Med Glossary, Part 5

"I thought nothing of it."

As in, "I had this pain that shot up from my hip bone to my left ear, and I thought nothing of it, but then I got this tingly sensation in my right pinky so I decided I'd better go to the ER."

What he really means is,

1) I've been worrying about that 5 second pain constantly ever since it happened. And see how swollen my hands are? And what is this coating on my tongue?

2) My auntie just had a stroke, and I don't want to die. The doctor told her there was nothing wrong with her too.

3) On the internet I read that shooting pains on the left side can be signs of a heart attack.

4) I'm out of my Xanax. I fired my doctor last month and he won't refill it.

5) This is labor day weekend, and I have plans. Can I get a work excuse?

Have a great holiday, everybody!

Previous glossary entries here.

Pause

How to Fall Off the Wagon

Don't just fail a random drug test. That's boring.

Don't get photographed staggering out of a bar at closing time. Yawn. Everybody does that.

No, you should have a series of photos taken with you laying down ON TOP OF the bar with three hot women (your wife apparently not among them) who are licking whipped cream from your bare chest and you from theirs as you do body shots with them.

Way to go Josh Hamilton. You really are an All Star.

My Take on the Health Care Crisis - Part 1

Originally posted almost two years ago, here is my take on the healthcare crisis, the four parts presented in order below. Enjoy!


Here are the two major problems with our current health care system that have everyone in a tizzy:

1) The poor folks in America have limited access to health care services

2) Health insurance (and American medical care in general) costs too much

First, let's get something straight: anyone who is honest and who has even the most basic level of medical knowledge should admit that the quality of healthcare in America is the best in the world. Rich people didn't get that way by being stupid, so when they get cancer they aren't flying to Europe or Canada to get treated....they are going to MD Anderson or the Mayo Clinic.

The same thing can be said about heart disease, diabetes, musculoskeletal disorders, or any other medical problem you can think of: America treats these conditions better than anyone else in the world. When a multimillionaire pro athlete needs a complicated operation to save his career, he turns to American surgeons. When a wealthy foreign dignitary needs a heart bypass, he comes to America. Say it again, repeating as often as necessary until it sinks in: America provides the highest quality medical care in the world.

We also have the best medical training in the world. Physicians from other countries are lined up at our gates, hoping against all odds that they might be accepted into any one of our residency training programs. Only the best will be accepted. Our physicians accept training positions in other countries only as a last resort, because for the most part they are well-known to be inferior.

Of course we also have the best medical technology in the world. We have more advanced medical technology concentrated in 1000 acres in Houston than most other nations can even dream of. Do you really think the average Cuban is likely to get an insulin pump or an LVAD? How about a liver transplant?

Because we have the best physicians, the best medical training, and the best medical technology in the world, we also do some of the most important medical research in the world. Wealth begets wealth.

So why does American health care cost so much? Because it is the best. Why do our poor people have limited access to health care? Because they can't afford it. If we gave it all away, we wouldn't have the best quality healthcare anymore. Other countries ration healthcare by making everyone wait for it equally. That's why wealthy Canadians fly down here to get their hips replaced and upper-class Brits fly over here to get treatment for their breast cancer. They don't want to wait. We ration care by limiting access to those who can't pay for it.

Don't misunderstand and don't buy the baloney the frantic lefties are trying to feed you....poor people in this country still get better care than in any other country. I admitted a penniless patient with bowel obstruction from his colon cancer just last week, and an uninsured man with a large brain tumor last month. Both got the highest quality surgery the world has to offer the very next day.

Yes there are barriers to care for the poor. These people couldn't just walk into the Mayo Clinic and ask for a PET scan. And they will still get a huge bill they will be unable to pay. But they will ultimately get the care they need, thanks to EMTALA.

But our current system is unsustainable over time, as more people discover the EMTALA loophole and the willingness (and ability) of the insured to pay for the care of the uninsured gets stretched to the breaking point. So what is my solution? Stay tuned.

