1.
Featured Article:
Some Smokers Pay More for Health Benefits
By LISA CORNWELL, Associated
Press Writer,
A
growing number of private and public employers are requiring employees who use
tobacco to pay higher premiums, hoping that will motivate more of them to stop
smoking and lower health care costs for the companies and their workers.
Meijer
Inc., Gannett Co., American Financial Group Inc., PepsiCo Inc. and Northwest
Airlines are among the companies already charging or planning to charge smokers
higher premiums. The amounts range from about $20 to $50 a month.
"With
health care costs increasing by double digits in the last few years, employers are
desperate to rein in costs to themselves and their employees," said Linda
Cushman, senior health care strategist with Hewitt Associates, a human
resources consulting and services firm.
She
said the practice of smoker surcharges is becoming such a significant trend
that this year, it will be part of Hewitt's annual survey of companies' current
and future health care plans.
Cushman
said a general benefits survey of 950 U.S.-based employers last year showed
that at least 41 percent used some form of financial incentives or penalties in
their health care plans.
She
estimates that at least 8 percent to 10 percent of the businesses probably
aimed some of the incentives or penalties at smokers and says that percentage
is growing.
"With
smokers costing companies about 25 percent more than nonsmokers in the area of
health care, it just makes good business sense," she said. . . .
The
Centers for Disease Control and Prevention estimates $92 billion in lost wages
annually in the
"In
addition to employers having to pay out more in health care costs, public
opinion is now solidly on the side of eliminating smoking and workers are
realizing increasingly that they are having to pay for others' lifestyle
choices," said Helen Darling, president of the National Business Group on
Health, a nonprofit agency representing more than 200 of the nation's large
employers.
Gannett
Co., the nation's largest newspaper publisher, this year began charging its
employees who smoke an extra $50 a month for the company's insurance coverage.
"We have some strong feelings that smoking is really bad for employees,
and a healthier employee is better for us," said Tara Connell, a
spokeswoman for the McLean, Va.-based company.
PepsiCo
Inc., based in Purchase, N.Y., has been charging employees who use tobacco $100
annually for a couple of years, and Grand Rapids, Mich.-based Meijer Inc.
started charging smokers $25 a month this year. That fee is dropped if smokers
complete a smoking-cessation program, said Meijer spokeswoman Judith Clark.
Cincinnati-based
American Financial Group holding company and its subsidiaries waive the $37.92
monthly fee for a year if smokers make a good-faith effort and complete the
company's stop-smoking program, said Scott Beeken, a vice president with the
Great American Insurance Group subsidiary. If the employee starts smoking, the
fee would be reinstated the next year.
About
35 workers were expected to enroll if the voluntary program had not included
the financial incentive, but 325 have signed up so far. "The charge
probably was a motivating factor," Beeken said.
Public
employers also are requiring smokers to pay for their habit. The state of
Employers
say the surcharges are incentives rather than penalties, but that's not the way
many smokers see it. . . .
Some
employers have turned to even stronger measures to discourage smoking. Weyco
Inc., an Okemos, Mich.-based medical benefits administrator, fires employees
who smoke even if it is on their own time. . . .
To
read the entire article, go to www.sacbee.com/24hour/jobs/story/3175736p-11883836c.html.
* * * * *
2. In the News: The Maternal Brain - Does
Motherhood Make Women Smarter?
Pregnancy and motherhood
change the structure of the female mammal's brain, making mothers attentive to
their young and better at caring for them.
By Craig Howard
Kinsley and Kelly G. Lambert, who hold professorships in Neuroscience in their
respective Departments of Psychology.
In Scientific American,
Mothers are made, not born. Virtually all female mammals, from rats to monkeys to humans, undergo fundamental behavioral changes during pregnancy and motherhood. What was once a largely self-directed organism devoted to its own needs and survival becomes one focused on the care and well-being of its offspring. Although scientists have long observed and marveled at this transition, only now are they beginning to understand what causes it. New research indicates that the dramatic hormonal fluctuations that occur during pregnancy, birth and lactation may remodel the female brain, increasing the size of neurons in some regions and producing structural changes in others.
Some of these sites are involved in regulating maternal behaviors
such as building nests, grooming young and protecting them from predators.
