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Vote Llamacrat!

"So what do you think about the election?"

"So What do you think about Obamacare?"

"What do you think about this healthcare situation?"

I get these questions throughout my day. My patients are mostly suburban and white, so their view is overall on the conservative side. Yet I have found that few see the results of the election as a hopeful sign for healthcare. I don't either.

Anyone who reads this blog regularly knows that I am a "flaming moderate" when it comes to politics. I don't have much faith in anyone who identifies too strongly with one party of the other. I am really angry with congress and their lack of gonads to work on really coming up with solutions. Interestingly, my patients, regardless of their political leaning, agree with much of what I say. Here are the things they all seem to agree with:

1. Congressional politics is hurting us - Members of congress (both sides are equally guilty) are more focused on what is good for their party than what is good for those who they represent. If a democrat is elected to this district, I expect him/her to represent all of the people in that district, not just the democrats (the same is obviously true for republicans). This doesn't mean they must lose all of their ideology, but ideology should be a means, not an end. The reason to hold an ideology is to come to solutions to problems with that ideology as a vehicle. The goal is to help the people you represent through your ideology, not bang them over the head with it.

2. There are many villains in this story - I like to rail against congress (it's a hobby), but the president is to blame, as are past presidents who allowed the situation to get this bad. Obama inherited a bad situation, he didn't create it. Many of the bad things happening were set in motion during the Bush administration (or earlier). Now, Obama's leadership style of letting congress shape healthcare reform has created lots of problems. Then there is the system that lets money influence policy (which has been evolving over a long period of time). Lobbyists for those with money leverage the compulsion of politicians to be re-elected and get what they want by well-placed "contributions."

3. We can't afford to wait - The past two years has proven that even with a very large majority, a party can't get things done without cooperating with the other party. In two years we may get a different president, but is there anyone out there that thinks our government will work any better? If the republicans gain power, the democrats will unite and block anything they try to accomplish. Simply putting a different captain at the helm of a sinking ship won't change the final outcome. Healthcare is a mess, and that mess is getting worse, not better. Gridlock is unacceptable.

4. Our situation is scary - Our government doesn't work any more. The system we have thrives on debate, influence peddling, and party politics. It has survived over 200 years that way. The thing that scares me and most of my patients is the lack of any willingness to work together. If they were in a room with one exit, the democrats and republicans wouldn't agree on how to get out of it. Politics of party is so acute, inflamed by the ideologues on one side vilifying the ideologues on the other, that it seems impossible to get anything significant done. One commenter on my last post suggested that we are seeing the death-throes of our government. If our way of solving problems is screaming and pointing fingers, I begin to agree with that.

What to do about all of this? Do we form a third party? (I would suggest llamacrat as the name of the party). Do we write congresspersons? Do we get pitchforks and torches and march on Washington DC? Do we whine a lot in blog posts, hoping someone else will do stuff?

I don't really know. I do think that congress should be scared, not empowered. The people voted for change in the past 3 elections, which means there is overall dissatisfaction with all involved. Another 2 years of do-nothingness will prove only that our country is in danger. The mandate of this election is a "mad as hell" mandate.

I beg with any politician crazy enough to read what I write: please don't put re-election or party politics ahead of the people you represent. The election was not a game with winners and losers, it was a statement by the American public that you guys are screwing things up. Govern us. Lead us. Take care of us. Fix our problems.

If you don't, the llamacrats will be breathing down your necks.



Different Lunatics, Same Asylum

The top vote-getting answer on my poll about what people feel about the election: Different lunatics, same asylum. We are getting jaded by our system.  Being the "flaming moderate" that I am, I find it hard to hear the substance of the rhetoric on either side, just the shrillness and rancor of the voices. From the physician's perspective, it is very hard to know who to favor in this election.  The democrats seem to love lawyers and hate tort reform, and they also favor an expansion of government.  The republicans love big businesses and "free market," accepting the bad behavior of insurance and drug companies as "the market working itself out."  They both seem hell-bent on sticking it to the other party at the expense of getting anything done - and this in a time of crisis for our industry.

