Placebo Journal - Medical Humor With A Purpose

Have you heard about the doctor who hit a deer? No, not with his car but while skiing! This dude was flying down the mountain minding his own business when a deer came out of nowhere and they collided. Both got knocked down. Both were unhurt. The deer ran off into the woods while the skier got up, brushed himself off, and finished the run. If you Google “doctor hits deer while skiing” you will see hundreds of articles. The funniest thing is that this physician is my best friend and has been my medical partner for the past 13 years. Check out my book The Placebo Chronicles (pages 160-161) to see him in some interesting poses; none of which include a deer.

When he first told me the story, I predicted it was going to be big. The problem was that he had no interest in telling it to the press. Fortunately a skier, who was on the chair lift watching the whole thing happen, sent his version into the local paper. From there it went to a bigger paper in Maine and the rest is history. It spread like wildfire. The only issue I am having now is that he is becoming a celebrity. He has now stolen my thunder. Usually the Placebo Journal is the talk of the office as I get in trouble for one thing or another. All of a sudden, Dr. Deerlittle is the man. This sucks. I do have a plan, however. I plan to ski over a moose. Even if I have to buy one, drug it up and plant in the middle of the trail, it would be an endeavor worth undertaking. I’ll be back, don’t you worry.

If you haven’t heard, the generic form of Xenical is on its way to a pharmacy aisle nearest you. It has just been approved for being OTC (Over The Counter). In other words, you will be able to buy this weight loss drug without a prescription. Sounds great, right? Well, don’t get too excited. I remember this drug when it was launched for prescription use years ago. Some patients asked me about it and they were very interested when I mentioned that its properties allowed some of the fat you ingested to pass right through your intestines. This, in turn, gave a very modest weight loss. The unfortunate side effect, however, is that some people smudge. What is that you say? Well, did you ever hear that saying, “you’ll be out of here faster than sh*t through a goose”? Same thing. Leakage, my friends, is the issue and along with the fact that it really isn’t a miracle drug for obesity and you have the reason it never made it big on a prescription market. The pharmaceutical company, who makes the medication, thinks the OTC market would be great and they are probably right. Before that happens, however, I highly recommend that they stock it right next to the diaper section. Wait a minute, maybe that NASA astronaut was already using it?

3. Placebo Journal Update

The April issue of the Placebo Journal is now in the works. If you have any stories you want to submit, now is the time. We are especially looking for diaries that would fit our “Realistic Week in Medicine” column. If you are a specialist, I would really love to see what you are going through.

Now is also the time to start subscribing if you want to guarantee to make the next issue. Remember, the Placebo Journal is mailed to your house or office bimonthly. It is the only medical journal that will make you laugh (on purpose) and I promise you will read it cover-to-cover. There is no advertising so we survive on subscriptions from people like you (those with a sense of humor). If you are interested, click below:

I have written before about the ridiculous case against the physician and two nurses in New Orleans. If you don’t remember, Dr. Anna Pou, Lori Budo, and Cheri Landry were charged with the murder of four critically ill patients during the aftermath of Hurricane Katrina. These three poor souls who worked their butts off with no help and limited supplies are now without jobs and paying exorbitant lawyers fees to defend themselves. The Louisiana State Attorney General wants to make an example out of these three because he is convinced that they gave the four patients lethal doses of sedatives and morphine. Like that doesn’t happen in a humane way every single day and in every single hospital in America? Wake up. Anyway, no one is convinced these health care workers are murderers. The conditions in the flooded hospital were horrific. Unfortunately, their lives will never be the same because the DA won’t give up even though the coroner in the case has recently decided NOT to classify the deaths as homicide! Can you believe this? In an eerily similar situation to the DA in the Duke rape case (Mike Nifong), ego has taken over here as well. Something tells me this may be prevalent in their profession. This guy, Charles Foti, has to save face and will destroy people’s lives in order to protect his own ego. I therefore am describing this illness as Nifongitis. The only cure is an injection of humility….STAT.

A Get together of Old Docs

Last week we had a small informal gathering of some of my old colleagues. All of
them are smart enough to be retired. This was the single thing we all had in
common. Our collective health is not too bad and all of us are able to eat and
converse. Three of us were family practitioners, two were internists and all
practiced in our community. This of course was back in the days when physicians
still communicated with each other. Collegiality among the younger physicians has been considerably more problematic. Many of the physicians in practice at this time have financial problems. Disparity of incomes has not been a uniting
influence. The uniting influence of hospital staff membership is no longer a factor.
Hospital administrations have assumed not only the financial aspects of the
hospitals but in many instances have taken over much greater control of the
professional practice aspects as well.

