Thursday, August 19, 2010

Palliative Care May Trump Heroic Measures in Life Expectancy | Miller-McCune Online

Palliative Care May Trump Heroic Measures in Life Expectancy | Miller-McCune Online

Another commentary regarding the NEJM Palliative Care article, health reform and a quote or two from me (Thanks, Joanne!)

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Book Review - Churchill’s Empire - By Richard Toye -

Book Review - Churchill’s Empire - By Richard Toye -

Winston Churchill is remembered for leading Britain through her finest hour
— but what if he also led the country through her most shameful one? What if, in
addition to rousing a nation to save the world from the Nazis, he fought for a
raw white supremacy and a concentration camp network of his own? This question
burns through Richard Toye’s superb, unsettling new history, “Churchill’s
Empire” — and is even seeping into the Oval Office.

The Book Review is titled "The Two Churchills," and makes the point that for all the things we admire Churchill for, he was not always right.

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AMA Morning Rounds on NEJM Palliative Care Article

Early palliative care may prolong survival, enhance quality of life in patients with advanced lung cancer.

The New York Times (8/19, A15, McNeil) reports that a trial "paid for by the American Society of Clinical Oncology and private philanthropy" appears to "shed new light on the effects of end-of-life care." In fact, it "confirmed what...specialists had long suspected," that is, patients with "terminal lung cancer who began receiving palliative care immediately upon diagnosis not only were happier, more mobile, and in less pain as the end neared, but they also lived nearly three months longer." The paper appears in the New England Journal of Medicine.

Notably, "palliative care specialists lament that their image as the medical world's grim reaper deprives patients and their families of care and support that can ease the burden of serious illnesses that exact a steep physical, psychological, and social toll," the Boston Globe (8/19, A1, Smith) reports on its front page. "All too often, they said, patients and doctors outside their field equate palliative medicine with hospice care, even though hospice is the refuge for people who have stopped aggressive treatment and whose death is imminent." But, "palliative available at any juncture during a life-threatening illness and, at its core, is designed to make living with a serious ailment more comfortable, incorporating everything from exercise to counseling to pain medication."

The current study illustrates that and is "one of the best tests yet of palliative care," the AP (8/19, Marchione) reports. It should also "ease many fears about starting it soon after diagnosis, doctors say." Researchers at the Massachusetts General Hospital (MGH) began their study by looking at "151 people newly diagnosed with cancer that had spread beyond the lung."

Seventy-seven of the "newly diagnosed patients were assigned to receive palliative care along with the standard treatment for the cancer," while the "other 74 patients received the standard treatment without palliative care," the Los Angeles Times "Booster Shots" (8/18, Roan) blog reported. The team eventually discovered that "patients receiving palliative care...scored higher on measures of quality of life and enjoying the time they had left. They also were more likely to express their wishes regarding resuscitation at the end of life."

What's more, those "who received palliative care in addition to standard care had...a 50 percent lower rate of depression and they lived 2.5 months longer than patients not receiving palliative care early," HealthDay (8/18, Doheny) reported.

MGH's Jennifer S. Temel, MD, told WebMD (8/18, Mann), "We were surprised by the magnitude of impact that palliative care had on quality of life, which normally decreases over time in these cancer patients, and the magnitude of the impact it had on depression." And, "the survival benefit was the most surprising thing," she added. "Cancer care and palliative care are not mutually exclusive." Bloomberg News (8/19, Cortez), the Wall Street Journal (8/18, Hobson) "Health Blog" and MedPage Today (8/18, Bankhead) also covered the study

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Saturday, May 22, 2010



An analysis by Jonathan Chait of the philosophy of Ayn Rand and its influence on modern conservative thought. It is based upon 2 books about Rand Published in 2009.

Well worth reading, especially with the rise of Randian thought amongst the Tea Party crowd.

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Tuesday, May 11, 2010

New Law Could Help Hospice Patients Continue Aggressive Medical Treatments - Kaiser Health News

New Law Could Help Hospice Patients Continue Aggressive Medical Treatments - Kaiser Health News

But the new health law could lead to a major change in Medicare policy that allows patients to get treatment and hospice care simultaneously.

Experts say this dual approach, known as "concurrent care," may be especially useful for people using dialysis to extend their lives, and those waiting for organ transplants that may not come in time. More broadly, advocates say, the change may encourage people with any kind of terminal illness to take advantage of hospice care earlier.

"Having personally had to explain what’s good about hospice to families that think I’m about to shove them onto an iceberg, I know it’s a very difficult decision," says Diane Meier, director of the Center to Advance Palliative Care at the Mount Sinai School of Medicine in New York City.

It will be easier to get the terminally ill to accept hospice care, she says, "if you can say to
families, you don’t have to make this terrible choice here — it’s more, not less."

Medicaid Change

The new law instructs Medicaid, the state-federal program for the poor, to cover simultaneous hospice and curative care for children with terminal illnesses immediately. And it directs the federal Medicare program, which covers seniors and disabled people, to launch up to 15 pilot projects around the country to test the concept. If the experiment is deemed successful and doesn’t increase costs, then Medicare could make the benefit available to everyone in hospice.
Someone with heart disease, for example, could get cardiac drugs that improve blood circulation and at the same time receive hospice’s palliative services. Those include a team of doctors and nurses devoted to easing physical pain and symptoms, and social workers and
clergy who help patients and their families accept death. Hospice staff typically come to a dying person’s house or nursing home a few times a week.

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Wednesday, April 28, 2010

What If Summers and Romer Are Wrong Again?

I hope this gets passed around the White House like an Atul Gawande article!

Watching PBS NOVA last night, I am still amazed that there are still defenders of the efficient market hypothesis in a pure form. I am 50 years old and remember stagfaltion, the crash of 87, the S&L debacle, the internet boom/bust and our current fiasco. Who is so out of touch that they do not recognize these events for what they were and are: disastrous macroeconomic and microeconomic events casued by oh so 'inefficient' humans?

I an still dumbfounded to hear that conservatives still think that the business leeches will act in the best interests of their companies. They will act in their own best interests, period. And if that means earning $100 million as they ride their company into the ground? Hey, they still have their $100 million.

Greenspan, still such an Ayn Rand dupe, that he still seems to think, exclusive of his mea culpa last year, that we can count on people to act in the ultimate interest of themselves and all will be well. Voltaire's "Best of all possible worlds," for the uber-capitalist set.

Read the Article at HuffingtonPost

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Tuesday, April 27, 2010

Much Cheaper, Almost as Good: Decrementally Cost-Effective Medical Innovation — Ann Intern Med

Much Cheaper, Almost as Good: Decrementally Cost-Effective Medical Innovation — Ann Intern Med

Under conditions of constrained resources, cost-saving innovations may improve overall outcomes, even when they are slightly less effective than available options, by permitting more efficient reallocation of resources. The authors systematically reviewed all MEDLINE-cited cost–utility analyses written in English from 2002 to 2007 to identify and describe cost- and quality-decreasing medical innovations that might offer favorable “decrementally” cost-effective tradeoffs—defined as saving at least $100 000 per quality-adjusted life-year lost. Of 2128 cost-effectiveness ratios from 887 publications, only 9 comparisons (0.4% of total) described 8 innovations that were deemed to be decrementally cost-effective. Examples included percutaneous coronary intervention (instead of coronary artery bypass graft) for multivessel coronary disease, repetitive transcranial magnetic stimulation (instead of electroconvulsive therapy) for drug-resistant major depression, watchful waiting for inguinal hernias, and hemodialyzer sterilization and reuse. On a per-patient basis, these innovations yielded savings from $122 to almost $12 000 but losses of 0.001 to 0.021 quality-adjusted life-years (approximately 8 hours to 1 week). These findings demonstrate the rarity of decrementally cost-effective innovations in the medical literature.

From Drs. Nelson, Cohen, Greenburg and Kent in Annals of Internal Medicine.

Interesting article explicitly making the argument for more research to figure out where we reach diminshing marginal returns in specific treatments for specific conditions.

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Saturday, April 24, 2010

Health Care Cost Increase Is Projected for New Law -

Health Care Cost Increase Is Projected for New Law -

But Mr. Foster said, “Overall national health expenditures under the health reform act would increase by a total of $311 billion,” or nine-tenths of 1 percent, compared with the amounts that would otherwise be spent from 2010 to 2019.

In his report, sent to Congress Thursday night, Mr. Foster said that some provisions of the law, including cutbacks in Medicare payments to health care providers and a tax on high-cost employer-sponsored coverage, would slow the growth of health costs. But he said the savings “would be more than offset through 2019 by the higher health expenditures resulting from the coverage expansions.”

