Jon Stewart FTW!

Last Dailyshow episode of 2009, arguably one of the best! Very funny interview with Hugh Grant, but more importantly, Jon Stewart FTW @ 747 and 815. Oh Snap! on a stick!

The Senate compromise - hardly a better alternative

The Gang of Ten has recently come out with a new compromise in order to get rid of the public option: expanding Medicare downward to include people over 55 years old and leaving the rest of the population in the hands of various non-profit plans overseen by the Office of Personnel Management (OPM), which oversees Federal Employee's Health Benefit Plan (FEHBP).

The public option was put forward for two vital reasons - it should amass quite a bit of bargaining power, and more importantly its incentives as a government-run entity would be to lower cost while keeping the population healthy.

Keeping these vital reasons in mind, let's look at why the compromise cannot match up to the public option.

In terms of the ability to lower prices through negotiations, breaking up the population only reduces the bargaining power. Moreover, breaking up the population by age asks for a death spiral. Many argue that the public option will select for the sickest people without prior access to insurance - I'm no expert but I'm not so sure that this will be the case. Without the age divide, there could be a sizable number of relatively healthy, self-employed enrollees to balance the sicker counterparts. Keep in mind that there are the uninsured, and then the under-insured. The uninsured are probably sick, but the under-insured could look very much like the self-employed Mary and Mack Kroner - they are not super sick, they have been able to afford some necessary preventive care, if only barely. The uninsured and the under-insured, spread across all age groups, could make a nice, balanced risk group with reasonable premiums. We could be pessimistic and even say we don't know - the public option may or may not create the death spiral, but the Senate compromise to break up the age group definitely aggravates the likelihood. A good plan looks to create the biggest, most diverse group of enrollees for better risk-sharing, not breaking it down, especially not by age. This compromise wants to dump the sicker, older population onto Medicare, while leaving the younger, healthier population to non-profit plans, potentially run by friends of some powerful voices in the Senate?

In terms of incentives, keep in mind that non-profit does not equal government-run. The government on paper has the best interest of its people in mind - non-profit can aim to do whatever it wants as long as it does not make profit. The public option will be held accountable, while the smaller, fragmented non-profit plans will probably not be, considering the fact that OPM currently does not regulate the plans it oversees. In terms of costs, the public option does not need to advertise or lobby like smaller non-profit plans, and its scale could dramatically reduce operating costs, which means lower premiums for everyone.

Considering all the hypothetical arguments against the public option, this compromise only accentuates those shortcomings. The details of the compromise are not yet released, but so far it does not seem to pass as a better alternative. The Democrats in the Senate need to get their acts together, and Joe Lieberman just needs to get lost.

There is only one pie, and it is all we have and all we will ever have...

I unfortunately did not have a chance to go to the IHI national forum this year (or any year before that), but apparently it was Disneyland for quality improvement nerds. Don Berwick gave an amazing opening address comparing health care to the "tragedy of the commons" - in the common grazing area, without ownership, individual sheepherders exert externalities by grazing to the maximum, leaving the commons barren. Eventually, no one gets any grass. In health care, all stakeholders want green grass, but no one wants to stop grazing or pay for fertilizer. Some expect the government to pass laws that will grow grass and also please everyone, which means continued grazing and no fertilizers required - a Deus Ex Machina that is hardly possible in the real world.

Berwick urged us to look at the commons - it is all we have, and it has no one else but us. We, every individual, all need to step up and, instead of constantly taking, learn to give - or there will be nothing left for anyone to take. His inspiring speech says it all:

My friends, we can spend our days ahead fighting for our piece of the pie. We have plenty of role models for that. But, that’s for summer camp and the schoolyard; not for here. Not for this real and fragile world. Not for the Commons. Not when there is only one pie, and it is all we have and all we will ever have, and it is in our hands to preserve, not just for us but for our children and our grandchildren. We can wait for the rules to be written by others and for the laws on tablets chiseled by others to rescue us, but those rules will be less wise than the ones we can write, and those tablets will be, not our salvation, but weights upon our spirit. It is a very tough choice. Get everything we can? Or respect everything we have been given?

More on his address here.

Respectfully disagreeing with Atul Gawande

Gawande wrote a new article in the New Yorker about the Senate health reform bill. He argued that the current bill has no "master plan" to reduce costs, because the systematic problems in health care cannot be solved by master plans - it requires management over time and such management cannot be passed as a one-time bill.

I agree and also disagree with such assessment. It is completely true that our bureaucratic medical system could use better management like I have mentioned in prior posts, but our health care problems are complicated - they result from many types of problems, managerial being only one of many. I'd like to argue that another big cause of our soaring medical expenses is the price tags - it is not managerial, we can fix it with a master plan which the House bill has put forward (i.e. the public option), and it is one of the low-hanging fruits that we can easily reach, much more easily than systematic improvement which will take decades.

Consider how much we pay for a pill of medication - I'm going to use Misoprostol manufactured by Pfizer (aka Cytotec) because I do have first hand information on the pricing of this medication. In Thailand, a pill of Cytotec costs 13baht - that is about 30cents with the current exchange rate. According to Epocrates, 60 pills of 100mcg Cytotec costs $72.76 ($1.213/pill), 60 pills of 200mcg Cytotec costs $104.99 ($1.75/pill). That is 4x-8x what people pay in Thailand.

Now consider a can of coke - one in Thailand costs 14 Baht (40 cents), one in the US reasonably costs 1 dollar. I'd like to argue that even taking into account the difference in costs of living (~2x), there is a huge price discrimination at play when in comes to medication pricing. In the US, with our one limited example, it seems that we are paying 2x-6x more than other countries. Could that be a reason why our health care costs so much more than the rest of the world? Is that why pharmaceutical companies make fat profit in times of economic downturn, even fatter than that of insurance companies?

If pricing contributes to the equation, then the public option will amass bargaining power that will lower the price of medical supplies. Allowing Medicare to bargain will also help. Private insurance companies will follow suit due to competition. The public option could be the master plan that quickly reduces costs, while the also necessary managerial improvement takes place over time.

Another point that both doctors and patients must realize is that health is an amalgamation of many factors, medicine being at the end of the spectrum. Most patients get to their doctors when the body is already broken, many times beyond salvage. A morbidly obese patient carrying a heart clogged with fat since the age of 14 cannot be saved by the best doctors or the best health care system - he is most likely destined for a short and unhealthy life. Fixing the medical system will not completely fix our health - we also need to pay attention to socio-economic stability, public health measures, education.

But a successful health care reform will, of course, also be helpful.

Management pearls

Good management lessons do not limit to business - they belong everywhere, including in health care and everyday life. The sooner we realize this fact, the better off our world will be.

Below I list management pearls that I have the fortune of coming across. If they sound primitive, remember that most brilliant ideas are simple - it is the implementation that makes all the difference.

- Leaders are not satisfied with what they are given - they always envision better possibilities. Followers inherit the best freighter in the world and treasure it - Leaders inherit the best freighter in the world, tear it up and make a speedboat.

- Shun the incremental and go for the leap. Meet the basic targets then stretch to the point where the organization almost comes unglued, without punishment for failure.

- Eliminate boundaries and bureaucracy. All good ideas should be valued and encouraged, regardless of their sources, be they from your janitors or your competitors. All employees have equal opportunities of constantly improving their performance and contributing to their workplace. Read more about "work-out" and "best practices" at GE.

- The contract between the company and its employee is not the perceived lifetime employment that leads to complacence, but the promise of personal and professional growth that pushes people to be their best. Each department rents the employees, but it is the company that truly owns them.

- 360 degree evaluation with equal consequences across the board is very important. Smiling up and kicking down should not be tolerated.

