Thoughts on Obama, last night, and the GOP

Okay, it was a fascinating evening. From a poly sci standpoint, this was a great election.

Several thoughts come to mind..

#1 The GOP is elated and confused at the same time. Why? Cause now they actually have to do something. Eric Cantor was interviewed by Wolf Blitzer last night who pressed him on WHAT exact cuts he was going to make to government. Cantor kept repeating 100 billion over ten years, but was unable, or unwilling to articulate exactly HOW they are getting to that figure.

John Boehner's tearful moment was the most disingenuous, comical thing of the evening. If you had ever met the man, you would realize within a second that that was staged. In his interviews he has stated many platitudes about the American people, and how they trust him, yada, yada, yada, but, like Cantor, when pressed on what cuts he needs to do, he is unable to answer at this time.

#2 Obama has failed in a more massive way than I thought possible. He was downright indignant in his interview today, and unwilling to concede that perhaps he might have been wrong. This better change, or he will most assuredly be a one term President.

His biggest failure is the one I never saw coming with him....COMMUNICATION. In uncertain financial times, tough times, with people losing their jobs, an economy struggling like a newborn horse to get on it's fight, people are scared. For right or for wrong, people are scared, frightened, and he did nothing to help assure people. In these difficult circumstances, people need comfort, they need re-assurance that things will be okay..

Where were Obama's fireside chats? Where were bi-weekly TV addresses to the nation taking tough questions, and trying to re-assure the populace? Had he done this, I think we might have seen a very different outcome last night, but we'll never know.

#3 The Tea Party has rolled in, they officially have candidates in office. From a poly sci standpoint, it will be interesting to see how they, and more specifically, the TP base reacts when they realize that they simply cannot achieve about 80% of their goals.....

What will they do? What will the elected TP officials do when they run into the machine that is DC? It changes everyone, and is akin to running full speed into a brick wall. It is immovable, and massive. What will happen to the TP candidates when lobbying money begins to come their way? How will the base react? Are they going to vote for the debt increase?

For example, healthcare will not be repealed. Not now, and not in 2012, even with a GOP administration. The bill is polling fairly well.

I DO see some tweaking of the bill, and some amendments to it. Likely interstate insurance sales, tort reform, and possibly an attempt to remove the mandate.

Of course, that will only hasten the collapse of the US healthcare system, so part of me hopes that they do it, but it will be interesting to see.

I'm getting a BIG bowl of popcorn, this is going to be a fascinating 2 years of political history to watch unfold before our eyes

Last Editorial....

Thought some might like to see my latest editorial which was published in JAAPA in September.


See HERE

I also have two clinical articles being published in JAAPA soon.

One on Etomidate and Sepsis and one on the use of Steroids in Spinal Cord Injuries.

Aging.....Not liking it

Okay,

So I am "officially" old now.

I was a friends wedding a couple weeks ago back home, and one day, when I was at my family's farm with my wife and daughter, everyone is hungry, and becoming crabby.

Well, the only real option near the farm is a McDonalds. I go there, and surprise, my 17 year old niece is working. She is very nice to me as I go through the drive thru...apparently, after I left. Her manager came over and asked, "Shaynna, why were you hitting on that old guy". Yeah, that was nice. Of course, my wife had to tell all my friends.

Then I return home, and go to see the eye doctor. I've been getting headaches for about 6 months, and found that I was holding papers farther and farther from my face. Yep...

I needed reading glasses. In fact, I've needed them for some time.

Nice.....I hate getting old.

Absence...I'm back

Okay,

I've been gone..lax...lazy....out of mind.

Actually, I've been in the grant writing process. Anyone who has done this in the past, will realize quite quickly how painful this is.

I'm also getting my "Assistant Professor of Medicine" rank.

I've been writing, publishing, speaking at various public venues..etc.

BUT, in the immortal words of the drunk pilot in "Independence Day", I'm BAAAACCCKKKKKKKKK!!!!!!

Health Insurance Premiums passed on to workers this year....

News at 11.

While this years premium increase was lower than in the past (average 10.4% increase per year from 1999-2009)...about 5% higher for single, and 3% higher for family premiums, workers contributions rose to 19% from 17% for single coverage, and 30% from 27% for family coverage.

Interestingly, since 2000, premiums have risen 114%, but the employee contribution has risen 147%.

This is problematic, and is not really addressed in the current legislation. At least not adequately, but only time will tell if the implementation of certain measures will lower preimum increases even further, or stagnate them eventually.

THIS

paper recently done at Kaiser is outstanding, and a must read for those trying to understand this a little better.

Patient perception in the ED.....

THIS

Article was written by a good friend, and it has certainly caused a stir. From the abstract...

Physician assistants (PAs), nurse practitioners (NPs), and medical residents constitute an increasingly significant part of the American health care workforce, yet patient
assent to be seen by nonphysicians is only presumed and seldom sought. In order to assess the willingness of patients to receive medical care provided by nonphysicians,
we administered provider preference surveys to a random sample of patients attending three emergency departments (EDs). Concurrently, a surveywas sent to a random
selection of ED residents and PAs. All respondents were to assume the role of patient when presented with hypothetical clinical scenarios and standardized provider
definitions. Despite presumptions to the contrary, ED patients are generally unwilling to be seen by PAs, NPs, and residents. While seldom asked in practice, 79.5%
of patients fully expect to see a physician regardless of acuity or potential for cost savings by seeing another provider. Patients are more willing to see residents than
nonphysicians.

This brings up the subject of educating the public about various providers, and the various discussions of the principles of ethical assent to treatment.

But there are also some flaws in this study. When we look at the methodology, this was done at only 3 academic medical center ED's. This creates an automatic selection bias. While I understand the intention of the authors to examine patient willingness to be seen by residents, as well as PA's and NP's, it could easily be argued that patient expectations in academic tertiary centers are quite different from those in small, community or rural hospitals. Also, the study was conducted only at hospitals in Pittsburgh, or Dallas. There may be a geographic variation in patient attitudes that remains untested.

While this is an important study, and discussion ABOUT this study is imperative, we must also resist the urge to draw extreme extrapolations from a limited study.

Perhaps a validation study, done in a series of smaller community ED's with no residency presence may yield different results, maybe not?

Also, perhaps repeating this, using the HRSA data to break up the country into geographic regions, and examining one academic, one community, and one rural ED in each area would provide a rich data yield, and would be an outstanding validation attempt.