Part 2

Part 2 - The Patients

First let me begin by admitting that I don't have an MBA or even a degree in economics. I haven't hashed out any numbers to see if this plan would even get off the ground, I have no authority to implement my recommendations, I have no illusions that these suggestions will ever become the blueprint for any sort of significant healthcare reform, and I fully expect to instead be led like the rest of you by the yoke of Hillarycare Obamacare over the cliff of doom as we plummet into a lobotomized pile of decaying socialized medicine zombies.

But it's my blog, and I don't have to support my assertions with facts. These are just the ideas of an anonymous ER doc in the trenches, so take them for what they are worth. I'm not breaking any new ground either, so anyone who thought I was going to reinvent the wheel is going to be just as disappointed as the liberals who won't be happy with any plan that requires any amount of personal responsibility or features any amount of inequity whatsoever.

So what is my solution? I'm not ready to tell you yet. But here's some more table-setting:

For the sake of argument, I'll divide people into 5 categories:

1) Healthy people with a few minor chronic medical problems who can afford insurance and want to be protected against the big expense of a surprise appendectomy or heart attack. We'll call this group "the typical family."

Currently, the typical family is doing OK with our current system, and they ultimately will do well with any system that is put in place. They would like to pay less for medical care, but so would everybody else. They have full access to care right now, but they are afraid that any change in the system will reduce their access to (or quality of) care and/or increase their costs further.

2) Healthy people who work and would like to pay something for their medical care, but lately it seems that medical insurance and healthcare costs too much for them. I'll call this group "the struggling family."

The struggling family is struggling, as usual. They have had a recent ER visit that they are gradually paying off (with difficulty), and they are scared of a really big ticket medical catastrophe that might bankrupt them. They would like to be insured, but would accept access to cheaper care if it were available. I'll also place the healthy young working-class uninsured into this category, but they aren't really scared of a medical catastrophe, they are just betting they will stay healthy and will deal with the consequences (for better or worse) if they fall ill. The medical industry and the responsible insured both need to be protected against the ones who bet wrong, because they drive up costs for everyone else.

3) People who think the government should provide everything for them and don't want to pay anything at all for their care. We'll call this group "the gold tooth trauma victims." They can be sometimes be identified by their gold jewelry, their expensive cell phones, or their dripping bodily fluids. Age 16-30 for the most part, their medical conditions are often self-induced.

The gold tooth club doesn't give a shit about healthcare reform, because they ain't paying nothin' anyway, foo. They give fake addresses, refusing to show ID so that we can't bill them, and they throw away all the prescriptions we write except the vicodin. They'd rather get a shot of antibiotics for their crack-induced bronchitis so they don't have to pay for a prescription.

The medical industry would like to get paid for our often expensive treatment of these patients, however, so we are the ones who need some help from the government in this case. These patients are putting a strain on the system, particularly on the inner-city county hospitals that are the true safety nets of society. They also drive up the cost of everyone else's medical care.

4) Chronically ill people with diseases that require frequent or expensive healthcare visits and are currently uninsurable. I'll call this group "the dialysis patients."

The chronically ill dialysis patients are all covered by Medicare and/or Medicaid, so they actually get outstanding medical care. Others who are chronically ill, for example the multiple sclerosis patients or the rheumatoid arthritis patients who don't quite qualify for disability and can't get medical insurance, are in more of a bind. They can't afford their Tysabri or their Remicade for much longer, and an ER visit or hospital admission is a financial disaster for them. They hope that whatever healthcare reform is passed somehow creates more Rheumatologists and Neurologists and also somehow requires their fellow citizens the government to pay for their expensive medications and therapies that they are increasingly unable to pay for themselves.

5) The poor, the children, and the disabled

Truly poor and disabled patients are already covered by Medicaid, as are poor children, otherwise they may fall into one of the above groups. The sick children of struggling or sick families occasionally fall through the cracks of our current system and deserve a solution.

So what are my solutions? Sorry, I'm going to have to string you along a bit more. These posts require a lot more thought than my typical "Ooh, look at this gross chunk of butt wax" post. I'm almost finished, but I'm still polishing it up a bit. Most of you aren't going to like it anyway, so don't get too excited.