The results of this playground brawl between the two gangs of bullies is that all of us wimpy kids (the ones without power) end up lying bloody in the dirt.  Here are the facts as I see them about healthcare in our country:

  1. It costs far too much.  The top item on the agenda needs to be cost control.  The only way to control cost is to stop paying for things that are unnecessary or for which there is a cheaper alternative.  I know that's not simple as it sounds, but so much of the discussion is about coverage and how things are paid, while the real issue is not who pays, it's what and how much gets paid.
  2. Too much of the cost is hidden.  How much does it cost to see the doctor?  That's an incredibly complicated question.  It depends on the insurance carrier, the doctor in question, the way the doctor codes the visit, and the nature of the doctor's ordering practice.  The same thing is true on a grander scale for hospitals.  Drug costs are hidden by copays (allowing companies to wheel-and-deal to get drugs on formularies).  Insurance companies hide their administrative cost and pass on any increases on to the people buying the policies.
  3. It is totally disorganized.    Nobody knows what anyone else is doing.  As much as people rail against the mandated EMR, the coordination of care will be impossible without it.  We need to know what has been done using clinical information, not billing data.  Up to now the insurance industry has controlled the information about what is done on patients, using the withholding of payment as the club to change physician behavior.  While there is risk that doctors might get screwed with the recording of our behavior, not doing so makes the chance of real improvement nearly impossible, leaving the payors with the data and hence with the most power.
  4. Nobody is pointing out the naked emperor.  It is insane that drugs cost as much as they do.  It is crazy that we pay what we do for technology.  What exactly is it in the 2 day ICU stay that costs $100,000?  Price gouging is rampant because it is allowed (and even encouraged by our system).  Why can a drug company raise the price of a gout drug by 5000%?  Because the FDA lets them.  Why can granny in the nursing home with alzheimer's get put in the hospital and spend a week in the ICU?  Because Medicare pays the hospitals and physicians who put her there.  The credit card bill is shooting up, yet we are not asking why we keep spending so much?
  5. The people with the most at stake are those with the least power.  Patients (and primary care physicians) are the ones with the most at stake.  The discussion is being run by politicians (who don't have to use the plan they pass), hospitals, specialty organizations, insurance companies, and other health-related industries.  Those with money can most influence the process to their advantage, and patients are definitely not the ones with the money.
  6. We cannot afford gridlock on this issue, but that is undoubtedly what we will get.  I have not met one person, liberal or conservative, who is optimistic about the next two years.  We are living with a cancer but are unable to do anything about it.  That cancer is not going to sit around and wait for the politicians to agree, it will spread and will choke out any hope of survival.

I am not too charged up this election season.  It seems that very few people look with optimism on what's going to happen over the next 2 years.  The best thing we can do?  Raise your voice.  Vote in a way that will change the process.  We need to change the asylum and make it into a place where things get done.  We need people with the political gonads to work with others not in their party.  We need more sense and less shrillness.

If we don't get this fixed soon, the patient will be beyond saving.



No T

I've been tired lately.  I've been gaining weight and feeling unmotivated as well.  I thought that maybe it was because I wasn't sleeping enough and was eating too many donuts.

Then my life changed.

I saw a commercial that talked about "Low T" being associated with ALL OF MY SYMPTOMS!!!  It seems obvious that my sleeping and donut-eating habits aren't the culprit.  What luck!  I just need to rub a gel on my body and everything will be great.  I am going to get checked for "low T."

Play this scenario (sans hyperbole) 100 times, and that is what I've been hit with.  Multiply that times the number of PCP's in the US, and you see evidence of very good marketing.  Testosterone replacement for men has become the new magic bullett, a counterpoint to the request for thyroid tests by my female patients - with one big difference: it's clearly safe to replace a thyroid hormone deficiency, but not so clear with testosterone.

Today's NY Times addressed this very issue, comparing testosterone replacement to one-time dogma of estrogen replacement in women:

Despite beliefs based on observational evidence that estrogen therapy enhanced the health and well-being of menopausal women, when a definitive study was finally done, clinicians and researchers were shocked to discover that the risks of long-term hormone replacement could outweigh its benefits.

Would a similar study of testosterone therapy for men experiencing “andropause” likewise reveal more hazard than help? The answer would be welcomed by an estimated four million men in the United States who have subnormal levels of this important hormone, a common result of advancing age.