Just a few thoughts....

Football season is coming soon....

It is almost upon us.....YAY...

OF course I am a Browns fan, so perhaps I should be in mourning.

Jake Delhommw...REALLY????

Mandates.....

So, the election in Missouri came and went....

WOW....Proposition C passed by 71%. Sounded like a major defeat to the health reform legislation, and analysts like myself were scratching our heads thinking, WHAT? Mainly because polling was showing increased support for the legislation with about 50% of Americans supporting the bill (AP polling).

SO, I dug a little deeper, AHA, there it is.....turnout was 65% republican.....which means that (assuming all R's voted against it), that approximately 6% of independents and democrats don't like the mandate.

From this link.

As written on the ballot, voters had to decide whether to “Deny government the authority to penalize citizens for refusing to purchase private health insurance or infringe upon the right to offer or accept direct payment for lawful health care services” and “Modify laws regarding the liquidation of certain domestic insurance companies.”

Prop C did not ask Missourians if they’d like to repeal the entire federal health law (and, just an aside--how was a voter suppose to vote if, say, he or she supported the second statement but not the first?). That would require the ballot to also ask voters if they’re for or against parts of the law that the public approves, like prohibiting health insurers from excluding children with pre-existing conditions. Or banning the practice of insurance companies kicking people off their insurance plans when they get sick. But Missourians weren’t asked to judge these and other popular provisions of the health care act.

Absence

Sorry for all of those that read this, or should I say, USED to read this blog on a regular basis.

Summer came FAST and HARD. School was a bit overwhelming, trying to get two research projects off the ground, trying to get funding, and working. OH, and taking vacation. It left little time for anything else, and something had to give.

Anyway, I'm Baaaacccccckkkk.....

Robert Wood Johnson Fellowship

SO, when I was in DC, I was able to meet with, and talk with several of the Robert Wood Johnson Health Policy Fellows. It is a prestigious one year fellowship (residential) in DC for mid career providers to work ON the hill, and in the Senate and WH, writing the legislation, drafting proposals, leading meetings, and advising the POTUS and Congress.

It's an incredible position, and so far, NO PA has ever done it, it has always been MD's, and the occasional PhD, RN.

Well, to make a long story short, I also got to meet one of the directors who thinks I would be the "ideal" PA candidate with my interest in Health Policy, and my informal association with the Mayo Health Policy Center.

What an opportunity, but alas, I cannot. Family is more important. But I'd be lying if I said I haven't been thinking about it EVERY day since.

Annual AAMC Physician Workforce Research Meeting

So, last week, I was in DC for several things, including meeting with a lobbyist, and several good friends who work in various committees on the hill. I was also there for the AAMC Meeting. It was great.

Contrary to the AAMC's usual position regarding workforce issues (train more physicians), they were very open to discussing teams of healthcare providers. Our AAPA has been working with the AAMC on some research into workforce issues, and they have been VERY impressed with our data. They have been very un-impressed with the NP workforce data mostly because it is so poor at this time.

One of the primary focuses of the talks, and agenda was a discussion of the recent legislation, and it's impact. Some of the absolute top researchers in the country were there, including several Robert Wood Johnson Fellows, as well as representatives of various medical schools. and several top think tanks such as the Robert Graham Center. Many of these folks, like the head of the Osteopathic Medical Association I've known, and talked at other meetings with, some were new to me.

The discussions surrounding Accountable Care Organizations, and the need for good primary care as it's foundation were good, and there were several research presentations dealing with PA's and primary care utilization, including community health clinics. Very positive outlook for the PA profession, and something that we should be very happy with.

One of my research focuses here, is going to be with experimentation in different care and team models, and how can we best design a team. My thoughts are ONE physician, and 4 PA/NP providers, and the preliminary numbers I've run show that this combination can see the equivalent of 4 physicians alone, or close (3.8 FTE by estimation).

Another thing that I learned on my trip, although not at the meeting per se, was that congress is becoming increasingly open to a cause that is very near and dear to my heart. Reducing the pay disparity gap in primary care. This will involve cuts to specialists, specifically interventionalists, and to a lesser degree surgeons, and an increase in pay to primary care. It makes sense, but Congress has been reluctant to involve itself in the marketplace in the past. However, this is one market that is in non pareto, and does not appear to be willing, or more specifically able to correct itself.

All in all, a great meeting, and the PA profession and community should be proud. I got more questions at the meeting, as well as many more after the meeting by email, than I have in a long time about PA training, education, and how can we increase the supply of PA's, and how to implement them into a team based model.

Plus I got have lunch with Len Nichols.....(BIG PLUS)

Kudos to you all, it is your work that has brought about these possibilities, I am but a mere ambassador and researcher.

Academic Medicine....

Most of you know that I live, work, and practice in Minnesota....which has one of the most liberal practice acts for PA's. I can prescribe Sched II-V, and basically do pretty much anything as long as it is allowed in my practice agreement, and is within my physicians practice standards. In EM, that covers a lot.

However, I also practice in an academic environment, which I enjoy for the most part, however, there are some detractions as well. I get to precept MS III's and IV's, and teach the residents occasionally, but too often, procedures will get passed to the residents. Not LP's of course, as I have done more of those than I ever care to think about, but chest tubes, intubations, and central lines often get re-assigned to the residents. I understand that they need to complete so many, as part of their training, but sometimes I like to do those things as well. At my other ER's I occasionally do them, and as I usually tell PA students, knowing WHEN, and WHY you want, or need to do these procedures is 1000 times more important than actually doing them.

I'm also heavily vested in research, particularly physician/medical workforce issues.

Occasionally, however, my faith is rewarded. Recently I got to do an elective cardioversion in the ED. Propofol sedation, Fentanyl, 100 joules biphasic, and BAM....NSR.

At another ER, I recently had to intubate someone as well. So, while the opportunities may be more limited than some of the EM PA's who work in non academic environments, I am for the most part, happy as a clam at mine.

Interstate Insurance competition.....

Another fancy reform gadget that is thrown around by both parties is the concept of “increased competition”, as if Adam Smith’s magical hand will wave over the marketplace and prices/premiums will magically lower. It is not true for a number of reasons, but a real discussion of free market economics in healthcare can wait for another day. Today, we will discuss insurance competition. There is much to discuss, although interstate competition has not been allowed, there is often substantial instate competition.

