1. Free Sample?
2. All Fluff
3. Placebo Journal Update
4. Gorback’s Thoughts by Michael Gorback MD
5. Start Writing
6. What Was He Thinking?
7. Placebo Radio
8. Joke of the Month
9. Bacharach’s Beliefs by Ted Bacharach MD, retired
10. In-store Clinics
11. What a Deal (Tenesmus Award?)
12. Not His Fault
13. Feedback About The Placebo Gazette

If you check the most recent issue of the American Medical News you will see some great stuff.  First they report how the Center for Medicare and Medicaid Services (CMS) is touting how great their P4P demo is doing.  This physician profiling was a “rousing success” according to them because for the 30 quality measures they used there was an improvement of 12 percentage points over the first two years.  Top hospital performers, all 115 of them, will get a whopping bonus totaling around $8.7 million!  That comes to an average of $75,000 each or the cost to cover one uninsured patient’s ICU charges (I added this).  The CMS is claiming that this is evidence that  P4P works and will now expand to all hospitals in the Medicare network and then onto all doctors. 

Interestingly enough, a study in the New England Journal of Medicine showed that those hospitals in that weren’t in the demo project mentioned above did only slightly worse than the superstars touted by the CMS. 

In the same AMNews issue, my main man and president of the AMA, again ripped Pay-for-performance.  I recommend you read it as he truly puts up a nice case about how it is all about cost control and not really about quality.  He truly is challenging his members to push back against this whole fad.  This is impressive since doctors tend to be lemmings in areas like these.  I’ve got to give this guy credit for trying to redirect us from going off the cliff but alas, my hunch is that there will be a huge body count at the bottom when the dust settles.

 

We are working overtime to get the next journal ready.  If you have stories just go to our website and submit to get a free subscription (if used).  Otherwise, isn’t it time you read a magazine that made you laugh out loud?  Get your smile back and subscribe to the Placebo Journal.

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I was reading an article in AARP Magazine about eating well. It said that as one ages there is a greater likelihood of being deficient in Vitamins B12 and D, and calcium. They recommended taking daily supplements. Later on in the same article they discussed how the aging body's thirst mechanism starts to fail, and there was a recommendation to drink water even if you're not thirsty. The article suggested that:

"You can monitor your own fluid intake by urine color. If the color is light, you're doing fine. If it is bright yellow and smells bad, you need to be drinking more fluids."

No, AARP Magazine, that's incorrect. If your urine is bright yellow and smells bad it's because you took the previous advice and are ingesting a lot of B12, which makes your urine bright yellow and causes it to smell funny. I can just imagine the panic this article will cause. On second thought, I can just imagine how much hyponatremia this article will cause, with advice to drink water even if you aren't thirsty and keep your urine light-colored.

Disability Forms

"Why are you on Medicare? You're only 37."

"I'm disabled."

"Disabled? I thought you said you lived on a sailboat and you sailed it here yourself from Florida last week. That's over 500 miles."

"Yes, but I am still disabled."

"In what way?"

"It's my bowels. I have to go very frequently. I can't work at a regular job."

[I am NOT making this up. I was actually told this by a woman who wanted disability forms filled out and who was already collecting SSDI.]

A lot of doctors are plagued by disability forms. Most of us have no idea how to fill them out - certainly not when it's not so much inability as hypermotility. I never received any training in disability evaluation, but if I had you can bet that I still wouldn't know anything about it because it's boring, like nutrition. I would have skipped that lecture, just like I skipped the nutrition lectures. Over the years I have managed to cover up that one teensy little area of incompetence by resorting to a simple and time-saving technique, which I shall reveal below.

Let's walk through a typical doctor's evolution in dealing with disability forms:

Phase I. You try to do your best and figure out how many hours a day the patient can sit/stand/stoop/bend/belch/blink/work around bad smells/climb a forklift or whatever. This may be the "purest" way to do it, but it is also the most guaranteed way to generate angry phone calls from the patient ("What do you mean I can work in a pink room? Pink makes my teeth itch! It's in my medical file: Allergic to pink rooms! Didn't you read my records?"). It is also the hardest and most time-consuming method. Given the unfavorable combination of hard work and strong negative feedback, the young doctor quickly learns that this is a suboptimal approach. Also, the only way to make money doing this is to charge the patient, and you feel bad about that because he are already down on his luck and money is tight. By the way, Medicare announced that next year there will be only a 1.2% raise in fees.

Phase II. This involves still making an effort to do an honest appraisal but incorporating the patient into the process with an office visit. It's easier to determine whether the patient can fart while operating foot controls if he or she is right there in the room where you can just ask directly. If you add a physical exam to a disability form I'll bet you could hit a level 5 code easily enough. "Can he climb a ladder?" sounds pretty close to "Social History" to me, and if you write in "No, but his father can" then you have nailed the "Family History" criterion. Another advantage is that you and the patient can make sure you have your stories straight. Of course, the healthcare carrier will end up paying for the disability carrier's forms to be filled out, and that, um, well, that wouldn't be . . . fair. Hey, on second thought screw the healthcare carrier. By the way, Medicare announced that next year there will be no raise in fees.

