Archive for the ‘Policy’ Category

Healthcare insurance but no healthcare access

Wednesday, February 13th, 2013

Lucy VanPelt The Doctor is INCalifornia doesn’t have enough doctors to provide healthcare to newly “insured” patients under the UnAffordable Care Act.

California state senator Ed Hernandez asks “”What good is it if they [state citizens] are going to have a health insurance card but no access to doctors?”

Wait. Health care insurance doesn’t mean that patients will have access to health care? Where have I heard that being said for more than 3 years?

The government is going to give patients their medical “insurance,” but access to physicians is limited by government policies, payment cuts, and administrative red tape — which are driving many doctors from the primary care business and are, in effect, rationing care to patients.

California’s grand plan is to allow physician assistants, nurse practitioners, optometrists, and pharmacists to provide primary care services. I liked one of the commenters who said that he went to see the doctor, but was referred to the janitor who gave him a bag of medications for $5. These other health professionals and their organizations seem to naively think that the patients they will treat only require management of simple medical problems. In reality, most patients have multiple interrelated chronic medical problems that must be managed together.

Take diabetes, for example. Will it really be cost effective to have an optometrist manage a patient’s diabetes and perhaps monitor the patient’s diabetic retinopathy while the patient still has to be assessed and monitored for diabetic nephropathy, diabetic wounds and wound care, diabetic neuropathy, the increased risk of heart disease, oh and the impotence that often accompanies diabetes? Should the optometrist prescribe Viagra for a diabetic patient with heart disease or not?

If the optometrist refers the patient to a bunch of physicians to make those decisions, then the government has just created an additional layer of bureaucracy which will cost more money.
If the optometrist just blissfully monitors the patient’s glucose levels, prescribes insulin and doesn’t regularly evaluate the patient for diabetic complications, then the patients are receiving government-sanctioned poor medical care. That should make the trial lawyers happy … if the optometrists have insurance for the millions of dollars in damages when bad outcomes occur.

These health care providers are begging to get in over their heads and we need to let them do so. The medical establishment should really stop fighting this idea.

Allowing governments to implement a system that reduces access to doctors, increases complexity in medical care, and that will likely increase bad outcomes will eventually create patient outrage with government officials who adopt the idea.
We all should be part of a team, but not everyone is able to play quarterback.
I predict that these types of policies, if implemented, will ultimately increase the demand for physicians.

Unfortunately, the underlying problem is that most of us will be expected to pay more in “taxes”, insurance premiums, and other fees … for less medical care.

But remember that everyone will be insured, so things will be OK.

In anticipation of hate mail from nurse practitioners, physician assistants, optometrists, pharmacists, and possibly even Lucy VanPelt expressing outrage at my unprofessional stance because there aren’t any studies showing worse outcomes in medical care provided by those with less medical training, I’ll quote a comment that I posted on KevinMD’s site a couple of months ago in response to a nurse practitioner who asserted that he had “the same ability to provide patient care [as physicians] based on the evidence.”

You’re right about all the studies, I’m sure. In fact, I bet there aren’t any studies showing that treatment rendered by grade schoolers is any worse than that rendered by nurse practitioners, so next down the line to help patients save money will be gifted grade school student phone advice and then Shaman Skype toddlers with their magical rattles of health. Goo goo ga ga.

I don’t care how good you think you are, if you can’t pass a doctor’s board exam, you shouldn’t be [independently] treating patients, so lose the ego. Actually, the law says that you can treat patients, but you damn well better tell the patients that you aren’t a doctor and then let the patients decide whether they trust you with their lives. But lose the ego, anyway. It’s a team sport and you don’t get to be the captain just because you think you’re better than everyone else. When there’s an emergency in the hospital, no one goes running to find the nurse practitioner.

Social Media Fair Play

Wednesday, February 6th, 2013

JustADoc commented about a Yahoo News story concerning an obstetrician who posted a mini-rant on Facebook about one of her patients always being late. The obstetrician’s post said

“I have a patient who has chosen to either no-show or be late (sometimes hours) for all of her prenatal visits, ultrasounds, and NSTs. She is now 3 hours late for her induction. May I show up late to her delivery?”