The health insurance market has been traditionally regulated in a federalist model with each state being responsible for various regulations, including coverage limits, financial solvency of both the individual, as well as the insurance company, and to help protect against fraudulent behavior, ensuring that members/enrollees are provided the benefits as promised. State regulations have also imposed rating, and rate banding legislature to prevent health insurers from charging too much for certain “high risk” patients (Kofman, Pollitz, 2006). Additionally, there is variance between states as pertains to a “guarantee of issue”, as many states have different qualifications, this could potentially destabilize the market by causing an asymmetry, as sicker patients would not likely qualify for out of state insurance, while healthier patients could opt for cheaper out of state plans. Kofman and Pollitz also describe how the detection, and prosecution of fraudulent activity would be quite difficult, and might even raise some state constitutionality issues when trying to enforce different state laws. This creates a murky situation at best, and potentially exposes many patients to fraud, and potential predatory pricing tactics, as well as many companies to unfavorable market conditions. As mentioned above, another potential problem that arise with sales of health insurance across state lines, is the risk of creating an adverse risk pooling. Health insurance, like any other insurance commodity, relies on pooling of risk, meaning that costs need to be spread across both sick and healthy people in order to maintain a stable economic foundation. By allowing the sale of insurance across state lines, out of state insurers will get to “cherry pick” individuals, and because there is no guarantee of issue for an out of state transaction, healthier individuals may be offered lower rates than they can obtain locally, while sicker individuals will be denied coverage. This will result in the in-state insurers covering an increasing percentage of sick individuals resulting in an adverse risk selection bias. This will undoubtedly cause prices to rise in-state, and overall health insurance premiums will increase as a result. This is especially important when we realize that only 5% of our population accounts for 49% of healthcare spending (Stanton M, 2006). By denying insurance companies that ability to pool risk, and to spread healthcare costs throughout a specific population, they will have no choice but to increase premiums for those who are sick, or have chronic medical conditions. When we examine the interstate sales of health insurance, it appears on the surface to be a good idea, however, real time examination of current markets may reveal otherwise. An important concept in financial exchanges is leverage, and companies and institutions will attempt to use whatever leverage is available to negotiate better financial terms. In healthcare, this frequently occurs between health insurers and healthcare providers/institutions. When one party gains leverage on the other it is used to either raise, or lower prices depending on the entity involved. When we look at certain markets, as BNET reported, for example Milwaukee, where there is no dominant insurance company, leverage is given to the healthcare providers and hospitals, and many physicians will not accept less than 200% of Medicare rates, in contrast to a nearby city like Chicago, where typical payments for private payers are only 112% of Medicare rates (Terry K, 2009). Which raises an interesting dilemna.

Providers in the example provided via BNET, are actually driving costs higher, due to decreased market share in the insurance industry. I got all excited, and actually though of doing this as a full on study, using the Herfindahl index and getting to play around with some fancy math, but the NBER beat me to it...unfortunately, they found that an increased concentration in the marketplace, could only account for an increase of 2% in premiums over an 8 year time span, with health insurance premiums rising an average of 10% or more per year over that same time period.

PAPER HERE
We examine whether and to what extent consolidation in the U.S. health insurance industry is leading to higher employer-sponsored insurance premiums. We make use of a proprietary, panel dataset of employer-sponsored healthplans enrolling over 10 million Americans annually between 1998 and 2006 to explore the relationship between premium growth and changes in market concentration. We exploit the differential impact of a large national merger of two insurance firms across local markets to estimate the causal effect of concentration on market-level premiums. We estimate real premiums increased by 2 percentage points (in a typical market) due to the rise in concentration during our study period. We also find evidence that consolidation facilitates the exercise of monopsonistic power vis a vis physicians, whose absolute employment and relative earnings decline in its wake.

Let's talk tort reform....

Lot’s has been said about the holy grail of tort reform by those in the medical field. The problem is, most of it isn’t true. Physicians and providers are very good at assigning the blame for rising costs on every one else. We are good at describing the “evil” insurance companies, and “greedy” pharmaceutical companies (partly true here), and those “bastard” lawyers. However, this blame game ignores the fact that while all of those players are culpable to a degree, it is the provider that also shares a significant amount of blame for cost increases.

Tort reform is currently the shiny object over in the corner of the room. That’s not to say that it can’t help, but the latest CBO estimates are a savings of 54 billion over ten years, or roughly 5.4 billion per year. In a 2.4 trillion dollar healthcare system, that doesn’t amount to much. Latest estimates are 0.5% savings. I would posit, that perhaps it might be closer to 1% once defensive practices are slowed. However, I don’t think the CBO is too far off here.

Let’s look at Texas, in 2003, they introduced the most aggressive tort reform legislation to date in the US. It is true that this reform, after 2003 lowered malpractice premiums, and increased physician supply to the state. However, Texas, since 2004 has seen a growth in testing expenditures that has outpaced the national average by more than 50% (Arkush, Gosselar, Hines, Lincoln, 2009). Additionally, the same report found that Medicare spending per patient had doubled between 2003 and 2007, in contrast to the decline in Medicare spending that was noted prior to the laws enactment. They also found that Texas has the highest rate of uninsured patients in the country, both prior to the law, and accelerating after the law was passed. The additional physician presence has only increased because of an increasing population as well, and there was only an increase of 0.4 physicians per capita after the law was passed. In addition, ACEP gave Texas an “F” on access to emergency care in 2009. Lastly, the National Board of Economic Research (NBER) commissioned a comprehensive study, which concluded that a targeted reform may have some impact, but that overall, it would be neglible (Lakdawalla, Seabury, 2009). Additionally, they found that for every 10 percent reduction in medical malpractice costs related to liability, there is a 0.2% increase in patient mortality. The NBER article is particularly poignant, and I have posted the summary here, as the article is 60 pages long, and the economic math is quite intensive.

