Corralled in the waiting room

I took my daughter to her pediatrician's office for her shots at five years old. What a madhouse that waiting room was. We got there in time for our appointment but had to wait until forty minutes after the appointment time to be seen. And we didn't even have to see the doctor. The nurse was the one who gave the vaccinations. The waiting room was standing room only. There were people sitting on the floor in the hallway outside the office.

When we were walking to our examination room, we passed by the doctor. He was all smiles and gave a quick hello before going into another room. I don't know how he does it. If it was me, I'd have a big storm cloud over my head virtually all day long working in that environment. That's one reason why I didn't go into primary care. And probably why fewer medical students are going into primary care each year.

So what happens when there is universal health insurance, either by mandate or single payer? Where would all these new patients find doctors who have the time to take care of them? Presumable everybody in that waiting room has health insurance. Would he have to close his practice to new patients if everybody is trying to break into his front door? Would people then have to resort to the emergency room to get their routine care, like the uninsured do now? These are concerns that are not being discussed during this health care debate.

Death of objectivity

The Los Angeles Times is having a fit today about the Facebook poll on whether President Obama should be killed. Using words like "The poll was outrageous" and "The inflammatory poll" the editorial made it clear they objected to the thought of assassinating a sitting president.

"Heated rhetoric is a staple of political discourse, but death threats -- whether real or insinuated -- are not."

But what did their editorial board say back in 2006, when the movie "Death of a President" was released? That film depicted the fictional scenerio of the assassination of President George W. Bush.

"But what exactly about "Death of a President" is controversial? Is it the content of the movie, which its creators describe as a political thriller? Or is it simply the premise itself, as many of its critics say?"

"But the film is complex, restrained and painstakingly careful not to glorify violence (of which there's actually very little). "

Is it any wonder many people don't trust the liberal media? Though news organizations consider themselves objective and fair, they are only kidding themselves. People can see the hypocrisy despite their insistence that they offer nonpartisan coverage.

The AMA Conspiracy

The current issue of Anesthesiology News reports that some people believe there is a more sinister reason the American Medical Association so quickly endorsed the passage of the House health care reform bill (H.R. 3200) despite many doctors' misgivings. AMA president J. James Rohack, MD has publicly stated that the organization's stance on health care reform is to provide "health coverage for all Americans as well as providing stability and security for Americans that currently are insured, including Medicare patients." But to some doctors who are opposed to the public option provision in the reform bill, there is another reason for the AMA's approval. That would of course be money.

The current health care reform bills all preserve the use of CPT codes in physician billings. CPT (Current Procedural Terminology) codes are published annually by the AMA. These codes correspond to every service and procedure performed by physicians. They must be accurately filled into insurance forms for proper reimbursement. Any deviation could potentially limit insurace payments or even result in outright denial. Because the AMA owns the copyright to the CPT, they receive millions of dollars from its publication each year.

According to the AMA's web site, a 17 member CPT Editorial Panel meets 3 times a year to consider updates and changes to the CPT. If a doctor wishes to get paid properly, he/she is forced to buy the new version each year. But that's not all. Because the CPT is so complicated and the changes each year may be very minute, the AMA also sells (from its web site) "CPT® Assistant, a monthly newsletter, CPT® Changes: An Insider's View, an annual publication explaining the intent and use of new/revised procedures/services, CPT® Principles of Coding, an educational primer covering the basic concepts of CPT® coding, CPT® Network, an online service that provides users with expert advice on code use, and an annual CPT® coding symposium." Even the AMA acknowledges how complicated the CPT codes are, but they are willing to help you out, for a price.

So does the AMA really have patients' and doctors' best interests at heart? With only 15% of active physicians among its members, can the AMA legitimately claim to speak for the country's medical interests? Why has the AMA failed to address the concerns of many doctors about the dangers of a public option in health insurance, instead rushing to endorse reform bills vilified by a majority of the population and most doctors? Can the AMA ever attain the clout with physicians that it once did? Can doctors ever regain influence with Congress if they keep splintering into smaller subspecialty groups while the lawyers stand together under the ABA? The passage or failure of health care reform will tell the answer.

Happy Yom Kippur!

I guess that title really isn't appropriate as Yom Kippur is the Day of Atonement, the holiest day of the Jewish calendar. But in our hospital we get the day off. So for us non-Jews who aren't on call, it is a happy long holiday weekend indeed. And what did my wife and I do on this Jewish holiday? We went to eat dim sum, of course.

