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.
Sunday, August 30, 2009
Saturday, August 15, 2009
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.
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.
Thursday, August 13, 2009
Thursday, August 6, 2009
The Lowest Bidder
Our pilots take comfort in knowing that they go to battle in fighters manufactured by the lowest bidder. Why shouldn't we all feel better knowing that our healthcare will be provided by the lowest bidder?
Sunday, July 19, 2009
The Greedy Physician
In the current debate over healthcare access and financing, the greedy physician has been cast as a stumbling block for making reform possible.
Consider the finances of a solo cardiologist.
If he is fortunate to have a busy practice, he might bill about $2 million for his services in a year. About half of those services are given to Medicare patients, and Medicare pays him about 35 cents on the dollar, or about $350,ooo. About 40% of his patients have commercial insurance. These days, commercial insurance plans reimburse for services as a percentage of Medicare reimbursement rates, and he receives about 45 cents on the dollar for these services, or about $360,000 each year. About 10% of his patients have Medicaid coverage or no insurance at all, and he is paid about 25 cents on the dollar for those services, or about $50,000 per year. This gives him a total income of about $760,000 a year for the $2 million of services he rendered. About 60% of this income goes to pay for his office space, utilities, insurance, and staff. If he controls his costs well, he keeps 40%, or $304,ooo, for his personal income.
To generate that income, the physician works an average of 100 hours per week. This puts his hourly wage rate at about $50/hr, assuming we allow him "time and a half" for the 60 hours of overtime he works in a week. That's a little less than GM estimated for the total wage of their average auto worker during recent Congressional hearings.
One can argue that doctors and/or auto workers are overpaid, but their wage is about the same. Of course, the average auto worker didn't have to train in college, medical school, and residency to learn his trade. The average auto worker doesn't usually get called away from his family on nights or weekends or holidays to take care of a malfunctioning car or assembly line, and he rarely has to talk to a plaintiff's attorney if a car didn't turn out great.
To finance expanded healthcare, though, large cuts are proposed to physician's fees, which have been judged to be the real problem here. In Cardiology, for example, the proposed cuts in 2010 are estimated to be about 40%. Naively, we might think that means the physician will have to accept $30/hour for his services. In truth, though, it is unlikely that his landlord, or utilities, or suppliers will consider it their patriotic duty to cut their bills to the physician by 40%. So the 40% reduction in payments to the physician will leave him no salary at all after he pays his staff. That's right. $0/hr. I think that's less than the federally mandated minimum wage. Financially, he would do better by closing his practice and working at a fast food restaurant.
He could try to keep his practice doors open by investing in diagnostic equipment to perform testing that is done on outpatients in the hospital. That would allow him to finance the professional care he is now being asked to render for free. Too bad that Congress is preparing legislation to restrict his ability to do that.
Since he is respected in his field, he could speak to groups of physicians to educate them on the treatment of illnesses. He has been approached by pharmaceutical companies and device manufacturers who are willing to sponsor him. Too bad that Congress feels this is a conflict of interest for the physician, even though members of Congress can receive funds from lobbyists to deliver lectures on their areas of expertise.
He could layoff a large portion of his office staff, which unfortunately would eliminate those live people on the phone his patients want to speak with when they have a problem, or need a prescription refilled, or want to make an appointment. This might save him $100,000 per year in overhead.
He could always increase his work week to 120 hours. This could increase his payments by about $90,000 under the new reimbursement rates, and he would still have almost 7 hours a day to shower, sleep, and spend time with family. With $190,000 salary from staff cuts and expanded work hours, he could make almost $30/hr ... at the cost of firing staff and reducing service to his patients.
Hmmm....did someone say that Goldman Sachs is hiring? Or McDonald's?
Consider the finances of a solo cardiologist.
If he is fortunate to have a busy practice, he might bill about $2 million for his services in a year. About half of those services are given to Medicare patients, and Medicare pays him about 35 cents on the dollar, or about $350,ooo. About 40% of his patients have commercial insurance. These days, commercial insurance plans reimburse for services as a percentage of Medicare reimbursement rates, and he receives about 45 cents on the dollar for these services, or about $360,000 each year. About 10% of his patients have Medicaid coverage or no insurance at all, and he is paid about 25 cents on the dollar for those services, or about $50,000 per year. This gives him a total income of about $760,000 a year for the $2 million of services he rendered. About 60% of this income goes to pay for his office space, utilities, insurance, and staff. If he controls his costs well, he keeps 40%, or $304,ooo, for his personal income.
To generate that income, the physician works an average of 100 hours per week. This puts his hourly wage rate at about $50/hr, assuming we allow him "time and a half" for the 60 hours of overtime he works in a week. That's a little less than GM estimated for the total wage of their average auto worker during recent Congressional hearings.
One can argue that doctors and/or auto workers are overpaid, but their wage is about the same. Of course, the average auto worker didn't have to train in college, medical school, and residency to learn his trade. The average auto worker doesn't usually get called away from his family on nights or weekends or holidays to take care of a malfunctioning car or assembly line, and he rarely has to talk to a plaintiff's attorney if a car didn't turn out great.