The report says that 34 million uninsured people will gain coverage under the law, but that 23 million people, including 5 million illegal immigrants, will still be uninsured in 2019.

Sounds like success to me. Uwe Reinhardt used to estimate it would cost an additional $100 billion a year to cover everyone. This doesn't seem to far off from that estimate.

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Wednesday, April 7, 2010

A Conservative Accidentally Makes The Case For Social Democracy | The New Republic

A Conservative Accidentally Makes The Case For Social Democracy The New Republic

So, let's look at a straight-up measure. How did the United States perform in comparison with European social democracies? Well, since 1980, the original 15 members of the European Union saw their real per capita income grow by 58%. Real per capita GDP in the United States grew by... 63%. And that measure actually overstates the difference. The European Union does not include Switzerland, Norway or Iceland -- three countries that clearly qualify as European social democracies. Those three countries had 71% growth in per capita GDP since 1980 -- thanks to Isha Vij of the Center for American Progress for pointing this out to me -- which, if added to the EU 15, would bring the growth record of the United States and the social democracies even closer to parity.
Interestingly, Manzi concedes in his essay that social democracy provides superior social cohesion. His essay simply assumes that it inherently produces dramatically lower growth. But now that we can see his assumption doesn't hold up, he's actually making the case for social democracy. To be sure, I'm not a social democrat, but Manzi has inadvertently softened my skepticism. If instituting a social democracy in the United States would dampen growth only very slightly, and create greater social cohesion and economic equality (meaning, for people who aren't very rich, higher living standards), why not give it a try?

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Thursday, March 25, 2010

Health Reform Implementation Timeline - Kaiser Family Foundation

Health Reform Implementation Timeline - Kaiser Family Foundation

This is a TERRIFIC summary of the Health Reform Bill.

The PDF Version is here.

I challenge anyone who has been against this bill to read this and tell me that this is a bad thing.

I am reaffirmed in my faith in government to do good things, as TR said,

"The poorest way to face life is to face it with a sneer. There are many men who feel a kind of twister pride in cynicism; there are many who confine themselves to criticism of the way others do what they themselves dare not even attempt. There is no more unhealthy being, no man less worthy of respect, than he who either really holds, or feigns to hold, an attitude of sneering disbelief toward all that is great and lofty, whether in achievement or in that noble effort which, even if it fails, comes to second achievement."

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Wednesday, March 24, 2010

O’Neill Institute » Legal Solutions in Health Reform » The Constitutionality of Mandates to Purchase Health Insurance

O’Neill Institute » Legal Solutions in Health Reform » The Constitutionality of Mandates to Purchase Health Insurance

Paper Summary
Health insurance mandates have been a component of many recent health care reform proposals. Because a federal requirement that individuals transfer money to a private party is unprecedented, a number of legal issues must be examined.
This paper analyzes whether Congress can legislate a health insurance mandate and the potential legal challenges that might arise, given such a mandate. The analysis of legal challenges to health insurance mandates applies to federal individual mandates, but can also apply to a federal mandate requiring employers to purchase health insurance for their employees. There are no Constitutional barriers for Congress to legislate a health insurance mandate as long as the mandate is properly designed and executed, as discussed below.
This paper also considers the likelihood of any change in the current judicial approach to these legal questions.
Download the Executive Summary (2pp.)
Download the Paper (25pp.)

About the Author
Mark A. Hall, J.D., is the Fred D. and Elizabeth L. Turnage Professor of Law and Public Health at Wake Forest University School of Law and School of Medicine. He is also an Associate in Management at the Babcock School of Management, all of which are located in Winston-Salem, NC.

And, courtesy of Scott R. of DFA,
"Some of my libertarian friends balk at what looks like an individual mandate. But remember, someone has to pay for the health care that must, by law, be provided: Either the individual pays or the taxpayers pay. A free ride on government is not libertarian." - Mitt Romney, 2006

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Wednesday, March 17, 2010

Think Progress » Catholic nuns break with bishops and urge passage of health care reform.

Think Progress » Catholic nuns break with bishops and urge passage of health care reform.

Ok, the nuns are for it:

The health care bill that has been passed by the Senate and that will be voted on by the House will expand coverage to over 30 million uninsured Americans. While it is an imperfect measure, it is a crucial next step in realizing health care for all. It will invest in preventative care. It will bar insurers from denying coverage based on pre-existing conditions. It will make crucial investments in community health centers that largely serve poor women and children. And despite false claims to the contrary, the Senate bill will not provide taxpayer funding for elective abortions. It will uphold longstanding conscience protections and it will make historic new investments – $250 million – in support of pregnant women. This is the REAL pro-life stance, and we as Catholics are all for it.
So is the Catholic Health Association and prominent Catholic and Evangelical scholars.

What's up with those darned Bishops?

Go to the ThinkProgress link at the top for all the links.

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Monday, March 15, 2010

T.R. Reid - Universal health care tends to cut the abortion rate

T.R. Reid - Universal health care tends to cut the abortion rate

Increasing health-care coverage is one of the most powerful tools for reducing the number of abortions -- a fact proved by years of experience in other industrialized nations. All the other advanced, free-market democracies provide health-care coverage for everybody. And all of them have lower rates of abortion than does the United States.
This is not a coincidence. There's a direct connection between greater health coverage and lower abortion rates. To oppose expanded coverage in the name of restricting abortion gets things exactly backward. It's like saying you won't fix the broken furnace in a schoolhouse because you're against pneumonia. Nonsense! Fixing the furnace will reduce the rate of pneumonia. In the same way, expanding health-care coverage will reduce the rate of abortion.

One of the commenters posted a useful link from the BBC on abortion rules in Europe.

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Monday, March 8, 2010

Slate: Why Stupak is Wrong

Slate: Why Stupak is Wrong
Because this keeps coming up and needs addressed, Slate's Timothy Noah explains:

"If you go to Page 2069 through Page 2078 [of the Senate bill]," Stupak told George Stephanopoulos on March 4 on Good Morning America, "you will find in there the federal government would directly subsidize abortions, plus every enrollee in the Office of Personnel Management-enrolled plan, every enrollee has to pay a minimum of one dollar per month toward reproductive rights, which includes abortions." Stupak is here referring to the exchanges created under health reform and to a nonprofit plan managed by the Office of Personnel Management that would be sold through the exchanges. The latter was a consolation prize to supporters of a public-option government health insurance program that didn't make it into the bill.
Let's go to Page 2069 through Page 2078 of the Senate-passed bill. It says, "If a qualified plan provides [abortion] coverage … the issuer of the plan shall not use any amount attributable to [health reform's government-funding mechanisms] for purposes of paying for such services." (This is on Page 2072.) That seems pretty straightforward. No government funding for abortions. (Except in the case of rape, incest, or a threat to the mother's life—the same exceptions granted under current law.) If a health insurer selling through the exchanges wishes to offer abortion coverage—the federal government may not require it to do so, and the state where the exchange is located may (the bill states) pass a law forbidding it to do so—then the insurer must collect from each enrollee (regardless of sex or age) a separate payment to cover abortion.
The insurer must keep this pool of money separate to ensure it won't be commingled with so much as a nickel of government subsidy. (This is on Pages 2072-2074.) Stupak is right that anyone who enrolls through the exchange in a health plan that covers abortions must pay a nominal sum (defined on Page 125 of the bill as not less than "$1 per enrollee, per month") into the specially segregated abortion fund. But Stupak is wrong to say this applies to "every
enrollee." If an enrollee objects morally to spending one un-government-subsidized dollar to cover abortion, then he or she can simply choose a different health plan offered through the exchange, one that doesn't cover abortions. (Under the Senate bill, every insurance exchange must offer at least one abortion-free health plan.)
One dollar exceeds health insurers' actual cost in providing abortion coverage. In fact, it's entirely symbolic. The law stipulates that in calculating abortions' cost, insurers may consider how much they spend to finance abortions but not how much they save in foregone prenatal care, delivery, or postnatal care. (This is on Pages 2074-2075.) This is to keep insurers from pondering the gruesome reality—one they surely know already—that covering abortions actually saves them money. For health insurers, the true cost of abortion coverage is less than zero, because hospitals and doctors charge less to perform abortions than they do to tend pregnant women before, during, and after childbirth. (Ironically, only the Senate bill—not the House bill—provides some small counterweight to this calculus by increasing aid for adoption assistance.)
What really rankles Stupak (and the bishops) isn't that the Senate bill commits taxpayer dollars to funding abortion. Rather, it's that the Senate bill commits taxpayer dollars to people
who buy private insurance policies that happen to cover abortion at nominal cost to the purchaser (even the poorest of the poor can spare $1 a month) and no cost at all to the insurer. Stupak and the bishops don't have a beef with government spending. They have a beef with market economics.