Phase III. What the heck, if you're just going to be the stupid scribe while the patient tells you what boxes to check, you can have your nurse do that and still charge for an office visit using "incident-to" billing. By the way, Medicare announced that next year there will be no rise in fees and they are instituting pay for performance.

Phase IV. It turns out your nurse hates doing these forms at least as much as you do, and it's clogging up the office schedule. By the way, Medicare announced that next year there will be a 2% fee cut.

Phase V. Let's eliminate the middleman and just have the patients fill out their own damn forms. After all, who knows his or her limitations better? Charge the patient $50 to sign the forms - cash in advance. Believe me, they will not complain. Where else outside the lottery can a $50 investment net you a regular monthly income? Besides, this bastard just lost his private insurance because of disability and he is now on Medicare, which just got cut 2%.

So there you have it. The patient does all the work and pays you $50 for your signature. Which is only fair since your taxes are paying for the patient's Medicare AND the SSDI.

I am vexed on how few people will offer up a diary of a typical week in their practices.  Come on people!  If you are a specialist, or any health care worker for that matter, please send me your stuff.  You can do it.  You know you always wanted to be a writer, so now is your chance.  I want it to be humorous and to have all the gritty details.  It will be published, if I like it, in the Placebo Journal in an anonymous fashion but you will get a free subscription.  You can submit your “Realistic Week in Medicine” here:

http://www.placebojournal.com/shopcontent.asp?type=submitstory

6. What Was He Thinking?

Another steroid scandal just erupted yesterday.  It seems a New York prosecutor has found evidence that some athletes and celebrities were involved in an illicit steroid sales network.  According to the prosecutors, they are not investigating these patients yet but just the producers and distributors of the drugs (read: pharmacists and doctors).  One name that came up was a Pittsburgh internist, Dr Richard A. Rydze.  He is one of seven doctors that work with the Pittsburgh Steelers on game days.  Hmmm.  They found that he allegedly used a personal credit card to purchase $150,000 of testosterone and human growth hormone in 2006 alone.  Why would he use his personal card?  How many regular patients use these drugs in a legal and ethical manner?  Sounds bad for this dude.  What was weird to me was checking out Dr. Rydze resume on the internet.  He was a silver medal winner in platform diving in the 1972 Olympics in Munich, Germany. It is also listed that , “he serves as medical director for the Little Sisters of the Poor nursing home, the Community College of Allegheny County, and the Pittsburgh office of the FBI”.  Yes, you read that correctly, the FBI!  What was he thinking!

7. Placebo Radio

 

 

I’m back.  I am starting to put more stuff on my Placebo Radio.  I have been accused of just wanting to hear the sound of my own voice so many times that I thought you should as well.  How is that for an ego problem?  Anyway, I hope to start posting weekly and my most recent discussion is on “genetic discrimination”.  The “provocative show about health care" can be heard right here:

 

http://www.placebojournal.com/shopcontent.asp?type=placeboradio

8. Joke of the Month

 

 

Canada Pension Plan

Having reached the age of 62, I went to apply for Canada Pension last week.
After waiting in line for a very long time, I finally got to the counter. They verified my age. I looked in my pockets and realized, to my great dismay,
that I had left my wallet on the nightstand in my bedroom. I told the lady that I was very sorry, but I seemed to have left my wallet at home.

"I'll have to go get it and come back later," I said.

At that point, she said to me, "Unbutton your shirt."

I was confused, but I opened my shirt, revealing lots of curly silver
hair.

She said, "That silver hair on your chest is proof enough for me," and, with
that, she promptly processed my application.

When I got home, I couldn't wait to tell my wife about my experience at the
Canada Pension Office. She listened to the whole story and then
said, "You should have dropped your pants; you might have gotten disability, too."

 

 

 

9. Bacharach’s Beliefs by Ted Bacharach MD, retired

 

 

Competency

Once upon a time physicians wishing to enter a specialty were required to take
examinations that were aimed at keeping many out. Failure rates in some
specialties were rather high and there was little pressure for physicians to get a
“certificate”. Probably the lowest paying specialty, Internal Medicine, had one of the highest failure rates. The increased pressure to obtain certified specialists put much pressure on the Boards and passing grades became the normal outcome for most applicants. Having spent the required time in a residency it was natural for the ones who completed the course to expect certification. Boards were really not designed to exclude properly trained applicants. The recognition of board certification as a measure of competency lost considerable prestige. Having completed a residency as well as having obtained a certificate rendered the physician certifiable. The measure of a physician’s ability depended to a considerable extent on his performance. In many communities colleagues and patients soon were able to distinguish the more capable physicians from their less capable colleagues and referrals to specialists were made on the referring physician’s evaluation. Hospital staffs also were critical of each new physician’s performance. Appointment to the medical staff was often conditional and a period of observation for further determination was possible.