- People must be rewarded with both the pocketbook AND the soul. Take care of your A players, and do not waste time getting Cs to be Bs - lose them early and you will do everyone a big favor.

- There are 4 types of employees, based on the combinations of whether they meet the targets (T) and whether they share your values (V). [+T+V] is an easy call, so is [-T-V]. [-T+V] gets a second chance, preferably in a different environment. [+T-V] is the hardest to deal with - they should be removed, because they will fail to deliver in the long term.

- Managers promote stability while leaders press for change, and every good organization needs both.

One good thing in a disappointing day for LGBT

Today the NY state senate voted down gay marriage 38-24. I'm ashamed to live in New York City, an establishment that shows so much promise but today has failed to deliver. But I do hope that this amazing speech, although did not win us the bill, will make a difference in some people's opinions. The message is powerful, because it is the undeniable truth that was flawlessly delivered - an epitome of motivational speech.

So much for consumer-driven health care!

Today, I was curious about how a hospital in New York performs compared to the national average, so I went to Center for Medicare and Medicaid Services (CMS) website, which hosts resources on hospital quality initiatives and, of my interest, Hospital Compare. According to the description on the website...

"Hospital Compare is a consumer-oriented website that provides information on how well hospitals provide recommended care to their patients. On this site, the consumer can see the recommended care that an adult should get if being treated for a heart attack, heart failure, or pneumonia or having surgery...The HQA effort is intended to make it easier for the consumer to make informed healthcare decisions, and to support efforts to improve quality in U.S. hospitals. The major vehicle for achieving this goal is the Hospital Compare website."

Reading this paragraph starts to turn me off a little bit, mostly because the part omitted (in the ...) contains terms like "30-Day Risk Adjusted Death and Readmission measures." What does that even mean? Adjusted how and for what? How would a layperson fully understand what that means?

But OK, sounds like a good initiative. Let's give the Hospital Compare website a try.

Well, as of 12/1/09, the website cannot be found! The only other somewhat acceptable alternative is to download data for past quarters to view on your computer. I went ahead and downloaded the zip file for the latest preceding quarter. The file consisted of a complicated PDF file giving legends to possibly the many abbreviations in the database which requires Microsoft Access to view. I do not have Microsoft Access but to give you a glimpse of how complicated this dataset may be, let's take a look at part of the legends listed in the PDF file...

"There are fourteen tables in the Hospital Compare database.

1) dbo_vwHQI_FTNT

2) dbo_vwHQI_HOSP

3) dbo_vwHQI_HOSP_MSR_XWLK

4) dbo_vwHQI_PCTL_MSR_XWLK

5) dbo_vwHQI_STATE_MSR_AVG

6) dbo_vwHQI_HOSP_MORTALITY_READM_XWLK

7) dbo_vwHQI_STATE_MORTALITY_READM_SCRE

8) dbo_vwHQI_NATIONAL_MORTALITY_READM_RATE

9) dbo_vwHQI_HOSP_HCAHPS_MSR

10) dbo_vwHQI_STATE_HCAHPS_MSR

11) dbo_vwHQI_US_NATIONAL_HCAHPS_MSR

12) dbo_vwHQI_HOSP_MPV_MSR

13) dbo_vwHQI_STATE_MPV_MSR

14) dbo_vwHQI_UA_NATIONAL_MPV_MSR"

To be fair, at the beginning of this PDF legend file, the disclaimer reads...

"This functionality is primarily used by health policy researchers and the media... For information about hospitals in a particular geographical area, you should use the Hospital Compare tool instead of downloading the data."

I think it's fair to say that it is out of the question that the underserved patient population will be able to navigate this set of data, considering the fact that they probably don't even have a computer. But consider a college-educated, middle-income family - they will probably have a computer, and access to the internet, and maybe acrobat reader, but will they have Microsoft Access? I don't use it enough to own it, even as an economics major in college. But don't even mind that, how can we expect a college-educated, middle-income person to navigate this monstrosity of a dataset? I'm hoping the Hospital Compare tool/website is easier to navigate and more readily available.

I think this goes to show that free flow of information in health care has a long way to go before the market can become somewhat efficient and patients can make truly informed decisions, because even an effort, like this one, made specifically to help inform consumers, so far isn't informing me anything, because I don't get to see the data. All it's doing is confusing me with abbreviations and Greek terms that are poorly-defined.

The website is set to for maintenance on December 17 - will check back at that time, but until then, I'm disappointed.

Ideas for a better health care 1

After reading a number of articles on health system improvement, it occurred to me that I should be writing the good ideas down, for my own record and for others to read. Obviously they flow in as I read, so there will continue to be many versions of this post.

What aspects contribute to a high-performing health care system?

1. Uniformity: the importance of uniformity is greatly illustrated by Paul Levy and the pig-drawing exercise. It is also reiterated in the famous NYT article on Intermountain Healthcare. Uniformity is crucial to quality improvement - variations cause deviations from standards of care/best practices, variations allow improvisation which leads to medical errors. More importantly, we can't inspect quality with variations. Think about quality inspection in a factory, say of buttons - to inspect quality effectively, the buttons must be uniform and look like the prototype. Without the prototype (standard of care), you won't be able to tell if the buttons look the way they are supposed to look, and you won't be able to tell if the new models of buttons look better than the last, if the buttons in each batch are all different. Of course, there are parts of healthcare that should be individualized, but the fact that we are all human beings means that parts of most things can be standardized.

2. Data is power: without data collection, many capabilities are lost. Data is everything - it can be used to leverage an institution's capability for research, but more importantly it is crucial for quality control. More and more leading institutions (Kaiser Permanente and Intermountain Healthcare) have been using collected data to monitor how each of their units/physicians/other health staffs are performing compared to hospital average/national average. This is quality control that all reputable businesses do on a daily basis - it is horrifying to think that the industry that deals with human lives can get away with doing none. (However, one must be careful of what the consequences of these measures should be.) On the same note, transparency is a boon. If good advances have been discovered, it's only wise to share this information with everyone in your institution so that they can spread these improvements and apply them to their work. If adverse events happen, it's also wise to spread the details of how they happened, so that others can learn from the mistake and chime in on how to avoid the same mistakes next time around.

3. Align incentives: reward wisely - and not with just money. Quality outcomes should be the goalposts, and not the amount of work done - doing more usually means inefficient use of resources that doesn't translate to better outcomes. There is also value in rewards that aren't money, like self esteem, pride in doing a spectacular job, being part of an impact. These rewards usually get people going farther and longer than money.

That's all I've got for now - more pearls will be added as I run into them!

There is no deal between the AMA and Obama, and "doctor's fix" does not count as part of health reform cost!

A few days ago the media started piping about the "doctor's fix" - Democrats have promised to cancel a plan to cut the fees that Medicare pays doctors by 21%. The cuts were scheduled for this January. The Washington Post claimed that the cancellation is planned to be passed separately from the reform bill so that Obama can hold up a fake promise of the reform not adding deficits to the budget. In exchange for this cancellation, Obama gains support from the AMA without breaking his promise. Over a ten-year period this “doctor’s fix” will cost $247 billion.

Now please read carefully - the above claim by the Washington Post (which has published more misleading, unsubstantiated articles of late) is false. Here, Maggie Mahar explained, very clearly, why.

With a little bit of digging, the Washington Post would have known that these proposed Medicare cuts were never actually performed even though they have always been budgeted in falsely during the Bush administration, simply because it is impossible to do. Part of the current problems with health care is that our current reimbursements are illogical, with important fields like primary care and palliative care underpaid, while other fields are overpaid. Blindly cutting reimbursements across the board is lazy and stupid - Problems with Medicare reimbursements are obviously complicated and require well thought-out, personalized, specific changes. If the Washington Post had done a little research, they would have known that suddenly accumulating all past unperformed cuts and execute it in one blow years later is a ridiculous idea, not to mention that Congress for all of those years never went through with it - why should they suddenly go through with a ridiculous idea at an even more ridiculous level (21%) now?

