Adoption of Health 2.0 Platforms by Physicians on Main Street

I felt honored to be included in a panel discussion at the Health 2.0 Conference in San Francisco last fall. Here is a link to the video of the discussion by 4 physicians reacting to the potential usefulness of these tools to enhance doctor/patient interractions in our practices. http://www.health2con.com/2009/10/20/adoption-of-health-2-0-platforms-by-physicians-on-main-street/

The Midnight Vote of Harry Reid

Listen my readers, while we opine
On the Patient Protection and Affordable
Care Act of 2009.

Reid said to Pelosi
If it looks like we have the votes tonight
Go to the Capitol dome
And hang a light
One if we have sixty,
Two if we have less,
And I on the Senate floor will rest,
Ready to call the bill for a vote
Before the senators can read what we wrote.

Some say that government-run
Healthcare is a joke.
So what if the VA is crumbling
And Medicare is going broke?
We'll make them buy insurance.
If they don't, levy a fine,
Or tax them again,
Or put them in jail for a time.

Since some feel a single payor
System is not fair,
We'll just change the name, and
Tell them they are in Medicare.
Those whining doctors and hospitals
Will come to their knees,
When we raise their taxes
And lower their fees.

And to make sure we don't lose
Any of the votes that we've got,
We'll change the bill's wording, so
They can't tell if we pay for abortions or not.
We can give up a little.
To compromise, we can pretend.
Then we'll fix it all in Conference
Committee in 2010.

And so through the night went his cry of alarm
To every Middlesex village and farm.
We'll change our healthcare system,
Driven by power, compromise, and greed.
The people will have a new system born of
The midnight vote of Harry Reid.

Medical Defendants and Defensive Medicine

My name is Steve, and I am a recovering defendant.



It has been a little over 15 years since I was last sued in a medical liability case, but the experience is still with me today.



Attorneys seem to be able to take these things fairly lightly. Sure, they work hard, and argue their clients' cases passionately. But at the end of the day, win or lose, they go home and start working on the next case. Maybe it is different when they are the ones being sued. Where you stand on an issue often depends on where you sit.



Physicians I have met who have been sued, though, have trouble not taking these things personally. They put a great deal of themselves into their patient care, and a lawsuit alleging that they have been negligent in that care or that they have not met the "standard of care" for their patients is often felt as a personal, as well as a professional, failure, even if they feel the care they rendered was appropriate at the time. And even if there was no wrongdoing, there is still a prolonged period of self doubt and agony leading up to the trial. Then there are the depositions and the trial itself, when the physician's life is examined under a microscope looking for flaws.



An "expert" witness for the plaintiffs at my trial testified that the standard of care required that any patient with chest pain unexplained by an abnormal EKG must have a CT of their chest. My malpractice provider even informed its other insured clients that this would now have to be considered the standard of care in our area. Although I was found not guilty by unanimous verdict in my trial, I would estimate I have ordered 4 or 5 chest CT's a month ever since then to avoid ever being put in such a situation again.


The costs in money and radiation exposure of this one change in practice is large. When multiplied by many other physicians who do not wish to undergo the personal agony and humiliation of leaving themselves and their families open to the possibility of a lawsuit, the cost is enormous. Estimates of the annual costs of "defensive medicine" are in the $100 to $200 billion range. These are likely underestimates of the costs, since the documented "indication" for a procedure is never stated as such. 83% of physicians reported they practice "defensive medicine" in a survey by the Massachusetts Medical Society last year (http://www.massmed.org/AM/Template.cfm?Section=Advocacy_and_Policy&TEMPLATE=/CM/ContentDisplay.cfm&CONTENTID=23559). They reported that 18 to 28 percent of tests, procedures, referrals and consultations, and 13 percent of hospitalizations were ordered for defensive reasons.



I have survived the death of two parents and a spouse. When these deaths occurred, I never had the inclination to find someone to blame...someone to sue. In our grief and pain the death of a loved one seems "wrong," but every death is not "wrongful." We are mortals, and none of us will get out of this alive. Ultimately, our expected mortality rate is 100%, even with appropriate medical care.