Other affected regions, though, control memory, learning, and responses to fear
and stress. Recent experiments have shown that mother rats outperform virgins
in navigating mazes and capturing prey. In addition to motivating females
toward caring for their offspring, the hormone-induced brain changes may
enhance a mother rat's foraging abilities, giving her pups a better chance of survival.
What is more, the cognitive benefits appear to be long-lasting, persisting
until the mother rats enter old age. . . .
Interestingly, once the reproductive hormones initiate the
maternal response, the brain's dependency on them seems to diminish, and the
offspring alone can stimulate maternal behavior. Although a newly born mammal
is a demanding little creature, unappealing on many levels-it is smelly,
helpless and sleeps only intermittently-the mother's devotion to it is the most
motivated of all animal displays, exceeding even sexual behavior and feeding.
Joan I Morrell of Rutgers has suggested that the offspring themselves may be
the reward that reinforces maternal behavior. When given the choice between
cocaine and newly born pups, mother rats choose pups. . . .
To read the entire article (Subscription required), go to www.scientificamerican.com/issue.cfm?issuedate=Jan-06.
* * * * *
3. International Medicine: Ethical Principles Such As
Patient Autonomy Vary Outside of the
There has been an increased effort in recent years to
have international standards for cardiopulmonary resuscitation (CPR), basic
life support (BSL), and advance cardiovascular life support (ACLS). Review of
the latest handbook emphasized some important international differences as well
as emphasizing the most important advance in the last 25 years, the Automated
External Defibrillator or AED.
Definition of "Patient Autonomy:" The ethical principle of patient autonomy holds that
every competent adult has a right to make informed, binding decisions about
his/her health care. Commentators and reviewers also use the term patient
‘self-determination' in a context synonymous with patient autonomy. This
principle includes the right to decide to forego CPR attempts in the event of a
cardiac arrest. Most western cultures respect and honor patient autonomy as a
core ethical principle. Citizens of the
Conditions for "Autonomy:" Patient autonomy requires that the patient have the
ability to communicate and the mental capacity to accept or reject medial
interventions, including attempted resuscitation. The "default
assumption", in most western countries is that all adult patients possess
autonomous decision-making capacity. In fact, in the
"Obstacles to Patient Autonomy
A number of studies over the past decades have
identified numerous obstacles to the practical realization of patient autonomy.
The gap between the ideal and the reality of patient autonomy remains large:
§
Failure to prepare
advance directives.
To exercise their right to make decisions about their
healthcare, people actually must make and express those decisions. People
rarely plan for future illness. They do not enjoy talking about death or the
end of life, and they do not want to prepare advance directives or discuss CPR.
Consequently they do not. Physicians share the same aversions and seldom
discuss advance directives, even with their seriously ill patients.
§
Failure to understand
CPR and its consequences.
The public generally overestimates the probability of
survival from cardiac arrest, or they overestimate the frequency of severe
neurological deficits with survival. The fact is that many studies describe the
quality of life for survivors of cardiac arrest as acceptable.
§
Gaps in physician
knowledge
Physicians often fail to learn or understand a
patient's perceptions of CPR, resuscitation outcomes, or quality of life.
Discussions can also be complicated by physician misconceptions and the inability
of physicians to accurately predict chances of survival from cardiac arrest.
§
Different opinions on
what constitutes a "good" quality of life
Younger physicians, for example, might think an inability
to remain ambulatory, active, and involved in recreation would be an
unacceptably poor quality f life. Their senior patients, in contrast, might
require only daily communication with friends and loved ones to experience a "good" quality of
life.
§
Surrogate decision
makers not the answer
Surrogate decision makers, acting on behalf of
incompetent patients, do not always reflect patient preferences. The superior
approach is to establish patient preferences before a severe clinical
deterioration.
§
Administrative
mandates not the answer.
Current regulations mandate some attention to whether
a patient being admitted to a hospital has a "living will" or an
"advance directive." Although well-intentioned, the Patient
Self-Determination Act of 1991 has resulted in administrative behavior that
falls far short of the goals of having an advance directive in place for every
patient. There is no regulatory substitute for a concerned physician sitting
down with his/her patient to discuss end-of-life issues."
Patient Autonomy-"It's the Law."
