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Showing posts from August, 2009

Computers and the medical record

Many of the elected officials who I respect--President Obama, our own Idaho congressman Walt Minnick, and anybody else appropriately fired up about health care reform--say that we will all be better off when the records of our blood tests, medical procedures and office visits are made accessible by computer. It sounds simple and beautiful. Two and a half years after starting to use such computerized medical record keeping system I have a few opinions about how good it is, and what it is really good for.

In a state of unrealistic optimism, many health care reform proponents are saying that electronic medical records will, when combined with Americans adopting healthier lifestyles, save enough money to pay for health care for the presently uninsured. Healthier lifestyles are indeed a money saver, but I'm not exactly sure what transformation is supposed to happen to make us eat less crap and stop smoking.

On the other hand, though, a computerized medical record is not a cost saving …

Do no harm

After finishing medical school, we all stood together in the big hall where we had been educated for 4 years, and took the hippocratic oath. The only part of the oath that I remember well is "primum, non nocere." Those words recognize that a doctor has the ability to harm as well as help, and needs to have the humility to recognize that.

Today in the New England Journal of Medicine, the most well regarded journal of research and practice for internists, an article appeared that referred to medical harm. I think it may be available to non subscribers at http://content.nejm.org/cgi/content/full/361/9/841. The author looks at the evidence of help and harm from radiological procedures that are done to prevent disease.

The number of CAT scans and heart imaging studies that are done is rapidly increasing, and yet there is no evidence these save lives or improve health in most instances. There are definitely times when they are helpful or appropriate, but most of them may be time an…

Why do doctors make so much money?

In the discussion of why American health care is so expensive, it is certainly necessary to entertain the question of why doctors salaries are as high as they are. The average American makes $38,000 a year, and the average primary care doctor makes around $150,000 a year. These numbers vary by geographical region, certainly, and the primary care doctors I talk to in my small Idaho town mostly make less than $100,000. But they certainly do command a higher salary than teachers or carpenters or most university professors at our esteemed and underpaid state university. So why is this?

To practice medicine, a doctor has to finish 4 years of university, 4 years of medical school and at least 3 years of residency as an MD in training. In order to get into medical school, they need to be in the top of their university classes, and have finished a set of premedical requirements that is heavy in science and math. Medical school is an order of magnitude harder than university. The first two year…

Cost shifting--is that why hospitals charge so much?

If health care costs go down significantly, as providers order less unnecessary tests, and as tests and procedures come down in price due to the incentives of actual competition (OK, I'm making a rather huge and optimistic assumption) hospitals will see less money coming into radiology departments and labs. When there are more primary care doctors available to see patients, and patients seek care earlier in the course of their illnesses, there will be less patients seen in emergency rooms, and hospitals will see that revenue go down.

Or will they?

If we truly get universal healthcare, the amount of uncompensated care that hospitals have to cover will be dramatically reduced or completely eliminated. Right now if an uninsured young man is brought into the emergency after a gunshot wound, that man will get top of the line trauma care, with specialists called in, multiple imaging procedures, needed surgery and medications, and the hospital will simply eat those costs. It is not clear t…

Cost transparency--what's not to like?

Cost transparency, that is making sure that patients and providers know what everything costs at a time that is relevant for discussing options, is a great idea. The effects of sharing this kind of knowledge would be powerful. Cost could become part of conversations about what is the most appropriate care. A patient could ask if a particular $3000 test would really change their treatment, for instance. If everyone knew, up front, what things were supposed to cost, billing errors and fraud would be much easier to identify. And when things cost way too much, we could start asking why, and begin the process of making these costs competitive.

There are, however, some pretty serious obstacles to making this information available.

I would like a patient to know, before she even sits down with me, how much her visit will cost. Unfortunately, I don't know. The amount of time and complexity of the encounter, including office procedures that might have to happen, will unfold during the vis…

Why isn't malpractice reform an issue for the democratic party?

Malpractice reform is not traditionally an issue that Democrats support. Why?

I think it is because democrats feel strongly that everyone, no matter how poor or disenfranchised, has a right to his or her day in court.

This is good: we are right to hold on to systems that allow people who have been wronged to be heard. But our tort system does not work in the case of medical injury and malpractice.

Most people with a medical injury never sue for malpractice. Most of their injuries are too small for a lawyer to take the case, and many of the injured don't want to enter into the complex and contentious world of the legal system.

Most cases that go to court are ones in which a person has a very bad and often expensive outcome, in which a lawyer could hope to get an amount of money worth his or her time. Most of these cases have no convincing level of negligence, and so there is no significant benefit for the injured party.

During the time that the case is being prepared, usually a number …

How to fix it

The problem:
Health care costs too much, insurance costs too much, and people are suffering because of money spent directly in bills or indirectly through taxes. Because of the cost of insurance and health care, too few people have access to it.
Scope of the problem:
Huge. Because of the lack of access, America’s indicators of overall health, including infant mortality and average age at death aren’t as good as most countries we consider our peers. Because of the cost, average Americans’ take-home salaries are significantly lower than they would be and federal and state governments are unable to afford other basic services such as education and other social services.
Causes of the problem:
1. Doctors practice medicine that is not cost effective because of worry about malpractice, and perceived patient expectation that costs are not a consideration where health is concerned.
2. The number of primary care physicians is shrinking because primary care physicians are not paid as well as medical…

How to waste over $21,000 before lunch

Health care in the United States is too expensive, and because it is too expensive, a large number of Americans do not have access to it. The story that is not being told in the national debate about health care reform is what exactly costs too much, and how to remedy the situation. Unnecessary costs directly related to the practice of medicine are only a portion of the waste, but the magnitude of this kind of expenditure may be huge. Saving a fraction of this money could make it possible to give health care to everyone who needs it, withhitout any negative impact on our national budget.

The schedule below is a reasonable scenario of what happens in many primary care offices. The costs are inexact, but within range. The major causes for this waste are pretty easy to remediate: 1. primary care doctors don’t spend enough time with patients because they are underpaid for counseling. 2. Providers and patients don’t know what things cost. 3. Doctors are afraid of being sued for malpract…