It's not often we get to eat dim sum on a weekday, when the crowds are smaller as well as the prices. Our older one was in school so that is one less kid to worry about in a crowded restaurant. We got there at 11:30 and the wait was less than five minutes. Once we were seated, the usual orchestral movements of a dim sum restaurant appeared. In a good establishment, the carts quickly come to your empty table. We started picking all the foods we wanted: shau mai, shrimp dumplings, chive dumplings, chicken feet, fried radish cakes, beef meatballs, steamed pork buns, etc. Soon enough the table is overflowing with little dishes. Then we relax and start working our way through them all. One surprise I had on this trip was that my two year old son LOVES chicken feet. I was afraid he would choke on the metatarsal bones in them but my wife taught him how to gnaw away the skin around the bones. He was eating chicken feet like he had been doing it his whole life. They grow up so fast (sniff, sniff).

One by one the little plates got taken away. As the table got emptier, the stomach got fuller. Even though other tempting dishes passed us by, we couldn't look at another one. We were stuffed. This was quicker and better than any western fast food restaurant. When we left shortly after noon, there was already a big crowd waiting in the lobby. (One of these days somebody's going to notify the fire department about the crowds in this place waiting to be seated, especially on a weekend.) Time to think about getting back to work again.

If you are a dim sum lover in the Los Angeles area, you probably already know this restaurant. For everybody else, the place is New Capital Seafood Restaurant in San Gabriel, CA. Google it for their phone number and address. It is on the fourth floor of a large supermarket strip mall.

Is the AMA legit?

During the health care reform debate, the public and Congress seem to believe that the American Medical Association represents the views of physicians in the country. But does it really? There are approximately 900,000 practicing doctors in the U.S. The AMA's membership is a little over 240,000. But that includes everybody from medical students up to retired doctors. According to MedPage Today, in 2005 only about 135,000 practicing physicians belong in the AMA, or about 15% of the total.

When the AMA approved of the passage of the House health care reform bill (H.R. 3200), this was widely publicized as the country's medical doctors agreeing with the need for radical change to our health care system. However, public rifts with H.R. 3200 and the AMA quickly surfaced. Many doctors opposed the public option found in the House bill. They feel this would quickly sink the private health insurance market and herd everyone into a Medicare monopoly with its low reimbursement rates. In fact, in a recent poll, 45% of doctors would consider quitting their practice if the current health care reform bills passed through Congress.

The American Society of Anesthesiologists made a very public appeal to its 43,000 members to reject H.R. 3200 and the AMA. ASA president Roger A. Moore, MD argued that the public option provision would link physician reimbursement to Medicare rates. For anesthesiologists, this is very bad news indeed. The ASA has been trying for over a decade to increase Medicare reimbursements for anesthesia services. On average Medicare pays only 33% of what private insurance pays for anesthesia while other medical specialties receive from Medicare about 80% of private insurance payments. AMA president J. James Rohack, MD responded that the Medicare link provision is not finalized and in fact was left off a competing bill from the House Energy and Commerce Committee.

Is there a nefarious reason for the AMA to approve of H.R. 3200 so quickly? Does the AMA have a self interest in passage of this bill that has nothing to do with compassion for the uninsured? Stay tuned.

Above, a picture of AMA's headquarters in Chicago

Kristen Diane Parker, guilty

In a follow up to a previous entry, Kristen Diane Parker, the Colorado surgical tech who infected scores of patients with hepatitis C, has pleaded guilty to five counts of tampering and five counts of illegally obtaining a controlled substance. She will serve a 20 year prison term for her actions. She had faced a life sentence if she had not accepted the plea bargain.

Apparently some of the victims are not pleased with the deal:

"Hollynd Hoskins, an attorney representing nine Rose Medical Center patients who have tested positive for hepatitis C, said her clients were not happy with the plea deal and are considering civil action against the hospital."

I guess they are going where the money is.

Running Thoughts

Is blogging bad for your health? Maybe just mine. Since I started this blog last July, I've gained nearly ten pounds and added two inches to my waist. I've never been athletic. I reluctantly go to the gym whenever I start getting embarrassed about my weight. Once I achieve my goal, I start slacking off and balloon up again. Thus I've been a yo-yoer my whole life, like Oprah without the billions. But this blog has given me another excuse not to exercise regularly.

