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Archive for December, 2007

Wednesday, December 26th 2007

Medical Gift Cards


Oh…Thanks, Honey

Medical gift cards? Why limit where they can spend what you’re giving them?

The card is issued by Visa, so it can be used anywhere Visa is accepted for health-related services. They are not sold in stores and need to be purchased online or over the phone for up to $5,000.

“The peak audience we believe though is women 35-50, the famous sandwich generation,” Bellard said. “So, they’ve got parents that have health needs, and they’ve got a spouse that has health needs, and older children going off to college or living on their own that have health needs.”

How does the card impact medical deductions? The person who uses it gets any eligible write-off.

“Be sure to record how much you spent on that card because that is a legitimate medical expense that you can use when you fill out your taxes,” said Jack Gillis of the Consumer Federation of America.

Still if you insist on buying one then here they are.

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Monday, December 24th 2007

Happy Holidays


A Much Merrier Christmas Than If I Had Posted This Picture

Sunday, December 23rd 2007

Would Single Payer Have Saved A Patient Requiring Liver Transplant?

This is one of the worst stories I’ve ever heard. A girl goes into liver failure, is sent by her insurer to get evaluated for a transplant. Then develops complications and the insurer denies the transplant despite the organ sharing network having found a match for her. Then just hours after her family has taken her off life support, they learn the insurer has changed their mind.

The case of a Northridge teenager taken off life support just as her insurance company reversed itself and agreed to pay for a liver transplant is highlighting tensions among physicians, patients and insurers over the definition of experimental procedures.

About 4:40 p.m., just as Sarkisyan said the family had decided to remove Nataline from life support, Cigna sent a letter to the family’s attorney approving the transplant.

The letter, faxed to attorney Mark Geragos, is stamped 4:44 p.m. Geragos said his staff tried unsuccessfully to reach the Sarkisyans at the hospital. The family said they didn’t see the letter until after they removed Nataline from life support at 5:20 p.m.

“They took my daughter away from me,” Krikor Sarkisyan, 51, an automotive technician, said at the news conference outside Geragos’ downtown L.A. office.

The trouble was two-fold. First, the procedure was considered ‘experimental’ and the family had not purchased a plan to cover such. Basically it failed to reach some mystery threshold of evidence in the literature, the guidelines for which probably only exist in some dark room at CIGNA HQ. Second, she had a gross 65% survival rate at six months.

Dr. Goran Klintmalm, chief of the Baylor Regional Transplant Institute in Dallas, said the operation that UCLA wanted to perform was a “very high-risk transplant” and “generally speaking, it is on the margins.”

But Klintmalm said he would consider performing the same operation on a 17-year-old and believes the UCLA doctors are among the best in the world.

“The UCLA team is not a cowboy team,” he said. “It’s a team where they have some of the soundest minds in the industry who deliver judgment on appropriateness virtually every day.”

I think the aftermath of this tragedy, by some of the groups who have latched on, is a really lovely demonstration of America’s expectations for health care versus their complaints about cost.

A representative for America’s Health Insurance Plans had the best quote to summarize the voices that should be favored in making health care decisions,

“The transplant was recommended by the medical professionals at the bedside,” [Karen] Idelson said. “They should have been listened to.”

Keeping the bueacrats out of health care decisions costs money. Demanding absolute deference to the physicians in a controversial case like this while also expecting low health care costs or pining for health care hand outs is incompatible. For instance, while certainly not even attempting to make a judgment in this case, the issue of coverage for experimental therapy.

In such a battle of costs versus expectations, the California Nurses Association made a particular ass of themselves,

The California Nurses Assn. publicized Nataline’s case, calling it an illustration of the need to abandon private insurance coverage in favor of a single-payer plan.

The reality is that Natalie would’ve almost certainly been less likely to get a liver transplant under a single payer system. An ‘exponential’ (I use that as hyperbole) increase in rationing is the trade off you make with health care systems with global budgets. Never forget that.

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Sunday, December 23rd 2007

The Crystal Ball: Claifornia Taxes Will Pass

A new Fields Poll finds that the majority of Californians support the new health care proposal to increase access which recently passed the Assembly.

The Field Poll found 64 percent of California voters inclined to support the universal health insurance plan outlined in the bill, compared with 23 percent opposed.

The Field Poll also found 63 percent of voters in favor of the state raising its cigarette tax to support the medical insurance plan, compared with 33 percent against doing so.

