In Defense of the HSA

Greg Scandlen of Consumers for Health Care Choices set the record straight on Health Savings Accounts (HSA's) in his recent May 14, 2008 testimony to the Health Subcommittee of the Ways and Means Committee of the US House of Representatives.

Via We Stand FIRM:

* You were told that lower-income people cannot afford the out-of-pocket responsibility that comes with an HSA. You were not told how those same people could afford the higher premiums that are required to avoid that cost. In fact, money that is paid to an insurance company for first-dollar coverage is money that is lost forever. Lowering the premium and using that saving to pay directly for services gives the low-income consumer a chance to save money that would otherwise be lost.

* You were told that the tax break associated with HSAs is unprecedented and a boon to the "wealthy." In fact, the tax treatment of HSAs is precisely the same tax treatment afforded to employer-sponsored health insurance. Premiums are untaxed and benefits are untaxed. It is true that the "wealthy" get a larger tax benefits than the unwealthy, but that is the case for employer-sponsored comprehensive coverage as well as for HSAs. Further, the opportunity to save, say, $2,000 a year that would otherwise go to an insurance company is of far greater benefit to the low-income worker who earns $20,000 a year than to the wealthy executive who makes $200,000, regardless of the tax treatment.

* You were told that "the sick" do not benefit from HSAs because of the higher out-of-pocket responsibility. In fact, both the healthy and the sick have less out-of-pocket exposure with an HSA, a point that was well documented in a recent Health Affairs article. In fact, HSAs limit a patient's out-of-pocket exposure, something that is not true for the Medicare program, for instance.

Read the rest.

Gold Bond Powder

Cranky Prof discovers the magic pixie dust.

Needless to say, I'm a huge fan of the stuff.

Taboo Words

"The strange emotional power of swearing--as well as the presence of linguistic taboos in all cultures-- suggests that taboo words tap into deep and ancient parts of the brain. In general, words have not just a denotation but a connotation: an emotional coloring distinct from what the word literally refers to, as in principled versus stubborn and slender versus scrawny. The difference between a taboo word and its genteel synonyms, such as shit and feces, c**t and vagina, or f***ing and making love, is an extreme example of the distinction. Curses provoke a different response than their synonyms in part because connotations and denotations are stored in different parts of the brain...

On the whole, the acceptability of taboo words is only loosely tied to the acceptability of what they refer to, but, in the case of taboo terms for effluvia, the correlation is fairly good. The linguists Keith Allan and Kate Burridge have noted that shit is less acceptable than piss, which in turn is less acceptable than fart, which is less acceptable than snot, which is less acceptable than spit (which is not taboo at all). That's the same order as the acceptability of eliminating these substances from the body in public."

Language warning, of course.

Who Needs a Spacesuit?

OnePlusYou Quizzes and Widgets

Just a Flesh Wound

Photographer speared by javelin at track meet. Photo at link.

Quote of the Day

"We can't drive our SUVs and eat as much as we want and keep our homes on 72 degrees at all times ... and then just expect that other countries are going to say OK."
- Barack Hussein Obama

Quote of the Day, Part 2:

"If Barack Obama had given a speech on bowling, it might well have been brilliant and inspiring. But instead he actually tried bowling and threw a gutter ball. The contrast between talking and doing could not have been better illustrated."
- Thomas Sowell

Global Warming Alert

Don't look now, but we're about to be surrounded by great tits.

h/t Ace.

Happy Mother's Day

The older I get, the more I appreciate everything you've done for me.

Quote of the Day

"This faux pas is beyond weird; I know the guy is tired, but “How many states are there in America?” is the kind of question they ask you at the hospital after you've had a seizure to see if your brain is still working."

I'm going to add it to my repertoire.

Chief Complaint of the Night

"Stinky farts."

I shit you not.

Emergency Response to Disasters

UPDATE: here is a link to a grand rounds presentation by Dr. Doug Hamilton, who was the doc who ran the Dome during every night of the crisis. He has lots of great photos and personal anecdotes to share. Thanks to Fidel, MD for the link.

GruntDoc posted a link to this article which concludes that our already-strained emergency departments and hospitals could not handle a large unexpected bolus of patients after a terrorist attack or natural disaster.

"The bombings in Madrid, on the eve of a national election, killed 177 and injured 2,000. Almost 1,000 of the injured were taken to 15 hospitals. One hospital alone received 270 patients in less than three hours," the article breathlessly states.

It seems intuitive that even our Level I trauma centers would be overwhelmed by such a disaster. No ER would be able to suddenly change gears and accommodate that many patients, would they?

Perhaps they would:

"Largely unreported by the media, on September 11, 2001, NYU Downtown Hospital, a 170-bed facility located four blocks from the World Trade Center, treated 500 patients, yet was never overwhelmed-despite the failure of virtually every logistical support system. This was the largest civilian disaster response in U.S. history. The experience suggests clear that the capacity of hospitals to treat victims of a disaster is many times greater than has been assumed."

But what about an overwhelming event like Hurricane Katrina? We all know that the emergency medical response to that disaster was a failure of epic proportions, right? Not in the least. Houston responded in a matter of hours, transforming an empty facility into a fully functioning field hospital that evaluated and treated thousands of patients:

"Staffed by physicians serving 12-hour shifts 24 hours a day, the clinic seamlessly accommodated the majority of medical needs. Countless nurses, allied health professionals, technologists and others volunteered their service, with more than 200 health care professionals assisting during the peak periods of the first two days of the evacuees' arrival. During those first hours, the clinic saw an average of 150 patients per hour. By Day Three, that number had dropped by two thirds.

By being treated on site, children stayed connected to their families, and emergency centers in the Texas Medical Center remained "decompressed to the greatest possible degree," according to Dr. Ralph Feigin, chair of pediatrics at BCM and physician-in-chief at TCH.

Important lessons:

"The experience of setting up the "Katrina Clinic" at the Astrodome/Reliant Center Complex in Houston provides important lessons to cities planning a medical response to disasters and other large-scale emergencies.

For several reasons, the situation in Houston was "logistically and politically" conducive to receiving and treating large numbers of evacuees. Most importantly, the area was not affected by Hurricane Katrina, leaving its extensive health care system intact and ready to respond. A wide range of academic, governmental, and private organizations came together to make and implement plans for the Katrina Clinic. A key first step was the creation of a unified command and control system to direct and coordinate services — a public health infrastructure equivalent to that of a small town was created almost literally overnight.

The Clinic was built in a 100,000-square-foot space in the Reliant Arena. Within 12 hours — aided by the use of existing exhibit hall materials — workers had created a facility including 65 examination rooms. Over the next 2 weeks, the Katrina Clinic saw more than 11,000 of the estimated 27,000 evacuees seeking shelter in the Complex. Clinic staff wrote nearly 17,000 prescriptions, performed nearly 600 x-rays and other radiologic studies, and gave more than 6,000 vaccinations."

Key points to remember about disasters (this article is a must-read):

• Less than 10% of the challenges faced during a disaster are medical.

• Only 10% of persons who arrive at a hospital or shelter following a disaster are in need of acute medical attention.

• Only 10% of those presenting to a shelter clinic or a hospital following a disaster have a potentially life-threatening condition.

• All disaster response is local (at least for the first 48–96 hours).

• The time, effort, and expense needed to transport out-of-state doctors and nurses into the area is rarely justified or needed, especially during the first 48–96 hours.

• All outside assistance and resources should be locally coordinated and arranged at the local level, because that is where the knowledge base for need is most reliable.

• Integrated, collaborative networks with intrinsic local discipline, support, and assignment of responsibility represent the most effective planning and action model.

Read the details here, Dr. Mattox explains how it's done:

"The local response to any disaster is more a function of management of people, ideas, supplies, and strategies, and less a matter of practiced drills for chemical, biologic, radiologic, and blast conditions."

The Medicare Problem

What does Alan Greenspan believe poses the greatest threat to the US economy?

A) The war in Iraq
B) The mortgage/housing crisis
C) The trade deficit
D) Gasoline prices

None of the above. The answer is Medicare.

Fortune Magazine's Geoff Colvin:
"Unfortunately the day of reckoning is imminent. Sometime in the next President's first term, Medicare Part A (hospital insurance) will go cash-flow-negative, and it's all downhill from there. (...) The federal budget has averaged about 18% of GDP over the past several decades. If that average holds and if the rules of our social insurance programs don't change, then by 2070, when today's kids are retiring, Medicare, Medicaid, and Social Security will consume the entire federal budget, with Medicare taking by far the largest share. No Army, no Navy, no Education Department - just those three programs."

The problem is actually much worse than that, because the above projection relies upon unworkable assumptions. So how can we bail out this failing social program? We're going to have to change the rules.

I'd start by raising the Medicare eligibility age to 70, but eventually it will need to go even higher. When the Medicare program was first signed into law in 1965, the average US life expectancy at birth was 70 years. Despite the fact that medical advances have increased our current life expectancy to over 77 years, the Medicare eligibility age has remained constant. Even indexing Medicare eligibility to life expectancy might not be enough to save the program, however.

So what other changes can we make?

The Happy Hospitalist has some brilliant suggestions, but some of you are going to be shocked and horrified by them. The truth hurts sometimes. Go there now and read his take.

The Horror

I've seen some pretty nasty things happen to people over the years. Severed limbs, faces blown off with shotguns, electrocutions and other terrible burns, drownings, and plenty of deforming injuries, to name a few. The adrenaline rush tends to overpower the horror I might otherwise naturally feel about those situations.


For me, personally, the active lower gastrointestinal bleed is a completely different matter. I hate stool, particularly when it's someone else's stool and especially when it's bloody. I'll take the liberty of speaking for my colleagues by suggesting that the second worst package we can be given in the ER is the dreaded stool sample, brought from home.

"It's over there," said my patient Deborah Peel as she gestured toward the innocent-looking bag on the table. On a better day, that bag might contain her prescription bottles or maybe some test results from the clinic. But not this time.

The temptation was to just ignore it or dispose of it without even investigating the contents, but I felt obligated to look. So after gloving up and taking a deep breath, I carefully approached the package.

Now I've been spit on, puked on, coughed on, farted on, and miscarried on without it bothering me much at all. I keep an extra set of scrubs handy for just those occasions. But nothing could have prepared me for what was about to happen next.

Deborah Peel had thoughtfully collected her stool sample in a Tupperware container, and she even double-bagged it with plastic grocery sacks. Unfortunately, as I picked up the package to get a closer look, I discovered the reason she had double-bagged. The bloody watery diarrhea had leaked from the unsecured container and filled the inner bag. About a liter's worth, I would guess.

As soon as I picked it up, the foul contents poured down the front of the cabinets, soiling the tongue blades, alcohol pads, and cotton-tipped swabs in the top drawer, contaminating the towels in the next drawer, and even making its way onto the bedpans in the bottom drawer. Hey man, nice shot.

My scrub pants and shoes? You don't even want to know.