1.
Featured Article:
Forgetting Has Its Benefits
You Must Remember This: Forgetting Has Its Benefits By MELINDA BECK WSJ, Nov 11, 2008
There's an old saying
that inside every 70-year-old is a 35-year-old wondering, "What
happened?"
What happened is that
countless days, nights, meetings, commutes and other unremarkable events went
by, well, unremarked. They didn't make a lasting impression on the brain or
they were overwritten by so many similar experiences that they are hard to
retrieve. In short, they've been forgotten.
That's not necessarily a
bad thing. Neuroscientists say forgetting is crucial to the efficient
functioning of the mind, to learning, adapting and recalling more significant
things.
"We focus so much on
memory that forgetting has been maligned," says Gayatri Devi, a
neuro-psychiatrist and memory expert in New York City. "But if you didn't
forget, you'd recall all kinds of extraneous information from your life that
would drown you in a sea of inefficiency."
That was what prompted
Jill Price to contact the memory experts at the University of California at
Irvine in 2000. As she wrote in a book published this summer, "The Woman
Who Can't Forget," Ms. Price could recall in detail virtually every day
since she was 14, but she was mentally exhausted and tormented by her memories.
UC Irvine scientists are interviewing more than 200 people who say they have
similar "autobiographical" memories, but so far have found only three
more.
Memories of singular,
significant events -- say, last week's historic election -- are generally easy
to recall; people typically store them in long-term memory with many
associations attached.
Memories of mundane,
recurring events compete to be recalled, and scientists say the brain appears
to be programmed to forget those that aren't important. Neuroimaging studies
show that it's the brain's prefrontal cortex, the area of complex thought and
executive planning, that sorts and retrieves such "like-kind"
memories. Researchers at Stanford University's Memory Laboratory demonstrated
last year that the more subjects forgot competing memories, the less work their
cortexes had to do to recall a specific one. In short, forgetting frees up
brain power for other tasks, says psychologist Anthony Wagner, the lab's
director.
A real-world example, he
says, is having to learn a new computer password every few months: As your
brain suppresses the memory of the old password, it gets easier to summon the
new one.
In fact, forgetting is a
very active process, albeit subconscious, neuroscientists say. The mind is
constantly evaluating, editing and sorting information, all at lightning speed.
"Your brain is only taking a small amount in, and it's already erasing
vast amounts that won't be needed again," Dr. Devi says.
Much that happens during
the day doesn't make an impression at all because our attention is focused
elsewhere. Take your daily commute, says Dr. Wagner: "A heck of a lot of
stuff is landing on our retinas as we're driving down the road. But if you were
focusing on the presentation you have to give, you didn't perceive it and it
didn't get stored."
He notes that people face
such a constant cognitive barrage that they frequently fail to attend to
information that isn't essential at the time. "I have two 4½-year-olds and
I'm already thinking, where did those first four years go?" Dr. Wagner
says.
Numerous studies have shown
that when people are asked to focus on one thing, they can fail to notice
others - phenomenon called "change blindness." In one famous test,
when viewers are asked to count how many times a basketball changes hands in a
video, roughly half don't notice that a gorilla walks through the scene.
Conversely, people who
have remarkable memories for, say, sports statistics or who-wore-what to
parties paid attention at the time and attached significance to it, while it
doesn't register on other people's radar screens at all.
Are memories for events
you didn't focus on stored in your brain nevertheless -- like unwatched
bank-surveillance tapes? That's an area of much debate. Some experts believe
hypnosis can trigger long-buried associations. But so-called recovered memories
are also susceptible to distortion.
"Memory consists of
billions of puzzle pieces, and many of them look the same," Dr. Devi says.
"Each time you retrieve a memory, you're reconstructing a puzzle very
quickly and breaking it down again. Some of the pieces get put back in
different places."
What if you want to
remember more about each passing day? One simple method is to keep a journal.
Writing down a few thoughts and events every day not only makes a tangible
record, it also requires you to reflect. "You're elaborating on why they
were meaningful, and you're laying down an additional memory trace," says
neuroscientist James McGaugh at UC Irvine. Taking photographs and labeling them
reinforce memories too.
But remember that
forgetting can be very useful, says Dr. McGaugh: "If you used to go out
with Bob and now you're married to Bill, you want to be able to say, 'I love
you, Bill.' That's why forgetting is important."
Write to Melinda Beck at HealthJournal@wsj.com.
http://online.wsj.com/article/SB122635803060015415.html?mod=todays_us_nonsub_pj
* * * * *
2.
In the News: Coverage With Limits Is Better Than No Coverage
What Tennessee Is Doing About Health
Insurance
Coverage with
limits is better than no coverage at all. By PHIL BREDESEN, WSJ
Nashville, Tenn.
Three years ago, I realized
something about health care. I've taken part in uncounted policy discussions
about America's uninsured, both as governor of Tennessee since 2003 and before
that as CEO of Nashville-based HealthAmerica Corp. Everyone regularly
criticizes the unfairness of the system. But we don't make progress.