Part 3

Part 3 - Why Incentives are Important

The goals of my solution to the healthcare crisis are as follows:

1) Restore the free market system to the medical industry
2) Incentives should encourage personal responsibility
3) Increase access to medical care for all groups

Instead of eliminating the concept of multi-tiered medical services, I suggest that we nurture and develop it. The different groups of people I discussed in my last post do not all need the same sort of coverage, and they do not all deserve identical healthcare services just because they happen to have a social security number and a pulse (or not). Some people bring more to the table than others, and I believe that whoever makes the coffee should get to enjoy the first cup. In order for our society to excel we must encourage success, discourage abuse, and protect the helpless.

Achievement of success requires proper encouragement. While some people have a natural drive to excel, most of us will be as lazy and useless as we can possibly get away with. This is why the welfare system is a failure and why all Socialist programs are doomed to mediocrity: if excellence goes unrewarded, then excellence ceases to exist. This can be considered a corollary to the concept of entropy.

The Problem with Medicare/Medicaid

Our present socialized medicine experiment, otherwise known as the CMS, is a perfect example of what happens when incentives are poorly conceived. Currently, payments to physicians for their services are standardized across the nation without regards to outcomes, quality of care, or years of experience. These payments seemingly decrease every year and are burdened with stifling bureaucratic regulations which complicate and restrict the provision of medical care.

When patients are not personally responsible for payment of services, they have no incentive to question or limit the medical services that they seek or that are recommended. The stroked-out granny might as well have that feeding tube placed so that she can be tuned up a little bit in between ICU visits. When they don't have to pay anything for their ICU admission, patients have no financial incentive to go to their dialysis appointment instead of the crack house. When patients pay nothing for their medications, there is no incentive to choose cheaper ones.

Furthermore, the incentive for physicians (since their payments are fixed) is to spend less time with these patients and to perform better-reimbursed (even if questionably necessary) procedures. How can costs not continue to escalate in such a system? The incentives are all wrong!

My proposed solution for this problem is to restore the free market to medicine by allowing balance-billing of Medicare services and copays for Medicaid patients. Only when physicians are allowed to charge market price for their services will the proper incentives be restored. Not only will more physicians be likely to accept Medicare patients, but they will be able to spend more time with them as well. When Medicare patients are given the choice of paying $50 extra to see a physician this week or waiting 4-6 weeks until the "free" doc has an opening, then they are empowered. When families are faced with the prospect of actually paying for some of granny's end-of-life care, then they will likely make more reasonable decisions. And that's money in the budget that can be used for more appropriate indications.

Access of the Medicare population to medical services is already becoming difficult for some, but a true crisis looms in the next couple of decades as the baby-boomers reach retirement age. Those patients who are able to spend some of their extra money to obtain premium medical services should be allowed to do so. Those who cannot may have to rely on the safety net I will propose in my next post.

As far as Medicaid goes, I would institute other reforms in addition to requiring copays for medical care and medications. Although I think it would be difficult to implement, I think mothers on Medicaid should be required to take mandatory depoprovera shots as long as they are receiving public assistance. If they can't support their current family then they shouldn't keep popping out more of them.

Medical insurance

HSAs are the best option for most people, particularly if they are begun early. These plans cost much less than traditional medical insurance, although they feature much higher deductibles and limited prescription benefits. The monthly savings from such a plan can be invested on a pretax basis, and these savings are used to pay for most routine medical needs. These plans encourage both personal and fiscal responsibility, because they essentially reward healthy lifestyles and punish overuse of medical services. These are the proper sorts of incentives we need in this country if we are going to reduce our overall healthcare expenditures. Contrast these incentives with those of the typical Medicaid patient, who gets a bigger monthly check for every extra kid she pumps out that she cannot afford, who gets three free prescriptions per month, and who pays nothing whatsoever to visit the ER as often as she wishes, signing in all of her kids whether they are symptomatic or not. Do you think that would happen if she were responsible for paying the bills? Hell no, it wouldn't.

Once the savings account is well-funded, the financial stress of paying a high deductible for an unexpected medical disaster is eliminated. And of course the expenses in excess of the deductible are covered, preventing financial ruin. Furthermore, the higher cost of medications forces the insured (or their physician) to carefully examine the med list and choose specific medications which balance affordability and efficacy, rather than passing the cost of the latest and greatest medication onto their fellow citizens as in traditional or "single payer" plans.

Of course HSAs do not fit the needs of many chronically ill patients, but in reality such patients are not good candidates for any insurance plan if cost-containment is the goal. And make no mistake, cost-containment is always a goal of anyone who oversees a budget. The unspoken purpose of healthcare rationing is to delay the diagnosis and treatment of the sick in the hope that some of them will tire of jumping through hoops and either get better on their own, give up, or die before they run up the bill. While a healthy patient infuses money into the system, a chronically ill patient who requires expensive tests or therapies is bleeding dollars, no matter whether the coverage is single-payer or private insurance. To the bureaucrats, a cancer patient who dies before starting expensive chemotherapy and bone marrow transplantation only means more money for next year's budget (or their yearly bonus). Therefore if anyone but yourself is paying the bills, you should be aware that they will NEVER have your best interests in mind.

That's why I think that most people should pay for their own medical care whenever possible, depending on outside coverage only as a last resort. Whew, I've still got a lot more to say, but that's enough for now. In the next post, I'll discuss the safety nets I have in mind as well as some ideas that might improve the access of care for many.

Part 4 - The Safety Net

Part 4 - The Safety Net

(This is the final part of the series. I'll return to lighter topics soon enough.)

So what do we do about the struggling families who can't afford insurance, who don't want to pay for insurance, or who have chronic illnesses that effectively disqualify them from insurance plans? We definitely need a safety net for these folks. If we as a society are willing to pay for the care of the totally disabled, then we should be willing to support the working class when they need a little bit of help too. But as the brilliant Bill Whittle once wrote,

"I’m all for a safety net. It’s the safety hammock I have a problem with."

I think it's important to try to keep health insurance affordable via sensible but not overbearing insurance reforms, so that the healthier segment of the "struggling family" group can purchase private insurance if they choose to pay for a higher tier of healthcare. The sicker or lower-income members of this group should probably be covered by state or federal assistance programs instead. These folks don't need "insurance" anyway...they need someone else to pay their medical bills for them. They are the ones who need government handouts, not the rest of us, so I am against any plan that would force healthcare rationing on the population at large. And to answer a previous question by Ms. Alison Cummins, this same safety net (and the lower tier of care it represents) applies to the previously healthy/insured patient who because of financial or medical disaster finds himself unable to afford the higher tier of medical care he previously enjoyed.

Providing the care

Why not increase indigent medical access by increasing the role (and perhaps the number) of our outstanding medical training programs? We can expand the services provided by medical students and residents at the state and county level, using a sliding scale for charges based upon income. In my experience, indigent patients are typically appreciative of the relatively inexpensive and compassionate care provided by medical trainees. Insured patients, on the other hand, occasionally disdain such treatment. Despite the perception of a lower tier, the quality of care that is provided by housestaff and supervised by teaching physicians is often superior to that offered in private facilities. It surely isn't as convenient, but convenience is something you pay extra for.

I suggest that community indigent clinics could also be staffed on a rotating basis by physicians who have been disciplined by their state medical boards as a retribution for various medical misbehaviors. Volunteer physicians might also staff such clinics if they were offered some sort of tax writeoff and malpractice protection.

The additional cost to patients

Access to discounted rates for medical services do not come without a cost to the relatively indigent but able-bodied individuals. They should have to make some sacrifices in order to obtain their bargain medical care. They will have to pay their dues by allowing themselves to be on the teaching service, to obtain primary care by less-experienced (but supervised) physicians, and to accept the possibility likelihood of increased waiting times, fewer clinic locations, and decreased availability of expensive therapies. They may be able to obtain certain more expensive services or medications by participating in research studies coordinated by the teaching hospitals.

Funding for these programs should be primarily the responsibility of the individual states

I suggest that each state should be primarily responsible for funding their own indigent and preventive medicine programs as they see fit, perhaps with some limited federal assistance or incentives. In Texas we fund our programs with sales taxes and property taxes, and we still don't have a state income tax. Teaching hospitals should establish or expand programs which send medical students and residents to satellite facilities in their state for clinical rotations. That would provide better access of care to uninsured patients, enhance the educational experience of budding physicians, and perhaps increase student interest in primary care. Expanding the concept of student loan deferment for physicians who agree to practice in these rural communities for a given period of time might be a good idea too.

EMTALA - follow the original intent

Acceptance of transfers of stabilized indigent patients who present to community hospitals should be expedited by state/county facilities so that definitive care can be provided by the funded teaching hospitals. If EMTALA is going to remain the law of the land, then the original concept should be followed rather than the tar baby into which it has evolved.

Tort reform can increase access and reduce costs
(edited for clarity)

One of the biggest crises in America today is the increasing difficulty of obtaining emergency surgical specialty care. Neurosurgeons, Orthopedists, Ophthalmologists, and Plastic Surgeons, for example, are avoiding ER call by giving up their hospital privileges to practice in free-standing surgical centers, leaving trauma patients in some areas with limited access to critically important services.

Optimally, the provision of free medical care (edit: such as that provided under EMTALA) should operate under the protection of Good Samaritan laws, thereby eliminating the prospect of malpractice torts and the extra associated costs of defensive medicine. If a patient is receiving free medical care, why in the heck should he be allowed to sue for a bad outcome? I think more (specialist) physicians would be willing to provide unreimbursed (emergency) treatment if they were immune from lawsuits. Alternatively, incentives to provide uncompensated medical care could be given to physicians by allowing them to write off the costs of their unpaid services as charitable donations.

"Self pay" patients should also be able to barter for discounted emergency or nonemergency care if they agree to sign a waiver releasing the treating physician from malpractice liability, or perhaps limiting the scope of such liability. With the current system, the patient is forced to pay for maximum liability protection for each and every encounter. High risk patients, therefore, often find it difficult to obtain medical treatment. Allowing more flexibility in this area is another potential way to reduce cost and increase access to medical services.

The trauma fund

Finally, a catastrophic medical fund should be established to help pay for uncompensated trauma care. And I would suggest that this money should be distributed by each state wherever it is needed most, such as a rural EMS system, an inner city trauma center, a LifeFlight program, or even to build additional county medical facilities. This could be partially funded by additional levies on automobile sales, drivers licensing, automobile registration, gasoline, traffic violations or various misdemeanors and felonies. Other options include specific taxes on the sales of motorcycles, skateboards, or rock-climbing equipment to name a few only partially tongue-in-cheek suggestions. The most outstanding trauma surgery residents I've had the pleasure to work with all went on to make a living doing more lucrative lower-risk elective surgeries such as bariatric procedures and laparoscopic fundoplications. If we don't provide incentives to do the dirty work, not enough capable specialists are going to be around to do it.

Conclusion

I believe that my plan would make healthcare more accessible to Medicare patients while increasing the efficiency of the Medicare and Medicaid programs. It might decrease the cost of insurance to make it more accessible to the middle class while still maintaining the benefits of the current system for the insured. And I suggest that it would provide increased access to care of the uninsured. What more could you want from a healthcare plan?

Now I can badmouth Hillarycare Obamacare to my hearts content without anyone asking me snidely, "well what's your plan then?"
Here it is...take it or leave it.

"I'm Not a Doctor...."

Agent of Chaos

via Newsbusters

Obama - Don't Mess With Texas

AUSTIN — Gov. Rick Perry, raising the specter of a showdown with the Obama administration, suggested Thursday that he would consider invoking states’ rights protections under the 10th Amendment to resist the president’s healthcare plan, which he said would be "disastrous" for Texas.

"I think you’ll hear states and governors standing up and saying 'no’ to this type of encroachment on the states with their healthcare," Perry said. "So my hope is that we never have to have that stand-up. But I’m certainly willing and ready for the fight if this administration continues to try to force their very expansive government philosophy down our collective throats."

Hell yeah.

via The Other McCain