Unreality show

From RangelMD: 10 Rules for Doctor TV Shows

Data Breach

BlueCross BlueShield data breach affects 850,000 doctors:

Physicians’ names addresses, federal tax ID numbers and national provider numbers were contained in an unencrypted file on the laptop.

The data breach presents the possibility of massive medical insurance fraud, but the 187,000 doctors who used their Social Security numbers as tax ID numbers or provider numbers are most at risk of identity theft.

The unnamed employee, in dereliction of company policy, downloaded the database to his personal laptop to work on it at home. The computer was stolen from the employee’s car August 27 and the crime was reported to the Chicago police.

No patient information was in the file.

The file was encrypted while on the insurance company’s network according to protocol, but the employee unencrypted it before downloading it.

I’d like to buy the world a Coke

So, any reaction to that AAFP/Coca-Cola deal?

The Skeptical OB says Family docs: Have a Coke and a bribe!

The Radical Clarity Group says In one stroke, AAFP has indicated that it can be bought.

The Newbie Vegetarian likens the deal to the sale of the AAFP’s soul.

On a practical level, the money the AAFP will get from the Coca-Cola Company will doubtless be put to good use.  The question is how much ire from the Academy’s membership and how much lost credibility with the public is the organization willing to accept?

UPDATE: Marion Nestle at Food Politics says This partnership places the AAFP in embarrassing conflict of interest.  Julie Deardorff at Julie’s Health Club says the venture will—and should—undermine the credibility of the AAFP, one of the leading family doctor groups in the U.S.

UPDATE II: From the Later On blog: Oh, Jesus! This is just pathetic.

UPDATE III: Ken Terry at BNET: [A]t the end of the day, corporations do not spend money on “educational materials” unless it somehow promotes their products. And I am not sure that the AAFP is doing people any favor by telling them it’s ok to consume soft drinks that have no nutritional value but can make them fatter–and therefore, more subject to a host of chronic diseases.

Blogger Lauren Melissa says the AAFP has sold their soul.  Adds Melissa: Pardon my language, but what the shit?!

UPDATE IV: Katherine Hobson at U.S. News & World Report has picked on the story.  Some interesting comments. too.

UPDATE V: Several [AAFP] members spoke [at a recent town hall meeting] of their concerns about the AAFP partnering with a company whose products have been linked to increased obesity, especially in children.

Things go better with Coke

From the What Were They Thinking? Department:

The AAFP today announced a corporate partnership with The Coca-Cola Co., in which the beverage giant will provide a grant for the Academy to develop consumer education content related to beverages and sweeteners for the AAFP’s award-winning consumer health and wellness Web site, FamilyDoctor.org.

Yeah.  This was a good idea.  All will go well with this.  I mean, no AAFP member backlash or anything.  Nope.  Clear skies and smooth sailing.

Tired doctors told to drink more coffee

The Australian government has found the solution to fatigued physicians: drink coffee and/or energy drinks.

Hey, it worked in med school.

H1N1 Plush Toy

The swine  flu virus that  is the cause of so much hysteria concern by the news media is now available as an adorable plush toy.

Talk to your plants

First it was irate people shouting down the speakers at these town hall meetings.  Now there are allegations that some of the people at these meetings are Democrat plants.

An 11 year old girl allegedly chosen at random told President Obama at one such meeting that there were people “outside saying mean things about reforming health care”.  The girl’s mother was reportedly an Obama organizer.

And at a Texas town hall meeting attended by Congresswoman Sheila Jackson Lee (D-Tx), a questioner who was purported to be a “pediatric primary care physician” is reportedly a graduate student in social work and an Obama delegate.

Have a primary care physician, live longer

This study claims that more primary care means less mortality:

Analyses at the county level show lower mortality rates where there are more primary care physicians, but this is not the case for specialist supply. These findings confirm those of previous studies at the state and other levels. Increasing the supply of specialists will not improve the United States’ position in population health relative to other industrialized countries, and it is likely to lead to greater disparities in health status and outcomes.

A profession of fighting

That’s how the Angry Pharmacist describes pharmacy, and he inadvertantly describes the practice of medicine at the same time.  As far back as my interviews for medical school I did notice how curiously confrontational medicine seemed to be.  Even now, 15 years later, there is a constant feeling of being in combat not simply against disease and injury but against patients, insurance companies, the government, the legal system, the media, and even at times other physicians.

Trainwreck Nation

Fact #1: Most Americans’ healthcare is paid for by a third party, either private insurance/pharmacy benefit managers or governmental entities like Medicaid and Medicare, or by both.