What I realized was this:
Everyone proposing solutions or criticizing unfairness was doing so from the
comfortable vantage point of having good health insurance. While we work to
build a better system, wouldn't it also be responsible to find a way to get
something -- not a perfect solution, not even a long-term solution -- into the
hands of the more than 46 million uninsured Americans who don't share our good
fortune?
Dottie Landry is one of those
uninsured Americans. She lives in Nashville and is self-employed. She makes and
sells jewelry. Over the years, she has been generally healthy but uninsured. In
2000 she got very sick -- from a tick bite -- and had to spend about $9,000 for
medical care. She put most of it on her credit cards, which took years to pay
off.
We all want to help Ms. Landry,
but here's the problem: a comprehensive health-insurance policy for her costs
about $5,000 a year, and someone has to pay that. That's a real number that
won't go away with group purchasing or by beating up insurance companies. Ms.
Landry can't afford that, and in a world of trillion-dollar deficits it's hard
to see how the federal government can either.
We need a national
health-insurance solution, but isn't it sensible in the meantime to make sure
everyone has a basic health plan before we give a few more people a perfect but
expensive one? Shouldn't we make sure everyone at least has a Chevy rather than
providing a Cadillac to a few and letting the rest walk? We're trying that in
Tennessee with CoverTN.
CoverTN, which began in 2006, is
a health-insurance plan for those who are self-employed, or who work for small
businesses that can't afford a traditional policy.
It is not free health care.
Rather it is a limited plan with shared costs. In devising this plan, we didn't
start out the usual way -- by defining what benefits we wanted -- but instead
set how much we wanted to pay. And then we began a competitive-bidding process
to see how much health care we could buy. We initially set the amount we would
pay at an average of $150 a month, and split the responsibility for that premium
three ways. The company would be responsible for $50, the individual for $50,
and the state for the final $50.
The bidding was vigorous. It was
ultimately won by BlueCross BlueShield of Tennessee with a benefit package that
meets a great many -- not all -- of the real needs of the uninsured at a cost
far below conventional plans.
At these premium levels -- less
than half of what a conventional plan might cost -- the benefits are limited.
But the benefit structure is also different than in a conventional plan. Most
limited plans achieve their savings with high front-end deductibles, requiring
a person to spend often thousands of dollars out-of-pocket before benefits kick
in. But when we asked our customers -- uninsured Tennesseans -- what they
actually wanted, we found that they were most interested in some help with the
more common things; a doctor's visit, prescriptions, a short hospital stay.
CoverTN emphasizes covering these
front-end costs. It features free checkups, free mammograms and $15 doctor visits
without deductibles, for example. And it achieves its savings on the back end,
with relatively low limits on hospital stays and an overall $25,000 benefit
limit in any one year. It does not cover truly catastrophic events.
This makes medical sense. Good
access to a doctor and a drugstore when you first have a problem can avoid a
lot of cost and heartache later.
One thing that has been
unexpected is the success of a generics-only prescription drug program. We
needed to cover medications, but because of the high prices and aggressive
marketing of branded prescription drugs, we were concerned that the costs would
overwhelm the program. With some misgivings, we required our bidders to propose
a largely generic prescription program. It's worked surprisingly well.
Physicians have typically been able to select suitable medications for their
patients, and patient satisfaction has been high and complaints few.
Having been badly burned by
uncontrolled growth in costs in Tennessee's Medicaid program (TennCare once
gobbled up a third of the state's budget), we proceeded cautiously with CoverTN
and have been rewarded with good control of costs. This fall we added some
benefits: The number of primary care visits doubled from six to 12, for
example. Best of all, we added them without increasing rates. When did you last
hear of a health-insurance plan whose annual update was a benefit improvement
but no rate increase?
An obvious and valid criticism of
health insurance such as this is what happens when a patient exceeds the
benefit limits.
What we're finding is that even
in health care, when people know that there are limits, they work to manage
their costs. This year, as of the first nine months, only four people out of
the more than 15,000 people covered had hit the maximum overall limit of
$25,000, and only three had exceeded the separate in-patient hospital limits. A
larger number, under 4%, hit the quarterly pharmacy limits during those first
nine months.
Even those who go over the
benefit limits get the significant advantage of being able to piggyback their
personal expenditures on the contracts CoverTN has negotiated. By doing this,
they often can cut their costs on uncovered health care in half.
Ms. Landry, to continue her
story, has joined CoverTN and is very happy with it. About a year and a half
ago, right after she joined, she had a bad dog bite that put her in the
emergency room with several follow-up visits. The cost for this episode was
about $4,000, and CoverTN paid for almost all of it.
The Chevy plans certainly have
their critics, and I don't offer CoverTN as the perfect or ultimate answer, but
it sure has worked for Ms. Landry and thousands of other Tennesseans.