To finance expanded healthcare, though, large cuts are proposed to physician's fees, which have been judged to be the real problem here. In Cardiology, for example, the proposed cuts in 2010 are estimated to be about 40%. Naively, we might think that means the physician will have to accept $30/hour for his services. In truth, though, it is unlikely that his landlord, or utilities, or suppliers will consider it their patriotic duty to cut their bills to the physician by 40%. So the 40% reduction in payments to the physician will leave him no salary at all after he pays his staff. That's right. $0/hr. I think that's less than the federally mandated minimum wage. Financially, he would do better by closing his practice and working at a fast food restaurant.
He could try to keep his practice doors open by investing in diagnostic equipment to perform testing that is done on outpatients in the hospital. That would allow him to finance the professional care he is now being asked to render for free. Too bad that Congress is preparing legislation to restrict his ability to do that.
Since he is respected in his field, he could speak to groups of physicians to educate them on the treatment of illnesses. He has been approached by pharmaceutical companies and device manufacturers who are willing to sponsor him. Too bad that Congress feels this is a conflict of interest for the physician, even though members of Congress can receive funds from lobbyists to deliver lectures on their areas of expertise.
He could layoff a large portion of his office staff, which unfortunately would eliminate those live people on the phone his patients want to speak with when they have a problem, or need a prescription refilled, or want to make an appointment. This might save him $100,000 per year in overhead.
He could always increase his work week to 120 hours. This could increase his payments by about $90,000 under the new reimbursement rates, and he would still have almost 7 hours a day to shower, sleep, and spend time with family. With $190,000 salary from staff cuts and expanded work hours, he could make almost $30/hr ... at the cost of firing staff and reducing service to his patients.
Hmmm....did someone say that Goldman Sachs is hiring? Or McDonald's?
Friday, June 5, 2009
How many aspirin can you buy for $11,000?
Evidence-based medicine requires that we treat patients with medications and procedures that have been proven to be safe and efficacious. Drug A might be indicated to treat an illness, for example, if it reduces the mortality of that condition over some period of time studied.
The efficacy of a drug is often determined by trials which statistically compare patients' outcomes using that drug, to outcomes in similar patients either treated with a different drug or with a placebo, a tablet or injection which has no drug in it at all.
Some drugs show such statistical superiority that their use is considered to be the "standard of care" in treating certain conditions. Recently, doctors have even been offered "bonuses" by Medicare, if they document the use of some of these agents in certain disease states, in a system called the Physician Quality Reporting Initiative (PQRI).
For example, Measure #6 in the PQRI determines what percentage of patients I treat with coronary artery disease are taking a drug that inhibits platelets from clumping together. Most commonly, this would be a prescription medication called clopidogrel (Plavix), or nonprescription aspirin. For years I have told my patients with coronary artery disease to take an aspirin daily, as a cheap and easy way to prevent future heart attacks or strokes. For the individual patient, it is a good decision, and the economic cost to that individual is minimal.
However, when we begin to look at the finances of healthcare delivery, as we debate the administration's evolving plans for healthcare reform, we have to consider the implications and costs of such a recommendation to the healthcare system. In 2002, a study by Gaspoz and his colleagues estimated the cost, based upon improvements in mortality with aspirin treatment, at $11,000 per quality-adjusted year of life gained by therapy. Using clopidogrel instead of aspirin, by the way, was estimated to cost $130,000 per quality-adjusted year gained.
Similar estimates have been generated for cardiology procedures. Parmley, et al, estimated in 1999 that performing an angioplasty in the setting of a heart attack costs $12,000 per quality-adjusted life year. Wong, et al, estimated in 1990 that angioplasty costs $6,400 to $8,800 per life year saved in patients with severe angina, but $28,000 to $132,000 per life year saved in patients with mild angina. Placing a stent in an artery, as opposed to angioplasty alone, was estimated by Cohen, et al, in 1993 to add another $32,000 per life year saved for patients with single vessel coronary artery disease.
It is difficult, if not impossible, to place a value on a year of a person's life, particularly if that person is your patient, or a family member, or yourself. On the other hand, if we, as a society, are going to pay for the health care costs of our fellow citizens, what costs are we willing to bear?
And what about promoting less expensive life-style changes, as well? What is the cost of throwing away our cigarettes? It might even save us enough to pay for our prescriptions. What is the cost of a healthier diet, to decrease our growing problems of obesity and to help control our elevated cholesterol levels and our diabetes? What is the cost of taking a walk each day to improve our physical conditioning, our blood pressure control, our good HDL cholesterol levels, and our muscle and joint health?
That daily aspirin may help us prevent our second heart attack. But the effect would be even more striking, if we took it on the way out of the house for our daily walk.
The efficacy of a drug is often determined by trials which statistically compare patients' outcomes using that drug, to outcomes in similar patients either treated with a different drug or with a placebo, a tablet or injection which has no drug in it at all.