The appetites of our small group were good and adequate lubrication was supplied by a small quantity of reasonably good wine. The conversational drift was diverse but one topic garnered everyone’s attention ——”Routine Physicals”. It seems that all of us have experienced similar problems in obtaining an old fashioned type physical exam. I suppose the fact that routine physicals are not authorized by Medicare as well as many health insurance companies plays a significant role. One member of our group who was not present at this gathering and is still working, had taken the reins and gone to Mayo Clinic where he was able to get a physical for around $8,000.00. The rest of us all seemed a little upset that we could not get a physician to listen to our heart, listen to our lungs and feel our stomachs or listen to our complaints. Removing clothing for a physical examination is apparently excessive and not necessary. The allotted time is too short for such extravagances. Time marches on but a few of us are still mired down in the antiquated standards we once cherished. We were fortunate to have been able to practice medicine in a way no longer possible with the dictates and mandates as well as financial constraints physicians have to live with at the present time.

The Valentine’s Month is upon us, and it is time for the chocolate to start flowing. The big heart shaped boxes will be passed out, ripped in to, and goodies gobbled. Bellyaches, whacked out glucometers, and March cavities notwithstanding, do you ever notice that no matter how good and varied the fillings, everything in the box still smells and tastes overwhelmingly like…chocolate? That’s about the size of things in health policy as the nation finishes its’ collective post-power change sigh. The Dems are busy fortifying their hold on issues for the 2008 race, while the GOP scrambles for ways to recapture the public’s imagination. And most everything will end up tasting about the same.

On the Republican side, the two big health care names are Schwarzenegger and Romney. The governor of California intends to launch a program both bold and broad, in its intent and ramifications. The “governator” seeks to force all Californians to have health insurance coverage through a fun mixture of mandates, taxes, wage garnishes, and confiscations. Business owners with more than 10 employees must cover them OR shell out another 4 percent of their Social Security wages to a state fund to provide insurance for the otherwise uninsured. Patients will have new costs to complain about, as their hospitals attempt to pass on the cost of a tax on 4 percent of gross revenues. Another favorite and noticeably thinner cash cow – the doctors- will each be assessed 2 percent of their gross revenues. Can somebody say “dwindling profit margin”? The governor is hopeful that spending more on Medicaid will trigger more federal matching funds, leading to Medicaid payment increases to doctors and hospitals that will more than offset their new taxes. But the tax is on all doctors, even those who don’t take Medicaid. What do they get back? Schwarzenegger will also forbid insurance companies from turning down applicants, which will result of course in higher premiums and perhaps, a flight of insurers from the Golden Gate State. Add that to the governor’s planned expansion of Medi-Cal (including illegal immigrants?) and the number of patients getting care via the state could rise dramatically. And that in turn, will inflate the cost of private insurance, which will encourage more employers to turn their charges over to the state for coverage. And the governator will also make goo-goo eyes at the notion of preventive care that reduces future costs, and lavish new subsidies accordingly. Michael Cannon of the Cato Institute breaks down the big fraud of Arnold’s cash grab, which will suck in even more money for California from the rest of the nation, but leaves unsaid a more ominous consequence which we will get to in a moment.

A leading name in the GOP primary race for 2008 is former Massachusetts Gov. Mitt Romney, whose plan for universal coverage in his state has drawn mostly applause. The plan is scarred with the compromise expected in a Left-leaning state, but has some features that are innovative. The intent is to cover everyone, with said coverage reaching consumers through (more) market-based approaches. The method is hoped to decrease prices and increase choice, the miracle of capitalism. So far so good. The state will establish a medical stock exchange called “The Connector” to allow small businesses and self-employed to access group plans, and use pre-tax dollars (something not previously possible under Federal law). These actual innovations are explained in an excellent article by Nina Owcharenko and Robert Moffit of the Heritage Foundation. But there are flaws: the state imposes an employer mandate just as Arnold would, which certainly will encourage business owners to make do with fewer employees; Medicaid will expand eligibility to more children, which will worsen the state budget woes, and harm access to families who should be encouraged to pursue the now-more accessible private plans. Another problem is a “pay or play” rule that fines a person who does not buy into any plan at all, which is rather contrary to a basic notion of individual responsibility.