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Tuesday, March 2, 2010

Physician Incomes Internationale

Responding to my post about doctors stepping up for health reform over at FireDogLake, wigwam linked to a couple great pieces from the NY Times. ( I have a Google Alert on "physicians salaries incomes," so I don't know how I missed them, but, here they are now.)

In order, Uwe Reinhardt pointed out in a post about Rationing Doctors' Pay

When Medicare reduces its payments to doctors, it rations money to them. It does not directly ration the health care the doctors might render patients.

If physicians refuse to treat patients at the lower fees, it is they who ration health care, even if the incentive to do so came from Medicare.

While I doubt that the payments to radiologists and cardiologists actually will be cut by 21 percent soon — more on that next time — let us suppose it were so. Would there then be “few radiologists and cardiologists working” after such a fee cut?

Presumably, the afflicted physicians would withhold their services only from Medicare and Medicaid patients, assuming that private insurers pay more. But
could most radiologists and cardiologists actually earn an adequate livelihood only from privately insured patients? I have my doubts.

Like everyone else, radiologists and cardiologists certainly can claim to be sorely underpaid relative to the extraordinarily high compensation of bankers and corporate executives, which appears to have little correlation with contributions to society. But relative to their colleagues in internal medicine, pediatrics and family practice, radiologists and cardiologists actually are very well paid.


So even if Medicare cut fees of radiologists and cardiologists by 21 percent, the income of these specialists would still exceed that of their colleagues in primary care by 60 percent or more.


The only question then is whether such fee increases [for primary care] will come at the expense of taxpayers or from other parts of the health care sector, perhaps even the more highly paid medical specialties, including radiology and cardiology. That is a political call.

Reading through just a few of the comments revealed this gem:

As someone who is training to be a radiologist, I have mixed feelings about what you’re saying. While you are correct that Radiologists and Cardiologists do make more than primary care physicians, there is also a reason for that. Specifically, it is that when primary care physicians can’t figure something out, who do they turn to? SPECIALISTS. We train for MUCH longer than primary care docs (often times greater than twice as long) and this is the reason that we are paid more per RVU. We also have more responsibility; in fact, the levels of responsibility are worlds apart. While a primary care doctor can always turn to a specialist for help, we have no one to turn to… The buck stops with us, we are the final authority.

Wow. Sounds like our friend suffering amongst us "less skilled physicians" from last year.

Subsequently, CATHERINE RAMPELL cracked open the Congressional Research Service's analysis of the OECD database to find out "How Much Do Doctors in Other Countries Make?"

As a country’s wealth rises, so should doctors’ pay. But even accounting for this trend, the United States pays doctors more than its wealth would predict.

According to this model, the 2007 report says, “The U.S. position above the trendline indicates that specialists are paid approximately $50,000 more than would be predicted by the high U.S. GDP. General practitioners are paid roughly $30,000 more than the U.S. GDP would predict, and nurses are paid $8,000 more.”

But it’s important to keep in mind, the report notes, that health care professionals in other O.E.C.D. countries pay much less (if anything) for their medical educations than do their American counterparts. In other words, doctors and nurses in the rest of the industrialized world start their medical careers with much less student loan debt compared to medical graduates in the United States.

Rampell also links to the MGMA report on American physician income, which you may find either eye opening or eye popping.

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Monday, March 1, 2010

NEJM -- Have Physicians Stepped Up for Reform?

NEJM -- Medicine's Ethical Responsibility for Health Care Reform -- The Top Five List

The medical profession's reaction has been quite different. Although major professional organizations have endorsed various reform measures, no promises have been made in terms of cutting any future medical costs. Indeed, in some cases, physician support has been made contingent on promises that physicians' income would not be negatively affected by reform.

It is appropriate to question the ethics of organized medicine's public stance. Physicians have, in effect, sworn an oath to place the interests of the patient ahead of their own interests — including their financial interests. None of the for-profit health care industries that have promised cost savings have taken such an oath. How can physicians, alone among the "special interests" affected by health care reform, justify demanding protection from revenue losses?

Dr. Brody makes some interesting points about physicians' role in health care reform, including the general unwillingness of organized medicine to step up and make concessions on income or to vigorously work on the problem of practice variation.

He is only partially correct in his assessment of organized medicine's advocacy role this time around. I think it is a real accomplishment, an unprecedented consensus, that the ten largest physician organizations have come out in support of the House Bill, which includes many very important reforms including the public option.

What amazes me is that this has NO currency in the media. Does anyone know this fact? Does anyone realize how monumental this should be? So regardless of whether organized medicine has made the right offers or concessions in this current debate, the fact that they have stood up, in many cases with much pushback from conservative members and advocated for health reform is a big deal.

Secondly, even if organized medicine's endorsement of reform has not taken the form some of us would like (single payer, Bismarkian insurance), individual physicians, in surveys published in the NEJM have indicated overwhelming willingness to make a deal (i.e., accept a public option) and accept concessions.

a large majority of respondents (78%) agreed that physicians have a professional obligation to address societal health policy issues. Majorities also agreed that every physician is professionally obligated to care for the uninsured or underinsured (73%), and most were willing to accept limits on reimbursement for expensive drugs and procedures for the sake of expanding access to basic health care (67%). By contrast, physicians were divided almost equally about cost-effectiveness analysis; just over half (54%) reported having a moral objection to using such data "to determine which treatments will be offered to patients.

...the 28% of physicians who consider themselves conservative were consistently less enthusiastic about professional responsibilities pertaining to health care reform.

So i would differ with Dr. Brody's assessment that physicians and organized medicine have not stepped up adequately.

The problem, as I see it, is that the media and the pro-reform contingent in Congress, have done an abysmal job of letting the public know that the people whose opinions they value most in this debate - physicians - are overwhelmingly in favor of reform.

What we see in the media are the conservative physicians in congress (Sens. Coburn and Barrasso, Congressman Boustany) who are ridiculously out of touch with mainstream physicians. Though in touch with the angry tea partiers and the admittedly sizable contingent of conservative American physicians (not accidentally all of these physicians practicing in high income specialties - ob/gyn, orthopedics and surgical subspecialties ), they do not represent the thinking of most physicians.

Furthermore, as Dr. Brody rightly points out, physicians have a higher duty to our patients than to our own narrow self interest. But here, again, physicians have acknowledged this in a formal way in the Charter on Medical Professionalism, published in 2004 by the American College of Physicians and endorsed by more than 50 major national and international medical organizations:

Principle of social justice. The medical profession must promote justice in the health care system, including the fair distribution of health care resources. Physicians should work actively to eliminate discrimination in health care, whether based on race, gender, socioeconomic status, ethnicity, religion, or any other social category

It seems pretty clear that physicians have answered the call, but somehow, in spite of opinion polling showing how highly the public values our opinion, nobody has noticed.

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Saturday, February 27, 2010

AlterNet: Ayn Rand, Hugely Popular Author and Inspiration to Right-Wing Leaders, Was a Big Admirer of Serial Killer

AlterNet: Ayn Rand, Hugely Popular Author and Inspiration to Right-Wing Leaders, Was a Big Admirer of Serial Killer

If you knew Ayn Rand was a bit whacked, you had no idea...

So what, and who, was Ayn Rand for and against? The best way to get to the bottom of it is to take a look at how she developed the superhero of her novel, Atlas Shrugged, John Galt. Back in the late 1920s, as Ayn Rand was working out her philosophy, she became enthralled by a real-life American serial killer, William Edward Hickman, whose gruesome, sadistic dismemberment of 12-year-old girl named Marion Parker in 1927 shocked the nation. Rand filled her early notebooks with worshipful praise of Hickman.

According to biographer Jennifer Burns, author of Goddess of the Market, Rand was so smitten by Hickman that she modeled her first literary creation -- Danny Renahan, the protagonist of her unfinished first novel, The Little Street -- on him.What did Rand admire so much about Hickman?

His sociopathic qualities: "Other people do not exist for him, and he does not see why they should," she wrote, gushing that Hickman had "no regard whatsoever for all that society holds sacred, and with a consciousness all his own. He has the true, innate psychology of a Superman. He can never realize and feel 'other people.'"This echoes almost word for word Rand's later description of her character Howard Roark, the hero of her novel The Fountainhead: "He was born without the ability to consider others."

