So, I just got home from a motorcycle trip from Pennsylvania to Milwaukee, around the Great Lakes, through Canada to Niagara Falls, and home again.  This is a beautiful country. 

http://pjmedia.com/lifestyle/2012/12/22/the-sleep-deprived-doctor-saving-your-life/2/

 I went max of 36 hours at a shift during residency, which is long, but not much different than "pulling an all-nighter" which I did frequently during college.  The argument against these shifts is clear, but we should also consider the cost (everything in life is a trade-off).  If you are working less hours per year in training, (we did 100-120 and the current standard is 80) and there is the same amount of material to learn/practice (actually there is more now) do we want less trained young physicians, or do we want to extend residencies to minimums of 6 years, to more than 15-20 years for neurosurg?  Keep in mind also, that when I was in practice, there was no protected sleep, or limited hours.  I slept more than residency, but I was available.  Is this something we can train for, or how does it change availability patterns if during training you are told how important "protected time" is?  We all know it is harder to get physicians to take call nowadays.  Does this have something to do with it, and is that a fair trade-off? Are we willing to have less doctors available at night?  Does this mean we keep all new parents from working, since I slept less when I had a newborn at home? At least during residency it was one night in three or four, not every night! How about mandatory curfews for any doctor who has to work tomorrow? 

http://www.weeklystandard.com/blogs/obama-asks-doctors-help-deal-guns_696121.html

How about an addendum to allow doctors NOT to discuss this?  I don't want any responsibility for this.  What makes us think that we are experts on this subject?   I've never held a gun in my life;  should I be telling an ex-Marine how he should store his weapon?  If there is a violent member of their household, I think they probably already know.  What expertise do I have to add to this situation?

Economics and Emergencies

 This is actually my Economics course homework.  But it kinda belonged on my blog!  

I'm starting to think that everyone should be required to take economics before they are allowed to serve in government.  We already have a good example of what happens on a small scale with the kind of "reforms" Obamacare creates.  What makes us think that expanding it from tiny Massachusetts to the entire USA will make it work better?

http://www.wwlp.com/dpp/news/massachusetts/emergency-room-costs-way-up-in-ma-but-lawmakers-think-it-will-go-down

A timely article I found concerning prices is the attached article from the Boston Globe discussing the price of emergency room visits in Massachusetts recently.  The background information required to analyze this price change includes the enactment in 2006 of the Massachusetts health care insurance reform.  This law required everyone in Massachusetts to maintain health insurance and provided free insurance for residents making less than 150% of the federal poverty level.   The supply of emergency rooms is held constant, both by government regulation, and by the practicality of building new hospitals. 

                The price increase in emergency room services has resulted from an increase in demand.  As more people have insurance for emergency visits, they are more likely to go to the emergency room, thereby increasing demand.  If a person is required to pay for health insurance, he will have more of a tendency to “get his money’s worth” and visit the emergency room for health issues he may not have in the past.  Also, the subsidy for poor residents has increased their demand for health services over all, including emergency visits.   Another driver of increasing demand is the change in expectations that occurred with the health insurance reform.  The law was passed as an increase in access to health care for everyone, and when the patient feels he is entitled to immediate care, he frequently arrives at the emergency room.  These changes all result in a large shift of the demand curve to the right.

                Another interesting aspect of this article is the result of the change in the substitute service of primary care physicians.  As the supply of family physicians has decreased*, the price (either as money or as waiting times or as inconvenience) of their services has increased.   Since emergency care acts as a substitute good for primary care, this has shifted the demand curve to the right.  In the last few paragraphs of the article, the state is attempting to shift the supply curve of primary care to manage the equilibrium point of emergency room care.   

                It remains to be seen how the contradictory aims of health insurance reform will play out in Massachusetts as well as the far larger national reform.