After the post became widely distributed, some people called for the doctor to be fired. Others defended her as a good physician.

The hospital assured all their concerned patients that the hospital would “reinforce their high employee standards.”

The Yahoo news story created a fake retort from the obstetrician’s hospital (I looked up the hospital’s Facebook page to make sure it was a fake retort) saying

Mercy Hospital St. Louis Facebook

When I look back at my post last week about State Medical Board investigations for what are deemed to be inappropriate online posts, I started thinking.

If people agree that doctors’ livelihoods and the money and time they spent on their medical educations should be threatened because of a potentially offensive statement, shouldn’t that be the standard for everyone else as well?

An offensive statement is made by a hospital, investigate the administrative staff. Maybe fire them and blackball them from further jobs in hospital administration.
Politicians make an offensive statement, investigate them, too. Maybe they get fired and prevented from working as a politician. Same for CEOs, federal workers, journalists, editors, public employees, judges, lawyers … everybody.
Anyone receiving government assistance gets the same treatment. Make any offensive statements and you get investigated. If the statements are offensive enough, you’re on your own. You are no longer eligible for government assistance.

Sound outrageous?

I agree … in all cases.

Art Kellermann Rand Rant

Saturday, January 26th, 2013

One of the posts in my Twitter feed was a re-tweet of something asserted by Dr. Art Kellermann (@ArtKellermannMD). Dr. Kellermann is a distinguished physician. He is the Director and VP of Rand Health. At one point he was a professor at Emory University, but apparently does not practice emergency medicine any more.
Dr. Kellermann’s tweet said the following:

Kellerman Quote

Dr. Kellermann’s tweet references an editorial article that he wrote in the Annals of Emergency Medicine titled “Waiting Room Medicine: Has It Really Come to This? The article was from 2010, so I’m not sure what prompted him to tweet about it in 2013, but nevertheless, the article at least seemed pertinent … until I read it.

The assertion in Dr. Kellermann’s tweet was a quote from his article and was reportedly supported by a 2001 brochure created by the UK Department of Health (.pdf file). The context of Dr. Kellermann’s assertion in the article he wrote is as follows:

The ED is more than a clinical setting; it is a “room with a view” of the best and worst of modern health care. In the United Kingdom, a crowded ED is considered a telltale sign of a poorly managed hospital. If that perspective ever takes hold on this side of the Atlantic, things will change. Until then, it is up to us.

Things will change if our perspective changes. Until then, change is up to us.

What a feel-good nonsensical assertion of nothingness.


Pressure to Admit

Monday, December 3rd, 2012

We were away for the weekend, but in a restaurant, I caught glimpses of this segment on 60 Minutes called “The Cost of Admission.” Couldn’t hear the conversations in the restaurant, but luckily CBS posted the entire report online. If you didn’t see it, you really need to watch the video and/or read the transcript.

In summary, 60 Minutes spent a year investigating irregularities in hospital admissions. Administrators at Health Management Associates and at EMCARE (one of the national emergency medicine contract groups) were accused of putting pressure on emergency physicians to admit at least 20% of patients that came to hospital emergency departments.  For Medicare patients, the “benchmark” for admissions at one hospital was allegedly 50%. The 60 Minutes expose also included spreadsheets showing comparisons of different physicians’ admission practices and text from e-mails saying such things as “I have been told to replace you if your numbers do not improve.”

HMA held a conference call disputing the allegations and stating that they “take all allegations regarding compliance very seriously.” HMA allegedly had outside experts review the data (not the medical records?) and the experts determined that “the data simply do not support the allegations.”

Now HMA is being investigated by the US Department of Justice for Medicare fraud. I predict that HMA will make a large settlement with the government to drop all charges (without admitting wrongdoing, of course) and that things will return to business as usual shortly thereafter.

With things like this, I can’t really blame patients for thinking that medical care is “all about the Benjamins.”