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Friday, February 26, 2010

Individual Irresponsibility in the President’s Healthcare Reform Plan

Individual Irresponsibility in the President’s Healthcare Reform Plan

A response to the above titled post from "Health Leaders"

"The result is that nearly everyone will be "covered" whether they're insured or not. They'll be treated, and someone else will pay the cost. That's the way it is now, and that's the way it will continue to be if these bills pass—just under a different mechanism."

And with considerably fewer uninsured to require that cost shifting. That's the whole point, isn't it? Less uninsured.

Look, a certain percentage of the population will always try to game the system, by paying the penalty rather than buying insurance. But even those people will stop that behavior as soon as someone in their family has an illness requiring more than a couple visits to the doctor. So, yes there are gamers, but most people want to do the right thing, I still believe.

"Premiums from commercial insurers will be sky-high, if commercial plans even continue to exist long-term."

That's not what the CBO says.

"What better way to get the deeply unpopular public option back in the mix in a few years?"

Except it isn't unpopular, except with the Fox News crowd, who still think it is some sort of Sino-Soviet hybrid system.

And, just for the record, the 10 largest physicians organizations support reform with the option.

Posted using ShareThis

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Individual Irresponsibility in the President’s Healthcare Reform Plan

Individual Irresponsibility in the President’s Healthcare Reform Plan

Posted using ShareThis

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Sunday, February 21, 2010

Why doctors’ pay keeps on rising - Herald Scotland | News | Politics

Why doctors’ pay keeps on rising - Herald Scotland News Politics

"GPs, who earned an average of £80,959 in 2007, benefit from “aspiration” and “performance” payments under the Quality and Outcomes Framework (QOF)."

This is an article about bonus payments to GP's in the NHS for a variety of things, including taking care of oncology patients, MRSA screening, practicing in underserved areas in the UK, among others. The grumbling is that they are getting paid pretty well, since a new contract from 2004, and they are out sourcing night call to other services.

They were doing this in London back in 1984 when I was there for some medical school electives, and they were grumbling about it then, too. My feeling is that, especially with the upcoming generations, that life style is important and it is important to bring in people to the profession who are bright and enthusiastic. A miserable life style makes that less likely.

For the record, the £80,959 average salary in US Dollars equals $125K at the current exchange rate, comfortably in the top quintile of earners. But it comes without hundreds of thousands of dollars in expense/debt to get through college and medical school.

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Saturday, February 20, 2010

Tea Partiers as Christians - Big Fail

Non-negotiable Core Beliefs from's Dale Robertson
(Founder/President) and my comments in italics.

Illegal Aliens are illegal.
Pro-Domestic Employment is indispensable.
Stronger Military is essential.
Gun ownership is sacred.
Government must be downsized.
National Budget must be balanced.
Deficit Spending will end.
Bail-out and Stimulus Plans are illegal.
Reduce Personal Income Taxes a must.
Reduce Business Income Taxes is mandatory.
Intrusive Government Stopped.
English only is required.
Traditional Family Values are encouraged.
Common Sense Constitutional Conservative
Self-Governance is our mode of operation.

....and Yes, we are a Christian Nation!

So, let's start with the hilarious first, "Yes, we are a Christian Nation!" Well, not hilarious, just sad. Look through all of those and tell me which items would get Jesus all fired up? Nothing about universal access to health care ("when I was sick"), nothing about the unprecedented dependence on Food Stamps, not only to buy food ("when I was hungry"), but for subsistence needs ("when I was naked"), nor anything about our embarrassingly high incarceration rates for Americans ("when I was a prisoner").

But these "Christians" did include those damn illegal aliens!! The Bible is terribly draconian on aliens:
Exodus 22: Do no wrong to a man from a strange country, and do not be hard on him; for you yourselves were living in a strange country, in the land of Egypt
And Leviticus is even worse: The alien living with you must be treated as one of your native-born. Love him as yourself, for you were aliens in Egypt. I am the LORD your God.
Anyway, may as well go through the rest of his list, briefly.
Pro-domestic employment. OK, we can agree on this one. However, I expect their view is very anti-union, which the Pope, at least (he's Christian, right?) opposes.

Thus, the encyclical rises strongly to the defense of labor unions, which are still vehemently opposed by large numbers of politically conservative Catholics. The pope notes that unions "have always been encouraged and supported by the Church.

Stronger Military. How about smarter military? How abut defunding "Star Wars," and preparing for the wars we are fighting and will fight in the future: "wars" against terrorist organizations. Oh, wait, that's law enforcement and intelligence. Then how about focusing the Pentagon on human resources instead of lining the pockets of Haliburton, Blackwater, Northrup and the rest of the Military industrial complex. Eisenhower was so prescient and wise:

Every gun that is made, every warship launched, every rocket fired signifies, in the final sense, a theft from those who hunger and are not fed, those who are cold and are not clothed. This world in arms is not spending money alone. It is spending the sweat of its laborers, the genius of its scientists, the hopes of its children. The cost of one modern heavy bomber is this: a modern brick school in more than 30 cities. It is two electric power plants, each serving a town of 60,000 population. It is two fine, fully equipped hospitals. It is some fifty miles of concrete pavement. We pay for a single fighter plane with a half million bushels of wheat. We pay for a single destroyer with new homes that could have housed more than 8,000 people. This is, I repeat, the best way of life to be found on the road the world has been taking. This is not a way of life at all, in any true sense. Under the cloud of threatening war, it is humanity hanging from a cross of iron. ... Is there no other way the world may live?
Gun Ownership is sacred. Fine, this is way low on my list of issues to get exorcised about but gun rights are not unlimited. Again, I don't see this as being near the top of Jesus' list for important aspects of national governance. Also, why is it that the most heinous crimes always seem to be done with legally purchased guns?
Government must be downsized, National Budget must be balanced, Deficit Spending will end. Reduce Personal Income Taxes a must. Reduce Business Income Taxes is mandatory.
Typical right wing BS. Run up the most massive deficits in the history of the country, first under Reagan and again under Bush, then bitch about it as Democrats try to clean up the mess (Clinton for Reagan, and Obama for Bush). I'll let you all in on a little secret: Tax cuts never have, never will pay for themselves. "Supply side" economics, wherein lightening the tax burden on the wealthy so that they will supply more products and thus stimulate demand is as S-T-U-P-I-D as it sounds. Besides, investment income is taxed at such low rates already, the wealthiest in America have far lower tax rates than the rest of us! Patriots like Teddy Roosevelt would be out there railing against this injustice.
Bail-out and Stimulus Plans are illegal. Very stupid, poorly thought out, way too generous to Wall Street with not nearly enough regulatory "burden" injected in return for the favors. Did anybody else notice that the same stupid Ayn Rand- Milton Friedman stupidity that led to the S&L Bailout under Reagan-Bush I led Phil Gramm to believe they could do even more damage to the tenuous regulatory environment in place in the 90's and everything would turn out just swell - for the "Fortunate 400", and the pretty fortunate 40,000.
Intrusive Government Stopped. This is just so funny because of where I expect they see the government is being too intrusive and where I think it is too intrusive. I am one of those silly Bill of Rights types, and so I reject pretty much every intrusion into the lives of Americans that the chickens in the Bush administration thought were so vital to national security. And yet, I have been paying attention enough to realize that intrusions into the affairs of Corporate America in general, and Wall Street gambling, in particular, are vital to the stability and prosperity of the country.
English only is required. I guess this goes up above with how we treat each other and the strangers among us. I think Jesus, who spoke Aramaic, while living under Roman rule, might have a touch of sympathy for the non-English speaking.
Traditional Family Values are encouraged. This is a little tricky, in that Jesus and Christian tradition is so clearly liberal in matters of economics, social justice, immigration, etc., and yet Jesus was pretty darn tough on sexual issues. So, I'll make an offer to the Tea Partiers: You make Jesus' rule against divorce into law, help us with the big social justice issues like universal health care, reforming prisons, strengthening workers rights, and more, and then we'll go after gay marriage. Deal?
Common Sense Constitutional Conservative Self-Governance is our mode of operation. I really don't know what the heck this means, but I did find it amusing that there is another organization called "We the People" (From the Constitution - get it?) that is an ANTI-government, Tea Party type organization.
But I do think this last bit is critical: I think progressives view government as "us" (as in "We the People") and conservatives view government - when they are not in power - as them. Even when my party was not in power, I still believed government was us, but that we had failed our country by allowing the Siths to win so many elections.
So, in summary, these people who constantly complain that we are not acting as a Christian Nation, seem to completely miss the point of Christianity, the social justice mission, the generosity of heart, the embracing of the weak, the poor, the hungry the sick, the loving of those NOT like us :
If you love those who love you, what credit is that to you? Even 'sinners' love those who love them. And if you do good to those who are good to you, what credit is that to you? Even 'sinners' do that. (Luke 6)
Update just to add this from
"...How terrible it will be for those who make unfair laws, and those who write laws that make life hard for people. They are not fair to the poor, and they rob my people of their rights. They allow people to steal from widows and to take from orphans what really belongs to them. (Is 10:1-2 NCV)"

