects at more than 260 hospitals to reward physicians and institutions that meet quality metrics. The program is called "pay-for-performance." Many private insurers are following suit with similar incentive programs.

In Massachusetts, there are not only carrots but also sticks; physicians who fail to comply with quality guidelines from certain state-based insurers are publicly discredited and their patients required to pay up to three times as much out of pocket to see them. Unfortunately, many states are considering the Massachusetts model for their local insurance.

How did we get here? Initially, the quality improvement initiatives focused on patient safety and public-health measures. The hospital was seen as a large factory where systems needed to be standardized to prevent avoidable errors. A shocking degree of sloppiness existed with respect to hand washing, for example, and this largely has been remedied with implementation of standardized protocols. Similarly, the risk of infection when inserting an intravenous catheter has fallen sharply since doctors and nurses now abide by guidelines. Buoyed by these successes, governmental and private insurance regulators now have overreached. They've turned clinical guidelines for complex diseases into iron-clad rules, to deleterious effect.

One key quality measure in the ICU became the level of blood sugar in critically ill patients. Expert panels reviewed data on whether ICU patients should have insulin therapy adjusted to tightly control their blood sugar, keeping it within the normal range, or whether a more flexible approach, allowing some elevation of sugar, was permissible. Expert consensus endorsed tight control, and this approach was embedded in guidelines from the American Diabetes Association. The Joint Commission on Accreditation of Healthcare Organizations, which generates report cards on hospitals, and governmental and private insurers that pay for care, adopted as a suggested quality metric this tight control of blood sugar.

A colleague who works in an ICU in a medical center in our state told us how his care of the critically ill is closely monitored. If his patients have blood sugars that rise above the metric, he must attend what he calls "re-education sessions" where he is pointedly lectured on the need to adhere to the rule. If he does not strictly comply, his hospital will be downgraded on its quality rating and risks financial loss. His status on the faculty is also at risk should he be seen as delivering low-quality care.

But this coercive approach was turned on its head last month when the New England Journal of Medicine published a randomized study, by the Australian and New Zealand Intensive Care Society Clinical Trials Group and the Canadian Critical Care Trials Group, of more than 6,000 critically ill patients in the ICU. Half of the patients received insulin to tightly maintain their sugar in the normal range, and the other half were on a more flexible protocol, allowing higher sugar levels. More patients died in the tightly regulated group than those cared for with the flexible protocol.

Similarly, maintaining normal blood sugar in ambulatory diabetics with vascular problems has been a key quality metric in assessing physician performance. Yet largely due to two extensive studies published in the June 2008 issue of the New England Journal of Medicine, this is now in serious doubt. Indeed, in one study of more than 10,000 ambulatory diabetics with cardiovascular diseases conducted by a group of Canadian and American researchers (the "ACCORD" study) so many diabetics died in the group where sugar was tightly regulated that the researchers discontinued the trial 17 months before its scheduled end.

And just last month, another clinical trial contradicted the expert consensus guidelines that patients with kidney failure on dialysis should be given statin drugs to prevent heart attack and stroke.

These and other recent examples show why rigid and punitive rules to broadly standardize care for all patients often break down. Human beings are not uniform in their biology. A disease with many effects on multiple organs, like diabetes, acts differently in different people. Medicine is an imperfect science, and its study is also imperfect. Information evolves and changes. Rather than rigidity, flexibility is appropriate in applying evidence from clinical trials. To that end, a good doctor exercises sound clinical judgment by consulting expert guidelines and assessing ongoing research, but then decides what is quality care for the individual patient. And what is best sometimes deviates from the norms.

Yet too often quality metrics coerce doctors into rigid and ill-advised procedures. Orwell could have written about how the word "quality" became zealously defined by regulators, and then redefined with each change in consensus guidelines. And Kafka could detail the recent experience of a pediatrician featured in Vital Signs, the member publication of the Massachusetts Medical Society. Out of the blue, according to the article, Dr. Ann T. Nutt received a letter in February from the Massachusetts Group Insurance Commission on Clinical Performance Improvement informing her that she was no longer ranked as Tier 1 but had fallen to Tier 3. (Massachusetts and some private insurers use a three-tier ranking system to incentivize high-quality care.) She contacted the regulators and insisted that she be given details to explain her fall in rating.

