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Archive for October, 2009

Sunday, October 25th 2009

The Public Option Lives

I’ll be honest, I’ve declared off this blog and with full confidence that the ‘public option’ was dead. Even with all the hope for reconciliation I just did not think the Democrats had the cohesiveness or that Harry Reid commanded the authority to muster his conservative wing for the vote. Comments like this stirred me to that belief,

U.S. Sen. Blanche Lincoln said today she opposes a public health insurance option because it would be too expensive.

“For some in my caucus, when they talk about a public option they’re talking about another entitlement program, and we can’t afford that right now as a nation,” Lincoln said in a speech to the Elder Law Task Force at the University of Arkansas for Medical Sciences.

But now some are reporting that Reid has churned up a good chunk of the caucus to support at least a true up down vote on an ‘opt out’ public option.

Reid’s efforts got a boost Friday when two key Senate moderates signaled that that they were not inclined to block him.

“I conveyed to Leader Reid that a number of moderates still were extremely concerned about a government-run, taxpayer-funded, national public plan,” Sen. Mary Landrieu (D-La.) said in a statement after meeting with Reid. “However, I am encouraged that the conversations taking place over the past week among Senators who back different versions of a public option could potentially lead to a compromise. I believe this compromise should happen sooner, rather than later, so we can get to work on other critical aspects of heath care reform.”

An aide to Sen. Joseph Lieberman (I-Conn.) said that, while the senator does not favor a public option with a state exemption, he was “inclined” to vote for a motion to proceed. This would put Reid closer to the 60-vote threshold.

I don’t support a public option or any government involvement in health care. But it is hard to deny that if your goal is to control costs then a global budget system is the way to go. A public option is, without a doubt, a backdoor to a single payer system in a decade or so.

It will save money if simply because of economy of scale. There might be some cost savings in the efficiency of how it functions as compared to the private insurers but the real savings will be as the public option narrows the market. If you thought health insurance was a monopoly in some areas already, it will get even less competitive. But as competition dries up, what the insurers and the public option are willing to pay for health care will as well. The entire cost of the operation will go down as providers are dictated less reimbursement for care.

Indeed I would argue a ‘public option’, and eventually a global budget system, is the only long term viable way to control costs.

Without a ‘public option’ any “health care reform” the Democrats achieve will be laughable.

If Harry Reid pulls this off in the Senate it will be impressive, even if I don’t support it. Like I said, I thought the public option was dead for sure.

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Friday, October 23rd 2009

SGR Fix Fails

The Sustainable Growth Rate is a Medicare formula under which when Medicare goals over annual budget (virtually guaranteed every year) physicians reimbursements are automatically reduced the next fiscal year to bring Medicare expenditures back in line. In 2010 physician fees are to be cut 21.5% across the board under the SGR formula.

Every year, with significant prodding, Congress forestalls the cuts due to take place under the SGR formula. But they do it merely on a year to year basis.

Proposals to scrap the SGR formula have come and gone, without success, through the Congress under Republican leadership.

Last Wednesday, perhaps the most promising and realistic attempt to do away with the SGR to come up in years was put before the Senate for a cloture vote. It failed.

“In the Senate’s first vote on health care spending this year, a bipartisan majority rejected the Democrat leadership’s attempt to add another quarter trillion dollars to the national credit card without any plan to pay for it,” Mr. McConnell said in a statement. “With a record deficit and a ballooning national debt, the American people are saying enough is enough. Today’s vote shows that this message is finally starting to get through to Congress. Hopefully it’s a sign of things to come in the health care debate ahead.”

In case you’re wondering here are the Senators who let down the physician community:
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Tuesday, October 20th 2009

Radiation & Software

Threat Level is an interesting blog published by Wired. Every once in a while they throw out an interesting piece of medical technology. They’ve got a piece up right now about how some Gamma Knife machines have a pretty significant software bug awaiting fixing which makes the emergency stop button non-functional under certain conditions.

[W]hen the couch moved out of position during a treatment at an university hospital in Cleveland last December, staffers hit the “emergency stop” button, expecting the couch to pull the patient out of the Gamma Knife, and the radiation shields at the mouth of the machine to automatically close. Instead, according to a report eventually filed with the Nuclear Regulatory Agency, nothing happened.

“Staff had to manually pull out the couch from the Gamma Knife and manually close the doors to the Gamma Knife to shield the source,” reads the report, which states that neither the patient nor the workers were harmed. “Radiation exposure to all individuals involved with the incident was minimal.”

Gamma Knife, CyberKnife, all these proprietary radiosurgery devices are pretty incredible.

I have a pretty strong clinical interest in image guided surgery, stereotaxy and, to a lesser extent, radiosurgery. Computer aided or directed surgery is going to become the norm well before my career is over, if I have a full one, and I imagine this isn’t the last we’ve heard of ‘glitches’ and ‘bugs’. A little scary, admittedly. Still you have to imagine that the risk versus reward in this situation, and most others, very much favors the patient. I’m not sure I’d forgo life saving radiosurgery over a story like this is my point.

Monday, October 19th 2009

First Catch


It’s A Big One

There’s something gut wrenching about being an intern in July. You’re a ‘doctor’ in name but there’s nothing magical that happened when they handed you your degree.

To be fair, I would argue that the data leans heavily that patients receive no worse care at teaching hospitals in July, when new interns start, than any other month of the year. As well major teaching hospitals, where residents are involved intimately with patient care, consistently provide better care than non-teaching hospitals.

But that’s all a sidetrack. The fact remains that being a new doctor is not without some butterflies.

Every once in a while however you do something of effect. Opportunities to truly help patients often arise from the fact that as an intern I’m probably the physician who lays eyes on our patients the most.

I was two weeks into my intern year when I first ‘caught’ something with a patient. I was in the Surgical Intensive Care Unit. Late one day the ENT resident caught me to tell me about a post op patient they had put in SICU admission orders for. I can’t remember what he had had done but he had been a tough intubation and didn’t have an air leak when they were done with the procedure. So they kept him intubated and ventilated and dosed him with some steroids.

On a ventilator, of course, he was going to require an ICU bed.

I went down and visited him in the Post-Anesthesia Care Unit. There was a good chance he was going to spend the entire night down there as there were no ICU beds open. At that time he was hanging out. I put in some standard ICU orders, talked briefly with his wife, wrote a note and headed back up to the ICU.

About two hours later I get a call from the nurse in the PACU that the patient is agitated.

Something made the experienced nurse caring for him sit up and take notice when this patient began to pull at his restraints, rather than just turning up his Versed drip. As such I probably shouldn’t be calling this ‘my’ catch.

In anycase, I get down there and the guy is tachycardic on the telemetry monitor. I’m an intern so my modus operandi is to order every test in the book for every little thing and I’m already thinking about a PE protocol CT scan with this guy. But first things first, the nurse and I get an EKG. I’m admittedly surprised at how classic it looks.


The EKG Looked Something Obvious Like This

I remember MONA, call the cardiology fellow, fax over the EKG, call my upper level, call the ENT resident and the patient ends up in the cath lab with a clot pulled from his LAD.

The patient ended up in the MICU and I’ll be honest I don’t know how he ended up. Hopefully well. For me, this patient taught me some valuable lessons; he taught me to respect what the nurses have to say about patients, to lay eyes on patients whenever there’s any change. Things I need to keep in mind as I get along in my residency.

Friday, October 16th 2009

Expand Coverage, Save Money

[zdvideo width=550 height=420 theme=simple2 border=no]http://www.youtube.com/watch?v=ahXC4DF4CkU[/zdvideo]

And we’re back to a discussion of the Sustainable Growth Rate.

Excuse a physician for tying healthcare reform efforts back to the SGR. In the eyes of any physician, with even a tangential interest in policy or how they’re paid, all of healthcare policy centers around Medicare reimbursement and more specifically the SGR (and maybe tort reform). Eliminating the SGR, and chiming for its yearly postponement, has been the almost singular lobbying focus of organized medicine for the past decade plus.

The Sustainable Growth Rate formula “originally was designed to control Medicare utilization by reducing physician fees. The primary drivers of utilization, however, are new or improved technologies, increased beneficiary awareness of potential treatment options, and a general shift from inpatient to outpatient care. Physician behavior controls none of these factors.”

Whether you agree or disagree with the points of that statement, the Sustainable Growth Rate remains a growing political hairball. Each year Congress routinely passes legislation to prevent the cuts in Medicare physician reimbursement from going into effect. However that simply makes the projected cuts for proceeding years larger. In 2010, if nothing were to be done, physicians would be facing cuts of 21.5% across the board for all services.


Numbers Are So Sexy…

There’s nothing new there. Every year it’s the same story, only the cuts get larger. Every year, with some jockeying from doctors the cuts are forestalled. And it is a major deal to doctors, or at least the ones who take the time to participate in the politics of healthcare (and by that I mean participate in organized medicine). And it is a major deal for healthcare reform. It is so much of a major deal that I would argue the Sustainable Growth Rate was the major deal in the American Medical Association signing on to HR 3200. The House bill scraps the SGR in full.

And you see, we’re back to a discussion of the Sustainable Growth Rate.

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Thursday, October 15th 2009

Acute Care Resources

Lexington, a pseudonymous columnist for my favorite magazine The Economist, had the following to say about efforts to reform American health care,

We are all going to die. And the demand for interventions that might postpone that day far outstrips the supply. No politician would be caught dead admitting this, of course: most promise that all will receive whatever is medically necessary. But what does that mean? Should doctors seek to save the largest number of lives, or the largest number of years of life? Even in America, resources are finite. No one doubts that $1,000 to save the life of a child is money well spent. But what about $1m to prolong a terminally ill patient’s painful life by a week? Also, who should pay?

I couldn’t agree more. I’ve long been a proponent of the idea that expectations of healthcare in the United States are something else, more demanding as compared to the rest of the world. We try everything here in America for a patient, cost not prohibiting, before the plug is pulled. This trend is especially prominent in acute care situations. Situations of immediacy, of life and death.

[zdvideo width=550 height=420 theme=simple1 border=no]http://www.youtube.com/watch?v=F2n7H-8o5GI[/zdvideo]

Consider I’m at a major trauma center for training right now. I know I’m not seeing unique scenarios and I, with some frequency, am witness to scenarios like the following. An 80 year old man comes in following a motor vehicle crash. He was the restrained driver. There was a death at the scene.


He had a prolonged extracation from the vehicle

On the scene he had a Glasgow Coma Scale of 9 and was combative and was intubated for such. En route to the emergency room his hemodynamics become a little marginal and he starts with progressive fluid requirements. On arrival to the emergency room a FAST scan is inconclusive and his pressures, while marginal, are stable enough for him to make a quick run through the scanner. His injuries are documented by imaging as bilateral femurs, open pelvis with active extravisation, splenic and liver injuries with active extravisation, a subdural hematoma on the right with marginal shift and bifrontal contusions.

Coming out of the scanner his pressures collapse as he’s being rolled emergently to the operating room. At this point his TRISS score predicts a mortality approaching 95%.

Intraoperatively he loses close to 20 liters and requires massive resuscitation. Resuscitation includes more than 50 units of packed red blood cells and corresponding fresh frozen plasma and cryo and platelets. He is transported to the SICU status post a splenectomy with an open packed abdomen. He requires continued resuscitation with another 10 of pRBCs and 10 of FFP. He requires ACLS overnight although a pulse is returned. He is not stable enough to make a trip back to the operating room as planned through the whole of the next week. At one point he has a reexploration of his abdominal wound at bedside under sterile conditions because he is too unstable to be transported to the OR.

He continues like this for a week despite the clear non-survivability of his injuries, until finally made comfort care and allowed to peacefully expire.

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Wednesday, October 7th 2009

Ted Kennedy’s Ghost

In case you missed it during his life Ted Kennedy was dedicated to health care reform.

[S]oon, very soon, affordable health coverage will be available to all, in an America where the state of a family’s health will never again depend on the amount of a family’s wealth. And while I will not see the victory, I was able to look forward and know that we will – yes, we will – fulfill the promise of health care in America as a right and not a privilege.

[zdvideo width=500 height=400 theme=simple1]http://www.youtube.com/watch?v=PrJVbCzJH6c[/zdvideo]

I owe lengthy discussions on Obamacare: Options on Reform (including HR 3200 and Baucus’ bill and the HELP bill), as well as Obamacare: Support for Reform and a final post opining on what is likely to happen. I haven’t gotten into the full fledged set of posts I planned on the current healthcare reform effort because intern year is beating me down. They’re coming, hopefully before reform actually happens.

But I thought it was important to talk about Ted Kennedy’s role in all of this. It’s much less substantial than many imagined it would be. The Reno Gazette-Journal has taken the interview down but following Kennedy’s death Harry Reid had this to say,

Q: How will U.S. Sen. Kennedy’s death affect things?

A: I think it’s going to help us. He hasn’t been around for some time. We’re going to have a new chairman of that committee, it’ll be, I don’t know for sure, but I think Sen. (Chris) Dodd, (D-Conn.). He has a right to take it. Either him or (U.S. Sen. Tom) Harkin, (D-Iowa), whichever one wants it can have it. I think he (Kennedy) will be a help.

Delightfully crass and yet slightly tactless.

Part of it is that the proponents of reform have simply lost the debate for hearts and minds. I honestly didn’t see such coming, I thought Obama’s election represented the absolute best chance for reform that America had ever known. But such warrants a full fledged and detailed post on support for reform and how brilliantly the insurance industry and others have played this whole mess.

The truth is Senator Kennedy’s presence in the limelight has shrunk over the years, only more so following his diagnosis of cancer. He was not the voice for healthcare reform he might have once been. It is difficult for the public to identify him with the issue.

[SEIU President Andy Stern] and Randel Johnson, a senior vice president of labor, immigration and employee benefits at the U.S. Chamber of Commerce, predict that any benefit to advocates of a health care overhaul will be temporary.

“I don’t think it’s ultimately going to have any long-term effect,” says Johnson, who said he has the “highest admiration for Sen. Kennedy, although we were on opposite sides of the labor issue.”

“He’s been out of the public debate, and the health care issue is so huge across the country that it has eclipsed one personality,” he says.

A shout of ‘Do it for Teddy’ is overbeared by the shouts of town hall enthusiasts.