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Thursday, February 18, 2010

Go forward on health reform - Washington Greene PA Letter to Editor -

Go forward on health reform - Washington Greene PA Letter to Editor -

I didn't realize this had been published until just now. Here is my letter for the DFA LTE Campaign:

I am a practicing physician who routinely sees the suffering and deaths caused by a health care system that leaves tens of millions of people on the outside, unable to access health care except when so desperately ill, they find their way to an emergency room, and often end up in my ICU, far sicker than they would have been with access to a doctor earlier in their illness - and at this point a drastically more expensive illness as well. Every doctor you know can tell you similar stories.

That is why it is no accident that the 10 largest physicians organizations support health reform including the House Bill that passed last year, which includes a public option and an individual mandate, so that private insurers will have a competitor and benchmark, and so that everyone will be "in," with an option to buy insurance from a true, not-for-profit insurer if they can't get it anywhere else.

It is no accident that the American Cancer Society has made reform its top advocacy priority, because they see the needless anguish of cancer patients trying to get the care that they need, fighting with insurers, struggling to pay the bills, begging not to be thrown off insurance plans.

So when you hear the naysayers complaining about this or that aspect of the bills, remember that your friends, your families, and our patients continue to struggle with getting good care and paying for it.

Forty-five thousand of us die every year due to lack of access to health care. And that number is only a fraction of those suffering due to untreated or under-treated illness and chronic conditions.

We need to move forward, not step back for all of our sakes.

The comments from the right wingers are, sadly, all too predictable, but hey, it had been read 422 times when I checked a bit ago.

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Tuesday, February 16, 2010

Exodus 22:21 "Do not mistreat an alien or oppress him, for you were aliens in Egypt.

Exodus 22:21 "Do not mistreat an alien or oppress him, for you were aliens in Egypt.

Bible in Basic English

Do no wrong to a man from a strange country, and do not be hard on him; for you yourselves were living in a strange country, in the land of Egypt.

And Leviticus 19:34

'The stranger who resides with you shall be to you as the native among you, and you shall love him as yourself, for you were aliens in the land of Egypt; I am the LORD your God.

Just throwing this in for all of those who get the vapors when the subject of providing health care for illegal aliens comes up.

First, we should do it because it is the right thing to do, but on a more pragmatic level, just as with all of the other uninsured in the country, it costs a lot less to take care of them in an ongoing, preventive manner rather than during crises in our EDs and ICUs.

I'm going to post a few more here for my own future reference...

Matthew 5:43-48, Love for Enemies

"You have heard that it was said, 'Love your neighbor and hate your enemy.' But I tell you: Love your enemies and pray for those who persecute you, that you may be sons of your Father in heaven. He causes his sun to rise on the evil and the good, and sends rain on the righteous and the unrighteous. If you love those who love you, what reward will you get? Are not even the tax collectors doing that? And if you greet only your brothers, what are you doing more than others? Do not even pagans do that? Be perfect, therefore, as your heavenly Father is perfect.

And the version from Luke 6:27-36

"But I tell you who hear me: Love your enemies, do good to those who hate you, bless those who curse you, pray for those who mistreat you. If someone strikes you on one cheek, turn to him the other also. If someone takes your cloak, do not stop him from taking your tunic. Give to everyone who asks you, and if anyone takes what belongs to you, do not demand it back. Do to others as you would have them do to you.
"If you love those who love you, what credit is that to you? Even 'sinners' love those who love them. And if you do good to those who are good to you, what credit is that to you? Even 'sinners' do that. And if you lend to those from whom you expect repayment, what credit is that to you? Even 'sinners' lend to 'sinners,' expecting to be repaid in full. But love your enemies, do good to them, and lend to them without expecting to get anything back. Then your reward will be great, and you will be sons of the Most High, because he is kind to the ungrateful and wicked. Be merciful, just as your Father is merciful.

And here is a very nice summary for the Biblical case for social justice from the United Church of Christ website, with this nice bit:

God, however, requires both charity and justice, and justice can often be achieved only through the mechanism of government. The view that nations, as well as individuals, will be judged by the way they treat the weakest and most vulnerable among them is deeply embedded in the witness of prophets such as Isaiah, who said:
How terrible it will be for those who make unfair laws, and those who write laws that make life hard for people. They are not fair to the poor, and they rob my people of their rights. They allow people to steal from widows and to take from orphans what really belongs to them. (Isaiah 10:1-2)

Jesus criticized and disobeyed laws when they got in the way of helping people. He healed people on the sabbath, for example, even though all work was prohibited on the sabbath. Religion and government were intermixed, so Jesus was challenging the law of the land. The threat Jesus posed to both religious and political authorities led to his crucifixion.

Government is not the only or always the best instrument to deal with injustice. But it is one of the institutions created by God part of God's providence for the welfare of people. Because we live in a democracy, a nation with a government of the people," we have a special privilege and responsibility to use the power of our citizenship to promote public justice and reduce hunger.

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Saturday, February 13, 2010

Georgetown/On Faith: Pope Benedict on Economic Justice - Thomas J. Reese

Eavesdropping on a Facebook conversation my wife was having with some conservatives, and they sent her a well produced, but intellectually 5th grade level, video on a certain view of "liberty," mainly a diatribe against social responsibility and community. You know, John Galt crap.

Anyway, I knew many hardcore Catholics were on this list so I Googled around a bit to find this bit from Pope benedict's Encyclical of last year...

Georgetown/On Faith: Pope Benedict on Economic Justice - Thomas J. Reese

The pope disagrees with those who believe that the economy should be free of government regulation. "The conviction that the economy must be autonomous, that it must be shielded from 'influences' of a moral character, has led man to abuse the economic process in a thoroughly destructive way," he writes. "In the long term, these convictions have led to economic, social and political systems that trample upon personal and social freedom, and are therefore unable to deliver the justice that they promise."

Benedict even supports "a political, juridical and economic order which can increase and give direction to international cooperation for the development of all peoples in solidarity. To manage the global economy; to revive economies hit by the crisis; to avoid any deterioration of the present crisis and the greater imbalances that would result; to bring about integral and timely disarmament, food security and peace; to guarantee the protection of the environment and to regulate migration: for all this, there is urgent need of a true world political authority, as my predecessor Blessed John XXIII indicated some years ago."

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Wednesday, February 10, 2010

Ezra Klein - The six Republican ideas already in the health-care reform bill

Ezra Klein - The six Republican ideas already in the health-care reform bill

Yes, they are already in there.

As Ezra sums up in his last paragraph:

On Sunday, John Boehner and Mitch McConnell responded to Barack Obama's summit invitation by demanding Obama scrap the health-care reform bill entirely. This is the context for that demand. What they want isn't a bill that incorporates their ideas. They've already got that. What they want is no bill at all. And that's a hard position for the White House to compromise with.

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Tuesday, February 9, 2010

Organized Medicine on HCR Updated Again

Update: the ASA, No. 7 below did not support the HCR Bill, just a Public Option. See the full correction here. My apologies.

Not an earth shattering update, but a membership update on one of the organizations courtesy Alice C. of Doctors for America

Below are the largest physicians organization, in order, with estimated membership numbers based on their own websites (or other sources when the Web Site didn't have them). Previously we had the AOA, American Osteopathic Association, as number 5 because their web site had previously said they "represent" 67,000 Osteopaths. Alice sent me actual numbers indicating they have about 40,000 members, still keeping them in the top ten, just not as high up.

All are YES on reform with Public Option and supporting the House Bill, with some points of contention, but generally have endorsed it.

1. AMA 240,000
2. ACP 126,ooo (Internists and many medical subspecialists)
3. AAFP 94,000 (Family Practice)
4. ACS 76,000 (surgeons)
5. AAP 60,000 (pediatricians)
6. ACOG 52,000 (ob-gyn)
7. ASA 43,000 (Anesthesiology!)