Or maybe I'm just a lazy ass SOB who prefers to sit comfortably in front of the computer monitor over sweating it out at the gym. I see my colleagues who train for marathons and triathlons while still achieving a productive work and family life. So what is my excuse? If I'm not careful, I could wind up looking like Marc Andreeson, again without the billions. So tonight I went to the gym for the first time in about three months. It was pathetic. It's amazing how quickly the body deconditions when not regularly trained. I did the most minimal workout ever just so I won't be sore in the next few days and have another excuse for not going to the gym. I only did a little powerwalking on the treadmill and lifted some weights.

But I feel better already. I always feel pumped up after working out. I tell myself I'm going to be a gym rat from now on, no excuses allowed. But life has a way of intruding into these grand plans. I'm just going to have to manage my time better and accept the fact that I have to take good care of myself or nothing else will matter in the long run. If I don't update my blog as often as before, you'll know why. More updates in the future on my exercise program.

Bionic vision

This is one of the coolest inventions I've seen recently. Researchers at the University of Washington have implanted electronic circuits and LEDs into contact lenses. Energy is transmitted wirelessly to the lens, lighting up the LEDs. Still in very early experimental stages, the applications are endless. From video game players to airline pilots to anesthesiologists, anyone who has to look at a computer screen for an extended period of time would find this useful. It's like a heads-up display you find in some car models, where you don't have to turn your head to find important information. Reminds me of science fiction movies like Terminator, where the robot's eyes view complex graphs and numbers while staring down the victim.

Phenergan, bad for your arteries

The Food and Drug Administration has now required a stronger warning label on the antinausea drug Phenergan, or promethazine. This came about because a patient in Vermont received an accidental intraarterial injection of Phenergan in 2000 and subsequently lost her arm. She successfully sued the drug's manufacturer Wyath and received $6.8 million. She complained that Wyath should have placed a stronger warning on the drug's label to prevent the accident. Wyath's position was that the FDA's approval preempted the patient from suing in court. The case made it's way to the U.S. Supreme Court. In a 6-3 decision, the Court ruled that FDA approval does not shield the drug maker from liability.

This raises the question of ultimate responsibility. Is Wyath responsible for somebody accidentally injecting a drug intraarterially? Would any amount of warning have prevented this from happening? Will this stronger warning label prevent a similar incident from happening in the future? I can't think of a single drug that is safe to inject into an artery. Should we put a black box label on all drugs? If an FDA approval does not shield a drug manufacturer from liability of a known side effect, then what's the point of getting FDA approval? The clinic where this patient was injured had settled out of court but of course the attorneys went after the much deeper pockets of Wyath. Wyath has now stopped making Phenergan, one less treatment choice for patients and physicians.

Universal right to legal care

Raymond Clark III, the alleged killer in the murder of Annie Le, the research student at Yale University was seen in court with a new lawyer. His original lawyer, David Dworski, was with him at the time of his arrest. But now, at his arraignment, he has Joseph Lopez and Beth Merkin, public defenders handling his case.

Me thinks somebody did a wallet biopsy and decided this case was not worth his time. Wouldn't it be nice if doctors could abandon their clients (patients) just because they could not afford their care? Where is the universal right to legal care in all this talk about reform? What is more important than fighting in court for somebody's life?

When to know you're working too hard

You know you're working too hard when:

1. The hood of your car is still warm when you leave for work in the morning.

2. You always commute when headlights are required.

3. You never worry about driving through rush hour traffic.

4. The nurses you greet in the morning are the same nurses you said goodbye to the night before.

5. You know the hospital's evening cleaning crew on a first name basis.

6. You use the bathrooms at the hospital more often than your own at home.

7. You can recite the theme cuisine in the hospital cafeteria for each day of the week.

8. The only time you see your children are when you look at their pictures on your cell phone.

9. People comment on how pale your skin looks, and you're not Caucasian.

10. This blog's title makes you feel like a hypocrite.

Patrick Swayze R.I.P.

I think it's finally safe to say that I had the honor and privilege of taking care of Patrick Swayze in the last couple of years of his talented life. He and his wife were the nicest and most down to earth people you'd ever want to meet. When I first met Patrick, I must say I was more than a little intimidated. There on my schedule that day was the name Patrick Swayze. I thought, "No, it couldn't really be HIM." But how many people are named Patrick Swayze? And there in preop was the man. I started introducing myself by saying "Hello Mr. Swayze." He was so kind; he said I could just call him Patrick. At the time he looked exactly like in his movies, though of course a bit older, but instantly recognizable.