Yes, I lived through the estrogen replacement therapy about-face caused by the landmark study, The Women's Health Initiative.  The medical community was convinced that estrogen replacement gave a good enough heart disease and osteoporosis risk-reduction that it would easily offset any slight increase in breast-cancer risk.  There was even a retrospective study supporting this hypothesis.  The WHI not only didn't show a cardiac benefit, it showed an increase in risk.  Wyeth pharmaceuticals, the company who makes Premarin and other estrogen replacement drugs (and the company who funded the study) was devastated, and never really recovered.

So now we have commercials for "low T" blasting the airwaves, suggesting a treatment that may not be safe.  Is that ethical?  Again, from the NY Times:

Late last year, for example, a six-month federally financed study of a testosterone gel put a surprising hitch in efforts to improve the lives of aging men who experience a decline in energy, mood, vitality and sexuality as a result of low testosterone levels. The study, conducted among 209 men 65 and older who had difficulty walking, was abruptly halted when those using the hormone had an unexpectedly high rate of cardiac problems.

The article goes on to point out that the evidence is unclear at this point, and that the study mentioned had flaws.  Still, it stirs up the ghosts of hormones past, with the strong possibility that treating "low T" will cause harm.  And at least estrogen therapy had clear benefits (osteoporosis) and studies that supported the replacement therapy.  Unanswered too is if the therapy increased prostate cancer risk (one of the main treatments for prostate cancer is castration, which is cutting the body's production of testosterone almost completely - no pun intended).

So how should I respond to these men who just want a little "get up and go?"  Why is it that I have to fight against a potentially harmful advertising campaign?  What is the service (aside from that to investors) the drug companies perform by educating men about "low T?"  It puts doctors like me in a situation where we could potentially harm our patients.

So what are the limits to advertising by drug companies?  Most people are not in favor of any of such advertising, but the government has so far allowed it.  Are there ethical guidelines?  Consumers assume these ads are being vetted.  I really wonder about this in light of the "low T" campaign that is allowed to go forth despite lack of proven health benefit ("get up and go" doesn't qualify as a health benefit) and significant potential risk.  I had a man with known coronary heart disease recently insist on getting checked for "low T."  I told him that the no matter the lab result, I would not prescribe it for him.  He insisted, and yes, the level was low.

Now his doctor is standing in his way to a better life.

Thanks a lot, drug companies.



Drug Down

I used to defend pharmaceutical companies.  "What companies out there have contributed more good?  Should care manufacturers make more when all they do is make transportation that breaks after a few years?"  It made sense to me that you should put a pot of gold at the end of the rainbow so that companies are motivated to invent more drugs and innovate.  We throw a lot of money to athletes and movie stars who simply entertain us, shouldn't we do better to those who heal us?

I used to say that.  I don't any more.

No, I don't think the drug companies are "evil."  People who say that are thinking way to simplistic.  These companies are doing exactly what their shareholders want them to do: make as much money as possible for as long as possible.  That's what all companies do, right?  They are simply working within the system as it is and trying to accomplish the goal of making money.  To say that they should "sacrifice" is foolish.  They are simply playing by the rules that have been set out there.  Those rules are the thing that has to change.

The system that allows them to charge $200 per month for a drug that does the same thing as 5 other drugs on the market is the real villain here.  The system that does not obey the rules of free-market is what is at fault.  Those drug prices are absolutely killing us - literally at times.  The entire healthcare system operates under a stealth billing system that allows for exorbitant charges.  Why can hospitals charge $10 for a dose of Tylenol?  Because nobody sees it unless they read the fine print, and because it gets paid for.  Why can a company charge $100 for a hemorrhoid cream that has the same things in it that over-the-counter drugs have?  Because insurance pays for it and nobody complains.

It's crazy.  It's how our system works.

Here are my top gripes about drugs and what they cost:

1.  All the drugs in a class always cost about the same. Why do all of the blood pressure, reflux, or antidepressant medications in a class always go for about the same price?  I have never in my 16 years of practice seen two drug companies go head-to-head in a price war.  Isn't that what the free-market system encourages?  Shouldn't competition drive the price down?  It doesn't in our healthcare system.

2.  Drug rebates. Most folks don't realize it, but drug companies pay insurance companies "rebates" if their drugs are chosen for their formulary.  This means that it is often not the real price for the drug or its superiority to the competition that determines formulary status, it is the "rebate" that the drug companies agree to pay.  In other circles this is called "extortion."  "I promise that my friend Vinny won't beat you up if you pay me $10 per week."  And do you think the "rebate" is sent back to the policy-holders of the insurance company in the form of lower rates?  Do I have to ask that question?

