Monday, December 15, 2008

A good primer

This document is actually a very condensed and informative primer on the American Health Care System, how it came to be and where we go from here. Happy holidays!

Tuesday, December 02, 2008


As we wait, if and when health care reform is a reality (or what it would look like), I can't help but notice the external forces that are affecting the landscape for solo practitioners like me, currently, and in the future as the wheels keep turning and time is ticking. Below are some examples that highlight some of what I'm worried about.

1. CCHIT, also known as Certification Commission for Healthcare Information Technology (who comes up with these acronyms, I don't know...but as you'll see later, it's quite fitting for what kind of mess this is). It was a great idea on have an agency that sets standards for electronic medical records with the aim for interoperability and allow secure exchange of medical information. However, as it quickly evolved, it has become a sore spot for me as the $COST$ of being certified as a CCHIT product no longer becomes reasonable, especially for us smaller doctors that don't that have much overhead to negotiate without affecting our day to day operations. What bothers me is...why do they (CCHIT) have to be some agency that requires that an EMR company to pay them a substantial amount (I believe it's around $30,000 for the initial 3-year cert and then $5000 every year in the 2nd and 3rd years to cover licensing fees). That's a HUGE burden and that cost gets passed down to the physicians/hospitals/etc who are purchasing these products! As someone who also dabbles with computer software/programming (I'm actually a supporter of open-source projects), I see "standards" as a set of guidelines that in order for other systems to work or connect or to meet a minimum level of acceptability for user-friendliness...a good example is the W3C (World Wide Web Consortium) that determines the standards for HTML code for website that get translated by Web browsers like Mozilla Firefox...there's NO huge cost layout to make these standards established and for other computer software companies to comply if they want to be competitive. This is yet another example of how the cost of *anything* that is related to health care is so absurdidly high for no real, substantiative reason other than the profit motive. I mean, to get a "medical" stool costs 5 times as much from a medical vendor than it is to get from Costco (just a different color). What's the reason for that?! (and I hope it's not that the dyes for vinyl covering for the medical stools comes from some special factory that uses gold screws).

Anyways, pretty soon, Medicare has plans to make sure that doctors are using these certified EMRs and electronic prescribing. That too, on paper, sounds like a good would be great if health care finally uses electronic methods to input, store, and analyze the banking system has been doing for, what, 40 something-odd years? But who's gonna pay for this? Why pay for some "standards" that have no benefit for me when I pay the EMR company who has to shell out this money to this agency to create the standards? Does it help me in any way?

I'd rather pay an EMR company to create a excellent product on its own merits and not have to up their price just to be certified. Oh, by the way, I do have that right now. I use Amazing Charts...but the bad news is that they held out for so long not having to be pressured to be certified. However, with the inevitablity of Medicare mandates, they have now made the decision to become certified, and (guess what?), the cost of their EMR is now 10 times more than when I purchased it including the annual fees for updates. YIKES! So I'm actually trying to shore up a way to create some HTML/PHP templates for OpenEMR...that's what I do in my spare time these least the EMR is free.

I don't really know what I would offer as a solution; I think there's definitely a developed culture of "If it's medically-related, it's gotta be expensive. Let's offer a product to doctors and because they have lots of money, we can up our charge for the same product that we sell to others, but let's don't tell them that." Yeah, well I'm rowing up CCHIT creek because I'm not one of those well-paid doctors.

2. Vaccinations - a nightmare of epic proportions for me. Let's say you're a clothing store and you order your merchandise from the manufacturer for $10 an item. As a store, you need to increase the charge cover the cost of your operations, so you bring the total to $20 and that's the asking price to the customer.

OK, so now let's say that instead of the customer paying for $20 item, he/she uses their grandmother to pay for the item and the grandmother says, "I'm not going to pay for this item for $20, I'll pay you $5". What would the store do at this point? The store would say, "I'm sorry, that's how much we charge".