HERE

The impact of liability for medical malpractice on the cost of medical care has been one
of the highest profile issues in debates over the U.S. health care system for many years.
Malpractice payments have grown enormously over the past 15 years, but this has likely had a
modest impact on the cost of health care in the US. It may have other significant effects, such as
decreasing the supply of physicians or changing the nature of treatment. Our findings, however,
suggest that limiting malpractice liability is no panacea for rising health care costs.
Moreover, while the mortality benefits of malpractice may be quite modest, these seem
more likely than not to justify its direct and indirect health care costs. Therefore, we conclude
that — for values of statistical life traditionally employed by US regulators —reducing
malpractice costs is not likely to be a worthwhile policy goal in itself. As emphasized by Currie
and MacLeod (2008), however, specific policies must be evaluated on a case-by-case basis, as
they can have unexpected effects on physicians’ expected liability and incentives. In addition,
there may be policies that reduce malpractice costs but have other social benefits; we do not rule
those out, but note that the case for their adoption rests on their auxiliary effects.
At a minimum, our analysis reveals the tenuousness of the case for tort reform, but it is
important to note its limitations. First, we account only for impacts of tort reform on medical costs and mortality, excluding its impacts (if any) on morbidity, physician utility, and patient
satisfaction. These quantities are extremely difficult to measure objectively. In addition, we do
not account for the adjustment costs (e.g., on the utilization of the health care system) that would
be induced by any large-scale reform project. The size and even direction of these excluded
effects is not clear. Finally, even if we ignore these limitations and accept the estimates at face
value, the probabilistic nature of our analysis means we cannot rule with (even approximate)
certainty for or against tort reform over conventionally accepted values of life.
Putting our results together with earlier work suggests that malpractice may have
substantial impacts on the care and costs of specific patient subgroups — like heart attack
patients — but much more modest impacts on the average patient, and on health care spending as
a whole. Future research should endeavor to determine whether tort reform can be targeted
toward these subgroups in a cost-effective manner.
Another important avenue for future work is to evaluate whether malpractice has effects
on more fine-grained outcomes in the health care system, such as morbidity, disability, or the
nature of care delivery. Medical costs and mortality are likely to be the first-order costs and
benefits of changes to the malpractice system, but the auxiliary effects may be quite significant.
If, for example, malpractice risk has had limited impacts on costs but appreciable positive
impacts on average outcomes other than mortality, the malpractice “crisis” may be anything but.
If, on the other hand, it has negative impacts on outcomes, the major costs of malpractice may be
in health rather than in dollars.

Real Effects of the legislation.

I got this email from a friend who also works in the health policy arena. I thought is particularly poignant, and obtained his permission to post it here. It is sometimes easy to get lost in the data and statistics, and forget, that there are REAL people out there, and this will have REAL effects.

I turned on the television tonight and saw a newsflash that the last vote had been taken on health care reform. For some reason it hit me – the sheer magnitude of the events of the last week, the last few months, and the last few years.

It made me think of my dad. Born in 1952, he has lived his life with a form of muscular dystrophy that has deteriorated the muscles in his legs. He has lived his life as a hard working farmer, as the sole owner/operator of an auto body shop, and as the best role model I’ve ever known. Considering his medical condition and his line of work, he has always had to purchase his own insurance – and has never been able to afford it.

No insurance plan would ever cover my dad’s condition and he has never received the kind of therapy that he truly needs.

He has now applied for disability as he is no longer able to work, an incredibly difficult decision for a proud, hardworking man. He is only months away from spending the rest of his life in a wheel chair, and this would have been preventable if he only had access to medical care.

The work that we have done, and the work that we will continue to do, is important as it truly impacts people’s lives.

With the new health care reform legislation, my dad now qualifies for the immediate high risk insurance pool until he is eligible for Medicaid, and is approaching Medicare eligibility. But, more importantly, millions of individuals like my dad will now be able to afford insurance and seek high quality health care from the finest medical institutions in our great country, and never reach the point where they are on disability and have to give up their livelihood.

My sister, born in 1981, has the same muscular dystrophy as my dad, and is currently uninsured. She will now be able to afford insurance through the exchange and receive the type of therapy early in her life that my dad was never able to afford.

My family owes each of you a debt of gratitude, individuals and families across this country owe each of you a debt of gratitude, and I am proud of what this team has accomplished.

I am going to celebrate. You should celebrate. And we should celebrate this historic accomplishment together.

I honestly believe that every day of our lives is a momentous day, and considering how many individuals like my dad and sister who will truly benefit from this health care reform, this is especially true of our collective days over the last few years.

Thank you for all you’ve done and all you continue to do. And thank you for the continued dedication we will all carry with us as we enter a new era of health care reform.

Josh

Healthcare Reform Talk....

Well, I had to give a talk at the national SEMPA meeting this past Wednesday on "Healthcare Reform: Where are we now?" It was quite interesting. I arrived in Tucson on Sunday evening to find many of the other providers I know surrounding a TV in, of all places, the bar. They were watching the vote, and when it passed, a cheer erupted, with a few simultaneous groans. The president of our organization turned and looked at me with a grin, and said, "Well, I bet you have a little re-write to do" Ummmm. Yep. I almost asked if security would be provided. Holed up in hotel room I proceed to re-write and amend my initial talk. I was prepared, ready for an intense, emotional, intellectual debate. Unfortunately, attendance was small. I think this is because many were either so happy, or so angry that hearing anything more about it would be too much.

The talk went well.

Healthcare Insurance Reform...

The most groundbreaking, and comprehensive reform in healthcare was signed into law by President Barack Obama today, less than 48 hours after the house passed it. One side is decrying the legislation and claiming the ruination and destruction of the known universe. The other side is claiming that healthcare reform has finally been achieved.

As usual, they are both wrong. There are three distinct and separate components to healthcare reform, and this only addressed one of them. By no means, am I trying to diminish the symbolism of this achievement, but would rather caution that this is but the first ten miles of a grueling marathon.

I noted that President Obama was careful with his language today, and called this the "most comprehensive piece of health insurance legislation ever passed".

We still need to address healthcare financing reform (ie; how do we PAY for healthcare?) which this does to a very partial degree, but only through subsidies that remain somewhat murky as to the details of their financing.

The biggest hurdle, is perhaps the most important one. We desparately need healthcare delivery system reform. We need to reform the way that care is delivered. We need to develop strong comparative effectiveness data. We need to reduce the primary care income disparity gap, and we need start paying for value. We don't do this now. We pay for volume. We pay for quantity, not quality.

So there is still much to be done, and I will be on the front lines, carrying the banner of the PA profession into the fray.

Recent Study by Macy suggest changes to PA legislation...

