Wednesday, June 17, 2009

Idiots, the Private Insurance Idiots...

No, they didn't fly to Washington on private jets, and ask for money from congress, but the three top insurance company leaders did testify before congress about rescission. Rather than being in tune with the tone of the country, economy, and congress as pertains to health reform, and possibly eliminating the practice, they basically thumbed their noses at the public, and said NO.

What sheer audacity, matched only by it's sheer stupidity. This is not smart practice to begin with, and in this particular climate, it's akin to committing political suicide.


An investigation by the House Subcommittee on Oversight and Investigations showed that health insurers WellPoint Inc., UnitedHealth Group and Assurant Inc. canceled the coverage of more than 20,000 people, allowing the companies to avoid paying more than $300 million in medical claims over a five-year period.

It also found that policyholders with breast cancer, lymphoma and more than 1,000 other conditions were targeted for rescission and that employees were praised in performance reviews for terminating the policies of customers with expensive illnesses.

Thursday, June 11, 2009

The AMA is, if nothing else, predictable.

SO, finally the AMA has broken their silence, and released a press release regarding the possibility of a government backed plan to compete with private health insurance.

I don't think anyone will be surprised by their opinion.


Too bad their relevance is vanishing. Once a proud, vibrant, and powerful organization, they have lost a lot in the way of membership, and their revenues continue to decline.

They did it to themselves, and really have no one else to blame. They have fought against ANY, and ALL change within the healthcare system. First, they labeled physicians practicing in group practices as "communists", then they claimed that a DO's education was inferior, and would not recognize them as physicians, they have also picked battles with virtually every other group in the medical arena.

These acts have diminshed their power, much as the boy who cries "wolf", the AMA is not as respected as it once was. Physicians now overwhelming join their specialty groups. They are becoming what the republican party has. A shadow of their former selves, finding themselves on the outside, trying to find any sense of relevance.

Waste, Taxes, and an inept congress.

As usual, my friend an colleague Bob Laszewski has it right.


From his blog

Most experts estimate that the final health care bill will cost at least $1.2 trillion over those same ten years. It looks like the Democrats are getting ready to propose paying for half the cost of a health care bill with new taxes.

So, out of that $35 trillion we can’t find a little more than a trillion dollars in savings to pay the full cost of a health care bill?

Just taking the $17 billion that government will pay over the next ten years, we can’t find a trillion dollars there either?

Most experts agree that our system costs so much because we waste something like 30% of what we now spend.

At 30% in waste, that would mean that of the $35 trillion we will spend on health care over the next ten years there is more than $10 trillion in waste. Just in the $17 trillion government will spend on health care there would be more than $5 trillion in waste.

Just think about the logic of that for a moment.

It appears we are on our way to a $600 billion to $800 billion tax increase for a health care bill because we can’t find that amount of money in a system that will waste $10 trillion over the same period.


For starters, their is an estimated 60 billion in Medicare fraud annually, that the CMS does little, if anything about. They don't report many of their administrative costs, as they want to keep the illusion that their admin costs are under 2%, yet research done shows that their admin costs, without factoring in fraud and abuse, are actually closer to 5.8%. NOW, add in 60 billion. If we were to simply eliminate Medicare fraud, at 60 billion annually, we would save HALF of the money needed for Obama's healthcare reform plans by that action alone. We would save 600 billion over a ten year period. This isn't even touching on the 30% of waste that is estimated to occur in healthcare spending.

It makes me sick. I agree with Bob, these guys are morons. For, instead of actually DOING something to control cost increases, eliminate waste, eliminate fraud (which is illegal anyway), we are going to simply shift the costs to the taxpayer.

The more I see of both parties, the more I realize that they are simply indistinguishable from each other any more. There truly is little if any difference between them. They are concerned only with the accumulation, and maintenance of political power.

Wednesday, June 10, 2009

Putting it mildly

This article in the Washington Post might be the understatement of the century...


Much of current climate, and the current excitement in the democratic party is ominously reminicsent of the failed Clinton reform efforts of the early nineties.

The only thing that has possibly changed is that the public is likely more receptive, mostly due to the current economic downturn. Unfortunately, the american publics ideological opposition to any and all things government may not engender Obama's plans to the public. Only time will tell if his efforts will be more successful.

Thursday, June 4, 2009


Well, at the academy, I got to see a lot of old friends, and a lot of my friends and colleagues in both academia, research, and the academy leadership. One, Bill Kolhepp, suggested that perhaps I might be a good candidate for an upcoming opening on the NCCPA Board of Directors. This might be interesting. It was a good trip overall, the House of Delegates was relatively quiet. The only item that even engendered any real interest was the debate over the switch to a 10 year re-cert instead of the current 6 year term. It was referred back to committee. Not bad considering that Medical Marijuana was on the agenda, and many of us who have been around for awhile were expecting a lot of heated debate over that.

