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Showing posts from April, 2013

What does expensive care look like and who are the 1% of patients who use over 22% of health care expenditures?

I have been working almost exclusively in hospitals for the last 17 months and I often get a chance to rub shoulders with the 1%, that is to say the people whose poor health puts them in the position to spend more healthcare dollars than the other 99% of the US population.

At the opening speech of the American College of Physicians annual meeting a few weeks ago Ezekial Emmanuel, an adviser to the US Office of Management and Budget and head of the department of Medical Ethics and Health Policy at the University of Pennsylvania gave some interesting statistics. In the United States, 1% of patients at the highest level of medical spending are responsible for 22% of healthcare costs and the bottom 50% of healthcare utilizers use a little over 3%. I looked at the article, from the Agency for Healthcare Research and Quality, and found that this percentage is relatively stable over many years, and, in fact, the costs are slightly less concentrated in the upper 1% than they were in 1996. Al…

How to learn bedside (point of care) ultrasound: tips for the interested internist

I first picked up an ultrasound transducer 17 months ago, at Vicki Noble MD's emergency medicine ultrasound course at Harvard University. I had just barely heard about using ultrasound as a clinical tool and was vaguely interested. The course was 3 days long and cost a little under $700 and changed my life forever and made me a better doctor.

Emergency physicians have embraced the use of ultrasound at the bedside for many years and the vast majority of physicians who complete emergency medicine residencies are competent in using ultrasound for procedures and diagnosis. In bedside ultrasound, the doctor who examines the patient also does the ultrasound, often with a small portable machine, checking out the heart, lungs and other internal organs as part of the physical exam.  Internal medicine physicians have been very slow to pick up this technology, probably mostly because the equipment has been a little too large to be convenient and training to wield the probe and interpret the…

Attending the Annual Meeting of the American College of Physicians in San Francisco 2013: becoming a fellow

The American College of Physicians is an organization of internal medicine doctors, about 133,000 of us, which had its inception in 1915 with the aim of promoting the science and practice of medicine. It is the second largest doctors’ group in the United States, and has members and chapters  throughout the world.  The college has representation in the American Medical Association and influences government health policy.  
The ACP had its annual meeting this year in San Francisco, which is a wonderful place. It was located at the Moscone Center, a big convention hall with gorgeous architecture, and the weather was spectacular. It was right near Chinatown, so I didn't have to eat the overpriced pastries and coffee from the convention vendors, or sell my soul to the devil by eating what the industry sponsors supplied in the hall of evil advertisers. 
I went this year because I was receiving my fellowship in the college. If an internist has been doing medicine for long enough and has…

Hospital readmissions: what exactly is the deal with this?

Medicare has been costing the government a scary amount of money for many years, and the very popular program, established in 1965 under President Lyndon Johnson to pay for health care for seniors, has undergone many changes since its inception. Because the government funded program was a very deep pocket from which the sick could pay hospitals and doctors, it influenced the cost of medicine and the volume of health care in a pretty profound way.

In 1983 Medicare began to pay hospitals for care of patients in a way that was felt to be likely to reduce unnecessary and expensive care. This was the Inpatient Prospective Payment System, the IPPS.  Instead of paying a hospital for everything that was done to a particular patient, which would potentially encourage higher costs and higher utilization of services, Medicare began to pay hospitals a certain amount for each kind of sickness. These categories of sickness were called Diagnostic Related Groups (DRGs). If a patient had a particular…