*http://www.ama-assn.org/amednews/2011/10/10/prsc1012.htm

http://www.washingtonpost.com/opinions/michael-gerson-romney-should-lead-americas-solution-of-class-problem/2012/07/12/gJQA7eOQgW_story.html

My response:

Your recommendations for Romney at the end of the article are all wrong.  Early childhood education (Head Start) has been shown to make no long-term difference at a high cost.  High school completion leads to "social advancement" i.e. graduating seniors who can't read.  College education was the reasoning behind the higher education bubble,where graduates are $100,000 in debt and can't find jobs.  Wealth-building was the reason behind getting people in houses to "build equity" which led to the real estate bubble and sub-prime mortgages.  Every one of your ideas has led to problems and worsening effects.  Is your point that Romney should support these for political reasons regardless, or do you really think that government can do something useful about class?
Mobility comes from a family that pushes it's kids to achieve, and the government's role should be to equalize opportunity.  Fix the schools to emphasize learning, not fuzzy self-esteem.  Ensure that what you make you get to keep.  Simplify the process of starting a business, getting rid of unnecessary regulations.
The most important, however, is a family that pushes kids.  If your parents don't have any respect for learning, or any belief that you can succeed, there is no upward mobility.   Do you have any ideas on how Romney can fix the culture that mocks studying and hard work?  I am an immigrant who spoke no English when I hit kindergarten in Detroit's public schools.  My mother ensured that I could at least count to one hundred before I started so that "they won't think you are stupid".  I arrived to find that kids who were native English speakers couldn't count to ten.  My family is the source of my success, and I don't see where the government could do much but harm.

A Late Post for Father's Day (I was working)

The most important thing my father said to me about work was "It doesn't take a genius to be a good doctor;  it just takes enough guts to keep getting up and doing the right thing".  It's not hard to know that when a nurse calls at 3 a.m. and says a baby "doesn't look right", the proper thing to do is to get out of bed and go look at the baby.  The difference between a bad doctor and a good doctor is how many times you can keep doing that.  It's obvious that when an insurance company (or Medicare) denies your patient care that you think is needed, the right thing to do is call till you get someone you can argue with and get your patient the care he needs.  It doesn't matter if that is the first time or the thousandth time you have had to make that call, or how long it takes to get someone. 

Do you see that problem with this?  To be a good doctor, you have to fight the bureaucracy, and they will make it longer and harder and as miserable as they can.  What do you do?  Do you hold to your principles and spend your entire life fighting with bureaucrats rather than seeing patients?  Or do you compromise and become less and less of a "good doctor"?  Or do you stop practicing and decide not to be a doctor at all if you can't be a good one? 

So, in our system, who is left as the doctor you count on?

Silliness

I've been following the Elizabeth Warren story fairly closely for someone who has no vote in Massachusetts.  I'm fascinated by the affirmative action side of this silliness.  I think that most people would assume that Elizabeth Warren, whether she believed it or not, put down that she was a Native American for affirmative action purposes.  It got her a position at Harvard Law.  I'm not challenging her abilities, but the plain fact is that there are hundreds of people who are qualified to teach at Harvard Law, so why did they pick her?  She is the only professor at Harvard not to graduate from a top ten law school.  Her degree from Rutgers is the second lowest ranked school of all the Ivy League professors.  She had no spectacular accomplishments before being picked for Harvard Law, and they started touting their "diversity".  Doesn't take rocket science to figure out what got her there. 

Now, regardless of what you think of Elizabeth Warren, this shows the silliness of affirmative action.  She is a middle-class woman from Oklahoma, who never suffered any discrimination from her "diversity".  Why should she be in the affirmative action group at all, regardless of her family background?  A girl whose parents came from the Cambodian boat people, who emigrated without a dime and no English, who works incredibly hard and does well in school, gets no preference because she is not "diverse".  What? 

The rationale for affirmative action has always been that people who have been unfairly discriminated against in the past should have an advantage now.  Well, how many generations does that carry through?  Are we down to the "drop of blood" rule?  If my parents were discriminated against, and overcame it, does my son deserve an advantage?  How about my grandson?  If your parents made it to a comfortable middle class life, how do you deserve an advantage, regardless of the color of your skin? 

