1.
Featured Article:
A New "Designer" Treatment for Multiple
Sclerosis, Scientific American, By Nikhil
Swaminathan August 28, 2007
Research shows that estrogen can be used
to counteract nerve cell degeneration caused by MS without increased risks of
breast and uterine cancers
Researchers have proposed a new treatment
for multiple sclerosis (MS) that utilizes the hormone estrogen to stave off and
even reverse some of the mysterious disease's debilitating symptoms without the
dangerous side effects of some other hormone therapies.
MS is largely believed to be an autoimmune
disease in which the immune system turns on healthy tissue - in this case in
the brain and nervous system. Current treatments include medicines designed to
suppress an overactive immune system and reduce inflammation, a first-line
response of the immune system. Whereas Copaxone and other such drugs often
improve some of the muscle weakness and movement issues associated with the
condition, they do little to combat the accompanying neurodegeneration. To read more, please go to www.medicaltuesday.net/index.asp.
In recent years, researchers began
focusing on the potential of estrogen in battling MS after observing that the
disease went into remission during pregnancy. "Pregnant women had this
beautiful effect
their estrogen levels went skyrocketing," says Seema
Tiwari-Woodruff, an assistant professor of neurology at the University of
California, Los Angeles, and lead author of a study on estrogen as a potential
MS treatment published in Proceedings of the National Academy of Sciences
USA. "As soon as they had the baby, the MS came back, and more
drastically."
In the body, estrogen binds to two types
of receptor proteins in cells: estrogen receptor α and estrogen receptor
β. The former - often referred to as estradiol - is known to play a role
in mediating the effects of tumor-causing agents - and a major risk of estrogen
treatments is the increased risk for breast and uterine cancer in women.
Estrogen receptor β has no known connection to tumor cell proliferation
and, thusly, the research team believed it may present a better treatment
option.
The U.C.L.A. team was able to target
specific receptor proteins in a mouse model of multiple sclerosis by attaching
receptor-specific compounds to estrogen. Young adult female mice (five to six
weeks old) were given a compound that induced encephalomyelitis, an autoimmune
condition similar to MS. Some of the infected animals immediately received
estrogen targeted to the α receptor, whereas others received the β
receptor-specific hormone.
The α group did not develop any MS
symptoms; the animals did not display any movement effects or damage to nerves
or to the myelin (protective sheath) on the cells' axons, which transmit information
- in the form of electrical impulses - away from neurons. Tiwari-Woodruff notes
that despite the heartening result, researchers are not sure exactly why it
works. "We don't know if it was stopping inflammation," she says,
"or directly stopping the degeneration of neurons and axons."
The mice that received estrogen targeted
to the β receptor initially developed signs of MS, including difficulty
maintaining balance and a generally slower gait. The scientists say there was
inflammation throughout these animals' central nervous systems. But some 20
days later, these mice began to show improvements in motor control, eventually
regaining the ability to walk normally - and despite inflammation there was no
neurodegeneration, which typically occurs at this stage of the disease.
"This is the first time," she says, "a hormone treatment has
been described [that works] without touching the inflammation part" of the
equation. . . To read the entire article,
go to (Subscription required)
www.sciam.com/print_version.cfm?articleID=AF215C2D-E7F2-99DF-3743CC2251357EB1.
* * * * *
In the News: This Won't Hurt a Bit, Forbes,
No company benefits more than WellPoint from the
current health care mess. New chief executive Angela Braly is trying to put a
kind face on this controversial business.
Two months into her job as chief executive of health
insurance giant WellPoint, Angela Braly, number 16 on FORBES' list of the
World's Most Powerful Women, is on a listening tour in New Haven, Conn. She
makes a halfhour stop in the office of Marna Borgstrom, the head of the
Yale-New Haven Hospital. Yale offers a WellPoint plan to its 20,000 hospital
employees, who each get full coverage - unlike many of the patients who use the
hospital. Borgstrom is worried about the cost of caring for uninsured folks and
deadbeats. She favors some kind of government intervention.
Braly makes the case that the American system could be
worse, the if-it-ain't-broke argument. "In China they roll you out of the
hospital if you run out of cash," Braly tells Borgstrom. She's skeptical
that government can come to the rescue and predicts that Medicare will run out
of money in 2014, five years sooner than forecasted: "I think partnering
[among insurers, health providers and employers] on cost and quality is the
only solution." Braly plugs WellPoint's incentive policy - paying hospitals
more when patients have fewer complications. She also describes a new bonus
system that pays WellPoint workers more if the overall health of its 34 million
members goes up. As the meeting ends, the two women wish each other luck, their
views apparently unchanged. To read more,
please go to www.medicaltuesday.net/news.asp.