OK, so now let's say the vaccine manufacturer is our manufactuer in this example. The store is the doctor's office, the customer is the patient, and the grandmother is the insurance company (I mean no insult to grandmothers). Right now, the store would say, "OK...I'll give you the item, you pay me $5 dollars, and that's that."

I don't know how medical doctors and offices got into this (I think I know, we're probably too nice or maybe back in the day, we didn't read the fine print) but no self-respecting business person would even consider this a fair deal. It's a raw deal.

So you've got these mandates (again). I'm generally a believer in vaccines (but there are some caviats to some of the more recent ones, but I'll discuss that later) and there's a huge public health benefit for vaccinations. It sounds good on paper but the devil is in the details. The system is rigged so that in the end, doctors are losing money to give them. This is highly magnified in a smaller practice, hence the argument that to absorb the loss, you have to be in a bigger group. But why does it have to come to this? All that I ask is that the cost burden be fair, starting from whether the cost of the vaccine is justified, to making sure the insurance companies are actually paying the cost of the vaccine if the manufacturer is asking for that cost so that us doctors aren't left with the bill.

There are victims I see amongst some of my colleagues, too numerous to count, that have been so frustrated with this system and dealing with programs (Vaccine for Children's programs for the uninsured or on Medicaid) that try to aid because it's so unfair. We're literally at the mercy of money-hungry entities that believe you're well off and can be bought off and sold off; but there are no alternatives; no regulations.

3. A very well-written blog about the concept of "overtreatment." I second all the statements!

Thursday, November 20, 2008

Perhaps a little light from a long tunnel...

What a difference an election makes - it's all about dumping far-right, far-left ideologies and really address the issues that affects everybody today and now insurance companies are wanting to play ball as along as everyone is covered!

Speaking of which, this is an excellent summary on the plight of primary care. Again, more of the same but highlights the struggles and obstacles to improving our health care system. As I read this, I was reminded of my experience as a 1st year family practice resident at Hennepin County Medical Center in Minneapolis, Minnesota nearly 8 years ago and one of my esteemed preceptors, the now retired Dr. Harley Racer, talked to me about how I only get 15-20 minutes with a patient after I had spent nearly an hour talking to a patient who had diabetes, hypertension, liver disease, and tobacco use and managing the myriad of issues (sound familiar to other family physicians?); I certainly understood his position that we were working within a confines of a messed up system, but he encouraged me not to give up hope; that we went into medicine for noble, selfless reasons. I saw in his aged eyes, knowing that he participated in being a general physician since the 1940's, that he'd seen a world that has changed before him. I never forgot that lesson and I carry it with me to this day. Perhaps, with perseverence, there can be a light at the end of the tunnel.

Wednesday, November 19, 2008


As I scan through the various medical blogs since the election, I see an emerging civil war between specialists and generalists erupting from various proposals from policymakers, such as Senator Max Baucus from Montana. In order to fix the U.S. health care system, addressing the plight of primary care physicians is absolutely essential. What does that mean? For some, it's "spreading the wealth" in regards to income distributions between specialists and generalists and that strikes fear into the hearts of specialists who have depended on the decades long payment system that favors procedures versus investment in prevention. There's also stuff of sorts that primary care physicians don't work hard enough and we have to see more to make ends meet. Heard that before. When we cut through the spin and fear-mongering; the essential question is this:

Are we as a society going to understand and redefine what it means to have a health care system that actually values health? Or are we as a society going to believe that the direction we have been going is the best that we can do? Now, come up with your answer....

I've also read other weblogs where physicians are absolutely horrified by the prospect of a single payer system that the current examples of Medicare and Medicaid are going to spell doom to the health care system as a whole. Yes, if Medicare and Medicaid were the only payers in this nation and working exactly the way it is right now, I would be awfully afraid of what would happen to our healthcare system. However, in response to that concern, I propose the following.

