Friday, April 17, 2009
Callie Moore Is a 13 year-old young lady who lives in the Athens area and has a multitude of medical conditions:
Because of strokes she suffered while in her mother's womb, 13-year-old Callie Moore of Danielsville has a host of complex medical problems. They include spastic quadriplegic cerebral palsy, refractory seizure disorder, mental retardation, gastroesophageal reflux disease, cortical blindness, dysphagia, bone cartilage disease, scoliosis, kyphosis and restrictive lung disease.
Because of these she requires many services that are provided by Medicaid:
Callie's condition mandates round-the-clock care and treatment. Under federal and state Medicaid regulations and policies, she is entitled to screening, diagnostic and treatment services and, because she is medically fragile, skilled nursing care. Medicaid is a joint federal-state matching program that pays for medical assistance for low-income families and for people who would require institutional care if they were not receiving alternative services at home.Medicaid reduced Callie's hours of nursing care and her parents sued Medicaid:
The appeal of this decision was heard by the 11th circuit court of appeals. Part of the case was an amicus brief filed by the states of Florida and Alabama. The essence of which was: the state knows better than your physician
The Moores' lawyers convinced U.S. District Judge Thomas W. Thrash Jr. that the reduction was improper. The judge concluded the state must provide for the amount of skilled nursing care that Callie's treating physician deems necessary.
Thrash's June 4, 2008, ruling has states and Medicaid plan managers up in arms. They say that Thrash's order means that states won't have the flexibility they need and the discretion the law allows to allocate Medicaid resources fairly......
....When state authorities notified Callie's mother that her nursing hours were being reduced, they cited, among other things, a policy that the cost of in-home nursing care should be less than the cost of providing that care in an institution. But the state denies in its brief that it considered cost in determining what nursing hours Callie will receive. It says its experts simply disagreed with the judgement of Callie's doctor on how many nursing hours Callie needs.
After Thrash issued multiple injunctions in Callie's favor, he denied the state's motion for summary judgment and granted the Moores' motion in part.
"Treating physicians...cannot be trusted with this sort of discretion," Senior writes. "When left to their own devices, they advocate for their patients and deem all manner of unproven, dangerous, ineffective, cosmetic, unnecessary, bizarre, and controversial treatments as 'medically necessary.'"
He continued: "Case law provides examples of treating doctors claiming medical necessity and attempting to bill Medicaid for: cosmetic procedures; sex-change operations; (unapproved) drugs; abortion on demand; 'treatments' that have never been proven to work; and round-the-clock nursing and personal assistance for patients who obviously do not need it..." (emphasis added)
Amazingly, the omniscience of the government is not mentioned on the website describing the Obama administration's plan:
Under the Obama-Biden plan, patients will be able to make health care decisions with their doctors, instead of being blocked by insurance company bureaucrats.
Mickey Kaus seems to believe that the government will be so scared of offending anyone that everything will be approved and the promise of cost control evaporates:
The “rational,” cost-cutting, “hard-choices” pitch isn’t just awful marketing–I don’t even think it’s accurate. Put it this way: I’m for universal health care in large part precisely because I think the government will be less tough-minded and cost-conscious when it comes to the inevitable rationing of care than for-profit insurance companies will be. Take Arnold Kling’s example of a young patient with cancer, where “the best hope is a treatment that costs $100,000 and offers a chance of success of 1 in 200.” No “rational bureaucracy” would spend $20 million to save a life, Kling argues. I doubt any private insurance company is going to write a policy that spends $20 million to save a life. But I think the government–faced with demands from patient groups and disease lobbies and treatment providers and Oprah and run, ultimately, by politicians as terrified of being held responsible for denying treatment as they are quick to pander to the public’s sentimental bias toward life–is less likely to be “rational” than the private sector.But the potential for political interference can be strong. From the Coyote Blog: (Thanks Galen!!)
That is to say, the government’s more likely to pay for the treatment (assuming a doctor recommends it). So it’s government for me.