Fact #2: This type of third party payor arrangement only works when most people who are a part of it don’t need it.  For example, most people have car insurance but it is only a tiny subset of car insurance policy holders who find their cars damaged or destroyed at any given time.  Likewise, homeowners insurance works because the ratio of homes that are damaged or destroyed to those that are intact and therefore without any claims filed against them is very small.

Fact #3: The third party payor arrangement for healthcare doesn’t work very well because, not to put too fine a point on it, there don’t seem to be too many well Americans left.  Injury and illness — and increasingly chronic illness in particular — are very common.

In my own office, I see high blood pressure, high cholesterol, back pain, bipolar disorder, obesity, chest pain, anxiety, seizure disorder, and headaches…before we open the doors to see patients.  The above description covers some but not all of the complaints and diagnoses of my staff.  And my staff ranges in age from 24 to 45 years old, a fairly young office.  The military is having trouble finding young people who are physically and mentally fit for service.  As of 2006, a paltry 8% of Americans were adhering to a healthy lifestyle.  The obesity rate for children is at or above 30% in 30 American states.  Even with the current administration’s obsession over healthcare, we have a President who smokes and a surgeon-general nominee who is overweight.

Physicians are often taken to task for not practicing preventative medicine and for treating disease in its advanced stages rather than detecting it early or preventing it outright.  But exactly what arcane medical secrets are doctors supposedly holding back from the American patient?  That high fat, high carbohydrate, high calorie diets are bad?  That regular exercise is good?  That smoking is detrimental to one’s health?  While there is always room for improvement in medical practice with regard to prevention, the lion’s share of America’s medical malaise rests with the lifestyle choices made by patients.

There are plans being made to provide universal healthcare for all Americans.  These plans are predicated on the idea, which may not be entirely correct, that there are large numbers of Americans who are in desperate need of medical care but who cannot afford it.  If this is true, we can predict that a new influx of sick people into the third party payor system will create even more of a burden on a system that is already dysfunctioning badly.  In fact, after the state of Massachusetts implemented universal healthcare, that is exactly what happened.

I’ve written on Dr. Bobbs that I don’t think the third party payor model is the best or even a very good way of paying for healthcare.  But if we are going to persist with this model for the foreseeable future, we desperately need large numbers of healthy, vibrant people who can contribute funding to the healthcare system while utilizing little or no healthcare resources themselves.  But from where will these trim and vigorous people come?  Even the young, a term once almost synonymous with health, are smoking, getting fat, and not exercising very much.

Americans need to simply change their lifestyles and change them radically.  They also need to have a primary care physician who sees them periodically.  How can this be achieved?  One former presidential candidate went so far as to say, “[Y]ou can’t choose not to go to the doctor for 20 years. You have to go in and be checked and make sure that you are OK. ” While we are not quite to the point of compulsory visits to the family doc, the fact that a serious candidate for the presidency could seriously say such a thing is a sign of the times.

While the debate on healthcare rages on, it’s important to remember that what American healthcare really needs is not simply more coverage and more medicine and more doctors.  It would really help if we had fewer patients.

Is this company trying to extort money from doctors?, Part 2

The May 4, 2009 Tennessean has a story on Health Research Insights.  An excerpt:

Health Research Insights, the Franklin-based company that sent the letter, is riding a wave of interest among self-insured employers intent on examining bills from physicians and other providers for what could be overpayment errors.

For employers including Cookeville, Tenn., trucking company Averitt Inc., which hired HRI, it is all part of a push to control rising health-care costs while fulfilling obligations to ensure that their health plan dollars are spent wisely.

But doctors such as Hill question HRI’s techniques, suggesting that the approach seems to assume wrongdoing took place after studying payment data that doesn’t necessarily take into account all the details of a particular patient’s case.

“You should check the medical records before you accuse somebody of fraudulent billing,” said Hill, who responded two weeks later by providing records to show that his billings were accurate.

Others defend HRI’s practices and say it and other similar companies have a role in making sure health-care dollars are spent appropriately.

I’m pretty sure the “others” who defend HRI’s practices are people who don’t have a problem with physicians and hospitals being targets of intimidation by a company that doesn’t bother to look at medical records — the only way to confirm or deny that even the possibility of fraud or overpayment has occured — if it means more money in their pockets.  This sounds like something the Tennessee Attorney General might look into.

It’s just the flu, people!

Not to diminish the potential complications of the illness and with no disrespect to those who have lost loved ones as a result of it, but…it’s just the damned flu, folks!  And a mild strain of the flu at that.  Does putting the name “swine” in front of it and having the news media give it round the clock coverage make it somehow worse?  Some perspective here: In the last 24 hours 109 Americans have been killed in car accidents.  Another 109 will die in the next 24 hours.  On average, 109 Americans die in car crashes every day of the year.  Where are the news stories on the Bad Driver Pandemic?