At the youthful age of 46, with only a few years of
operational business experience, Angela Braly has become the most powerful
woman in health care. Her company provides coverage to one in nine Americans,
more than better-known UnitedHealthcare, Cigna or Aetna. The 42,000-employee
behemoth runs Blue Cross and Blue Shield plans in 14 states. It's the biggest
corporation in the world with a woman on top, its sales of $56 billion bigger
than those of Pepsi, Archer Daniels Midland, Kraft or Xerox.
But in today's heated debate over reforming health
care, Braly might wish at times she ran a less visible company. Well- Point's
strength has made it a fat target for people who think that for-profit health
insurers are callous and evil. Earlier this year the company settled lawsuits
with ten patients who claimed that their policies were canceled after an injury
or diagnosis. (WellPoint had argued that they had concealed preexisting
conditions.) Doctors in several states have filed class actions claiming
WellPoint plans withhold payments. It's the only health insurer in California
actively opposing Governor Arnold Schwarzenegger's plan to provide everyone with
health insurance.
In her slow Texas drawl, Braly, who was WellPoint's
general counsel before getting the top job, understands her challenge: "A
Senator told me recently: It's going to be a bumpy road, and you will be the
shock absorber.'"
Underneath the friendly veneer is a hardheaded
negotiator who grew up professionally in the health-care-industrial complex and
is not about to roll over for the likes of Michael Moore. While she talks about
health care reform, she insists it must be done by the private sector, and in
measured steps. Her success as a chief executive and public figure will depend
on whether she can smooth out bumps in the health care system while fending off
government intrusion - and keep Well- Point a money machine.
Earnings (including acquisitions) have risen 55% a
year on average since 2000, to $3 billion, while revenues have grown 37% a
year. It does big acquisitions without losing members, a fate rivals regularly
experience. Its health plans have 30% to 60% market share and offer the widest
networks of doctors and hospitals. Warren Buffett just quadrupled Berkshire
Hathaway's stake in the company to 4 million shares, even though the growth in
what WellPoint can charge is starting to slow (See charts at the URL)
WellPoint's history goes back to the 1980s, when
for-profit insurers started winning business away from nonprofit Blue
Cross-Blue Shield companies. In response, many Blues combined and started
writing policies using data on medical histories rather than offering the same
deal to everyone in a given community regardless of risk. The pushiest Blues
converted to for-profit, investor-owned companies. The final result was
WellPoint, now worth $48 billion, formed after Indianapolis insurer Anthem, led
by Larry C. Glasscock, bought the larger Well- Point in 2003 and took its name.
Of the 100 million Blues customers, a third are part of WellPoint . . .
Two years later WellPoint, which had started as Blue
Cross of California, bought RightChoice for $1.3 billion. In August 2003 Braly
finally got her chance to run the Missouri business, but her time in an
operating position was cut short by another promotion a year and a half later,
this time to general counsel of the national holding company in Indianapolis.
There she clicked with WellPoint chief Glasscock and
rode shotgun to finance chief David Colby on the $6.5 billion purchase of New
York's Empire Blue's plans in 2005. Then came the shocker. In February
Glasscock, who is only 58, announced he was retiring to tend to a family
matter.
How Braly, a dark-horse candidate, was selected to
replace Glasscock is a matter of some office intrigue. In WellPoint's last
proxy statement she was not even considered a top-level executive. . .
Ultimately the board gave her the job because she has
"no ego," is a good listener and was skilled at public policy, says
William Ryan, a board member and chairman of TD Banknorth in Portland, Me. The
conference call announcing it was awkward. Stock analysts pounced on why Colby
or Watts had not been chosen. "You can't get annoyed that easily or take
it personally," shrugs Braly, whose new contract includes $2.4 million in
salary and bonuses, plus 410,000 options. . .
Braly officially wants WellPoint to remake the health
care system by turning individuals into health consumers. It trumpets Tonik, a
$77 per month health plan for young people who go without coverage because they
freelance or work in retail. It covers a few visits a year and then goes to a
high deductible. WellPoint has expanded it to seven states. But despite the
hype, after two years WellPoint has sold only 70,000 policies. "Tonik has
gotten more press coverage than members," says David Olson, a senior vice
president at rival California HMO Health Net.
And for all the talk of individual directed plans, the
company is still reliant on traditional full-coverage corporate accounts. Sales
chief Watts recently landed Bank of America and Kroger as national clients. Is
there a plan to move big accounts such as these to consumer directed plans,
which are cheaper for employers and fit into WellPoint's vision? Nope, says
Watts, because such a move would hurt profit margins. Rather, he says, consumer
plans like Tonik will be used only to reach new customers. . .
Then there's California, where Well- Point's image has
taken the worst beating. WellPoint plan California Blue Cross has been savaged
in newspaper articles and at the Capitol for retroactively canceling plans of
sick members who it says falsified their applications. One woman who withheld
information about a yeast infection and later got her policy canceled ended up
blasting the company in Michael Moore's Sicko. (WellPoint says privacy laws and
lawsuit settlements prevent it from explaining what really happened.)
