Saturday, February 28, 2004


Georgia House panel OKs tort reform legislation

The House Judiciary Committee on Friday unanimously approved legislation designed to help doctors and hospitals in medical malpractice litigation.

Committee Chairman Tom Bordeaux (D-Savannah), a trial lawyer, called Friday's passage of the three bills "a significant step" in the tort reform debate. The legislation should result in lower malpractice insurance premiums for doctors and hospitals, he said.

But because none of the bills put limits on medical malpractice jury awards for a plaintiff's pain and suffering, Georgia's hospital and medical associations are not satisfied.

"The House hasn't produced anything to date that will address the fundamental problem that is causing physicians to leave the state and causing them to stop performing high-risk procedures such as mammograms and delivering babies," said David Cook, executive director of the Medical Association of Georgia.

The legislation, which the full House may consider as soon as next week, allows judges to punish lawyers who file frivolous lawsuits and court motions, elevates the qualifications for medical experts who testify in malpractice cases and shields hospitals from liability in certain emergency room situations.

I am having some difficulty in finding out the exact legislation that was passed out of the committee as it has many bills that address tort reform issues. Some of the more likely suspects include:
SB 408, SB 432, HB 1342, HB 1343 (the one that maybe didn't pass) and HB 1339. HB 1339 has great appeal to me as it would limit liability for emergency and trauma care.

I'll post a follow-up when I can find out more.

Tuesday, February 24, 2004

A Debate on Radiation in Breast Cancerfrom The New York Times.

Radiation treatment is being prescribed for more and more breast cancer patients, including women who would have been told just a few years ago that they could skip it.
The added therapy mostly affects those women who are treated with mastectomy and chemotherapy, and have fairly good prognoses at what is called Stage 2 cancer.
But cancer experts and doctors are divided over whether these women really need radiation to improve their chances of survival.
For some, radiation may enhance their prospects of preventing a recurrence of their breast cancer. But whether that translates into increases in the chances for long-term survival is not clear.

The benefits of post-mastecomy radiation in patients with 3-4 or more positive nodes began after these articles appeared in the New England Journal of Medicine. This was in spite of the weaknesses of the studies, mainly the low numbers of lymph nodes removed in the Danish study (average of seven) and the low numbers of patients in the Canadian study. So the standard of care has evolved that premenopausal women with four or more positive nodes receive post-mastectomy radiation, mainly to prevent loco-regional recurrence. The benefit on overall survival is less clear.

The debate is about what to do with the patient with 1-3 positive nodes. Patients like this in my practice have received radiation if they had larger primary tumors, extracapsular tumor in a node, or close margins. There can be some benefit to these patients from post-mastectomy radiation:

Radiation therapy after mastectomy reduces loco-regional recurrence rates for breast cancer patients with positive lymph nodes, positive surgical margins, or both, according to the results of a large retrospective study presented at the 44th Annual Meeting of the American Society for Therapeutic Radiology and Oncology ....For all patients treated with postmastectomy radiation, the total locoregional recurrence rate (with or without distant metastases) was 10%, compared with 19% for the patients who did not receive postmas-tectomy radiation, Dr. Woodward reported.
Looking specifically at the subset of 502 patients with T1-T2 stage tumors with one to three positive nodes, the investigators found that freedom from locoregional recurrence in patients treated with radiation was 97% vs 87% for patients not treated with radiation.
(Oncology News International Vol 11, No 12 (December 2002))

Again, keep in mind that the above is from a retrospective trial. The Southwest Oncology Group's randomized Intergroup trial (mentioned above) was closed due to lack of enrollment. Back to the Times...

What's clear is that women with a 25 to 30 percent risk of local recurrence can improve their chance of being cured by 10 percent," said Dr. Thomas A. Buchholz, program director of breast radiation oncology at the University of Texas M. D. Anderson Cancer Center in Houston. "The controversy is, Who has that risk?" Not, he said, the women with the fewest number of positive lymph nodes.

There is no question that if given radiation, these women would further reduce the rate of recurrence by two-thirds, bringing it down to 3 to 5 percent.

The question remains is the risk of increased lymphedema, post-radiation skin changes, and difficulties with breast reconstruction worth it for women with only 1-3 nodes? As with most issues related to breast surgery, it is largely up to the patient:

Some doctors leave it to the patients, who, experts agree, know what risks they want to take.

"Patients have an inner sense of what they want to do," said Dr. Lori J. Pierce, an associate professor of radiation oncology at the University of Michigan, who was the lead researcher for the study that failed to draw enough participants. "Patients need to have an informed discussion with the doctors to look at the pros and cons to help them make that decision." That wasn't happening three or four years ago.

Just remember the difference in recurrence-free survival and overall survival as the line is blurred by this paragraph:

The debate does not concern breast cancer patients who have lumpectomies or patients who receive mastectomies and have more than three malignant lymph nodes. In those cases, experts generally agree that radiation after surgery increases the chances of survival.

As I posted earlier, that link has not been solidified yet.

ADDENDUM: Personally I think that the reduction of loco-regional recurrence is reason enough to offer radiation to these patients as local recurrence after a mastectomy can be difficult to treat, requiring myocutaneous flaps in some cases.

Monday, February 23, 2004

Check out EchoJournal.
Yes, I know it was a bad pun.

Sunday, February 22, 2004

Johnny Cash's family nixes Ring of Fire hemorrhoid-relief commercial

Advertising writers in Florida were planning to pitch hemorrhoid-relief products with a commercial featuring Johnny Cash's classic song Ring of Fire, but his family says there's no way they'll let it happen

A good move on the part of the Cash family. I'm glad that they had the decency not to let this go forward. The Johnny Cash songbook has many tunes that could be of benefit to advertisers:

Man in Black featured in an ad for The Gap
I Walk the Line as a public service announcement against drunk driving
Boy Named Sue for a civil litigation law firm...the ad writes itself!!

Send in your suggestions!!

