Voices of Medicine by Del Meyer, MD
Jan/Feb | March/April | May/June | July/Aug | Sept/Oct | Nov/Dec
|The impact of prayer on recovery, and deciding whether to stay with Medicare.|
Emily Dalton, MD, discusses "Science and Intercessory Prayer" in the November 2006 issues of The Bulletin, published monthly by the Humboldt-Del Norte County Medical Society.
'Intercessory Prayer Ineffective!' touted the headlines in the medical periodicals when a major study on intercessory prayer and recovery from cardiac surgery was published in the American Heart Journal. The study looked at about 1800 post-op CABG patients and assigned each to one of three groups: 1) receiving prayer after being informed that they may or may not be prayed for, 2) not receiving prayer after being informed that they may or may not be prayed for, and 3) receiving prayer after being informed they would be prayed for. The complication and mortality rates were monitored. The authors concluded that the prayer had no effect on complication-free recovery from CABG, but that the certainty of receiving intercessory prayer was associated with a higher incidence of complications. Well, that doesn't sound good. It's hard to imagine how knowing you are being prayed for could increase your likelihood of post-surgical complications. In fact, the authors could think of no possible explanation for the results, and postulated chance as the most likely reason.
I think this study has some major limitations. The underlying assumption, which is not stated, but clearly implied, is that prayer should work in a simple 'ask and you shall receive' manner. This is a very immature approach to prayer, akin to a young child who asks God to grant him a new bicycle. Most people who pray do not expect instant, specific wish gratification, yet this does not deter them from praying nor does it detract from the value and importance of prayer.
The benefits of prayer may be hard to measure - they may occur at varying times and may affect the recipient, the person doing the prayer (stress reduction, lowered blood pressure), or the world at large. Prayers come in many various forms, including supplication, praise and worship, undefined, requests for self-transformation and so forth. One can pray for acceptance of the will of God, such as when Jesus prayed, "not my will but Thine be done" prior to his crucifixion. Some people pray without understandable words, and leave it a mystery as to what their prayers may be about - even to themselves. I don't think one can conclude much about the overall value of prayer from one study looking at one outcome from one type of prayer.
"Here is the real paradox: Belief in God is supposed to require a leap of faith. If you could prove the effectiveness of prayer, then belief in God would not require faith and would thus invalidate the initial premise. So, in a sense, the results of this study confirm what we know about God, that belief in God requires faith, not proof. To reiterate, faith is about belief I proof. Science is about belief based on proof. These two are like yin/yang opposites, and this is why using science to study religion doesn't work well..."
The entire article is at www.humboldt1.com/~medsoc/images/bulletins/NOVEMBER%202006%20BULLETIN%20for%20web.pdf.
Opt out of Medicare?
David Goldschmid, MD, President of the San Mateo County Medical Society, focuses on "Medicare's Web" in the SMCMA Bulletin.
The current concern to most physicians about Medicare is that Medicare reimbursement rates are not keeping up with practice costs as costs continue to rise. This leads one to consider changing one's Medicare status from a participating physician to another category. Are there any economic advantages to becoming a nonparticipating physician? Does it make sense to opt out of Medicare?
Recently we have heard several politicians informing us that Medicare's current reimbursement rates are acceptable as proven by classic economic indicators. They quote statistics that show a gradual increase over the past few years of the number of physicians who participate in the Medicare system. In this column I will outline the alternatives for physicians, and as you will see, the usual economic principles governing trade do not apply to Medicare. The options for physicians who treat the elderly are very limited.
Medicare recognizes three categories for physicians:
This category is the most familiar. These physicians accept Medicare's allowed charges as payment in full for all of their Medicare patients. Medicare pays 80 percent of these charges directly to the physician and the patient (or supple-mental insurance) must pay 20 percent. If the patient has supplemental insurance, Medicare automatically forwards medigap claims to the appropriate carrier for payment. Medicare pays participating physicians 5 percent more than nonparticipating physicians. Participating physicians are included in Medicare directories. Medicare carriers process claims of participating physicians more quickly and provide toll-free claims processing lines.
These physicians may decide on a case by case basis whether to accept assignment or to bill their patients more than the Medicare fee schedule. There are federal laws limiting what these physicians may charge. The effect of these laws combined with the 5 percent reduction provided in Medicare regulations have a net effect of allowing these physi-cians to charge 9.25 percent more than participating physicians. The payments go to the patient and must be collected from the patient.
These physicians do not participate in the Medicare program at all. They may treat Medicare patients using private contracts with the patients and may charge without the limits imposed by federal law. These physicians may not submit any claims to Medicare for a two-year period. Their patients may not be reimbursed by Medicare, or a supplemental insurance carrier, for any item or service furnished by the physician that would have otherwise been covered by Medicare had the physician been participating. It seems unlikely that any but the most wealthy Medicare-aged patients would accept this.
Several other principles are worthy of mention. The first is that participating physicians may only change their status to nonparticipating during a short 'open enrollment' period. Second, the government has shown its willingness to aggressively prosecute nonparticipating physicians for repeatedly violating the assignment agreement. Third, contracts between patients and opted-out physicians are complex and may require legal review. Finally, rules for treatment of emergencies are completely different, causing confusion.
So it seems that opting out means that you have basically decided not to treat any Medicare patients. Becoming a nonparticipating physician means you can increase your charges by a meager 9.25 percent in exchange for significant possible collection problems. The choices suggest that the only recourse we have to the dilemma of falling reimbursement is to fight the political fight to improve reimbursement or to limit access to optimize the expenses-to-cost ratio of running a practice. Once again, we need to stick together.
The complete article is at www.smcma.org/Bulletin/BulletinIssues/Oct06issue/President.html.
|A new tack on Medicare payment, electronic prescribing errors, a dim view of transparency.|
Kamelgarn, MD, discusses “Medicare Pay for Performance” in the January issue of The Bulletin of
the Humboldt-Del Norte County Medical Society
the 800 lb. gorilla, is about to strike out in new directions. As recently reported
in the New York Times, the 109th Congress, in a last minute flurry of
legislation, approved a change in Medicare reimbursement, that not only will not cut
physicians’ reimbursements 5.3% as originally intended, but will actually increase
their pay by 1.5% — if they provide quality care as defined by the
will qualify for the 1.5% increase if they report data on the quality of care: for
example, how often they use a particular drug after a heart attack, or control blood
pressure in patients with diabetes. On the surface this is a good idea.
talking about employing evidence-based guidelines for medical practice for years, and
in those areas where there have been a lot of studies (blood pressure and diabetes,
for instance) it is easy to draw up guidelines that all practitioners should follow
to practice good medicine. And it is true, that in many areas of medical practice,
there is a consensus of what the proper practice is.
most of what we do is not backed up by a hundred double blind studies that
unequivocally point us in the right direction. And since there is so much controversy
in how we deal with a variety of conditions, who’ll be the arbiters of what good
medical practice is — a government bureaucrat that wouldn’t know a CT from a
4-legged cat?; a committee? How will the data be collected and assessed — a series
of electronic check boxes where the questions are so poorly worded that they’re
impossible to figure out? Do the physicians have to hit a benchmark of 100% for all
of their patients with the particular condition to qualify for the extra money? How
much extra time and effort, i.e., money
will the individual physician have to spend in order to obtain his or her
The entire article appears at www.humboldt1.com/~medsoc/images/bulletins/JANUARY%202007%20BULLETIN_for%20web.pdf
Emily Dalton, MD,
Prescribing: A Help or a Hindrance? in the December 2006 issue of The Bulletin of
the Humboldt-Del Norte County Medical Society
alert’s top story from 8/17/06, reported that the Institute of Medicine urged all
prescriptions be written electronically by 2010. I agree, but I don’t think the
reduction in errors will be as dramatic as they hope. They cited facts: such as
medication errors are among the most common medical errors; that they harm 1.5
million people, and cost more than $3.5 billion annually. They stated that the
problem is so serious that the average hospital patient is subject to one medication
error per day. Causes for these errors included unexpected drug interactions,
confusion over similarly named drugs, bad handwriting, drugs given to the wrong
patient, and patients not understanding how to take the medication. Electronic
records may help with some of these — such as handwriting, but not with others,
such as patient comprehension or drugs dispensed to the wrong person…
“I decided to
try electronic prescribing. By and large it has been fun and effective when it works
(which it does most of the time) and patients like it. The set-up I use involves a
small device called a pocket computer. You can use other devices like advanced cell
phones, Treos, Blackberries or personal digital assistants, but I chose a pocket
computer because it has the most memory and processing capability…
“I have yet
to be convinced that electronic prescribing will result in error reduction. I still
get calls about mistakes from the pharmacists, but they are mistakes of a different
nature. They are never due to poor handwriting, but at times my unsteady hand has
selected the wrong name from my patient list and I’ve accidentally sent over the
right prescription but for the wrong patient. (The laxative prescription error was
probably the most embarrassing such incident). Pharmacists have called to ask if I
really meant to prescribe a gallon of Dimetapp, or if I really meant the dosing to be
every hour instead of every day. These are not mistakes one would ever make on a
traditional written prescription, but are very easy to do when you are pointing and
selecting from various options listed in close proximity on a computer menu on a very
The complete article can be found at www.humboldt1.com/~medsoc/images/bulletins/DECEMBER%202006%20BULLETIN%20for%20web.pdf
Moris Senegor, MD, editor of the San Joaquin Journal of the San Joaquin County Medical Society, wrote in the Winter 2006 issue on “Whether You Like It or Not...transparency is here!”
the last decade hospitals have developed elaborate Quality Departments, measuring
various parameters of their care both locally, and against national databases. The
trend first hit the field of cardiac surgery, which lends itself easily to objective,
mathematical analysis of outcomes such as mortality, complications, hours spent in
ICU, numerous physiological parameters and more. The Society of Thoracic Surgeons
(STS), created a national database reflecting averages, against which any hospital
could measure their results. It has functioned well and allowed for adjustments in
perceived weak areas, as well as cross-communication between different hospitals. For
instance an obscure hospital in Pennsylvania has outshined its brethren in rapid
extubation after open-heart surgery, and found itself transformed into a mecca for
those interested in improving their early extubation statistics. Our Stockton St.
Joseph’s Hospital sent a high level delegation of surgeons, anesthesiologists and
nursing staff to Lankenau Hospital in Wynnewood, PA for a fact finding visit, and has
since made efforts to adopt their practices…
“Why such an
intense effort for one detail of a multitude in services offered? Because CMS, the
government branch overseeing Medicare and other health policy has issued an edict
that this be done. Soon they plan to change the way they pay hospitals by rewarding
the top 20% in such statistics with higher reimbursement. With a multimillion dollar
per year carrot dangling in front of their faces, hospitals are enthusiastically
creating the infrastructure to make Herculean efforts in improving care for the
this all mean to us, and where is it headed?
with, it is obvious that the parameters currently measured are not comprehensive in
covering all areas of care provided by full service hospitals. Therefore those that
do well in pneumonia, cardiac services, and diabetes will be identified as “the
best”, and rewarded; never mind that their record in obstetrics, neurosurgery, or
orthopedics might be dismal. The government promises to correct this defect in due
course by measuring a more comprehensive set of parameters…
burgeoning problem that this new high stakes game ushers in, is the issue of honesty
in reporting. The gargantuan financial incentives will induce some to lie and fudge
article can be found at www.sjcms.org/magazine/Winter%20Quarter,%202006.pdf
|Not-so-humble physicians, thoughts of a 1,999-year-old, and problems in the ER.|
The Harvard Medical Alumni Bulletin has published
“The Seven Deadly Sins.” This is from one of them, called “Vanity Fair.” by
Peter Klass, MD. It appeared in the California Society of Anesthesiologists’ CSA
Bulletin , Winter 2007. See www.csahq.org/pdf/bulletin/issue_15/Klass_064.pdf
for the entire article.
“Tell physicians you’re writing an essay about doctors and pride, and they immediately start to snicker. One doctor friend launched into his favorite joke: How many medical students does it take to change a lightbulb? One — to stand there and wait for the world to revolve around him. Several others offered anecdotes — the arrogance of a physician who doesn’t bother to learn the names of non doctor colleagues, the rudeness of a doctor who never returns calls, the boorishness of a doctor who leaves his dirty dishes in the conference room.
“I protested, a little weakly, that character is more complicated than that. Those doctors may simply be plagued with a weak memory, or poor social skills, or bad manners; it wasn’t fair to interpret everything as just more evidence of the massive medical ego. But these were all doctors telling the stories, and, truth be told, they were more than a little self-satisfied in the telling—they were, each and every one of them, profoundly proud of having a keen eye for overly arrogant colleagues.
“The issue of pride — and the perception of pride — permeates medical practice. You could call it doctors’ besetting sin. It’s part of almost every cliché about our behavior — and misbehavior. I can think of two jokes right this minute about doctors and our overweening pride — one is completely unprintable, while the other opens with a fellow making it up to heaven. While the recently deceased is standing at the Pearly Gates, St. Peter points out a bearded gentleman strolling by in a long white coat. ‘Look!’ St. Peter says. ‘There goes God. Sometimes he just likes to play doctor…’”
The same CSA Bulletin contains a spoof called “Laughing Gas: The 2,000-Year-Old Anesthesiologist,” by Kenneth Y. Pauker, M.D., Chair, Division of Legislative and Practice Affairs, Associate Editor.
apologies to Mel Brooks and Carl Reiner.
“Recently I was privileged to interview with Dr. Methuselah Z. Heffenweisser, an ancient man of healing, who is here in Southern California to promote his book, ‘How To Be Weiss Without Really Trying.’ Reported to be 2,000 years old, Dr. Heffenweisser also claims in his book to be the one to give the first general anesthesia.
“KP: Dr. Heffenweisser, welcome to Orange County. It is a great honor for me to meet you after hearing for so many years of your exploits around the world.
“MZH: Thank you so much, sonny. It’s just great for me after all my travels all over the world to make it to your California Riviera, although I must say that I have often layed out in da true Riviera, and diss, my son, is no Riviera. And where are the oranges?
“KP: Oh, the oranges … Well, doctor, Orange County has changed. You’ll have to go to Florida now for oranges, but I’d like to ask you a few questions about your amazing life. So if I may, I’d like to ask the question that is foremost on everyone’s mind. How could you possibly be 2,000 years old?
“MZH: Two thousand years old? What are you talking about? I don’t know who told you that. NO, NO, NO, and NO! I’m not 2,000 years old!!
“KP: You’re not?
“MZH: Two thousand years old?! Look at me, sonny. Do I look 2,000? Come on! I’m not going to be 2,000 until next summer!
“KP: So you are 1,999 years old?
“MZH: In years, dat is correct, but inside beats da heart of a 28-year-old man.
“KP: OK, then. Everyone would like to know how you have lived so long. Would you say that to stay young, you must be young at heart?
“MZH: A young heart, yes!
“KP: So it’s really about one’s attitude and one’s enthusiasm?
“MZH: Who knows? Who cares? I had a heart transplant two years ago, and dey put in da heart of a 28-year-old man. Actually I had it done in India. Very economical. No waiting on lists. Done right in my hotel room, very convenient…”
To read the entire spoof, please go to www.csahq.org/pdf/bulletin/issue_15/laughgas_064.pdf
Mohammed Arain, MD, discusses “EMR, ER Calls and Reimbursement” in his President’s Message, in the April issue of Vital Signs, published by the Fresno-Madera Medical Society. It is at www.fmms.org/pdf/Apr07_VS_FINAL.pdf.
“There is talk all over about emergency room coverage by physicians and specialists. Increasingly, a number of hospitals have had to reinvent methods to keep their ERs open. Some hospitals have tried to close their ER, but due to loss in revenues from government-funded programs, they are forced to keep them open.
“Emergency room patients used to be a source of support to new physicians to help them build up their practice. This has now become more of a liability. Patients who come to the ER are either using them as a free walk-in clinic or they are noncompliant and seek care only when their illness becomes serious. There are patients who are acutely ill and need help, but ER patients are no longer a stabilizing source for physicians’ practices.
“Taking the ER calls puts more strain on physicians’ already limited income and time. Many hospitals have recognized the need to work with the physicians and accommodate their needs, but even in this day and age, some hospitals have no guidelines for taking ER call. Some require staff to take ER call, irrespective of their age or health condition and they refuse to relocate some budgets and work with physicians. There are no other professions where one is forced to provide free service. One has to have some returns to survive.
“Health insurance companies like any other businesses, have always kept up with the profits. The best buildings in any city are either banks or insurance companies. They keep increasing insurance premiums, keep cutting the benefits and keep on reducing the reimbursement to physicians. Since the rise of HMOs, the standard of payment has been Medicare or Medi-Cal. BCCMP and healthy family programs pay even less than Medi-Cal. Even PPO insurance compares their payments with Medicare and Medi-Cal.
“Office overhead is increasing every day due to increased paper work, more calls and more requirements by insurance carriers. Patients demand prescriptions and procedures which require pre authorizations. Just to get authorization for needed procedures takes hours of calls. A full-time secretary is needed to have this done with no returns. Malpractice insurance carriers keep increasing their premiums and do not hesitate to drop clients depending on their own discretion.
“All insurance carriers want electronic billing. The cost to set up can be up to $100,000, and the system can become obsolete the moment it is installed. The New York Medical Society is helping to fund physicians to set up an electronic system. Our California Medical Association is also seeking funding sources, including insurance companies, to assist California physicians in setting up their system.”
|A complication of volleyball, when religion meets medicine, the draw of surgery centers.|
Broken Nose, Big Problem
David Goldschmid, MD, the President of the San Mateo County Medical Society, writes about "When Doing The Right Thing Seems Wrong" in the society's April Bulletin.
"It is not always easy to do the right thing.
Sometimes we know what the right thing is, but either choose not to do it or find
ourselves in a position where we cannot. Sometimes we just do not know what the right
"My daughter recently broke her nose playing
soccer. She belongs to a Boston-based HMO associated with Harvard Medical School. She
called her primary physician hoping to get a referral to a surgeon who is able to fix
her nose. Instead, she was offered an appointment to see her primary care physician -
in two weeks.
"The medical director of the clinic explained
that it was his policy to require that all referrals go through the primary care
physicians, but there was a shortage of them, resulting in excessive delays. My
daughter was advised that she should go to the ER if she thought she should be seen
within two weeks.
"Off she went to the ER, where the resident
physician ordered a CT scan of her face. Apparently, having a nasal deformity is not
sufficient for a diagnosis of a nasal fracture. She was told she needed an image to
confirm the diagnosis in order to facilitate a referral to a surgeon. It was their
custom to always get a CT (not just nasal bones), to make sure that "nothing was
missed." Worried about unnecessary radiation, she insisted that she only get
plain nasal bone films if an image was required for a referral. This image showed a
"The primary care physician was contacted to get
a referral, but he thought that repairing a nasal fracture might be denied, as it was
probably 'cosmetic.' Eventually, she got her nose fixed, but her impression of
physicians was less than stellar. Suffice it to say that this real scenario is
peppered with people doing the wrong thing and is a good example of the chaos that
results when we forget our true purpose and limit our goals to immediate ones.
"The legitimate goal is to fix the broken nose.
Her physicians forgot why they are there. The goal of the medical director is to
limit cost, but his policies actually resulted in increased cost. The goal of the
emergency resident is to protect himself from his colleagues' criticisms and to be
sure he does not miss anything. This results in unnecessary testing and exposure to
radiation. Ultimately, this is a grand failure earning physicians loss of
The entire article is at www.smcma.org/Bulletin/BulletinIssues/April07issue/When%20Doing%20The%20Right%20Thing.pdf.
The Minister's Son
The May 2007 issue of San Francisco Medicine focused on medicine and religion. The President's Message of Stephen Follansbee, MD, was entitled, "A Prescription for Prayer?"
"As the son of a Presbyterian minister, I am
aware of how much I am my late father's son, despite my different career path. My
voice sounds like his. My hand gestures and mannerisms are like his. I think that at
times, when talking with patients about life-threatening illness, death, and dying,
or advising them about how to talk with their families and friends, I must naturally
rely on some of my father's innate counseling skills. Is the practice of medicine
that far from religion? As physicians, are we that different from clergy? The answer
is a resounding 'yes,' even though a majority of hospitalized patients would like us
to consider their spiritual needs…
"As physicians, we are certainly aware of the
conflict that can arise between religion and medicine. A 2005 study entitled 'When
Patients Choose Faith over Medicine: Physician Perspectives on Religiously Related
Conflict in the Medical Encounter,' by Curlin, Roach, Gorawara-Bhat, Lantos, and
Chin, looked at this issue. The authors conducted one-to-one, in-depth,
semistructured interviews with twenty-one physicians from a broad range of religious
affiliations, specialties, and practice settings. Although admittedly based on a
small study sample, their conclusions are interesting. The authors categorize the
conflicts between medicine and religion into three overlapping domains: religious
doctrine versus medicine, ethical controversy, and faith versus medicine. The refusal
of Jehovah's Witnesses to accept blood products is an example of religious doctrine.
Lawsuits have been won by patients who have sued their physicians for battery after
saving their lives with transfusions of red blood cells, against their expressed
wishes. The courts are clear: A patient's religious convictions must be respected,
even if doing so conflicts with the doctor's own judgment about appropriate medical
The entire article can be found at www.sfms.org/AM/Template.cfm?Section=Article_Archives&CONTENTID=2313&
Hospitals and Surgery Centers
Phillip Goldberg, legal counsel for the California Society of Anesthesiologists, discusses "Hospitals vs. Surgery Centers" in the CSA Bulletin.
"The proliferation of free-standing ambulatory
surgery centers in recent years has sometimes created tension between these new
facilities and acute care hospitals. Most of these surgery centers are physician
owned, in whole or in part, and physician investors are encouraged to steer patients
to their surgery center for qualified procedures that might otherwise have been
performed in the acute care hospital where the physician is on staff.
"This is not just a matter of the surgeon's
financial self interest. Federal regulations actually encourage procedures at the
surgery centers by providing fraud and abuse protection to a physician who performs
enough procedures at the surgery center so it is considered an extension of the
physician's practice. (42 C.F.R. 1001.952(r).) Many surgery centers require their
surgeon investors to perform enough cases to comply with the regulatory safe harbor
as a condition of retaining their investment. Generally, to fit within the fraud and
abuse safe harbor, the surgeon must perform at least one-third of his or her
outpatient procedures at the surgery center. Although compliance with the safe harbor
is not required to comply with the federal fraud and abuse statute, many surgery
centers adopt the safe harbor as mandatory for their investors, with the result of
increasing utilization at the facility.
"By necessity, surgeons bring their healthier
patients to the surgery center and leave their sicker patients at the hospital. By
choice, the better reimbursing cases are often performed in the surgery center, and
the lower paying cases are left at the hospital. As patients are leaving the hospital
and moving to the surgery center, anesthesiologists are following them. It is not
uncommon for some anesthesiologists to practice principally or exclusively at a
surgery center. This exodus of patients and anesthesiologists has created problems
for other anesthesiologists who continue to practice principally or exclusively at
acute care hospitals…"
To read more, go to www.csahq.org/pdf/bulletin/issue_16/LPAD071.pdf.
|A “medical” marijuana problem, ER’s growing caseload, on the sidelines of a Great Game.|
Emily Dalton, MD, writes on
“Medical Marijuana” in The Bulletin of the Humboldt-Del Norte Country Medical Society, July
“My neighborhood is going to pot.
Literally. There is a house on our block that has little or no traffic. The window
shades remain down all the time. No one comes, no one goes, nor is anyone ever seen
tending to the yard. Music never emanates from the home, but a funny aroma does —
fragrant, aromatic and pungent. Back when the home went up for sale I hoped a young
family would move in. The neighborhood is perfect for children: a dead end cul-de-sac
with scattered basketball hoops and nice lawns. Unfortunately, young families can no
longer afford the nicer homes. Someone bought it and decided to make it a rental.
Renting to a grower generally allows the owner to charge double or even triple the
“According to an officer in the
Sheriff’s department, an indoor grower can produce tremendous amounts of marijuana
in the space of an average living room. These indoor marijuana outfits are quite
common in Humboldt County. If a complaint is received, the approach taken by the drug
enforcement unit is to pay a visit and ask what is going on and why the place smells
like pot. If the grower has a 215 card, things stop there. If the grower cannot
produce the card, then a search warrant can be issued and arrests made.
“Think about it — the fate of
these dope growers depends on a physician’s authorization. How did this problem
ever get thrown in our laps? Unfortunately, there is no shortage of unscrupulous
doctors to dole out the 215 cards, and they undoubtedly earn more than most of the
rest of us who work legitimately…”
The entire article, including
references, is at www.humboldt1.com/~medsoc/images/bulletins/JULY%202007%20BULLETIN_for%20web.pdf.
Dr. Joshua Weil, chief of Emergency
Medicine at Kaiser Santa Rosa, writes on “Another Straw on the Camel’s Back” in Sonoma
Medicine, the magazine of the
Sonoma County Medical Association.
“It’s a typical Saturday night in the Kaiser Santa Rosa
emergency department. More than 30 patients crowd our 17-bed ED. Every bed is full,
including the six hallway beds, and about a dozen patients are still waiting to be
roomed. I pick the ‘next to be seen’ chart out of the rack and scan over the
triage paperwork: 26-year-old female with pelvic pain and normal vital signs. I look
more closely for better detail: ‘Pain for six months.’ I do a double take.
‘Pain for six months?’ I ask myself. ‘When did this become an
“It’s a rhetorical question in
a frustrated moment. But it’s one I also ask of our patients (in a less frustrated
tone), to try to get a feel for what has changed when they present to the ED with
chronic problems. In this case, nothing much has changed; but the patient’s mother
has grown tired of listening to her complain of the pain, and tonight seemed like a
good time to see a doctor. With no insurance and no doctor, they headed to our ED for
“Over the past few years, we have
experienced a steady climb of non-Kaiser members presenting to our ED, most of them
uninsured or underinsured. From the 7-8% of four or five years ago, the number of
nonmembers has grown to 12-13% of the 30,000+ patients that we see each year…
“The Emergency Medical Treatment
and Active Labor Act (EMTALA) requires that any person presenting to an ED receive a
medical screening exam to ensure that no life- or limb-threatening emergency exists.
What constitutes a medical screening exam is open to some interpretation; but as the
Department of Health Services has both the final say and the ability to levy large
fines, the vast majority of patients will be seen and evaluated in the ED…
“What is clear is that the
standard of care in the ED is different than in the office. While the office-based
physician focuses on what is most likely to be the problem, my job is to exclude what
is most likely to be the lethal diagnosis. ’Heartburn’ can be readily addressed
as GERD in the clinic, whereas I am obliged to perform more rigorous evaluations to
exclude coronary ischemia in that same patient. These procedural differences are even
more pronounced for patients with little or no history in our system and with whom we
are not familiar — especially if timely follow-up cannot be assured. In some cases,
this lack of knowledge may even necessitate hospital admission, which is surely more
What may be less obvious are the
hidden costs of meeting regulatory and compliance requirements, such as nurse
staffing ratios and timelines for cardiac, stroke, and pneumonia patients. EDs must
staff to meet these demands — and staff isn’t free. Meanwhile, hospitals and EDs
across California are closing even as populations are growing …
To read the entire article, go to www.scma.org/magazine/scp/sm07/weil.html.
“The Great Game” is the topic
of Dr. Jason Campagna in the
Bulletin of the California Society of Anesthesiologists, Summer, 2007.
“It was called 'The Great Game,'
and it referred to the epic imperial struggle for supremacy in 19th century central
Asia. For well over 100 years, The Great Game occupied the minds of the best men in
the most powerful governments on the planet. Today, another Great Game is afoot —
and it refers to who will control the vast resources and wealth associated with the
entire medical superstructure.
“Like the Great Game of the 19th
Century, there are concrete and tangible rewards to be had by playing — and winning
— today’s version of The Game. Then, the rewards were oil, natural gas, and other
precious resources, along with the money that derived from their control. Today, the
prize is the medical superstructure in its entirety. Such control allows one to lay
claim to one of the most benevolent offerings one human can provide another —
medical care. With this claim comes great power: power over people, and, more
important, power over vast sums of money.… Like any game, some potential players
remain on the sideline. Some do so for strategic reasons, while others do so out of
fear. During this time, the active players make mistakes, joust with one another and
withdraw. Most important, however, they learn — learn better how to play the game,
how to attack their opponents with force and brutal efficiency, and how to lie low
and wait when in danger. In short, these players are getting quite good at the game,
while those on the sidelines are not. This does not bode well for those observers.
“For physicians, these details of
the Great Game, and understanding the players and the observers, are vitally
important. The key issues, unfortunately, are that physicians do not like this game,
they are not very good at playing it, and, sadly, they are one of the most
conspicuous of those groups now on the sidelines…. If indeed we would like to
become players in this game, there are some things we must just simply acknowledge
and then move on. Chief among these is that there is nothing inherent in the concept
or title of ’physician’ that grants us any cultural authority, economic power, or
To read about those factors, go to www.csahq.org/pdf/bulletin/issue_17/campagna072.pdf.
|Huge profits = no health care, a merged Vital Signs, a wrong direction for prescriptions.|
Losing Out at the Casinos
Stephen Kamelgarn, MD, argues that "It's Time for Casinos to Contribute," in Editor's Thoughts of The Bulletin of the Humboldt-Del Norte County Medical Society, August 2007.
"It is increasingly expensive to provide health benefits for one's employees, and in today's business climate of decreasing profit margins this can be the difference between making it and bankruptcy.
"However, there are businesses that do earn a significant amount of profit, and it is important for them to pick up their fair share of the load. Wal-Mart has been rightfully blasted in the national press for not providing benefits for their employees. This is a world-wide corporation that earns billions of dollars in profits every year. Yet, somehow, they can't seem to get it together to provide benefits for employees who, in many cases, are earning just enough money to keep them for qualifying for Medicaid (Medi-Cal, here in California). Because of the national outcry Wal-Mart has begun to provide benefits for its employees.
"Locally, we're seeing a similar situation with some local businesses. These are concerns that earn tremendous amounts of money, yet don't provide for their employees. I am referring to the 3 local casinos (four, if you count the one in Klamath). In 2005, the Bear River Casino in Loleta grossed over $100 million, yet they provided no health insurance for many of their employees. If we assume that the other two casinos are doing as well as Bear River, then $300 million is going into their coffers.
"This is more than two thousand dollars per year for every man, woman and child in Humboldt County! It is not my point here to get into either the economics or morality of tribal gaming. But it is important to see that these casinos are tremendous cash generators, and a significant source of employment in the community, both for tribal members and non-tribal community members. Despite the fact that California State policy is that, in businesses of more than 50 employees, employers must provide insurance for anybody working more than halftime, the local casinos, being sovereign nations and therefore exempt from the rules, don't provide for many of the employees who work much more than 20 hours per week. This is true, not only of Bear River, but also Cher-ae Heights, and Blue Lake casinos.
"I find this reprehensible. The fact that businesses can earn a quarter of a billion dollars in gross income, and not provide benefits for all of their employees bespeaks a level of callousness and greed that I find incomprehensible..."
The entire article can be read at www.humboldt1.com/~medsoc/images/bulletins/AUGUST%202007%BULLETIN_for%20web.pdf
A New Vital Signs
Sandi Palumbo, the Executive Director for two medical societies, has announced a merger of their membership publications.
"With this month's issue of Vital Signs, the Fresno-Madera Medical Society (FMMS) and the Kern County Medical Society (KCMS) are pleased to announce the merging of their respective membership publications, FMMS Vital Signs and KCMS Bulletin, into one combined enhanced monthly publication.
"This combined publication is yet another cooperative effort on the part of FMMS & KCMS designed to meet the needs of both organizations while decreasing the individual financial burden of such activity for both organizations. (Effective with my employment as Fresno-Madera Medical Society's Executive Director early last year, through mutual agreement I also continued employment as Executive Director for Kern County Medical Society.)"
David Aizuss, MD, warns "Beware These Prescribing Minefields" in the October issue of Southern California Physician, the publication of the Los Angeles County Medical Association.
"Health plans are now incentivizing their patients to convince their doctors to change medications.
"Physicians are under constant pressure to alter their prescribing habits - and new developments are adding to the force.
"In the past few years, there has been tremendous negative publicity about pharmaceutical manufacturers' efforts to influence physician prescribing via 'drug reps,' or pharmaceutical detail salespeople. As a result, the Pharmaceutical Research and Manufacturers of America promulgated regulations that constrain what drug reps may do when they visit physicians' offices. For example, the representatives must combine education with an offer of dinner or lunch. Further, the medical profession continues to debate the ethics surrounding pharmaceutical 'freebies.' I consider this a tempest in a teapot. What ethical physician would alter his prescribing practices based on pens and sticky notes?
"More recently, insurance companies are entering the game to alter physician prescribing habits. For example, earlier this year, as a patient, I received a letter from my insurance company suggesting that I ask my doctor to prescribe double the dose of my medication, so I could save money by cutting those pills in half with a pill cutter at home.
"I was incredulous - such a policy is clearly not in the patient's best interest, but in the insurer's best interest. It might reduce the co-pay for the patient, but it definitely reduces administrative overhead and processing costs for the insurer. Worse, the practice may even hurt patients. Among the obvious dangers are that patients cannot necessarily cut pills exactly in half, the distribution of medication and binder is unknown, the effect of gastric absorption cannot be quantified, and patients may become confused and cut the wrong pills.
"Another even less ethical practice was just brought to my attention. Some health plans are now offering physicians financial incentives to switch their patients from higher-cost to lower-cost drugs. One plan paid physicians to switch patients from Lipitor to a generic version of its competitor, Zocor. The physicians were paid $100 for each patient switched between Jan. 1 and March 31, 2007. Incentivizing physicians to switch a patient's medication distorts the doctor-patient relationship and should not be permitted. The only consideration should be prescribing the best medication for the patient's condition.
"If two medications have an equivalent effect on the patient, then it is reasonable to factor cost into the prescribing decision. However, in the example above, the patient was not a consideration. Cost alone was the deciding factor, and the incentive failed to consider patient needs.
"Finally, a colleague on the Los Angeles County Medical Association board recently showed me a letter that a health plan in California sent to its patients. It offered patients a free month of simvastatin if they convinced their physicians to switch them from Lipitor. Consequently, health plans are now incentivizing their patients to convince their doctors to change medications. This strikes me as wrong. It clearly undermines the doctor-patient relationship. We prescribe medications we think are best for patients, only to see them back in the office waving a coupon for a free month of medicine if we switch their prescriptions..."
The entire article can be found at www.socalphys.com/article/articles/581/1/Presidents-Letter---Beware-These-Prescribing-Minefields/Page1.html.
Contact Del Meyer, MD
Phone: (916) 488-5864