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Showing posts from October, 2012

A sort of apology to hospitals, especially little ones struggling to make ends meet

In my previous post I said that an obvious reason why we over-diagnose serious conditions in patients who are not terribly sick is that this results in higher reimbursement to hospitals, "...and when a hospital does well they get remodels with big fish tanks and fountains and flat screen TVs which makes everybody happy."  This gives the impression that hospitals are evil and money grubbing, which is not true. Many small hospitals can barely make ends meet and are absolutely vital to the economic health of the communities they serve. Over-diagnosing and inflating severity are definitely the wrong way to go about making enough money to survive, but it is the strategy they are using now for lack of a better one. 

It is important to change payment structures so doctors and hospitals don't waste their time and energy doing the equivalent of clipping coupons in order to cover costs. Part of the costs that make it hard to survive are the administrative and documentation burdens …

What is health care like in India, why do Indian doctors come to the US and why are so many patients septic these days?

Lately I've been working in an unfamiliar state in a rural, but not small, hospital, and have been noticing all kinds of curious things. This is not the first time I've noticed these curious things so now I am sure that they mean something.

1. There are a lot of Indian doctors, especially in small towns in the US.

2. Small hospitals outside of major metropolitan areas often find it difficult to hire physicians, even though they pay lots of money.

3. There are many foreign doctors in the US who are not employed as physicians. They often work in hospitals but not as doctors.

4. In many hospitals patients are admitted to the hospital when they are not very sick and then proceed to have scads of tests and procedures done that are really expensive and not particularly helpful.

5. People who are not particularly ill get admitted to hospitals with the diagnosis of SIRS (systemic inflammatory response syndrome) which is a kind of synonym for "sepsis". (When I was training, s…

Balancing the budget: how exactly will we eventually pay for health care?

This week the American Medical News featured an article with the disturbing title, "Massive health job losses expected if Medicare sequester prevails." I wasn't entirely sure what a "sequester" was, since I thought it was a verb. Sequestration, I thought, was the noun. (I hear a loud knock. It must be the grammar police.) The story, as I understand it, is that when our government decided to pull together and raise the debt ceiling, they also passed the Budget Control Act, which was intended to reduce the deficit by $1.2 trillion by 2021. This was to be achieved by a bipartisan Joint Select Committee on Deficit Reduction, which would make well considered cuts in funding for various projects. They were unable to come up with a plan that they could agree upon (imagine that) and so automatic across the board spending cuts are mandated to go into effect in 2013, excluding only a few programs, such as childrens' health and disaster funding, and capping yearly cu…

The Ryan Plan and the Affordable Care Act--can market forces improve quality and cost in health care?

In today's New England Journal of Medicine an article by Republican health policy analyst, Gail Wilensky, brought up several excellent points. The article is entitled "The Shortcomings of Obamacare". She points out that the Affordable Care Act does not directly address the forces that have lead to high costs and less than optimal quality in American health care.  She points out that physicians are paid according to a relative value scale that creates perverse incentives to do more procedures regardless of whether they work, and that this has not been addressed by the ACA. She says that if we want to use market forces, putting consumers in a place where they can have an impact on cost and quality of the care they receive, we should look to Paul Ryan's health care proposal.

So I did.
I read the version called "Summary of the Legislation" in a .gov site dedicated to the "Roadmap Plan" that is part of a republican budget. It is much simpler than readi…

The changing nature of truth, answering questions for a chance to win a free MKSAP subscription and should we now stop using warfarin (mostly) for atrial fibrillation?

I am presently really excited about learning all over again what I thought I knew when I finished my medical education about 25 years ago. Since that time I have become wiser, learning how to do things and what works for patients by practicing medicine and reading literature. I also retain a body of knowledge that I absorbed from my grand old doctor professors at Johns Hopkins which is sacred and dear and not necessarily true.

Just recently in my e-mail I got an invitation from the makers of the MKSAP (the medical knowledge self assessment program which I used in studying for my internal medicine boards) to answer a set of not-ready-for-primetime questions in the various subspecialties, for which I will be rewarded with a chance to get the next MKSAP materials for free. I must answer these questions without using outside materials and the answers from all of the folks who do this will be used to standardize the test.

I took the endocrinology section first and had an answer for each o…

Back, but still a bit jet lagged: Health care in the Republic of Georgia

The Republic of Georgia is beautiful, welcoming, has great food, ancient and rich culture, is quite inexpensive, and I am now back. The language is fascinatingly complex, with an alphabet that does not resemble ours in any way, and the capital, Tbilisi, has the feeling of a thriving European city, but there is almost no crime and you can see snow capped mountains and farmed fields if you look up or out. I did no doctoring, but did sit down with a now unemployed pediatrician who told me a bit about their health system. I also talked to other Georgians about how they felt about their health care. Georgians are proud of their wine, their music, their architecture, their food and their loyalty, but they are not particularly proud of the quality of their medical care.

In the Soviet era, before independence, health care was entirely state funded and mainly based in hospitals. After the fall of communism, Georgia was torn apart by the sudden dissolution of their economic system and loss of …