Can Mitt Romney's plan play Cupid between voters and the GOP?

Over on the Left, multi-millionaire trial lawyer and prez wannabe John Edwards is still pumping the old-time religion of class warfare, and his health proposal shows it. Edwards wants a tax hike “on the wealthy” (isn’t it always?) to fund $120 billion new spending. Like the two GOP plans Edwards' proposal would require that every business provide health care coverage for employees or help them pay for it and every American has insurance. And like Arnold and Mitt, Edwards says this is the way to make it cheaper for families and businesses, AND to cover the uninsured. The champion of the little guy would also require employers to cover every worker or contribute 6 percent of each worker's income toward coverage they buy on their own. It seems to escape him that this mandated business cost would simply be passed on to the employees in the form of lower wages, reduced benefits, or fewer raises. Edwards also wants to provide government-funded insurance to all adults under the poverty line and all children and parents under 250 percent of the poverty line. In this he seems impervious to the very real experience of Medicare / Medicaid waste, and oblivious to the basic causes of inflation. And to prove it, he would expand government Medicaid and the State Children's Health Insurance Program. Edwards would require every citizen to get coverage, unless they have financial or religious exemptions (We smell a GREAT loophole…it’s against our religion to be preferentially taxed!). Sen. Barak Obama’s presidential exploratory website tells us …nothing. He has called publicly at a Families USA speech (talking to those socialists tells you enough) for “universal health care” by 2013, but has offered no specifics. President Clinton’s wife is also proclaiming these goals, and even U.S. voter memories should not be so short as to forget her position on the topic.

And what of the current president? In his 2007 State of the Union address, Bush joined all other politicians in calling for the impossible. He described Medicare and Medicaid as “commitments of conscience” and added “so it is our duty to keep them permanently sound.” This is a fiscal and economic impossibility and a fraud, and every member listening to that speech, if not whiskey-addled like Uncle Ted, knows it. Bush wants a standard tax deduction for health insurance where families with health insurance will pay no income on payroll tax of $15,000 (47,500 for singles). Like Romney, Bush seeks to “level the playing field for those who do not get health insurance through their job …[with a] tax savings of $4,500 for a family of four making $60,000 a year.” Bush also wants to free up more money for states which seek “innovative ways to cover the uninsured.” Apparently Schwarzenegger is listening. And of course Bush wants to expand Health Savings Accounts, the only good thing he has accomplished with health care. Then he recited the usual list of “reducing costs and medical errors with better information technology…price transparency…medical liability reform.” The problem with this really lame duck is two-fold. He will not have the clout to pass the tax cut of a health insurance deduction, which the Dems will demagogue as, incredibly, a break for “the rich.” And even if he could get the tax break passed, Bush has already reduced its’ effectiveness by his unwillingness to rein in Medicare and Medicaid. The continuing inflationary pressure of these two monstrosities will continue to push prices above any small initial tax relief. And whatever the White House claims its triumphs to be in terms of competition and cost control, the Medicare Part D giveaway has further institutionalized the entitled greedy attitude of the AARP crowd, and has whetted the appetite of the Dems for more. Their push for Medicare to directly negotiate drug prices is evidence of that.

In his comments on the Schwarzenegger’s plan for California, Mr. Cannon did not name the greater, scarier consequence. Whatever their rhetoric, the Republican, Democrat, and Bush plans all have the same core feature: they reinforce the idea in the minds of voters that employers and the government should be responsible for individuals. In fairness, Romney’s plan does seek to encourage the individual to be more active in pursuit of health care dollar value. But this will be in the context of a new state organ which, as such are apt to do, may grow beyond the intentions of its designer. Couple this with an expanded Medicaid, and rising prices may collapse this program onto the “Connector” scaffold which could be converted into a state-run single payer bureaucracy. Across the nation, Gov. Arnold, Obama, Pres. Clinton’s wife, Edwards, and Bush all continue to lay similar the philosophical and rhetorical framework needed for a truly nationalized system. And then like a stale box of chocolate, the flavor will be uniform and not nearly worth the calories.

As a family doctor, I know very little about neurosurgery. I even know less about a technique called deep brain stimulation. I recently was on a trip with a few buddies of mine; one of them being a neurosurgeon. He clued me in on this treatment and the following summary comes from the National Institute of Neurological Disorders and Stroke:

Deep brain stimulation (DBS) is a surgical procedure used to treat the debilitating symptoms of Parkinson’s disease (PD), such as tremor, rigidity, stiffness, slowed movement, and walking problems. At present, the procedure is used only for patients whose symptoms cannot be adequately controlled with medications.