Saturday, February 21, 2004

From the February 20th "Thinking Right" by Jim Wooten in the Atlanta Journal-Constitution

Congress absolutely should stop states from gaming the Medicaid program. Georgia has paid $110.5 million to a small Minnesota company, Copeland Glenn, over the last five years to get federal Medicaid money. A fee of $110.5 million! To exploit loopholes in federal programs. Scandalous. This is why federal money should come to states in block grants. States should manage money, not rip off federal taxpayers.

And when it rains it pours...

The state of Georgia may have to repay $50 million obtained through a Medicaid financing scheme that has not been approved by the federal government. Georgia's financing plan, which collects a nursing home "bed tax," went into effect in July, but recently the state was told it did not meet federal requirements.

The state said it violated federal policy by collecting matching federal money on the nursing home fee before it got the required approval. But the violation was unintentional, state officials said.

Apparently the nursing homes would pay a fee per patient which would be counted as a state "contribution" and would then result in an increase of the federal contribution toward Medicaid. Currently Georgia gets $1.67 of federal funds for each $1 of state contribution, quite a return on the nursing home's "investment".

So we have a program that had to cut of $148 million last year, and possibly run out of money in a few months, but has paid $110 million to this consulting firm, over the past five years. And my be on hook to the federal government for an additional $50 million.

Apparently the feds have had their eye on Copeland Glenn for awhile:

The federal agency that oversees Medicaid is reviewing the Georgia contract that will pay a consulting firm $107 million for finding federal dollars for state programs.

The federal Centers for Medicare & Medicaid Services "is asking very general questions about the procurement process and the terms of the contract," said Julie Kerlin, spokeswoman for the state Department of Community Health, which runs the state Medicaid program....

And apparently there were some irregularities concerning the bidding process...

A Journal-Constitution investigation last month reported that Copeland Glenn's fee was negotiated by aides to Barnes while he was governor. The fee evaluation process failed to follow the terms of the bid request, thus violating state policy. The percentage fee that Barnes' office established for the major piece of Copeland Glenn's Medicaid work was nearly 5 percentage points higher than the firm bid for that work.

A former law partner of Barnes', Michael Jablonski, said he advised the firm and helped incorporate it in Georgia. Barnes has said he did not discuss the matter with Jablonski.

The amount paid was set as a percentage of federal funds recovered, in this case about 12.9% percent of roughly 3 billion dollars. But such consulting contracts are beginning to come under federal scrutiny:

Iowa Sen. Charles Grassley cited a Georgia contract as one of two examples leading him to request the review of such Medicaid consulting deals

I think that the revenue streams that these efforts generated are going to be harder to come by.

Thursday, February 19, 2004

From the New York Times

Asked about the criticism, Mr. Kerry's press secretary, Stephanie Cutter, responded, "This is an interesting line of attack from the positive campaign of John Edwards considering that his campaign is wholly funded by trial lawyers, which are widely recognized as special interests and lobbyists." Mr. Edwards himself is a former trial lawyer.

Say it ain't so !!!

Well according to the good folks at Open Secrets, lawyers and law firms have contributed $3,474,264 to Sen Kerry's presidential campaign while health professionals have contributed $392,187. Of the twenty top contributors to the Kerry campaign are lawyers or laws firms.

Senator Edwards took in $8,072,511 from attorneys and $251,307 from health professionals. Seventeen of Senator Edwards' top twenty contributors are law firms (his top contributor is Goldman Sachs).

Walter Olson at Overlawyered points out that many of Senator Edwards' donors have "maxed out" their contributions. Sixty-five percent of John Edwards' contributors gave $2000 or more, compared to fifty-five for Kerry.

This is what Senator Kerry has to say about tort reform (scroll down):

Medical malpractice insurance has become so expensive in some states that physicians are moving or giving up their practices, cutting access to care for their patients. The Kerry plan will hold down malpractice premiums by requiring an impartial review of a claim before an individual could file suit and by eliminating punitive damages except in egregious cases. Kerry's plan will not put a cap on legitimate damage awards.

John Edwards' position on tort reform is, of course, well known. It comes as no surprise that John Edwards main supporters are trial lawyers, and has made no secret about it. But while raging against special interests Senator Kerry helps out individuals that are guilty of making illegal campaign contributions. Seems that Senator Kerry likes having his cake and eating it too.

Wednesday, February 18, 2004

A Charles County jury awarded a La Plata couple more than $5 million in damages on Friday after finding that three doctors failed to detect symptoms of child abuse in an infant in 1998 and could have prevented a subsequent, more serious injury that has disabled the boy for life.
The Circuit Court jury found that pediatrician Soma Reddy and Civista Medical Center doctors Donald Shell and Hammond Dugan should have performed a CT scan on then-11-month-old Jack Sprague on Nov. 18, 1998, when his worried parents took him to the hospital after he suffered a head injury at the Waldorf home of his babysitter, Nancy J. Brookbank.
A CAT scan likely would have found evidence of a subdural hematoma, or bleeding in the brain, which is typically caused by shaking a baby, said Robert W. Weltchek, a lawyer for John and Robyn Sprague, the boy's parents. Two weeks later on Dec. 4, 1998, Jack suffered another, more serious hematoma while with Brookbank, an injury that nearly killed him and left him disabled for life.
The jury decided the Dec. 4 injury would not have occurred if the Nov. 18 injury had been diagnosed correctly, because the family would not have put Jack back in Brookbank's care. "It could have all been possibly prevented," said a juror who asked not to be named. "The CAT scan should have been done."