Some drugs show such statistical superiority that their use is considered to be the "standard of care" in treating certain conditions. Recently, doctors have even been offered "bonuses" by Medicare, if they document the use of some of these agents in certain disease states, in a system called the Physician Quality Reporting Initiative (PQRI).
For example, Measure #6 in the PQRI determines what percentage of patients I treat with coronary artery disease are taking a drug that inhibits platelets from clumping together. Most commonly, this would be a prescription medication called clopidogrel (Plavix), or nonprescription aspirin. For years I have told my patients with coronary artery disease to take an aspirin daily, as a cheap and easy way to prevent future heart attacks or strokes. For the individual patient, it is a good decision, and the economic cost to that individual is minimal.
However, when we begin to look at the finances of healthcare delivery, as we debate the administration's evolving plans for healthcare reform, we have to consider the implications and costs of such a recommendation to the healthcare system. In 2002, a study by Gaspoz and his colleagues estimated the cost, based upon improvements in mortality with aspirin treatment, at $11,000 per quality-adjusted year of life gained by therapy. Using clopidogrel instead of aspirin, by the way, was estimated to cost $130,000 per quality-adjusted year gained.
Similar estimates have been generated for cardiology procedures. Parmley, et al, estimated in 1999 that performing an angioplasty in the setting of a heart attack costs $12,000 per quality-adjusted life year. Wong, et al, estimated in 1990 that angioplasty costs $6,400 to $8,800 per life year saved in patients with severe angina, but $28,000 to $132,000 per life year saved in patients with mild angina. Placing a stent in an artery, as opposed to angioplasty alone, was estimated by Cohen, et al, in 1993 to add another $32,000 per life year saved for patients with single vessel coronary artery disease.
It is difficult, if not impossible, to place a value on a year of a person's life, particularly if that person is your patient, or a family member, or yourself. On the other hand, if we, as a society, are going to pay for the health care costs of our fellow citizens, what costs are we willing to bear?
And what about promoting less expensive life-style changes, as well? What is the cost of throwing away our cigarettes? It might even save us enough to pay for our prescriptions. What is the cost of a healthier diet, to decrease our growing problems of obesity and to help control our elevated cholesterol levels and our diabetes? What is the cost of taking a walk each day to improve our physical conditioning, our blood pressure control, our good HDL cholesterol levels, and our muscle and joint health?
That daily aspirin may help us prevent our second heart attack. But the effect would be even more striking, if we took it on the way out of the house for our daily walk.
Monday, June 1, 2009
Too much food, too little exercise.....
It has been called the "obesity epidemic," the growing wave of obesity in the American population over the past 3 decades.
When we consume more calories in a day that we burn, we gain weight, even if those calories come from the fad food group of the month fueling the lastest diet frenzy.
A new study presented by Australian researchers attempted to determine whether the major driving force for weight gain in America was due to increasingly sedentary lifestyles or increasing food consumption.
They used data from the National Health and Nutrition Examination Survey (NHANES) maintained by the National Center for Health Statistics to determine the mean weight gains seen in American children and adults between 1971 and 1976 and between 1999 and 2002.
They compated this to food supply data from the U.S. Department of Agriculture to determine how much food was delivered to the American population between 1970 and 2002. This allowed them to estimate how much weight gain would have been expected between these periods solely from the change in calories consumed.
The mean weight gain of 4 kg seen in children was exactly what would have been predicted by increased caloric consumption alone. In adults, the observed mean weight gain of 8.6 kg was a little less that the 10.8 kg which would have been predicted from increased caloric intake. This suggested that adults may have been increasing their physical activity to some extent to burn off these extra calories.
While we could all benefit from increased physical activity, not only for weight control, but for increased cardiovascular health, this study strongly suggests that declining the offer to "supersize" our portions may be a more efficient way to stem the growth of obesity in the American population.
When we consume more calories in a day that we burn, we gain weight, even if those calories come from the fad food group of the month fueling the lastest diet frenzy.
A new study presented by Australian researchers attempted to determine whether the major driving force for weight gain in America was due to increasingly sedentary lifestyles or increasing food consumption.
They used data from the National Health and Nutrition Examination Survey (NHANES) maintained by the National Center for Health Statistics to determine the mean weight gains seen in American children and adults between 1971 and 1976 and between 1999 and 2002.
They compated this to food supply data from the U.S. Department of Agriculture to determine how much food was delivered to the American population between 1970 and 2002. This allowed them to estimate how much weight gain would have been expected between these periods solely from the change in calories consumed.
The mean weight gain of 4 kg seen in children was exactly what would have been predicted by increased caloric consumption alone. In adults, the observed mean weight gain of 8.6 kg was a little less that the 10.8 kg which would have been predicted from increased caloric intake. This suggested that adults may have been increasing their physical activity to some extent to burn off these extra calories.
While we could all benefit from increased physical activity, not only for weight control, but for increased cardiovascular health, this study strongly suggests that declining the offer to "supersize" our portions may be a more efficient way to stem the growth of obesity in the American population.
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