WellPoint is spending $2 million to attack
Schwarzenegger's health plan; one ad compares it to the electricity
deregulation that led to blackouts in California. Braly argues that
Schwarzenegger's plan, which requires that insurance companies open the door to
all applicants, will fail because healthy people will not buy insurance until
they get sick, sending the market into a "death spiral." She says
that in states where insurers must offer coverage to everyone regardless of
their health, premiums are three times as high. "You need to protect the
individual market. Right now it's very affordable," she says. Braly claims
that the Massachusetts universal coverage plan, which is based on similar
principles, is falling apart for the reasons she cites, though insurance
companies there deny that is the case.
Braly's stance annoys not just the governor's office
but also WellPoint's rivals. "We have spent a lot of time trying to talk
them into a more progressive position," says George Halvorson, head of
Kaiser Permanente, the second-biggest health plan in California after
WellPoint's Blue Cross subsidiary.
Expect a standoff, for which Braly is ready.
"People will say, Why don't you line up behind the governor?'" she
says. "That's not who we are." She recounts some good advice she once
received: "You have to know who you are because people will always tell
you who you should be."
To read the entire article, go to http://members.forbes.com/forbes/2007/0917/116.html?partner=alerts.
* * * * *
3.
International
Medicine: Whistleblower:
Surgeon breaks cover over NHS beds crisis, The Independent On Sunday, Exclusive
report by Andrew Johnson and Marie Woolf, 29 July 2007
Specialist wards full to
breaking point. Patients with serious injuries denied care. A health service
paralysed by arguments about funding. Martin Bircher, one of Britain's most
senior consultants, speaks out.
One of Britain's leading trauma surgeons has broken
cover to expose the scandal of a national shortage of emergency trauma beds
which is leading to thousands of serious injury victims suffering in agony.
In an unprecedented intervention by a senior
practitioner in the NHS, Martin Bircher, a consultant at St George's hospital
in London, one of Europe's leading centres in the treatment of major accident
victims, has revealed a system paralysed [sic] by red tape and disputes over
funding, which is putting thousands of patients waiting for treatment in
specialist wards at risk.
His revelations have prompted calls for a review of
funding for A&E services and a shake-up in the management of Britain's
leading trauma centres [sic].
Mr Bircher says the problem is worsened by the
bureaucracy of the internal market. He has become so frustrated that he has
broken free of NHS strictures against speaking to the press and agreed to talk
to The Independent on Sunday about the suffering patients are put through. To read more, please go to www.medicaltuesday.net/intlnews.asp.
Every one of Britain's specialist trauma beds is full,
which means some patients can wait up to three weeks after their accident
before badly broken bones can be repaired. The delay, says Mr Bircher, can
jeopardise recovery. With nothing but praise for frontline staff, he says
patients who have been critically injured in road or other accidents have to
wait an average of 12 days - often in agonising pain - before they can receive
the vital specialist treatment.
This is because only a limited number of hospitals
have the expertise to repair smashed bones, and those hospitals have a shortage
of intensive care beds. With the average cost of keeping a trauma patient at
around £500 a day and up to £2,000 a day in intensive care, this is also a
false economy. . .
Squabbles over funding
Mr Bircher, who risks censure from the NHS for
speaking out, said primary care trust and bed managers are involved in making the
final decision as to whether a patient can be moved. If they have to move them
there is often a conflict or reluctance because the new area does not want an
extra cost. So after initial admission to a general hospital's emergency wards,
where lives are saved, patients can find themselves waiting up to three weeks
before their real recovery process can begin. . .
Delays in treatment
He said: "The delays are caused at various
levels. If doctors, nurses, physiotherapists, the treating teams, were left to communicate
between themselves without bureaucracy, things would happen much more quickly.
In the good old days somebody would ring me up about a patient, I'd say send
them across, make one call to sister on the ward and it would happen.
"Now I'm loath to accept a patient unless I'm
sure their injury requires surgery. If I'm unsure I ask them to send X-rays.
Even in this technological age this can take two or three days. It's not
unusual for them to be delayed or get lost . . .
"You can argue whether a patient needs a hip
replacement at hospital x or y," he added. "As long as it's done in a
reasonable time by a good team it doesn't matter. You can't have these petty
squabbles. There just isn't time with trauma."
Patients in pain
His argument is illustrated by Lucy Lynn-Evans, a
21-year-old student from London who was severely injured in a road accident
last month. She was riding her scooter to Brighton when she was run over by a
10-tonne lorry which came to rest on her hip. She is alive only because a laptop
in her backpack took the full force when the lorry ran over her spine. Her life
was saved a second time by the staff at Redhill hospital, where she was
initially taken with a smashed pelvis, smashed knee and leg broken in two
places. They gave her a blood transfusion - she had lost five pints - and
wrapped her hip, described by doctors as a "bag of crisps", in a
sheet which was then pulled tight to keep the fragmented bones together.