The poll only surveyed support for one of the actual final proposed funding mechanisms. That is a cigarette tax as cited above. If you remember (here’s my previous post on California’s plan) the other funding mechanisms are a 4% tax on hospitals and a pay or play deal for employers.

But with media coverage like this, would anyone be surprised if voters just put those two other little new taxes out of their mind or weren’t even aware of them at all (I mean, the majority don’t even read the plain language explanations on the ballot in full) when they vote?

So despite whatever campaigns the California hospitals or the Chambers of Commerce roll out, I would expect the funding mechanisms to fall into place.


This Is A Stick Up! Give Us Your Money!

And despite claims that the bill faces a challenge in the Senate, the actual ballot initiatives are probably the most likely place for this plan to be defeated. That said, there’s a slight glimmer in the Senate as the bill will not even be taken up in that chamber until the new year.

Despite a last-gasp effort in the Assembly last week, the Legislature is about to finish the “year of health care reform” without passing a health care plan.

While that outcome had become expected, what was surprising to many observers was the person responsible for blocking action before the new year: Don Perata, the Senate leader and a liberal Democrat from Oakland who co-authored the bill.

Perata announced he would not allow the Senate to vote on the Assembly-approved bill – not until he knows more about how the $14 billion-plus measure would affect existing health programs and the state’s overall finances.

[...]

[B]y pushing Senate consideration of the bill into next year, some proponents privately fret that Perata may stall its momentum and kill the measure’s already slim chances of being enacted.

At one point last week, the blunt-spoken Perata said in a TV interview that the health plan was “DOA” – a remark his office quickly said that he didn’t mean literally.

[A] risk of waiting may be that by the time the Senate debates it, presumably sometime next month, the political climate will be much more treacherous. Gov. Arnold Schwarzenegger plans to call the Legislature into a special session to grapple with a projected $14 billion deficit, and Perata himself is stoking doubts about whether the sprawling health care proposal would widen that gap.

That said, because the new funding mechanisms for the plan are being put to a vote by the people, and thus the bill doesn’t need a 2/3rds majority in the rooms to either side of the capitol, the bill will likely squeak out of the Senate.

In the end, even Republicans expect Perata will scare up the votes to pass the bill sometime in January. But they have enjoyed hearing the senator talk their talk.

“I love it,” said Assembly Minority Leader Mike Villines, R-Fresno. “I’d love to see it happen throughout the year.”

The Fields Poll certainly seems to emphasis the political capital California politicians have to implement a plan like this. What’s funny is that, according to the poll, the enthusiasm for the plan is tempered under certain circumstances. It shows the absurdism in the growth of society’s greed expectations of hand outs. The circumstantial evidence for this: the plurality oppose the health care plan if it is funded by a 1% increase in sales tax.

Now true, sales taxes are regressive and place a larger burden on the very population this health care bill is trying to “help.” But if you think the average Californian is thinking that deeply when answering this poll question your faith in humanity is, uh, misplaced. We all know that the “more real” it fells like dollars are being taken out of our pockets the less likely we are to support helping our fellow man. Sure the reality is the costs for the program will be passed onto all in some shape or form, but it’s only when it is obvious enough for them to see it, to feel it’s a reality that they pull their support away.

That speaks wonders to society. It also speaks wonders to the growing expectations of the role of government as a teat to suckle at, as welfare provider. Have no doubt that as income disparity grows we will continue to see increasing clamor from the majority for various forms of wealth redistribution (not to sound like Marx and Engels or anything).

That’s a shame. Just because the majority hawk for such handouts doesn’t make it right.

p.s.
Now, I’ve said it numerous times on this blog, but I’ll repeat: I personally believe I have a moral obligation to help the less fortunate. My continuing efforts throughout my career do and will speak for themselves. I just don’t think the government has any place forcing such an “obligation” on others.

Friday, December 21st 2007

Med School Ain't Business School

Dr. Wes bemoans how little medical students are educated on the business of medicine.

Heck, it’s through no effort of my school that I can define a CPT (a procedure) from an ICD-9 (a diagnosis) code.

Thursday, December 20th 2007

Rudy Giuiliani For President?


Just Go Away Rudy

I’m not one to hold the past equivocally against someone. That despite the photo above. But it isn’t like Rudy’s past is glowing besides this.

We look upon authority too often and focus over and over again, for 30 or 40 or 50 years, as if there is something wrong with authority. We see only the oppressive side of authority. Maybe it comes out of our history and our background. What we don’t see is that freedom is not a concept in which people can do anything they want, be anything they can be. Freedom is about authority. Freedom is about the willingness of every single human being to cede to lawful authority a great deal of discretion about what you do.