After much effort, she discovered that in 127 opportunities to comply with quality metrics, she had met the standards 115 times. But the regulators refused to provide the names of patients who allegedly had received low quality care, so she had no way to assess their judgment for herself. The pediatrician fought back and ultimately learned which guidelines she had failed to follow. Despite her cogent rebuttal, the regulator denied the appeal and the doctor is still ranked as Tier 3. She continues to battle the state.

Doubts about the relevance of quality metrics to clinical reality are even emerging from the federal pilot programs launched in 2003. An analysis of Medicare pay-for-performance for hip and knee replacement by orthopedic surgeons at 260 hospitals in 38 states published in the most recent March/April issue of Health Affairs showed that conforming to or deviating from expert quality metrics had no relationship to the actual complications or clinical outcomes of the patients. Similarly, a study led by UCLA researchers of over 5,000 patients at 91 hospitals published in 2007 in the Journal of the American Medical Association found that the application of most federal quality process measures did not change mortality from heart failure.

State pay-for-performance programs also provide disturbing data on the unintended consequences of coercive regulation. Another report in the most recent Health Affairs evaluating some 35,000 physicians caring for 6.2 million patients in California revealed that doctors dropped noncompliant patients, or refused to treat people with complicated illnesses involving many organs, since their outcomes would make their statistics look bad. And research by the Brigham and Women's Hospital published last month in the Journal of the American College of Cardiology indicates that report cards may be pushing Massachusetts cardiologists to deny lifesaving procedures on very sick heart patients out of fear of receiving a low grade if the outcome is poor.

Dr. David Sackett, a pioneer of "evidence-based medicine," where results from clinical trials rather than anecdotes are used to guide physician practice, famously said, "Half of what you'll learn in medical school will be shown to be either dead wrong or out of date within five years of your graduation; the trouble is that nobody can tell you which half -- so the most important thing to learn is how to learn on your own." Science depends upon such a sentiment, and honors the doubter and iconoclast who overturns false paradigms.

Before a surgeon begins an operation, he must stop and call a "time-out" to verify that he has all the correct information and instruments to safely proceed. We need a national time-out in the rush to mandate what policy makers term quality care to prevent doing more harm than good.

Dr. Groopman, a staff writer for the New Yorker, and Dr. Hartzband are on the staff of Beth Israel Deaconess Medical Center in Boston and on the faculty of Harvard Medical School.

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Friday, April 10, 2009

Derivatives


In this tough economic climate with all the abbreviations being used to label the bailouts, here is a way to explain the Derivative markets in a more simplified fashion

Charlie is the proprietor of a bar in Detroit . In order to increase sales, he decides to allow his loyal customers - most of whom are unemployed alcoholics - to drink now but pay later. He keeps track of the drinks consumed on a ledger (thiseby granting the customers loans).

Word gets around about Charlie’s drink-now-pay-later marketing strategy and as a result, increasing numbers of customers flood into Charlie’s bar and soon he has the largest sale volume for any bar in Detroit.

By providing his customers' freedom from immediate payment demands, Charlie gets no resistance when he substantially increases his prices for wine and beer, the most consumed beverages. His sales volume increases massively.

A young and dynamic vice-president at the local bank recognizes these customer debts as valuable future assets and increases Charlie's borrowing limit. He sees no reason for undue concern since he has the debts of the alcoholics as collateral. At the bank's corporate headquarters, expert traders transform these customer loans into DRINKBONDS, ALKIBONDS and PUKEBONDS. These securities are then traded on security markets worldwide.

Naive investors don't really understand the securities being sold to them as AAA secured bonds are really the debts of unemployed alcoholics. Nevertheless, their prices continuously climb, and the securities become the top-selling items for some of the nation's leading brokerage houses.

One day, although the bond prices are still climbing, a risk manager at the bank (subsequently fired due to his negativity), decides that the time has come to demand payment on the debts incurred by the drinkers at Charlie's bar. Charlie demands payment from his alcoholic patrons, but being unemployed, they cannot pay back their drinking debts. This creates a bigger problem and Charlie cannot fulfill his loan obligations and claims bankruptcy.