Mr. Bredesen, a Democrat, is the
governor of Tennessee.
http://online.wsj.com/article/SB122731243742249447.html?mod=todays_us_opinion
* * * * *
3. International News: Collectivist Farming is as bad for your
health as Socialized Medicine
A EUROPEAN GENOCIDE
Among the past century's horrors, the Great Famine in
Ukraine manages to stand out. First, for the scale of the mass starvation
inflicted by Stalin on millions of people in Europe's agricultural breadbasket,
and second, for how little the world knows about this genocide. A
now-free Ukraine wants to change that and just marked the 75th anniversary of
the 1932-33 "terror famine," or "Holodomor," says the Wall
Street Journal.
Starting in the late 1920s, Stalin set out to
collectivize and hobble the Soviet peasantry. His aim was to crush
"the peasantry of the U.S.S.R. as a whole, and the Ukrainian nation,"
wrote Robert Conquest in his groundbreaking book, "The Harvest of
Sorrow." The result:
·
An estimated 14.5
million people starved to death in Ukraine, Russia and Belarus when farmland
was collectivized and harvests requisitioned; yet, the submission of Ukraine to
Moscow helped prolong the Soviet Union's life for another 60 years.
·
The Stalinist regime and
its ideological soul mates denied the famine at the time and later.
·
Walter Duranty, the New
York Times's longtime Moscow correspondent, was Stalin's chief apologist,
sending false dispatches from Ukraine; he won a Pulitzer Prize.
·
The left-leaning academy
condemned Conquest and the late James Mace, the leading researcher of the
famine, when their work appeared in the 1980s, and the Berlin Wall's collapse
shamed some of the denialists.
The exception is the current Russian leadership, says
the Journal. President Dmitry Medvedev accused Ukraine of seeking to
achieve "opportunistic political goals" based on "manipulations
and distortions, falsification of facts about the number of dead." As
in Stalin's day, Ukraine's independent identity and nationhood stands in the
way of a resurgent Russian imperium. By remembering the Holodomor,
Ukrainians say: Never again.
Source: Editorial, "A European Genocide,"
Wall Street Journal, November 24, 2008; and Robert Conquest, "The Harvest
of Sorrow," Oxford University Press, 1987.
Resource: www.ncpa.org/sub/dpd/index.php?Article_ID=17306
For text: http://online.wsj.com/article/SB122757088058354659.html
For more on International Issues: www.ncpa.org/sub/dpd/index.php?Article_Category=26
Socialized Medicare does not
give timely access to health care, it only gives access to a waiting list.
Collectivist Farming does not give access to food, it
only produces famine, hunger and death.
* * * * *
4. Medicare: New coding system to cost
$1.64 billion over 15 years. (See
Voices of Medicine below)
Why We Need 1,170 Codes for
Angioplasty By JANE ZHANG,WSJ, NOVEMBER 11, 2008
Government regulators are
expected soon to overhaul the aging coding system that doctors and hospitals
use to bill insurers -- a switch that many in health care say is necessary, but
that could initially cause headaches for consumers and their doctors.
Hospitals, insurance
companies and many doctors say the planned coding system is necessary to keep
up with the host of new medical developments that emerge every year. The new
system, known as ICD-10, would sharply increase the number of codes used to
define various ailments and procedures to 155,000, nearly 10 times as many
codes as are currently in use. Today, for example, there's just one code --
39.50 -- for angioplasty, a procedure used to widen blocked blood vessels;
under the new system, medical practitioners can choose among 1,170 coded
descriptions that pinpoint such factors as the location and the device involved
for each patient.
Decoding
the Codes
Doctors and hospitals may
soon be required to use a new medical-coding system. Here are some pros and
cons:
·
The new codes can offer more detail on patients' conditions.
·
Doctors complain that changing to the new system will eat up time and money.
·
Hospitals could get higher payments for performing more-advanced surgeries.
·
Consumers may see more billing errors as the new system rolls out.
The Centers for Medicare
and Medicaid Services, or CMS, the federal agency charged with maintaining the
medical codes, says the new system will allow doctors to include more details
on patients' medical records. This could give a boost to efforts by government
and industry to encourage the adoption of a nationwide electronic
medical-information system. The coding changes also will make it easier to
track outbreaks of new diseases, federal officials say.
Hospitals have been
urging the coding-system upgrade for years, in part because the new codes make
it easier to describe advanced surgeries and procedures that generally command
higher reimbursement rates.
But many doctors in
private practice are expected to have to scramble to adapt to the new system's
greater complexity -- especially because regulators are aiming for the new
system to be fully in place within three years. Many doctors and insurers are
lobbying to extend that deadline to about five years or more, and some say the
new codes are unnecessary.
"They are not simple
changes. All of that is going to cost money" to buy and install new
software and train physicians, coders and nurses, says Tom Felger, a family
physician in South Bend, Ind. He worries that in the short run, the five
doctors in his practice will end up spending more time on paperwork and less
time with patients.
