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Is the new professionalism and ACP's new ethics really just about following guidelines?

The Charter ( Medical Professionalism in the New Millennium.A Physician's Charter) did not deal with just the important relationship of ...

Friday, September 13, 2019

More very important insights regarding how hospitals make money-by not getting paid

Dr. G. Keith Smith's website is a great source of important insightful information about how not for profit hospitals operate and how insurance companies make money by having higher billed amounts from hospitals. The name non-profit hospital is analogous to dry cleaning.Dry cleaning uses liquids and if non-profit hospitals did not generate receipts greater than costs they would not be a hospital at all for very long.

See here for details from Dr. Smith regarding some of the ways hospital make money.

A few years ago  years ago a not for profit hospital sent me the following bill for a colonoscopy I had . This does not include physician's fee.

Total charge was $2527 and CMS and my Medicare supplemental carrier paid $ 589 leaving $1938 as "uncompensated" So why send me a bill for any amount that they knew would not be paid in its entirety? Thanks to Dr. Smith we have an explanation.

Smith calls it the "uncompensated care scam" which seems like an accurate characterization. To make up for the money that hospital "looses" in uncompensated care ( the difference between what they bill and what they receive) the federal government ( and I believe state governments may have a similar program for Medicaid) has a program known as DSH (Disproportionate Share Hospitals ). Using some arcade formula CMS computes a value that the hospitals will receive for this bookkeeping loss.

The medical insurance companies have their own scam,known as "repricing" in which they receive a percent of the "saving" they obtain for their employer clients by contracting fees for various procedures and hospital charges. The trick seems to be a mark up on the price the insurance company and hospital agree on so that the alleged savings and the reward for the insurance company is higher,

So the more the hospital losses the more they get paid by CMS and the higher the bills the hospitals charge the more the insurance companies make.


Thursday, September 12, 2019

Is it time to stop primary prophylaxis with low dose aspirin

Well, it might be if one construes broadly-perhaps too broadly- the results of a recent systematic review published in the Lancet. See here for summary- registration needed for full text) Also see here for a good discussion and some details of the study.

The authors meta-analyzed some six studies with mega numbers of patient years on the table and basically concluded that in secondary prophylaxis the beneficial reduction in heart attack trumps the risk of bleeding while in those individuals without established diagnosis of coronary disease the bleeding risk appeared greater than the heart attack risk reduction.This study is said to be more informative than an earlier meta-analysis of the same six studies because of access to some individual patient data.

The NCEP formula for heart attack risk estimate is based on data from The Framingham study.The current version of that formula cranks out a ten year risk of 24% for a 70 year old,non-smoking male, with a BP of 140 on blood pressure meds,a total cholesterol of 230 and an HDL of 40. Widely quoted guidelines would all agree that one should recommend low dose aspirin for such a patient. Does the new meta-analysis have sufficiently fine grained subgroup data to alter that recommendation?

An important insight to the data is the following.(quote is from the second link mentioned above)My bolding

This proportional reduction in serious vascular events did not depend significantly on age, sex, smoking history, blood pressure, total cholesterol, body-mass index, history of diabetes, or predicted risk of coronary heart disease. The authors point out that there was not even a significant trend in the proportional effects of aspirin in people at very low, low, moderate, and high estimated risk of coronary heart disease. "If the proportional risk reductions in these different subgroups really are similar, then the absolute risk reductions will depend chiefly on an individual's absolute risk without treatment," the authors comment.

I don't think this is anything new or surprising but the following could be:
They also say that their analysis suggests that the same factors that determine risk of heart disease also determine the risk of bleeding with aspirin, so that, even for people at moderately increased risk of coronary heart disease, the major absolute benefits and hazards of adding aspirin to a statin-based primary-prevention regimen could still be approximately evenly balanced.
So apparently not only heart attack risk increases with increased risk factors but so does the risk of bleeding.
There is an argument that since we now have statins as an arrow in the preventive medicine quiver and they seem so effective and also seem to do; God- only- knows how many other beneficial things maybe aspirin with its precarious and ambiguous balancing of thrombosis prevention and bleeding encouragement might do.

The meta-analysis was published in May 2009 so the most recent guidelines from the U.S. Preventive Services Task Force could not have taken its findings into consideration. This version of their recommendations give different advice for men and women. For men they say:

Men aged 45 to 79 with heart risk factors should take aspirin if the preventive benefits outweigh the risk of bleeding. The trick is , of course, to somehow discern if the benefits outweigh the risk.