DRINKBOND and ALKIBOND drop in price by 90 %. PUKEBOND performs better, stabilizing in price after dropping by 80%. The decreased bond asset value destroys the bank's liquidity and prevents it from issuing new loans.

The suppliers of Charlie's bar, having granted his generous payment extensions and also having invested in the securities are faced with writing off his debt and losing over 80% on his bonds. His wine supplier claims bankruptcy, his beer supplier is taken over by a competitor, who immediately closes the local plant and lays off 50 workers.

The bank and brokerage houses are saved by the Government following dramatic round-the-clock negotiations by leaders from both political parties. The funds required for this bailout are obtained by a tax levied on employed middle-class non-drinkers.

And this simplified version describes what happened with the subprime mortgage fiasco.

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Thursday, April 09, 2009

Financial Burdens and Medicine

With the economy struggling, we are seeing more and more individuals ignoring their healthcare or choosing lower cost alternatives.

Many are choosing to forego mammograms and other routine screenings to save money. Pinching pennies by scrimping on preventive care is becoming more common. This is risky behavior for patients and can place physicians in a legal bind as well. Legal, moral, and economic hazards abound in this environment. What if a patient doesn’t fill her prescription, gets sicker, and blames you? As the economy worsens, more patients will choose to call in or e-mail for scripts and treatment and not come in to the office. Physicians cannot be certain about a diagnosis over the phone or on an email and are placed at a higher risk.

There are some things physicians can do and the suggestions are as follows:

Talk money. Don’t be afraid to explain why certain choices may cost more. It may be drugs or types of testing and patients may not understand the reasoning. If a patient is already sitting there in the exam room planning to cut those pills you just prescribed in half to save money, it would help if you knew that so you can suggest alternatives. You may need to convince patients that paying for treatment is worth the money and may save them in the long run.

Tighten up recall and reminder processes. Patients routinely don’t show up for appointments and this will get more frequent with the economy. Better reminder policies could help. Although it is ultimately the patient’s responsibility, physicians are frequently sued for lack of follow-up.

Set restrictions on virtual care. Expect more calls or e-mails from existing patients, and be prepared with a standard policy that covers the reasons folks will need to make an appointment to see you. Current advise is to limit phone or Web-based advice to patients you’ve already seen in your office and not for new symptoms.

The reality is that in this economic climate, patient's finances will affect the decisions they make and physicians should assist them in making better informed ones.

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Wednesday, April 08, 2009

Allergies on the Rise

In this recent report from the CDC NCHS Data Brief, Number 9, October 2008, they found that there has been an 18% increase in the prevalence of food allergies in children since 1997.

The increase was largely attributed to a doubling in peanut allergies and the fact that children are taking longer to outgrow milk and egg allergies.

In 2007, approximately 3 million children were reported to have a food or digestive allergy in the previous year.

There is some difference in reported food allergy according to Hispanic ethnicity, with lower reported rates among Hispanic children compared with non-Hispanic white and non-Hispanic black children. However, reported food allergy does not appear to differ by sex.

Why we are seeing this remains a mystery with many investigators varying in their ideas.

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Tuesday, April 07, 2009

Donation from Floyd Memorial Foundation

Since I was appointed the Floyd County Jail Physician a few years ago, I have continued to work with the Sheriff and his department to upgrade our services to the inmates as well as response times to Floyd County residents related to healthcare.

With the generous donation from the Floyd Memorial Foundation, we now have 14 Automatic External Defibrillators (AED's) available for use on patrols and in the jail.

The tribune and courier articles are here: The News and Tribune - Foundation donates lifesaving devices to police, Police in Floyd get new life-saving tool courier-journal.com The Courier-Journal

I believe that this donation will help save lives in our community and keeps each of us a little safer.

My sincere thanks to the Floyd Memorial Foundation

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Monday, April 06, 2009

Taste Differences

We know that girls and boys are different in many ways and a recent study from the University of Copenhagen has found another.

The Danish study found the girls are generally better at recognizing tastes than boys. The tasting abilities of 8,900 Danish schoolchildren were examined and they found that boys need an average of roughly 10% more sourness, and about 20% more sweetness, to recognize these tastes when compared to girls.