CMS estimates additional
costs to the medical industry of adopting the new coding system of $1.64
billion over 15 years.
Some medical-industry
officials also are concerned that consumers could see, at least initially, an
increase in billing errors. That can lead, for example, to overcharging of
patients, or an insurer denying payment for a claim because it was submitted
with an incorrect code. Some officials also expect an increase in billing fraud
and more delays in payments to doctors and consumers.
CMS says it expects
implementation of the new system initially will boost by as much as 10% the
number of claims returned because of coding errors. But a study by the Blue
Cross and Blue Shield Association of insurers predicts billing errors are
likely to rise between 10% and 25% in the first year. The group says extending
to five years the deadline for implementing the changes could ease the
problems.
More Billing Errors Seen
"The [three-year]
time frame proposed is unworkable in the real world," says Alissa Fox,
vice president for legislative and regulatory policy at the Blue Cross and Blue
Shield Association.
"Because of the
complexity of the change, the provider could make the [billing] mistake or the
payer could make the mistake. The patient is stuck in the middle," says
Larrie Dawkins, chief compliance officer at Wake Forest University Health
Sciences, a network of 800 physicians in Salem, N.C. He says claim rejections
currently at medical practices typically run at a rate of 5% to 12%.
The U.S. adopted the
current coding system, known as the International Classification of Diseases,
about 30 years ago, based on a framework developed by the World Health
Organization. Most of the world's developed countries have already modernized
their versions. And while CMS has updated its codes regularly, the planned
overhaul would represent the biggest expansion by far in the U.S. coding
system.
CMS proposed the
regulation for the new system in August, closed the public comment period on
Oct. 21, and aims to publish the final rule before the end of the year, a CMS
spokesman says.
Lots More Codes
The new system of 155,000
codes includes 68,000 codes describing diagnoses, up from 13,000 currently, and
87,000 codes for different medical procedures, compared with 3,000 in the
current system. Hospitals use both types of codes, but physicians use only the
diagnostic codes. For procedures, physicians rely on a separate system of
nearly 9,200 codes from the American Medical Association that dates back to the
1960s.
Creaky System
CMS says the current
system of numbered codes has run out of room to expand. That has led to some
new treatments being grouped with unrelated diseases. For example, in the
rapidly developing field of heart treatments and procedures, some codes are
stuck in with eye treatments -- a section that still has spaces to add new
numbers.
"The lack of space
is a symptom of the fact that medical procedures are changing so quickly,"
says Karen Trudel, deputy director of the CMS's Office of E-health Standards
and Services. CMS also oversees the Medicare federal insurance program for the
elderly and disabled, which pays for about half of all procedures performed at
hospitals.
Hospitals See Benefits
George Arges, senior
director at the American Hospital Association's health-data management group,
says the new coding system could lead to higher payments for hospitals that
perform more-advanced surgeries, among other benefits. He expects hospitals
will see lower administrative costs because the new, more specific codes will
require less back and forth with insurers to clarify what treatments were
performed.
More Patient Details
Robert Tennant, senior
policy adviser at the Medical Group Management Association, a trade
organization for medical group practices, says the new coding system will
require that doctors get more medical details from each patient. Different
insurers also might require different levels of specificity, he says.
For example, the current
system has five codes describing a sprained ankle, but the new system has 45
codes, describing which part of the ankle joint was injured, whether it's the
left or right ankle, and whether it's a first-time injury. "That's very
complicated to a provider" to detail, Mr. Tennant says. If pressed for
time, he says, a doctor might just check "unspecified" to describe an
injury.
http://online.wsj.com/article/SB122636897819516185.html?mod=todays_us_nonsub_pj
-Alicia Mundy contributed
to this article.
Write to Jane Zhang at Jane.Zhang@wsj.com.
Government is not the solution to our problems,
government is the problem.
- Ronald Reagan
* * * * *
5.
Medical Gluttony: Quality Improvement Will Make Health
Care More Efficient
Physicians are probably the most highly trained,
sophisticated workers in the world. After four years of college, physician
training begins with four years of medical school and continues with four to
eight years of postdoctoral work and supervised clinical experience. These
newly trained physicians are then sent into the world at about age 34 to enter
the work force as doctors who assist people with diseases and other health
matters. As long as the patient pays the bills, they receive efficient care.
Even when Blue Cross came along with expensive hospital coverage, the patient
still paid the professional fees and kept expenses tight to the vest. If this
arrangement had remained in effect without government intrusion, health care
today would be about half of the present cost. It would be affordable to
everyone.
The county hospitals did an excellent job of giving
quality of care to the poor, usually with physicians donating their
professional services. Most doctors I knew would plan to donate 8 to 10 hours a
week to this charity. It was a good feeling for physicians and surgeons, and
the patients we saw were deeply appreciative. Many told their families of the
well-know doctors who took care of them in the county hospitals. All county
hospitals had interns and residents to take care of these patients on an
hour-to-hour basis with back up by the private doctor with whom they made the
morning attending rounds.