This makes me question - what type of irresponsible journalism led the Washington Post to make such false, inflammatory claim when a simple research would have shown that the claim is untrue?

More interestingly, watch this face-off between Maggie and Douglas Holtz-Eakin, a former director of the Congressional Budget Office, and a fellow at the Manhattan Institute. You can decide for yourself who to believe, but for me, Maggie obviously read the bills and knew exactly what she's talking about. She provided specific quotes and numbers that can be easily checked - she told you exactly how to check them. Holtz-Eakin, on the other hand, reverted to same memorized sentences and refused to directly address Maggie's rebuttal, because he didn't seem to know the issues inside out and therefore could not draw on hard facts and numbers to counter Maggie's comments.

I also have to criticize Lou Dobbs for his comments on the senators not reading the bills. He's trying to be tough and put Maggie on the spot but, really, that point is not relevant to the debate at hand and it's not even worth shouting and yelling about. Obviously, senators can't read every bill when each is thousands of pages long, so of course they rely on their staff to digest the bills for them, so that they can make decisions about myriad of issues and actually function. That's called delegation, and irrelevant attacks just so you can be tough is, for lack of a better word, stupid.

Is it possible that Thailand is ahead of the US when it comes to health care? - Part 2

Last time we outlined the inner-workings of Thailand's health care system. Today, we will explore problems within the system and finally examine where we stand compared to the US. Hopefully with all this information you can decide who will emerge on top, maybe 20 years from now.

What are the problems within Thailand's health care system?

1. Lack of oversight - many parts of the system operate haphazardly because the government lacks power/money to impose appropriate control. It does not have enough money to compete for young doctors for underserved areas with rich private hospitals in big cities. The residency process is largely unregulated - with more spots than the number of applicants, graduates flock to high-paying specialties, leaving primary care unattended. Because supply is higher than demand, no one could be forced into primary care spots, and the gov't can't incentivize young graduates with the money it doesn't have. There are no regulations on quality control within health care facilities, but that does not say much considering most hospitals in the US or any other country let doctors practice haphazardly without quality control either.

2. Lack of human resources - there are not enough nurses or doctors to go around. It doesn't help that most of them concentrate in city private hospitals with higher pay, but even if we were to spread them all out, the ratio of doctor/pt is still a whopping 1 per several thousands, which explains long lines at governmental 30-Baht hospitals. The bottleneck is with the limited capacity of major medical schools and also the lack of incentives to persuade doctors to serve understaffed rural areas. It is also precarious that new, inexperienced medical school graduates are sent to rural areas where they are left to their own devices without much supervision to treat patients - great clinical experience should not come at the price of patient safety.

3. Money problem - the current reimbursement system has some good qualities built in, but it is far from perfect. Here we return to age old debate on the pros and cons of various types of payment schedule: fee-for-service, capitation rate/salary, DRG, etc. The capitation rates paid to starting point hospitals is a good thing - it encourages consolidation of medical records, reduced transfer of care, a focus on primary care to keep people healthy and reduce cost/utilization. However, the capitation rates are too low, forcing major hospitals into the red as their popularity draws in 30-Baht customers. Doctors consider giving less care to prevent their hospitals from going bankrupt thereby losing their jobs in the process, since there are no quality control or incentives to consider quality other than their self esteem. Lack of facility fluidity in emergency situations is another problem - starting point hospitals and "emergency" hospitals engage in turf wars trying to rid cases of catastrophic accidents, since the costs usually exceed that paid by DRG rates.

4. Lagging medical curriculum - medical schools focus on multiple-choice test scores instead of knowledge application/acquisition and quality attributes that make you a good doctor, such as professionalism, communication skills, etc. They are aware that good test scores do not translate into good doctors, but they claim that without fair and effective measures for these attributes they must rely on numerical outcomes (which is true - what we use in the US is mostly arbitrary, US medical students just have no rights/say in the matter like Thai medical students). There is not enough focus on patient interaction or a comprehensive approach to health care (not that US doctors do), and the lack of role models like their professors or attendings on the floor does not help the matter. Evidence-based medicine is constricted by lack of adequate access to journals, lack of English proficiency, and lack of statistical knowledge to critically digest and understand journal articles, both in teachers and students. Students are overwhelmed by lectures focusing on memorizing knowledge that will become obsolete by the time they graduate, leaving no time for extracurricular activities that cultivate maturity, self-empowerment and leadership. With test scores as the only carrot on the stick, students become walking, obsolete textbooks who barely talk to patients and lack the ability to acquire new knowledge.

5. Low quality of care - doctors are usually only as good as their medical schools. The aforementioned problems in medical curriculum, combined with lack of money/oversight/human resources, result in low quality of care. The system is overwhelmed with new patients who with a snap after 2001 become eligible for care. Doctors never learned how to talk to patients, and now they also do not have the time. Lack of quality control/quality incentives does not help doctors synthesize and come to a realization that counseling their patients is more important than getting rid of them from the clinic to finish a day's work, for they will come right back with more problems, increasing costs for the whole hospital.

So where does that put us?

At the beginning of part 1 I mentioned that I had the opportunity to speak with a few local authorities in Thailand's health care system, one of them being the CEO of one of the three major hospitals in Thailand. We spoke at length comparing the pros and cons of our systems - I told him about incorporating lean manufacturing in hospital management and he was intrigued. A few days later as I was walking around the hospital, I in turn was even more intrigued to find that there was already a lecture on using lean manufacturing in hospital management taking place that week - most US hospital CEOs wouldn't know what lean manufacturing is.

I mentioned the above example to illustrate a point - Thailand has been aware of the right ideas for a long time, sometimes before the US, but they never materialized due to faulty implementation. We know lean manufacturing can be used in health care management, but if the hospital CEO never heard of it, the implementation is doomed. We know test scores measure nothing, but we haven't tried to find better outcome measures that encourage students to focus on becoming a good doctor and not a textbook. We know capitation-based payment is creating problems, but we have not learned to devise a scheme that draws from advantages of various payment schedule to achieve high quality (but neither has the US). We realize the importance of community integration, but our well-planned community-based health care system lacks doctors who recognize the importance of primary care with enough conscience to stay in rural areas and refuse to waste their talents in overstaffed private hospitals. We know primary care residency needs to be boosted, but no organization has stepped in to make that happen.

That's where Thailand stands, and I think that's where the US and most everyone else stand. Providing quality care is not rocket science - we know exactly how to do it and we've known it for years, but we have not achieved it for various reasons. In Thailand I think it is due to inexperience and lack of good management, but in the US I think it is mostly due to incumbent parties who fight inhumanely to keep the status quo and the money that comes with it. I personally think inexperience is easier to get rid of than big pharmaceutical companies, but we might find out in a few months if I'm right.

Is it possible that Thailand is ahead of the US when it comes to health care?

This trip home and a talk with local authorities in Thailand's health care system got me thinking - Thailand is still considered to be a developing country, but when it comes to health care, I'd like to suggest that the citizens of Thailand might be better off than the Americans. This is a big statement to make, but to substantiate it I will start off with the explanations of how the Thai health care system works. Then I will go over the problems within the Thai system, after which I will make an amateur guess on where our system is going compared to the US. This is when you can decide if we are indeed in a better position.

How does the system work?