True, there was little chance I was going to vote for Rudy (or Mitt or Mike) in this election, but this quote from a 1994 speech is exceedingly disturbing. Even within context.

*sigh* The widest open race in decades and I still despise my likely options (except for Ron Paul)

via The American Conservative

Wednesday, December 19th 2007

California 'Universal' Health Care


Why Am I Not Smiling?

California’s move towards a hacked together, significant expansion of health care coverage has been a little bit of a journey; but now we see they’ve taken a significant step towards realizing Schwarzenegger’s ambition. The State Assembly has passed the actual bill which enumerates the plan.

The measure, negotiated by Schwarzenegger and Assembly Speaker Fabian Nuñez (D-Los Angeles), would require almost everyone in California to have insurance starting in 2010. It would provide subsidies and tax credits for those who would have trouble paying their share of the premiums.

A summary is in order. A good one exists on the Cal Health Reform website. The bill includes:

  • An individual mandate, with exemptions if premiums are more than 5% of family income
  • Tax subsidies to families <400% FPL to help pay premiums
  • Expansion of Medicaid (including to young adults <250% FPL and older adults <100% FPL)
  • Employer pay or play mandate (tax of up to 6.5% on wages if employer doesn’t provide insurance as a benefit)
  • Hospital tax of up to 4% of revenues
  • New cigarette tax of at least $1.50/pack
  • State fund (employer pay + hospital taxes + cig taxes) to fund indigent who cannot afford care
  • Insurance requirement that 85% of premiums go to patient care
  • Kills experience rating and doesn’t allow insurers to refuse coverage because of a pre-existing condition
  • Increase in Medicaid reimbursement, potentially up to Medicare fee schedule

If you so desire to read it then here is the full text of the bill.

I’d say two down and forty-eight to go, but obviously that isn’t where my feelings are. My feelings are more like – Yikes! I know I was, if not ecstatic, pretty accepting of the Massachusetts plan and this California plan shares much with that. At least the final bill lacks this:

[D]octors also would have to pay 2% of their gross earnings back to the state to help expand coverage.

But keeping the hospital tax reeks of absurdism. Not that much about the bill is likable if you believe in economic liberty.

There is perhaps some “good” news. Despite the bill’s passage in the Assembly, this plan is far, far from a done deal.

[T]he measure faces a more skeptical reception in the Senate, where Democratic leaders are asking whether it makes sense to adopt such a giant change at a time when California has a projected $14-billion budget gap.

Senate President Pro Tem Don Perata (D-Oakland) did not attend a jubilant news conference with Schwarzenegger and Nuñez, though he is officially a co-sponsor of the bill. He issued a muted statement praising “progress” and saying that he would ask the Legislature’s fiscal experts to determine whether the plan would become a drain on the state’s already depleted coffers.

An even bigger concern may be about asking the citizens to approve the new taxes to fund the proposal. Granted not new personal taxes, but taxes on employers and hospitals which will be passed onto the public in a number of ways.

Nuñez left the financing out of the bill because it would have needed a two-thirds vote to pass, requiring some GOP support. The planned initiative would ask voters to approve taxes: $2.6 billion on employers that don’t provide healthcare, $1.5 billion on tobacco users and $2.3 billion on hospitals.

The initiative is still being drafted. But it almost certainly would have to overcome well-funded opposition from many business groups and the state’s largest insurer, Blue Cross of California.

Tobacco and drug companies might also join the fight, bringing along their substantial financial resources.

The California Chamber of Commerce, which along with the state restaurant association successfully campaigned for the repeal of the last major healthcare measure in 2004, derided the bill passed Monday as “half a proposal.”

The restaurant lobby is also opposed.

With a smirk I’ll note that I’m denouncing a bill which the California Nurses Association has as well if for reasons that are mirror opposites. My positions don’t match up very well with their’s.

As I’ve said over and over, this kind’ve wealth redistribution really doesn’t stand on an ethical base.

Is there a right to property?

Is there a right to…health care?

Without repeating the base on which I’m building this argument (it’s been spelled out numerous times on this blog) I don’t understand how liberals, beyond their emotional reaction to those suffering, are enshrining something as historically evanescent, as ill defined as “health care” into an infallible right. A right more important, more inherent than that of property. Because that is what you’re having to do here to justify a “universal” health care plan like this.