Patient satisfaction metrics are creating quite similar incentives with physicians. How long will it be before people wake up and see how much fraud that the satisfaction scores are causing?

What About MEN?

Tuesday, November 13th, 2012

Retired emergency physician/family physician writes letter to editor of Minnesota newspaper stating that insurance should pay for birth control for all women because otherwise rich women could afford to pay for birth control and poor women would be forced to have unwanted children or “back-alley abortions.

I’m not really sure how someone too poor to purchase birth control is going to be able to purchase insurance so that they receive free birth control via a government mandate, I’m also not sure how people too poor to purchase birth control are going to be able to afford to pay for a “back-alley abortion” on such limited income.

That’s OK. No one ever said that mandates have to make sense or have logically justifiable reasoning to support them.

He’s missing the simple solution to this problem.

Everyone should just be able to pick up as many condoms as they want at any federal building for free. Go drop off your mail, grab a handful of condoms. If government is going to mandate it, the government should pay for it.

Think about it: No worry about adverse side effects from “the pill.” No discrimination against males who don’t get to share in the free handouts. Plus, consider the added bonus of decreasing the spread of sexually transmitted diseases.

If they were smart, they could even sell political campaign ad space on the packaging. Then again, if that happened, people might get confused and think that the pictures are showing where to put the condoms.

Spidey Senses

Sunday, November 11th, 2012

This was one of the patients I submitted for Nurse K’s Dr. No BS contest. By my calculations, I was the unofficial winner in said contest, but I don’t want to brag.

The case involves what one of my old mentors used to call his “Spidey Senses“. Something just doesn’t seem quite right. You can’t figure it out, but something tells you that you need to dig deeper. Most of the time, the Spidey Senses are just a false alarm and you end up performing what some people deem an “unnecessary” test. Hey, even Spiderman wasn’t always right. But in a select few cases, listening to your Spidey Senses (and sometimes ordering “unnecessary” tests), can help to make an important diagnosis.
Psych wonks may use the term “cognitive dissonance” to describe the Spidey Senses. I’m leaving the post title as “Spidey Senses” because prolly no one would read a post about cognitive dissonance and because I couldn’t find a cognitive dissonance picture.

A 50-year-old man came in with R shoulder pain for about a week. He was already going to a pain clinic for low back pain, and that day he went to the pain clinic for a re-check of his shoulder pain. The doctor at the clinic prescribed him Neurontin for his shoulder pain and the patient came to the emergency department because “that stuff doesn’t work.”
He said that his shoulder pain was bothering him so much that now his right side was killing him, too. In fact, he wouldn’t lay back on the bed because of the pain. His wife sat next to him helping to support him while he was sitting as he slumped over to the right side and didn’t answer many questions because he was in too much pain. The patient’s wife did most of the talking.
I have to admit that my initial impression of this gent was tainted by the whole pain clinic story.
Maybe he was coughing from his pack-and-a-half day smoking habit and strained a muscle in his chest wall.
Pain from a gallbladder attack can cause referred pain to the right shoulder when the inflamed gallbladder irritates the diaphragm. Maybe he’s having biliary colic.
Maybe he had a pneumothorax.
Maybe he was doing something he shouldn’t have been doing and injured his shoulder, but he didn’t want to tell me.
But come on, now. Pain so bad you can’t even talk to the person trying to help you? Call me skeptical.


Obama vs. Romney vs. Honey Boo Boo

Sunday, September 9th, 2012

By Birdstrike M.D.


Once again, our upcoming election will have great impact on future health care policy.  Obamacare will either be kept intact, repealed or altered.  This will have great impact on patients, physicians in general, and especially Emergency Physicians.  By whom they choose to lead us, the electorate will decide whether treatments are rationed or not, and if so, to what extent, by whom and on what basis.  They will decide whether doctors are free to choose what tests to order, and if so which ones, how many and for what reasons.  Also, they will influence physician salaries, by choosing the leaders who will determine Medicare and Medicaid reimbursement, which generally lead with reimbursement cuts that private insurers follow.  Our electorate will determine our malpractice liability by choosing our leaders who will either, strengthen, weaken or ignore tort reform.  They will influence which charting systems we are required, or not required to use, given that Obamacare has already written into law penalties for failure to implement electronic health record use.  By whom they choose to lead us, the electorate will influence how much we are, or are not burdened by regulations, and whether these regulations will be logic based, or cumbersome and irrational.