As with most cases of this type, the experts differed in their opinions:

Cindy W. Christian, director of the child abuse program at Children's Hospital of Philadelphia, said 11-month-old Jack Sprague did not show telltale signs of a subdural hematoma, or bleeding in the brain, when his worried parents brought him to Civista Medical Center on Nov. 18, 1998.
Her testimony was bolstered by Robert W. Block, chairman of the University of Oklahoma Department of Pediatrics, who also testified Friday in support of Civista Medical Center and three doctors who are being sued for $13 million by parents John and Robyn Sprague, whose son was examined by the three doctors.
Jack "was basically symptom-free," Block said. "There is no indication that [the doctors] should have had any perception of abuse." ......
Philip H. Cogen, the Washington Children's Hospital neurosurgeon who operated on Jack, has testified for the Spragues, saying he saw two separate injuries: the massive subdural hematoma caused on Dec. 4, 1998, and another smaller, older hematoma.......
The Spragues' lawyers contend the smaller, older injury occurred Nov. 18, causing Jack to appear "lethargic" and "not his usual self" for several days, according to his mother.
But Christian and Block countered that such an injury would have caused more serious and pronounced symptoms. If there was a small injury, it would have healed before Dec. 4, when a CT scan was performed, Block said.
"It is possible that the baby was injured some time after" Nov. 20, Christian testified. She said Jack had "unexplained vomiting" and other symptoms that she speculated could have been caused by abuse on Nov. 30 and Dec. 1, when the child was again in Brookbank's care.

So let me see if I get this right.... the physicians in question are being held liable because the parents say if they had known about the injury on November 18, they would not have used this person as a babysitter and thereby avoided the more severe injury on December 4. It seems to be a bit of a stretch of proximal causation as the lack of a CT did not directly cause the disability of the child. They are being held responsible for actions, taken by a third party, that took place two weeks after they had treated the child. While I take exception to the causation argument, there may be some merit to the argument that a CT should have been done.

According to the Eastern Association for the Surgery of Trauma's head injury practice guidelines:

CT scan of the brain is the cornerstone test in the evaluation of traumatic brain injury. The literature generally supports the use of CT scanning for all cases of MTBI in which at least one of the following is present: loss of consciousness; post-traumatic amnesia (PTA); confusion or impaired alertness.

These guidelines are pretty broad, and the details of the infant's neurologic exam are not found in the media reports. While recent studies and other guidelines advocate selective use of CT in head injuries, lawsuits like this one will make those suggestions difficult to follow. A physician practicing now is concerned aboout being sued here and now over a missed injury, not fifty years from now for a possible malignancy. A dichotomy exists concerning radiation use as physicians are hesitant to use radiographs in pregnant women because of concerns of exposure, but have little hesitation about exposing children once born.

Or, as Ted Frank, pinch-hitting at Overlawyered, asks:

How many healthy children will end up with cancer because of defensive medicine in response to this verdict?

The answer to that question is a "known unknown" ,as Donald Rumsfeld, would put it. But I know of three physicians who wish they had ordered one more.


From the AAA foundation

Drivers over the age of 65 are almost twice (1.78 times) as likely to die in car crashes as drivers age 55 to 64, according to a new study released today by the AAA Foundation for Traffic Safety. The study found that the probability of death or injury in car crashes increase with age, as does the likelihood that an older driver will be involved in a left-turn crash, affected by illness, or suffer from lapses in perception that could contribute to a crash.

The "Older Driver Involvement in Injury Crashes" report also revealed that drivers over 75 were over two-and-a-half times (2.59) as likely to die in a car crash and drivers over 85 were almost four times (3.72) as likely to die when compared to drivers aged 55 to 64.

The reasons that elderly patients are more likely to die in a collision are mainly twofold: the diminished physiologic reserve in the elderly patient and the high incidence of medical comorbidities. As one becomes older, depth perception becomes more of a problem, which is why that the elderly are more likely to be involved in collisions making left turns. This increases the potential for injury, as the vehicle is struck on the driver's side, imparting more of the force of the collision on the patient.

As the population ages this will become more of a problem. The latest revision of Advanced Trauma Life Support has a chapter devoted to trauma at the extremes of age.

A good graphic presentation of the data may be found here.

Tuesday, February 17, 2004

When I posted a few days ago about the problems with Georgia Medicaid I thought it was the usual bureaucratic incompetence or the desire of certain legislators to get pork-barrel projects funded. But I now fear that the refunds that Georgia Medicaid are asking for may be for a more nefarious purpose.

The Bush administration is headed for a confrontation with states over the financing of Medicaid, the nation's largest health program, as federal officials crack down on arrangements used by many states to shift costs to the federal government.

The federal action comes as states, struggling with severe fiscal problems, are cutting benefits and restricting eligibility for the program, which serves 50 million low-income people each year. Federal officials and auditors contend that states use creative bookkeeping and other ploys to obtain large amounts of federal Medicaid money without paying their share.

Washington and the states split Medicaid costs, with the federal government paying 50 percent and sometimes more than 70 percent.

But in many cases, the Bush administration says, states have paid their share with "phantom dollars," instead of state or local tax revenues......In some cases, it said, "states have created the illusion that they have made large Medicaid payments" to county hospitals and nursing homes, and they claimed federal Medicaid money to help defray the costs, even as they required counties to return most of the money to the state.

So the state demands a refund claiming that the provider was over compensated. Instead of returning the federal government's portion of the Medicaid funds, it holds on to them. Up until now this "laundering" of Medicaid funds has been limited to government facilities such as hospitals and nursing homes, but I wonder if the target audience for this practice has been expanded? Not that any of this is new. The quote attributed to Kathryn Allen :
"State financing schemes have driven up federal Medicaid costs. Congress has repeatedly tried to curtail such arrangements, but states have consistently developed new variations"

Sounds much like this(PDF) testimony before the Senate finance committee in September of 2000.

In brief, the current scheme inappropriately increases federal Medicaid payments by paying certain providers more than they would normally receive and then having the providers return the bulk of the extra monies to the state. By making an excess payment, the state generates additional federal matching funds, which can be used to pay its share of future Medicaid payments—thus generating even more federal matching funds— or spent however the state determines. The providers receiving the inflated payments and passing back the excess to the state are entities owned by local governments—for example, county-owned nursing homes and local hospital districts. According to HCFA, as of late July, 17 states have state plans that could allow them to use this practice, and 11 other states have drafted plans for doing so. The exact amount of additional federal Medicaid dollars generated through this process is unknown, but it is in the billions of dollars and growing. While most states do not specifically acknowledge how they will use the money that makes the round-trip back to their treasuries, intended uses reported by elected officials in some states include funding other health-care or education programs, as well as subsidizing a state tax cut.