3.  Drug Marketing. Yes, the direct-to-consumer marketing nauseates me.  The plethora of drug reps pounding us to use their drug instead of their competitors makes me tired.  I am all for education and for companies being allowed to market.  How could a product be sold if it isn't marketed?  But when the marketing budget exceeds the R and D budget for a drug, something is way off.  The goal is to make a "blockbuster" drug that they can milk for a long time, and so they get docs to prescribe and patients to demand the drugs with the best profit-margins.  This happens because there is no competition between manufacturers on price, it is instead a marketing war.

4.  Patent Extensions. The patent process is supposed to protect the inventor of a product from having the idea stolen and used by someone else.  What the process has become, however, is a game to give companies exclusivity on a drug and hence higher-margins for as long as possible.  The system doesn't protect, it endows.  It turns drug development into a Vegas game with a chance to hit the jackpot if all of the columns line up.

5.  Generics. It used to be simple with generics: since there was no R and D involved, the drugs would be lots cheaper and so would reduce cost.  This isn't the case now.  When Effexor XR and Adderal XR went generic, the companies who made the drugs were granted the exclusive right to make the generic for 6 months.  Yes, the drugs were still made by one manufacturer, and that manufacturer had no motivation to lower the price at all.  There are also a bunch of generics that are priced suspiciously close to the price of the brand-name drug.  Why is that?  How can they be allowed to charge so much when they have no marketing or R and D?  The profit margins must be staggering.  Yes, that is the case.  Check out the generic drug companies' stock prices.  They are very successful.

6.  The FDA. The FDA has been the subject of much ire - some deserved, and some not.  But the presence of people from the drug industry in the FDA, as well as some of their decisions, has made their trustworthiness hard to hold on to.  Why is the generic drug Colchicine (a drug for gout that cost under $10 per month) being taken off the market leaving only Colcrys, a drug that costs $4.50 PER TABLET??  The reason is that colchicine is a very old drug, and so didn't have to go through the rigors of approval for use in gout.  But it works great, and was a very cheap way to relieve gout sufferers' pain quickly.  Now the company who makes Colcrys got its version of colchicine approved for use in gout, making the rest of the drugs "illegal."  They are being forced off of the market by the FDA, leaving a drug that costs 50 times more.  Surely it doesn't cost the manufacturer 50-times more than it did for the generics.  This isn't the first time this has happened, and with the jackpot won by the manufacturer of Colcrys, it will probably not be the last.  What's the FDA's role in this?  They hand out the golden tickets and take away a great medication for people who need it.

If we are going to fix our system, we need to become more transparent in our charges.  We need to make it so we know when we are being gouged, and when something actually costs a lot.  We still need to reward those who do great things.  We still need to motivate companies to innovate and to improve products.  But the nature of the current system turns our healthcare system into a source of quick money for many companies.

We can't expect things to improve until we change this.



Shadow of the Gallows

"It will never happen."

"They know better than to do it."

"They realize the disaster it would be if they let it pass."

That's what I hear.  I hear that the upcoming SGR adjustment, the one that will cut Medicare reimbursement by 23%, won't go through.  In case you missed it, the SGR is a formula coming from the Balanced Budget Act of 1997 that does automatic cuts to Medicare reimbursement.  This year we witnessed a legislative game of chicken in congress, with both sides agreeing that it was a bad idea to screw physicians in a time that they are trying to fix healthcare.  Here's what happened:

On March 3, 2010, Congress delayed the enforcement of the conversion factor until April 1, 2010.[5][6] On April 15, 2010, Congress voted to again delay the implementation and extended the 2009 rate to June 1, 2010.[7] On June 25, 2010, President Obama signed legislation that not only delayed implementation of the conversion factor until December 1, 2010 but also increased reimbursements by 2.2%.[4] The 2.2% increase is retroactive to June 1, 2010, and will expire on November 30, 2010. Barring any further congressional legislation, this will result in a 23.5% decrease in Medicare reimbursements on December 1, 2010. (Wikipedia)

So we are t minus 65 days until we face another congressional battle.  The thing that makes it scary: November 2.  On November 2, our current congress changes its members, making the current congress lame-ducks.  Lame duck, impotent, worthless.  They are the ones who are supposed to fix this once and for all?  They are the ones who aren't going to play political sabotage on the other side?