This is the correct procedure. But Redhill hospital
did not have the expertise to repair Ms Lynn-Evans's bones. That would require
specialist surgeons and equipment that can be found only in certain hospitals
around the country. All they could do in Redhill was put her on morphine and
wait for a bed which at one point she was told could take up to three weeks.
. .
Lack of beds
Ms Lynn-Evans's problem was that she was stable and
not going to die; when a bed became available it would go to another more
pressing case. At one point a bed became available at the John Radcliffe hospital
in Oxford, but before she could be moved John Radcliffe's fund manager had to
agree. The fund manager did not arrive at work until 9.30am. By the time Ms
Lynn-Evans's case came to the top of the administrator's pile and permission
was granted, the bed had gone. . .
"The delays not only cause distress to families
and patient, but other serious medical issues - thrombosis, bed sores, chest
infections and urine and wound infections," said Mr Bircher. "The
longer the bone fragments are left displaced, the more the clot begins to form
new bone, thus the harder it is to replace the fragment to the correct
position.
Patients suffer
"The first step to dealing with the problem is an
acceptance and realisation that the system isn't working with trauma and other
emergency services in medicine. Sending each other forms and bills is not a
good way of doing it. I'm acutely aware that resources are an issue. But basic
emergency services should be of the highest quality. If we consider ourselves a
leading nation we should have a first-class emergency healthcare system. We do
not, and the situation is worsening.
"It's pot luck where you go. There's not a
defined system. We have to fight every day to get patients in. We have to break
through the bureaucracy and develop a new system. There is a lack of intensive
care beds in London and around the country which further magnifies the problem.
. .
Further reading: 'NHS plc: The Privatisation of Our
Health Care' by Allyson M Pollock (Verso)
http://news.independent.co.uk/health/article2814751.ece
The NHS does not give timely
access to healthcare, it only gives access to a waiting list.
* * * * *
4. Medicare: CalPERS Plan Cuts Costs By Cutting Doctors
Two years ago, Blue Shield
and the California Public Employees' Retirement System booted 13 Sutter
hospitals out of its health maintenance organization network, saying they cost
too much.
Now, the health plan and
giant benefits group are taking a similar -- and controversial -- approach to
individual physician groups. In January, local Mercy doctors will be excluded
from a new, lower-cost Blue Shield plan available to CalPERS members in 17
counties, including most of Greater Sacramento.
Sacramento-based Golden
State Physicians Medical Group Inc, also will be shut out of the new plan. The
only doctors available in the new "high-performance network" will be
those with UC Davis Health System and local doctors affiliated with San
Ramon-based Hill Physicians Medical Group Inc. . . . To
read more, please go to www.medicaltuesday.net/medicare.asp.
Medical groups were judged
on clinical data and patient satisfaction surveys used in the
pay-for-performance program run by the Integrate Healthcare Association: and
from a separate assessment of grievances, appeals, and complaints. . .
Blue Cross of California
next year will for the first time offer to CalPERS members a preferred provider
organization network with a narrow doctor panel. The narrower PPO will be
available in 54 counties, including Sacramento, El Dorado and Yolo. It also was
narrowed based on cost and quality and is cheaper than its counterpart, PERS
Choice. But far fewer CalPERS members are signing up for with PPO Plans.
The plan, approved by the
CalPERS board in June when it adopted new premiums for 2008, finally makes a
business case for groups that support high-quality medicine, said Steve
McDermott, CEO of Hill Physicians. Doctors who provide quality care at a
reasonable price stand to reap more business, while the rest could lose
patients.
It also stands to make Blue
Shield competitive in price with Kaiser Permanente in the CalPERS program,
possibly prompting Kaiser members to switch plans, McDermott said. This could
bring a significant bump in enollment for the selected groups overall. . . To read the entire article, go to
(subscription required) www.bizjournals.com/sacramento/stories/2007/08/27/story1.html?ana.
[Ever feel like doctors
and patients can be traded like commodities or ball players?]
Government
is not the solution to our problems, government is the problem.
- Ronald Reagan
* * * * *
5.
Medical Gluttony:
Just Do The Tests One More Time
Mr. Moore had shortness of breath, a cough with some
phlegm. His family insisted on taking him to the emergency room of the local
hospital. A simple course of antibiotics should have been sufficient.
Instead he had extensive x-rays, an ECG, CT exams,
numerous laboratory tests and was told he had an infection. However, he was
discharged. When the doctor reviewed his work later the next day, he noted that
he had failed to treat his infection and the patient was called in to get an
intravenous infusion of antibiotics. To read more,
please go to www.medicaltuesday.net/gluttony.asp.
