Halloween candy economic indicator

Another year, another trip around the block with my daughter for trick or treating. This year she was Snow White, another princess costume brought to you by the great corporate conglomerate called Disney. I noticed this year that more houses had their lights off than before. Therefore we had to walk a longer distance to get candy. The candy was also of lower quality. During the good times people were passing out oversized bars of chocolate. This year it is mostly hard candies or minibars of chocolate. Some people even gave out homemade cookies, just like the old days. I ate those, as the official family food safety inspector.

I get the feeling the economy around here is not quite as rosy as the news media is portraying. With so many houses turning kids away from this Halloween tradition and the cheap candy being passed out, I think there are still many people not doing well. Handing out free candy is one way to cut back. By turning out all their lights, it also saves on their electricity bill. I long for the day when we get giant sized bars of Snickers again. Then I'll know that we are doing well as a nation.

Medical marijuana, a new line of work

If doctors' incomes fall substantially after the passage of ObamaCare, there appears to be a promising new line of work. In the LA Times, a columnist writes about his visit to a doctor to get a prescription for medical marijuana. Now you have to know that in Los Angeles there are close to 800 marijuana dispensaries throughout the county. I see several on my way to and from work; the telltale sign being a green cross over the front door. And thanks to President Obama, the feds will not be raiding any of these places anymore since Californians have legalized medical marijuana.

The writer of the article is initially concerned that he may be turned down, that he isn't sick enough to warrant a prescription for marijuana. When he goes to the "doctor's" office, he talks about his long history of back pain. The doctor "examines" him visually, never laying a hand on him or even getting out of his chair. When asked about the anatomy of the back, the doctor confesses he has no clue, he is a gynecologist by training. And just like that, he is given a recommendation that he can take to any dispensary for legal marijuana.

The great part for doctors is that the writer hands over $150 in cash to the clerk at the end of the ten minute exam. No complaints about copays. No sob stories about how he can't afford his medications. In this office all the patients willingly pay cash for the visit and dutifully fill out their prescriptions ASAP. This could be the greatest line of business for physicians since Botox.

Doctors are not a systemic risk

President Obama proposes giving every senior citizen in America a $250 bonus check because, gasp!, they will not get an increase in their Social Security checks due to lack of inflation.

Congress wants to extend the $8000 first time home buyers tax credit into next year, possibly including all home buyers.

Legislation is likely to be approved to extend unemployment benefits for another 20 weeks for the long term unemployed.

There is not a single major medical tort reform legislation in the works during this health care reform debate.

GMAC is likely to get another $2.8 billion to $5.6 billion from the government because it can't stay solvent and nobody would be able to buy the GM cars the government is manufacturing for the benefit of the UAW without it.

The health insurance companies are likely to get millions of new subscribers as everyone will be required to have health insurance under the health reform bills.

Doctors will face a 21% cut in Medicare reimbursements next year because Congress doesn't think losing access to physicians poses a systemic risk to our country.

Carnegie Hall followup

Here's a follow up to my blog about the enormous salaries of stagehands working at Carnegie Hall in New York. In today's New York Times, they interview Clive Gillinson, the executive and artistic director of Carnegie Hall. He justifies the stagehands' six figure incomes by stating they work over 80 hours per week. Anything over 40 hours is 1 1/2 to 3 times base salary. The men (they're all men) also don't take much vacation time off so that gets paid back in income. Their salaries also include a share of money off of recordings made at the Hall (nice).

The men are responsible for setting up 800 performances a year in the three stages within Carnegie Hall. He goes on to say that hiring extra crew would not lower the total crew expense to the Hall. Plus since it is the same performer rehearsing in the morning and then playing for the evening performance, it doesn't make sense to have a different crew for day and night work. Their salaries aren't that beyond reason when compared to other stages in New York, where the average stagehand at Avery Fisher Hall makes $290,000 per year.

They describe the stagehands existence as rather tortured. According to James Nomikos, a former supervisor of the Carnegie stagehands, “They sacrifice their family life, their time. By the time their careers are over, they’re broken, with all that lifting.” Hmmm.

So how many of you are out there working 80+ hours per week, sacrificing family life for your meager red-taped, overscrutinized, hassled existence without making $500,000 a year like a Carnegie Hall stagehand?

Insurance coverage for anesthesia

Here is an interesting comment (#25) on the Prescriptions blog of the New York Times. I copied it in its entirety.

Rein in the anti-competitive practices of the anesthesiologists

One of the overlooked issues in the entire health care debate has been the fact that most anesthesiologists who work at hospitals choose not to “participate” in the health insurance programs that the hospital accepts. So, wise consumers can choose a “participating” hospital and also select a surgeon who “accepts:” their insurance but find that they will have to pay the anesthesiologist whatever is charged. And, they cannot elect to bring in an independent anesthesiologist. All who work at a hospital either are in one large group practice or choose to accept the same insurance programs.

Therefore, the only insurance coverage for the anesthesiologist will be “out of network” coverage. This requires a “first dollar” expense each year and then only reimburses about 70% or “usual and customary” charges — regardless of the actual bill. This means that an operation that, is in-network for the hospital and the surgeon, might result in a bill from the anesthesiologist for over $5,000. Of this amount the patient might have to pay $3,000 or more.

The simple solution, in the sprit of cost containment, full price disclosure and anti-monopoly practices, is to require all medical procedures done in the hospital, by any personal, be covered by the same set of insurances. So, if a patient inquires of a hospital, “Do you accept the XYZ medial plan?” an affirmative answer will mean that all doctors, nurses, lab technicians, and anesthesiologists will be covered by the same reply. People and firms who do not agree to accept the fees of that plan will not be allowed to work at the hospital. They can choose to work elsewhere.

The reason this is critical, is that once admitted to the hospital, a patient does not get to choose which anesthesiologist will participate in the procedure. One meets the anesthesiologist minutes before being rendered unconscious. The anesthesiologists who practice at the hospital have a monopoly on all the anesthesiology business and should be regulated and required to “accept” the insurance programs that the hospital itself accepts. If they do not like the requirement rates of the insurance programs accepted by the hospitals where they work, they can seek changes or they can choose to work elsewhere.— steven epstein

While this rant sounds like it came from a disgruntled surgeon, it could just as easily have come from a patient suddenly faced with a large anesthesia bill they were not expecting. I've had patients ask me whether I accepted their insurance. If it's Medicare, that's a no brainer. But unless I call my business office, I really couldn't tell you which insurance companies, other than one or two offhand, that our group accepts. I've never had a patient write me a nasty letter afterwards saying they felt deceived by our insurance acceptance so I presume they were fine with our insurance coverage.

What has been the experience of anesthesiologists out there in regards to this issue? Are we being needlessly criticized for not accepting the same insurance policies as the surgeons? Would we then be beholden to the surgeons and the hospital to accept some insurance contracts but not others thus limiting our ability to negotiate a fair rate of reimbursement?

I love this bumper sticker.

Anesthesia Shit List

Sorry if the title sounds so crude, but that is a pretty succinct description of the list of surgeons who have angered me so much that I refuse to work with them. Luckily our group is large enough that I don't have to work with these people ever again if I don't want to. Some of these surgeons have such bad reputations that only a select few anesthesiologists will even step into their OR. And we're all grateful to them for walking into the lion's den every day.

Why do surgeons like the ones on my ASL continue to hold positions at the hospital? Despite all the lecturing by Human Resources about how we all should treat each other with respect, some individuals seem to be above the law, untouchable and unimpeachable by all. They either bring a lot of well paying patients to the hospital. Or they have a special skill set that would be hard to replace if they went to a different facility. Or they have support from higher ups in the hospital system.

I'll always remember one of my early cases with one surgeon. He was about to do a thoracoscopic procedure. After I intubated the patient and positioned the double lumen tube, I turned away from the patient to draw up some drugs from my cart. When I turned back, the surgon had lifted the patient's torso and turned him lateral, with NOBODY supporting the head. The head was just dangling in midair, flopping around while that carefully placed double lumen tube was in danger of falling out of position, if not out of the patient entirely. He obviously had no respect for the patient, me, or my job. So he was the first surgeon on the ASL.

Through the years, I've had many opportunities to work with mean or bad surgeons. There was the surgeon who screamed "Get the F*** out of my OR!" when he started manipulating a broken extremity and the patient moved about ten seconds after I had placed an LMA into a patient. He of course thought it was my fault the patient moved before the patient was completely under. A**hole. Automatic ASL. Another surgeon arrived forty-five minutes late for his first case of the day. When asked why he was late, he response was "I'm calling the anesthesia director. I want another anesthesiologist NOW!" ASL. Another surgeon, thinking that I was his anesthesiologist even though the OR schedule had changed overnight, physically grabbed me by the arm and said "Let me introduce you to your next patient" even though I had just finished seeing my real patient. When I told him I was not his anesthesiologist, he got verbally abusive. That's one of the few times I yelled back at another physician colleague. I let him know very loudly, and I'm sure within earshot of his patient sitting in preop, that I thought he was a sh***y surgeon and nobody f***ing likes him in the OR. He said he never wanted to work with me again and I said I'm glad the feeling's mutual. ASL.

There are some surgeons who are just marginally on the ASL. But I'm sure with more exposure to them, they will become full fledged members of the list. Maybe that's when I'll know when to retire, when every surgeon in the hospital is on the ASL, then I'll know it's time to go.

How much did you make last year?

This from Bloomberg.com:

Dennis O'Connell, the man responsible for moving around props at New York's Carnegie Hall made $530,044 last year in income and benefits. Four other crew members made an average of $430,543. Artistic and Executive Director Clive Gillinson made $946,581.

What do the stagehands do to earn this much money? According to the report, the crew "move equipment in and out of the hall, prepare the three stages for performances and operate audiovisual and sound fixtures." If that doesn't sound like the responsibilities fit for a six figure income, you forget that they have a trump card, the International Alliance of Theatrtical Stage Employees. The union shut down Broadway for three weeks in 2007, resulting in losses of millions of dollars. (Shrek the Musical just announced it is closing because they couldn't make a profit with gross weekly receipts of over $500,000.) Since nobody else in the world appears to be capable of doing the same tasks as this stage crew, management felt they had to appease the union with this ridiculous salary and benefits package.

How much do you owe on your medical school loans? Maybe you can get a handout from the Carnegie Hall stage crew.

Malpractice insurance disclosure too great a burden for lawyers

In a hilarious post from White Coat's Call Room, the Texas Supreme Court has asked the State Bar of Texas whether it would be too great a burden for lawyers if they had to disclose to their clients whether they carried professional liability insurance or not. Mind you, this doesn't mean the lawyers have to spend thousands of dollars and actually pay for insurance. This is just about whether they should tell their clients if they carried it. The outcry among the legal community is deliciously ironic. The complaints range from the inability of small practices to buy expensive insurance to having insurance will invite more frequent and bigger lawsuits. You can go to the post to read the complaints.

The Congress that can say no

Well it eventually had to happen. After a decade of relentless spending by the federal government, Congress has finally decided that an unfunded mandate for a lobbying group was too much and they voted it down. When the music stopped, the group that was left without a chair was...doctors. This afternoon, Congress didn't approve an AMA supported bill, S1776, that would have prevented a 21% cut to Medicare reimbursements for next year and abolished the SGR system that has driven down physicians' incomes every year. Though it was a bad bill, just the thought that physicians, of all the special interest groups, would come out on the losing end is galling.

The Republicans in the Senate decided that they are the party of smaller government and fiscal discipline after all. This despite the trillions of dollars spent in the last ten years for two wars and the new Medicare drug entitlement program. They unanimously voted against S1776. They just couldn't stand the thought of spending another $250 billion over ten years ($25 billion per year out of a $2 trillion federal budget) for doctors unless some way was found to pay for it.

The Democrats came to the conclusion that enough was enough. They had to draw the line somewhere on federal spending. This after spending trillions in the last year on bailouts for: banks, insurance companies, brokerages, auto companies, auto suppliers, car dealers, home builders, unions, etc. The Blue Dog Democrats decided to live up to their reputations as "conservative" Democrats and said no to more spending without limits.

I wouldn't be too concerned about the welfare of doctors though. We won't get our Medicare reimbursements cut; Congress will issue their annual "doc fix" to make sure we continue to subsist off the crumbs of the federal budget while a more permanent solution is found. The reason they will do this is not because they are afraid of angry doctors and the AMA, which has proven itself to be a paper tiger. No, it will be because they are afraid of all the elderly voters and the AARP, who will be up in arms if they have trouble finding a physician to take care of them. Doctors, the biggest losers so far during this health care debate.