"… Healthcare institutions are required to
facilitate completion of advanced directives if patients desire them. The
requirements were designed to encourage use of advanced directives, but there
is little evidence of increased use. Advanced directives have had minimal
impact on resuscitation decisions in the
To read the entire chapter 2: Patients, Families, and Providers: Ethical
Aspects of CPR and ECC (emergency cardiovascular care), visit your local heart
association. To take your BLS training (every citizen should take this course)
or ACLS training (Every health care worker should take this course.), find the
site nearest you at www.americanheart.org/presenter.jhtml?identifier=3011764. Why?
In 2000, more than 5 million people were evaluated in
the U.S. Hospital Emergency Departments for Chest Pain. Of these, 2.5 million
were diagnosed with acute ischemic syndrome. Of these, 1.4 million were
admitted with unstable angina. Each year, 1.1 million Americans experience a
myocardial infarction. Of these, 500,000 die within one year. One-half of these
deaths occur within the first hour with most of these never reaching the
hospital emergency departments. More than 90 percent of these deaths are caused
by ventricular fibrillation, the type that can be treated in the community with
the relatively new AED devices. AEDs are now found in many public and some
private establishments that have CPR or BLS trained individuals on their staff
that can defibrillate such an individual within three minutes. The 911 ACLS
team generally arrives in 5-7 minutes, which is very fast, but may be too late
to save the heart and brain. Both teams, the 911 and the in-house if there is
one, however, should be called immediately when a person collapses or becomes
comatose.
* * * * *
4.
Medicare: [The]
Elephant in the Room
Budget Wish Lists Come and
Go, But 'Entitlements' Outweigh All
They Cost $3 Billion a Day,
Rise 8% a Year, Leave Bush Little Room to Maneuver
By JACKIE CALMES Staff Reporter of THE
President Bush on Monday
will tell the nation what he wants done with the budget next fiscal year. But
the significance of his proposals and Congress's response is dwarfed by one
daunting fact: Some 84 cents of every dollar the government spends is
essentially committed before he and the legislators even have at it.
That is the amount that goes
to three all-but-untouchable elements: interest on the federal debt; defense
and homeland security; and, above all, "entitlements" programs such
as Medicare, Medicaid and Social Security.
It leaves just one-sixth of
spending for nearly everything else the government does domestically, from
secretaries' salaries to research -- what is known in budget jargon as
"discretionary" spending.
Entitlements are the real elephant
in the room. Formulas for spending on these social programs are set by law.
Anyone eligible can collect. And the programs are growing far faster than
either inflation or the economy, some 8% a year.
Medicare, at $391 billion
this year, is close to equaling the entire domestic discretionary slice of the
budget. Add in Social Security and the federal share of the state-run Medicaid
program for the poor, and the big-three entitlements total $1.1 trillion for
this year -- $3 billion a day. This spending is the big issue in the federal
budget, not post-Katrina rebuilding, headline-grabbing pork like
"The 2005 Pig
Book" put out by the conservative Citizens Against Government Waste identified
13,997 earmarked projects costing $27.3 billion. Yet even if Congress repealed
every one of them, it would cut just 1/100th of the budget. Meanwhile, spending
on the three main entitlement programs is set to rise $93 billion in the coming
fiscal year.
Similarly, Mr. Bush said in
his State of the Union speech Tuesday he has identified 140 programs to cut or
end. "We will save the American taxpayer another $14 billion next
year," he said. He got applause, but that is 0.5% of the budget.
With so little maneuvering
room, Mr. Bush, to hold down deficits, sometimes has to rob from his own
domestic initiatives to fund others. In education, he now espouses new college
grants for low-income math and science students, but he hasn't pushed for
increased Pell grants for poor students, as he campaigned to do. And the
government has less fiscal flexibility to respond to disasters like Katrina: To
help pay for hurricane aid last fall, Congress cut both domestic and defense
funding 1% across the board.
To trim spending in the
fiscal year ending Sept. 30, Mr. Bush and Congress essentially froze
discretionary domestic programs at $386 billion, according to figures from the
Congressional Budget Office and the liberal Center on Budget and Policy
Priorities. And that doesn't account for inflation or population growth. For
next fiscal year, Mr. Bush again wants to reduce such funding below a nominal
freeze that doesn't allow for inflation.