Call me an optimist, but there have been numerous periods in American history that when there is a calling and we have an inspirational leader, we can acheive great things together. Franklin Delano Roosevelt and the New Deal and the defeat of Nazi Germany and Japan; John Fitzgerald Kennedy and taking the man to the moon; Lyndon B. Johnson and the Great Society. If we can do that then, how come we cannot acheive a perfected health care system for all, starting now? The great start, which I'm glad that President-elect Barack Obama stated in the debates, is that health care is a right for all Americans. And I think most people will agree on this now. Not too long ago, that was not the case.

Lately, over the past 30 years or so, we have not had the gumption or clarity to take us where we need to go...and just like someone who has not yet understood the importance of change because there is lack of awareness in the problem (alcoholics, for example), perhaps the most of us in the U.S. were led to believe that our system is the greatest and infallable in all the world. We've all heard in some way, shape, or form that our health care system is the "greatest in the world", and it's all because it's not "Socialized" medicine. Peel away the layers and over time, the symptoms of the illness we call the dysfunctional health care system shows through. The growing numbers of the uninsured. The hurting businesses trying to pay for health care for their workers and losing competiveness around the world. Our fallen economy. Mounting health care bills for families. Overflowing, overburnded, burnt-out emergency rooms, urgent care clinics, and primary care clinics. Rural clincs struggling to stay afloat. Medical students, wanting to do primary care, but with financial burdens, deciding that the wise thing to do is to be a specialist. The cycle feeds itself and leaving destruction, anger, frustration, and fear in its wake. And the results show. The "fundamentals" of our current system are misguided, bordering on unethical (in my opinion), overly complex, and highly counterproductive. These fundamentals are then fed and supported by fear and greed.

Right now we are peering down the chasm of this so-called illness and wondering, should we just continue to ignore it and pretend that it will just go away, or shall we face it and confront it?

Once we make the awareness, which believe we are at this junction (it's long over due, in my opinion), we have the capacity to start change and work together with a committed goal. Going back to my optimism statement, I believe that we have so much untapped potential - all of the current health care workers, those who work in our clinics, hospital, and yes, even the insurance companies, that can be channeled into this endeavor to look at our system with fresh eyes and renewing a commitment to care and quality for all Americans; look again and what it means to have "market-driven" medicine and focus again on what is good for all rather than just for a priveledged few. This is the stuff that's happening in the grassroots right now, in Oregon.

Imagine if this can spread to the rest of the nation. I can see, from our nation's history (I'm kinda a history buff), that we can have great ideas and great people - coming from true intentions that exemplifies the common good. Just look at our attempts to bring a man to the moon. We poured our efforts into education in math and science with true competition, not out of greed, but for the goal of space travel.

What I see is that we can have a system of health care that balances the independence of physicians and patients, taking the middlemen of payment out and consolidating it to the largest insurance risk pool (national insurance) and where the responsibility of the management of the risk pool is dictated by the mandate of the people (taxpayers and those who vote)...and where doctors no longer have to be torn between the triangulation and really focus on delivering quality health care (this is where my passion is!). What does that describe?

Single-payer health care.

Ahh, but do we have evidence that this works?

Yes, we do...think of all other industrialized nations in this world and everyone else has shown that health outcomes have generally improved when there is a unified, single-payer health care system (there's different variations, but all variations on the same theme, where everyone is covered). We may argue that the United States can choose to be different (like who else in this world use the English or Imperial system for measurements and temperature rather than metric?!?!...but that's another diatribe for me), but the cost of choosing to be different far outweights the benefit of making a smarter choice.

So, this is what I would say about the whole topic. Learn from others and learn from history. Use the links above to be the starting point and guiding light to get to the answer. Don't just take it from me, but maybe we'll all end up agreeing. Now that'd be nice, wouldn't it?

Tuesday, November 18, 2008

Hope, maybe?

I'm so glad the election went the way it did. Now, the hard work begins. Recognition of the problem is step one and that begins with more mainstream media attention being paid to the plight of the primary care physicians. The reason? Much that has been said here in this blog. Hopefully, the solution to the health care crisis will involve the recognition of the work of primary care physicians - prevention, education, and bringing back the meaning of health in "health care".