This was a good workforce study recently completed by the Macy Panel, which as part of their conclusion suggests:

Coupled with efforts to increase the number of physicians, nurse practitioners, and physician assistants in primary care, state and national legal, regulatory, and reimbursement policies should be changed to remove barriers that make it difficult for nurse practitioners and physician assistants to serve as primary care providers and leaders of patient-centered medical homes or other models of primary care delivery. All primary care providers should be held accountable for the quality and efficiency of care as measured by patient outcomes.

I like their conclusions....

The complete study can be found HERE

Interesting Ideas concerning PA evolution....

FROM a PA who went back to the Medical School, and became a physician. I don't see it happening, but interesting nonetheless.

PA’s are as diverse in personality, background and desires as the sands of the sea. A young PA will have differing opinions on various subjects than an older PA. Times change, exams change,people change but human beings are basically competative by nature. Anyone ever run a race to come in second place? My comments to you all are very contemporary, political but with “YOU” in mind. I recently spoke at a conference where a group of NP’s addressed a fellow DNP by the title Doctor. I was recently at a rural clinic where an older PA and a younger PA apparently had issues with a Doctorally trained PA using the titile “Dr.Jones the associate Physician” I didn’t have a problem with that but the two PA’s apparently did. My goodness the PA had a Doctorate degree in Public Health and 18 months of residency training under his belt and I as an MD would not insult this man, brush aside his skills and great bedside manner to consider him my assistant but rather my associate.

To the gentleman who erroneously states PA’s are not considered second class medical citizens check this out and then tell me what you think, then I will answer Daves question as to what the profession needs to do. I propose a scheme for PA’s that would answer the question of why some people got into the medical field and not the PA profession particularly. I think outside of the box so my proposals take into account the group that loves the assistant role and being supervised versus the group which recognizes the practice of medicine boils down to good training and a lot of experience, not a “HAZING” process of brutal medical school training with 3 years of inhumane residency slavery.

Proof that the medical community sees you as second class citizens.

The Michigan state medical board without letting you all know, listed podiatrists as supervising physicians of PA’s. How respected is the PA profession when foreign-trained doctors working in Federal facilities can get a PA license without any didactic or clinical training in a PA program? see

http://www.aapa.org/policy/unlicensed-med-grads.html
http://www.bop.gov/jobs/job_descriptions/physician_assistant.jsp

When a medical organization accepts a model of licensure that designates its practitioners as lifelong “interns/residents” needing supervision,(Post Graduate year 1/2 medical students). That profession is doomed to accept practice guidelines involving supervision by “any” independant healthcare professional, (podiatrist).

Statement by AMA to increase medical student seats to increase the primary care force. PA’s are not even considered a viable option. Physician workforce shortage: Yes, no, or maybe? e-mail story | print story In the March 2005 issue of the GME E-letter, we wrote, “It appears we are facing a national shortage of doctors. This shortage is currently confined to some regions and specialties, but the bulge of aging baby boomers threatens to widen the gap. “The Association of American Medical Colleges (AAMC) has called for a 15 percent increase in the number of medical school graduates by 2015--but that won’t solve the whole problem. We will need more GME positions as well. “To be feasible, this expansion will require removing the current caps on the number of federally funded residency positions as well as finding additional funding sources for GME. But how should these residency slots be distributed geographically and among the specialties? And how should we develop national policy on medical workforce issues such as these?”
http://www.ama-assn.org/ama/pub/category/14908.html

So when a Doctor gets disciplined or has his/her license revoked and the state medical board publishes this statement;

“Dr. John doe was placed on 2 years probabtion and is prohibited from SUPERVISING PA’s and NP’s”

So when those PA’s/NP’s just lost their job because of the MD’s incompetence and the underlying tone of such statements imply that a PA/NP can’t function without the valid,unrestricted license of an MD I have 2 questions;

a) Why then do you have PA/NP licensing agencies?
B) Why take exams,do clinical rotations,take CME’s or even have conferences?

Dave it was a Doctor who created the P.A profession now the PA’s should move the profession forward by doing the following;

1) Change your title to “Associate Physician”. The word Assistant in 33 standard dictionaries means “Clerical”.

2) Create a Doctorate Associate Physician (DAP). Read the history of DO’s then you will see that this just follows an already established precedent. A DO colleague of mine once said that “MD’s may look down upon me because I am a DO but at least I’m not a PA” the DAP degree needs to be created and granted with completion of accredited postgraduate clinical residency training programs. This should be a clinical degree, and you should use a doctoral title. Optometrist,opthomologist,psychologist and psychiatrist don’t have a problem with an established precedent of “Degrees”. I suggest the following licensing scheme to keep all Associates and Assistants happy;

4 year degree, Bachelors, Associate Physician. (BAP)

7-8 Year degree,(bachelors and 3 years of additional
training) Masters, Associate Physician(MAP)

7-8 Year degree, with Post-Graduate training,
Doctorate, Associate Physician (DAP)

This would be the key in a licensing system as defined;

Distinction/educational level is clear in this scheme.BAP, MAP and DAP. The bachelors trained professionals
are the only ones that need to follow the current PA-Physician supervisory model. This would keep all the assistants happy. If you want to be an assistant then stay here. The MAP and DAP should be independant practitoners however. In this scheme a seasoned, experienced Associate Physician could actually move up the career chain after many years of practice if they choose, or 26-30 year olds fresh out of medical school residency training will become supervising Physicians of a 30 year practicing PA. Doesn’t make sense to me. I had to put a 1 year out of residency training Board certified 30 year old FP in his place because the 50 Year old PA of whom he was the supervising Physician was correct regarding the use of basal -vs- bolus insulin in a Diabetic patient. It was quite obvious this board certified rookie learned all this detail about Lantus but didn’t understand you don’t use basal insulin for Bolus random blood sugar elevations, the 50 year old PA his “assistant” knew however.

Why am I on here? I don’t want my fellow hardworking, intelligent and innovative colleagues to go through the “Hell” I went through to move away from the clinical handcuffing I went through as a PA, going through medical school, residency training only to end up doing the same thing I did day in and out but now with a title change. Now with a better income and incentive pay. With hospitalist, I don’t need to manage patients in the hospital etc.....Wake up my friends and move forward. The grass is green on your side please water it properly.

Interesting, and timely discussion....

Example of Cost Increases.....

