2. Guarding the Funds

Here is a nice warm story for you for the holidays.  Ann Lynn Sorrel reports in the American Medical News that the Governor of Wisconsin is trying to transfer money out of the state’s medical liability compensation to both balance the state budget and pay for more Medicaid programs.  Here is how it went down.  Most doctors in Wisconsin are required to pay into a pool which covers medical liability claims above their minimum $1 million policy coverage.  This was created over 30 years ago to stabilize the liability climate.  It also is a pile of money that Governor Jim Doyle is salivating over.  So much so that he decided to dip into it for about $200 million which ultimately costs each physician an estimated $16K.  The Wisconsin Medical Society is rightfully going crazy over this and trying to block the cookie jar move but the Governor is defending his actions because the “account has plenty of money to spare to help make health care more affordable and accessible for residents”.  Nice spin.  This is like someone coming to your house and pulling out a $20 bill out of your wallet because, well, they want it and you have it.  To me it is also an example of how doctors get suckered into paying for something under one pretense and then getting abused later on.  It is also an example of another unlawful tax on doctors which we all have to stand up against.

 3. Placebo Journal Update 

You missed out on December’s issue of the Placebo Journal. Sorry.  But what about giving the gift of humor to your friends and loved ones, you ask?  Well, we have an answer.  We have created a “poster special” that will be coming your way soon.  Until Dec 31^st, you can receive a free poster for yourself or giftee when you order a gift subscription. You will be getting a separate email about this special soon.

4. Gorback’s Thoughts by Michael Gorback MD

Any gift a doctor receives proves that he or she is a crook, right?  Or could it be that government is pointing their fingers at physicians to cover their own trail?  Here is a counter example of corruption in their backyard:

www.10news.com/download/2006/0218/7171879.pdf

This is the sentencing document for Randy "Duke" Cunningham. Look at page
3 where, on Congressional stationery, he literally wrote out a price list for getting government contracts.

Other candidates would be the Clintons' amazing ability to play the options market, Tom Delay's shenanigans, etc. I think our politicians are, for some strange reason, looking at the wrong people. Gosh, I just can't understand why politicians aren't looking at political corruption. Focusing on whether or not doctors get $50 worth of dinner from a drug rep while our political system is corrupted by bribery on a massive scale is like Congress fighting over flag burning and gay marriage while things fester in Iraq and Social Security circles the drain.

And where is EBM (evidence based medicine) in all this? Has anyone shown that gifts change prescription patterns? Where are the RCTs (randomized clinical trials) for that?

5. Not A Rocket Scientist

A Rhode Island Hospital was fine $50,000 and reprimanded by the Dept. of Health after the third instance of a neurosurgeon operating on the wrong side of the head.  The most recent case occurred when a chief resident started brain surgery on an 82-year-old patient and realized that, whoops, this isn’t his right side.  I may be a lowly family doc but something tells me that this shouldn’t happen.  It is not like a person has two heads!  We only have one damn noggin and the whole basis of neurosurgery is predicated on the fact that you know how our circuitry is wired.  It seems to me that if you are drilling into the skull without a good idea of this blueprint than maybe neurosurgery is not for you.  Try orthopedics.

6. Let The Truth Be Told

In Tuesday’s (11/27) WSJ, there was an article about Medicare proposing an overhaul of hospital reimbursement.  The plan “would essentially redistribute cash by reducing payments across the board and then giving providers a chance to ‘earn back’ money by meeting quality-of-care thresholds”.  There you have it.  Proof.  It was never about “rewarding” doctors and giving them bonuses.  P4P is only about saving money by finding ways to penalize and punish physicians.  And our physician representatives bit into this hook, line and sinker. 

7. Joke of the Week

A new patient was quite upset when the doctor's nurse led him to a small, curtained cubicle and told him to undress.

"But I only want the doctor to look at an ingrown toenail!" he protested.

"Our rule is that everyone must undress," replied the nurse as she handed him a very skimpy Johnny.

"That's a stupid rule," grumbled the patient, "making me undress just to look at my toe."

"That's nothing," growled a voice from the next cubicle. "I just came to fix the phones!"

8. Ridiculous Study of the Month

Did you know that the “higher the percentage of residents in a state who say they can’t afford health care, the greater the prevalence of serious depression and the higher the suicide rate in that state”?  That is exactly what was reported by USA Today on Wednesday Nov 28^th.   In fact the headline ran: Report links higher rates of uninsured and suicide.

Talk about a ridiculous stretch.  Now who do you think may be behind such a report?  Well, Wyeth pharmaceuticals commissioned (paid for) the state-by-state analysis but the report hasn’t even been published yet!   Is that how bad it gets for the media? Now the media is reporting on data that hasn’t even been properly scrutinized and the layperson comes away thinking that because they don’t have insurance they may kill themselves.  Unbelievable. 

What is next?  How about the media report on something I just came up with while reading on the bowl.  In fact this morning I thought to myself that “the higher percentage of residents who live in a state that starts with the letter N, the greater the prevalence of kids with ADD who take medicine that begins with the letter R.”  The headline should read: Farrago’s Toilet Bowl Epiphany Links ADD to Letter N and R. 

You heard it hear first.

9.  More Gorback

The National Committee for Quality Assurance is supporting a model for helping employers and insurers to identify the best primary care doctors, steer patients their way, and pay those doctors for more services than are currently reimbursed under typical health plan payments for office visits.

The idea is to encourage doctors to meet with patients for more than a few minutes during an office visit and to also compensate them, or nurse coordinators, for communicating with patients by phone and e-mail outside office hours, while doctors would also be compensated for helping patients manage chronic conditions - like reminding diabetic people to take their insulin - and would be encouraged to transmit prescriptions electronically, reported the New York Times. Some of the measures have already been accepted by leaders of four primary care professional associations representing 330,000 doctors: the American Academy of Family Physicians, the American College of Physicians - Internal Medicine, the American Academy of Pediatrics and the American Osteopathic Association. Those medical groups have been coordinating their efforts with large insurers, including Wellpoint, UnitedHealth Group, Aetna, Cigna, Humana and the Blue Cross and Blue Shield Association, as well as the International Business Machines Corporation, CVS Caremark, Medco Health Solutions and Walgreen's, the Times noted. Experiments based on the proposed model have been conducted by employers like Boeing, which in a test in Seattle that began last February, is paying for special care for 450 employees and dependents with multiple chronic conditions like diabetes and heart disease, and may expand the program for chronically ill patients to other cities, the Times added.

New York Times, November 7, 2007

Yet another stupid attempt to pay "good" doctors more than "bad" doctors using arbitrary and artificial criteria that have no scientific validity. Where is the "EBM" for this horse hockey? Have these criteria been tested and shown to correlate with improved outcomes? NOT!

I have a better idea: It's called capitalism. If your patients like you and you have a good reputation in the medical community then you will be in more demand and can charge more. You don't need some unverified bullshit criteria from a bullshit organization or an even bigger bullshit insurance company to accomplish that. As for compensating doctors for treating chronic conditions - isn't that already part of the mission statement? We have to pay incentives now for a doctor to say "Remember to take your insulin"?

And paying us to talk to patients on the phone? Why don't we do that now? Because the HMOs and Medicare stopped paying for it, that's why. Now they come with the concept of paying us to do it like it's some freakin' epiphany on the road to Damascus.

Just let us set our damn fees. How about an insurance policy that pays X dollars for a given service and the doctor can charge whatever he or she wants above it? The patients will tell us if we're worth it or not. If your fees are too high you won't have any patients. If you are in huge demand you will have lots of patients even if you charge higher fees. Why do these systems always assume that patients are too stupid to tell if they have a good doctor (well, ok maybe they are), and what makes them think they can improve upon stupid patients with stupid criteria? I can template out perfect charts if I want, but in the end what matters is did I make the right diagnosis and apply the proper treatment? Any idiot can fluff up a nice chart with "Patient reminded to use insulin" and if they try this incentive crap you can be sure that every idiot will.

10. Results Are In  

Remember the Medicare program that had physicians voluntary participate to “quality reporting”.  Well here is the October report from the Medical Group Management Association.  It turns out the Physician Quality Reporting Initiative or PQRI cost doctors a lot of extra money.  Here were some results:

• Approximately 35 percent indicated that they had to create an addendum to their "superbill" paperwork to capture information to report the quality codes.
• On average, practices assigned one employee to the administration and oversight of program reporting.
• Approximately 22 percent required additional staff support.
• Seventeen percent had to increase staff salaries.

Also as a nice reminder of usefulness, the respondents are uncertain about how the reporting of the PQRI measures correlates with an improvement in patient outcomes.  So, as you can see, this is all proof needed for Medicare to go full steam ahead and make it mandatory soon. And it will cost doctors and patients dearly.

11.  Curb Your Empathy

Researchers have found through the use of MRI scans that a physician’s brain learns to edit out emotional reactions to pain during medical procedures.  It seems they are able to shut off the section for empathy and therefore shield themselves from distractions.  An article by Damon Adams did a nice piece on this in the American Medical News.  What was funny to me was how this “quality” was described in such a positive manner.  In fact, one professor describes how this editing process is needed by medical students in order to prevent from being overwhelmed, exhausted or burned out.  While I agree with this, I think the story goes deeper.  In one sense we need to be thick-skinned in order to do our job correctly.  On the other end, we need to be able to turn it off so that we can be more human as well.  That is the trick to surviving in this medical field.  That balance of sensitivity is very hard to learn and partly what the Placebo Journal is all about. 

12. Bait and Switch Plans

Did you know that the average monthly premium from the top 10 Medicare drug-benefit plans went up 21% this year.  Why?  Because insurance companies are greedy and smart.  Their goal was to lure the elderly into their plan in 2006 with low monthly premiums (the bait) and then raise it up soon thereafter (the switch).  They knew that there was evidence that the elderly don’t normally switch plans because they found that last year there was little transferring even though there were programs with better offerings.  With that information, the insurers are set to make some good money because no one is going to call them on the carpet for this.

13. New Relationships

With the holidays upon us, I wish you all the best in both your career and your relationships.  And remember, if your spouse catches being too happy, you just tell them you have Alzheimer’s dementia.  Here’s to you John O’Conner, husband of former Supreme Court Justice Sandra Day O’Conner, for leaving a road map for the rest of us.  Sandra blessed John’s new romance at his Alzheimer facility because he was relaxed and happy.  As many of my friends have said, “Dude this guy gets to cheat without repercussions?  Who wouldn’t be happy?” I tried to explain that it really wasn’t the case and that Alzheimer’s dementia is a devastating disease but it was to no avail.  Now I have friends and patients everywhere getting lost on purpose, forgetting things and pretending not to know their spouses.  Funny thing; they all seem relaxed and happy.

14. Feedback About The Placebo Gazette

I WANT TO KNOW WHAT YOU THINK.  Please go below and post your thoughts under the WRITE A REVIEW section.  You can also see some one of these articles on our blog:

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

Doug

King of Medicine