He and his wife never asked for special privileges. Frequently they were at the hospital by themselves without the usual Patient Advocate tagging along. But of course we treated him like the superstar that he was. He was very open and we could ask him anything. He talked about his old movies, the injuries he sustained when doing his own stunts, his love of dance and theater. He said people frequently confused him with Kurt Russell, though I found the resemblance remote at best. Plus the onscreen personalities were completely different.

Any discussion of his movies would start with Dirty Dancing and end with Ghost. While Dirty Dancing made him a star, I find his character bedding an underage Baby a little disturbing to contemplate in this day and age of rampant child molestations. His opus was definitely Ghost. In it he was funny, sensitive, aggressive, sympathetic, and charming. That's quite a trick to pull off when you're playing a murder victim. Who couldn't laugh when he was chanting "I'm Henry the Eight I am..." over and over again, torturing poor Whoopi Goldberg into accepting his demands. And who had a dry eye at the end of the movie when, spoiler alert for the two people on this planet who haven't seen the movie, Patrick's character was summoned to ascend to heaven. I'd like to think that's what Patrick Swayze saw in his final moments on earth. Farewell Patrick Swayze. You were a part of my growing up and your death only reinforces what we should hold dear in life: family, friends, integrity, character.

France's advantage in medical costs

Last week in the Prescriptions blog of the NY Times, there was an interview with Victor G. Rodwin, a professor of health policy and management at the Wagner School of Public Service at New York University and co-director of the World Cities Project, International Longevity Center-USA. He extolled the virtues of the French health care system and how everybody can get affordable health care with little rationing, no waiting lines, high quality, blah blah blah. But what stood out for me was this exchange:

Q. Doctors in the United States complain about having to practice “defensive medicine,” ordering unnecessary tests just to cover any potential charges of negligence later on. Is that an issue in France?

A. No, this is not an important issue in France for two reasons. First, since 2002 there has been a national no-fault compensation scheme. Second, the number of attorneys per capita in France is far smaller than in the United States.

Gee, wouldn't that be a dream in this country, a no-fault medical compensation plan. That and fewer trial lawyers. For all those who advocate a European style health care system here, this is probably one of the biggest hurdles to overcome. Imagine how much less a doctor or hospital can charge a patient if malpractice insurance didn't cost so much. Though people have repeatedly said actual malpractice awards are a tiny percentage of health care costs, the expense of practicing defensive medicine is large though difficult to estimate. Virtually every doctor every day practices some form of defensive medicine, whether it is getting that extra CBC that looks almost precisely like the previous day's or that extra chest X-ray with no discernable difference from before. All in the name of defensive medicine.

Why isn't Congress and the president looking into this potential savings bonanza? Has anybody looked into the political discussions in France in 2002 that led to this no-fault compensation system? Did French lawyers just roll over and let this happen or was there some payback involved? If physicians in the U.S. didn't have to pay $100,000 a year or more in malpractice insurance then maybe physicians' fees wouldn't be so high. If fewer tests and procedures can be ordered and still get the same high quality medical care the savings to the system will be enormous. Why can't we do this? Silly question--it's the trial lawyers' belief in the patient's right to sue the system. Seems like if we had a no-fault system here, then the patient or his family couldn't exact the revenge they seek by suing the hell out of the doctor and hospital. Even if the case is without merit the lawyers turn their greed into client advocacy by demanding compensation. So there you go, one main reason why we could never achieve the economic savings of other countries.

Medicare perversion

The NY Times details the struggles of a young kidney transplant patient. Apparently Medicare is all too willing to pay for a kidney transplant at a cost of over $100,000 but is only willing to pay for antirejection medications for 36 months if you're not over 65 years old or disabled. This poor patient thus lost her first kidney when she became unemployed and couldn't afford her drugs. Now she has a second Medicare paid kidney transplant but the clock is ticking on her eligibility for government paid medications. The cost of antirejection drugs is $1000-$3000 per month but the government would rather pay the much higher cost of a transplant than the lower cost of medications. This system points to one of the reasons Medicare is going broke. Arguments have been made in a previous editorial that in a rational world, we would pay more to keep younger patients healthy instead spending unlimited sums to maintain old age. But that is the power of older voters and the AARP.

Though I sympathize with the article's subject, I couldn't help but think something else is going on that isn't reported. The article said her "downward spiral" began when her dog chewed up her hearing aid, leading to the loss of her job then the loss of her transplanted kidney. But I thought she took her job precisely because it offered health benefits. Didn't her insurance cover hearing aids? Doesn't Medicare disability cover hearing aids? And even if they didn't couldn't she just go down to Walmart to get one and put it on her credit card? Couldn't her grandmother help her out with getting new hearing aids before catastrophe happened? What's her job worth to her? Does she just expect everybody to do everything for her instead taking the initiative to get her own hearing aid? Curious.