So, some time ago, I had a younger, obese female patient present to the ED. She came with a complaint of a breast lump with skin discoloration. At first, I thought of potential mastitis, could she have a ductal abcess, something bad...right? Nope. This had been present for 2 months duration, and she had done a "lot of research on the internet". That is not usually a good statement to hear from your patient, primarily because there is just so much BAD information out there, and you often spend a great deal of time correcting misinformation, or even more often, MISINTERPRETATION of information. Anyway, she saw her local MD, who referred her to a breast physician locally. She was extremely concerned that she had Invasive Ductal Carcinoma. In fact, she had already staged herself, and was concerned that she had already progressed to stage II. Mind you, she had not seen a breast physician yet. She had been concerned, and had already called our breast clinic, for which she had an appointment in 2 days.

This was unacceptable apparently. The patient wanted an MRI (which we rarely ever do in the ED, and only in the instance of a severe emergency), or to have it biopsied in the ED. I explained to her calmly that I could not offer her either of those options. I explained some alternative ways that she could potentially move up her appointment.

A completely unnecessary visit, which cost hundreds of dollars, and added nothing to her care. I don't blame her. I blame the system in which this is encouraged. This is not even an unusual story, as there are dozens of patients who present every day with complaints that should have likely been seen in an outpatient clinic.

Wellpoint CEO....

Well, those of you who follow this blog, know that I don't have a lot of empathy for insurance companies, and some of their practices.

THAT being said, I agree with the CEO of Wellpoint Angela Braly's recent stance. She's right, while some of the insurance industries practices are a bit distasteful, such as recission, and denial of claims. The insurance industry is not the main reason costs are increasing. Hospitals, physicians, and other providers are raising rates. Add in a tumbling economy, and you get a risk selection bias as healthier individuals forego insurance, and an increase in COBRA enrollment, which is almost universally full of sick individuals. This creates a problem for the insurance company. While I am not going to say I feel sorry for Wellpoint, I believe that most people are missing the point of Ms Braly's comments.

She's right, we need more than simple health insurance reform. We need DELIVERY system reform, and right now, we're not getting it.

How about this idea. If we are going to mandate that all patients have insurance, and we are going to mandate that all insurance companies cannot deny pre-existing conditions, or cancel policies, and must have higher MLR ratios, then how about MANDATING that all providers accept Medicare patients. Tie it to their DEA number. If they refuse to see new Medicare patients, they lose their DEA number.

Providers need to have some skin in the game too.

More HERE

Free Markets and Healthcare

I seem to be having this recurrent conversation lately....."Government can't run healthcare, let the free market do it". To which I reply "Well, so you're saying that you want to get rid of Medicare, Medicaid, and SCHIP?"...to which the usual answer is "NO, just let the private market function as a free one"....my reply is. "you've never studied economics, have you?"..."No, why?"..."Thought so".

Free market principles DO NOT work in healthcare. It's a great news soundbite, and sounds like a great libertarian fantasy....in fact, John Galt would be proud, but it's simply not factual. There are any number of reasons, including the resultant distribution inequity that would result, but a large part of it is inelasticity. Market forces tend to work well when a commodity or service is elastic. That is, if prices rise by x percentage, then demand falls by an equal precentage. When there is inelasticity, that falls apart. Deflationary pressure isn't applied to prices, and they continue to rise unabated. Sound familiar?

Paul Krugman had a great opinion about this last summer.

HERE

He's right, and essentially he is talking about a resultant inequity in distribution, but he never comes out and says it exactly. In other words, the richest people would benefit from reduced prices and increased competition. The upper middle class would see some benefit, but not much, and everyone would else would suffer with decreased access, an inability to afford anything more than a throat culture, and our society would be much worse off.

But sure, the market can solve everything....talk about an "invisible" hand...

I am reminded of a quote from James Buchanan...no NOT that one, James M Buchanan, a nobel prize winning economist, who said:

“Gross misperception, especially in the minds of noneconomists, often prompts the claim that ‘the market’ (or ‘capitalism’) either works or does not work without constraints, a claim that is demonstrably unsupportable, either in analytical logic or in empirical reality.”

Healthcare Summit....

So, it's over.

President Obama met with the Republicans today to discuss bipartisanship. Except it didn't happen. And that really wasn't the purpose of this meeting anyway. Obama has known from the outset, that obstructionsim is the republican goal, and it is their only goal.

This meeting was more about lining up moderate democrats for the reconciliation maneuver. The problem is, that there are portions of the bill that cannot pass through a reconciliation process. This will leave holes in the bill that will require future legislation.

Part of me hopes that they do it. The republicans have no real ideas regarding healthcare reform, and have no agenda, despite what they say publicly...(YES, that means you John McCain). Their only agenda is taking back seats in Congress in November, nothing else matters to them.

The Senate bill is "okay". There are a number of good provisions, and some bad ones in the bill, and you know what....that's okay. We are NEVER going to get a perfect piece of legislation, it simply ain't going to happen. What we need is a starting point, and this seems as good as any legislation to start with.

What the US public needs to know, is that reform is a process, not a destination. This is going to take YEARS to implement, and we are going to try things that aren't going to work, and things that are going to work. It needs to be built upon.

The other part of me rationalizes, that we need a complete teardown of the current delivery system. We need to hire a team of systems engineers to completely re-design it from the bottom up.

We owe it to our patients, and our future patients.

Obstructionism....and Republicans....

One of the best articles I have ever read regarding the current rather venomous climate in DC....From the article...

ARTICLE HERE


With these acts of legislative sabotage, Republicans tapped into a deep truth about the American people: they hate political squabbling, and they take out their anger on whoever is in charge. So when the Gingrich Republicans carried out a virtual sit-down strike during Clinton's first two years, the public mood turned nasty. By 1994, trust in government was at an all-time low, which suited the Republicans fine, since their major line of attack against Clinton's health care plan was that it would empower government. Clintoncare collapsed, Democrats lost Congress, and Republicans learned the secrets of vicious-circle politics: When the parties are polarized, it's easy to keep anything from getting done. When nothing gets done, people turn against government. When you're the party out of power and the party that reviles government, you win.

Greenspan earns dubious distinction....

The dynamite prize in economics.

Alan Greenspan, Milton Friedman, and Larry Summers, after over 18,000 votes have been awarded the dynamite prize, and have been proclaimed the economists most responsible for blowing up the global economy....

Can we now proclaim neo-classical economics dead on arrival....

See HERE

Funny photo

Okay, now this really made me laugh out loud....LOL......

Economic Rant.....

Paul Krugman has stated that the government stimulus was not enough. He is concerned about the possibility of a "liquidity trap", of the type that the Japanese fell into in the 90's. Their recession worsened, and lasted over a decade. He sees a lot of similarities with our current situation. Small stimuluses, just enough to avoid the brink, but not enough to turn it around. Strange that so many ignore history. Additionally, I don't think that Summers and crew have handled this well. Obama has been positive because, well, that's his job to increase consumer and investor confidence. Right now. GDP predictions for 09 were all over the place, for example, 3rd Q estimates were first at 3.5%, then revised to 2.8%, and finally revised to 2.2%. Additionally, the 3.5% estimates only represeted 0.5% of real growth once government spending was excluded. REAL GDP growth was still negative. There is no vector in the marketplace ready to really stimulate and grow the economy. Energy maybe, in 5 years or so, but the infrastructure is not there to do it currently. The excesses of spending and credit obligations of the last 30-40 years are not going to simply work their way through the system in 1-2 years.

I haven't even touched on jobs yet, but with minus GDP growth, it ain't gonna happen. Okun's Law states that you need 3% of growth in production to get a 1% growth in employment. However, this only represents a 0.5% decrease in unemployment, as the modeling suggests that at least 0.5% of that 1% is an increase in hours worked by those already employed. We're nowhere NEAR 3% yet.

I'm also stuck on the dollar because while it helps our export market, the combination of a weak dollar and prolonged low interest rates creates a real potential for severe inflation. Although right now, most economists think we will hit a deflationary period first. The IMF actually is calling for countries to raise interest rates, and to aim for a consistent 4% inflation goal. It won't help us now, but they are thinking of ways to try and prepare to deal with future events. Additionally, we import more than we export. We are a consumer nation, and while a weak dollar will help a few companies, many others who import components and pieces will only have to raise prices... and there's that pesky inflation again.

Anthem in California is raising ire..

Exhibit A....Anthem in California raises rates on 700,000 enrollees by an average of 25%, for roughly 25% of them, they will see a rise in premiums of between 33 and 39%. Even at 25%, this represents roughly 4 times medical inflation (average of 6.2% per annum over the past ten years). If you don't think that this is coming to your state soon, well, I want some of whatever you are smoking.

More HERE

Appendicitis is a CLINICAL diagnosis

This is a pet peeve of mine. The loss of clinical assessment skills. I have seen over the past 20 years, an increasing reliance on tests of all sorts to evaluate things that might not need a test. I will also say that I have been guilty of this as well. However, some diagnoses are rather straightforward.

I had a patient a few years back who was a younger female patient with RLQ abdominal pain. Her story was classic. Started as periumbilical pain, migrated to the RLQ, complained of fever, nausea with no vomiting, and anorexia (lack of appetite). On exam she had tenderness at McBurneys, and a positive Psoas. She also had rebound tenderness on the LLQ, and guarding with palpation. WBC was around 12. I called our general surgery service and was confronted with the question. All ER docs know this question "What did the CT scan show?" I told the resident that there was no CT scan, and that she didn't need one. The resident proceeded to argue that perhaps it could be ovarian. I explained calmly that it was not ovarian. It was a CLASSIC presentation of appendicitis. Silence. I finally told the resident that I would only order a CT scan if they came DOWN to the ER, and LAID THERE HANDS on the patient. Otherwise, NO way. Resident comes down...not happy. (I don't really care) 5 minutes later she walks out, and says "Yep, we're taking her to the OR". The attending surgeon was so happy I thought that they were going to hug me. I saved that patient around 1700 dollars for an enhanced CT, and unnecessary radiation, which she DID NOT need.

We need to return to a focus on clinical exam techniques, and the development of a clinical gestalt.

Lastly, I would only add, that of course NOT every patient fits this scenario. Many have a mixture of symptoms that makes delineation much more difficult. But when it is clear.....

Sometimes less is more.

Now on Facebook.

Alright, so I finally figured out that Facebook thing. You can follow me on there as well, although most of my stuff on there is a bit more nonsensical. As if this isn't bad enough....LOLZ.

Mike

Aughts the worst decade in modern times...

ZERO net job creation.....Does anything else need to be said? We took a decade, and started it with a dot com bubble that burst. Now, rather than examine the gaping fundamental flaws that were beginning to be exposed, we created another bubble...construction and housing, and people took out second loans to buy boats, and RV's, and take vacations...OOOPS. Yeah, the pesky MBS market blew up.

This article HERE, details it.

Here's a snippet:

For most of the past 70 years, the U.S. economy has grown at a steady clip, generating perpetually higher incomes and wealth for American households. But since 2000, the story is starkly different.

The past decade was the worst for the U.S. economy in modern times, a sharp reversal from a long period of prosperity that is leading economists and policymakers to fundamentally rethink the underpinnings of the nation's growth.

It was, according to a wide range of data, a lost decade for American workers. The decade began in a moment of triumphalism -- there was a current of thought among economists in 1999 that recessions were a thing of the past. By the end, there were two, bookends to a debt-driven expansion that was neither robust nor sustainable.

There has been zero net job creation since December 1999. No previous decade going back to the 1940s had job growth of less than 20 percent. Economic output rose at its slowest rate of any decade since the 1930s as well.

Middle-income households made less in 2008, when adjusted for inflation, than they did in 1999 -- and the number is sure to have declined further during a difficult 2009. The Aughts were the first decade of falling median incomes since figures were first compiled in the 1960s.

And the net worth of American households -- the value of their houses, retirement funds and other assets minus debts -- has also declined when adjusted for inflation, compared with sharp gains in every previous decade since data were initially collected in the 1950s.

"This was the first business cycle where a working-age household ended up worse at the end of it than the beginning, and this in spite of substantial growth in productivity, which should have been able to improve everyone's well-being," said Lawrence Mishel, president of the Economic Policy Institute, a liberal think tank.

Economic Contraction in 2010...Say it isn't so?

WOW...

not often that two nobel laureate economists speak out on the same issue in agreement.

I don't always agree with Krugman's columns, as often he speaks from the more liberal portion of his conciousness. But I respect the man immensely, and find his economic predictions to often be right on the money.