Never forget where this money is coming from. I know income disparity (and perceived commercial greed) immediately entail a gut reaction of unfairness…somehow. But com’n, in the end, by and large these aren’t greedy hospitals and corporations you’re taking from. These are real people. Granted they’re at the top of the income pyramid and sure they can ‘spare’ it to fund a “better life” for those at the bottom, but is it really your place to make that determination? You violate it once (just once) and a truly infallible right, like that to property, holds no meaning. That isn’t hyperbole. A political right like that either exists without ex post facto restrictions or it doesn’t exist at all.

I don’t think it is heartless to admit this but I’m disturbed by the emotional rhetoric from those supporting the bill.

Fresno Mayor Alan Autry, gave the most emotional presentation of the [news conference], choking back tears as he recalled how his father, a farm worker, died after receiving substandard medical care that he blamed on a lack of insurance.

“It’s not a political issue,” Autry said. “It’s not an economic issue. It’s a moral issue.”

[...]

“I believe history will show that California was the tipping point in the long-sought dream of an America where every single man, woman and child who works has a choice of secure and affordable and quality healthcare for themselves and their families,” said [SEIU president Andy] Stern…

Maybe Mr. Stern is right. Apparently speaking for the SEIU this was published on The Health Care Blog,

We see this legislation as a work in progress—a crucial step toward the goal of quality, affordable health coverage for every woman, man, and child in America. The plan is not perfect, but waiting around for the perfect plan is a luxury too many Californians and Americans do not have.

Nay-sayers beware: if meaningful healthcare reform can happen in California, America’s largest and most ethnically, economically, and politically diverse state, it can—and must—happen nationwide.

I’ll say this: there’s no doubt that the California plan will fall short of it’s goals but perhaps that won’t matter, perhaps what it will achieve will still be significant. I know it has provisions to try to avoid such but the plan is going to suffer some of the same pot holes that the Massachusetts plan has.

To remove the threat of a public backlash, the state plans to exempt nearly 20 percent of uninsured adults from the state’s new requirement that everyone have health insurance.

The proposal…is based on calculations that even the lowest-cost insurance would not be affordable for an estimated 60,000 people with low and moderate incomes who do not qualify for state subsidies. Forcing them to buy insurance or pay a penalty could jeopardize the rest of the state’s initiative, officials said. Instead, the state board appears prepared to settle for near universal coverage, all but 1 percent of the state’s population.

Read More »

Wednesday, December 19th 2007

NEJM Image Challenge

Credit to The Haversian Canal for apparently helping to lead the NEJM website into making this new Image Challenge a reality.


Hey Look! I Got One Right…Just Not On My First Try

I’m a big fan of these self quiz resources on the web whether they be derm atlases or radiology cases. Good to find a new one with some breadth and some actual physical exam findings.

Wednesday, December 19th 2007

Debunking Third World Myths


Hans Rosling Debunks 3rd World (Global Health) Myths

Wednesday, December 19th 2007

To Promote Health Tourism

A new EU proposal, in it’s current form, would have member states guarantee health care costs no matter where their citizens are in Europe.

The commission was due to announce that that anyone who could not have “appropriate care” for their condition in their own country “without undue delay, will be authorised to go abroad, and any additional costs of treatment will be covered by public funds”.

Basically: think you’re queue to get that hip replaced is too long in the UK? Hope on over to France to have it done, pay for it and when you get home the UK Department of Health would have to write you a check to reimburse you for it.

Not every face is smiling with the proposal.

Anticipating a frosty reception, the commission was expected to propose giving member states prior authorisation of reimbursement for a hospital stay abroad.

For that to happen, a country would have to provide evidence that the number of patients seeking hospital care abroad would affect the planning of their home country’s hospital sector.

[...]

Non-hospital treatment would not require prior agreement.

As the BBC Euroblog says,

[The plan] would be pretty radical, and mean that Britain would have to adapt to a much more continental insurance-based system. But there is a potential opt-out.

If a Government can provide evidence that the impact of the law would undermine planning in their health service then they can partially opt out of the scheme.

They would be allowed to insist that patients get the green light from the health service before they travel.

It’s widely thought that this clause has been stuck in to satisfy the British Government.

Indeed, pretty radical and ridiculous (I bet you didn’t see that opinion coming from me). Although I suppose if you’re already guaranteeing health care within your borders, it isn’t a real philosophical jump to guarantee it outside of them.

It does however threaten the entire NHS model, which until the date this is enacted has never had to deal with reimbursement; never had to act as a real payer.