There was no such item as uninsured. Everyone was
covered by his or her hospital insurance or by the county welfare departments.
Hospital insurance could be equated with high deductible insurance since the
physicians' fees could be considered the deduction, although always affordable.
For those that couldn't afford these fees, all the physicians I knew would
provide them with free care. Physicians expected to give ten percent of their
time to charity, either in their own offices or at the county hospital.
Then the cry came from unions, governments and
socialists that it was demeaning to go to county hospitals as charity cases;
these patients should be placed in the mainstream of health care. This resulted
in the Kerr-Mills bill, the first significant intrusion into general health
care. However, this didn't pacify the cry for Medicare which came along in 1965
and resulted in socialized medicine for everyone over 65 years of age. Then all
the disabled were added. Then all the patients on kidney dialysis were added.
Medicaid was also implemented to replace the Kerr-Mills aid for the poor.
These huge programs caused the largest inflation in
health care costs the world has ever seen. Hospital construction boomed to take
care of all the people that now wanted first-class inpatient services that in
the past were happy with outpatient or county hospital services. The county
patients never understood the economics of health care any better than their
own. They padded down in the hospitals and were usually able to get a few extra
days of free care. The daughter of one patient refused to take her mother home
on December 23 stating that it was cruel to burden them with her care just
before the holidays. It would be better if she could stay for an extra week
until all the festivities were over and the guests had returned home. Why
should anyone be concerned about an extra week of "mother" sitting at
$2,000 a day? Isn't that what free care is all about?
Physicians have been criticized for the last three
decades as being the cause of most of the excessive health care expenses. The
whole managed care system was implemented by the government to control health
care costs and much of it was directed against physicians. I remember managed
care meetings where the managers were almost in tears saying, "Why can't
you docs just put away your pen? That would save us a lot of money." I
received a personal call from the CFO saying that he noticed I saw most of my
heart and lung patients four times a year. Wouldn't three times a year be
adequate? That will save us 25 percent of our cost of office calls. So the big
push was less tests, less office visits, less consultations, less procedures,
and less of anything that costs.
Now we have total reversal. With the emphases in the
last several years to improved the highest level of health care in this country
and make it an even higher quality, there has been a big push to make sure more
tests, consultations and procedures are ordered. Lipids are requested to be
checked more frequently, even if normal. Mammograms in later life are still
requested yearly, even though many authorities recommend every second or even
third year. Same for pap smears. At the medical grand rounds at the University
of California at Davis, a visiting GI professor stated that far too many
colonoscopies are done. He even suggested that unless there are risk factors,
one procedure in the 60s was adequate and if a polyp was found, a second
procedure in the late 60s or early 70s. The HMOs, presumably for PR purposes,
are now recommending colon screenings starting at age 50. The
gastroenterologists are being overwhelmed with the number of colonoscopies that
are being requested, and their schedules are quite full. Colonoscopies are not
an inexpensive procedure.
Bureaucrats feel that doctors are not adequately
performing all these supposed procedures and, therefore, have concluded that
physician care is inferior. This attitude will not really improve the quality
of care but will make health care considerably more expensive. The impression
of many of the physicians suggests that health care expenses will increase 25
to 30 percent with questionable improvement. With health care consuming close
to 20 percent of GDP, these are significant cost increases.
Social Security would have remained viable if the age
of retirement would have been the index for life expectancy. Then over the past
80 years, the retirement age would have been 75 and Social Security would have
remained viable. There was no way that with retirement years now twenty years
longer than in the 1930s, the worker could pay an extra twenty years for
everybody to live off of everybody else. There is no Social Security depository
- benefits are paid out of the Social Security taxes.
The same situation should hold for Medicare. To
preserve Medicare, it should have been indexed with Social Security. At the
current Social Security threshold, benefits would start at age 67. It should
also be gradually indexed to age 75 according to current actuary life
expectancy. Medicare would then have remained viable.
But Medicare will crash sooner if the current proposed
Secretary of Health and Human Services gets his way and lowers the age for
Medicare to 55. This will precipitate disaster since the current unfunded
liability of Social Security, Medicare, Medicaid and SCHIPPS programs is
estimated at ninety-nine trillion dollars. The president-elect's infusion of
one trillion dollars in new taxes will have no effect on these liabilities. But
they will keep the crowds pacified until the next elections. Rather like the
Romans who kept the masses pacified by throwing the Christians to the lions.
* * * * *
6. Medical Myths: Health Reform Plan -
Improving Health or Limiting Access?
Plan Could Be Economic
Disaster According to NCPA Economist Devon Herrick
The sweeping health reform plan
proposed by Senate Finance Committee Chairman Max Baucus suffers from several
expensive and fatal flaws, according to a National Center for Policy Analysis
health economist.
NCPA Senior Fellow Devon Herrick
called the Baucus proposal a "blueprint for economic disaster in health
care coverage for Americans."