Got to see old friends, and sat up one evening having drinks with two of the most respected PA researchers in the country. It was a little flattering that they both were quite interested in my opinions, and both are wishing to possibly do projects with me in the future.

All in all, a good trip.

Mayo Clinic and The New Yorker.

Atul Gawande has written a great piece in the New Yorker about the costs of healthcare in this country. For his comparison, he has chosen McAllen, Texas, and of course, the Mayo Clinic in Rochester, MN. My home, and place of employment. The article is


It is a well written piece, and Dr Gawande seems to have an excellent grasp of the facts. I, in fact, chuckled at one point in the article when he describes being a visiting surgeon at Mayo, and being astonished at the preoperative care of one patient. I felt similarly after coming here from Cleveland Clinic, and although CCF is an outstanding instituion, practicing at Mayo is different. I also felt that the conversation with physicians in McAllen was a particularly insightful part of this piece as well. I also agree with him in principle on some of the problems inherent in many of the high cost areas within this country. He is also quite correct when he states that local influence, and/or "culture" is absolutely imperative as a means of cost controls. However, I disagree with his conclusion or assertion that Mayo as a model, is losing ground to more expensive models. I think the current administration's focus, particularly Orszag's, as well as an emphasis on the "Medical Home", Pay for Performance initiatives, and the rising emphasis on Evidence Based Medicine, and quality metrics shows quite the opposite. In fact, in the near future, judging from some of the grumbling amongst the physician community, the "Mayo Model" may become the ideal, a visionary example of excellence in the medical community, not only in the treatment of disease, for which we have achieved considerable recognition, but in the DELIVERY of care.

Make no mistake, there will be resistance, likely considerable resistance, and while there is certainly already some, judging from my conversations with physicians and providers around the country, it will likely increase substantially. The truth may become difficult to hear above the noise, and dogmatic expressions from both side will dominate any real discussion. But, and this is a huge but, IF we can see with clarity, work with purpose, and focus our efforts, real reform may be possible. As I have said on here previously, our problems are many, and many have not even been clearly delineatd yet, however, this should not deter us from striving for true and lasting change. Our patients, and their families deserve nothing less.

Monday, June 1, 2009

Shamu must die!

So, in San Diego, at the conference, I managed to sneek away a few times for a little family time. My daughter, at the tender age of 3, wanted to go to Sea World, which was really cool.

We not only watched the Shamu show, but had "Lunch with Shamu", which for the rather exorbitant price tag should have had prime rib served with a nice bottle of wine, but instead we got a cafeteria style meal, and watched giant orcas swim about us.
This was all fine, fun was had by one and all. A monument, an image in time.

HOWEVER, she has not stopped talking about Shamu now. Like constantly. For days on end. Like to the point where I have been begun to formulate an imaginative strategy for his demise. I am now living in that fantastical world of imagery, and hyperbole. Shamu, your days are numbered my friend.

At least, I hope they are in my household.

Comparative Effectiveness Study...

Alright, so I am back from sunny San Diego, had a good time at the annual AAPA conference. The HOD was relatively boring this year, and got to take in some of the sights.

I am about to undertake the monster, my Moby Dick, the whale that no one wants to deal with. I am about to do, and have submitted for IRB approval, a comparative effectiveness study evaluating the care provided by PA's, working autonomously, vs MD attendings. This, at least to my knowledge, has not been done in the ED setting before, and I am interested in examining the results.

In order to keep the study manageable, and in order to obtain good results, we will be limiting the study to 3 diagnoses.

1. Renal Stones
2. Thromboembolic Events
3. Asthma Excacerbations

I chose these 3 diagnoses, as they all have defined endpoints within the ED setting, and am interested in comparing clinical outcomes, ie; did the PA group treat the patients in the same manner as the physician group?, Were there any missed diagnoses? Was there an increase in complications? etc.etc.
Also, I want to examine the financial impact, ie; we claim to be more cost effective, but is the PA group ordering more tests, and/or unnecessary interventions when compared to the physician group, thereby negating the cost savings?

As my friend, and colleague James Cawley noted, you may find things that you might not like. Which, at least in my mind, is even more of a reason to do this. If we are NOT meeting benchmarks, then we need to know this.

May be interesting.

Also, we have one NP in the group, and she will be included in the study group as well.