The ascendancy of the accountants and administrators in determining policy as
well as staff privileges has altered the way many hospital staffs operate. Many
physician staffs having lost much control do not wish to engage in any activity that hospital administration might not like. The result has been that administration exerts far more control over who is a member of the medical staff then physicians. The physician like many medications has become generic! All surgeons are equally competent as are all other specialists. Even though many physicians believe this is nonsense they are given little choice when it comes to referral patterns. How is the public to determine which physician is best prepared to handle their medical problem? The physician referring them to a specialist for further care is limited by the organization he works for or the group he is associated with. In both instances he may not be a true believer of the system he is required to adhere to. Clinics, hospital and medical groups all engage in extensive advertising. Their hiring practices are based on the fact that a physician has a certificate, not on performance. In advertising their physicians they use phrases like “Outstanding specialists”, “Expert Highly Trained Specialists”, “Recognized Authorities” and so forth. Actually these so described experts often are generic specialists whose qualifications are questionable and who have been ousted from several different positions in the past three or four years. There are no restrictions in the field of medical advertising.  As in all business ventures let the buyer beware.

 

 

10. In-store Clinics

 

 

In-store Clinics, like Minute Clinics, were recently rated by consumers for a study by Forrester Research.  Around 50% pf patients feel the primary reason they go to these places is for the convenient hours and the convenient location.  That was the highest score for all reasons.  About 55% would also use these places again.  Only 7%, however, felt the in-store clinics offered better care than a typical doctor’s office visit.  Forrester Research concluded that convenience, rather than quality, seems to me the most important thing.   Good thing that we are all diving into the P4P quality measure craze.  Even the patients, 93% of them, don’t care about it.

 

 

11. What A Deal (Tenesmus Award?)

 

 

 

Kaiser Permanente placed a 25-year-old employee on administrative leave after he criticized the HMO giant’s $3 billion investment in their Electronic Medical Record system.  Justen Deal sent an email around to 180,000 employees (including the board of directors) detailing the system’s history of problems, lack of accountability, and poor leadership.  You can find the long email on line at http://hcrenewal.blogspot.com/2006/11/kaiser-healthcare-it-meltdown.html. He finished his email stating:

 

“Please, help me fight to protect the future of our organization, the future of Kaiser Permanente, the future of America's foremost healthcare leader”

An article in the San Francisco Chronicle stated that Kaiser Permanente could lose as much $7 billion over the next two years if its operating expenses continue to rise at the current rate.

 

"What I'm doing is working to ensure the waste and abuse stops," said Deal, who lives in Los Angeles. "That's not something you get fired for."

 

Well, Justen, it actually is.  You really can’t send out emails to 180,000 people and think you will get away with it.  I just blame it on his youth.  The administrators have already covered their tracks.  One stated that Deal, “has bits and pieces of information and has managed to construct a theory .. but what he doesn't have is any of the subsequent data about what we're doing to manage those costs".  They have already described Justen as an alarmist.  In other words, this guy is cooked.  By the time it shows that he was right it would take years and then the administrators would cook up some other theory to cover their asses.  I know because I have been there before and have earned some very similar labels as Justen. It doesn’t mean he shouldn’t be nominated for the Tenesmus Award.  What do you think?

 

12. Not His Fault

 

I will rip a frivolous lawsuit any chance I get so when I saw this one I just had to tell you about it.  James Pacenza was fired from his IBM job for hanging out in the adult chat room online and at work for too many times.  Though he was warned, he just kept going back to the well.   Now he is suing for $5 million under the Americans with Disabilities Act.  His lawyer states he has a disease.  You see, James is a sex addict and needs to be in those porn sites because he has PTSD from Vietnam.  I am not making this crap up.   How is it possible for James and the lawyer to go through with this with a straight face?  If he wins this case then there will be an epidemic of patients trying to get disability for this problem.  I mean billions of dollars spent on the internet porn industry can’t be wrong. Can you imagine the future?  The boss will walk in on Jim and tell him, “Oh, sorry to interrupt you.  Go ahead and just treat your disease, but this time can you clean up after yourself”.  Theoretically, wouldn’t Mr. Pacenza need a WiFi enabled laptop to treat his disability during the whole court proceeding.  Now that is what I want to see.

 

13. Feedback About The Placebo Gazette

 

All future feedback will be posted as reviews for each issue.  Please go below and post your thoughts under the WRITE A REVIEW section.

 

Until next time, keep smiling, keep laughing and keep out of the sample closet.

Doug

King of Medicine