"The end result of Baucus'
plan would destroy any choices that consumers have to select health coverage
that meets their individual needs," said Herrick. "We would be stuck
with a government-designed and regulated health plan that will drive up costs
and limit access for too many consumers."
"Whenever these types of
regulations are imposed at the state level, premiums have jumped two to three
times the national average," said Herrick, a noted NCPA health
economist. "Mandated coverage would force consumers to buy plans
with benefits they may not want at prices they cannot afford."
The Baucus plan includes many of
the same elements implemented in the Massachusetts mandated health plan, which
Herrick said is now suffering from massive cost over-runs for the state and
escalating premium costs for consumers." He added, "Many newly
insured patients have been unable to find doctors willing to treat them under
the new reimbursement levels."
The solution, said Herrick, is
portable coverage that moves with workers from job to job, and that allows
families to choose the level of benefits they need at a cost they can afford.
"The bottom line," said
Herrick, "is that the Baucus plan will exacerbate current problems of
skyrocketing costs and limited access while creating a huge burden for
individual taxpayers and businesses. There is no such thing as free
health care."
Herrick is a preeminent expert on
21st century medicine, including a variety of critical health care
issues, such as health insurance and the uninsured, patient empowerment and
trends in state health policy reform.
http://cdhc.ncpa.org/news/baucus-health-plan-is-fatally-flawed
* * * * *
7.
Overheard in the
Medical Staff Lounge: Is Medical Care Hazardous to Your Health?
Dr. Rosen: I had an interesting and challenging patient today.
Dr. Yancy: What was it a gallstone?
Dr. Edwards: Don't mind Yancy. Surgeons can't think of anything
interesting unless they can cut.
Dr. Yancy: What's wrong with that? I'd operate on my mother if
she needed it.
Dr. Rosen: I had a 70-year-old
professional man who has a pulsation in each eye at 5 o'clock. Since, it is in
both eyes at the same spot, I put the lesion in his optical cortex.
Dr. Ruth: Well, what did the MRI show?
Dr. Rosen: He declined. Actually, he was in for a GI problem,
not the type that Yancy could operate on. The visual pulsation was just an
incidental comment he made. He's had this for 15 years.
Dr. Milton: Sounds like an aneurysm in his brain to me. Don't you
think it should be removed before it ruptures?
Dr. Rosen: That was my first impression. But since he's had it
for so long, he thinks he will live longer with it in his head than with an
operation gone wrong and half his body paralyzed.
Dr.
Patricia: But wouldn't you like to know? Wouldn't HE like to
know?
Dr. Kaleb: I don't think I would want to know if I was 70 and
had it for 15 years. I'd just make sure my BP was normal.
Dr. Rosen: Actually he does have hypertension. But he keeps it
well controlled - to the point that he gets light headed if he gets up to
quickly.
Dr. Kaleb: So he's doing exactly what I would. Keep that BP low
and keep the surgeons from cutting into his brain.
Dr. Sam: Milton might be correct. But it could also be an ugly
A-V malformation and it wouldn't come out so smoothly at surgery. With a large
defect in his brain post op, he would have some obvious deficits. Instead of a
small pulsation, he might have half of his visual fields missing.
Dr.
Patricia: Why don't you get an MRI and put his mind at ease?
Dr. Sam: You really want to give him something to worry
about. That would be the last thing to put the mind at ease.
Dr. Edwards: What did his ophthalmologist think?
Dr. Rosen: Actually he also ran that by his ophthalmologist some
time ago and he said he didn't see anything in the retina to explain the
pulsation.
Dr. Ruth: Obviously not. It's in both visual fields so it has
to be in the cortex of the brain.
Dr. Sam: There are neuro-ophthalmologists now. They would have
clues. You could consider getting their opinion.
Dr. Edwards: There are two sides to that coin also. They would be
much smoother into talking your patient into a craniotomy with greater
confidence. The patient would have increasing difficulty in saying
"no."
Dr. Rosen: My patient even mentioned that he had one knee
arthroscopy. When the other knee went bad, he declined to go back to the
orthopedist precisely because he wished he hadn't had the first one. But he saw
no way of politely declining and he didn't want to put himself in such a
situation again where someone smoother could talk him into surgery. He thought
the brain was more crucial than the cruciate in his knee.
Dr. Edwards:
I suspect when Mr Daschle gets national health care
going and everybody's at war with everyone else in the health care field, who'd
get dinged for not doing the highest quality of care even if it kills the
patient.
Dr. Rosen: With the current crises, and Medicare and Social
Security with a $99 trillion deficit, there's not enough money to even think of
extending socialized medicine.
Dr. Edwards:
But lack of logic has never deterred Congress from
doing the illogical even though it is detrimental to your health or your life.
Dr. Rosen: I think I'll go back to my office before I get carried
away about the Federal Government.
Dr. Edwards:
Yes, our government is following the history of
government oppression and slavery throughout the ages. Except we're doing it without
a dictatorship. Without Congress
being knowledgeable about history, we are destined to repeat the mistakes.