On his return, the ER couldn't find his records and so
proceeded to obtain additional x-rays, an ECG and laboratory tests to confirm
the logged in diagnosis and proceed with the antibiotic infusion. He had no
chills or fever.
Before the infusion was completed, the old records
were found and he was given a prescription for additional oral antibiotics.
When he came in today for the standard one-week later
ER follow up, he brought in both ER records which proved to be nearly
identical. Now he was worried if this infection that was discovered could be
life-threatening and questioned whether he should be on more antibiotics or
possibly be admitted to the hospital for intensive treatment. The examination
failed to reveal any evidence of infection. It took considerable time to allay
his anxieties produced by the excessive testing and comments in the ER.
If his family had allowed it, the estimated cost of
coming to the office would have been for an office call and a prescription, or
a total cost of about $150. The estimated costs of an ER visit, if he only saw
the doctor and obtained a prescription, is on the order of five to ten times
the identical office evaluation. However, as our last newsletter pointed out,
ER physicians don't have a longitudinal history of a patient and those
standards are entirely different, which explains the five- and ten-fold costs
over the patient's personal physician. To then duplicate those costs and pay
the hospital charge for two ER visits, the extensive x-rays, ECGs, CTs
laboratory tests, and antibiotic infusion is why ER visits can be as high as 50-
to 100-fold more expensive as we have enumerated in these pages over the years.
No system can sustain costs of such exorbitant magnitude.
Then how can such gluttonous behavior be stopped?
Medicare and Medicaid have not been effective in controlling costs, even with
all the restrictions and controls the government has implemented. Standard
first-class health insurance has not been able to control costs even as the
fixed-dollar co-payments have increased. Health maintenance organizations (For
profit HMOs) have not controlled costs, even with the $billions spent on
policing and controls on doctors and hospitals.
Patient-directed health care (PDHC) plans, where
patients are responsible for some percentage of every charge levied against
their health plan, is the only mechanism that can control costs. If every day
in the hospital costs the patient a certain percentage of that day's charge, if
every visit to the ER costs the patient a certain percentage of every test done
in the ER, or if every visit to the doctor or lab or x-ray costs the patient a
certain percentage of the charge on the office visit or test, then this
gluttonous behavior will be stopped in its tracks.
Unfortunately, the players are against such logical
behavior. Hospitals, insurance companies, physician organizations, unions,
employers and the government would not dare implement such a plan even though
actuarial estimates that such a plan would save 30 to 50 percent of health care
costs. This innovation will have to come from the private sector. It would take
someone on the order of Bill Gates, Sergey Brin, Larry Page, Andrew Grove,
Gordon Moore or William Buffet to implement such an innovation. This would
place their accomplishment into the Annals of the Greatest Health Care Event of
the twenty-first century on the order of our Constitution, which changed the
world order in the eighteenth century. It would easily merit the first double
Nobel Prize in Medicine and Economics.
* * * * *
6.
Medical Myths:
Universal Care Myths, by Lawrence R.
Huntoon, M.D., Ph.D., Lake View, NY
I expected the Buffalo News, a very liberal
newspaper, to have a litany of praises for Michael Moore's movie Sicko
and a story on how wonderful universal care is for Canadians. I was shocked to
read the headline story on July 29 about a man who almost certainly would be
dead now had he waited to receive "universal care" for his brain
tumor. He had an MRI done in Buffalo rather than waiting 4 months in Ontario.
Armed with a study that showed a possibly malignant tumor, Lindsay McCreith
headed home to Canada. The next available appointment with a neurosurgeon was
in 3 months. To read more, please go to www.medicaltuesday.net/myths.asp.
Back to Buffalo he went for a biopsy that showed low-
grade astrocytoma, which was immediately removed. Reimbursement was refused
because he failed to get pre-approval which also takes months. McCreith is now
suing the government for violating his right to life, liberty, and security,
the same approach taken by Dr. Jacques Chaoulli in Quebec. Each province has it
own ban on private insurance. If successful in Ontario, this would be a big win
for freedom in medicine in Canada. The trial is scheduled soon. www.aapsonline.org/newsletters/sept07.php
* * * * *
7.
Overheard in the
Medical Staff Lounge: Changing Medicare and Medicaid Addresses
Dr. Edwards: Our
office building was sold and to bring the heating, air, plumbing, electricity,
elevators and restrooms all up to code, they increased our rent 80 percent.
Dr. Milton: I
understand three-fourths of the building moved out.
Dr. Edwards: We
got out within 30 days of the notice and moved into more reasonable quarters at
half the rent.
Dr. Michelle: That
should be the easy part. We moved twice in two years. But changing addresses
proved to be the biggest hassle.
Dr. Edwards: We're
just finding that out. When we gave our notice to the Landlord in May that we'd
be out in 30 days, we immediately began notifying all the patients, our
business contacts and our insurance carriers. We thought it would require just
a simple change of address form.