Tanstaafl??

Maybe I should explain the name of this blog.  I first heard of tanstaafl way back in my mis-spent youth when I read TONS of science fiction.  Robert Heinlein was the best, of course.  For those of you who have never read his books, GO GET THEM!  Tanstaafl came from The Moon is a Harsh Mistress, and it stands for there ain't no such thing as a free lunch.  If more people knew and believed that, the world would be a more rational place.  In healthcare, most of our problems are the result of people trying to find the free lunch.  Ain't there, folks.

Why Does My Band-Aid Cost $50 in the Emergency Room?

Why Does My Band-Aid Cost $50 in the Emergency Room?

 

     Everyone who has the misfortune of needing the emergency room eventually gets a bill.  Many of them wonder why simple supplies and treatments cost so much when they are delivered in the emergency setting.  The specter of gouging by greedy hospitals is frequently raised.  There are actually reasons that are obvious for the huge markup when analyzed with financial data.   I propose to clarify this situation by explaining the income and expenses portion of an emergency room’s financial statements.  While many hospitals are non-profits, I believe that the analysis is the same, whether the goal is profit or continued operation of the hospital. 

     Income, or revenue, comes almost exclusively from payments made to the emergency room for services rendered.  In looking at these revenues, it helps to think of the different payers, Medicaid, Medicare and the private insurances, as different lines of products.  In the same way that a department store may sell several different lines of jeans, most of which have similar costs, at far different price points, an emergency room providing a certain service has several different price points.  Medicaid and Medicare reimbursement rates are set up the government, and not open to change.  Private insurance payments are negotiated on an annual basis.  Like any business, when a product is sold for a higher price, if the cost of the product remains similar, profit goes up.  Medicaid and Medicare are frequently priced below the hospital’s breakeven point for providing services.  This results in most of the profit coming from the private insurance payments, which requires more markup.  Medicaid and Medicare act as loss leaders, providing the hospital with marketing and volume, but their price points require augmentation from the private insurances.  Currently, in Pennsylvania, Medicare is paying between 70-85% of private payers.  Medicaid pays on average 66% of that.  Clearly, if the payment is coming from private insurance, prices will be higher than if the payers were all equivalent. 

     Fixed expenses in an emergency room are quite high.  Usually, there is a great deal of square footage that is needed to operate.  Staff expenses are fixed in a set range of the number of patient visits.  Physicians, nurses, aides, physician extenders, registration clerks, housekeeping, financial services counselors, respiratory technicians, radiology technicians, social workers are a few of the myriad positions that need to be staffed around the clock, regardless of the patient volume.  As most businesses know, payroll is frequently a large portion of expenses, as it involves benefits, and tax consequences.   Also, malpractice insurance is necessary for all involved in the emergency room, including the hospital itself.   Another large fixed expense is the equipment necessary for modern medical care, x-ray machines, CT scanners, ultrasounds, MRIs, ambulances, sometimes even helicopters.  Each of these expensive machines requires staff to ensure that they continue to operate at all times.  These purchases can be depreciated on a financial statement, but frequently become obsolete quickly.  The useful lifespan of each generation of machine can be quite short.  Each certification that is required, JCAHO (Joint Commission on Accreditation of Healthcare Organizations), trauma certification, emergency nursing certification, board certification for physicians, is another fixed expense, requiring licensing fees, and personnel time to maintain paperwork.  Mandated electronic medical records require computers, programs, backups, and information technology personnel, also around the clock. 

     Variable expenses could be thought of as supplies, medications and utilities.  However, in the emergency room, many of these variable expenses are less variable than is commonly thought.  Medications that are used for specific purposes frequently need to be replaced because of expiration dates.  For example, a “code cart”, the cart holding medications for reviving a patient who has stopped breathing, has to be constantly up to date, even though it is hopefully not used often.  Once a month, the cart will be cycled and all the medications thrown out.  Even utilities, thought to be variable, are really not in the emergency setting, since all the equipment needs to be kept powered on and ready to go at a moment’s notice.