Our current medical tort system does more than damage our budgets. It damages the trust our patients have for their doctors, and the trust our doctors have for their patients.



Until we are ready to recognize these economic and personal costs, and enact meaningful tort reform, we will not be able to enact meaningful healthcare reform.

These Pills Work Best When Taken Internally

A patient was referred to me for treatment of refractory hypertension. Her medication list was quite long, and I reviewed the medications with her, I asked "How many times a day do you take this one?" She took the bottle, and looked at it for a moment, and replied "I don't take this one at all. I just keep it on the nightstand." When I asked her why she wasn't taking it, she told me "Doctor, I just don't like to take medicine." I spent some time explaining to her the need to control her blood pressure to prevent a heart attack or stroke or kidney disease down the road, and that the pills were not likely to work by sitting on the nightstand. They needed to be taken internally.

The benefits of treating high blood pressure, high cholesterol, and diabetes are well documented. These treatments are cost effective, because of the reductions in cardiovascular disease they yield over time. The problem, though, is that patient acceptance and compliance are variable.

A new study released by the New England Healthcare Institute last week estimates that one-third to one-half of patients in the US do not take their medications, as prescribed. It estimates the increased cost of healthcare for these patients, based on increased needs for hospitalization, treatment of uncontrolled conditions, and early deaths at $290 billion annually. It also shows that patients with chronic diseases are less likely to take their medication correctly than are patients with an acute problem.

After all, a pain medicine can make you feel better quickly. An antibiotic can clear up an infection in a few days. While there may be some early reduction in blood pressure or cholesterol when treatment is started, blood pressore and cholesterol medications do not make you feel better on a daily basis.

It takes education and a receptive patient who is willing to endure the cost and inconvenience of taking medication daily to achieve the future benefit of preventing health problems later in life.

Prescribing medication is easy. Assuring that the patient will be a compliant partner in the treatment plan is not. Clearly, though, the medications work better when taken internally.

Wouldn't this time and money be better spent taking care of patients?

A recent study published in Health Affairs estimates that the cost of time spent by physicians and their office staffs interacting with insurance companies was $21-31 billion annually, or about $68,000 per physician per year. This includes nearly 4 hours of nursing staff time per physician per day, and 7.2 hours of clerical staff time per physician per day, as well as 43 minutes per day of direct physician time.

Wouldn't this time and money be better spent taking care of patients?

A thought to consider as we debate the future of healthcare delivery in this country.

Expanded healthcare coverage...at what cost?

The Obama administration's goals for expanding healthcare coverage to those who are currently uninsured is admirable, and who could criticize such a plan? Wouldn't we all like to have the security of knowing that our healthcare needs will be met, no matter what the future brings?

Much has been written about the direct costs of such a plan. The estimates are probably no more accurate than the estimates for GM's needs to avoid impending bankruptcy.

What about the indirect costs to our society in the form of future tax increases for funding the plan, and in the form of inflation created by growing deficits that will be passed on to our children and grandchildren?

How about the costs to our healthcare delivery system, that will be forced to accept lower payment rates for providing healthcare services. One cannot afford to deliver care that costs more than the reimbursement given for very long. Neither hospitals nor physicians can make up the loss generated on each transaction by increasing the volume of transactions.

Meanwhile, our patients demand better, more accurate diagnostics and cures, despite the costs involved in providing them. Our current healthcare delivery often removes the consumer (the patient) from the financing of the purchase, which is handled by anonymous insurers or government agencies. There is always unlimited demand for a "free" service, and patients feel they are entitled to unlimited care, despite their ability or inability to pay for it.

As we transition to increased public financing of this effort, how do adjust our patients' expectations that they can continue to use services without any limits? And if limits are imposed, will they simply access the system through healthcare's back door, the emergency room, where the threat of a plaintiff's attorney's shadow is always lurking if a bad outcome occurs?

We need more than the bandaid of a new entitlement program to solve the problems of healthcare financing and delivery. We need a frank discussion of what our society's goals and objectives should be. Only then can we design a system to take us there. As Lewis Carroll wrote: "If you don't know where you are going, any road will get you there." We have come to a fork in the road. We should follow Yogi Berra's advice, and take it.