Health insurance exchange

Confused by the talk of health insurance co-ops or health insurance exchanges? I know I am. And I consider myself a reasonably intelligent person (though my wife frequently disagrees). Here is a pdf from the House Ways and Means Committee on their vision of a health insurance exchange that is in HR 3200. And here is a cautionary tale about California's insurance exchange that was in place in the 1990's until being closed down ignominiously in 2006. It seems that Massachusetts learned heavily from California by requiring every resident in the state to purchase health insurance, thus widening the risk pool to allow insurance to be more affordable. I hope this illuminates some light on the dense language of insurance exchanges.

Speaking of which, I don't understand the opposition that some people have in requiring everybody to buy health insurance. Everybody who owns a car is required to own car insurance. Everybody who owns a house is required to buy homeowner's insurance. The government is even willing to subsidize middle class tax payers to purchase health insurance. So why is it unreasonable to require purchasing health insurance?

Wells Fargo's new executive vacation home

The LA Times today reveals that an executive from Wells Fargo bank was living at a beachside mansion in Malibu that had been foreclosed. The former owner was a victim of the Bernard Madoff Ponzi scheme. After he moved out the neighbors noticed new people living at the $12 million house, holding expensive parties over the summer. License plate tracing showed the new residents were the family of Cheronda Guyton, a senior vice president for foreclosed commercial properties at the bank . When real estate agents inquired about showing the home for prospective clients, the bank said the house was not for sale. The bank said it is investigating the situation. Just adds more fuel to the fire of government bailout and big business haters.

9/11 Conspiracy

The actor Charlie Sheen has openly discussed his belief that the 9/11 terrorist attacks were a conspiracy set up by the U.S. government. But what's most amusing, or disturbing, about this article in the LA Times is the comments that follow. Seems like this feeling is pretty widespread, particularly here on the west coast. I can't tell whether the commentators are left wing Bush hating liberals or right wing government hating conservatives. The dorky picture of Mr. Sheen in the article is quite funny. I presume this is supposed to be the LA Times reaction to Mr. Sheen's theories.

Planning for end of life

President Obama tonight also made a reference to the lies being told about the creation of "death panels," as Sarah Palin so memorably puts it. The initial plan was to reimburse physicians for talking to patients and families about planning for end of life care. I thought, great, we will get paid for something we already do. Then politics got in the way. Now we won't get this little bonus for doing something that's right and which we do anyway.

If you don't think talking about end of life care and Advanced Directives is important, read this article in the NY Times. It's a heartbreaking story about what can go wrong when everybody involved tries to be a hero to the detriment of the patient.

You lie!

This is the shout out from Republican Rep. Joe Wilson (S.C.) when President Obama said the health care reforms would not pay for treatments for illegal immigrants. I couldn't have said it better myself. If he wants universal health coverage, the emphasis should be on universal. Treating illegal immigrants is a mandate set by the federal government. We physicians do not ask for a passport or Social Security card before taking care of a patient. Yet if the government refuses to pay for this mandatory treatment, guess who eats the costs, physicians and hospitals. The costs of this unreimbursed mandate then gets passed along to the rest of the population. The people are not dumb. They know that illegals have to be medically treated if necessary and just saying the reforms bills do not provide money for this treatment doesn't mean somebody doesn't have pay for it. If an illegal immigrant gets into a trauma situation, or has complicated labor and delivery, or needs hemodialysis, are we supposed to just stand there and watch them die? Even without a federal mandate physicians would treat these patients. I think that's what the government is counting on, our generosity and moral obligation to do this and not raise too much of a fuss.

On the local talk radio this afternoon after the speech, the talk show host was interviewing a newly elected Democratic Congresswoman in L.A. In a city with millions of illegal immigrants, he asked her, how can the government promise not to pay for the care of these illegals and yet demand that they be treated like everybody else? The Congresswoman hemmed and hawed, trying to change the subject by saying there are plans in the bills to help poor families obtain health insurance. But of course she had to concede that these subsidies would not apply to illegal immigrants. So even Congress haven't a clue about how to resolve this huge problem. But what would you expect when the senators in charge of making a "bipartisan" health care reform bill include Max Baucus, Chuck Grassley, and Olympia Snowe, all small state senators with hardly any local illegal immigrant issues.