The president addressed
entitlements in his State of the Union speech by calling for a bipartisan
commission to offer solutions. "The rising cost of entitlements is a
problem that is not going away," he said. But skeptics abound in both
parties. What is missing, they say, is political will and trust. Even some
supporters predict Mr. Bush will end up doing what he has vowed in nearly every
stump speech that he won't: Leave these problems to a future president and
Congress. In that course, he would follow President Clinton, who also hoped to
shore up the popular programs but who was defeated by political paralysis.
This will not get done in
this president's term," predicts Republican Rep. Jim Kolbe of
Few dispute the staggering
dimensions of the problem. Mr. Bush and analysts in and out of government use
the same word to describe the fiscal trend: unsustainable.
Social Security spending now
equals 4.2% of the gross domestic product, the value of all goods and services
the
Moreover, federal taxes
don't cover even 20%. They average 18% of GDP -- hence the persistent budget
deficits.
Budget-watchers have long
used metaphors such as tsunami or iceberg to warn of the fiscal problem looming
as the postwar baby-boom generation nears retirement. For 30 years, the
Robert Reischauer, head of
the Urban Institute think tank and a former CBO director, popularized the
tsunami comparison. Now he draws a parallel to global warming, slow and nearly
imperceptible. He says the nation and economy may be forced to adjust to
spending more on entitlements, but doing so would bring painful dislocations
and even the extinction of some beneficial programs in other parts of the
budget.
The pressures are visible in
the five-year window of projected spending that Mr. Bush's new budget will
address. In 2008, the first of the 77 million baby boomers turn 62 and qualify
for Social Security's early-retirement benefits. In 2011, the first of the wave
will become eligible for Medicare. Social Security is projected to start
running annual deficits by 2017. Medicare's hospital-care trust fund already is
paying out more annually than it's collecting in payroll taxes.
When Mr. Bush accepted
Republicans' nomination at their 2000 convention, he charged that the
More recently, these
congressional leaders have struggled for months to muster Republican votes to
pass a deficit-reduction bill lowering Medicare and Medicaid spending by almost
$50 billion over 10 years. That would equal less than 0.6% of the projected
spending on the two health-care programs over the coming decade. . . .
Cost-saving options on
Social Security could be simple and straightforward. They include slightly
increasing retirement ages; reducing annual cost-of-living increases and the
formula for computing retirees' initial benefit; and expanding the amount of
income subject to Social Security payroll taxes so the biggest earners pay
more. Neither party will do any of this without political cover. . .
To read the entire article
(Subscription required), please go to http://online.wsj.com/article/SB113892884384763928.html?mod=todays_us_page_one.
Government
is not the solution to our problems, government is the problem.
- Ronald Reagan
* * * * *
5.
Medical Gluttony:
How Can We Avoid or Diminish It?
Mr Norman came in last week complaining that for about
six weeks, since about Thanksgiving, he had been gagging, trying to remove
phlegm caught in his throat. He was also short of breath. He didn't seek
medical attention since he thought it was not severe and would pass. He visited
his daughter in
He spent a half day in the emergency department
undergoing all sorts of blood tests, electrocardiograms, chest x-rays, sinus
x-rays and allergy evaluations. He was sent home on corticosteroids, both orally
and by nasal spray. He had completed the two-week steroid burst on the day he
was seen in our office.
His complaints at this time were that he was gagging
on thick phlegm caught in his throat and he had shortness of breath. These
symptoms were not significantly different from his problems during the
Thanksgiving and Christmas season. No one had given him antibiotics for the
green pus in his throat. On examination, he had forced expiratory wheezing
which he had not previously appreciated. Pulmonary function tests revealed an
initial expiragraph that was normal but made his wheezing worse. The second
expiragraph was about two-thirds normal for his age. The third expiragraph was
about one-third normal indicating rather significant bronchospastic disease consistent
with asthma. A stethoscope was no
longer required to hear this wheezing.
The post bronchodilator test revealed a 100 percent
improvement over his third expiragraph, which was still about two-thirds
normal. He responded to a generic antibiotic and a generic bronchodilator.
Some observations:
The patient had been happy with the treatment he
received at both the "doc-in-a-box" and the emergency department of
his daughter’s hospital. But as his hour with me progressed, he began to
realize that they had not helped him. His symptoms were unchanged and
essentially still not treated.
He was very proud to have brought eight pages of
information to the office for me to read. Three pages were related to an
allergy program to implement in his home, one page was a complete blood count,
one was a chemistry panel (kidney and liver functions - patients assume that
these contain cholesterol, lipids, PSA and a host of other tests but they
generally do not), one was an ECG, and there were several pages of disclosures
to reduce medical liability or comply with government intrusive regulations.
However, there were no x-ray reports of either his chest or sinuses. These
eight pages essentially had no significant medical value for his
"emergency situation" even though the costs may have been
substantial.
It is difficult for us to get charges from the
hospitals - perhaps because many hospital administrators receive this
newsletter. However, we never mention any hospital, administrator, physician or
nurse by name. Our only goal is to highlight generic problems and look at
possible solutions for the benefit of the health and well being of our
patients. In the Emergency Department, tests are done on a rather continuous
basis. We have never seen an emergency department bill which was less than one
thousand dollars an hour. We can safely assume that his six hours in the
emergency room cost $5,000 or more. From past experience, we have seen HMO
reimbursement for these kinds of charges at $600 to about $900.
The patient's one hour in my office included a $100
office call (anticipated reimbursement from his HMO at $60) and a $200
pulmonary function test (anticipated reimbursement from his HMO at $75).
However, it yielded the diagnosis, which formed the basis of the treatment
plan. The office call continues to be the most economical, appropriate, and
cost effective value and charge in medicine.
When a patient obtains test in different offices, or
different communities, the overview of the medical evaluation is lost. Since he
allegedly had a chest x-ray, which he stated was normal, I did not repeat it
even though the last one I had was obtained a year earlier. Using a patient's
verbal reports in our experience can be hazardous because they may be abnormal
or at least have clues to the illness being treated.
The patient was outside of the diagnostic
decision-making process in the hospital but was an active participant in my
office. A fixed co-payment did not reduce the charge. Only the strong arm of
the insurance carrier (or in other instances the government) forcibly reduced
the payment of the charges. This could have been accomplished with equal force
in the free market environment with the patient in charge had there been a
percentage co-payment. The hospital would then have been forced to give full
disclosure at every step of the unnecessary diagnostic evaluation. The patient
could have then stopped the unnecessary testing probably after he realized he
had a normal chest x-ray and electrocardiogram. This would have amounted to
about one-tenth the charges and thus been more effective than the strong arm of
an insurance or government bureaucracy. And the hospital could have gotten paid
in full for the emergency visit along with the chest x-ray and ECG. This would
then have brought about transparency in hospital billing and payments that
could then be understood.
Managed care with all this forcible reduction without
recourse has not significantly altered the course of spiraling health care
costs, despite making many insurance executives very, very wealthy.
Medicare got it right in 1965 by requiring a 20
percent co-payment on outpatient medicine. However, it was lost when they
allowed the deductibles and co-payments to be insured. Deductibles and
co-payments are never an insurable item.
Re-instituting percentage co-payments would solve the
health care cost problem within one year.
Charges would drop and reimbursements would be
reasonable.
Insurance carriers, doctors, hospitals, providers, and
patients would all be happy again.
* * * * *
6.
Medical Myths:
Pay for Performance Will Improve Quality of Health Care
Medicare has various initiatives to encourage improved
quality of care in all health care settings where Medicare beneficiaries
receive their health care services, including physicians' offices and
ambulatory care facilities, hospitals, nursing homes, home health care agencies
and dialysis facilities.
Through these collaborative efforts, CMS (Center for
Medicare and Medicaid Services) is developing and implementing a set of
pay-for-performance initiatives to support quality improvement in the care of
Medicare beneficiaries. In addition to the initiatives for hospitals,
physicians, and physician groups described below, CMS is also exploring
opportunities in nursing home care – building on the progress of the Nursing
Home Quality Initiative – and is considering approaches for home health and
dialysis providers as well. Finally, recognizing that many of the best
opportunities for quality improvement are patient-focused and cut across
settings of care, CMS is pursuing pay-for-performance initiatives to support
better care coordination for patients with chronic illnesses.