8. AOA 40,000 (osteopaths)
9. APA 38,000 (psychiatry)
10. ACC 37,000 (cardiology)

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Friday, February 5, 2010

The Cost of Living : Cardiologists' Lament

The Cost of Living : CJR:

The Herald’s story, by John Dorschner, said the doctors were complaining that Medicare had reduced “reimbursement for cardiac services on average by 40 percent,” and that another 21-percent cut was coming March 1. The doctors’ letter warned that they “will be either forced out of business or forced to drastically increase the number of patients seen, most likely with physician assistants or nurse practitioners.” Oh, oh. The specter of rationing and inferior care—and from nurse practitioners no less!

Dorschner’s story described a new Medicare rule, which took effect January 1, that cut projected total revenues for cardiologists by 13 percent on average over four years while increasing the revenue of internists, family doctors, and general practitioners.

Think of it as income redistribution designed to make primary care more attractive to med students and increase the supply of those kind of docs. (At a minimum, the health-reform debate has illuminated payment disparities between the primary-care doctors and the high-priced specialists who have always commanded big bucks.)

Heart doctors across the country—not only in Miami—cried foul, and Jack Lewin, who heads their trade group, the American College of Cardiology, vowed “to do everything we can in the legislative, legal and regulatory arenas to stop these cuts.” Lewin could have added the media to that list of arenas, because the ACC pulled out all stops to sound the alarm with the nation’s press and public through its Campaign for Patient Access.

The Herald’s story was the best of a bunch of news articles that for the most part passed along the cardiologists’ complaints, threats, and warnings without any hint that there was another side to the story. Between the slanted newspaper articles and audio news releases from the ACC, millions of Americans learned that the incomes of heart doctors, which can be upwards of $400,000, could take a hit. As an example of the kinds of cuts Medicare envisioned under the new rule, the administrator of one Florida heart practice explained that the reimbursement for a nuclear stress test could drop from $850 to $600. Presumably he said it with a straight face.

We will need to have this very important discussion at some point, so I'm glad to see someone looking critically at the need for substantive analysis of complaints about reimbursement.

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The Debate Over Selling Insurance Across State Lines

Kaiser Health News Today's Headlines:

An article giving a brief overview of the issue. My favorite line, from John Shadegg is here:

"Why are Republicans critical of how Democrats handle the issue?

They say its redundant for states to have to pass laws to allow their residents to buy coverage from other states. And they don't like the idea of having the federal government set minimum standards. 'In reality, (their) bill nationalizes federal insurance regulation and gives the average American family no relief from expensive mandates that drive up the cost of health insurance,' said Rep. John Shadegg, R-Ariz. said."

Expensive mandates like, covering stuff.

But, according to CBO estimates quoted at the end, even the states with the laxest regulations would only generate a 5% reduction in premium costs.

Until, of course, the industry picks a state, buys the insurance regulating apparatus and the state's legislature, and develop the classic "never pay policy."

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Monday, February 1, 2010

SGR History

Just looking up a little SGR history.

It was part of the 1997 Balanced Budget Act passed under Congress controlled by Republicans and Clinton signed. It was designed to save $115 billion over ten years to avoid making any other painful, politically unpopular changes to Medicare.

In 1998, all the interested parties were pushing back:

"Everybody who got a tuck and a trim in 1997 wants more money," said Ari Fleischer, spokesman for the House Ways and Means Committee, which oversees the nation's health care program for the elderly and disabled. "If everybody . . . gets more money, Medicare will go broke even faster.

And here we are, gearing up again...

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Escaping To England To Find Treatment She Can Afford

From Kaiser Health News Today:

Sometimes my husband Roger gripes about what he calls the British “nanny state.” So much is done for the English, he maintains, they can’t think for themselves anymore. Showers, for instance, are statutorily equipped with automatic shut-off valves on the thermostats. In case the water gets too hot. I remind him that the opposite of the nanny state is me in the U.S. with breast cancer and no steady job and insurance.

I had some wonderful doctors in New York, caring and helpful. But I also had to fight with my hospital there to get the tests I needed, and several of the specialists were so difficult to deal with I chose medical protocols to avoid them—no matter what the best option for treatment was. What I really notice about the health care providers in England is that they seem to have more than half a second for me – and they actually listen.

A nice piece about the nightmare that medicine is not in England. She left the US to go to England because she couldn't afford the US health care system, and found out there were other bonuses to a differenet model of financing health care.

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Thursday, January 28, 2010

Mary Landrieu Blasts Obama Over Health Care

"I think the president should have been more clear about a way forward on health care last night," Sen. Mary Landrieu told reporters on Capitol Hill Thursday. "I'm hoping in the next week or two he will be, because that's what it's going to take if it's at all possible to get this done." [from CNN]

I agree with her in this much: Until the White House steps up and says what it wants from the House bill and what it wants from the Senate Bill AND WHY and clearly elucidates its reasoning and priorities, they are doing us all a disservice.

I have heard they are negotiating behind the scenes, in the vernacular. Man up and say what it is you want to do.

Bill Clinton was right when he said better to be strong and wrong than weak and right. Last night was a start trowards strong, but until they say what they are willing to go to the mat for, they are not being strong enough!

A lot of us out here in the fields (I'm with Doctors for America) are waiting for some forceful language and commitment from this group. If they learned nothing this year it should be this: The anti-HillaryCare approach of not getting involved AT ALL has been a failure. Get in the trenches and fight!
Read the Article at HuffingtonPost

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My notes for Testimony for GOP doctors caucus January 21, 2010

[I know, I know,State of the Union! I did want to get this up, however, for the record. My opening statement is here.]

As I do not have a transcript, and the video posted by the Caucus only contains the opening statements of the Congressman and not the panel (imagine that!), these comments reflect what I recall based on my note taking on the fly during the hearing.

The committee was co-chaired by Congressman Tim Murphy and Rep. Phil Gingrey.
Rep. Murphy started hearings and made some comments about the congressional process, the election in Massachusetts, and then outlined his specific ideas for healthcare reform: these included purchasing insurance across state lines; focus on cost, outcomes and transparency;health insurance should be personal portable and should not lose insurance with job. He also in passing mentioned that Medicare has not been overhauled since it was passed.

Gingrey also opened with observations about Massachusetts election. He then quoted Jefferson, "Whenever the people are well-informed, they can be trusted with their own government;... whenever things get so far wrong as to attract their notice, they may be relied on to set them to rights." He postulated that people don't like the House or Senate bills, and that deals or cut behind closed doors were bad, and finally that the GOP stands opposition to health care reform is currently constituted

Congressman Roe stated that the process should be open and transparent and that simple ideas will increase access. He is opposed to special interests deals that were made, and quoted a survey that said that 91% of people surveyed like what they had in regards to health insurance, and something along the lines of "when you take this much money out of the system..." bad things will happen.

Congressman Broun had a very simple message that can be summed up as the market will fix all. He has introduced HR 3889 along these lines . He referenced the original intent of the Constitution. He spent a few minutes complaining about CLIA regulations that shutdown labs and he thought this was inappropriate and was bad for healthcare.

Congressman Fleming said that we agree on the need for increased access and decrease costs.

Congressman Boozman: transparency is critical.

Before I move on to the testimony, I do want to say a few words about the opening statements. I do not doubt that all of the Congressman would like to achieve universal access to health care in some sense of the word. I do not believe that their sense of universal access to health care comes anywhere near my concept of universal access to health care. They are perfectly comfortable, I believe, with a multitiered system, with poor receiving charity care when it is available, the less poor receiving Medicaid rationed as it is by its fee structure, and then others with very poor insurance policies which limits their access to care, and so on. It is fairly striking to me, that Medicare really is the Cadillac plan in the United States. Private health insurers may pay more for procedures or office visits or what have you, but Medicare provides care to everyone in the level that ensures the basic dignity of every patient. Is dignity important? To some, it is not. But I think, as someone who advocates for a traditional view of social justice and basic dignity of human beings, that the ability to seek medical care and not beg for it is important not only to the individual, but to us as a society.