DBS uses a surgically implanted, battery-operated medical device called a neurostimulator—similar to a heart pacemaker and approximately the size of a stopwatch—to deliver electrical stimulation to targeted areas in the brain that control movement, blocking the abnormal nerve signals that cause tremor and PD symptoms.

What intrigued me more was that my friend has patented a technology that blows away the old stuff. The big and cumbersome stereotactic frames have been the method of choice for performing deep brain functional neurosurgical procedures for the past fifty-four years. It sits around your head looking like a cage. I keep thinking of the George Orwell book 1984 with the guy waiting for the rat to eat his face. This frame-based stereotaxy is accompanied by many difficulties including patient discomfort due to the time it takes to do the deep brain stimulation surgery.

My neurosurgical friend tells me his device (almost 9 years old) has still not got a foothold in the industry. He thinks it is because it is a “destructive technology” or something that would do away with those obsolete but very expensive “cages”; something that other neurosurgeons and hospitals don’t want to do. His STarFix technology, pictured above, are these small looking “starfish” devices directly attached to the skull. The patients are now much more comfortable and the procedure takes only about an hour as opposed to the 15 hours it takes with the cage! As an inventor myself (Knee Saver) I am always intrigued by other ideas. I also can commiserate on how long it takes for a product to gain traction on the market. As a medical pundit, I am distraught that the managed care companies or Medicare haven’t demanded the neurosurgeons around the country make the switch. How much money, operating room time and patient convenience has been wasted? It just blows my mind (pun intended).

The OIG has announced the 2007 work plan. Among other things they are worried that since billing services are paid a percentage of the collections they will upcode the doctor's bills in order to make more money. Let me preface my remarks by stating that I don't run a billing service and I don't use one.

Imagine an arrangement where the billing service did not get a percentage of collections. I guess this would mean they get a flat fee per bill. What happens when people are paid a flat fee? They realize that the only way to optimize their reimbursement is to either do lots and lots more billing volume (and damn the quality of service), or to do the minimum amount of work possible on each bill. What's wrong with this picture? There is no incentive to work the unpaid collections, or fight over underpayments, bundling and all the other nasty things insurance carriers do.

Every billing company I have ever known has done one of two things: (1) Submit the bill as the doctor sent it to them (most common), or (2) review each office note and make sure it meets the criteria for the level billed (much rarer and more expensive). I have never heard of a billing company that upcodes without the doctor's knowledge. Let's face it, there will always be temptation and there will always be dishonest people, but to object to a billing service working on commission is absurd. The billing companies would have far less incentive to fight for collections. That would only, um, well, it would only hurt, you know, um . . . the doctors.

Well, I guess that's settled. There will be a new rule banning billing companies from working on a percentage basis by 2008. You can bank on that, just like you can bank on the pathetic 1.7% raise they are talking about in 2008. Don't you feel like Oliver Twist asking for another bowl of gruel?

Do you have a comment on the Ralph Nader study of malpractice? It was summarized on the AMA morning Rounds webmail. In case you did not read it, they report that 54% of malpractice settlements and judgments are paid by 5% of the doctors (My numbers may be slightly off here, but close). The AMA disputes the study, saying it is based on flawed data, The National Practitioner Data Bank. Have a thought? Where there's smoke there's fire? In my community, in my specialty, this seems anecdotally to be true. We have one guy sued 11 times in 5 years and another one a close second. They both have never won a case. Paid in every one. My partners and I have been in practice a collective 90 years and none of us has been sued. Comments?

I rarely comment on emails or reviews of previous Placebo Gazettes. I find this one, however, interesting. I too have known some physicians who always seemed to get sued. So this is a good point. The problem, however, is that some specialties lend themselves to more lawsuits (OB/GYN, for example). If we remove the high risk specialties then I think you will find some doctors that just plain suck. It happens in every industry. If the intent of Nader’s study was to smoke these docs out and get rid of them then I am okay with it. How do we address the 46% of the cases by the other 95% of docs which may be human error or frivolous? Let’s see Nader do that.

10. New Vaccines Are Going To Kill Us

The following is from Herschel R. Lessin MD, avid reader of the Placebo Journal/Gazette and the Medical Director & Director of Clinical Research of The Children's Medical Group in Poughkeepsie, NY.

I am a pediatrician. Pediatricians are “nice guys”. We would do anything for children, including put ourselves out of business. This is evident by the onslaught of the new vaccines such as Rotateq, Gardasil, and ProQuad. Let me get one thing straight. I think vaccines are the single greatest and most cost effective advance in modern medicine. Their value far exceeds any of the new technology or drugs. I want to give every new vaccine as widely as possible. The trouble is, if I do that in today’s era of “managed cost”, I will no longer be able to give vaccines at all because I will be bankrupt.

In the old days, when vaccines cost $10 each and we were paid $12, that was sort of OK. Now that the cost is $120 per dose, payers still think it reasonable to pay anywhere from the same $2 above cost. They argue that we are making a profit as long as they pay us a dime more than our cost. Anyone who runs a business realizes that this is pure nonsense. If we drop a single dose, there goes our “profit” on the next two dozen doses!! This is not to mention the overhead of giving a vaccine in terms of staff cost, documentation cost, supply cost, compliance cost, time cost and the cost of borrowing the massive amount of money needed to pay for them. The MCO’s say that their generous offer of $5 administration fee should cover these costs. Right…. In fact HCFA has calculated that in NYS it costs $17.85 per dose simple to give any vaccine, irrespective of cost. I get paid that much from Medicaid!. This does not even consider the problems of existing vaccine price increases that are not recognized nor paid for up to a year after we start incurring them. Or for the months and sometimes years it take payers to even recognize that a new vaccine exists, despite the huge publicity build up prior to their release. It’s always “news” to them.

In the old days, there was no money in vaccines and big pharma exited the business in droves. Now there is big money in vaccines and big pharma is back earning record profits. I actually do not begrudge them their profits that much. The trouble is the system has pediatricians paying for them, not insurers. I am expected to lose money on every single dose that I give. In our rather huge practice (22 peds, 7 offices, 32,000 patients), we calculated that it would cost us $2 million to immunize according to the guideline with Gardasil alone. All of this to receive a princely return in 6 months of $2.04 million. I would lose less money by keeping my funds under my mattress, assuming I had $2 million to keep there. But I will have to borrow it, so I lose even more.

I really do want to help kids and to prevent cervical cancer and other really bad diseases. However, pediatricians cannot pay for this out of their own pockets. That is what insurance is for. MCO’s begrudge us $25 to break even, but they are more than happy to pay for multiple $1000 MRI’s when the women get their cancers. But I guess the shareholders don’t care about savings 30 years down the line. To enhance shareholder value and executive payouts, they need to save money now.

We are now placed in the position of being the bad guys in this drama. After all it is the "rich" and "greedy" pediatricians who are refusing to give the shots, not the "altruistic" insurance company, because, as we all know, “they do not practice medicine”. It is unreasonable in the extreme for this to occur and I would hope that someone would see fit to mention our dilemma in their coverage of these new products.

Our academy does very little. I have been quoted recently in a national Associated Press story about this. We should all be contacting our local news organizations to publicize our broken vaccine delivery system. We should refuse to give vaccines at a loss. Because if we continue to do so, not only won’t there be vaccines, there will be no pediatricians to provide care for our beloved kids.

I start back to work as a family doc in two weeks. Part of me is dreading it but the other part is starting to rev up. When I said goodbye to my patients in December, I was allowed to inform them that I would remain local but was not allowed to give any more information. It made the conversations very awkward. Patients, however, are savvy and usually knew much more than I could tell them. Joe G., age 68, comes to mind. I saw him about a week before I left. He had been my patient for 10 years and went through a lot of hospitalizations from many severe illnesses. I was there for them all. I was also there when his wife died about a year ago. It was a very tough time for him. When I shook his hand goodbye, he just smiled and said I will see you on the “other side” which I took as meaning the other hospital I am going to.

As I was reading today’s local paper, I saw a picture of Joe in the obituary section. He “died unexpectedly” according to the clipping. It definitely hit me hard. I really liked this guy. He reminded me a lot of my Dad who, by the way, had many of the same illness and died at about the same age. What hurts me now is that I really wasn’t there for him in the past 6 weeks. I almost feel like I let him down while I enjoyed myself on this sabbatical. I am not sure if I could have helped him but I would have liked to say goodbye. I guess I will have to see him on the “other side” but hopefully he, and my Dad, can wait. I have some more to do before I go.

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