Mr Johnson at The Business Word asks:

So is this the Enron story of state budgeting?

I would have to say yes. Taking federal money earmarked for Medicaid and using it to support a tax cut certainly looks "Enronesque".

Mr Holt has more to say at The Health Care Blog

Monday, February 16, 2004

The Proximal Tubule
A few weeks ago Matthew Holt of The Health Care Blog posted this comment at Medrants in response to a John Edwards post.

There's no chance that Edwards will get the VP nod, Kerry (who's about to wrap up the nomination) needs a bullet-prrof southerner on the ticket and a trial lawyer just ain't that. And he also needs someone strong on defence and Edwards knows bupkiss about that.

But consder the VP debate between Max Cleleland, triple amputee in Vietnam and cheated out of his senate seat by Diebold voting machines (read the excerpt from the UK Independent in the middle of this), and draft-dodger war profiteer Dick Cheney. My mouth is watering (Wes Clark would do fine too).

Within the comment is a link to this site which cites this article from the Independent. (You have to pay for the whole story).

Something very odd happened in the mid-term elections in Georgia last November. On the eve of the vote, opinion polls showed Roy Barnes, the incumbent Democratic governor, leading by between nine and 11 points. In a somewhat closer, keenly watched Senate race, polls indicated that Max Cleland, the popular Democrat up for re-election, was ahead by two to five points against his Republican challenger, Saxby Chambliss.
Those figures were more or less what political experts would have expected in state with a long tradition of electing Democrats to statewide office. But then the results came in, and all of Georgia appeared to have been turned upside down. Barnes lost the governorship to the Republican, Sonny Perdue, 46 per cent to 51 per cent, a swing of as much as 16 percentage points from the last opinion polls. Cleland lost to Chambliss 46 per cent to 53, a last-minute swing of 9 to 12 points.

Living in Georgia I have heard a great deal about this since the 2002 election. People opposed to electronic voting are quick to point out the polling cited above in claiming the election was "stolen" from not only Max Cleland but from Governor Roy Barnes as well. From Sunday's Atlanta Journal-Constitution

Touch-screen opponents have alleged that Barnes' and Cleland's 2002 upset defeats are suspicious because of a last-minute fix to the machines.
The state had to apply "patches" — software repairs — at the last minute because many of the screens were freezing during tests. Patches are common in the computer world. But the state didn't have time to recertify the machines to make sure the fixes contained no malicious commands. The patches were tested after the election and found to be legitimate, Cox said.
Bobby Kahn, Barnes' chief of staff and now the interim chairman of the Georgia Democratic Party, has found himself in the odd position of defending his boss's loss.
"I would love to believe that Governor Barnes really won and that he lost because of a computer meltdown or a grand conspiracy," Kahn has said. But the count was accurate, he said.
In an interview, Kahn said the last poll conducted before Election Day by Barnes' pollsters showed the governor with a 5 percent edge. The polls underestimated the number of rural whites who turned out against Barnes, Kahn said.
(emphasis mine).

As I posted in July the main issue with those rural whites was Gov. Barnes' change of the Georgia flag. While some may have legitimate issues with the way he ran his campaign (the television ad with Sen Cleland and Osama bin Laden comes to mind). Chambliss was able to paint Cleland as, well, not Zell Miller. Even Common Cause makes it clear that the losses suffered by Cleland and Barnes were not due to fraud:

The Green Party has alleged in its publications through innuendo that Georgia's 2002 election was stolen.

"In 2002, Georgia saw six big upsets of Democrats by Republicans, including one where incumbent US Senator Max Cleland (Dem.) had a big lead in the polls but was surprisingly upended by Republican Saxby Chambliss."

This simply is not true. While Cleland did show a stronger lead in early polls, that had disappeared by election day. On November 4, 2002, the Atlanta Journal Constitution wrote, "A recent poll by the Atlanta Journal-Constitution /WSB-TV indicated Cleland has a slim lead among likely voters. But a poll released Sunday by Zogby International indicated Chambliss had a slight edge. The race has been put in the 'toss-up' category by most national analysts." Chambliss went on to win with 52.8% of the vote.

While the Greens don't state it, the bigger surprise in Georgia 2002 was the upset victory of Republican Sonny Perdue over incumbent Democrat Governor Roy Barnes. Most analysts reason that Perdue got most of the same voters Chambliss got. (The totals were 1,071,494 for Chambliss and 1,041,700 for Perdue.) While both Barnes and Cleland had the power of incumbency, and Barnes had a huge advantage in fundraising, the Republican victories do not mean they stole the election. Georgia had already elected Republican Senators before, and the congressional delegation has been mostly Republican for years. As disappointing as the 2002 results might have been to Democrats and Greens, there is no evidence to support a stolen election.

I'm sure that we will see more of this as the election year proceeds. On a personal note I found the touch-screen system very easy to use and quite user-friendly.


Friday, February 13, 2004


NYC Panel Mulls Tax on Cosmetic Surgery

A tummy tuck may someday make a cosmetic surgery patient's wallet thinner, too, if a New York City tax panel has its way.
Imposing sales tax on Botox treatments, breast surgery and other cosmetic procedures could bring in $62 million in revenue for the city, according to the Independent Budget Office.

The suggestion was among nearly 70 options included in a report released by the publicly funded, nonpartisan agency on Thursday.

"The business of cosmetic enhancements, including both surgical and nonsurgical procedures, is one of the fastest-growing industries in the United States," the report said, adding that the number of procedures more than quadrupled between 1997 and 2001.

Cosmetic procedures such as collagen injections and laser treatments are not subject to sales tax now because they are considered medical procedures, the agency said.

Have politicians ever met a tax they didn't like?

