Wednesday, September 9, 2009

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.

Tuesday, September 8, 2009

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?

Sunday, September 6, 2009

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'ĂȘtre 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.

Saturday, September 5, 2009

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.

Wednesday, September 2, 2009

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.