There were other parts of the study that revealed the boys preferred stronger, more extreme flavors, while girls preferred milder tastes. Taste is also something that seems to change with age, as those between the ages of 13 to 14 became much more sensitive to sour tastes than younger children, while the older children's preference for highly sugary flavors decreased.


In the soft drink part of the test 48% of the children said they preferred the sugary soft drink taste better and boys preferred the sugary soft drink more often than girls.


How does this help with anything? I have no idea, but just thought it was interesting trivia!

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Friday, April 03, 2009

Why Are Men Happier?

NICKNAMES:
If Laura, Kate and Sarah go out for lunch, they will call each other Laura, Kate and Sarah.
If Mike , Dave and John go out, they will affectionately refer to each other as Fat Boy, Godzilla and Four-eyes.

EATING OUT:
When the bill arrives, Mike , Dave and John will each throw in $20, even though it's only for $32.50. None of them will have anything smaller and none will actually admit they want change back.
When the girls get their bill, out come the pocket calculators.

MONEY:
A man will pay $2 for a $1 item he needs.
A woman will pay $1 for a $2 item that she doesn't need but it's on sale.

BATHROOMS:
A man has six items in his bathroom: toothbrush and toothpaste, shaving cream, razor, a bar of soap, and a towel .
The average number of items in the typical woman's bathroom is 337. A man would not be able to identify more than 20 of these items.

ARGUMENTS:
A woman has the last word in any argument.
Anything a man says after that is the beginning of a new argument.

FUTURE:
A woman worries about the future until she gets a husband.
A man never worries about the future until he gets a wife.

SUCCESS:
A successful man is one who makes more money than his wife can spend.
A successful woman is one who can find such a man.

MARRIAGE:
A woman marries a man expecting he will change, but he doesn't.
A man marries a woman expecting that she won't change, but she does.

DRESSING UP:
A woman will dress up to go shopping, water the plants, empty the trash, answer the phone, read a book, and get the mail.
A man will dress up for weddings and funerals.

NATURAL:
Men wake up as good-looking as they went to bed.
Women somehow deteriorate during the night.

OFFSPRING:
Ah, children. A woman knows all about her children. She knows about dentist appointments and romances, best friends, favorite foods, secret fears and hopes and dreams.
A man is vaguely aware of some short people living in the house.

THOUGHT FOR THE DAY:

A married man should forget his mistakes. There's no use in two people remembering the same thing!

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Thursday, April 02, 2009

Current Legislative Updates

Legal Issues

BILL: SB 16 – Learner’s Permits and Graduated Licenses
AUTHORS: Sen. Travis Holdman, R-Markle; Sen. Tom Wyss, R-Fort Wayne; and Sen. Karen Tallian, D-Portage
ISMA POSITION: Support
THIS WEEK: Received testimony March 25 in the House Roads and Transportation Committee. No vote was taken, but several amendments were distributed for discussion at the next hearing.
Several amendments were added to this bill in the Senate, including one changing the entrance age for the classroom portion of driver education instruction from 15 to 15 ½ years of age. Amendments also removed language requiring probationary drivers to display indicators for the first 180 days, signifying they are newly licensed drivers, and added language specifying that an individual who holds a probationary license may not operate a motor vehicle while using a telecommunications device — unless that device is being used to make a 911 emergency call.

BILL: SB 341 – Wrongful Death or Injury of a Child
AUTHORS: Sen. Vaneta Becker, R-Evansville, and Sen. Brent Steele, R-Bedford
ISMA POSITION: Oppose
THIS WEEK: Bill withdrawn on second reading but still eligible for consideration.
This bill specifies that the law concerning wrongful death or injury of a child: (1) does not apply to a legally performed abortion; and (2) applies to a fetus that has attained viability.
It also provides that the law concerning wrongful death or injury of a child does not affect or supersede any other right, remedy or defense provided by any other law.

Insurance

BILL: HB 1300 – Health Provider Patient Limit Study
AUTHOR: Rep. Peggy Welch, D-Bloomington
ISMA POSITION: Support
THIS WEEK: Passed out of Senate Health and Provider Services Committee 9-0 with the additional provision that the commissioner of the Indiana Department of Insurance shall provide the Health Finance Commission with actuarial information on requiring reimbursement paid directly to out-of-network providers.
HB 1300 requires the Health Finance Commission to study health plan provider contract provisions that would require a contracted provider to accept more than a certain number of patients. The bill also requires the Health Finance Commission to report its findings and recommendations to the legislative council before Nov. 1, 2009.