One of the nice things about having a January birthday is that I am able to put off my New Year's resolutions off a little bit. With DB singing the praises of exercise and the GruntDoc doing the Adkins thing I decided it was time for me to get serious about losing weight. This coincides with the Big Hospital's recently launched "Physician's Health Initiative"(PHI). Apparently the hospital has a large amount of excess funds from the application and renewal fees physicians pay to be on the medical staff. So after some debate about what to do about the money, during which the ideas of refunding the money or reducing the fees were dismissed out of hand, the PHI is what they came up with.

This involved some lab work and the measurement of BMI. The participating physicians will also have the opportunity to meet with a personal trainer for one session a week for six weeks. So at 6'4" and a weight of 310 yours truly had a BMI of 38 with a body fat percentage (measured by one of those impedance things) of 41%. Room for some improvement, I would say.

So for the past two weeks I have been arriving at the gym at 0600 every weekday for 30 or so minutes of elliptical
machine work with a return later in the day for weightlifting if I can get off work in time. While it is a pain to get up so early to workout I'm afraid that if I put it off I would come up with a million reasons not to do it. I also would be later getting home and missing out of family time. I'm also being much more careful about what I eat since the doctor's lounge at Big Hospital serves excellent breakfast and lunch.

I enjoy eating and since medical school have gotten into the bad habit of treating each meal at the hospital as if it would be my last. This attitude comes from the oft quoted RULES FOR THE SURGICAL RESIDENT

1. Sleep when you can
2. Eat when you can
3. Go to the bathroom when you can
4. Don't mess with the pancreas

Another good one is "Never go into the OR with an empty stomach or a full bladder"

So we will see how it goes over the next few months.

Dr. Smith points to the ground-breaking coverage by the National Enquirer concerning physician's eating habits.

Thursday, February 12, 2004


While driving in to work today from the gym (more on that later) I was listening to the Georgia Public Radio news broadcast about how Georgia Medicaid is going to go broke this spring:

Georgia's Medicaid program will run out of money in May unless it can recoup an estimated $400 million in overpayments to hospitals and other medical providers. Our backs are against the wall," Tim Burgess, commissioner of the Department of Community Health, told an agency board meeting Wednesday. "The option is to run out of cash."

The dire cash situation exists despite the expected infusion of $172.8 million from the General Assembly, and anticipated federal funding.

Greedy doctors to blame, you say? It's their fault!! How dare they rip off the state to the tune of $400 million!! Well the situation is largely of Georgia Medicaid's own making:

The payment discrepancies came as a result of claims snags starting in April 2003, when a new computer system run by Texas-based Affiliated Computer Services took over Medicaid billing.

Because most medical bills weren't being paid then, the state began paying providers an amount based on their billings in the previous year. Now, DCH has estimated that the state paid providers about $700 million more than the same period the previous year.

As I posted in August this involved sending checks to providers without any indication of which patient the money was for. It was several months before we were able to reconcile accounts. The amount the state wants back from the Acme Surgical Corp: $15,000 a month. While that won't reduce us to eating ramen soup for three meals a day, it certainly isn't a good thing.

It's not like no one saw it coming, according to the November 10th Atlanta Journal-Constitution:

A last-minute deal that balanced this year's state budget and funded pet local projects could leave Georgia's health care program for the poor and disabled short of money to pay bills by the spring.

The state's Medicaid program may need a quick infusion of money during the upcoming 2004 session of the Georgia General Assembly because $148 million was cut from its budget as part of an agreement to help balance the state's $16 billion spending plan.

What frightens me about this is what if Medicaid (i.e. the government) was the only game in town? As it is now, we at least have the private insurance population to ensure that we can get some income. But what if such a budget crisis were to occur under a single-payer system? What would happen then? Would the legislature have the political will to raise taxes? At first glance not likely:

The money originally was proposed by Perdue in January to help pay for Medicaid health care services this fiscal year, which began July 1. Channell said it was cut out by Perdue's administration to help balance the budget. The administration pointed the finger at lawmakers.

"The governor's budget left that money in. The reality is, the legislators took it and used it to fund a variety of their pet projects," said Dan McLagan, the governor's spokesman.

Lawmakers added more than $20 million in local projects, including money for a museum in the hometown of the House Appropriations Chairman Tom Buck (D-Columbus); seed money for a housing project in the hometowns of other House leaders; and bond money for construction projects in the districts of Senate Appropriations Chairman Jack Hill (R-Reidsville) and Sen. Don Cheeks (R-Augusta), one of the budget negotiators.

While Graham and I do not agree on the single-payer question, I agree with the point made in this post that the question is not if we CAN do it, but do we WANT to do it. Which is about the same as realty doesn't matter, but the perception of reality does.

Wednesday, February 11, 2004

Man Drives For Help With Shark Attached To Leg

Lifeguards at a beach post north of Sydney couldn't believe their eyes when a man walked in with a small shark attached to his leg.

Luke Tresoglavic swam 1,000 feet to shore, walked to his car and drove to the local surf club with the 23-inch shark biting his leg and refusing to let go.

"I just realized I had to swim in like that, hanging on to it," Tresoglavic told Australian Broadcasting Corp. radio on Wednesday.

Tresoglavic, 22, was snorkeling on a reef off Caves Beach near Newcastle on Tuesday when a wobbegong, or carpet shark, attacked his leg.

"Once I got on to shore, a couple of people tried to help me, but I could not remove it," he said. "It was stuck there, so I got up into my car and then drove to the clubhouse, and luckily the guys down there had a clue what to do."

A senior lifeguard at the clubhouse, Michael Jones, said he couldn't believe his eyes when Tresoglavic turned up -- shark in tow.

"He basically asked the question: 'Can you help me get it off?' There's nothing in our procedure manual for that type of thing," Jones said.

The lifeguards flushed the shark's gills with fresh water, forcing it to loosen its grip on Tresoglavic's leg -- with blood oozing from 70 needle-like punctures. The shark later died.

"He's lucky he didn't get into difficulties in the water trying to swim with that thing thrashing around," Jones said.

But he said Tresoglavic remained in good spirits throughout the ordeal. "There was a side of humor to it," he said.

Tresoglavic was taken to hospital, but it was not immediately clear what treatment he received.

Wobbegong sharks can grow to nearly 10 feet in length, possess razor-sharp teeth and are said to be moody and short-tempered.


via Drudge

Sunday, February 08, 2004

From the Atlanta Journal-Constitution: Georgian building his dream with Lego bricks

Garrett Barati sees his future in a bin full of Lego bricks — the nubbly red rectangles, the canary-yellow cubes, the flat squares that look like Chiclets — set on a table before him in the middle of the Legoland California theme park. If he can take those 4,000 plastic bricks and in two hours stack and snap them into something spectacular, he might achieve the goal he's been working toward for six months, and perhaps his entire life.

Barati wants to be a professional Lego builder and spend his 9-to-5 constructing life-size elephants, tiny skyscrapers, speeding trains and 3-D dinosaurs out of Legos for exhibits at the theme park.

Now the job is within reach — he's been picked from a field of 500 to fcompete against 26 other Lego fiends in this Jan. 23 event, the final build-off for the first Lego Master Model Builder Search.

To prepare, Barati spent 12 hours a day in his sister's cramped apartment in Columbus, Ga., hunched over a mound of primary-colored blocks, bettering his techniques and times, smoking too many cigarettes, drinking too much coffee and agonizing about what would happen to his ego, his future and his escalating debt if he failed to get this job.

Lego building may seem an odd or perhaps trivial aspiration; the bricks are a child's toy, after all. When Barati plays with them, he doesn't look like a 29-year-old artist who can talk endlessly about politics, religion and economics. With his hand wrist deep in a bucket of Legos, he looks like a kid, and he knows it.

But this isn't child's play to Barati. To him, Lego building is an artistic pursuit more gratifying than, say, sculpture. With Lego, there's no conceptualizing on paper, then shaping with clay, then painting, then firing in a kiln before having a finished product. And Barati loves the mathematical challenge of taking sharp-edged rectangles and creating a curvy mushroom cap or a kitten's arched back.

The master builder contest gives Barati a one-shot chance at taking this beloved hobby and turning it into a career. So for that he'll suffer the quizzical looks, ignore the dire predictions and try not to obsess about the consequences.

"It's one of those pipe dream kind of deals where it really does seem like, what's the chance?" Barati says. "But if you're going for something like this . . . you really want to give it your all."

Barati's desire is not unlike that of the waiter who labors in secret on his novelIf he can take those 4,000 plastic bricks and in two hours stack and snap them into something spectacular, he might achieve the goal he's been working toward for six months, and perhaps his entire life.

Barati wants to be a professional Lego builder and spend his 9-to-5 constructing life-size elephants, tiny skyscrapers, speeding trains and 3-D dinosaurs out of Legos for exhibits at the theme park.

Now the job is within reach — he's been picked from a field of 500 to compete against 26 other Lego fiends in this Jan. 23 event, the final build-off for the first Lego Master Model Builder Search.

To prepare, Barati spent 12 hours a day in his sister's cramped apartment in Columbus, Ga., hunched over a mound of primary-colored blocks, bettering his techniques and times, smoking too many cigarettes, drinking too much coffee and agonizing about what would happen to his ego, his future and his escalating debt if he failed to get this job.

Lego building may seem an odd or perhaps trivial aspiration; the bricks are a child's toy, after all. When Barati plays with them, he doesn't look like a 29-year-old artist who can talk endlessly about politics, religion and economics. With his hand wrist deep in a bucket of Legos, he looks like a kid, and he knows it.

But this isn't child's play to Barati. To him, Lego building is an artistic pursuit more gratifying than, say, sculpture. With Lego, there's no conceptualizing on paper, then shaping with clay, then painting, then firing in a kiln before having a finished product. And Barati loves the mathematical challenge of taking sharp-edged rectangles and creating a curvy mushroom cap or a kitten's arched back.

The master builder contest gives Barati a one-shot chance at taking this beloved hobby and turning it into a career. So for that he'll suffer the quizzical looks, ignore the dire predictions and try not to obsess about the consequences.

"It's one of those pipe dream kind of deals where it really does seem like, what's the chance?" Barati says. "But if you're going for something like this . . . you really want to give it your all."

Unfortunatley Mr. Barati did not win the contest, but he says he will continue in his efforts to work for LEGO, probably one of the coolest jobs in the world.

Saturday, February 07, 2004

Posting has been light, mainly because my day job has gotten in the way of my blogging. Anyway, I was on call Wednesday and accepted an elderly automobile collision victim from a referral facility that had no available neurosurgeon. The patient had a subdural and subarachnoid hemorrhage and a clavicle fracture. Their blood pressure was in the low 100's and improved with some adequate resuscitation. FAST exam showed a small amount of fluid so I obtained a CT scan of the abdomen and pelvis. The scan showed a large amount of fluid with no evidence of solid organ injury. Usually that means one of two things: a hollow viscus injury, or a mesenteric injury. Given the lack of free air on CT I doubted a bowel injury, and was leaning toward a mesenteric injury that had stopped bleeding. But off to the OR...
Encountered a large amount of old blood and a mesenteric injury that was no longer bleeding. A small splenic laceration was at the upper pole and did not respond to surgicel and other methods to achieve hemostasis. Out comes the spleen. While exploring the remainder of the abdomen I found, to my unpleasant surprise, a near-obstructing transverse colon cancer. Several large lymph nodes were seen in the mesentery. I resected it via expanded right hemicolectomy (terminal ileum, cecum, ascending colon and transverse colon). The question then becomes: Do I perform an anastomosis or construct stomas?
The current recommendations in the trauma literature are that colonic injuries may be treated with resection and anastomosis if the patient is not hypotensive, and soilage is minimal. Unfortunately this patient did not really meet the criteria for anastomosis. So in addition to the injuries described above the patient now owns a ileostomy and a mucus fistula.