www.cms.hhs.gov/apps/media/press/release.asp?Counter=1343
The administrative costs of this needless study have
not been calculated nor will they be. The decreasing quality in health care is
caused by government and administrative intrusion into a medical environment envied
by the entire world. Any administrative attempt to improve quality will result
in a hugely expensive increase in health care costs. Physicians' clinical
judgment has always kept the health care costs at the highest quality for the
lowest possible cost. To mandate quality issues that may or may not be
justified, will just increase the cost of an already exorbitantly expensive
national health care program. It will drive health care costs out of sight,
increase the drag in an efficient health care system, increase morbidity, and
further jeopardize quality of care. Each unsuccessful attempt to control a
smooth running health care system seems to whet bureaucratic appetite for
control of the profession.
To see how this bureaucracy that doesn't understand the
health care system they want to control, please scroll down to Section 8 – VOM
and Dr Luther Cobb's comments on controlling that portion of health care that
is relatively simple that a government employee can understand. Be sure to note
the perspective that organizations that are cooperating are doing so
reluctantly.
Pay for Performance Will NOT Improve Quality, but It Will Increase Health Care Costs
* * * * *
7.
Overheard in the
Medical Staff Lounge: Another Cause Of Homelessness-Federal Taxes
Twenty years after a flood
washed away much of their lives, thousands of Yuba County California residents
are getting hit by another flood-related disaster: their tax bills. . . .
Many
of the victims of both floods apparently didn't know that the payouts - which
ranged from a few thousand to several million dollars - were taxable, said
David Shaw, a
But
58-year-old Johnny Wooten, who is disabled from a back injury and four hernia
operations, was more resigned. Of his $75,000 settlement, about $25,000 went to
lawyers and the rest he put into the bank. "I haven't touched nothing
because the government scares me," he said. "I've lived here for 26
years and my house is paid for, but if you don't pay your taxes, the government
can put you out on the road."
Now
we know that federal taxes are another cause of homelessness.
[If
33 to 40 percent went to attorneys, with a federal marginal tax rate of 37 percent
and state tax rate of 9 percent, the actual insurance benefit to the victims is
on the order of 15 to 20 percent.]
The Bee's Clint Swett can be
reached at (916) 321-1976 or cswett@sacbee.com.
www.sacbee.com/content/business/taxes/v-print/story/14184271p-15011409c.html
Locked Bedroom Door -- Cause Of Being Burned Alive – By Cigarettes
During the medical interview
on discussing the family history, the patient mentioned that she lost one of
her seven sons in a fire. He was living with his grandmother, her mother, in
the former garage converted into a bedroom and had retired for the night. He
always locked his bedroom door at night. He was having a cigarette in bed and
it apparently caused a sudden and very hot fire. Her mother could not enter the
bedroom because of the locked door. The fire truck responding to a 911 call had
made a wrong turn, which delayed it several minutes. The garage was engulfed in
flames almost immediately. When the firemen entered, her son was on fire,
having apparently been burned to a cinder.
Two Rules for Living: Don't lock your bedroom door
in a house where only your family members live. Don't smoke. If you must, never
smoke in bed. It's a painful way of dying.
* * * * *
8.
Voices of
Medicine: Is There Some Level Beyond Which Our Tolerance for Intrusion Will Be Exhausted? By Luther
F. Cobb, M.D., President,
Guest editorial in Mendocino
– Lake Physicians' News: mendolake_medsoc@yahoo.com
The
elephants are dancing in
Paying For
Performance. That sounds like something we should all get behind, like apple
pie, motherhood, and the flag. (Come to
think of it, even those are controversial these days). The basic underlying
idea is that, as Medicare is currently run, every "provider" (I hate
that word!) is reimbursed at the same rate for the same CPT–coded level of
service. Of course with fudge factors added in for geographic variations, etc.
(And again those are the source of much consternation as well.) So, shouldn't
we reimburse the ones who do the very best work at a higher rate? Won't that
save lives, add to quality, and reduce all those preventable deaths we all know
are out there being killed by less competent "providers"?