I was talking with some of my colleagues last week, and the "it won't happen" line didn't work.  They were all depressed, and all making plans to deal with a systemic melt-down.  They talked like men living in the shadow of the gallows.  Plan for the future?  The only way to do that is to stop accepting Medicare, which will be hard to do when 40% of the practice is Medicare patients.  There were a lot of downcast eyes, a lot of frustration.  There was not much comfort to give when the dark clouds are gathering.

Things are about to get worse.

Oh wait!  I forgot!  It will never happen.

Now I feel happy.




The "empowered patient" movement (which I think is a good thing) strives to take the doctor out of the center of care and put the patient at its focus.  The role of doctor is not to be the star of the show, the quarterback, the superhero, but the advocate and helper for the patient to accomplish their goal: health.  Many rightly attack doctor prima donnas who want the exam/operating room to be about them instead of the patient.  This is health care, not health performance. They want doctors who care more about the people they treat than they do about money, praise, or status.

I get it.  I get the message that doctors have to adjust to this new age of patient empowerment and patient-centeredness.  I get the fact that making patients wait is a bad thing, and that communication is as essential of a skill as is medical knowledge - remove either one of them and you don't have care.  I hear the message: doctors should care about patients more than they care about themselves.  That is what we are paid to do, and that is what we have neglected at our own peril.

So why is it, then, that those of us who try to be patient-centered in our care end up getting penalized?  If the days of the doctor-god are over, then why are we still paying premium dollar for those huge egos?  Why do we pay more for technology than humanity?  When I face the continued threat of declining reimbursement (don't forget, then next SGR battle will be over a 30% drop in Medicare reimbursement) I feel angry.  I am the point of care, not cost.  I am cheap. I spend my day trying to keep people well, trying to find cheaper medications for them, trying to avoid expensive procedures and consultants.  How am I rewarded for fighting the tide of spending?  With increased expectations, increased fear of the future, and decreased pay.  I see the gratefulness of my patients, and that keeps me from fleeing altogether; but I also face the callous cuts by CMS, the increased micro-management by the insurance industry, and accusations of being a "greedy doctor" for not wanting my pay cut.

Why is this?  Why is a system that is growing more and more expensive seeing cutting my pay as a means to saving money?  Why not focus on the durable medical goods that solicit business from my Medicare patients, suggesting that they can get "free" commodes and scooters?  In the past few weeks I have done three "mobility evaluations" for people who are trying to get scooters.  They have done this in response to the commercials or direct phone calls from the companies that provide these devices.  Beyond that, I have seen a huge increase in the number of ludicrous requests by these companies who prey on innocent and ignorant patients.  They are leeches.  They are bloodletters removing the life-essence from a dying patient.  Yet their presence is growing.

Why not focus on the generic drug manufacturers who are still able to charge premium prices for their drugs?  It used to be that when a drug went generic, it got cheap.  For some reason, however, things have gotten far more complicated.  I now need to know which are the "cheap generics" and which are expensive.  I need to remember which medications that were inexpensive have been forced off of the market by more expensive competitors (cough syrups and colchicine, a drug used for gout are two examples of this)?

Why not focus on the hospitals who are buying physician groups so they can order more tests in their facilities?  The pendulum has swung now back to the hospital-owned physician groups, with doctors fleeing the fear of SGR and other reimbursement debacles for the "safety" of a salary from a hospital.  The problem with this is that the hospitals are huge consumers of healthcare resources.  Hospitals hire doctors because doctors can send them "business."  In case you forgot, "business" is another word for "spending."  Hospitals are things patients should avoid, but doctors are hired to be a turnstile into the land of medical spending.  I have lived in both worlds, and I am far more patient-focused and cost-conscious than I ever was when owned by a hospital.

We have a bunch of hands being plunged into the coffers of healthcare, and yet we are penalizing those who are too busy caring for patients to do so.  I honestly get depressed when I see all of the waste around me and yet face huge cuts to my reimbursement.  It shows people don't understand.  It shows people don't care.  Do you want doctors who care?  Then put your money where your mouth is.  Stop rewarding the parasites.  Stop throwing money at the turnstiles.  Stop rewarding the spenders.