Tuesday, February 03, 2004

From today's New York Times: Multiple Missions Put Teaching Hospitals at Risk.

For more than a century, Americans have expressed confidence that an ever-increasing, well-trained cadre of physicians and medical scientists will protect and enhance their health. So for much of this period, the steady expansion of medical schools, research laboratories and teaching hospitals has been justified as an agent of public good.
More recently, however, with the fiscal crisis in health care, experts are beginning to question whether the nation's academic medical centers are financially sustainable in these times when Americans tend to worship the free market.
It has become increasingly difficult in recent years simultaneously to educate and train young doctors, treat patients, advance medical research, and hew to the bottom line. All these endeavors require more and more costly technology. Salaries and health care delivery expenses continue to rise. And the competition among all medical centers, whether affiliated with universities or independent, is ferocious.

Much like in the non-academic centers, things are not always warm and fuzzy between the faculty and the administrators, university and hospital alike:

More pointedly, Dr. Guy McKhann, a professor of neurology and a former member of the Johns Hopkins Hospital's medical board observed: "In many academic medical centers, there is a real split between those who run the hospitals and those who run the medical school. They'd rather undercut each other than survive."......What has changed most over the past century is that today's academic medical centers are almost or completely financially independent from their parent universities. To make matters more precarious, when economic times are good, many university presidents look to their hospitals' profits to support other growth plans in the less lucrative schools or colleges. But when these revenues are threatened or reduced, they often seek ways to minimize the university's financial responsibility to its academic medical center.

And some view a role in the future of the academic medical center as an instrument for social change:

Dr. Robert P. Kelch, chief executive of the University of Michigan Health System, predicts that research-oriented medical centers will need to be run and financed differently from the centers that focus mainly on patient care and the training of doctors and nurses.
"The free market never gets things right," Dr. Kelch said. "In this case, it has led to a more stratified health care system that may lead to a real crisis as the baby boomers age. My hope is that academic medical centers will help Americans come to a national consensus that will not only ensure the highest quality of health care and medical science but also universal access."

Sounds like herding cats to me.

BTW...here is the link to the book, Governance of Teaching Hospitals: Turmoil at Penn and Hopkins mentioned in the article.
As Medicare reimbursements are falling, smaller community hospitals are struggling for survival....

While looming health-care cuts and rising insurance costs have affected hospitals throughout the state, smaller community hospitals have been especially burdened as they struggle against tight budgets and poor perceptions to provide quality health care in rural Georgia.
Glen Pearson, executive vice president of the Georgia Hospital Association, said that since 1990, 27 Georgia hospitals have closed, a significant number of them rural community hospitals.
Pearson said that currently 59 percent of all hospitals in the state are losing money. And 70 percent of rural hospitals find themselves in the red, he said.Starting with 1997's Balanced Budget Act, $3 billion have been cut from Medicare payments for older patients; Medicaid for low-income patients currently pays about 94 percent of the actual cost of treatment. And since rural hospitals often have a high percentage of Medicare and Medicaid patients these cuts hit them especially hard, Pearson said.
Minnie G. Boswell Memorial Hospital in Greensboro felt the bind of government red tape in October when delayed Medicaid and Medicare payments left its officials $96,000 short and unable to pay its staff. It was only a private donation of the sum that paid the staff of the 25-bed facility on time.

The problems with smaller community hospitals go beyond the Medicare cutbacks and increases of insurance, however. One problem mentioned in the article is the perception of the local hospital as being a hospital of "last resort". Regional hospitals such as Athens Regional advertise aggressively in the smaller markets as well. Frequently specialists don't want to practice in smaller towns so patients who require care from cardiologists or orthopedic surgeons, for example, travel to the larger facilities. This feeds the perception of the local hospital as "inadequate".The lack of such specialists means the income that could be realized from cath labs or operating rooms is not available to provide for improvements of the hospital. The hospital can't improve so the perception of it as a dangerous place worsens, and fewer people utilize it, and so goes the vicious cycle.

Another problem is that many of these hospitals were used by physicians and administrators as their personal piggy bank. Since in many towns the hospital was a major employer, nothing was said to threaten it. I have family that live in Greensboro and describe how in the past someone could be admitted for "respite care" to the hospital there, and have insurance pay for it no questions asked. Kind of a narcotic and benzodiazapine assisted vacation from life, without the travel. When these "admissions" were denied payment, a major source of income was lost. Many such hospitals were bought up by larger hospitals in an attempt to create a network of sorts. But like hospitals that bought physician practices soon found out, such ventures lose a great deal of money.

Administrators at smaller hospitals hold out some hope, however....

Weinmeister (an administrator) said technology is making size irrelevant. And Hill said the hospital's smaller size cuts down on administrative red tape, often making his job easier.

Unfortunately technology requires something that these smaller hospitals do not have a tremendous amount of, investment capital. With the growing data showing correlation between hospital volume and outcomes for procedures there is a potential for more patients to seek care at larger facilities. The situation for smaller hospitals is likely to become worse before it becomes better.

Monday, February 02, 2004

In today's Wall Street Journal (subs. req.), partly to avoid the wrath of the New York State Legislature and this man, hospitals in New York are willing to take their chances with Medicare and provide discounted pricing to the uninsured:

Amid mounting criticism of hospitals' treatment of the uninsured and warnings of tough legislative remedies, hospitals in New York state have agreed to a voluntary program to cut prices and provide charity care for their poorest patients. They have also pledged to restrict punitive collection tactics.

The trade group representing the state's 230 not-for-profit hospitals -- ranging from state-of-the-art teaching facilities in Manhattan to small hospitals in economically depressed towns upstate -- quietly adopted the program two weeks ago following seven months of wrangling........The New York guidelines urge hospitals to offer immediate price cuts to anyone who makes 200% or less of the federal poverty level of roughly $9,000 a year for an individual. They also encourage institutions to offer discounts to families who earn more. In particular, the guidelines steer hospitals away from billing the uninsured at full charges, suggesting instead that they charge low-income patients the far lower amounts they receive from HMOs, insurers and the government.

The guidelines also specifically discourage such collection measures as home foreclosure and "body attachment," a practice under which a hospital has a patient arrested and jailed for missing a court appearance related to a medical debt.

As with all good compromises both sides are unhappy:

Participants in the process recall testy discussions over discounts. Some hospitals wanted the bare minimum threshold, perhaps 150% of the poverty level, while others wanted to go as high as 400%. And some didn't want any fixed number.

New York City hospitals, which have their own trade group, were resistant to the whole idea of statewide guidelines at first. "Frankly, there was a debate whether or not if you published a policy it would push you in the direction of legislation," says Kenneth Raske, president of the Greater New York Hospital Association. He and some of his members also worried that guidelines would be "a floor, not a ceiling," though they eventually embraced the policy.

Hospital-critic Elisabeth Benjamin of the Legal Aid Society reacted favorably to the new guidelines, though she says, "They can still charge 9% interest, they can still grab your paycheck, they can still sue you, they can put liens on your house." She also believes that legislation will still be necessary to regulate hospital practices, and that the 200% threshold is too low. But she says she's pleased that "New York hospitals have finally woken up," and that even 200% will help young singles and childless couples, who often fall through the cracks because they don't qualify for Medicaid or other government programs.

I wonder what Medicare will do?
When I saw the first round of recent posts on Sen. Edwards' career as a plaintiff's attorney for medical liability claims by Dr. Smith, Dr. Rangel, and DB, I thought, "Would Edwards have been able to pull this off in a state like Florida where they have a birth related neurological injury compensation fund?"
Well thanks to Dr. Smith and the The New York Times I know that he didn't want to find out:

An examination of Mr. Edwards's legal career also opens a window onto the world of personal injury litigation. In building his career, Mr. Edwards underbid other lawyers to win promising clients, sifted through several dozen expert witnesses to find one who would attest to his claims, and opposed state legislation that would have helped all families with brain-damaged children and not just those few who win big malpractice awards.......One approach would be to limit awards and create a fund to be shared by all families with similarly afflicted children.
This is not the first time Mr. Miller has championed the idea. In 1991, his legislation to create such a fund was defeated, in large part by the state's trial lawyers. Among those who spoke out against the bill was Mr. Edwards, who called it a baby tax.

One purpose of such a fund, as a former North Carolina State legislator states, is to provide compensation to those who cannot get a lawyer to take their case. Another is to provide a predictable method of compensation that cannot be achieved with a system relying on jury verdicts. Another program exists in Virginia. According to an evaluation of the Virginia program:

The legislature's Joint Legislative Audit and Review Commission (JLARC) evaluated the program in November 2002. It determined that the program overall was beneficial for ob/gyns and hospitals and that children in the program fared better than they would have under the tort system with a malpractice award cap.

As of October 2002, 75 children had been found eligible for benefits. JLARC found that their annual compensation exceeded the tort system's annual awards and expenses for severe birth injury cases, which it estimated at $ 10. 8 million. Program beneficiaries had received $ 25. 3 million since 1992 when the first distribution was made, an average of $ 62,000 per year per participant.

But certainly, Senator Edwards wasn't doing anything illegal by working against such a fund, any more than a physician who lobbies in support for tort reform or adjustments to the Medicare fee schedule. But the use of questionable expert testimony by Edwards (was it "debatable" or "junk science"?, if it was junk science did Edwards know it was?) is generating debate among the lawyer blogs.

Walter Olson and the folks at Overlawyered "aren't buying this line of reasoning" about the requirements of "zealous advocacy" to present all evidence at a trial to support the position of one's client.

While the LitiGator has links to the ACOG report on neonatal encephalopathy and cerebral palsy. He also writes this:

As a defense attorney who has been defending doctors for the last two decades, I can state quite definitively that during that entire time there has been no perception that the association between perinatal oxygen deprivation in the neonate and neurological deficits in later life is "junk science" as that term is generally used. It has instead been an actively debated and litigated issue of causation. "Junk science" refers to a principle of causation which is unproven and not generally accepted in the relevant field of practice. Up to 2003 for many forms of CP, and even now for others, that label would not properly apply to the causal arguments in question.

Peter Nordberg has this to say:

The duty in question arises not from any particular verbalization of the litigator's responsibilities in codes of professional conduct, but rather from the litigator's role in an adversary system. That role does not include adjudicating the claims, or withholding admissible expert evidence because the litigator might reach different conclusions as an armchair medical scientist. It does include what the client has a right to expect, and does expect: viz., that on pain of malpractice exposure, the litigator will press the client's interests through whatever evidence is legitimately at the litigator's disposal. That is the "honorable" thing to do. And under the rule of law, it is not the litigator, nor any single man or woman, who ultimately defines the boundaries of evidentiary legitimacy. The rules of evidence do that, for honest advocates and scoundrels alike.

And finally, David Bernstein at The Volokh Conspiracy makes perhaps the most salient point of the debate (emphasis mine).

It's obviously foolish to have such complex issues of medical causation being determined before a nonexpert jury in an adversarial process to begin with, and I can't really begrudge Edwards, or any other attorney, who play their appointed roles in the system. It's convenient for civil justice reformers to use wealthy trial lawyers as their public enemy, a good robber barronish foil. And certainly I object when trial lawyers manipulate the political process to their benefit, as they did in many ways during the tobacco litigation. But when they are merely doing their jobs within the system as it exists*, I refuse to demonize them; repeat after me, civil justice reformers: blame the system, not the participants in it.

Or, as the title to this post suggests, hate the system that lets things like this happen, and work to fix it. I'm not suggesting that anyone vote for Edwards (I'm not), nor am I suggesting that Sen. Edwards get a free pass on this because I believe it reflects on his character. I am playing the Devil's advocate (no pun intended) a little bit on this issue because it helps me in my feeble attempts to stay intellectually honest.
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