     If the goal is to deliver quality medical care at a lower price point, there are several things that can be changed in this system.  On the revenue side, equalizing price points between the payers will bring down the costs for private insurers, but may increase the overall spending by increasing Medicare and Medicaid costs.  To decrease medical system costs, ideally, only problems that require all the expensive resources of a fully functioning emergency room would enter.  A system could be put in place to direct less urgent problems to centers with less fixed costs.  Currently, federal law prohibits this.  Hospitals can increase the number of patient encounters to move further from the breakeven point.  There is a practical limit to this, as none of us wishes to be rushed through our emergencies without adequate time and attention.  On the expense side, we must realize that every mandate and requirement added to the system increases fixed expenses that need to be covered.  Malpractice reform resulting in lower malpractice insurance premiums for all parties would decrease expenses.  Under the current system, however, a $50 Band-Aid pays only a small portion of all the technology needed to run a modern emergency room. 

The government wishes to mandate electronic medical records. The price of a mandate comes from my pocket directly. If the government requires a computerized medical record, it is my money that goes to buying it. I have to sign a loan, and pay it back with interest. It is not a cost-free "improvement". If it translated into more income, no one would have to mandate it, we would be lining up to get one. Therefore, if the government is requiring it, it must lose money. Does it improve care? The studies don't back that up. No cost-savings, no improved care. So why the push to computerize records? Who would that benefit?

Hybrids

This has nothing to do with medicine. Just a stray thought.
My Harley gets 60 mpg. A Prius gets 50 mpg. Why is a Prius so eco-friendly, and my Harley is not?

New York Times misses the point

http://www.nytimes.com/2010/04/07/business/economy/07leonhardt.html?hp
Do you think they miss the point on purpose? The second sentence of that article tells the entire story. The federal government wants to set up "institutions" that decide what care is worth it. We already have the medical societies and the university medical centers doing studies to determine the best outcome treatments. This takes a while to establish, but is being done all the time. What people don't trust is the government coming in to decide what is reasonable on a one size fits all plan. The article contradicts itself when it describes patients deciding that more is not necessarily better when given the tradeoffs of treatment, but also describes the public (which is the same as patients, isn't it?) wants everything. What the patient needs is a primary care doctor who stays current on the information available, giving the best advice he can on treatment options and side-effects. Then the patient has the option of deciding what is appropriate for his own case. What the patient doesn't want is a government agency deciding what if appropriate. Who knows what criteria they used to decide your medical care?

I've been insulted. Grievously. And, yes I take it personally.
Dr. Obama has stated that doctors will take out kids' tonsils just because they get paid better. I've been in medicine for 20 years, and grew up in a medical household. The number of physicians I have met who would do procedures harmful to their patients, just for money, could be counted on one hand. Yes, they exist (unfortunately) but we despise them. They are the marginal in our profession, and are treated as such. Certainly the percentage of greedy physicians is much lower than the percentage of greedy, unscrupulous politicians, by far.
Let me explain how the system should work. Children who are sick with a sore throat, as judged by their parents, come in to see the pediatrician. The pediatrician treats them with antibiotics, or allergy medicine or nothing, as he sees fit. If the child keeps coming in with sore throats, he starts looking for other problems. If he decides the child needs a tonsillectomy, he sends the child to an ENT surgeon. The ENT surgeon then decides whether he agrees that the child needs a tonsillectomy or not and if so, does the surgery. Now, the pediatrician DOES NOT get paid for the surgery. He does not get a percentage; he does not get a kickback. The surgeon gets paid for the surgery, but if he does surgeries that the pediatrician did not think was necessary too often, he gets no more patients from that practice. If the parents disagree with the pediatrician or the surgeon, they are free to find another one. If that happens too often, the pediatrician has no practice. Automatic checks and balances.
Do you see the problem with that system? When anyone other than the parent and the pediatrician have control over the interaction, it fails. So when the government wants to control costs, where's the check and balance on their control?