There are some of us who still care, but it's getting harder to stay that way.



What's a Duck Got To Do With It??

Dear American Academy of Pediatrics: I think there is a mistake.  Kids started coming into the office recently with forms for sports physicals, and the form is different.  See Below:

Someone added stuff to the form!  Not only do we have to continue the inexplicable obsession with the hernia check (for maximum humiliation of boys, we try to use only female examiners for this), there's a bunch of new stuff.  I do understand why we need to check for heart problems, with the risk of hypertrophic cardiomyopathy that can kill previously healthy kids.  But what's this with the femoral and radial pulses?  Yes, I know it is a screening test for coarctation of the aorta, but so is a simple pedal pulse check.  Plus, checking a femoral pulse on kids is almost as bad as a hernia check.

Then there's the "functional" part of the exam.  The kids all think this is hilarious, but we were quite confused.  I never was taught in medical school or residency what a "Duck-walk" was.  I did a Google search and found that it is a brand of wine, but I don't think that's appropriate for a sports physical (you know, with underage drinking being such a problem).

Google also had lots of pictures of Chuck Berry.  I assume his walk in a squat position is referred to as a "duck walk."  So are we supposed to have them do air guitar and pretend to be Chuck Berry?

Would the Chicken Dance be OK?  Most of the kids these days have never heard of Chuck Berry.

Then finally, there's the hopping on one leg thing.  Why would hopping on one leg include or exclude a child from sports participation?  Wouldn't a child who couldn't hop on one leg have a low likelihood of making the team in the first place?  What exactly are we looking for?  I guess if we gave them some of that Duck Walk merlot, they pretty much would do anything.  Come to think of it, I wonder if they were drinking merlot when they made this form.

I wanted to bring this to your attention because it's caused quite a stir among the teens.  They apparently are swapping stories about doing duck walks and are very disappointed with having to do the Chicken Dance.  Somebody thought that hernia checks were not humiliating enough and wanted to share the love with girls as well.

I hope you fix this problem as soon as possible.


Dr. Rob




Chicken - noun - A game in which the first person to lose nerve and withdraw from a dangerous situation is the loser.

This definition is wrong.  As of June 18, 2010, the definition is as follows:

Chicken - noun - A game in which members of congress put Americans in a dangerous situation, with the healthcare system being the loser.

In my lament about losing my Medicare population if the  21% cut went through, Maggie Mahar commented on my post:

Please don't worry about the 21% cut. This is something that the AMA and conservatives use to fear-monger-- it will never happen.

It is a very crude solution to health care costs--even our Congressmen understand this. That is why they never implement it.

On the other hand, moderates are afraid of upsetting conservative voters by killing it. So they just keep postponing it. And then conservatives use the fear of it to advance their agenda with doctors.

But it won't happen.

Well, the government is, at this moment, cutting checks for service I rendered earlier this month that are 21% smaller than in the past.  Despite the fact that the senate passed a bill not only putting off the 21% cut, but actually raising the pay of doctors, the house is not happy with it.

WASHINGTON — The top House Democrat says her chamber won't vote on Senate legislation to reverse a cut in Medicare payments to doctors.

House Speaker Nancy Pelosi says the bill — it would reverse a 21 percent cut on Medicare doctor fees that was imposed on Friday — has to include elements of the Democrats' jobs agenda.

The move by the California Democrat appears aimed at pressuring the Senate to break a logjam on long-sought legislation to extend unemployment benefits and give money to states to help them avoid additional layoffs and furloughs. That bill is stuck on the Senate floor because of a GOP filibuster.

The Senate passed the doctor fee fix as a stand-alone measure on Friday after a GOP filibuster killed the bigger jobs-related measure the night before. The measure would only forestall the cuts — they are required under a 1990s budget-cutting law that Congress has routinely waived — for six months.  (Associated Press)

So as of now, I am being paid 79% of the already low Medicare reimbursement.  I hope Maggie Mahar is right about this being simple political posturing, but pardon me if my trust of politicians acting rationally is a bit weak.  It's a great big game of chicken.