Dr. Rosen: We can be ignorant about history, but can we be
ignorant about current events? Bastions of socialized medicine, like England
and Sweden, are struggling to privatize medicine because their care is
deteriorating so badly with state medicine after sixty or more years.
Dr. Edwards:
So that means our Congress has a bull-headed
irrational agenda that further restricts our freedom, which will take sixty or
even a hundred years to reverse.
Dr. Rosen: And with that observation, I will really excuse
myself.
* * * * *
8. Voices of Medicine: We Don't Need 1,170 Codes for
Angioplasty
Increasing the number of diagnostic codes from 16,000
to 155,000 will not improve the quality of health care. It will only increase
government intrusions into Medicare and the practice of medicine to the
detriment of all concerned.
When the Relative Value Study assigned an RVS number
to all medical procedures in 1964 and 1969, it was quite simple. In regards to
clinical medicine, there was the new patient consultation (90220) and the
regular office visit (90250) and a couple of smaller codes (90240), which were
generally used for a nurse visit and one for a medical assistant visit (90230)
for an injection or a BP recording, now obsolete with the readily available
blood pressure devices.
The government and medical society executives and
legal types, then in an effort to balance clinical medicine with surgery
procedures, developed the Resource Based RVS (RBRVS) for greater flexibility.
There were now five different types of office calls depending on how much
evaluation transpired, such as how many problems the patient had, how many
organ systems were reviewed and how complicated the medical issues were (99211,
99212, 99213, 99214, 99215 and others). This was a thinly disguised subterfuge with
the old 90250, the normal internal medicine charge for office evaluation,
between the 99214 and the 99215, which could be variously interpreted.
With the era of For Profit Health Maintenance
Organizations (FP-HMOs), the reimbursements were reduced. Doctors frequently
upgraded their codes. This was technically a crime. To police the process, the
government intruded to inside the office, actually reviewed the charts and
counted the number of entries and problems discussed and examined. They would
review a series of charts and extrapolate that percentage to the whole
practice. For example, if there was evidence of over coding in ten charts in a
hundred examined, then extrapolating that to the entire practice, of say 1000
charts, would mean criminal activity in 100 patients. With several variations
in each chart at $10,000 fine per line, the number of dollars could reach
millions in a busy practice.
Some physicians didn't comprehend the government's
intent and allowed their staff to the assign new codes. The doctors felt that
they did the same amount of work on each visit as before, the charges were the
same as before for the office visit and what could be wrong with that. One
physician was arrested after his charts were reviewed, and he was prosecuted. After
being told by Medicare that what he did was wrong, he apologized and said he
would use whatever code Medicare wanted in the future. The Medicare prosecutor
then handed the doctor a document to sign stating that he acknowledged his
error and would refrain from doing that again. Not even legal counsel
understood the government's intent until they saw their client handcuffed and
led off to jail. This particular colleague in my community received a two-year
sentence, and since he is now a felon, lost his license to practice, lost his
home, and lost his wife. Since he no longer can practice medicine, his father's
quarter million dollar investment in his medical education vaporized and he has
to do ordinary labor. What a waste of resources.
The current attempt to increase the ICD 9 codes, which
has one code for angioplasty, to 1,170 codes for angioplasty in the ICD 10, is
a similar hostile move by Medicare. To see if a cardiologist used the correct
code with the correct diagnosis and, therefore, the correct charge means that
Medicare will have to hire another army of reviewers to review cardiac
catheterization reports and make a judgment on whether the cardiologist
committed a crime and should be prosecuted and subject to fines and
incarcerations.
http://online.wsj.com/article/SB122636897819516185.html?mod=todays_us_nonsub_pj
* * * * *
"The Shield":
Crime and Punishment, By James J. Murtagh, M.D.
Police Drama vividly
portrays a lower circle of hell for a guilty conscience.
Warning: spoiler alert.
If you have not seen the final episode of The Shield, do not read
further. The episode contains a major plot twist which is discussed in this
Op-Ed.
"Corruptio optimi pessima,"
Latin proverb for "corruption of the best is
the worst of all."
It is fiendishly appropriate that the television
police drama, The Shield, ended its series in 2008, exactly 700 years
since Dante began writing the Inferno. The Shield, possibly more
than any other series, demonstrates the most intense hell on earth, forcing its
worst characters to kill the people and things they love best.
Exquisitely appropriate punishments are meted out to
the guilty, with twisted, but appropriate, justice. There is no escape for the
damned, spiraling into lower and deeper cycles of pain.
For seven years The Shield, like the Sopranos,
and HBO's "The Wire", shows evil in all its seductive guises.
Of the three series, the Shield was most shocking, even moving its audience to
cheer for the central character, Vick Mackey, the macho corrupt police
detective at his most murderous and torturing self. Even Mackey's murder of a
fellow policeman evoked a morbid fascination. How much could one man get away
with?