The choice of the electorate will affect which pay for performance measures we and our salaries are subject to.  Likely, they will also influence which form of patient satisfaction surveys we are or are not subject to.  Also influenced, will be our overall workload depending on whether patients are adequately insured, by which doctors and in which settings.  This will influence who is most, or the least burdened by the overall shortage of healthcare providers, and whether or not the millions of newly insured will end up in primary care physicians’ offices, shunted to emergency departments with growing wait times, seen in specialists’ offices or remain uncared for.  How informed, or uninformed our electorate is, particularly as it relates to health care policy, will affect the health of our patients, our livelihoods as physicians, not to mention the health of our families and ourselves as patients.

Since the end our nation’s two major party conventions, it caught the attention of several major news organizations that on any given night of the week of either the Republican or Democratic National Conventions, that both parties faced stiff competition for viewers from the new and controversial TV show on TLC called “Here Comes Honey Boo Boo,”  which TLC describes on its website as a show where a “six-year-old pageant sensation proves that she is more than just a beauty queen.” As said by the child’s own mother, June Shannon on ABC News, “We are a little redneckish, and we live in Georgia and that’s what people do in the country — get muddy and have fun with the family.”  In the first episode they take part in the “Redneck Games,” bob for pigs feet and take part in a “mud pit belly flop.”  Although fortunately the overall viewership of the conventions was greater according to ABC News, this show did draw more viewers than Fox News’s coverage of the Republican National Convention on at least one night and tied the ratings of the Democratic National Convention during Bill Clinton’s speech.  Does anyone know where Honey Boo Boo stands on health care?

Apparently, a large part of our electorate would prefer to watch a show like TLC’s “Here Comes Honey Boo Boo” over either convention.  Whether this is more of a reflection on our political parties, our electorate, our “Democracy” or (hopefully) none of the above, I am not sure.  However, two months before an election where we will choose a President, seat our entire House of Representative and 1/3 of the U.S. Senate, that will have a huge impact on future health care policy, I think it is worth discussing how informed or uninformed, and how engaged or apathetic our electorate is about the health care issues at hand.  Their decision will affect our patients, our health, our work environments, our salaries, and countless details of our health care system going forward.  It is our responsibility as physicians to educate the public on this part of their vote and its potential consequences.

Have we done our job as physicians to educate our patients, friends and co-workers on the issues at hand and how important this election is?  Have we come to grip ourselves, with how much this current election will affect the lives of our patients, our families, as well as every aspect of our profession?  If the answer to either question is no, then between now and Tuesday, November 6th 2012, we have a lot of work to do.

Which did you watch, the Republican Convention, Democratic Convention, or “Here Comes Honey Boo Boo”?




Choosing Wisely – Good Medical Practice or Prelude to Rationing?

Saturday, September 8th, 2012

EP Monthly has an important Pro-Con debate between ACEP President David Seaberg and EP Monthly founder Mark Plaster about the “Choosing Wisely” program.

Choosing Wisely is being pushed by the ABIM Foundation as a way to get specialty societies to label certain tests as “unnecessary” or of questionable benefit.

I side with Dr. Seaberg in this argument.

I disagree with the concept some people advance that we need to essentially “do it to ourselves before someone else does it to us” (see the comment to Dr. Seaberg’s position). Reasoning like this is how physicians and patients have lost much of the control of the house of medicine. Read through the news and look at the emphasis on reducing the amount of “unnecessary” care. Just last week, the Washington Times published an article about how the Institute of Medicine stated that we waste $750 billion each year in health care. How could anyone disagree with reducing that which is “unnecessary”? It’s a great sound bite. But as Dr. Plaster notes in his article, the devil is in the details.