Well, to re-use a very
trite phrase, the devil is in the details. How exactly do we measure
‘quality"? It's not as if it is a new concept, or that physicians and lay
groups haven't been trying for a very long time to do exactly that. Now, of
course, if it's going to be worth MONEY, it's going to be worth a fight too. I
have talked with folks at the CMA who are intimately involved with this
process, including Ron Bangasser, M.D., a former CMA President and a really
smart and energetic guy. It turns out that the factors they're looking at are
things like hemoglobin A 1 c levels in the diabetics in your patient
population, or whether patients get beta blockers, things that are pretty
non-controversial and, most important of all, easily measured. I asked Ron
whether they had come up with any criteria for my field of general surgery.
After all, there are a lot of operations done every year on Medicare patients,
a great proportion of which are done by general surgeons. Would infection rate,
post-op thrombo-embolic complications, length of stay, be included? How about a
careful, time-consuming plastic closure of the surgical incision, instead of
staples? Wouldn‘t patients like that? Would that be quality'? Well, Ron
confessed, the working groups couldn't come up with a single criterion for
surgery that they thought would withstand scrutiny. So, there will be NO
criteria for surgery, at least as things currently stand. Well, maybe that's a
good thing. It certainly seems to me that the criteria being proposed for
quality indicators have the character of the old joke about the drunken man
looking under a lamppost outside a bar for his lost house keys. A similarly
inebriated friend volunteered to help, and after looking fruitlessly for a
while and not finding the keys, asked the fellow where he lost the keys.
Halfway down the block, he was told. The question naturally followed why are
you looking here? The answer, of course, was that the light was better under
the lamppost.
Because these criteria
must be objective and verifiable, they almost have to be limited in impact. I
also think they're highly likely to be unfair. I could be wrong, and maybe this
really is the best thing that could happen. But it reminds me of the debate at
the time of he original passage of the Medicare legislation. When AMA
representatives expressed concern about the control that was being given up
over the practice of medicine, they were reassured that "the only thing
that will change will be the signature at the bottom of the check." I
think we all know how that turned out. What will be reimbursed under these rules
will be things that will be quantifiable and clear-cut, which will practically
demand electronic medical records and data retrieval. This could well be a huge
unfounded mandate, because whatever the P4P reimbursements, I really doubt
they'll cover the cost of the currently available EMR systems, which still, of
course, aren't interoperable. A lot of this information will go whizzing over
the Internet also. Despite HIPAA, I suspect a lot of this information will get
out; after all, we hear almost weekly of equally sensitive information, like
credit card numbers being stolen by hackers. This criteria may be simple and
straightforward now, there's a huge potential for creeping imperceptibly into
more basic areas that may threaten our independence as physicians. In a lot of
ways, this concept reminds me of the "No Child Left Behind" federal
education legislation, which is wreaking havoc in public education as we watch
from the sidelines. Just ask any public-school teacher whether "teaching
to the test" is improving their students' educational performance.
So, maybe I'm just a
technophobic curmudgeon. Certainly my skepticism won't be the deciding factor
in whether this gets through Congress or not, because it's pretty much a done
deal. I just suggest we watch out, pay attention, and consider whether there is
some level beyond which our tolerance for intrusion will be exhausted.
This
article had not been posted at publication time. www.humboldt1.com/~medsoc/
To
read more Voices of Medicine, please go to http://www.healthcarecom.net/vom2006.htm
* * * * *
9.
Book/Movie Review: "Good Night, And Good Luck"
Of Witch Hunts, Red Scares,
and
George Clooney shows that false patriotism is the first refuge of a scoundrel
Warning: movie spoiler
alert. If you have not seen "Good Night, And Good Luck," consider
seeing it before reading
And the
{Scape}Goat shall bear upon him all their iniquities unto a Land not
inhabited." (Leviticus 16:22)
Was
Clooney shows,
as Miller showed previously in "The Crucible," that in desperate
times, citizens are depressingly predictable, and burn for short cuts and
scapegoats. Mobs lynch scapegoats, or burn them at stakes, or torture them,
intern them in camps, or simply blacklist them. Good people look the other way,
rationalizing desperate times make due process impossible. But when are
times not desperate?
The press fears
the mob, not wanting to be accused of obstructing, or being liberal, or biased
in another way, or unpopular, or to lose subscriptions or advertisers. No press
wants to be called a scapegoat lover, witch lover, commie lover, etc. This is
how national tragedies occur. And when the press repeatedly forgets how it
failed during a prior emergency, the cycle worsens.