As for the rest of the president's speech, I think Mr. Obama has been a reader of my blog (ha ha). He mentions moving malpractice cases out of the court system and into arbitration panels composed of medical experts. Suprisingly he doesn't even have to go through Congress for that. Apparently this can be accomplished by executive order. If that's the case then what's been taking them so long when we've had nearly 28 years of conservative presidents in office? We'll see how soon President Obama can defy the trial lawyers and create this new system.

The president also endorsed setting fees for "Cadillac" high cost health plans. As expected, the unions are opposed to this, even though most of their rank and file would not be affected by this fee. The insurance companies are already threatening to pass along this cost to everybody else, of course. But this would help pay for the new universal coverage plus make it just slightly more fair for people who have to buy their own health insurance and don't get a tax deduction out of it, like moi.

Overall nothing too surprising in the speech. I think it's a little too late to change minds though. And we still haven't seen any reconciliation bill between the House and Senate so it's too early to decide whether one should be outraged or rejoicing. We'll just wait and see.

Better anesthesia slogans

The American Society of Anesthesiologists' official slogan is "Anesthesiologists: Physicians providing the lifeline of modern medicine." Boring. I thought I could think of a few better ones.

Anesthesiologists: Physicians providing a legal supply of propofol.

Anesthesiologists: Got milk? You betcha!

Anesthesiologists: Because Michael would have wanted one.

Anesthesiologists: We would have asked for cash up front.

Anesthesiologists: Physicians providing surgeons excuses for bad outcomes.

Anesthesiologists: When Lamaze only takes you to 4 cm.

Anesthesiologists: I slept with mine today.

Anesthesiologists: Physicians providing narcotic wishes and propofol dreams.

Anesthesiologists: There is no substitute.

What do you think the ASA should do with its slogan?

That sinking feeling

A bad day at the fire department in Los Angeles. Do fire fighters call 911?

Why the rest of the world hate us.

Some recent LA Times articles detail the insanity of the consumer based economy in the U.S. in the last few years. These should give pause to researchers who think consumers always think rationally when making lifestyle choices. It is these kinds of decision-making that is causing this prolonged recession here and worldwide.

A lengthy article about people down in the dumps in Las Vegas shows this with perfect clarity. One woman, who is an assistant for a homebuilding executive, made $28 per hour. With that income, and a "small inheritence," she felt secure enough to buy a Mercedes S500. She and her husband, who worked at a golf course, bought a $417,000 home and paid thousands of dollars for remodelling. At her home she has a pool with FIVE waterfalls. Now she has been laid off and is currently unemployed.

Another article discussed the hardships California state employees face when they are furloughed for several days a month due to budget cuts. One couple, who made a combined $70,000 a year working for the workers' compensation insurer, suddenly had difficulty paying their $3,200 per month mortgage. So they rented out that home and then "took a town house" whatever that means. Well their tenant couldn't pay his rent so the couple couldn't make their mortgages on the original house and the town house. Their car was repossessed at their place of work. Now they live with their families.

Excuse me? What are these people doing spending so much money on this level of income? Who can justify buying a Mercedes S500 on $28/hr? I make several times that income and I still won't allow myself to trade in my trusty 2003 Honda Accord. And what idiot banker (I bet it was Countrywide but pure speculation) would allow a $3,200 monthly payment with an income of only $70,000? That is over 50% of their monthly gross income. Is it any surprise the United States is the largest debtor nation in the world, if not its entire history? In the future, cash (maybe the euro or the yuan) will be king again.

Public vs. Private

Industries with "public option" alternatives

Mail delivery: U.S. Postal Service vs. FedEx and UPS

Education: Public schools vs. Private schools

Personal Protection: Police Department vs. Private Security

Health Care Systems: VA and Medicare vs. Private Health Insurance

Media: Public Airwaves vs. Cable and Satellite TV

Roads: Public Roads vs. Private Tollways

As you can see, having a public option does not necessarily mean the end of private industry. However it does mean the private insurance industry will have to do a better job, with lower prices and better customer service, or people will flee to a government run health care program. A public option should be available for services considered so essential they are considered a universal right such as education and protection. Certainly the public services listed above leave a lot to be desired (don't get me started on all the post office jokes). But a public option is not supposed to represent best in class. It is just a fall back that provides the minimum level of competence to get a job done. That leaves the door open for private industry to do a better job and offer a profitable alternative. Industries that say they can't compete against a government run service aren't trying very hard.