In a typical flu season, hundreds of thousands of people worldwide die from complications related to the disease.  One flu death is one too many and reasonable precautions against the swine flu should be taken, but the context of this statistic seriously suggests that the impact from the swine flu problem is, from a dispassionate epidemiological perspective, trivial.

Two “probable” cases of swine flu at a local school has resulted in every school in the county being shut down for days.  Today at lunch, I noticed the restaurants were full of happy, healthy teenagers.  Instead of congregating at school, they were congregating in restaurants.  While I doubt these young people are immune to the swine flu, they do appear to be immune to the swine flu hysteria that has gripped the media, the World Health Organization, and any number of local, state, and national politicians who now have an excuse to appear concerned and authoritative in front of television cameras.

Let’s define our terms

For me, saying “This was written by Thomas Sowell” is usually sufficient for me to conclude that the article or book in question is required reading, utterly brilliant, and eminently quotable.  And this piece is all that.  Some excerpts:

Insurance is not medical care. Indeed, health care is not the same as medical care. Countries with universal health care do not have more or better medical care.

…

Those who think in terms of talking points, instead of trying to understand realities, make much of the fact that some countries with government-controlled medical care have longer life expectancies than that in the United States.

That is where the difference between health care and medical care comes in. Medical care is what doctors can do for you. Health care includes what you do for yourself – such as diet, exercise, and lifestyle.

…

Even for things that take longer to do you in – obesity, alcohol, cholesterol, tobacco – doctors can tell you what to do or not do, but whether you follow their advice or not is what determines the outcome.

Americans tend to be more obese, consume more drugs, and have more homicides. None of that is going to change with “universal health care” because it isn’t health care. It is medical care.

YOUR ILLNESS WILL BE EXTERMINATED!!!

In Touch Technologies’ remote presence robotic system, known as the RP-7, has already found its way into hospitals.  The Cult of Skaro was unavailable for comment.

But I thought their health care was so much better than ours, Part 7

From The Vancouver Sun via John Goodman’s Health Policy Blog:

[T]he health minister, attorney-general and Medical Services Commission of B.C. deny…claims that patients have a constitutional guarantee of access to medical care in the private or public systems.

“There is no freestanding constitutional right to health care,” the government’s statement of defence says in contending that the Charter of Rights and Freedoms doesn’t protect patients who wait long periods for care.

So health care is not a right?  Then what could it be?  Hmm…

FP residencies under attack

AAFP News Now is reporting  on  an  FP  residency  in California that the Centers for Medicare and Medicaid Services (CMS) has decided to stop supporting. The CMS even wants back $19 million paid to the residency. Meanwhile, an FP residency in New York City shuts down.

You’d think that the recession, brought on by absurdly bad decisions on the part of business, government, and individuals, would have taught people the dangers of shortsightedness.  You’d be wrong.

Snow job, Part 2

Our old friend, David Snow, CEO of Medco, is back to share his thoughts on health care reform.  Nothing new here.  The usual boilerplate on “protocol-based” medicine, making everything “wired,” focusing on lifestyle modification, et cetera.  And, as usual, we’ll allegedly save hundreds of billions of dollars. 

Today at the office, my med tech spent 10 minutes on the phone with Medco trying to get a prescription approved to help a patient stop smoking.  My med tech was told that it would only be approved if it were being prescribed for smoking cessation.  My records show we tried to get Medco to approve this drug 4 months ago for, you guessed it, smoking cessation.  It was denied.

Yes, if anyone has the right to lecture the medical community on things like cost savings from lifestyle modification and making health care more efficient, it’s David Snow.

A cautionary tale from California

This article from the Pasadena Star-News is about selling gasoline, not health care.  But the following quotes, particularly the last one, seem infused with a lot of health care — and especially primary care — resonance:

Dozens, and potentially hundreds, of gas stations around California are choosing to shut down rather than comply with a state mandate that would require owners to purchase new equipment to reduce vapor emissions at the pump.

It requires gas station owners to individually purchase tens of thousands of dollars of equipment designed to prevent harmful vapors from escaping into the air when gasoline is pumped.

But smaller retailers say that the requirement puts an unfair burden on businesses that don’t sell enough gasoline to offset the extra cost – and that don’t contribute much to the problem in the first place.

Among them is George Fasching, who after 31 years of selling gasoline at Fasching’s Car Wash in Arcadia, stopped in December.

“I came to the decision that I was too small a volume operator to continue on with the expenses imposed by the bureaucracy of the state,” Fasching said.

April’s requirements would have cost him $35,000, he said. Fasching used to sell the gasoline as a convenience for his car wash customers, and blames the new regulations for forcing him to stop.

“It will have some effect on my business, but at least I have the relief that I don’t have to deal with these people anymore,” he said.

Snow Job

David Snow, the CEO of Medco, the pharmacy benefits management company, displays unbelievable arrogance and ignorance in a recent Wall Street Journal Health Blog entry:

Snow said the time has come for doctors to follow set protocols on how to treat patients, and to be paid based on whether they do it. Basically, ‘If X, then do Y,’ and ‘If Y, then do Z,’ sort of stuff. Snow concedes the public doesn’t trust the private sector to come up with these kinds of rules. So he wants some smart folks to get together in an “apolitical” body like the Fed, and do it themselves. “I’m fine with this big, national board creating this standard,” Snow says.

Doctors often bristle at the idea of these sorts of rulebooks, because they argue the rules don’t take into account the nuances and intangibles of caring for individual patients. Plus, they think insurers basically use such rules as excuses not to pay for things.

Perhaps that’s because that’s exactly what insurers frequently do.  He should know that.  After all, his company has been successfully sued for its prior authorization policy.

“I have no patience for a doctor who says, ‘I’m above it all, I don’t want to practice cookbook medicine,’” Snow says. Too many doctors, he says, just don’t keep up with the science. For instance, Medco last March asked 1,000 doctors who prescribe the potent blood-thinner Coumadin about a genetic test that the FDA has endorsed to keep patients from getting dangerous, excessive doses. Only three of them had heard of the test, he says. That’s an important test.

It is?  How important, exactly?  What is the cost of the test?  What are the false negative and false positive rates?  You see,  doctors ask those kinds of questions and don’t just start ordering a new test that was approved just a few months ago.  Or as Bussey, et al in Pharmacotherapy (link, registration required) put it:

Can genetic testing be used to determine the right warfarin dosage? Does such an approach reduce clinical complications and save the health care industry billions of dollars annually? The answer, quite simply, is maybe, but no one knows for sure. Although the concept may be attractive and this evolving area needs to be researched, good clinical data to support the use of genetic testing for warfarin dosing are not yet available. Also, it is important to realize that the impressive conclusions from the Brookings report mentioned above are based on supposition and projections, not on solid clinical outcome data. Furthermore, some experienced clinicians question whether genetic testing adds significantly to the information one may discern by carefully monitoring the inter-national normalized ratio (INR) and by taking into consideration the numerous patient-specific factors that influence warfarin dosing requirements, such as age, underlying disease states, and concomitant drugs.

Doctors do keep up with the science.  But keeping up with the science does not mean confusing the latest information with the best information or jumping on every bandwagon that rolls by until the science has been properly vetted.

Snow does offer a carrot to make this approach more attractive to docs. He says doctors shouldn’t be held accountable legally if they follow the protocol and their patients have bad outcomes. That’s what he calls tort reform.

 While Snow appears clueless when it comes clinical medicine, his views on the legal system may carry more weight given his first hand knowledge on the subject:

Medco Health Solutions, the largest pharmacy benefits management company in the United States, last week settled lawsuits brought by state and federal authorities by agreeing to stop switching patients over to more expensive drugs not prescribed by their doctors (these drugs were favored by Medco because of private “rebate” agreements with drug manufacturers). Medco also pledged to begin disclosing its rebate practices to employers, doctors and patients.

This doesn’t sound like such a good idea

Another telemedicine story:

In the midst of a frantic week in September filled with auditions and deadlines, New York casting agent Michael Cassara had zero down time. So one day, when he felt a sore throat coming on, Cassara had his doctor beamed into his office.

Cassara didn’t use lasers; he used his laptop. Logging into his account at hellohealth.com, Cassara clicked on the link for video chats and made an appointment, and an hour later, Dr. Sean Khozin popped up on his screen.

Based on how Cassara was feeling and his propensity to get strep throat, Khozin diagnosed a strep infection, “and five minutes later I had a prescription phoned in to a nearby pharmacy,” Cassara says.

And two days later, your immune system eliminated the virus you had.

Call me cynical, but I get quite a bit of inaccurate and inconsistent information when taking a history from a patient.  Often, the physical exam and/or an objective test reveal the genuine diagnosis.  Telemedicine certainly has the potential for wide application, but I’m not rushing to jump on the cybermedicine bandwagon.