I had a conversation with a doctor in training the other day. She didn't really pay much attention to health care policy, because she is too busy learning what she needs to know to care for children when she graduates. Lovely person, she'll be a terrific doctor when she's done. We talked about health care reform, and the problems of a nationalized health care system. I said something about the government deciding what procedures would be done for which kids, and her response was, "Well, the first time that happens, Dr. (someone she really admires as a good physician) will quit!" Of course he will. And who will be left to care for our children?

The administration made an important speech to the AMA recently about the health care reform debate. I'd like to take the arguments presented in it one at a time. I think one of the major points of the plan being presented is the public insurance option. Obama says that we need a public option for more choice in health insurance. It's not too difficult to see why that argument resonates. Most of us have little choice in which plan we have. Our employer picks our options, and in many cases has only 2 or 3 plans to choose from. Most of the options are from the same 2 companies. In my area, 2 insurance companies have 80% of the insureds. So clearly a lot of us feel we need more choices. But why is our choice so limited? First, why should my employer have any say in the insurance I have? That was born of a previous period of salary caps when "benefits" was the only way to raise pay for workers you needed as a company. It's way past time to change the tax laws so that there is no reason for employers to be involved in insurance decisions. But that still leaves me with only 3 plans to choose from. Why is that? There are over a thousand companies offering insurance in this country. State laws keep me from shopping for insurance across state lines. State laws also mandate what "must" be included in a policy. The effect is to limit my choices. Why not open up competition by eliminating these restrictions? There is no reason for me to buy a policy that covers chiropractic for example, because I'll never use it. But it's been placed in many state requirements. Let the companies and the states involved offer policies tailored to choice. How about a low-tort option like the car insurances offer? I'd sign on for that. Just limiting pain and suffering to $250000 makes a huge difference in malpractice premiums, so let me choose that option to lower my premiums. How about an option to lower premiums by refusing second opinions? Not sure I would sign that, but it should be an option. I don't need insurance that covers maternity anymore. THAT should lower premiums a lot. How much am I willing to pay in co-pays to lower my premium? That would increase more responsible use of services. How about discounts for exercising regularly? I'd sign that one! Nothing like my pocket book to encourage good behavior. This would be real choice. The public option would be a false choice that would end up by limiting all our options. Who would it really benefit?

I keep hearing that the most expensive, inefficient way of providing health care is through our emergency rooms, so that is why we need universal health care. Has no one noticed that our Medicaid population does just that?! Our ER sees patients for colds, hangnails, dental cavities, and bugbites on a regular basis. These patients aren't there because they don't have insurance; they are all covered, and have assigned primary care physicians. They are there, because we don't require an appointment, and we are open 24 hours, and there is no reason NOT to use us. Does anyone really believe that having universal health care will DECREASE the amount of patients using the ER unnecessarily?

Does anyone remember when HMO's first came in? Yes, I'm old enough to remember when they started. There was a study that showed that when you had an HMO, you were 25% more likely to see a doctor. I remember being shocked that it was so low, because my experience was that it was WAY more likely than if you had to pay full price for an office visit. Parents would bring in their children for me to "just check their ears and make sure they're all right for our trip", or "he woke up crying today, and he doesn't usually do that". Then throw $3 in change at the clerk at the desk. Certainly that made it harder for us to give appointments for the children who were actually sick. Now imagine that attitude and that behavior magnified 100X for a nationalized health care system. If it's on the government's dime if you need to see a doctor, what is the barrier? It may end up being the availability of the doctor. Will medicine be overwhelmed by the banal and the impatient? And who decides? Not the doctors, and not the patient......so who?

The dash to national healthcare

This blog is being started because of the current rush to nationalized healthcare. Thru my career, there has always been a push for socialized medicine, from Medicare, to Hillarycare, to Obamacare. It is imperative now to debate the underlying causes and drives for this push, and accept or not accept it based on reality, and to discuss what no one wants to admit.