  • The house is playing chicken with the senate.
  • The Democrats are playing chicken with the Republicans.
  • They aren't in the cars themselves, we are.  Doctors and patients are careening toward destruction in the name of political gamesmanship.

Surely they will flinch.  Surely someone will understand the consequences of the crash.  But you know what?  Sometimes each side expects the others will be the ones who flinch.  Sometimes nobody flinches.  Sometimes the cars crash and people are killed.

The longer the 21% cut is allowed to exist, the less shocking it will seem.  The checks are being cut, and the world hasn't ended yet, right?  Patients are still getting care.  Doctors are still earning an income.  People will adjust.


The only thing that is preventing absolute chaos in the system is the fact that nobody thinks politicians could really be this stupid.  But is that really true?  Who will take the political fallout if the 21% cut stands?  The Democrats in the house for not passing the senate bill?  The Senate Republicans who are filibustering the bill the house would accept?  Each side can demonize the other, and each side is insulated by that fact.  Maybe the politicians see the implosion of the system as an opportunity to bury their opposition in the fallout.

But we are in the cars, people.  We are the "casualties" that they will posture about: doctors who lose income, patients who lose doctors.  It will happen.  The longer the 21% cut is in place, the more solid this insanity seems, the more physicians - especially primary care doctors - will simply close their doors to Medicare patients.  We can't "get used to" losing money by seeing people.  It is already happening, and it will gain momentum as this madness continues.

Medicare is fragile, and this cut is a sledgehammer.  It's not evil Democrats.  It's not stupid Republicans.  Conservatives and Liberals are both acting irresponsible.  They're all betraying the trust we gave them.

Trusting congress is more and more feeling like being asked to trust and abusive spouse.  We want to think the best of these people who claimed they meant to take care of us.  We want to think that they understand what damage they are doing.  But sometimes insanity grips people and they stop looking at any needs but their own.  They betray their vows.

Even if this disaster is averted, staying in Medicare feels more and more like we are enabling the pathological behavior of our "representatives."  If they don't pay the political price for destroying healthcare for their own political gain, we all lose.  The gamesmanship will continue and the stakes will get higher.  I am just getting tired of being a pawn in the game.  Averting this disaster will only embolden congress to go further in this game of chicken.

If things don't really change, the cars will really crash.  That's when we all feel the sudden shock when our car meets the other at 100 miles per hour.

Then there is just wreckage.

It's not a game.

People will die.




Would I Quit?

I love being a doctor.  I like my patients (most of them), and have had a pretty good career.  One of the things I say to my older patients is that I want to keep them well enough so I can see them at my retirement party.  I just turned 48, so that would be 17 years... give or take.

Given what I have been reading lately, the "takes" may be getting the edge on the "gives."  Apparently the department of justice and the FTC are getting active in the scrutiny of doctors.  From the Christian Science Monitor (via Dr. Wes):

This case is a watershed for two reasons:

First, until now the Federal Trade Commission, not the Justice Department, has taken the lead in prosecuting physicians. Since 2000, the FTC has brought about three dozen cases against physicians (all but one of which settled without any trial). But the FTC only has civil and administrative jurisdiction; the Antitrust Division has civil and criminal jurisdiction. The Sherman Act makes no distinction between civil and criminal “price fixing,” so in a case like this, it’s entirely a matter of prosecutorial discretion whether to charge the doctors with a civil or criminal offense.

Based on the descriptions in the Antitrust Division’s press release, there’s certainly no reason they couldn’t have prosecuted the doctors criminally and insisted upon prison sentences — and there’s little doubt such threats were made or implied to obtain the physicians’ agreement to the proposed “settlement.”

The second reason this is a landmark case is that the Justice Department has unambiguously stated that refusal to accept government price controls is a form of illegal “price fixing.” (Emphasis by Dr. Wes)

The FTC has hinted at this when it’s said physicians must accept Medicare-based reimbursement schedules from insurance companies. But the DOJ has gone the final step and said, “Government prices are market prices,” in the form of the Idaho Industrial Commission’s fee schedule. The IIC administers the state’s worker compensation system and is composed of three commissioners appointed by the governor. This isn’t a quasi-private or semi-private entity. It’s a purely government operation.

What’s more, the Antitrust Division has linked a refusal to accept government price controls with a refusal to accept a “private” insurance company’s contract offer. This lives little doubt that antitrust regulators consider insurance party contracts the equivalent of government price controls — and physicians and patients have no choice but to accept them.