Dr. Michelle:
Welcome to the bureaucratic world of medicine.
Dr. Edwards: I
don't think you can blame medicine. The bureaucratic hassles were all
government. To read more, please go to www.medicaltuesday.net/lounge.asp.
Dr. Michelle: Well,
just Medicare and Medicaid which were somewhat more involved. It took about a
month longer to square them away. That was about two years ago. Have things
changed?
Dr. Edwards: Our
simple change-of-address notices were received with a note that we had to
access their websites, print out a change of address form and complete the
application process. So we did.
Dr. Michelle: And
so was everything fine as soon as they received it?
Dr. Edwards: Maybe
that was two years ago. But on July 15, we received a rejection notice stamped
"Received June 15, 2007" stating that the forms were incomplete and
were returned. When reviewing the new forms, they were essentially identical to
the old forms - both the seven-page initial form and the 17-page detailed
version. We completed them again, paying attention to their comments, and two
weeks later, they were again returned for additional information. So now at
three months, what we thought a simple change of address within the same city
and zip code, we still have not yet heard if the third completion was accepted.
We have not received any payment for the work done these past four months.
Dr. Dave: We've
had a very similar experience, only our Medicaid harassment was even worse. It
took more than four months, then we had to serve a 12-month probation, which we
didn't have to do when we first started some twenty years ago. We were treated
like a new employee.
Dr. Rosen: We
shouldn't forget the now third great government bureaucracy, the National
Provider Identifier Number (NPI). This has now been expanded to include health
plans and a large bureaucracy. The National Plan and Provider Enumeration
System (NPPES) has been developed. Remember when the Medicare and Medicaid
sites said it just takes 20 minutes to apply for the NPI number?
Dr. Milton: When
this was implemented last year, that's about how long it took me.
Dr. Rosen: With
our recent move, we had to go through a lengthy reapplication with two
rejections, just like Medicare, and it took about two months. This number is
also required before Medicare and Medicaid will make payments.
Dr. Michelle: Well,
I must say it was very simple to work with Blue Cross, Blue Shield, HealthNet
and others.
Dr. Bob: Let
me toss out another caveat. I retired the end of August. I started notifying
insurance companies in June that my patients would be seeking other physicians.
I made the huge mistake of notifying Medicare and Medicaid. Since June, we have
not been reimbursed by Medicare or Medicaid for any work we billed since that
date, which included some of our May work.
Dr. Michelle:
You've got to be kidding.
Dr. Bob: No
I'm not. For two months, we've been
trying to figure out how to break into this bureaucracy and get paid and have
been totally unsuccessful. So, when you retire, don't tell the government for
at least six months after your last patient and until all your accounts
receivable have been worked over to as close to zero as you can get them. Don't
ever trust the government, especially when they say, may we help you.
Dr. Rosen: Wait
till patients have to wrestle with such a condescending bureaucracy to obtain
health care when the only provider is the government, whether Medicare,
Medicaid, Schip Program or A Single-Payer HealthCare program. The mortality
from the wait period will exceed the dangers of the flu pandemic, whether bird
or swine variety. Only then it will be too late. And there won't be any
treatment or antidote.
* * * * *
8. Voices of Medicine: A Review of Local and Regional
Medical Journals
From San Francisco Medicine: A Symposium on
Medicine and Religion, May 2007
Editorial: Religion and Healing Mike Denney,
MD, PhD
According
to Harold G. Koenig, MD, director of the Center for the Study of Religion, Spirituality,
and Health at Duke University Medical Center and author of many books, including Spirituality in Patient Care: Why,
How, When, and What, "There have been more than 1,200 studies on
religion and healing. Two-thirds to
three-fourths of them find a link between religious practices and physical and
emotional well-being. For example, religious patients are less likely to be
depressed or anxious than others, and they're more likely to be in better
physical health, with better-functioning immune systems and lower blood
pressure." To read more, please go to www.medicaltuesday.net/voicesofmedicine.asp.
On the
other hand, scrutiny of scientific studies of religious effects upon healing has
exposed serious flaws. Lynda Powell, PhD, epidemiologist at Rush University
Medical Center, reviewed nearly 150 studies on religion and healing and, noting
scientific weaknesses, concluded that although subjective faith has its place
in relieving suffering, it cannot be said to influence objective physical
outcomes of disease. Reporting in The Lancet, Richard Sloan, MD,
Professor of Medicine at Columbia University, cites weak data and erroneous
logic. After evaluating the literature, Sloan says, "Doctors should feel
free to refer patients to hospital chaplains, but that's as far as the
religious conversation should go."
Religious
leaders have also criticized scientific study of spiritual beliefs, noting that
to reduce God to biomedical statistics may be an arrogant affront to the
divine. Raymond J. Lawrence, an Episcopal priest and director of pastoral care
at New York-Presbyterian Hospital of Columbia University, states flatly,
"Scientists who undertake the work of theologians are as reckless as theologians
who pretend to be scientists."
Viewed from a mythological and historical perspective,
these opposing arguments may seem superfluous. Religion has always been closely
associated with sickness, health, and healing. The Encyclopedia of Religion (Macmillan)
notes, "Healing occupies a singular and prominent place in religious
experience throughout the world. Often
the most important figure or symbol in any given religious tradition is the
source of healing." In their book Future Science, John White and
Stanley Krippner offer names for spiritual healing energy from ninety-seven
different cultures . . .
Yet our objective science seems inadequate when it
comes to measuring those religious aspects of healing that seem to be inborn.
Many psychologists and philosophers, including Freud, Jung, Hume, and Kant,
have described an innate natural propensity in humans to seek the divine.
William James, the father of American pragmatic psychology, speaking of
religious experiences, put it this way, "Treating these as purely
subjective phenomena, without regard to the question of their truth,' we are
obliged, on account of their extraordinary influence upon action and endurance,
to class them amongst the most important biological functions of mankind."
At the very least, we accept the fundamental subjective reality that there
seems to be something rather than nothing - and we can become awestruck when
contemplating whence that "something" came. And when we become sick,
our awe may turn to deep concern about our own place in the cosmos.
And so it is that as in this issue of San Francisco
Medicine we contemplate the place of religion in medicine, we quite
naturally accept the reality that sick patients experience a relationship with
the mystery of life and death. With articles on the many facets of the
relationship of medicine and religion, we find a salutary union of objective
science and subjective faith working together to heal both body and soul. In
the words of the great theologian Paul Tillich in the book The Meaning of Health,
"Only a medicine which denies the nonbiological dimensions of life in
their significance for the biological dimension can come into conflict with
theology. An understanding of the differences as well as the mutual
within-each-otherness of the dimensions can remove the conflict and create an
intensive collaboration of helpers in all dimensions of health and
healing."
To read the entire article, go to
To review the entire symposium, go to www.sfms.org/AM/Template.cfm?Section=SF_Medicine_Magazine&Template=/CM/HTMLDisplay.cfm&ContentID=2316.
* * * * *
9.
Book Review: Current Books,
from Sonoma Medicine: Nice Car By Brien A. Seeley, MD
Questions
of Value, by
Patrick Grim, "Great Courses" lecture series, The Teaching Company,
$35 and up, www.thegreatcourses.com.
The state of happiness comes down to engaging in
activities just beyond our skill level.
-Mihaly Csikszentmihalyi
At about age 5, my daughter liked to play the game of
"What would you rather have?" She would ask questions like,
"What would you rather have, a nice car or a swimming pool? No arms and no
legs or be blind?" Such conscious explorations of values are important to
children. They learn early on that every act involves a choice, and that, in
order to choose well, one needs to prioritize values.
Prioritizing values is what philosophers do, and they do it as a science, by
rationally testing their theories against the history of human culture and
individual behavior. Philosophers argue that some things are far more valuable
than a nice car. Indeed, philosophers examine the deeper questions in life that
are the fundamental drivers of how we choose to live. Their teachings about the
hierarchy of values have perhaps never been more relevant to physicians than in
today's medical system.
SUNY philosophy professor Patrick Grim, in a series of 24 half-hour lectures
entitled "Questions of Value," laments the fact that people so often
lead unexamined lives, growing up and starting a family and career without ever
deliberately prioritizing their values. They go through life as mere
spectators, spending the only life they have by passively accepting value
systems imposed by others, falling victim to peer pressure and advertising
buzz. To remedy such passivity, Grim says that we should each write down our
own Big List of Values, and then carefully prioritize them. Only then, he claims,
are we able to commit to an examined life with a direction and purpose clearly
aimed at what we value most. Only then do we live our lives to the fullest. To read more, please go to www.medicaltuesday.net/bookreviews.asp.
To aid that effort, Grim presents a starter list of "good things,"
including accomplishment, freedom, recreation, intelligence, fame, honesty,
love, a good education, fun and adventure, money, romance, safety, respect,
meaningful work, a fulfilling sex life, generosity, a big house, and a nice
car. He points out that some of these "good things" have intrinsic
value (e.g. freedom), while others have merely instrumental value (e.g. money).
He lumps together things that are good to do, good to be, and good to have. The
Big List also includes more than just ethical and moral values. Grim's lectures
deal with axiology, the study of values in general, and as such also cover
spiritual, aesthetic, communal, character, material, relationship, and
knowledge-seeking values. As we begin prioritizing the Big List, we must ask,
"Is there a single highest good, and how does one choose it?"