From the Huffington Post....

HERE

Also, Joseph Stiglitz has been saying the same things, and actually, before Paul.

HERE

Part of the answer is both economists do not like the projections for GDP grow for 2010, before their recent revisions. They did not seem aware of the recent revisions. As Bloomberg has explained them –the economy is poised for a “surge” as Dean Maki, the most-accurate forecaster in the Bloomberg survey, sees it, with growth in the area of 3.5% for the year. The two economists do not consider even that a real surge, especially when recovering from a deep recession, implying that, although he has denied it, we should have more of a V shaped recovery than both have foreseen in the past. It is the last half of 2010 that bothers both economists. They don’t see where the source of recovery or engine of growth is going to come from, especially when the effects of the first stimulus package totally wears off. It is noteworthy here that we have two arch Keynesians recognizing that the stimulus efforts of government by means of deficit spending are transient and do wear off, giving us only transitory boosts in GDP.

Thoughts???

Contractionary Monetary Policy...Oh boy

NOW???? Really....

I personally cannot think of a worse time to do this...but over at the economist, Ezra Klein posted this....

HERE

EZRA KLEIN notes that the Fed is plowing ahead with its planning for withdrawal of monetary supports for the economy, like:

"The Federal Reserve on Monday proposed allowing banks to set up the equivalent of certificates of deposit at the central bank, a move that would help the Fed mop up money pumped into the economy and prevent inflation from taking off later.

Under the proposal, the Fed would offer "term deposits" that would pay interest. Doing so would provide banks with another incentive to park their money at the Fed, rather than having it flow back into the economy.

The proposal comes as no surprise. Federal Reserve Chairman Ben S. Bernanke and other Fed officials have repeatedly said the creation of "term deposits" -- essentially the equivalent of CDs for banks -- would be one of several tools the Fed could use to drain money from the economy when the time is right."

"When the time is right" says the story, but the Fed's commitment to undo its interventions is already having an effect. In expectation of more of these moves to come (as well as, perhaps, increases in interest rates) markets have been bidding up the dollar, which has busily appreciated during the month of December. That, in turn, will deprive the American economy of a potential source of demand—growth in consumption of American exports thanks to the effect of a weak dollar.

More bluntly, we're seeing a move toward contractionary monetary policy at a time when unemployment is at 10%. Funny that.

And, over at this SITE:

HERE
I've been thinking about this question more and I've come up with a speculative possibility. Right now banks are earning their way back into profitability by playing the spread. They're paying close to zero on deposits and earning fair sums on long-term loans. Perhaps this term structure is sustainable because people are expecting little inflation in the short run but moderate inflation in the longer run, plus there is some risk on the loans. (These inflationary expectations may be changing; if you wish pretend I am writing this six months or a year ago.)

So let's say we move from zero expected short-term inflation to three percent short-term expected inflation. The nominal short rate rises to three percent and the real short rate remains more or less constant. Long rates would go up a bit but not much, since beyond the short run there is already an expectation of moderate inflation. In sum, the spread between short and long rates might narrow.

Here is the key point: from the bank's point of view, what is the correct measure of the real rate of interest? Is it defined by the nominal rate relative to the expected growth in the CPI? I doubt it. When you're near the bankruptcy or nationalization constraint, it's often nominal profits that matter (relative to fixed nominal liabilities, accounting standards, capital standards, etc.), not "real profits" defined relative to the CPI.

In sum, maybe three percent expected inflation conflicts with the desire to rapidly recapitalize banks through maintaining a wide interest rate spread. Maybe we need that zero nominal short rate or at least the Fed thinks we do.

I don't wish to push too hard on this hypothesis, it is speculative rather than confirmed by evidence. And propositions about the term structure of interest rates do not always run the way you think they will or should. I'm aware of other problems. What kind of zero profit condition is imposed on the banks? Given the odd objective function of the banks, how exactly does the Fisher effect work in the short run? Or is it imposed from without by competition from non-bank lenders? I'm not sure on these questions and they suggest possible holes in the above speculation.

I also regard this as a somewhat gruesome hypothesis. It means that "Main Street" is paying for "Wall Street" (forgive me the use of those awful terms) in at least two ways: high unemployment and inability to earn much on one's savings. Risk on the Fed balance sheet is also paying some big part of the bill, since presumably that is helping to maintain the interest rate spread.

The term structure also implies that the market is expecting rising short rates, so if the bank mess isn't cleaned up soon, heaven forbid. The spread, as a means of restoring bank profitability, won't last forever.


This combined with the possibility of hits to the export markets due to contractionary policy scares the living cr*p out of me. What a way to start 2010.

BTW- found the second link over at Angry Bear. Just want to make sure to give credit where due.

Economics Sunday....First up, Employment Forecasts

SO, the BLS releases their employment forecasts...

Found this over on Angry Bear, but it stems from the recently released BLS labor and employment report for 2008-2018.

Here's a snippet:

HERE

Here's the BLS report link:

HERE

Total employment is projected to increase by 15.3 million, or 10.1 percent, during the 2008-18 period, the U.S. Bureau of Labor Statistics reported today. The projections show an aging and more racially and ethnically diverse labor force, and employment growth in service-providing industries....and...

Projected employment growth is concentrated in the service-providing sector, continuing a long-term shift from the goods-producing sector of the economy. From 2008 to 2018, service-providing industries are projected to add 14.6 million jobs, or 96 percent of the increase in total employment. The 2 industry sectors expected to have the largest employment growth are professional and business services (4.2 million) and health care and social assistance (4.0 million).

...and...

The largest decline among the detailed industries is expected to be in department stores, with a loss of 159,000 jobs, followed by manufacturers of semiconductors (-146,000) and motor vehicle parts (-101,000).

...and more...

Occupations that usually require a postsecondary degree or award are expected to account for nearly half of all new jobs from 2008 to 2018 and one-third of total job openings. Among the education and training categories, the fastest growth will occur in occupations requiring an associate degree.

So the workforce is becoming older, and more service oriented. Does anyone think that in the absence of goods production that this is sustainable over the long term? Also, what will this mean for retirement?

Happy New Year everyone...

Whew, 2009...what to say...besides GOOD RIDDANCE.

Hopefully, 2010 will be better, but we might be in for some real bumps, particularly in the second half.

Anyway, we talk more about this.