I must confess that my ADD makes reading legalese impossible (with out the use of a triple Ritalin latte), but the implication of this seems to be that I will be forced to accept what Medicare pays, and that contracts based on Medicare rates will follow suit.  I have also heard it told that lawmakers are considering making acceptance of Medicare a requirement for licensure.

This makes me ask the question: what would it take to make me quit practice?

Let me emphasize that when it comes to job satisfaction among PCP's, I am at least in the top 25%, if not 10%.  When people ask me if I would recommend medicine, I enthusiastically say I would.  At least I have in the past.  I love the job - I don't think there are many better.  But given the very small margins we work by in primary care, I am terrified by these possibilities.  I am a small businessman (no, I am not small; my business is small) who is providing a service and charging for it.  I get dragged around with a hook in my mouth by insurance companies and by government payors, but I do so by choice.  I stay in it, but I always know I can dump them if I choose.

These actions would change everything.  I don't know why people would do one of the most taxing and responsibility intense jobs with the government forcing me to do it cheaply.  It makes me furious.  It makes me terrified.  It makes me consider studying homeopathy and selling herbs for huge profits.  OK, not the last one, but the non-regulated nature of the CAM providers makes me envy their control.  Yes, I am actually starting to envy CAM providers.

I am sure I am not alone in this.  I go home tired every day - emotionally drawn out by the emotional energy of propping up people's lives, comforting their pain, and working to help heal them.  It's a very draining job, but it is also very rewarding.  If primary care doctors are not allowed to be payed in accordance to their true value (the ones who actually save money for the system), the healthcare industry will be in deep trouble.  The patients would be in deep trouble.

Yo, politicians: we are dangling out here.  You are playing political chicken with our futures with the whole SGR issue, but so far you haven't scared me off.  We are having the weight of reducing cost put on our backs and are then we may forced to eat the gruel HHS serves out.  Don't do it.  We are not evil.  We are not in a conspiracy to steal money from the government.  It's not about my Lexus (I drive a used Honda).  It's not about my golfing holidays (I don't own clubs).  It's not about a cushy retirement (I won't go there, but let's just say that I have a lot of work to do in that area).  It's about whether or not I will be around for my retirement party in 17 years.

I may just be selling herbs.



One Big Little Change

It's just plain stupid. Why does the government not allow patients with Medicare part D to use pharmaceutical discount cards?  What is the ethical rule broken by making the government pay less?  What is the legal reason that the elderly should be prevented from saving money?

I know there are probably reasons having to do with discounts not being allowed that are not extended to all Medicare participants, but isn't that a little silly?  As long as the discount is available to all Medicare participants, why can't they receive help from the pharmaceutical industry.

I do my best to prescribe the cheapest medications possible.  I love the $4 list at Wal-Mart et. al., and I try to never use a brand when a generic would do the trick.  But there are times where I have no choice.  These newer drugs are sometimes the only choice we have to help control their blood pressure, diabetes, or pain.  Without these drugs, we end up with worse blood pressure, worse diabetes, and more pain.  What do you think is the consequence of that?  More people:

  1. Develop complications of chronic disease poorly controlled.
  2. Are hospitalized for these complications.
  3. Visit the doctor for management and/or treatment.
  4. Have pain.

What's the complication of that?  More money spent by both the patient and the government.

Come on, you government goof-balls!  The pharmaceutical industry actually wants to do something that will reduce cost to both patient and to the plan paying for their care.  The private insurance companies benefit from this, as do the patients without insurance at all.  It's not a golden ticket that solves all of our cost problems, and there is the risk of people paying more in the long-run if more branded drugs are used.  I know those things.  But I also know that there are a lot of people paying more money and not taking medications they need.  I know that people have complications that could be avoided and preventable hospitalizations.

If a bill was put forward to change this one thing, who would vote against it?  Who wants to go on record against disease prevention and helping the elderly?  Why not let the pharmaceutical companies help?  Really.  I have a lot of privately-insured people getting necessary drugs that they otherwise couldn't afford.

But not my Medicare patients (and Medicaid as well, but that's a bit more complicated).

One little change would make a big difference.  Is there anyone in DC willing to do something so sensible?