Advocating for universal health insurance

Some of you long term readers may wonder if I've had a change of heart after reading my last blog advocating government run health care or the public option. Especially if any of you read the entries in August where I compare government insurance to cash for clunkers and the French health system. In those cases the objection was to government incompetence estimating the cost of a federal program requiring an ever increasing tax rate to fund it or a poorly run system that requires long waiting times for patients to see a doctor and poor reimbursements to physicians.

But is the private health insurance industry doing a better job? Patients have procedures delayed if not denied while waiting for approval from insurance companies. Our premiums go up every year while their CEO's enrich themselves and their shareholders. According to Highline Data Analysis, the total health insurance industry revenue in 2007 was over $400 billion, having risen 8.7% over the previous year. The health reform bills in Congress attempt to cap the cost at $1 trillion over ten years. Let's say we are especially generous and want to give universal health insurance at a cost of $2 trillion over ten years. That is only $200 billion per year. If only half of the health insurance industry survives and the money instead goes to the government for unversal care, costwise we would still wind up even.

Or if nearly the whole industry is subsumed by the federal government and the premiums that otherwise would go to the insurance companies instead goes towards a tax on everybody to pay for health insurance, like the current Medicare tax withholdings, then the feds will have over $400 billion per year to expand coverage. That's $400 billion for opening new hospitals and health clinics to alleviate long lines and waiting times. The time and money wasted in dealing with multiple insurance companies for reimbursements and treatment approval is a savings that is difficult to quantify but real. The peace of mind people have knowing they will have insurance regardless of employment or pre-existing conditions should also factor into the cost equation.

Ironically some of the biggest objectors to a truly universal public option are the unions, normally a stalwart of liberal Democrats. One of their biggest accomplishments is the employer covered health benefit. The unions have been the most vocal about taxes on health benefits, even for "cadillac" plans costing tens of thousands of dollars per year, never mind that those plans are usually reserved for the reviled corporate executives. If universal coverage existed, the need for corporations to spend billions on employee health insurance disappears and the unions' raison d'être is diminished.

So there you have it. The key is that everybody should have peace of mind when they get sick, not worrying about denials of treatment or policy cancellations by their insurance company. Subsidizing people to buy insurance will not change the industry's current practices. As physicians we should all be out front advocating for our patients. The money is already there; the nation is already paying more than the cost of universal coverage through our insurance premiums. The cost is also carried by the writeoffs doctors and hospitals make because they can't collect on treatments for the uninsured. If this sounds wishy-washy, well it's my blog and I'll say it if I want to.

Where's the panic button?

I get called to start an emergency laminectomy for a patient who has a large mass compressing his spine, causing paralysis and urinary incontinence. The background story is the patient showed up in the ER two days ago complaining of back pain and leg weakness. He was discharged from the ER accused of being a drug seeker. The patient has a friend who is a physician who tells him to return to the ER the next day when the symptoms got worse. When he is wheeled into the ER this time, he gets an MRI which shows spinal cord compression and the neurosurgeon is quickly contacted. The surgery goes well but the patient still can't move his legs. Only time will tell how much recovery he'll have.

While I was doing the case, I kept thinking about the Happy Hospitalist's algorithm for how doctor's think. I think this case will lead down the arrow that points to the PANIC button, don't you think?

Public option is good according this conservative

What's so great about having a choice in health insurance? The more I think about this, the more reasonable a government run national health insurance plan like Medicare seems. Don't get me wrong. I'm a diehard conservative who's watched his fair share of Fox news and grew up in Limbaugh country. What I don't understand is why many physicians are so upset over the thought of the Feds offering a public option if not outright taking over the health insurance industry.

We physicians have been complaining about the insurance industry for years. They arbitrarily deny reimbursement for procedures performed due to some asinine paper work technicality. They deny approval of recommended treatments, usually from some minimally trained clerk taught in the art of denials. The overhead of office staff just to fill out insurance forms and calling for approvals is wasteful. The insurance companies pay their executives millions of dollars a year while scrimping on reimbursements in order to maximize shareholder returns.

As users of health insurance know, the policy holders also lose out. We pay thousands of dollars a year for insurance but the instant we use it, the premiums go up. There are well documented cases of insurance companies cancelling policies after a policy holder gets sick. If you've ever gotten a prescription from a doctor, you may be denied health insurance in the future. Insurance companies have left policy holders destitute after cancelling policies during the middle of expensive medical treatments.

By comparison, Medicare is available to everyone, with the only eligibility criteria being age and citizenship. Sure Medicare reimbursement fees would be laughable if it wasn't so low, especially for anesthesia, but at least the government pays. In a field like anesthesiology, the reimbursement from patients with private insurance can be perilous. Patients ask the surgeon if their insurance will cover the procedure but maybe don't think to ask the anesthesiologist. If the anesthesiologist doesn't take the same insurance, the patient is on the hook for hundreds if not thousands of dollars in anesthesia fees. Thus the anesthesiologist frequently doesn't get paid at all.

Think of the savings in overhead if there is only one insurance company to deal with, Medicare. No more wasted staff time filling out dozens of different insurance forms and calling different companies. That savings alone in time and money could almost replace the lower reimbursements. Also no more headache of telling an anxious and sick patient he cannot be treated because his insurance company has denied the procedure.

There's a reason many of the protesters at these town hall meetings are the elderly. They love Medicare. They don't want any changes to it. It gives them the freedom to see any doctor they want, anywhere they want, whether it's in Florida, New York, or Boise Idaho. They don't have to deal with insurance representatives and their unhelpful call centers. Do physicians give different treatments to patients just because they have Medicare? No. We offer the best treatment based on scientific principles, not insurance status. So where is this fear of rationing under Medicare?

So I think doctors' reflexive dislike of a public option for health insurance is misguided. How can we justify a for-profit industry that interferes with how we treat our patients? Under the Hippocratic oath we are supposed to do no harm. But when the industry denies treatments and forces doctors to drop their patients because the patient no longer has insurance, isn't this harming the patient? It is time we rethink our self-serving dislike of Medicare and think about the greater public good. As far as the costs, I've mentioned before that perhaps the U.S. needs to spend a lot more on health care. Until we can change the prevalent attitude that it is abhorrent to place a price tag on a human life in this country, everybody is just going to have to keep shelling out more money but that is a whole different subject.

Julie/Julia Project

I saw the movie Julie & Julia a couple of weeks ago. For those who are not familiar with the movie, it revolves around the stories of Julia Child and Julie Powell. Everybody know Julia Child. Unlike most reviewers I found Julie Powell's story more interesting. Hers is the tale of a bored cubicle worker for the Lower Manhattan Development Corporation who hears complaints from the victims of the 9/11 attacks all day (this is the first time I've seen a movie mention the emotional turmoil of 9/11 victims and it is still uncomfortable to listen to today). To get out of her misery she decides to start a personal project to take her mind off her office misery. On the advice of her husband, she starts a blog called the Julie/Julia Project. She chronicles her journey through Julia Child's Mastering the Art of French Cooking, cooking all the recipes in the book within one year.

The movie seems to give more screen time to Julia Child but I wanted to know more about Mrs. Powell so I've been reading her original blog. It is fascinating reading. She starts out as a complete novice, having never even eaten an egg up to that point in her life. You'll have to read the blog to understand. But soon she is making statements like "...artichokes no longer seem such a pain in the ass as they once were. I just broke off the stems and then the leaves, chopped off the top of the cone and trimmed the green bits. I didn’t have lemons (this is getting to be a trope), so I rubbed the cut placed with vinegar, and it seemed to really help with the discoloring. I made a blanc of flour, vinegar and water, and boiled the trimmed artichokes in them for forty minutes or so, then cleaned the chokes out. Easy."

Pretty quickly she's expertly discussing the differences between Bechemel and Mornay sauces, Sauce Robert vs. Sauce Brune vs. Sauce Perigueux. But this blog is not just a list of recipes. It's her sense of humor that drives her wide readership. You have to be a little thick skinned to get through some of her profanities. But every once in a while you'll come across gems like this "I’m rolling lamb like a lonely rancher’s son. Eew. I mean like a champ." Priceless.

As a new blogger myself I'm in awe of her style, the casualness that comes across the internet. She goes into details of her marriage to her intrepid husband Eric. He is almost saintly in her descriptions, hardly ever complaining about eating close to midnight every night while she pulls together another three course French meal. He shops for her all over Manhattan to get her ingredients, spending their savings down to nothing. And he cleans all the dishes after these late night feasts. In the entries in spring of 2003 she frequently mentions the start of the Iraq war. The night the Iraq war started I was cramming for my oral board exams the following morning so the memories of that night are very vivid. It's funny to read about what other people were doing at that exact same time.

I have not completely finished reading the Julie/Julia Project yet. I haven't even read most of the comments that accompany each blog entry. But like most books, it is far better than the movie that came from it. Each blog is short so it's easy to read if you have a few minutes of free time. Highly recommended especially if you've seen the movie and want a little more background information.