Even the practice of using low dose aspirin for primary prophylaxis in diabetes has come under attack. This article in the BMJ makes the argument that evidence supporting aspirin use is weak even though their analysis did show a 43% decrease in myocardial infarction men, but not women.

Doctor, were you wrong then or are you wrong now?

Wednesday, September 11, 2019

"Population Medicine" is not just intellectually empty it is dangerous

Over twenty years ago my partner, who was a very good physician, would occasionally say somethng that puzzled me. He would say  we probably should not  do such and so for a given patient because of the cost to the society or the system. Sometimes he used one word sometimes the other. I let it- go we had a great working relationship which I did not want to damage it  with philosophical discussion in which we would each probably talk past the other.

He was ahead of curve of the philosophy of population medicine- a philosophy that places importance of the health of a group or a collective as opposed to the individual's health which had been the emphasis and the polar star for the physician in the centuries old  physician-patient relationship.

But the health of a group had never been the role of the physician-it was the health or well being of the person acrosss from him in the examining room. The fundamental ethic of the medical profession stood in oppostiton to the notions of population medicine. For the notion of population medicne, which included reference to social justice,and a utilitarian calculus to prevail medical ethics had to be chosen.

Leading the charge for change were a group of leaders of the American College of Physicians  and some like thinking European  internists.

Tuesday, September 10, 2019

Population Medicine is much worse than just a very bad idea

Here are the comments of Apu,owner of the Kwik e Mart after Homer Simpson quite his job there:

"He slept,he stole,he was rude to the customers.Still, there goes the best damned employee a convenience store ever had. "

In a way a free market based society is something like that. With freedom and capitalism there are booms and busts, there are demonstrable inequalities  among various parameters,there is information asymmetry, externalties, and apparent market failures.Still it is the best damned economic, social system a country ever had.

Quoting Deirdre McCloskey speaking on why freedom and markets are better than central planning:.

"How do I know that my narrative is better than yours?  The experiments of the 20th century told me so.  It would have been hard to know the wisdom of Friedrich Hayek or Milton Friedman or Matt Ridley or Deirdre McCloskey in August of 1914, before the experiments in large government were well begun.  But anyone who after the 20th century still thinks that thoroughgoing socialism, nationalism, imperialism, mobilization, central planning, regulation, zoning, price controls, tax policy, labor unions, business cartels, government spending, intrusive policing, adventurism in foreign policy, faith in entangling religion and politics, or most of the other thoroughgoing 19th-century proposals for governmental action are still neat, harmless ideas for improving our lives is not paying attention."

 Those medical progressives who champion the medical collectivism euphemistically referred to  to as population medicine have not been paying attention.

The 20th century made it crystal clear that collectivism does not work.Marx et al promised prosperity and equality by doing away with private property and individual liberty and delivered mass murder and starvation. The greatest welfare program in the history of the world was when Communist China did away with collective farming.

And astonishingly there is a faction of the medical leadership in this country who would institute a system of collective planning in regard to everyone's health  replete with acceptance of sacrifice of the individual to some purported calculable greater health metric for the group.

The very old wine in new bottle is labelled population medicine.

Population medicine is wrong on so many levels.It is antithetical to not only traditlonal medical ethics but also to classical liberal thought as well as Rawlian ethical precepts. It is something that both Robert Nozik and John Rawls would oppose.

His Bundle pacing is no longer the lastest thing in EP,Left bundle branch pacing may be

His Bundle pacing (HBP) is no longer the latest thing in cardiac electrophysiology (EP).Now direct pacing of the left bundle branch seems to be.

HBP is increasing recognized as a safe and more physiological alternative to right ventricular apical pacing. HBP is now part of the latest AHA/ACC/HRA guidelines. (2018).

HBP has been shown to be capable of normalizing the QRS duration and  the ejection fraction in as many as  80% of cases of nonischemic cardiomyopathy with left bundle branch block (LBBB). However, in 20% of cases HBP cannot correct the abnormal conduction pattern at a capture threshold suitable for long term pacing or is not effective because of distal His Purkinje disease.

There have been several case reports of  successful pacing in the left bundle branch in such cases. More recently Dr. Pugazhendhi Vijayaraman from Geisinger Clinc discussed his experience with Left bundle branch area pacing(LBBAP) in 100 cases at the 2019 Heart Rhythm Society meeting. See here.

He reported early success but emphasized the many yet to be answered question and concerns with this new technique. The electrode screw is inserted much deeper ( a centimeter or more) into the heart than with typical HBP pacing and the long term consequences of that are yet to be determined. Early report are encouraging ( lower capture thresholds and good r wave sensing )and hopefully better implantation tools will be developed to improve the process and more long term followup will help define what role LBBAP will have.

Friday, September 06, 2019

Medical scribes may help a bit but will not fix the EHR mare's nest


Some developments have appeared on freeing the physicians from a bit  hegemony of the computer mandates . Back in the old days physicians would often see a patient and  do an exam and then dictate a note, in other words they used a scribe. Enter the computers and the reason for scribes was somehow forgotten and it was thought to be appropriate for physicians to transcribe their own notes  using the computer keyboard.

 The reason for scribes to begin with is explained by the economics 101 notion of opportunity cost. Simply put, the physician's time was worth more seeing the next patient than typing. This would be true even in the unusual case in which  the doc was a better typist that the scribes he uses.The opportunity cost of a physician doing her own typing is too high. Now it looks like the scribes are coming back. My eye doctor has been doing that for years. See here for details on the new scribe resurgence. Of course, this fix  does not alleviate the problem of "meaningful use".Scribes may decrease the amount of time wasted by physicians but the issue of the  mandated or quasi-mandated use of computers not  designed to facilitate physicians' work  is not fixed by this.

Wednesday, September 04, 2019

Why would physicians advocate replacing Hippocratic medicine with Platonic Medicine?

The notion of a fiduciary duty of the physician to his patient is long standing . In the era in which I grew up medically  ( now over fifty years ago) the idea that a physician should be obligated to care for the group of which his patient is a member was not talked about.

I first read about the Platonic notion of the physician as one obligated to provide the best care for a group as opposed to an individual in a series of articles in the Journal of the American Medical Association (JAMA). I make no claim that this was the earliest advocacy but only the first of which I became aware.

A series of articles was published  in 1995 authored by Dr. David Eddy that championed the  merits of decision analysis which he hailed to be a mechanism to increase the quality of medical care while reducing costs. Eddy defined quality as the greatest medical good for the greatest number within some economic medical collective. Eddy discussed the merits of decision analysis but the purpose of his version of medical decision analysis was to bring about a utilitarian outcome, namely the greatest medical outcome for the greatest number. Eddy admitted that there would be winners and losers in such an approach and implied that the group benefits trumped any individual loss or losses.

Dr. Robert Berenson  carried forward the plea for Platonic medicine  in the Annals of Internal Medicine  in 1998  in which he proposes that physicians should be devoted to  the health of the collective rather than the individual patient.

"We propose that devotion to the best interests of each individual be replaced with an ethic of devotion to the best interests of the group for which the physician is personally responsible."

Berenson recommends a replacement of the fiduciary duty of the physician to the patient with a duty to a group .This represents a sea change in medical ethics.

Outside of the HMO setting (or now the ACO) to what group would a physician owe his allegiance ?(Would a retainer physician strive to maximize the health of the city or states in which he practices or the country or what? Berenson's ethical proposal seemed to be aimed  primarily at HMO physicians as in the late 1990s the role of physicians in HMO settings was of concern and the topic for much discussion.


Tuesday, September 03, 2019

I'll pretend to be your doctor,Medicare will pretend to pay me

Has it really gotten that bad? Are things devolving to the point where an application of a version of the following Russian joke is applicable to the changes in medical practice? Russians would say " we pretend to work and they pretend to pay us"?

This off-the-wall thought emerged from two of us perhaps catalyzed by dinner wine, as three retired internists gathered for a meal and pointless complaining session.

One of the three played several roles in my life; partner in an internal medicine practice,consultant when I left that practice, my personal physician until his group practice faced bankruptcy.It was he who remarked about his recent annual check up with a younger general internist who had been his former partner. He was irritarted how brief and perfunctory his physical exam had been. I was able to top that.

My recent annual exam with another former partner from that same clinic was interesting.He had me strip to shorts and put on a open-in-the-back paper gown. He then auscultated my posterior chest and that was it. I could have had an alien creature bulging from my anterior chest or abdomen and it would have gone unnoticed.