Thailand consists of 70 or so provinces - Bangkok is one of them. In each province, the smallest unit is called "Tumbol," where local health care centers are run by trained community health workers who are fully integrated into the community. These health care centers are low-capacity clinics without admission capability, and there just simply aren't enough doctors/nurses to staff all these rural clinics. The health workers (the good ones anyway) know their communities in and out, they draw from resources to solve all types of problems affecting the community (income generation, sanitation), and they focus on prevention and disease detection (they use simple symptom-based algorithms to arrive at possible diagnoses and preliminary instructions on how to deal with the illness).

When things get too complicated for the health workers to handle, they refer patients to "Amphur" hospitals, which take care of "Tumbol" health clinics in their areas. Amphur hospitals can take care of simple cases and admit a few patients. They are staffed by a few senior doctors who are also CEOs of the hospitals, and the day-to-day work is handled by new graduates from gov't medical schools who rotate out to these facilities to pay back their tuition before they can move on to residency (gov't medical schools are better than private ones, and the tuition is cheap because the gov't reaps its human investment through these post-graduation rotations). Most graduates consider this to be a great clinical experience, while others who loathe the rural area have to pay a ridiculous sum of money to avoid it.

For patients who are too sick, they are transferred to big provincial hospitals, which are responsible for Amphur hospitals in their jurisdiction. Provincial hospitals have full capacity similar to that of big shiny hospitals in Bangkok. They are staffed by a number of physicians, many of whom are specialists.

To recap: Tumbol health clinics --> Amphur small hospitals --> Provincial big hospitals

How do we pay for it?

Before 2001, most people did not have insurance - they pay out of pocket. The lucky few to have insurance were government workers (gov't insurance), the poor (Medicaid-like insurance), social security (this has a different meaning than social security in the US - in Thailand it means insurance for retired people who contributed to the fund during their lifetime), and the rich (private insurance-very small %, insurance wasn't and isn't big in Thailand).

In 2001, the gov't introduced the 30-Baht program - everyone can get comprehensive care at participating hospitals (all gov't hospitals and some private) for a co-payment of 30 Baht (it's so puny you can maybe buy just a meal with it - after a while this co-payment was canceled and people can get care even if they forgot their wallet at home). People can pick any hospital as their "starting point," where ideally they will have primary care doctors who then refer patients to specialists anywhere when needed. Each hospital gets capitation (per head) payment based on the number of people who signed up, and that's all the money they get no matter how sick their patients are. Patients can get care outside their starting point only in emergency situation. When patients are stabilized, they can be transferred back to the starting point, or if the base hospital refuse to take their patients back, the "emergency" hospital can collect money from the base hospital based on Diagnosis-Related Group (DRG) rates.

As for the fate of other programs: Medicaid was eradicated. The rich continued to pay out of pocket at private hospitals to avoid the now much longer lines at participating hospitals. Old gov't workers can keep their gov't insurance, but the new ones will only get the 30-Baht program (most gov't institutions are now "leaving" the gov't systems to become private-like entities - the gov't still controls the policies, but to encourage efficiency, the management will resemble that of private entities and the gov't worker benefits will no longer be offered). People getting social security refused to let their program and their hard-earned savings vanish, so they get to keep social security if they want to. However, if they choose social security (usually with better benefits), they are not eligible for the 30-Baht program.

And that's where we stand now: the system remains fragmented, but arguably anyone in the country, regardless of ability to pay, will now be able to get health care.

What are our problems? - Find out in part 2!

Want to cut cost as part of health care reform? Start here!

Reiterating once again that Pharmaceutical companies are the big cost inflater in our health care business (they consistently make huge profits among the Fortune 500 companies even in an economic downturn), this video points your attention to biologics and under-the-radar pharma proposals to keep these life-saving medicines overpriced far longer than it needs to cover the R&D costs that it never spent (many of these drugs are developed by governmental/non-profit organizations like the NIH or university research labs).

Take action now. Call/email/fax your congressmen. Here is your chance to make a difference in health care reform!

Analyzing Glenn Beck...

Glenn Beck recently did an interview with Katie Couric. I would post a link here but, really, Glenn Beck has more than enough air time as it is, and I would hesitate to contribute to alerting more people about Glenn Beck because if someone does get hurt because of what he says, I would feel guilty.

But watching the interview I understood why people listened to him and believed what he said - He really appealed to the frustration of the common man and combined that with sound bites to manipulate people's beliefs and behaviors. Manipulate is a strong word, but it was much deserved for Glenn Beck. Much of what he says lacks evidence but is fueled with strong words, all of which totaled up to irresponsibility. Responsible media would not give idiots airtime and paint them up to be experts on the matter (like Betsy McCaughey or angry mobs at town hall meetings - whoever yells gets to be on TV!), but putting Fox's dirty paws aside, if Glenn Beck is such a government buster like he makes out to be, he needs to bust with facts and not hate words. Otherwise, he's a big fat hypocrite in the hypocritical world of government that he sets out to burn.

Katie Couric, on the other hand, is quite genius. She was always calm and collected, but more than that she busted Glenn Beck many times, not with accusations but simply with questions, fair and square questions. On another level, she humanized him with personal questions that showed him to be a normal, vulnerable human being - like a wounded enemy you can't sucker punch in your right mind. She showed Glenn Beck as he is - a manipulative, irresponsible bag of hate words - but Glenn Beck, watching the interview, wouldn't be able to point the finger at Katie Couric.

The public option: do not give up hope or your dissatisfaction for the lack of it!

Interesting (and encouraging) post from Maggie Mehar, making a point once again that the Senate Bill is not everything. SOMETHING just needs to pass so that it can be debated in conference, at which time the administration just needs to realize that:

1. They cannot pacify the conservatives - the conservatives will never be happy unless the status quo remains or the incumbent parties benefit at the cost of the disadvantaged

2. So if you cannot make the conservatives happy, the best thing you can do is make someone happy, that someone being the average Americans and your voters, because without a real change that cuts costs and makes health care accessible to everyone, NO ONE will be happy.

Maggie puts it best here:

President Obama and White House budget director Peter Orszag understand that if health insurance isn’t affordable, reform becomes a sham. The political penalty for promising what you can’t deliver would be steep. Thus they understand that for health care reform to work they must do what Massachusetts didn’t do: reduce the cost of care before rolling out full coverage.

So if you're upset at the lack of the public option in the Senate Bill, please continues to voice your concerns to your representatives, and do not give up just yet. The only thing that really matters is that the public option make it out of conference, and your voice can make that happen.

The Good and the Bad Betsy McCaughey

I guess when you watch or listen to Betsy McCaughey and you know the least bit about the truth that is out there, you know she's full of crap - but how full of crap is she? Read this interesting article about the facts on Betsy McCaughey to find out.

I think people in health care and NGOs can read this article and fully understands the magnitude of the lies and exaggerations from McCaughey, since they know what things are really like from observing their every day work. We know PhDs don't call themselves doctors in front of patients or national television, because that is simply misleading. We know that any good NGO collaborates with others to achieve their goals - it only makes sense to put our heads and resources together, instead of doing nothing and claim credits on other people's work.

The media needs to stop rewarding her attention-seeking behavior and covers real organizations that make a difference and needs real funding to back that up.

Obama's speech and Ted Kennedy's letter - an inspiration

Obama's address to the joint session of congress tonight, and the full length Ted Kennedy's final letter to Obama mentioned in the speech.

I hope these messages can help us reach deep down inside, underneath the superficial values of right wing/left wing, to the simple moral values of helping another human being in need. I think underneath all the scare tactics and lies that muddle the conversations, we just need to ask ourselves - are we really willing to let our friends and neighbors die just because they are less unfortunate than we are, just because they do not make as much money as we do? For the same reasons most people would stop from going about our day to help a dying person, maybe in a car crash or in a medical emergency, I think we could learn to give up a little bit of ourselves, our money, to help others dying from lack of health care.

Please forward widely. The time for change is now, or most likely never.

Public Option in 70 seconds - please forward widely!

Robert Reich explains the public option in simple terms in 70 seconds - all the points he made are accurate and on target. Please forward widely - we do need to step up, this is really our last chance in the foreseeable future.

The death penalty and medical errors

A fascinating, beautifully-written article on a death penalty granted to a most likely innocent man, with interesting details on fire dynamics and the history of the judicial system pertaining to the death penalty.

Reading about the system in place that should prevent an innocent man from being wrongfully executed reminds me of the supposed system that prevents medical errors from occurring - both are imperfect, with innocent victims falling through the holes in the leaky swiss cheese model to the void of failure on the other side. It used to boggle my mind how the consecutive holes could all possibly align when each slice represents safeguards designed to compensate for failures of other steps in the series of prevention. However, after being in the hospital, I realize the slices, unintentionally, have evolved to make for failures. Below are examples, in place at our hospital, of unfortunate happenings prone to encourage medical errors:

1. Barriers against effective communication
- Nurses who are primary caretakers of patients (administering drugs, collecting vital signs, administering neuro checks) are often too overworked to relay information to physicians who are decision makers in need of first-hand information on the patient. Many nurses could not finish progress notes on their patients, others are too overworked to answer questions or notify physicians of important mishaps during their shift.
- At our hospital, nurses change shift at the same time physicians round on patients - it is impossible to find nurses close to rounds to ask them about events overnight, day nurses often did not receive complete, important signouts from night nurses. Often times, important information is lost during shift changes.
- At our hospital, nurses are listed on the board next to their patients by only their last name, but all the ancillary staff on the floor call each other by their first names. Physicians trying to find a nurse for their patient will look on the board, ask around for nurses by their lastnames without an idea of their appearance and unable to call for them by first names. There have been suggestions that nurses are listed by their first names along with their contact info (beeper, voicera). It is a difficult feat.

2. Lack of continuity of care
- There have been cases of medical errors stemming from the change of medical teams or change of patient location. Many times when patients are off the floor for studies or dialysis, medications are held and not subsequently administered - there is no sign off between, for example, floor nurses and dialysis nurses to continue floor medications when patients are stuck on dialysis units for hours, missing scheduled floor medications. When medications are held, medical teams should be notified.
- At our hospital, residents are on clinic on post-call days, leaving the team, down one intern, to handle newly admitted patients unfamiliar to the less-experienced PAs and interns. A better system might be for residents to be on clinic on No Admit days, when both interns who had admitted the patients are around to provide continuity of care.

3. Lack of idiot-proof information system
- The information technology system in medicine really has to be idiot-proof, considering doctors take care of many patients, many of whom are not familiar to them. With a heavy load of patients, sleep-deprived doctors are trained to scan and scavenge information from different sources, creating a setup for human errors. Medication list/reconciliation has been a favorite area of mistakes - a good IT system should automatically reconcile medications and reduce human input to a minimum. It should also provide useful reminders to help prevent predictable sets of bad outcomes - for example, an order for insulin should prompt physicians to enter orders for parameters of when to hold insulin and what nursing should do in case of hypoglycemia. It should also ask physicians what to do in cases of HYPERglycemia (i.e. give x units of insulin) and automatically sends off hyperglycemic labs (chemistry, urine ketones, etc). An admission order should prompt physicians to enter orders that are not directly related to medicine and are often forgotten, such as DVT prophylaxis, precautions, diets, etc.

4. Multiple opportunities for medical errors
If a medical process, such as administering medications, involves 7 steps (ordering the right dose, pharmacists sending the correct drugs, nurse administering drugs to the right patient) and each step is performed correctly 99% of the time, the probability that the whole process is performed appropriately approaches 93%, and this probability exponentially reduces as more steps are introduced to the process. I think most people agree that we do not do our job correctly close to 99% of the time, and cutting down complicated steps can be helpful.

5. Lack of appropriate education
- Medical staff should be educated to recognize events resulting in potential errors and trained to respond in anticipation to prevent those adverse events. For example, if a patient fails to receive important medications when off the floor, nurses should recognize that such missed medications can cause significant outcomes and alert physicians so that they can appropriately respond (re-order medications, prophylaxis against complications). They should also convey these mishaps to ancillary staff in the next shift so that they are aware of potential complications developing as a result of inciting events occurring in prior shifts.

This is only a brief listing - various other ideas are not touched on here. The important step toward figuring out how to prevent medical errors is to learn from our mistakes - find out what had gone wrong and plug the leaky holes, incorporating inputs and encouraging communication among all parties involved.

In the case of this death row prisoner, errors stemmed from reliance on beliefs without regards to scientific evidence, and lack of interest/caring for the victim at hand - the same problems plague the medical system.

The lessons from one of the best hospitals in the world...

During the past month at MGH, arguably one of the best hospitals in the US, if not the world, I looked for subtle, innovative ideas that outsiders might not notice from simply taking a brief tour around the hospital. Health care is a complicated beast, and it really was the little things that made a big difference, not the obvious surgical robots or shiny buildings that meet the eyes of visitors.

1. The Get-to-know-me chart
In the room of every patient who cannot communicate for various reasons (stroke, delirium, intubation, whatever prevents a person from communicating), there was a Get-to-know-me chart, which consists of:
- Name AND "Likes to be called"
- Important people in my life
- Favorites
- At home I use (patients check all that apply): glasses, contacts, hearing aids, dentures
- I understand information best when...
- Achievements
- Things that stress me
- Things that cheer me up
- Others
Some of these charts are filled by the patient before surgery expecting that they might not be able to communicate post-op. Others are filled by their family members. We can imagine how important these answers are when a patient is unable to communicate well with their providers, when they may only be conscious enough to respond to the names they are called everyday, when their world tumbles in times of sickness and the important people in their lives or things that usually cheer them up can make a huge difference, when they are thrown into a new environment and things you usually rely on to function (like hearing aids, glasses) are taken away.

2. The ED observation unit
It is the limbo between the ED and the floor. Many times ED patients await beds or lab results to determine whether they need to be admitted, at which time they no longer need the specific sets of skills and services from the ED staff. The ED observation unit houses these patients so that the ED can triage new patients that need urgent care.

3. Radiology consult
Any physician in the hospital can walk into radiology reading rooms (all of which are located in the same area: neuroradiology, CT, MRI) to review imaging of their patients with a radiologists in person, in order to ask field-specific questions that are usually not answered by the broad comments in the final read. Every time we walk in, the radiologists say with a smile, "How can we help you?," as if they were greeting customers. It is definitely a far cry from Elmhurst hospital, where you can't get a hold of radiologists at whom you need to yell and argue to have them approve the study that you want. Asking them for a personal imaging review would be asking for insults coming your way.

4. Location, location, location
At MGH, all microbiology labs (virology, parasitology, etc) are grouped together, next to the Infectious Disease offices and team rooms, and that is no accident. Whenever a test result is positive, the teams walk down the hall to review lab findings in person, ask questions and get rapid updates as soon as a culture turns positive. A neurosurgery ward is across the hall from the neuro SICU - crashing neurosurgical patients can be rapidly whisked across the hall to be stabilized in the ICU. The CCU is next to the cardiac step down unit - cardiac patients can move rapidly between the two units depending on their cardiac status.

5. The Bigelow service
In most hospitals, interns on a team split patients - one intern does not know anything (or care) about another intern's patients. On the Bigelow service, all the interns share all the patients on the floor. This requires the interns to communicate among themselves regarding all development and treatment choices for each patient. It fosters a foreign concept of teaching physicians to work together and communicate with one another regarding a shared patient, which above the intern level actually happens everyday and everywhere. It also makes sense that an intern knows all the patients on the floor, since all of them are only cared for by one intern on call each night.

6. Communication
On the consult service, I learned to uphold utmost politeness in communicating with other doctors. At the end of every consult we write - thank you for this interesting consult, we will follow along with you. We also make it a point to always communicate recommendations verbally to the primary team, ON TOP OF recommendations written in the chart. At Sinai, I inched gingerly up to the consulting team and before I could ask a question, their first comment was whether I had read the chart, as if we were meant to talk to one another through pieces of paper deprived of personal cues that enhance our grasp of a message.

7. The staff
Most of the hospital staff (nurses, in particular) were there for the grind to earn money - many took no interest in the medicine or in their patients. They clock out right at the end of their shift. Many refuse to do anything other than the required lab draws and vital checks - they refuse to assist others looking for information on the status of their patients, which arguably nurses know best. Others do not care to learn what the patient has and what treatments are coming their way. None of this is true at MGH - nurses ask to be present when doctors explain treatment plans to patients. They suggest care alternatives that improve patient outcomes or reduce costs.

MGH may have flaws that plague other hospitals across the nation (commercial-driven hospital policy, budget cuts in times of depression), but it has merits that sure make for a special place for the lucky patients that can afford it.

Ex-Director of PR of Cigna testified to the Senate about the dirty deeds inside insurances companies and why we *need* a public option.

Wendell Potter, an ex-director of PR of Cigna, has been coming forward to expose the dirty practices used by insurance companies to please Wall Street investors. In this testimony to the Senate, Potter explained how insurance companies think and how that thought process ends up in creating angry, misled Americans now yelling at town hall meetings, not to mention the utterly inadequate health care system that we have now.

At the end of his testimony, Potter delineates why the public option is a must:

Thank you, Mr. Chairman, for beginning this conversation on transparency and for making this such a priority. S. 1050, your legislation to require insurance companies to be more honest and transparent in how they communicate with consumers, is essential. So, too, is S.91278, the Consumers Choice Health Plan, which would create a strong public health insurance option as a benchmark in transparency and quality. Americans need and overwhelmingly support the option of obtaining coverage from a public plan. The industry and its backers are using fear tactics, as they did in 1994, to tar a transparent, publicly-accountable health care option as a ―government-run system.‖ But what we have today, Mr. Chairman, is a Wall Street-run system that has proven itself an untrustworthy partner to its customers, to the doctors and hospitals who deliver care, and to the state and federal governments that attempt to regulate it.

Our choices at this crossroad in the reform are not between the government and freedom in the free market - it is between the government and Wall Street/for-profit insurance companies. Doing nothing leaves us in the hands of hungry Wall Street wolves looking to profit from our sufferings.

It is not an option.

Great videos - highly high-larious!

This first video is a great and simple animation explaining why we *need* a public competitor in the health care reform.

This other video is just high-larious, but somehow I'm afraid some people (like Sarah Palin) will watch it, actually believe it, propagate it, and someone else will end up really buying it. Prove me wrong, America.

Get your facts straight!

Get your facts about health care reform here, compiled by mediamatters.

Based on a prior post, I'd like to draw you attention to Myth 10:

MYTH 10: Co-ops are an adequate substitute for a public option
CLAIM: The co-op "compromise" eliminates the need for the public option.
REALITY: Progressive experts argue public plan is necessary for successful reform. Numerous media figures and outlets have characterized Sen. Kent Conrad's (D-ND) cooperative health insurance proposal as a "compromise," "hybrid," or bipartisan "alternative" to a public insurance option without noting the view by progressive experts that a public option is necessary for health care reform to be successful and that any departure from that will result in the failure of reform efforts. These experts dispute suggestions that Conrad's co-op proposal is a plausible midway point between competing methods of addressing health care reform, because, they say, it precludes a fundamental component of effective reform: bargaining power against the health care industry. For example, former Clinton Labor Secretary Robert Reich described the co-op proposal as a "bamboozle" and said that "[n]onprofit health-care cooperatives won't have any real bargaining leverage to get lower prices because they'll be too small and too numerous. Pharma and Insurance know they can roll them. That's why the Conrad compromise is getting a good reception from across the aisle." And University of California-Berkeley professor Jacob Hacker argued that Conrad "has offered no reason to think that the cooperatives he envisions could do any of the crucial things that a competing public plan must do." Additionally, ABC's Charles Gibson reported that "several health care experts" have said, in Gibson's words, "[I]f you take out the public option in terms of insurance, there's going to be no restraints on the cost of insurance." [ABC's World News with Charles Gibson, 8/17/09]

Without a significant public option that would cover a sizable protion of the population with adequate bargaining power to lower prices, this reform would not accomplish much. Even if there is temptation to pass a watered down bill and declare victory, a failed reform would not bode well for Obama or dems at future elections.

A side point: it would be reasonable to expect that the new and cheaper public plan will absorb the previously unhealthy/uninsured and the lower-income groups that may be a proxy for bad health - a setup for the death spiral. However, the same may be assumed for Medicaid, but somehow it still costs much less and provides more care to its members than most private insurances. And what is the alternative to no competition and downward pressure on prices from the public option? Private insurance companies fueling profits on people's sufferings and fulfilling its goal of providing as little care as possible regardless of need, all the while passing costs on to consumers. I think the clear winner is some form of significant public competitor that will drive down costs and focuses on health and not profit, for once.

It's not over until the ?fat senator sings...

An article by Maggie Mahar delivering a glimpse of hope to progressives everywhere - I can only hope she is right, and to help her be right, maybe all of us liberals have a role to play in all of this.

In brief, there are many proposals out there on how health care should be reformed, but here is the bottom line - without the public option, no significant changes will be made.

Why? You ask.

It is simple - any combination of subsidies, payment cap, cost shifting, mandate, or any other fancy tricks we could come up with, does not matter without a reasonably-priced, outcomes-based alternative that could be the public option, because with only private insurers to choose from, insurance will remain overpriced as these companies' only goal is to please shareholders, and not to protect consumer's health. Any combination of the tricks mentioned above, again, only alters ways money is channeled - in the end, all that money still goes to the richest 10% of this country, and all that money still comes from you and me. The only difference is the forms in which we pay through our noses - taxes, premiums, deductibles - that difference does not make us healthier in the long run.

So if anyone tries to convince you that our healthcare can change without the public option, listen to them with a grain of salt. But more importantly, it is not over until the last senator sings at the conference, and until then, the least we can do is to pipe about how we will not rest until a reasonable public option is part of the bill.

Hilarious - socialism sarcasm FTW

We got rid of the public option, let's get rid of all of these too!

Liberals: Sarcasm FTW

Republicans: *does not compute*

Obama - what a disappointment (that is still better than McCain)

There is talk coming down the pipeline of democrats weakening once again, with the public option likely to be dropped and the health reform plan so watered down, it is basically the status quo. What kind of reform will this be if it creates no change?

How is this most recent proposal any different than status quo? The only difference is the potential mandate, which is even worse than no change at all. Now lower income family will have to forgo food and be forced to pay for expensive health insurance, forced into the open arms of private insurance companies who now claim the newly open market of the uninsured. Public option will be dropped in exchange for an allowance of not-for-profit co-ops, which we ALREADY HAVE. Big not-for-profit providers? Sounds like Kaiser Permanente - I'm not sure if there are subtle differences I'm not aware of. Anyone who does - please enlighten me.

I won't go into the terms fascism, communism that are thrown around the debate - please read this post as I hate to glorify these terms as if they were valid. Let's just say - I see people in USPS, they don't seem to be complaining, and still FedEx did not get push out of the market. Everyone loves the fire department, our beloved heroes from 9/11. Some seniors would rather die before the public option is passed, yet they love their Medicare - I don't understand how these things do not compute in their heads. Many countries around the world has the single-payer system, and they are much happier and healthier than we are - really, what could be SO bad about it compared to the mess we are in now?

Not to mention reimbursement for end of life discussions will be dropped. How do we let idiots (for lack of a better term) like Sarah Palin push this out of the bill? It boggles my mind - I hope any health care professionals agree that end of life discussions are extremely important and are really one of the most difficult things you'll have to do as a physician. Anyone who has participated in the discussion or has actively dying relatives - I hope you agree that the discussions were helpful. This is really a huge setback for palliative care, which in many circumstances heal patients and their family more than any medications we can offer.

Obama is no Kucinich - Obama has no uncompromising integrity that Kucinich possesses, which explains why one is the president and the other is only a senator. The strength of Obama's message for change before the election has vanished. The public option is really one of the main pieces of his health care proposal, now claimed to be only a "sliver" of the whole reform. What a 180.

Read the comments and not the analysis

A really crude analysis on the cost-effectiveness of health care - findings were not surprising. I think the comments by the readers were more interesting.

Many of the comments mentioned that this analysis may not be relevant due to the fact that Americans start off less healthy or have more unhealthy habits compared to other countries.

This is probably correct, but it does not make the analysis irrelevant. PYLL (Potential Year of Life Lost) is a crude proxy for health outcomes, which include people developing bad health habits and starting off more obese/unhealthy in life compared to other nations. Our starting points in health and unhealthy habits should improve if we spend wisely.

Other posts argued that in this analysis, we make an unsubstantiated assumption that spending more on health care will lead to better health - this assumption is, indeed, untrue. (One comment says: If I'm an obese smoking couch potato I can assure you that no amount of spending will make me healthier than a vegetarian marathon runner). But I think that is exactly the point of this argument - because the US is ridden with managing chronic conditions like diabetes and heart disease, we are spending more on people at the end of their disease spectrum without much return, hence more PYLL/dollar and hence why we suck so much compared to others - because we are not spending money on prevention and stop people from getting sick to begin with.

I think this article is on to something, but not in terms of right wing thinking oranges and left wing thinking apples. I think it is on point in that right now we are arguing about how the money will be channeled to the final benefactors: through insurance companies as premiums, through the government as taxes, etc. We are ignoring the fact that in the end the money comes from you and me - the government does not make money without its taxpayers, insurance companies do not make money without their customers. If the cost does not change, changing the channeling is not going to save us any money. We indeed should look at the cost-effectiveness of our health care dollars, in order to ascertain where to save (reflex EKG) and where to spend more (prevention and public health).

Disappointing statement from the president of the American College of Physicians

A statement sent to the American College of Physicians members from its president, Joseph Stubbs. It has some good points, but all in all still physician-centered and not advocating for the best interests of patients (even though it pretends to do so), as demonstrated by his support for physician-negotiated reimbursement rates and not discounted Medicare's rates, which are most likely more efficient and cheaper for patients.

Also find it funny that he advocates for "increased Medicare and Medicaid payments to primary care internists and other primary care physicians, funded in a way that does not cut payments to other internal medicine specialists." I wonder where he thinks that money should come from.

---------------------------------------------------------------------------------

Dear Colleague,

Today, I write to you in my role as President of the American College of the Physicians, but first, let me tell you a little bit about my "day job." When I am not traveling around the country to represent your views as ACP President, I spend my time taking care of patients in a general internal medicine practice in rural Albany, Georgia, as I have done for the past 30 years. Like you, I take enormous professional pride and satisfaction in keeping my patients healthy, helping to heal them, and providing comfort and relief when they are nearing the end of life.

I also share the frustrations with a health care system that often is stacked against patients and their doctors. Too many of my patients can't find affordable health insurance because they have a "pre-existing condition" -- as the insurance companies like to call it. Some of them have lost their jobs -- and their insurance -- during these economic hard-times. Rising premiums and out-of-pocket expenses have brought some to the brink of bankruptcy. At the same time, patients and doctors alike are drowning in a sea of red tape, rules and regulations we cannot understand.

We physicians struggle to provide our patients with the best care possible, even as payment systems reward rushed, episodic care over spending time with patients on prevention and care coordination. Regrettably, few young physicians are choosing internal medicine or other primary care fields, and as a result, we are facing a shortage of tens of thousands of primary care physicians. All of these are barriers to our ability to provide our patients with the care they need.

All of these are barriers that health reform legislation can help overcome. This is why ACP believes that health reform cannot wait. Not just any kind of health reform, but health reform that does at least the following:

1. Provide all Americans with access to an affordable health insurance plan that does not exclude or discriminate against those with pre-existing conditions. We believe that people who can't afford coverage should be provided with help, in the form of tax credits, to buy coverage. We believe the public should have a wide choice of health plans. We believe that health plans should compete based on innovations to improve patient care, not on cherry-picking out the young and healthy. We advocate that all insurers cover preventive services and other essential benefits. We believe that if a public plan option is included, physician and patient participation in the plan must be completely voluntary, the public plan should compete on a level playing field with private insurers (no unlimited access to federal funds) and it should pay competitively -- and not base its payments on Medicare's discounted rates.

2. Create incentives to increase the numbers of general internists and other primary care physicians. We support providing medical students with loan forgiveness and scholarships if they go into general Internal Medicine or another primary field. We advocate for increased Medicare and Medicaid payments to primary care internists and other primary care physicians, funded in a way that does not cut payments to other internal medicine specialists. We support funding and pilot-testing, on a national basis, of paying internists for the work involved in care coordination through a qualified Patient-Centered Medical Home.

3. Put an end to the annual cycle of Medicare payment cuts due to the flawed Sustainable Growth Rate (SGR) formula. Year after year, Congress has used the SGR to threaten physicians with cuts, and then it ends up passing a short-term fix that makes the cuts in future years even worse. This must stop.

4. Reform the medical liability system and reduce the administrative burdens imposed by health insurers. We advocate for caps on non-economic damages and testing of new models -- like health courts, which would have cases heard by an expert panel rather than by a lay jury. We call for standardization of insurance credentialing, quality reporting, and patient eligibility verification, and other reforms to simplify and reduce administrative costs.

As ACP evaluates pending bills, we lend support when they are consistent with the above priorities, and call for changes when they are not. For instance, although we support provisions in the current bills that would make health insurance coverage more affordable by providing subsidies to help people buy coverage from qualified plans, we expressed strong concern about a new public plan that would pay doctors based on below-market Medicare rates. The House has since agreed with us and decided to change its bill so that a public plan would have to negotiate its payment rates with doctors and hospitals, up to prevailing private sector rates.

Congress has decided that it will not take a vote on legislation until after the August recess, which began on August 7. Congress will return after Labor Day. The recess gives us an opportunity to continue to influence the bills so they meet our priorities, as described above. To get the changes we want, ACP needs to continue to participate in the process -- being insistent in supporting the policies we like and seeking changes when they do not. We can't move the ball toward our policy goal posts if we walk off the playing field.

Now, I know that some of you are concerned about ACP lending its support to particular bills. ACP represents a diverse membership of 129,000 internal medicine physicians and medical student members, and no two internists will agree on every issue. Some of you are deeply conservative and distrustful of any reforms that involve a larger role for government, and you especially object to a public insurance option. Some of you are deeply liberal and favor a single payer system and oppose any plan that would cover people through private insurance and eliminate a public plan option. Many of you, like me, are somewhere in-between.

Still, we are all internists who share a passion for patient care and the desire to make sure that health reform meets our patients' needs. As internists, we must be unified in our quest for health care reform that delivers on the priorities I've described above – priorities that came from ACP's members and that are supported by most of us. While unity is important, so is respectful recognition and discussion of our differences as we, together, sort through the often conflicting and large amount of information on health care reform. I, along with everyone at ACP, will do my best to make sure that we provide you with up-to-date and accurate facts so you can assess the various health care proposals and engage in a productive dialog. You can learn more about how to become involved in ACP's advocacy activities through our Legislative Action Center.

We should also consider the consequences if health reform fails, and we leave it to a future Congress to pick up the pieces of a broken health care system -- years or even decades from now. The result will be more uninsured patients, more families going bankrupt because of high health care bills, more cherry-picking, Medicare insolvency, and continuation of a payment system that undervalues the care provided by internists, leading many young physicians to choose other fields. This is not a future I want for my patients or our noble profession.

Within our grasp is achievement of health reform legislation that makes coverage affordable by building upon and improving our current employer-based system, providing incentives for young doctors to go into primary care internal medicine, reforming and improving Medicare physician payments, and reducing the costs associated with our broken medical liability system. Let's not let it slip away.

Yours truly,

Joseph W. Stubbs, MD, FACP
President

Why Can't Americans Get Health Care Right?

A good article by a professor at the Harvard Business School, outlining points similar to my earlier post on why health care really cannot be left to the market forces.

The misguided debate that is health care reform

The health care problem that we have now is complicated - many aspects of it needs to be fixed. The current debate focuses so much on the payer that it misses other points, such as supply and demand that drive costs. Ultimately, only individuals pay for the costs of health care, through premiums if they pick private insurances, taxes if the public plan goes through, etc. The money comes from you and me, and right now most of what we are debating is on how it will be channeled to the payees. In the end, this debate is moot if we don't fix inflating costs driven by many factors, including the fee-for-service system, which is a major agency problem where agents (physicians) are also suppliers, and they almost always decide whether products are consumed (I can't imagine patients negotiating with doctors whether they need an MRI or a surgery).

Even a debate that focuses on reducing costs or on health care in general is still limited. Health care is in no way equal to health. Considering that the majority of health costs today stem from managing chronic diseases, health care is really a bandage on health already lost. By the time patients first present with a stroke, there is little medicine can do, when if only a fraction of the same resources is spent on public health initiatives affecting various root causes of health, we can prevent people from getting sick to begin with and improve health much more effectively. Similar points are put forth in this testimony

The testimony also make a salient point about individual vs social responsibility in terms of health - it really speaks for people who most likely do not have resources to blog or explain to people that matter why they continue to consume unhealthy food and do not exercise.

Stop Playing Homework and Do Your Video Games - A Video Game Quintet

Check out this awesome video! Really, stop playing homework and do your video games!

What goes on behind the doors of insurance companies?

An interview with an ex PR-head of Cigna, describing what goes on behind the doors of insurance companies and why healthcare should not be a business driven by profit.

Healthcare is a sensitive and complicated problem, and I don't claim to know the answer to the grave situations that America (and the world) is in, but one thing I know for sure is that healthcare cannot be left in the hands of for-profit business. Here is why:

- Insurance companies and rich, powerful interest groups like the American Medical Association (AMA) claim that status quo is best, that free market is efficient. This is untrue, because, apart from the fact that barely any industry in this world is truly free, fair and efficient, you will see in any basic economics book that fair and efficient free market requires that the following conditions be met:

1. Consumers make rational decision - when it comes to life and death, I think we all know that any kind of rationale goes out the window. How do we even begin to calculate how much our loved ones' lives are worth accurately? Sometimes allowing a comatose, frail elderly to die would seem sensible, but how do we make that decision when the vegetative elderly is our grandmother?

2. Free flow of information - there certainly is not. Apart from the fact that incumbent powerful groups actively try to prevent flow of information, it is almost impossible to expect patients to understand the healthcare they are getting or what insurance companies provide in a package. Even most doctors, people who supposedly know healthcare the best, get headaches thinking about insurance and cannot begin to figure out what insurance plans cover. Getting a surgery is nothing like buying a cereal - you can't try it a few times until you find the brand you like, you can't taste it before you buy it, there are no pictures to show you what it looks like. Healthcare is a black box of cereal without any kind of commercial or free samples for it, and you only get one box.

3. No barriers to entry - either for competitors or consumers. As outlined clearly in the above interview, insurances companies are geniuses at establishing oligopoly and eliminating competitors. Barriers for consumers go way beyond pre-existing conditions and dumping employers from the rolls, to name a few.

4. Many buyers/sellers - so that competition exists which leads to efficiency. As mentioned in 3, the insurance companies are actively trying to eliminate sellers and problematic buyers

5. Homogeneous products - so that consumers can choose the most efficient supplier who can produce at the lowest cost. Healthcare products found in each hospital and offered by each insurance companies are drastically variable - there is nothing homogeneous about it.

Based on the points above, healthcare industry is far from free, fair or efficient. Now one may argue that we allow many industries in America which are neither fair nor efficient to exist, what makes healthcare so special?

As outlined in the interview, healthcare industry deals with human lives - your neighbors down the road, your wife, your son, and not the corn that is made into cereal or trees that are made into tissue paper. The ramification of what we allow in insurance companies or hospitals affect human beings, and for important services that involve human lives, like the fire department or the police, most countries rely on the government to provide these services to make sure that there is a safety net for everyone and that these services are not cut short or distorted by private profits and corporate greed. If we are ok with the government-run fire department, which is efficient and has not failed to prove itself in the times of crisis (remember 911?), why would it be so disastrous to have the public option and put just part of healthcare into the hands of the government?

To help alleviate the fear, these are facts, as delineated by Senator Kucinich in this video

In Canada, a single-payer, government-run, universal insurance health care system which supposedly ration health care:

- Wait time for procedures and diagnostic imaging is much shorter than in the US
- Much lower incidence of medical bankruptcies
- Fewer people go without health care due to the inability to pay
- Canadians are much happier and more satisfied with their health care system. Walk down the streets of America and ask people if they are satisfied with their health system, I think it is pretty obvious that Canada wins by far.

So as the debate for healthcare reform unfolds in the coming months, please do not let lies and lobbyists fool you. Go out there and look for facts, listen to witnesses, make an informed decision on which kind of healthcare you want to have.

And fight for it.

Watching death

I find it crazy that in today's world, the power of technology allows me to access medical records from home, and in so doing, allows me incredible insight into people's lives.

It is 946PM - someone will die from pneumonia very soon, but not quite yet, and although this person is not my patient, I know that his brother is traveling from far away to be with him at his deathbed. Alas, his brother can't make it here until 10PM, and until then I refresh my screen frequently, hoping against hope that this patient can hang on for a bittersweet closure.

What a weird feeling - watching someone die through a computer screen.

Shinigami academy

If medical schools were to be a shinigami academy, I guess we as third years are looking for placements in various squads. The squads are divided into melee-based (surgery) and kidou-based (medicine). Based on the characteristics of each squad, the fields can be best assigned as below:

1st Squad: Boss of every other squads - politicians
2nd Squad: Assassins - Critical care
3rd Squad: Despair - palliative care
4th Squad: Getting shit on by everyone - ER
5th Squad: Tricked everyone else - The MudPhuds who puppet us using their cunning EBMs
6th Squad: Elites - Derm
7th Squad: Run by a fox - vets?
8th Squad: Stoned womanizer - Addiction medicine
9th Squad: Run by a handicapped - Rehab
10th Squad: Run by a teenager - Pediatrics
11th Squad: Blood-thirsty meathead - Ortho
12th Squad: Researcher - Pathology
13th Squad: TB-ridden captain - ID

The espadas were created by the 5th squad to eliminate all other doctors - big pharmaceuticals?

I'm the biggest dork. I wonder how many people understand what I just wrote.