Grim
invites the listener to explore these questions from every angle by supplying a
comprehensive, elegantly interwoven critique of classic and modern
philosophies. His lectures encompass a wide range of topics, from religion and
business ethics to hedonism versus self-sacrifice; from immortality,
conscience, the greater good, and capital punishment to the value of a life,
Darwinism, game theory, and free will. This philosophic tour de force amounts
to a tool kit to help listeners compose and manage their Big List of Values and
their lives.
The lectures lead off by cautioning listeners to be on guard against arguments
that use so-called "is-ought" syllogisms to define values. In 1739,
David Hume famously pointed out the flaw in such derivations, which array
several "is" statements of fact toward a final, non-factual
"ought" statement that sneaks in a value judgment unsupported by the
facts. A medical example would be as follows: Fee-for-service health care
"is" expensive. The premium for fee-for-service "is"
negotiable. It "is" a fact that premiums can be reduced by corporations
or governments that unionize patients into large groups. It "is" a
fact that such large groups can demand that physicians work for less money. A
physician "is" forbidden from unionizing to resist such demands.
Reducing premiums "is" a way to make health care affordable for more
people. Therefore, unionizing patients to force doctors to work for less
"ought" to be done.
The utilitarian value judgment in the final sentence disregards the rights of
individual physicians. Note also that the emotionality or affect of the
syllogism is flat until the final "ought" value judgment is stated.
Professor Grim warns that history is filled with hindsight about the unintended
consequences of such syllogisms. To read Dr. Seeley's entire book review,
please go www.scma.org/magazine/scp/sm07/seeley.html.
Dr.
Seeley, a Santa Rosa ophthalmologist, serves on the SCMA Editorial Board.
* * * * *
10. Hippocrates & His Kin: Differential Diagnosis by
GOOGLE?
At the Medical Grand Rounds last week, the visiting
professor gave his differential diagnosis of the patient presented to him as an
unknown, working through additions and deletions in his well-formatted Power
Point presentation. After discussing all the esoteric possibilities in the
case, he said it's a good practice at one point to Google the symptoms and
findings before making the final determination of the most likely diagnosis. He
said one should put in 5 or 6 of the findings in the case and let Google sort
out the diseases with those findings. He stated that Google was very good at
classic diagnosis of unusual diseases.
Any idea of what might be next?
Bereavement Leave
Doctor: Noting that his
receptionist was crying, asks, "Is something's wrong?"
Receptionist: My mother died.
Doctor: Why don't you take the day
off? We'll be able to manage.
Receptionist: No, I'll be alright. I'd
rather work.
Doctor: Later sees that the
receptionist is crying again, and asks "Is there something else?"
Receptionist: I just got a call from my
sister, her mother also died.
Doctor: Please take some time off.
Receptionist: I'll be alright. I'll keep
on working.
Doctor is quite concerned now and
calls his attorney and asks if a third sister calls in and tells his
receptionist that her mother also died, can he insist on at least a nine-month
bereavement leave?
Competency shows itself in
the most unusual circumstances.
To read more
vignettes, please go to www.medicaltuesday.net/hhk.asp.
Is Congress Really In The Toilet?
Just 20 percent of California voters
approve of Congress' performance, while 66 percent disapprove. That's worse
than the 23 percent approval rating state voters gave the Republican-led Congress
in May 2006 before the GOP lost its decade-long control in the November
elections. It's the lowest rating for Congress since the Field Poll started
asking the question in 1996.
www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2007/08/24/MNTSRO7DI.DTL&hw=zachary+coile&sn=004&sc=382
Congress hasn't change course for 10 years
since 1996 aiming for the sewer. If they ever control health care, our health
would really be in the cesspool. There are really deadly germs down there.
Legalized Stealing from Taxpayers by
Congress
Top congressional lawmakers still rake in
dough in earmarks. While spending on earmarks may be trimmed and more closely scrutinized
this year, top Democrats like House Speaker Nancy Pelosi aren't exactly
suffering. The San Francisco Democrat raked in almost $100 million in earmarks
in the spending bills passed this year, according to an analysis by Taxpayers
for Common Sense, which tracks congressional spending. That means Pelosi is
getting more than 1 percent of all earmarks doled out to the House's 435
members.
www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2007/09/02/MN97RQ7PU.DTL&hw=zachary+coile&sn=001&sc=1000
If any of us subverted $100,000,000 of
taxpayer's funds, we'd be prosecuted, tried, and probably end up in Jail. Why
can't we put Congress in Jail?
Incentives to Die
In a new political satire, Boomsday by
Christopher Buckley, baby boomers born between 1946 and 1964 are to be offered
tremendous incentives to "voluntarily transition" (commit suicide) by
age 75. If only 25% do so, Social Security and Medicare will supposedly become
solvent.
My, what a way to keep stealing from our children and
grandchildren to balance our gluttony.
* * * * *
11. Organizations Restoring Accountability in HealthCare,
Government and Society: