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Archive for January, 2011

Wednesday, January 12th 2011

The Post Call Vibe

I don’t know what I owe my sleep bank but it must be something substantial.

I probably fall asleep anywhere, anytime in less than 2 minutes and usually a matter of seconds. I wonder if it borders on pathologic, as do people around me who have witnessed me fall asleep on a dime.

That said, my constant state of fatigue obviously has it’s ups and downs. And I have trouble picking out exactly what makes me really tired. There seems to be poor rhyme and reason to it.

For example, I’m post call right now. I got no sleep on call last night. It was just one of those nights where the consults rolled in kind’ve intermittently and included an emergency cranial reconstruction and multiple sick patients. I’ve noticed, on nights like this, around two or three in the morning I hit a wall. But there’s a point where the circadian rhythms kicks in and you start feeling better as the cortisol levels rise.

That’s certainly enough to carry through the morning.

What I wonder however is why, some days, I feel like collapsing and exhausted again as my time awake approaches thirty, thirty-five, forty hours and why some days, I may not be crisp, but I feel relatively functional even well into my post call day.

Today I came home post call and took a two hour nap but awoke and I feel good now as I get ready to sit down for dinner. Granted I’m functioning on a lot of caffeine but I’m just not sure why today a two hour nap did it for me and my next post call day I may come home and crash for 12 hours straight.

Not that I’m not going to sleep well tonight probably.

Sunday, January 9th 2011

Paul Levy Stepping Down

Social media, the internet has created a remarkable, egalitarian communication conduit between those at all levels of an enterprise. It has incredible, somewhat recognized promise, promise as a utility for transparency. If those at the top are willing to embrace it. When it comes to health care perhaps no one of more prominence embraced social media more fully than Paul Levy.

Now the CEO of Beth Israel Deaconnes Medical Center in Boston is stepping down. Levy’s time leading BIDMC has almost universally been regarded as success in terms of the revitalization of the hospital’s finances, his push for transparency and the general reorganization of the workings of the facility. Not that his time hasn’t been without notable controversy. All that considered, I’ll certainly remember Mr. Levy for how much he shared from the inside including on his blog Running A Hospital.

He used that medium of recent to post the email he shared with the BIDMC community. In it he says,

I have been coming to a conclusion over the last several months, perhaps prompted by reaching my 60th birthday, which is often a time for checking in and deciding on the next stage of life. I recently traveled to Africa and while biking through the Atlas Mountains had plenty of time in a less cluttered environment to think this through.


While I remain strongly committed to the fight for patient quality and safety, worker-led process improvement, and transparency, our organization needs a fresh perspective to reach new heights in these arenas. Likewise, for me personally, while it has been nine great years working with outstanding people, that is longer than I have spent in any one job, and I need some new challenges.

So, last night, I informed the Chair of our Board that I will be stepping down as CEO. We will work out an appropriate transition period, and things will continue to run smoothly here. I leave confident that the Board will find many able candidates to succeed me.

He does promise to continue his presence online. Which is certainly a good thing.

I don’t know Mr. Levy personally. This Pre-Rounds column I wrote for Medscape is my sole interaction with him. However, I’ve certainly kept up with what he’s had to share through social media and enjoyed it. I hope he finds success in whatever new challenges he takes on, and I hope he keeps sharing his observations.

Saturday, January 8th 2011

The Horror of Penetrating Missile Head Injuries

In a terrible scene in Arizona Representative Gabrielle Gifford and others were shot as she held a meeting with her constituents outside a supermarket. At least six are dead. My prayers are with everyone involved in this, their families and loved ones.

Even as at least one of the suspected perpetrators has been identified and theories on motive swirl and the unfortunate game of politics is already playing out, the major attention has been on how Rep. Giffords is doing.

Rep. Giffords suffered, per reports, a single gunshot wound to the head with both an entrance and an exit. From eye witness accounts with a posterior entrance wound.

In the same press conference it is commented that the bullet transversed just one hemisphere. She underwent neurosurgery, although the exact nature of such isn’t clear. Post operatively she was following commands.

Of course, no one but her physicians right now know exactly what is going on but missile wounds to the brain are tough things. There is some optimism but I’m afraid we should probably be more cautious than some of the vibes coming from the media.

Read More »

Saturday, January 8th 2011

The End Is Nigh…The Right Insists

I recently talked about what changes came into effect on the New Year under the Affordable Care Act. One of the tangential things I didn’t comment on was an executive Medicare regulation running parallel to congressional efforts which came into effect January 1st and promised to pay providers for any time spent discussing end of life issues with patients.

The new rule says Medicare will cover “voluntary advance care planning,” to discuss end-of-life treatment, as part of the annual visit.

Under the rule, doctors can provide information to patients on how to prepare an “advance directive,” stating how aggressively they wish to be treated if they are so sick that they cannot make health care decisions for themselves.

Section 1233 of the bill passed by the House in November 2009 – but not included in the final legislation – allowed Medicare to pay for consultations about advance care planning every five years. In contrast, the new rule allows annual discussions as part of the wellness visit.

The proposal for Medicare coverage of advance care planning was omitted from the final health care bill because of the uproar over unsubstantiated claims that it would encourage euthanasia.

The new rule says Medicare will cover “voluntary advance care planning,” to discuss end-of-life treatment, as part of the annual visit.

Critics decried the new rule as taking control away from patients and devaluing life and setting up death panels.

There is…something at least vaguely disturbing about a government incentivizing doctors to [discuss end of life issues] as part of an expansive regulatory program that has, as one of its primary goals, cost reduction.

At least the linked to criticism at Hot Air,

There is nothing wrong with patients planning for contingencies through advance directives. There is also nothing wrong with doctors discussing those options with patients ahead of those decisions. As the spouse of a patient who has faced life-threatening circumstances on more than one occasion, I certainly understand why these conversations need to take place before the pressures of acute circumstances come into play. This new regulatory effort at least puts the conversation where it belongs, in routine wellness visits, rather than as a five-year set conversation. It also appears to make this a voluntary conversation (at least for now), one the patient can decline without any repercussions.

I couldn’t agree more but I would argue that there should be reimbursement for it at anytime, anywhere.

Too bad, as bowing to political pressure, the Obama administration soon backed off of the regulation this week.

Lacking a pallative care team there may be no one outside my team, the neurosurgery service, who sees as much end of life issues. Neurotrauma, aneurysmal bleeds, primary central nervous system cancer, bad things. And the choices family have to make in the heat of the moment are gut wrenching and painful and full of angst.

Patients and their physicians need to have conversations with families present concerning end of life issues well before anything happens. The young and the old need to have the conversation. In some ER with a loved one with a massive subdural on Coumadin, with me, is not the place to have the conversation for the first time.

The best way to promote people discussing end of life issues with their physicians is to pay physicians for such discussions. Too bad the political establishment on the right has a problem with that.

Wednesday, January 5th 2011

What It Means To Ration

Healthcare is a limited commodity. It’s limitations are defined by the numbers of professionals supplying it and their physical limitations on the number of patients they’re able to treat, on availability of biomedical equipment and technology, on availability of physical space to safely provide medical care and, underlying all of these, on the funding for such.

And so, not everyone can get all care they need or want.

And, it is true, no system will even be able to supply such. There will always be limitations. And there will always be some rationing.

The argument from many proponents of reform has long been that at present we covertly ration healthcare and we do it haphazardly and so reform that makes rationing more transparent and planned is actually a positive. Essentially the argument is that, everyone is scared of rationing in health care reform but what many don’t realize is that such is already occurring and we should embrace making rationing more rational with health care reform.

It is an argument made recently by ration as a verb,

to supply, apportion, or distribute as rations (often fol. by out ): to ration out food to an army.

to supply or provide with rations: to ration an army with food.

to restrict the consumption of (a commodity, food, etc.): to ration meat during war.

It’s a verb, it’s an action. It implies planning and action. Not the haphazardness that defines who currently does and doesn’t get certain care within the American health care “system.”

The Economix piece quotes former CMS head Dr. Mark McClellan later,

“Just because there isn’t some government agency specifically telling you which treatments you can have based on cost-effectiveness,” as Dr. Mark McClellan, head of Medicare in the Bush administration, has said, “that doesn’t mean you aren’t getting some treatments.”

And I agree but it’s important to keep our terminology straight, at least to opponents of rationing and health care reform as defined currently by things like the Affordable Care Act. In that quote above I would claim only the former represents rationing and not the latter.

And the end results are not the same.

Rationing, the centralized distribution of health care resources is vague but for many proponents of current national health care reform efforts essentially it means the most bang for the most people for the buck. An egalitarianistic vision of health care.

However, down the slippery slope, it promises to leave peripheral exotic patients on the sideline and to limit freedom of choice.

By some quantitative quality measures health care, over the whole population, may be better. But in rational rationing these are the physicians you can see, these are the procedures you’re entitled to no matter the nature of your specific disease or your personal means. It could potentially stifle innovation in health care and certainly will limit choice.

Currently your economics and your social status influence the care you receive and they choices you have. In a rationed system, as envisioned by many proponents of current health care reform, the care you receive and the choice you have are influenced by some centralized entity who determines such. The latter is certainly more rational and has the potential to improve some measurements of health in this country but it holds the potential to inherently redefine the notion of choice within your means, of freedom upon which (and I don’t mean to be hyperbolic here) the American dream has been based. Or at least the mythos that is the American dream.

Tuesday, January 4th 2011


Over at The Health Care Blog Dr. Robert Wachter is very articulate, at times blunt, and in the end utterly convincing of its benefits concerning a project at UCSF wherein a hospitalist team co-manages certain complicated neurosurgical patients.

Here is the Archives of Internal Medicine publication.

I think there’s more than great promise for this, I think it’s approaching the norm in vertically integrated health systems and in some academic environments and even out in the wider private world. Certainly there’s some of this going on in my faculty’s private practice, maybe not to degree Dr. Wachter describes. And there was a well established relationship where my fiancee was training before she transferred to be with me.

Certainly it’s something I would think any future neurosurgeon would be interested in.

Monday, January 3rd 2011

Healthcare Solved

Problem Solved

Saturday, January 1st 2011

Health Care Reform & The New Year

The healthcare reform law comes into effect piecemeal, as the provisions of so many laws do. Today, the first of 2011, marks the coming of age of new provisions. The most notable of first may be a national medical loss ratio cap.

Today , many insurance companies spend a substantial portion of consumers’ premium dollars on administrative costs and profits, including executive salaries, overhead, and marketing.

Thanks to the Affordable Care Act, consumers will receive more value for their premium dollar because insurance companies will be required to spend 80 to 85 percent of premium dollars on medical care and health care quality improvement, rather than on administrative costs, starting in 2011. If they don’t, the insurance companies will be required to provide a rebate to their customers starting in 2012.


Over 20 percent of consumers who purchase coverage in the individual market today are in plans that spend more than 30 cents of every premium dollar on administrative costs. An additional 25 percent of consumers in this market are in plans that spend between 25 and 30 cents of every premium dollar on administrative costs. And in some extreme cases, insurance plans spend more than 50 percent of every premium dollar on administrative costs. This regulation will help consumers get good value for their health insurance premium dollar.

Essentially the law requires 80% of premiums coming from individual plans to go to actual policyholder health care costs. For those in large employer based plans the law requires an even higher medical loss ratio of 85%. Dollars falling short of that must be given back to policy holders.

The law allows for the various states to ask for a waiver to individualize their medical loss ratio requirements. So far only Maine has done so.

MegaLife…threatened to leave Maine if the new loss ratio is imposed.

“Based on preliminary discussions I had with [MegaLife],” Kofman wrote in her July letter, “the company … would probably need to withdraw from this market if the minimum loss ratio requirement were increased.”


In November, Sen. Olympia Snowe added her support to Kofman’s waiver request, reiterating the concern about losing what little competition exists for Maine’s individual insurance market. Still, there has been no answer from Washington, D.C. Snowe could not be reached Friday for comment.

To be fair a lot of states require certain medical loss ratios already, but few at levels like the Affordable Care Act requires. I’m not sure how tenable the medical loss ratio requirement will be at 80-85% if the individual health insurance mandate doesn’t survive come 2014.

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We All Know How I Feel About Reform, And The Medical Loss Ratio Requirements In Particular

There are other new provisions coming into force. Maybe none as significant as the national, standardized restrictions on what health insurers can spend their revenue on but important none the less. You can look over some of the other provisions here.