Tobacco

BILL: HB 1213 – Statewide Smoke-Free Air
AUTHOR: Rep. Charlie Brown, D-Gary
ISMA POSITION: Support
THIS WEEK: The ISMA learned that the Chairman of the Senate Committee on Commerce, Public Policy and Interstate Cooperation, Sen. Ron Alting, R-Lafayette, is willing to amend the bill back to a comprehensive version. However, Sen. Alting is unsure whether enough support exists in the committee to pass a comprehensive version. The ISMA is meeting with members of the committee urging them to hear the bill and support comprehensive language.
The ISMA supports legislation that would create a comprehensive, statewide smoke-free workplace law. Originally, HB 1213 would have prohibited smoking in any workplace throughout the state – including restaurants, bars and casinos.

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Wednesday, April 01, 2009

Breaking News


In an unprecedented statement and reversal of policy, President Obama has directed congress to reverse the present course of action. He has acknowledged not only his deficiency in leadership but also in his misdirected vision of where America is heading.

Obama has apologized for his selections of Tom Daschle and Nancy Killefer who were forced to bow out because of revelations over their nonpayment of taxes. He acknowledged the double standard with the fact that another tax-dodging nominee, Tim Geithner, was made Treasury secretary.

He also voiced his understanding that the selection of Hillary Clinton as Secretary of State was controversial because her husband was being allowed to accept money for his foundation from foreign governments that also make deals with the top US diplomat.

He also stated that he has not worked with the Republicans as promised during the campaign which was readily apparent by the stimulus package vote that the Republicans voted against 100 percent.

And in a show of understanding Obama criticized the Democrats who talk about the out-of-control spending of the Bush administration that led us to this recession and how he now realizes that continued uncontrolled spending is not going to get us out of this recession.

In this rare and unprecedented move, Obama made the statement that doubling the deficit in 5 years and tripling it in 10 years is by far the worst fiscal policy plan that has been conceived and he plans to make major cabinet changes to replace his advisors.

Obama admitted he was wrong when it declared the stimulus would "save or create" 2.5 million, then three million, then 3.7 million, and then four million new jobs. He acknowledge that it hasn’t happened and is unlikely to occur with his current policies

Obama is now agreeing with conservatives on the issues of Afghanistan, the War on Terror and has a full grasp of the situation at Guantanamo Bay and stated that it will not be shut down. “These prisoners are terrorists and they cannot be housed in the United States. They are being treated better than any other prison in history.”

President Obama stated he has been living off his campaign reputation and admitted that the reputation is now frayed, and all the bumbling and unforced errors will have an impact. He understands that his media appearances are not helpful and that stocks decline nearly every time he speaks.

Obama commented that he is the first black president with a total of only 42 days experience as a U S Senator from the most politically corrupt state in America whose governor was ousted from office and he just needs more time to learn.

Obama wants to reassure the American people that the U.S. Congress’s rush to confirm a black Attorney General, Eric Holder, whose law firm represents seventeen Gitmo Terrorists was also probably a mistake.

Obama will apologize for these other controversial decisions in a press conference later today. The partial list includes:

· The CIA Boss, Leon Penetta who has absolutely no experience for his current position and has a daughter that appears to be a true radical anti-American activist and supporter of all the Anti-American regimes in the western hemisphere.
· His choice of Hilary as his Secretary of State who has an endless number of controversial issues surrounding her and Bill.
· The Tax Cheat for Treasury Secretary who files his own taxes.
· The Commerce Secretary nominee who withdrew due to corruption charges.
· The Tax cheat nominee for Chief Performance Officer who withdrew under charges.
· The Labor Secretary nominee who withdrew under charges of unethical conduct.
· The Secretary of HHS nominee who withdrew under charges of cheating on his taxes.


He plans to publicly thank all the conservatives who have provided him with factual information about the war, health, religion, morals, pro-life viewpoints, guns, and family values and he vows to Govern in a way that is true to these beliefs.

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Yes, you can now pinch yourself, wake up from the dream and get back to the reality of the nightmare we are living in!

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April Fools.

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