All of the Congressman at some point during the day reference how important they felt it was to have the ability to purchase insurance across state lines. My view, and the view of many economists and health policy experts, is that this will lead to a race to the bottom. In one of my meetings with Congressman Murphy, he expressed great skepticism in the ability of a government program to do anything properly. He argued that he'd seen some government programs go so wrong as to make him supremely cautious about allowing any new government programs to be enacted. I understand the skepticism. But my skepticism of the ability of state governments to avoid the corrupting influences of money and corporate power far, far outweigh any concern that I have about a federal government program going out of control. And I say this as someone who believes that the privatization of our defense efforts in the forms of Blackwater and other extra governmental agencies has become extremely dangerous for this country. But, looking out across states, and seeing how easy it is for corporations to drastically influence state elections including those for judges and Supreme Court justices, the ability to pressure insurance commissioners, the ability to influence elections for state representatives, and also seeing how poorly some states manage and fund their Medicaid programs, I worry about the states.

I certainly think all the sentiments expressed about transparency in the process and the avoidance of sweetheart deals and backroom deals are very true. However, to hear this from the party of Medicare Part D, and Billy Tauzin, energy policy by Exxon and Enron, the party that by and large believes the BS of Ayn Rand, I find this concern, well, inconsistent. But, I will echo all of those sentiments.. FDR would have gone out and challenged all those special interests that the Democrats made deals with. I, too, am disappointed in my party's leadership.

Regarding the comment about Medicare not been changed since its inception, I guess one could argue that the general concept of Medicare hasn't changed since its inception, but obviously, many parts of the program have changed. Some of the biggest changes included the massive increases in spending in the 60s and 70s allow for growth hospitals expansions of a residency programs in medical schools and so on. Other big changes have come in the forms of DRGs in order to contain costs, this remains a mainstay of financing of health care by both public and private insurers around the world. Payments to physicians and the structure of these payments has changed drastically since the inception of Medicare. Another interesting one is, the addition of the end-stage renal disease benefit program. Because of the sympathy engendered by patients who cannot afford dialysis and were driven to destitution and death, a benefit was added to pay for people with end-stage renal disease. This is now also an untouchable program. But consider that even this program with such good intentions has the same fatal flaw as much of the rest of American medicine, in that it focuses on taking care of the patient after the disease has progressed beyond retrieval. Very telling, indeed.

I was quite surprised by Congressman Roe's comment about the ill effects of taking large amounts of money out of the system. If American medicine were anything close to lean mean machine, there might be some validity to that comment. But the massive amounts of bureaucratic waste, the massive amounts of over testing, under testing, over treating, under treating, the perverse incentive system of rewarding procedures over prevention and high-tech healthcare often with marginal benefit, over coordinating the care of complex patients, the abysmal end-of-life care, the "sweetheart deal" of Medicare part D., the excess subsidies in Medicare advantage plans, and on and on make this comment ludicrous.

Briefly, regarding the Thomas Jefferson quote, all I could think at the time was, that's why the Democrats have overwhelming majorities in both houses and the White House. They'd finally had enough. I do not claim to be an expert in the Massachusetts election, but the only sound clip I saw of the victor was a short sound bite in which he made proclamations about health care reform that were, to be kind, misleading. This dovetails with Congressman Roe's notation that most Americans are happy with the insurance they have, if they have it. I think doctors and nurses will back me up on this: most of them are only happy because they haven't had to try using their insurance. It's that sticky part about when you actually have to use your benefits and become sick and miss work and possibly lose your job and so on and so on so many become unhappy with their insurance and stunned to find out how poorly it sometimes functions. Monty Python said it best with their "never pay" insurance companies sketch.
Panel testimony then followed. Besides myself, the panel concluded Paul Fronstin, Ph.D. of the Employee Benefit Research Institute testified on how the excise tax in the Senate bill will force companies to limit employee coverage, and The Lewin Group’s John Sheils told the Caucus that if these bills passed, wages will decrease as employers pay more in healthcare benefits. Other witnesses included Jim Martin of 60 Plus Association and Dr. Karen Nichols with the American Osteopathic Association.

Fronstin of the EBRI: I will admit that my mind wandered here and I did not critically analyze his testimony on excise tax. A couple of points he did make were that 20% of the population accounts for 80% of the cost of health care, and that chronic conditions are the bulk of the cost.

Jim Martin of the 60+ organization, the conservative alternative to the AARP and, he did not disappoint. It was, unfortunately, like listening to a mash up of Limbaugh/Hannity/Beck/Coulter/Malkin quotes. They believe in healthcare reform but incremental and he emphasized first do no harm. He argued to not take a wrecking ball to the current system, that cuts to Medicare will hurt seniors "whether you're for Medicare or against it" (an interesting quote, eh?), that seniors are scared, that they "paid their due" and expect their due, and he also perseverated on the size of the bill in pages, and also that that "bureaucrats are asking seniors to sacrifice more." You know, I'm not even going to bother.

Dr. Nichols of the AOA: one of five medical students is osteopathic; there is a physician work force shortage; graduate medical education funding needs to be expanded not just reapportioned; Medicare pays for graduate medical education the hospitals and so training incentivize to stay within the hospital and out of community areas and underserved outpatient settings; international medical graduates-the US imports doctors and this creates an international brain drain; primary care physicians are disincentive on by income; only 55% of the work of a primary care physician is actually taking care of patients; payment system values procedures and not coordination of care or cognitive services; emphasized the need to repeal the SGR; threefold difference in income in primary versus specialist; national health service Corps deferments need reinstated.

Shiels of the Lewin Group (he had lots of charts and graphs but we did not get copies, so I missed a lot): the House bill creates a $372 billion increase in employer costs; talked about the change in after-tax income which I didn't follow; changes in average family health spending; if under 50,000 they get a net savings, if over 100,000 there was a modest increase in cost and if greater than 150,000 there is a $443 increase in the House bill and hundred $47 and the Senate bill.

Question-and-answer period. I'm going to have to free flow this because i don't have many notes because - can you believe it- I was paying attention.

Medicare advantage, why is it being cut?
Mr. Martin said it's because the AARP wants market share
We disagree, as does the AMA, and other organizations, and the White House explanation is here.

Gingrey Massachusetts hates the Massachusetts health care reform plan. Except that 68% like their own plan. And 70% of physicians like it, too. And among Obama voters who voted for Brown, only 23% thought Health Reform went too far, with 41% not knowing why they opposed it and 36% didn't think it went far enough! He is worried about the work force adequacy
Nichols reiterated the need to fix the SGR.

Mr. Martin voiced his disgust at people at the Townhall meetings August being called un-American clearly did not get the point. I almost grabbed the microphone next to me to shout him down so he would get the point. Really. I almost did it.

Martin also mentioned that we should scrap all the bills and the Medicare is going bankrupt. I find this magical thinking by the Right about medicare truly amazing. Medicare is going bankrupt, but taking money out of Medicare, even overspending on Medicare Advantage, reducing practice variation, increasing preventive care and improving care coordination and all the things we talk about to improve quality and decrease cost, are off the table. It reflects the schizophrenia of having a popular government program that they would love to vilify and gut if they could, but they can't because seniors will have their heads. And seniors like Martin want it all and more in terms of spending on them, the rest of the economy and the country be damned.

Mr. Broun tried to get us all agree that market reforms that solve the system's problems
I was wondering if Medicare was unsustainable for Part D, as it is now...I will try to find out.

Broun reiterated his idea of four things he considered "critical:" 1. being able sell insurance across state lines is critical, 2. association pools were critical, 3. high risk pools were critical, and 4. health insurance costs be 100% deductible. Dr. Brown also made the amazing statement that he went to Canada and only found one Canadian happy with Canadian healthcare. Just one table for now, because this is just so terminally stupid: 34% of Americans think we need to completely rebuild our system compared to only 12% of Canadians. And only 28% of Republicans still believe that we have the best system in the world.

There was more, but this is enough for now.

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Tuesday, January 26, 2010

Uwe on Reform :Hits Nails on Head

"President Obama's plan to overhaul the nation's health care system hangs in the balance. Uwe Reinhardt, professor of economics and public affairs at Princeton University, says it won't make much difference to most Americans if the legislation dies. But Gail Wilensky, a health care economist who served in the administration of President George H.W. Bush, says she believes there needs to be an overhaul of the system because the soaring costs are unsustainable."

Uwe Reinhardt nails it again. You can click away when Wilensky atarts.

Lose Valerie Jarret, bring in Uwe. (And bring in Krugman for Geithner while we're at it!)

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Monday, January 25, 2010

Beware: Cut Medicare Fees to Doctors and Watch the System Die

(Trying to cross post this at Huffington Post for this piece: )
Sorry, nice try.