Tuesday, September 23, 2008

Well said...

In these tough times right now, we must take perspective of our view of this crazy world. This editorial below by Norman Solomon succinctly and clearly makes a claim for "waking us up" and taking perspective.

Too Big to Fail and Too Small to Matter

by Norman Solomon

These times provide a crash course on the corporate state:

If a company like AIG is too big to fail, the government will rescue it. Mere people -- too small to matter -- are expendable.

The insurance industry is too big to fail. A person's health is too small to matter, so -- when it fails due to the absence or loopholes of insurance coverage -- that's tough luck.

The Defense Department is too big to fail. The people it's killing in Iraq and Afghanistan are too small to matter.

The U.S. nuclear arsenal is too big to fail. The Nuclear Non-Proliferation Treaty, undermined by Washington, is too small to matter.

Overall, the warfare state is too big to fail. The virtues of peace are too small to matter.

Agribusiness is too big to fail. Family farmers are too dirt-small to matter.

The leverage for the U.S. Treasury to subsidize Wall Street is too big to fail. The leverage to subsidize mothers and children kicked off welfare is too small to matter.

The political momentum for bailing out corporate America is too big to fail. The political momentum for funding adequate payment rates from Medicaid to reimburse healthcare providers is too small to matter.

The oil conglomerates are too big to fail. Global warming is too small to matter.

The prison industry is too big to fail. The need for preschool is too small to matter.

Corporate power is too big to fail. The ordeals of working people and want-to-be-working people are too small to matter.

Human worth as maximized by dollars: too big to fail. Human worth as affirmed by humanistic values: too small to matter.

The current odds of pumping at least several hundred billion taxpayer dollars into corporate America: too big to fail. The current odds of launching a massive federal jobs program: too small to matter.

Such priorities and mindsets are in overdrive at the intersection of Pennsylvania Avenue and Wall Street. But a basic shift in government priorities is possible. That's what happened three-quarters of a century ago, when a progressive upsurge prevented the re-election of President Herbert Hoover -- and then effectively mobilized to pressure the new occupant of the White House.

After campaigning in 1932 on a middle-of-the-road Democratic platform, Franklin Roosevelt went on to become a president who denounced the "economic royalists" and made common cause with working people and the unemployed. People across the country organized for social change. In the process, you might say, the power of progressive movements became too big to fail.

Something like that could happen again.

Monday, September 22, 2008

Little empathy

I came across a recent article on the Archives of Internal Medicine which struck a chord to me. Actually, I'm not really surprised since I have had concerns of this since I was in medical school and the emphasis on training for the "science" of medicine and the lesser emphasis of the "art" of medicine. I came in naively to believe that there is a balance to both. I still believe in that balance but the training for new medical professionals as well as the emphasis of over-specialization has definitely tilted to the point where we now see doctors no longer having that empathetic skill to connect to their patients. Even more striking is with the recent tide of "market-forces" and "letting the market decide" for medicine is how people are just treated like commodities and widgets - it's pretty sobering...whatever happened to real interaction with real people? It's definitely lost in translation with all the hype of the cure-all pharmaceuticals and state-of-art technology. *Sigh*.

Wednesday, September 10, 2008

A sorry state of affairs....

More bad news on the horizon - not much of a surprise as this trend was going on since I started medical school in 1996, however, I feel that the backbone has broken and the demoralization of primary care has, in essence, become the end result of the reliance and emphasis of overspecialization, supported by the the Medicare payment schedule equations and de-valuing of primary care visits in general.

Thursday, August 28, 2008

This is nuts!

Just had to put this link on my blog as it completely astounds me that there are individuals to this day that believe that the healthcare crisis in the US can be solved by abolishing the "uninsured" term in the census and use the ER as the solution! The actual blog by John Goodman gives more details on this *ingenious* solution; which by the way was also the same solution George W. Bush suggested several years ago. As you can see, I'm all about single payer health care - it's really the only solution that makes sense from every perspective - for the patients, the physicians and health care providers, and the community.