"Good
Night, And Good Luck," brilliantly shows Edward R. Morrow's fight against
McCarthy.
The scapegoat
originates in Leviticus 16. The community projected its troubles ritually
on a sacrificial goat that was driven off into the wilderness on Yom Kippur Day
of Atonement. Psychologically, the community may have felt better, but blaming
the scapegoat was a bit of witch doctoring that only prevented real solutions
from being found.
McCarthy gained
power by falsely accusing good men of being Communists. This prevented
confrontation of real threats, and ultimately made a mockery of the entire
problem. The scapegoating was counterproductive.
Murrow, with
unflinching integrity, faced down McCarthy, his network, and his sponsors. Can
anyone imagine that Murrow would not have outed the faulty intelligence that
preceded the current war? Murrow, a decorated war correspondent, would never
have allowed violations of the Geneva Convention.
Puritans of
Salem, 1659 were every bit as terrified of witches as we are today of our
adversaries. The population demanded due process be suspended.
However, if one
is going to try and decide who is a good witch and who is a bad witch, one
needs a definition of what a witch is. The same with the red scare. Being a
card carrying-communist meant as little then as carrying an ACLU card now.
Ironically, the
whole concept of law originated in of all places
Hammurabi was
clear. There must be due process. However, age after age somehow authority
forgets this bedrock, we end up with an Inquisition, a crusade, a gulag, a
concentration camp, a red scare or a witch trial.
Some claim a
trade off between due process and national security is inevitable. They are
dead wrong. Lack of due process always makes a society less safe. Without due
process, the innocent will be locked up and the criminals will go free. To get
tough on crime, we must be tough on due process. That way, we know that the
truly guilty are punished. To get tough on terror, we must have scrupulous due
process, and we must have probing intelligence that spares no one.
The very people who have
advocated getting tough on crime have also advocated soft inquiries into
intelligence failures. We must have intelligence that we can absolutely rely on
that will stand up to international scrutiny. The folly of simply pointing a
finger and claiming "weapons of mass destruction" has led us down a
path that of great insecurity.
Indeed, if we
accuse a criminal of the wrong crime, the criminal is going to get off, and the
whole process will become a laughing stock, as McCarthy did. The
US policy makers need to see "Good Night, And Good Luck." They need to ask, do we want the rule of law, or do we want scapegoating? Due process is our best guarantee of security, and it is time we all knew it.
This review/OpEd piece is
posted at www.healthcarecom.net/JM_GoodNight&GoodLuckReview.htm. To read Dr Murtagh's
resume and other reviews and OpEd pieces, go to www.healthcarecom.net/JM_Profile.htm.
To read more book reviews, please go to http://www.healthcarecom.net/bookrevs.htm
* * * * *
10. Hippocrates & His Kin: The Emperor Is Wearing No
Clothes
Pay for Performance (P4P)
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$195
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programs continue to grow in popularity from 35 last year to 80 today.
Healthcare Web Summit and the authors of the 2003 national study on provider
pay for performance (P4P) programs, invite you to attend their upcoming
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The summit will cover trends, measures used, implications, and valuable
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To enroll, you may spend your money at www.healthwebsummit.com/p4pstudy.htm.
Since
But The Emperor Has No Clothes.
Senior Citizens' Residences –Individuality
Still Shows Through
On a recent tour of The El Camino Gardens, where a number
of my patients live, the tour guide was a nonagenarian retired bank Founder and
CEO, who was widowed a few years earlier. His apartment was part of the tour.
It had a kitchen, spacious living room, office, bedroom and private garden.
Three meals were served each day in a lovely dining room. There were private
dining rooms and bedrooms for rent to residents who had visiting family or
guests. There were lounges, a country store, and snack rooms to alleviate hunger
pangs or just to socializing both day and night. The doors were all decorated
as part of a contest. One had a simple sign: “Satisfaction is when your own
children have teenagers of their own.” A number of the residents were retired
widows. Some of them had compiled a book to memorialize their service to their
country. These women had helped the war effort by working in defense plants
across the nation while their husbands were off to fight the war. The title of
their book was
“Rosie, the Riveter.”
* * * * *
11. Restoring Accountability in HealthCare, Government and
Society