Mackey initially plans to get away Scott-free through
a devil-deal to turn state's evidence and become a snitch himself. He claims he
beat the system. Or has he?
Wrong! Fate reserves circles in hell for treacherous
murderers even below simple murderers. Not being caught appears infinitely
crueler than being fried by 2,400 volts in an electric chair.
For his immunity, Mackey betrays everyone and
everything he cares about. Mackey is sentenced to life in a cubicle, cut off
from anything or anyone he ever cared about. He is in a deep freeze as cold as
great lake Cocytus Dante described at the bottom of the ninth circle of hell,
reserved for the great traitors of all time.
Hell's best-kept secret is that we create it for
ourselves. Mackey connived, threatened, hoodwinked and betrayed to get this
cubicle. It is nothing but an existential nightmare.
Others also receive punishments befitting their great
sins. Mackey's one-time sidekick, Shane Vendrell kills his own wife and child,
then kills himself. But not before Vendrell realizes the enormity of his crimes
and comes to true contrition.
In a subplot, a sixteen-year-old serial murderer is
caught. A haunting reminder is made that this boy could have grown up to be Vic
Mackey, and there is little moral difference between the boy murderer and the
ex-police cop. Both operate on the same ethic.
Robert Frost wrote that torment by ice can be much
more painful than by fire, metaphorically contrasting passionate torments with
death by hatred. Mackey's fate is death by ice, frozen into a bland
cubicle, with no hope of redemption.
What is the best way to punish a depraved guilty
man? To punish him? Or just possibly, not punishing the guilty would be
even worse pain.
To read the entire OpEd Review, go to www.healthcarecom.net/JM_TheShield.htm.
To read more of Dr. Murtagh's other reviews, go to www.healthcarecom.net/JM_Profile.htm.
To read more book reviews, go to www.delmeyer.net/PhysicianPatientBookshelf.htm.
To read book reviews topically, go to www.healthcarecom.net/bookrevs.htm. www.delmeyer.net/.
* * * * *
10. Hippocrates & His Kin: The Art of Getting Well
The art of being sick is not the same as the art of
getting well. Some cancer patients recover; some don't. But the ordeal of
facing your mortality and feeling your frailty sharpens your perspective about
life. You appreciate little things more ferociously. You grasp the mystical
power of love. You feel the gravitational pull of faith. And you realize you
have received a unique gift - a field of vision others don't have about the
power of hope and the limits of fear; a firm set of convictions about what
really matters and what does not. You also feel obliged to share these insights
- the most important of which is this: There
are things far worse than illness - for instance, soullessness. -Tony Snow
in the Jewish World Review, 2005.
Who are the
Losers in the HHS Secretary's Proposed Health Care Plan?
Among the explicit "losers," he includes:
"Doctors and patients might resent any encroachment on their ability to
choose certain treatments, even if they are expensive or ineffectual compared
to alternatives. Some insurers might object to new rules that restrict their
coverage decisions. And the health-care industry would have to reconsider
its business plan (emphasis added)." That is to say, they can stay in
business and deliver their services, but only as the government bureaucrats say
they may. They no longer would be genuinely independent. -Tom Daschle, proposed
Secretary of Health and Human Services.
What an
ultimatum to Doctors and their Patients. Where did all this anger originate?
With their approval rate of 12 percent or one-half that of the President, what
is their basis for stance?
Will the
Internet replace doctors?
Patients now frequently check out the doctor's
diagnosis and treatment plans on the Internet. Sometimes they check their
symptoms before the visit or phone call so as to appear knowledgeable about
health issues. Recently a patient called and said that for the last 24 hours he
was dizzy on getting up and felt better as soon as he lay down again. He also
mentioned that he gets dizzy in bed if he turns too fast. Since he has
hypertension and the pills were reduced because of low blood pressure from over
treatment, I suggested he take his BP the next time he's dizzy on getting up to
see if he's still over medicated. He had forgotten to do so. If he gets dizzy
on turning his head too fast, I said that sounds more like vertigo and perhaps
his wife could run to the corner drugstore and get some Antivert or Meclizine
and take one to three tablets a day. With this new information, we should be
able to diagnose his condition the next day in the office.
He stated that he had searched the Internet and
thought it might be his back causing this. I tried to explain that I saw no
correlation to the bones of his back. He stated he thought it was his spinal
cord causing these symptoms. I told him I was unable to see a connection. I
still thought the differential was between a postural effect on his blood
pressure or his middle ear, which can cause vertigo. He agreed to try the
recommended approach and come in the next day on Monday with the suggested
data.
Looks like
Tom Daschle may still find a place in his new government health plan for
Doctors. He needs this information before he closes all the Medical Schools
since he thinks all the medical facts are now on the web and are free to
everyone.
To read more HHK, go to www.healthcarecom.net/hhkintro.htm.
To read more HMC, go to www.delmeyer.net/hmc2005.htm.
* * * * *
11. Organizations Restoring Accountability in HealthCare,
Government and Society: