Proof and Prayer

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:

1. Participating
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.

2. Nonparticipating
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.

3. Opt-Out
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.

Medicare’s New Direction

Stephen Kamelgarn, MD, discusses “Medicare Pay for Performance” in the January issue of The Bulletin of the Humboldt-Del Norte County Medical Society

“Medicare, 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 government.

“Physicians 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.

“We’ve been 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.

“However, 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 ’bonus?’”…

The entire article appears at www.humboldt1.com/~medsoc/images/bulletins/JANUARY%202007%20BULLETIN_for%20web.pdf 

A Different Kind of Error

Emily Dalton, MD, discusses Electronic Prescribing: A Help or a Hindrance? in the December 2006 issue of The Bulletin of the Humboldt-Del Norte County Medical Society

“The CMA 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 small screen…”

The complete article can be found at www.humboldt1.com/~medsoc/images/bulletins/DECEMBER%202006%20BULLETIN%20for%20web.pdf 

Transparency In Medicine

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!”

“In 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 parameters dictated.

“What does this all mean to us, and where is it headed?

“To begin 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…

“Another 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 their numbers…”

The complete article can be found at www.sjcms.org/magazine/Winter%20Quarter,%202006.pdf

Vanity, thy Name is… MD?

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…’”

And Now for Something Entirely Different

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.

“With 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 

The Trouble with ERs

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.”

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 thing is.

"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 nasal fracture.

"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 stature…"

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 care…"

The entire article can be found at www.sfms.org/AM/Template.cfm?Section=Article_Archives&CONTENTID=2313&
SECTION=Article_Archives&TEMPLATE=/CM/ContentDisplay.cfm.

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.

My Neighbors the Potheads

Emily Dalton, MD, writes on “Medical Marijuana” in The Bulletin of the Humboldt-Del Norte Country Medical Society, July 2007.

“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 usual amount.

“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.

Non-Emergency Emergencies

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 ”emergency”?’

“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 answers...

“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 costly…

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.

Capturing the Medical Superstructure

“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 political influence…”

To read about those factors, go to www.csahq.org/pdf/bulletin/issue_17/campagna072.pdf.

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.)"

Incentivizing Prescriptions
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.