1. The projected cost of Medicare will bankrupt the United States.
Only if we do nothing to bend the curve and reduce unnecessary procedures and increase preventive care and care coordination. I suggest you read some Gawande and then come on back here. And "This American Life":

2. There remains tens of millions of US citizens that do not have adequate policies or means to pay for health care coverage.
Yet none of them are over 65.

3. The cost of adequate health care coverage for those citizens still fortunate enough to be able to pay is rising at an unsustainable rate.
See number 1.

4. Systemic waste remains.
See number 1 again.

5.Doctors are compelled to practice expensive defensive medicine due to fears of almost infinite liability and costs associated with litigation.

Really? When was the last time you saw a physician bankrupted by medical liability? That is why we have insurance. Patients, on the other hand are bankrupted routinely by health care costs.Defensive medicine varies inversely with the time you are willing to put in with the patient explaining what you are doing. The big problem with defensive medicine is that we are reimbursed well, in many cases to practice it, and rewarded very poorly for explaining why a patient does not need a CT scan or antibiotics or whatever.

I will acknowledge a frightening trend against science, however:

Yes, we're all against fraud and we all SAY we are for universal access to prevent pain and suffering, but there are different views of that. For example, is going to a Remote Access Medical clinic good enough? Some would say that, yes, as long as there is a free clinic somewhere, that's good enough. I disagree.

At the risk of starting a food fight, I think if we totally revamped what Medicare pays for (quality, not quantity; counseling over procedures), we could absorb that 20% OVER THE LONG TERM without too much trouble. When specialists make 3 or more times what a PCP makes, something is wrong with the paymenty system (I'm an intensivist, BTW).

I'll stop there, and not take the bait on teachers. I hope you have some in your life and they read this!

Read the Article at HuffingtonPost

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Wednesday, January 20, 2010

Testimony to GOP Doctors Caucus

I am giving testimony on Health Care Reform to the GOP Doctors Caucus on Thursday morning, Jan. 21, 2010.

UPDATE: My notes on the back and forth are posted here.

I am representing myself for sure, and, if I do well, will claim to be representing Doctors for America, as well (just kidding).

Here is my opening statement:

Thank you for this opportunity to speak to you today.

A study published recently in the New England Journal of Medicine[i] indicated that 78% of physicians “agreed that physicians have a professional obligation to address societal health policy issues. Majorities also agreed that every physician is professionally obligated to care for the uninsured or underinsured (73%), and most were willing to accept limits on reimbursement for expensive drugs and procedures for the sake of expanding access to basic health care (67%).”

I was greatly encouraged by this study. But also, sometimes being a glass-half-empty kind of guy, I also was disappointed that 22% of physicians do NOT think they have a duty beyond their individual practice or owe a duty only to the patients in patients in front of them.

In 2004, the American College of Physicians and the American Board of Internal Medicine Foundation published the Charter on Medical Professionalism,[ii] which included language that very pointedly noted that physicians have a duty to social justice in health care:

Principle of social justice. The medical profession must promote justice in the health care system, including the fair distribution of health care resources. Physicians should work actively to eliminate discrimination in health care, whether based on race, gender, socioeconomic status, ethnicity, religion, or any other social category.

It also states that we have a duty to improve access to care and to a just distribution of finite resources. The ACP reports that more than 50 professional organizations in America and around the world have signed on to this Charter.

I am pleased to say that the leadership of most of our medical professional organizations are now not only talking the talk, but walking the walk, and in an unprecedented manner, the 10 largest physician organizations are supporting health care reform that coincides with their stated goals of universal access to health care in America.

But it is not only organized medicine in favor or reform, as most physicians support reform as well. Another survey from the New England Journal showed overwhelming support (63%) for either reform with a public option or straight up single payer health care.[iii]

It is estimated that 45,000 people die in America every single year due to lack of access to health care.[iv] Whether this is twice as high or half as high as the “true” number is almost immaterial, as it is unacceptable in any case. My experiences, and the experiences of my colleagues, convince me that this number is true, and perhaps even a gross underestimate. Every physician I know has stories of patients who ignored some illness or deferred seeking treatment due to lack of health insurance. I had a patient who was literally coughing up blood for months and had a severe cough for many more months before that before he finally came into the hospital with respiratory failure and advanced cancer.

And, just as in war there are multiples of wounded for every casualty, so too, in our struggle with illness, we see much more suffering that does not get counted. The cab driver supporting a family of five who ignores his diabetes (he knows that is what it is), because he is trying to get health insurance and knows this diagnosis will doom his chances. So he ends up in my ICU with severe diabetic ketoacidosis. The construction worker with a seizure disorder who cannot see a neurologist to adjust his medications because of lack of money to pay for his last visit. He develops uncontrolled seizures for the second time in a few months and ends up in the ICU on life support.

Every physician you know can tell you stories like this. And there are more than 800,000 of us in the US, so the 45,000 number strikes me as not only low for preventable deaths, but only the tip of the iceberg in terms of the human cost in physical suffering and anguish. Remember, all these patients had families who loved them.

I know you hear from many disgruntled physicians who are concerned and even fearful of change. It is unfortunate that this fear prevents many from listening to the “better angels of our nature,” and, instead of striving to improve reform as proposed, simply attack and reject any and all proposals on the table.

It is also worth noting that the changes Congress makes now will certainly affect me and my peers with gray hair, but these bills are really about physicians just starting practice, still in medical school or still just thinking about medical school. And, if you have kids, you know this: they don’t think like us. In medicine, in particular, surveys have shown that they view medicine as a chance to help people and serve society, and don’t have that “calling” to medicine as older generations did. They don’t expect to make a small fortune, but they do expect fair compensation for all they have had to go through to get through medical school and residency, financially and in opportunity cost. So, remember when you hear grumbling about reform, consider the source, and, to channel Yogi Berra, remember the future.

In this final minute, I do want to run through some particulars of what we like in the current House and Senate Bills and would like to see in the final reform bill:

  1. Provide health insurance coverage for 96 percent of Americans while reducing the federal deficit by $30 billion.
  2. Provide substantial subsidies to help make coverage more affordable for our patients.
  3. Implement insurance market reforms to prevent individuals from being denied coverage because of pre-existing conditions, and to limit premium differentials based on age, gender and other factors.
  4. Establish a public health insurance option to ensure there is adequate competition and affordable health insurance options in all areas of the country.
  5. Provide a 10% bonus payment for all primary care providers and a 10% bonus payment for general surgeons and PCPs practicing in underserved areas to ensure a strong physician workforce.
  6. Increase Medicaid payment for primary care services to at least Medicare payment rates and expand Medicaid.
  7. Expand the National Health Services Corp and Title VII health professions training programs.
  8. Expand the medical home pilots and other health care delivery improvement models in addition to creating the Innovation Center to focus on improving the health care delivery system
  9. Invest billions to strengthen our public health system and focus on prevention and wellness.
  10. Establish a new program to encourage states to implement alternatives to traditional medical malpractice litigation – the first step .
  11. Create the Innovation Center and expand the medical home pilots – the kinds of health care delivery models that will improve care coordination and efficiency.
  12. Create an Independent Medicare Advisory Board, isolated from the political process to ensure patients get the care they need, to make recommendations on cost containment and improvements.
  13. Focus on prevention and wellness including reimbursement for an annual Medicare wellness visits, advance care planning, and eliminating the cost burden on patients for preventive services

So, in conclusion, I would ask all of you to strive for health care reform where our bottom line is quality affordable health care for everyone. Because ultimately, our goal is to reduce the number of deaths and needless suffering due to lack of access to care as close to zero as possible, and to leave our children with a better system than we inherited.

Thank you.

Christopher M. Hughes, MD, FCCP, FACP, FCCM
State Director, Pennsylvania, Doctors for America
Board of Trustees, Pennsylvania Medical Society

[i] Antiel, Ryan M., Curlin, Farr A., James, Katherine M., Tilburt, Jon C.Physicians' Beliefs and U.S. Health Care Reform -- A National SurveyN Engl J Med 2009 361: e23

[ii] Medical Professionalism in the New Millennium: A Physician Charter
Project of the ABIM Foundation, ACP–ASIM Foundation, and European Federation of Internal Medicine Ann Intern Med February 5, 2002 136:243-246

[iii] Keyhani, Salomeh, Federman, AlexDoctors on Coverage -- Physicians' Views on a New Public Insurance Option and Medicare Expansion. N Engl J Med 2009 361: e24

[iv] Health Insurance and Mortality in US Adults.Wilper et al. Am J Public Health.2009; 99: 2289-2295

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