But Kaus is correct that if some high-powered and well-funded interest group gets behind a certain procedure, cost-effective or not, the government overlords of the program will likely approve it. As a result, for example, no potential treatment for breast cancer will ever be denied given the proven strength of women’s groups lobbying for breast cancer treatment (already, breast cancer research is hugely over-funded vs. other diseases given its mortality, due in large part to this powerful lobbying).
But it is not one dynamic or the other. Both will exist. There will be huge pressures to cut back somewhere, as costs skyrocket. And there will be huge pressure from certain interest groups to fund treatment for certain diseases in unlimited amounts. The result will not be, as Kaus posits, that everything will be funded more than it is today — the result will be that certain procedures and conditions with strong lobbying and political muscle will get funded more, with the difference being made up from cutting funding for conditions and procedures without a well-organized lobby.
And if you think that the current enthusiasts of health care reform will ignore special interest politics, or their own interests please ask them their position on wind energy.
(Hat tip Red State) |
Tuesday, April 14, 2009
See this week's best of the medical blogosphere, hosted by Pharmamotion. |
Monday, April 13, 2009
I have been dragooned into a leadership position at Big Hospital. Hooray. Another physician (employed by the hospital) pointed out the multiple
This got me to thinking, are the days of the independent medical staff numbered? And are they relevant today?
I define as an independent member of the medical staff as a physician who :
- Has full, unrestricted admitting privileges (no "consult" or "courtesy"privileges).
- Takes call, according to bylaws, without compensation from the hospital.
- Does not receive a payment from the hospital on a fee-for-service or other basis for providing uncompensated care
- Does not have a contract to provide services to any hospital, with the exception of such things as EKG, echo and PFT interpretation. I am uncertain as how to approach unpaid "medical directorships".
I will admit that the above requirements are stringent, but they probably were the norm for most non hospital-based physicians in the not too distant past. I will also admit that I do not meet my own definition of "independence". My thoughts as to the "why":
- The rise of hospitalists and the economic realities of outpatient versus hospital burdens for primary care providers has caused many to forgo hospital privileges
- Hospitals are having to pay physicians to take call and provide guarantees for Medicare/caid rates for unfunded patients
- Hospitals are increasingly employing specialist physicians, as the procedures they perform can generate income for the hospital.
- Given the lifestyle concerns of recent (and not so recent) residency graduates, the appeal of a salaried hospital position is strong.
It is also difficult to get physicians to participate in the ongoing workings of the medical staff. yes the quarterly meetings are popular because a free dinner is thrown in. But it is a Herculean effort to get physicians to agree to be on committees, much less show up for them, for many the same reasons that local medical societies struggle to survive.
Proponents of a strong medical staff have our old, dear, friend the Joint Commission to thank since they require hospitals to utilize their medical staffs for credentialing and peer review.
But if the members are dependent on the hospital for all or a goodly portion of their income, just how independent are they?|
Saturday, April 11, 2009
Red 13 Black 3
You know college football is big in Georgia when for your spring game: 1)About 40,000 show up, and 2)It's covered live on ESPN and Herbstreit does the play-by-play.
Yes, I know that that many or more will show up for the A-day game in Tuscaloosa next week. But it is Easter weekend, and The Masters is underway, so there! |
Wednesday, April 08, 2009
In this post Kevin throws down the gauntlet:
Make no mistake, specialist organizations are ready to throw primary care under the bus, with the opening salvo of implying that generalist doctors can be easily replaced by mid-level providers telegraphing their intentions.Two enter, one leaves indeed.
Let's hope that the ACP is aggressive in countering these tactics. It's becoming clear that a conciliatory approach with specialist organizations may not be feasible, and more contentious, potentially confrontational, methods may be needed to be heard above the din.
Kevin links again to Bob Doherty'sblog where the American College of Surgeons is taken to task over their Operation Patient Access website and advocacy program:
The American College of Surgeons, joined by other surgical specialty societies, has created Operation Patient Access (OPA), a campaign to "bring into focus the urgent issues facing access to quality surgical care in the United States ... and to call attention to urgently needed policy changes to address gaps in the availability of quality surgical patient." According to the OPA website (which is pretty nicely done, by the way), 400 surgeons - sporting "Will a surgeon be a there when you need one?" buttons - descended on Capitol Hill last week to urge lawmakers to "consider a wide range of solutions, such as providing more funding for graduate surgical education, reducing liability costs, expanding the National Health Service Corps, and implementing alternative payment methods for health care. If we fail to act now, these shortages will undermine attempts to expand access to health care and will further endanger the lives of all our citizens."While there is a distribution problem with subspecialist surgeons there is a growing shortage of general surgeons. This is primarily due to the static number of residency slots, it is further worsened by the twenty-five percent of graduating chief residents that stay within general surgery. Some of the websites claims can be chalked up to advances in technology and declines in revenue: ("There aren't enough applicants to fill needed training spots in cardiothoracic surgery"), lifestyle and liability concerns: ("75% of U.S. hospitals report inadequate on-call surgical coverage in their Emergency Departments", "Emergency Departments have a shortage of neuro, orthopedic, general and plastic surgeons"), or demographics: (1/3 of rural hospitals have a surgeon leaving in the next two years). Given the income that surgeons bring in to those rural hospitals, a great many of them may close.
If this sounds familiar, it is because the surgeons' diagnosis and policy prescriptions are virtually identical to the case that ACP has been making on the primary care physician shortage.
Which is a problem, because it blurs the urgent need to rebuild the primary care physician workforce in the United States by suggesting that the crisis in surgery is of greater concern. The tools to increase the numbers and proportions of primary care physicians in the United States - payment reform, scholarships and loan forgiveness in exchange for service obligations, and graduate medical education funding - will be ineffective if the limited funding for such programs are broadly diverted to increase the numbers of surgeons, including some surgical specialties where there is scant evidence of a shortage. The OPA website speaks broadly of shortage of surgeons, when the evidence that I've seen - including the evidence on the OPA website - suggests that the shortage is principally in general surgery and a few of the surgical subspecialties and in certain parts of the country, particularly rural areas.
Demographics not only in the patient population, but within the specialty itself, will have a large impact. According to the AAMC's Center for Workforce Data's 2008 Physician Specialty Data general surgery had a higher percentage of its' workforce over 55 years of age (42.4%) than IM (32.3%), FP (36.7%), pediatrics (33.6%), or all specialties (37.6%). Even more interesting, while from 1996 to 2006 the numbers of family practitioners increased by 20.2 percent, internists by 30.2 percent, and pediatricians by 31.7 percent the number of general surgeons fell by 2.3 percent over that time. While the number of physicians of all specialties increased, on average, 28.6 percent, the number of general surgeons declined. All during Dr. Parker's post-medical school career.
If the number of primary care physicians grew by 21 percent over the past 10 years , and they are perceived to be in crisis, what of the specialty that not only shrunk, but grew older during that time period?
In fairness to Bob Doherty, he does give the ACS credit for a well-designed site. Here is a link found on the site to a Good Morning America interview with one of the best speakers I have ever heard, Dr. L.D. Britt. |
Tuesday, April 07, 2009
Monday, April 06, 2009
Gentleman working on a landscpe project. The worker above him falls and drops one of these on him:
And they strike him in the neck. He arrives alert and oriented, but every time he speaks or coughs air comes out of the wound on his neck. Off to the operating room...
THE FOLLOWING IMAGES MAY BE OFFENSIVE....blah, blah,.....
The yellow circle represents the entry wound. Given his stability and the size I did not anticipate the degree of injury. I asked my friendly neighborhood ENT to assist. The yellow line indicates the endotracheal tube. The green line is the inferior portion of the thyroid cartilage, the white line the cricoid cartilage. He had been given a cricothyroidotomy. A tracheostomy was placed and the defect was covered with a rotated strap muscle. Post-injury direct laryngoscopy:
The black line points to the strap muscle.
The white line again indicates the muscle, the black lines represent the medial borders of the vocal cords. No evidence of vascular injury on exploration. Bronchoscopy allows for evacuation of some blood and esophagoscopy shows no injury.
Labels: Tales from the Trauma Service|
Thursday, April 02, 2009
But I will watch the last episode of "ER" tonight.
Labels: medical television|