How do we define “unnecessary”? A pregnancy test in a male patient is “unnecessary.” No way to justify its use. But other tests which seem to have little clinical utility may be deemed “necessary” for non-clinical reasons. A CT scan may only infrequently show the etiology of a patient’s syncope, but some doctors may believe the CT scans are “necessary” to avoid accusations of improperly evaluating a patient or to prevent being sued for missing a rare neurologic cause of a patient’s syncope. If we want to decrease the amount of “unnecessary” testing, we need to address all of the reasons that such testing is performed. Why doesn’t Choosing Wisely change the preamble of its campaign to include: “The following tests are medically unnecessary and no type of professional or legal liability should ever be imposed upon physicians for failing to order or perform them …”?

I question whether the ties that several ABIM foundation trustees have to the Obama administration (hat tip to A Line of Sight) will affect the mission of this project.

Finally, many of the groups listing “unnecessary” testing in the Choosing Wisely campaign are making their directives at other specialties. Radiologists are telling emergency physicians not to order so many CT scans. Neurologists are telling emergency physicians not to order CT scans for migraine headaches. Unless those specialists are going to come to the emergency department, evaluate the patients, and follow their own recommendations, they have no business telling other specialties what to do. Easy to point fingers when you have no skin in the game.

We need to reduce the amount of testing performed in this country, but I still think that the best way to do so is through deregulation and free market principles. If patients want to pay for a test with little clinical validity, they should be able to do so. They should be able to have the test done ten times if they want to pay for it.
Patients should be able to make an educated decision as to whether they want a have a test performed. And physicians should function as advisers to the patients in this regard, not gatekeepers who deny testing.

In this respect, I predict that Choosing Wisely just won’t work for its intended purpose and it will likely be used as a first step toward rationing care – especially care that ends up with “normal” results.

Unnecessary Testing

Wednesday, August 22nd, 2012

Real patient encounter …

A 22 year old guy comes to the registration grabbing his chest. He’s having palpitations and chest pain.

He’s a pack a day smoker, has no family history of heart disease, and was out late the prior evening partying. So when he woke up, he was dragging a little. He had to be at his construction job in an hour, so he drank a “Monster” energy drink. When he got to work, he still felt tired, so he drank another “Monster” energy drink. That’s when the palpitations and chest pain started. He was anxious and felt a little short of breath, too.

The EKG from triage showed a mild sinus tachycardia of 106. No arrhythmia. No ischemia. His physical exam was completely normal except for his anxiety and his elevated pulse. He got an aspirin and some Ativan.

A half hour later, he wasn’t feeling any better even though his pulse was in the 80s.

Now everything points at this guy being acute “Monster” caffeine overdose. It was suggested that he be discharged with a prescription for Ativan and an order to lay off the caffeine. But because he was still symptomatic, he got an entirely unnecessary cardiac workup. His second EKG was normal sinus rhythm and still showed no ischemia. His CBC, chemistries, cardiac enzymes, and urine drug test were all normal.

Oh, and his chest x-ray showed a complete collapse of his left lung.

The problem with labeling testing “unnecessary” – even though the tests may be normal most of the time, they aren’t normal all of the time.

Where do we draw the line between what is and is not “unnecessary”?


This and all posts about patients may be fictional, may be my experiences, may be submitted by readers for publication here, or may be any combination of the above. Factual statements may or may not be accurate. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail me.

Political Quote of the Day

Thursday, July 26th, 2012

Maybe we should have started with you at the very beginning, talked to the physicians before they started writing a 2,000-plus-page bill that many of them [politicans] didn’t read, yet passed.”

Republican Rep. Scott Tipton, commenting about the Affordable Care Act during a House Small Business Committee meeting last week which showed how “physicians have reached a tipping point” due to overregulation by Congress and insurance companies.

Dr. Louis McIntyre does a very good job at putting things into perspective during the included video interview. Not bad for an orthopedist … ;-)


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