Rude Hippies

I went to a Van Morrison concert recently. I've always liked him but I had no idea what an instrumental virtuoso he is. Guitar,sax, harmonica, and not least of all,that voice. His songs are poetic but fit driving rhythms--rather awesome.

Most of the audience were people of My Age. The old Fillmore East crowd, minus marijuana. In them daze, we would go to a concert and, not just because we were stoned, sit mesmerized, trying to hear every note, every word, how they interacted, all of it.

Imagine my surprise when I found people sitting behind me, chatting as if they were watching MTV at home. Heartless bastards. This is VAN MORRISON, for God's sake--SHUT UP!!

It was like being around Cheetahs in a zoo. They used to be fast, but now they're just bored fat slobs, waiting for someonee to feed them, unused to being able to catch the food themselves. They got real middle class, and they got rude--no universe outside themselves, no soul.

I don't pretend to be clear of all these vagaries. I have an IRA. I have a job. I cross the street when suspicious people are walking on my side. But I haven't forgotten the mystery of people creating music for me to listen to, and that in order to hear, in order to listen, you have to SHUT UP.

I would have told them to shut up, too, if I hadn't been sitting in an orchestra seats that I hadn't paid for.

Centifugal Bumble-Puppy

The Great Health Care Plan still doesn't exist. Oh, there's sound bites by 'people' like Max Baucus who said with a presumably straight face that a tax on employer funded health plans would be a boon to society, as it would force the companies in question to offer policies that cover substantially less, and thus stem the gross overuse of medical services in the US.

Um---OK. Gotta go,Max. Got a date with reality.

I was growling through some stats on the MEPS website. No connection to the Coneheads. It's the Medical Expenditure Panel Survey arm of the Agency for Healthcare Research and Quality portion of the Department of Health and Human Services branch of the Federal Government. It's most recent data is 2006. It does things like sending (self-administered)questionnaires to diabetics between the ages of 18 and 65 to find out what percentage of them had a foot exam that year.

That's not unimportant. Au contraire. Foot infections in diabetics are a mess and we spend a bazillion dollars on them every year.

But aside from the people at MEPS sending their data to AHRQ at HHS, you know what happens to this valuable data?


Nada. Nothing. Zip. There is no way, at least from the blogosphere, to find out if this data is ever used to actually help people. It's just like that large ball tossed up to the top of the Centrifugal Bumble-Puppy tower with people standing around waiting to see which hole it'll shoot out of, and hoping they don't get hurt.

So when people start throwing data at you about who's going to get what in our New Health Care System, duck.

Paranoia

Dr. Arthur M. Feldman wrote an excellent article in the "Outlook" section of The Washington Post today entitled "10 Things I Hate About Health Care Reform." It was well thought out and clearly written.

His section on tort reform, however, I felt missed two important points on the amount lawsuits add to the overall cost of health care.

He correctly mentions the cost of defensive medicine. A survey published in NEJM last year showed that in Massachusetts, 23% of tests ordered by doctors were done not because the MD or DO thought they were necesary, but because they wanted to have all the ammo they could of they got sued.

He mentions the phenomenon of physicans moving to states that already have caps on pain and suffering awards leaving some states over doctored and some under doctored.

But there are two other aspects of tort reform that need to be empahsized:

1) Insurance companies make more and more money every time malpractice premiums go up. Im Massachusetts, an Obstetrician or Neurosurgeon's YEARLY malpractice premium starts at around $250,000.00. So you have to make a quarter of a million just to open the doors. Then you can start paying the office overhead. So, insurance compaines being the ones that run health care, both private and public, have zero incentive to back tort reform.

2) Without retreat into self-pity,it can be said honestly that being a physician is Very Hard Work. It requires the nicest sense of judgement applied to a vast storehouse of knowledge tempered by the experiencce to know when to inervene and when to refrain. The intrinsic drive to do it well is its only safeguard against mediocrity.

If you apply the above standard every day of your working life while knowing that a lawyer seeking only money, not justice, can drag you into court and paint you as a negligent uncaring bastard, it dulls your edge. More burnout. More defensive medicine.

As a doctor you have to document (in an easily readible form, usually with words of no more that two syllables)to multiple unconnected federal agencies that you are meeting the standards of 'good medicine' established by bean counting bureaucrats.

Then, on top of this, some jamoke who solicits people to file lawsuits via ads on TV, municipal busses and phone books can take over your life for years while a frivilous suit is adjudicated. In most cases, this means that motions (read: billable hours)fly back and forth until the su-er decides his input in work is liable to exceed the probable award, or the su-ee decides that the suit lacks merit, but they've already spent, say 80 grand, to defend against a probable 70 grand award: the 'suit' is settled.

As long as there is a system in place that allows insurance companies to make huge amounts of money on malpractice insurance and provides lawyers the opportunity to tap into that huge pile of cash (both prosecution and defense), there will be no tort reform.

So: Outlaw advertising by lawyers. As lawyers make the laws, this may not happen.

But if a judge were able to lable a suit as fivolous, and force the prosecution to pay the defense's costs, the phone book guys would be much more circumspect about filing suits. And the amount of energy a physician now spends on paranoia (and the defensive medicine costs it generates) could be put back into looking after the best interests of their patients.

The best doctors have medicine as a vocation, not a job. Let's try to get our legal colleagues up to the same standard.

Headache

So, I tried to write about how the US finances itself, but I got such a horrible headache, I gave it up. The Federal Government is an incomprehensibly complicated behemoth. I get better at navigating the Federal websites, but they are still so disconnected functionally that you wind up with no idea of how the structure is organized, let alone how it works.

I went to Muckety.com, a fascinating website that displalys organizational maps of all manner of businesses and governmental structures. It took me four tries to get Muckety to recognize a link to its own section outlining the genreal structure of Our Govenment. I still couldn't get it to map it out. Anybody has better luck, let me know.

This exercise in mental flagellation began as an attempt to figure out how the government would fund health care. The medicare trust was pirated years ago to be replaced with a bunch of congressional promissory notes. That Bridge to Nowhere could have been your grandmother's artifical hip, but it was not to be.

So, foolishly, I started with the Treasury web site, dove into the Bureau of Debt Management site, and got suckered into reading the minutes of the August meeting of the Treasury Borrowing Advisory Committee. Members? CEO's of Goldman Sachs, JP MorganChase, Pimco, BlackRock, Moore Capital Investment and so on. (BlackRock, if you're interested, is in the process of buying the Capital Investment Division Of Barclay Capital LLC for 6.6 billion cash and 38 million shares [19.9%] of Barclay's. The will rename themselves no doubt. But I digress).

Not knowing anything about Moore Capital Investment, I Muckety'd again. I suggest you try it. It starts out as a four-link map, one of which is the Mutual Funds Association. I Muckety'd that. That (much more complex) map had a link to the top 100 members of this association. The screen blossomed into a labrynth of companies. Like who? Oh, Goldman Sachs, JP MorganChase, Pimco.... Now I know how Mickey felt when he kept trying to chop up all those brooms.

Most, if not all, of these plutocrats run hedge funds. So the guys who advise the government on how to structure its debt are the very same knuckleheads (Very Rich Knuckleheads)that just screwed everybody and his brother out of houses, retirement funds, and, in the end, health care.

Migranous. Hemicranial.

The only comfort I can draw from this chalkboard screeching nail bed stabbing exercise, is that maybe--just maybe--the whole freaking thing is so incestuous that the plots of the few to rob the many may be too cumbersome to really organize, and that this last money meltdown was just as much by chance as that butterfly in Tokyo that flapped its wings and made it rain in New York. Maybe.

Where's the bar?

About 15 years ago, when one of my daughters was a hostess at a DC restaurant, Ted Kennedy came in for a private function. My daughter said "Senator, as a registered Massachusetts voter, I welcome you to (name of restaurant)."

"Where's the bah," Ted replied.

He was who he was, and somehow I like that story about him. He will be rolling in encomiums as they lower him down, most undeserved, but somehow I just can't help liking the guy.

The Kennedy/Feingold bill made me and just about every other doctor in the US a slave to paperwork. But real people with real jobs whose employers changed insurance every year suddenly found themselves relieved of the 'pre-existing condition' trap, and people got helped.

He was running against Ray Shamie (R) for reelection some years ago, and during one of their debates, Ted was declaiming on the network of support and intercalated logs that could be rolled, and Shamie interrupted.

"So, that's what you do?" Shamie sneered. "You crank up the democratic machine and just follow the party line?

"You BET I do!" Ted shot back. "That's how things get done in DC! And if you don't know that, you've got no hope of doing anything for the people of Massachusetts if you evah get up theah!"

You gotta love this guy.

I think in the end, Ted got what he wanted publicly and privately, and delivered on what he got paid to do by the people who bought him. Few others in the Senate have done even that. Graft is graft, but honest graft is honest graft.

And that's what Ted did. He was an honest thief, and given the state of the Union, we should have more like him. Senators will get paid. They just won't give quality for the money like Ted did.

We're from the home office...

Just a quickie:
Saw a patient today who is from mainland China. He's a researcher. He wants to stay in the US, so he is applying for a green card.

A great deal of the non-US world gets a vaccine as kids. It's called BCG (Bacillus-Calmet-Guerin, approximately). Bacillus CG is another word for Mycobacterium tuberculosis. If you receive this vaccine, your tb skin test (ppd--standing for Purified Protein Derivative) is always positive.

He produced a document from the US State Department saying that, even if you have proof that you had a BCG vaccine, and that you have a chest x-ray that shows no evidence of tb, you WILL NOT receive a green card unless you take INH (Isoniazid) for nine months.

INH can be hepatotoxic. And if you don't take it with supplements of Vitamin B6, you can develop a nasty peripheral neuropathy.

If I have a patient that used to have a negative ppd, and it changes to a positive one, you OFFER a patient six months of INH to lower the possibility of 'late reactive' tuberculosis as they approach old age. You OFFER it to them, and get their informed consent before they take it.

But, thank God, this guy left a totalitarian state and came to the US. Let freedom ring.

Lewis Mumford

The EMR has been touted as one of the things that can make health care affordable, universal, and of higher quality.

The first question that comes up is: Higher than what?

One would like to think that the methods used by practices that are 'high performing' (take good care of their patients) are reproducible. In order for them to be that, one would have to know what their methods are.

In a study in the Annals of Family Medicine in 2007, looking at such practices, they concluded that "[t]here is no single approach that explains the superior performance of high-performing practices," and that if you could figure out what that common thread was, "[t]he archtypes could prove to be a useful guide to to other practices selecting an overall quality improvement approach (my emphasis)."

So, if you knew what they were doing right (which you don't), maybe that information could be useful to other practices if they were looking to do something besides keep the shit at shoe level.

In the face of that, why are people hooting it up for an EMR? Does it help? The operative governmental line is that it does. I think it's just sexy technology that lets people feel like they're actually doing something.

The position of the Powers That Be is that the EMR improves quality of care for patients. There are a few assumptions on which this is based:

1) Clinical guidelines formulated from 'Evidence Based Medicine' will help physicians practice better medicine.
2) The EMR can help disseminate these guidelines and physicians will then use them.
3) Use of the EMR will then raise the quality of medicine practiced in the United States.

Don't you just love syllogisms?

Let's look at data about guidelines helping physicians practice better medicine:

Archives of Internal Medicine Jan 22; 16(2): 189-97

This is a study looking at what happened when MD's were electronically notified of a diagnosis of depression electronically vs other means:

"There were no differences in the agreement rate or treatments provided across guideline exposure conditions."

In other words, being aware of the guidelines didn't change anything.


Del Med J 2004 Mar 76(3): 111-22

"The Medical Society of Delaware's Uniform Clinical Guidelines are intended to standardize care for diabetes and other conditions. While the guidelines may help to reduce unnecessary duplication and confusion caused by multiple guidelines, this study showed that they have not yet resulted in substantial improvements in quality of care for diabetes."


Inform Prim Care 2006; 14(1): 29-40 ( a TechnoJournal)

Paraphrased, this study was done in the UK to evaluate concordance with Quality Points (clinical guidelines) and the quality of care for patients with strokes. The practices with fewer Quality Points had more adherence to the Royal College of Physicians advice on care for stroke patients. That is, awareness of the clinical guidelines had a negative correlation with patient care.


So: nobody seems to have a good handle on how good physicians do a good job. Maybe clinical guidelines help, maybe not. No one seems to know.

That having been said, why the bejeesus is disseminating those guidelines via an EMR so highly promoted?

I bet it's because people get better care in hospitals. Think?

Med Care Res Rev 2008 Aug; 65(4) 496-513:

"The authors...assess the relationship between hospital EMR use and quality performance...related to 3 clinical conditions: acute myocardial infarction, congestive heart failure, and pneumonia. ...They conclude that there is limited evidence of the relationship between hospital EMR use and quality."


Oopsie. Can't be that. Maybe office care gets better.

Arch Int Med 2007 Jul 9; 167(13): 1400-5

"For 14 of the 17 quality indicators, there was no significant difference in performance between visits with vs without EHR use....As implemented, EHR's were not associated with better quality ambulatory care."

Um--nope. Not that either.

So, where's the beef?

It is, as always, in the money, and the ease by which it can be acquired.

The first step the big insurance carriers took to maintain their profit margin was to make sure that if costs were cut, they were cut at the expense of providers and hospitals, not 'carriers.' They did this by making oversight of health care punitive, not supportive (see previous blog).

Now they'd like to cut the overhead on the information they need to not pay people (or make them give money back), and save themselves a bit more administrative moolah.

How?

Get EMR's everywhere, so the data they now administer will cost them no more than a USB cable.

I practice primary care medicine every day, and have for more years than I care to think about. I listen. When I listen, I find out things. When I find out things, I make diagnoses. When I make diagnoses, people either get better or don't get sick in the first place.

So when people start screaming that the answer to better health care is more technology, let us humbly recall the words of one Lewis Mumford:

"Some of the grotesque miscalculations and misappraisals that have been made in comparing the working efficiency of past ages with the present...[are based on] the blunder of confusing the increased load of equipment and the increased expenditure of energy with the quality of effective work done...The fact is that an elaborate mechanical organization is often a temporary and expensive substitute for an effective social organization."

Logic is adrift.