Friday, October 31, 2003

Yesterday's Wall Street Journal had a story (sorry, full story requires subscription)
about a little-known tactic that hospitals are using to collect overdue debt.

Throwing the patient in jail...

Late one night in June 2000, a police cruiser pulled up to Marlin Bushman's house on a quiet, tree-lined street. While Mr. Bushman's wife and son stood by, an officer handcuffed the burly truck driver and took him away to jail. The charge: missing a court hearing about a $579 hospital bill.

The story describes several patients who were arrested for not showing up for court appearances to resolve overdue bills, ranging from the $579 above to over $9,000 . The hospital administrators quoted in the story all defend the practice stating that they had exhausted all options:

........ just last month in Evansville, Ind., the not-for-profit Deaconess Hospital sought the arrest of a 22-year-old debtor, Jamie Ruston, who had missed two court hearings on a $5,664 debt related to gynecological surgery. Ms. Ruston, who works at a McDonald's, was briefly in custody before her mother arrived at the jail with the $500 needed to secure her release. "I cried the whole time," Ms. Ruston says.

Alan Shovers, a lawyer for Deaconess, says the hospital, which is affiliated with the United Church of Christ, made "innumerable efforts to get in touch" with Ms. Ruston to work out a payment plan or to see if she qualified for charity care. "In the range of 16 times, she has ignored us, ignored the hospital, ignored the court house," Mr. Shovers says. He defends the hospital's use of bench warrants -- as the proceeding is known in Indiana -- saying the hospital seeks them only when debtors have been repeatedly unresponsive. "Most people, whether rich or poor or whatever, can to some degree respond to the system -- and you have some people who go through life without responding," he says. "The question is, are we taking some unfair advantage, and I don't think we are."

While I feel that this is a drastic solution, I can agree with its' limited use. If you have someone who repeatedly shirks their responsibility to make good on their debt, it may take this to get them "scared straight":

Mr. Bushman was booked and fingerprinted at the Champaign jail. He posed for a mug shot, turned over his shoelaces and was escorted to a cell. A judge imposed bail of $2,500 -- with $250 payable up front. Mr. Bushman waited in a cell while his wife tried to come up with the money. He says he fell asleep on the concrete bench, using a roll of toilet paper as a pillow. Ms. Bushman borrowed the money from her mother-in-law, and Mr. Bushman was freed a short time later. Within three months, he paid Carle the balance of his debt, and the case was dismissed. (emphasis mine)

This was over a debt that was two years old. Another example is a man who had an unsuccessful suicide attempt in 1991:
In Champaign-Urbana, James Bean, the man who was treated at Carle hospital for a self-inflicted gunshot wound, says he has been pursued aggressively by a collections agent since 1995, when the hospital sued him over his $7,718 bill. In June 2001, Mr. Bean, who says he held a series of odd jobs during that period and couldn't afford a lawyer, missed a court hearing. He says he wasn't aware of the hearing. Carle's lawyer obtained a warrant for his arrest, and a few months later, Mr. Bean says, he heard about the warrant and turned himself in. Bail was set at $3,500, and he spent six hours in jail before his brother came up with the 10% required to release him.......Ms. Robbins, the Carle spokeswoman, says the hospital acted appropriately after Mr. Bean had failed for years to pay his debt. The suicide attempt was in 1991, and Carle unsuccessfully tried to collect for more than four years before filing suit. She says the hospital also encouraged Mr. Bean to apply for the state's insurance program for the poor, but that he didn't follow through.

In all of the examples give in the story, the people arrested were bailed out by family members several hours after being arrested. If you can go to mom, dad, Uncle Jed or Cousin It and get bail money, why can't you go to them for help with your medical bills? I think it is because that being in debt or declaring bankruptcy does not carry the stigma that it once did. When you have car dealers and others constantly flooding the airwaves with "no credit, no problem" , the consequences of not paying your bills are a nuisance at worst. It only becomes an issue when they "hit you where it hurts". None of those pictured in the article appear to be starving, or poorly dressed.
The story also has the "medicine is different" quote:

Patient advocates argue there is a fundamental difference between medical debt and other types of consumer debt. "If it is a car or a vacuum cleaner, they will simply repossess it. What do you want them to do? Give the heart valve back?" says Jane Perkins, an attorney at the National Health Law Program in North Carolina.

I cannot disagree more. Debt is debt. The patient is given a bill for a service that is rendered. The part that differs from other routine debt is that if you have past due car payments, or your car has been repossesed, the car dealer or lending company is under no obligation to loan you more money, or sell you another car. If money is owed to a hospital, and you show up with an emergency (as patients interviewed in this article did) they have to treat you.

Here at the Acme Surgical Corp., we are not trying to return to historical roots (Georgia being founded as a debtor's colony). We do turn people over to collections, but we also have a large number paying of their bills at amounts as low as five dollars a month. The theme of "rich hospitals picking on poor, defenseless patients" is played out, as the quotes from administrators take on a defensive tone.
Your comments, as always, are most welcome.

Wednesday, October 29, 2003

I had to be "on call" for the ADA again today. (The case was pled out). I wore a coat and tie into work today. Unusual since I only wear a tie once a week. Every one I ran into today made jokes about how I "must have court today".
Either this reflects poorly on physician dressing habits in general (or mine specifically), or is a sad statement about the liability situation that the only reason one would dress nicely was because of a court appearance.
I don't know which is worse.

Tuesday, October 28, 2003

CNN:Study: Kids' TV, computer habits start early

CNN:Study: Toddlers eat too much junk food

Monday, October 27, 2003

Over the weekend my partner admitted a patient from a MVC with a pelvic wing fracture, acetabular fracture, an external iliac thrombosis secondary to the above, and a splenic laceration. Treatment consisted of a splenectomy, embolization of pelvic vessels, external fixation of the fracture and a fem-fem bypass graft. Patient required massive infusions of crystalliod and blood products. Patient continued to manifest signs of shock as well as worsening pulmonary compliance. What could it be?
Well unlike Doc Shazam I won't keep you in suspense. The patient had abdominal compartment syndrome (ACS) with a bladder pressure of about 100. Was taken to OR for decompression, re-embolization, and prosthetic closure of the abdomen.
ACS is a frequently under-diagnosed condition in patients in the ICU. The initial reports of ACS and its' treatment arose from the trauma literature and what to do in the case of damage control laparotomy. But there are a wide variety of medical and non- traumatic surgical conditions which can lead to ACS as well.
ACS may present itself acutely or over time. Clinical signs include oliguria (due to renal vein compression as well as compression on the kidney itself), hemodynamic instability (diminished venous return) and worsening pulmonary function (decreased Vt for a given insp. pressure). Other manifestations may include venous stasis in the lower extremities, increased intracranial pressure, and possibly wound dehiscence.
Diagnosis is based on clinical grounds with an objective finding being the measurement of bladder pressures (scroll down). The results are broken down into classifications:

Burch and coworkers[1] proposed a grading system for ACS based on measured intra-abdominal pressure. Grade I ACS, defined as pressures between 10 and 15 mm Hg, rarely needs abdominal decompression. Treatment of grade II (pressures between 15 and 25 mm Hg) is based on the patient's clinical condition but requires close monitoring for any signs of decompensation. At grade III (25 to 35 mm Hg), some patients will require decompression, but overt signs of increased intra-abdominal pressure may develop insidiously. Grade IV appears at pressures greater than 35 mm Hg, and all patients require decompression.

The treatment for ACS is like that of any other compartment syndrome, decompression. The coverage of the abdomen is usually accomplished with an artificial prosthesis (the "Bogota Bag") and resuscitation is continued. Once the patient is resuscitated, closure is attempted, and may be done in stages. The patient may manifest a reperfusion injury when the abdomen is released, which may cause severe hypotension. This may be blunted by good fluid resuscitation and the use of mannitol. Another problem is the "shrinking abdomen", that is the inability to obtain definitive closure of the abdomen due to contraction of the fascia if the closure is not accomplished in a few days. These patients usually have to have a permanent prosthetic placed to prevent a hernia.
Having an open abdomen in your ICU can be a messy affair. When I was a resident we engineered a system of an opened 3 liter IV bag overlying the viscera, a VAC sponge over that, and then another IV bag sewn to the skin. An occlusive dressing was applied over the last bag. This resulted in a much cleaner bed, as the drainage was removed by the sponge, not by towels and chux placed around the patient. KCI now has a one-piece system that does the same thing.
We would often open these patients up at the bedside in the ICU if they were too unstable to go to the OR , what fun that was.
In addition to the links above, an excellent review of ACS (co-authored by an old attending of mine) may be found here. (PDF)
I have been waiting all day to go and testify in an assault trial. I did not schedule cases today just because the ADA told me he may need me. I find out 20 minutes ago that they won't need me until Wednesday. What jerks.

Sunday, October 26, 2003

Best of the Web Wednesday had a link entitled "What Would Gallbladders Do Without Experts" which leads to this article about a paper in this week's Journal of the American Medical Association. The same group of authors published another article describing a decrease in common bile duct injuries (CBDI) when intraoperative cholangiography (IOC)is used.
The main point of the paper is this:

Thirty-three percent of all patients died within the 9.2-year follow-up period (median survival, 5.6 years; interquartile range, 3.2-7.4 years), with 55.2% of patients without and 19.5% with a CBD injury remained alive.

I haven't had the opportunity to read the article but just based on the abstract, I have the following concerns:
Given the incidence of CBDI is higher with laparoscopic cholecystectomy than with open (0.7 percent versus 0.4 percent) how many of these were done laparoscopicaly?
How many of these deaths were directly related to their CBDI? (sepsis, cholangitis, liver failure). Given the population (Medicare beneficiaries) the deaths may be from other causes. The A=true,B=true but unrelated scenario from medical school tests.
These patients may have had more severe gallbladder disease than your routine biliary colic and with the resultant inflammation may have obscured the normal anatomy, with CBDI occurring.

Regardless of the reasoning, CBDI is one of the most common sources of
liability suits against general surgeons in the U.S. today. I had one in training that was recognized at the time of surgery, and repaired primarily. My indications for IOC and conversion to open cholecystectomy are pretty low, but some guidelines are useful...

Anatomy is obscured due to inflammation or other causes..
You have been working for 45 minutes without making progress...
You have bleeding which has required more than five clips to control...
Suspicion of malignancy..

Some advocate the use of dome-down cholecystectomy to avoid CBDI, but it has not gained widepsread acceptance.

The title of this post comes from a lecture I had as a first-year medical student where an attorney described when he would get a high-dollar case, such as a CBDI, he would call his wife and tell her to "book a cruise"

Saturday, October 25, 2003

UGA 16 UAB 13
Simply cannot play this poorly and expect to win against Florida next week. I thought that the upset of Virginia Tech by WVU would provide some inspiration to avoid looking ahead. Just barely.
Adulterous at Birth? Study Finds Biological Marker
via Scrapple Face

Friday, October 24, 2003

The ever-insightful Doc Shazam posted a comment to an earlier post....

.....For awhile, our IR (interventional radiology) guys were getting the ICU interns (primarily medicine, not surgery) to get patient consent for greenfield placement. Of course, the interns were not adequately prepared to obtain informed consent, most of us never having met any of the IR attendings. I obtained consent for one and felt like a fraud.....

And in doing so she made me think of another one of my pet peeves, physicians who (attempt) to get consent for procedures that they are not going to do. This is the difference between obtaining consent and obtaining informed consent. For example, a while ago a patient on the resident service at Big Hospital needed an angiogram to evaluate the arterial system in their legs to see if they were suitable for a bypass operation. The intern told me that he was going to "get consent" for the procedure and started towards the room..
ME: Are you doing the procedure?
DR. X.: No, sir. The radiologist is.
ME: Do you know the risks of the procedure?
DR.X: No.
ME: Do you know the alternatives for the procedure?
DR. X: No.
ME: Then why are you obtaining consent?
DR. X: (with a deer-in-the-headlights look) Ahhh,umm,errr... Feigns seizure. (Not really)
Informed consent is more than just a signature on a operative permit. It is an involved discussion outlining the indications for the operation, the hoped-for results, the complications that may arise (most of the discussion is about this), and the alternatives. This should be held between the operating surgeon and the patient. The example I gave was of misplaced good intentions, Doc Shazam's was one of simple laziness on the part of the radiologist.
Added more stuff to the right..
Why can't they get their headline right? The lesson to be learned from this is to make all of your family aware of your wishes concerning end-of-life care. And put it in writing.

Thursday, October 23, 2003

It was filter day at Big Hospital as my partner and I changed out four (two apiece) of the removable caval filters I talked about in this post. It amazes me that it takes less time to replace the filters than it takes to place them primarily. Why?, you may ask. Well....
When you place a caval filter, you ideally want to place it below the renal veins (although you can place it above the renal veins if need be). You assure this by performing a venogram prior to placing the filter. The conventional Greenfield filter is placed through a 14-french sheath (about 5mm). You can get a good cavagram with hand-injecion with a sheath that large. Since the newer filters are placed with a 6-french (2mm) it is difficult to get a good image without a power injector. You have to find the renals by selective imaging of them (or get the wire to go in, much easier on the left). This can take some time.
When they are replaced, the first thing you do is find it with the c-arm, lock the flouro machine, and mark the position on the screen. The filter is removed with a snare through a 9-french sheath, and the 6 french sheath is passed throught the left-in-place 9-french sheath. Since the position of the old filter is marked on the screen, I don't have to spend a lot of time hunting the renal veins. Pull the sheath and hold pressure for a few minutes. Done in twelve minutes. See you in four weeks.
Back form Chicago. The only internet access my hotel had was dialup or that LodgeNet device where you use the wireless keyboard and your TV. There was a cafe about three blocks away with Wi-Fi, but they closed before I could get back from the meeting.
While many surgeons don't like the ACS meetings that much, the college does know how to put on a course. I spent eight hours Monday and Tuesday in ultrasound courses that were execeptionally well done. A lot of hands-on with real people to scan.
Ate very well. Good steakhouse called Sullivan's one night followed by Maggiano's the next night.
Despite what the title to this post may imply, I found the airport screeners at both Hartsfield and O'Hare to be very professional and efficient.

Friday, October 17, 2003

Headed to Chicago tomorrow for the annual Party congress. I just wanted to comment on a few things:

I reached my 3000th visitor yesterday. It came pretty quickly because of people curious about liability nudity as well as the controversy surrounding the Nobel prize for medicine this year. Thanks to all who have visited my humble weblog.

The replaceable filters continue to do well. I am going to change or remove a few when I get back into town next week.

Two questions /comments I wanted to respond to:
The Acme Surgical Corp. will pay the princely sum of about $295,000 for liability coverage this year. I may have to set up a tip jar.
The "pancreatic mass" was a poorly-differentiated squamous cell carcinoma, as was the liver met. The primary has yet to be found.

Graham and Grunt Doc have posted on the new curriculum at Stanford. My comments on the subject are here. I don't think that this is going to catch on at your local State U. School of Medicine. Because of budget cuts and the primary purpose of those schools is to turn out workaday physicians to serve the medical needs of their state.

Since I am getting on a plane tomorrow, this is not encouraging.

Blogger is messing up again, Type Pad is becoming more attractive every day.

I'll be posting from the Windy City (a promise, not a threat) if my hotel has internet connections.

Wednesday, October 15, 2003


Medicare premiums will rise next year by 13.5 percent to $66.60 a month for about 40 million Americans in the program, the third-largest increase in its history, the government said Wednesday

This increase applies to part B (non-hospital) insurance. Quite an increase from the $3 per-month premium in the 1960's.
A graded premium structure is gaining support:

Key lawmakers reported a growing consensus Wednesday for the historic step of requiring higher-income seniors to pay more for their Medicare than other beneficiaries.

But not everyone is happy:

AARP, formerly the American Association of Retired Persons, said Congress should not approve additional payments to medical providers until it passes a prescription drug benefit. When the cost of the program rises, participants end up footing more of the bill.

What kind of position is that? Medicare access is an increasing problem. Without reimbursement keeping pace with cost increases more physicians will be dropping out of Medicare. A drug benefit is of little use if you cannot find someone to write the prescription.

Modafinil, sold under the name Provigil, was originally approved by the Food and Drug Administration in 1998 to treat narcolepsy, a serious condition in which people cannot stop falling asleep.

But since its introduction, the number of off-label prescriptions for Provigil has skyrocketed, with an estimated 80 percent of prescriptions for the drug going to night-shift workers, truck drivers, pilots and soldiers — jobs in which it's crucial to remain awake and alert. Now the FDA may approve it for wider use — a move that has met with some controversy.

This kind of reminds me of that X-Files episode where the soldiers were operated on in such a manner that they did not sleep and one of them was killing the medical team who performed the procedure.

Tuesday, October 14, 2003

The 2003 administration of the American Board of Surgery's qualifying exam (the written board) is tomorrow. It is the first of two parts that lead to a young surgeon becoming Board Certified in general surgery. The test is hard because it covers so much, a great deal of which a community surgeon does not see everyday. Questions about head and neck tumors, urology, gynecology, basic science (leukotrienes, physiology, ect...), and transplants are common. "Send them to a (urologist,gynecologist, the patient's transplant surgeon)" is not usually one of the options given as an answer. The pass rate last year was 75 percent.
The second part is the Certifying exam (oral boards). As I have written before the difficulty is mainly psychological, as the situations are those seen by a general surgeon in the community. A community without urologists, cardiologists, or pulmonologists, that is.
Passing the tests the first time is important, not only for one's ego, but with the written costing $675 and the orals $800, passing is important for your wallet as well. If a certain number of graduates from your program do not pass, your program may be placed on probation. You are given a limited number of times (I believe three) to pass the test over five years. If you fail to do so, you must repeat a year of residency. No fun.
If you pass, you get to take a recertification exam in ten years.
Anyway, best of luck to those who are taking the test tomorrow.
Grunt Doc posted about the AMA's requirement that the ACEP increase the numbers of its members that are also members of the AMA. If not, the ACEP may lose some of its members of the House of Delegates. Cough...cough...extortion...cough.....excuse me. His comments are worth reading. I won't soil his fine comment page with anything I would have to say, so I will rant on my own real estate. I agree with Grunt Doc that my specialty college (ACS) is more worthy of my support than is the AMA. In the town where I practice there is a "generation gap" in how useful the AMA is perceived to be. Many of the older physicians feel that the AMA is quite beneficial and are active members, while the younger physicians have little use for it.
I feel that this is due to the economic pressures on medicine. The Medicare pie is getting smaller and the AMA can't seem to keep it from happening. Physicians know that their specialty societies will look out for their interests and the interests of their patients. I know the ACS is fighting against further reimbursement cuts for the things I do. I know that this leads to the "balkanization" of physicians as one of the commentary wrote, but the AMA hasn't been perceived to be able to deliver the goods, which is not the case with the specialty societies.
So, do we light a candle or rage against the darkness? As Dr. Lacsamana writes:

If you are critical of AMA leadership and its goals, you can do something. Join your county and state medical societies, participate actively, and elect those who you feel can do the job. But that is always how it has been done for years. Even better, you can even have your society sponsor your candidacy, and I am certain they would elect you as one of its leaders if you can convince your colleagues you have something better than what the current leadership is doing

When a physician is forced to turn his practice into a volume business, squeezing in as many 15 minute patient visits as you can during the day, several hours devoted to chasing down paperwork, and then rounding at the hospital(s) how can they find time to participate, much less "participate actively"? I have better uses for my time and my money.

Monday, October 13, 2003

Actually just this post. My call weekend activites have included:
Exploration for bowel obstruction, found closed loop obstruction with gangrene. Resected and anastamosed. The surgical circus has come to town.
Two appendectomies
Laparoscopy for GSW to abdomen. Shot himeslf while cleaning his .380. (I belive him). Entry and exit on same side of abdomen. Peritoneum intact.
Chest tube for a spontaneous pneumothorax.
Emergent hemorrhoidectomy (don't laugh). Thrombosed and concerning for necrosis.
Another exploration for SBO. The obstruction was due to adhesions, but I also found a mass (probably pancreatic cancer) with mets to the liver. Surprise, surprise.
Four admissions (non-trauma)
Five consults
Eight trauma admissions
One central line. (my least favorite procedure see here).
Four cases on the schedule for tomorrow.
And five more hours on call.

Saturday, October 11, 2003

Especially sweet given Casey Clausen's comments after last years 18-13 loss in Athens:

"I could have played on one arm and we could have definitely beaten Georgia, but (the doctors) didn't want to risk it," Clausen said afterward. "If I had played that game we definitely would have won by at least two touchdowns."

Given Mr. Clausen's outstanding performance tonight: 11/23, two interceptions and a third-and-goal fumble on the three yard line which was returned for a touchdown, I hope he transfers to Florida and delivers a similar performance in a few weeks.

Friday, October 10, 2003

On call this weekend, may be posting a lot, or none at all, depending on how well the populace behaves themselves.

Thursday, October 09, 2003

The Department of Community Health in Georgia has announced $160 million of Medicaid cuts. This to comply with the across-the-board 2.5 percent cut in budgets ordered by the governor. This is primarily done by reducing those eligible for the program:
Community health officials said many of the proposed cuts would bring Georgia to the same level of coverage as other Southeastern states.

Georgia Medicaid eligibility for children and pregnant women would be reduced to those whose family income is equal to or lower than 185 percent of the federal poverty level. For a family of four, the income cutoff would be $34,044. Currently, a family of four with an income of $43,260 would be eligible for Medicaid benefits; that's 235 percent of the poverty level.

I didn't know that Georgia was so generous. Given that according to the Census Bureau the median household income in 2001 was $42,228 (down from $43,162 in 2000) your family income can be higher than half the population of the U.S. and you can still qualify for Medicaid. You can be a PGY 4 at the Medical College of Georgia with yourself or your spouse pregnant and qualify for Medicaid.
But of course, the providers will take it as well..
The budget plan also would lower payments to nursing homes and doctors, who have already experienced cuts in Medicaid reimbursements......
David Cook, executive director of the Medical Association of Georgia, suggested the reimbursement cuts would lead to fewer Georgia doctors accepting Medicaid patients.

Continue to follow...

Wednesday, October 08, 2003

Uh oh. Seems as if the Honorable Sonny Perdue, Governor of Georgia, is willing to overturn the Georgia helmet law:

"My personal view is that there [should] be more freedom in our usage in the field of motorcycles," said Perdue, who as a state senator supported efforts to give most adults over age 21 the option of riding without headgear.
"I think this is an interest that all riders themselves are interested in. I agree with them in principle," the governor said...

Georgia passed the first helmet law in 1962. Every year while the General Assembly is in session the "anti-helmet" proponents stage a big rally and get some press coverage, so far to no avail. But that may change:

However, state Sen. Joey Brush (R-Appling), the principal lawmaker behind the move to relax helmet laws, said Perdue told him last summer, before he was governor, that he would sign the legislation if it passed. "Sonny told me when he was running that he would not veto it," Brush said.

Helmet laws seem to be falling out of favor:

In 1975, 47 states required the use of helmets with motorcycles, according to the National Highway Traffic Safety Administration. Since then, the trend has gone against helmets, with a concurrent increase in fatalities. Georgia is now one of 20 states that require all motorcycle operators and passengers to wear helmets, according to the NHTSA.

While I am a libertarian on some issues I've got to side with the nanny state on this one for the simple reason that it is not fair for the taxpayers to pay for your hospital care if you suffer a severe head injury from not wearing a helmet. Even Florida's requirement to carry a $10,000 insurance policy is not enough. An critically ill trauma patient can go through $10,000 in a few hours.

Hospitalization costs are higher for motorcycle crash victims who don't wear helmets, compared to those who do. Numerous studies comparing hospital costs of helmeted and unhelmeted motorcyclists involved in crashes have found costs for unhelmeted riders to average $3,000 more than for helmeted riders. And, riders who don't wear helmets are less likely to have health insurance, resulting in the cost of their care being forced on to taxpayers.

More from the NHTSA:

Per mile driven, a motorcyclist is 16 times more likely to die in a crash than an automobile driver. Wearing a motorcycle helmet reduces that risk by almost one-third (29 percent).

Head injury is a leading cause of death in motor cycle crashes. Riders who don't wear helmets and who experience a crash are 40 percent more likely to sustain a fatal head injury.

Studies show that laws requiring helmet use are very effective in reducing motorcycle fatalities because such laws influence more people to wear helmets. In Louisiana, the first state to repeal and then re-adopt a helmet law for all riders, there were 30 percent fewer motorcycle deaths during 1982, the first year that the helmet law was reinstated

Georgia also has a mandatory seat belt law, but I don't see the Governor planning to repeal that.

Tuesday, October 07, 2003

Blogging to you via my new wireless network at the house. We got it because my oldest becomes quite offended when he wants to visit his Nick Jr., Noggin, or Disney sites and Dr. or Mrs. Parker are using the computer. Now everyone is happy!!!

Monday, October 06, 2003

Go visit Dr. Rangel now that he has completed his move.
With the announcement of the winners today I vaguely remembered reading something in the past about why the MRI had not yet gotten someone a Nobel. I found it here as an Opinion Journal piece from June of 2002. I details a controversy between the winners of the Nobel prize this year andDr. Raymond Damadian ,who claims also to have invented MRI.
.....Although some scientists had tinkered with trying to obtain a signal from biological samples, it was Dr. Damadian who first conceived of using T1 and T2 measurements to scan the body for cancerous tissue. He patented his discovery and, in 1992, won a patent infringement lawsuit against General Electric for $110.5 million. Today, more than 95% of all MRI scans use T1 or T2 measurements......
Nevertheless, his observation of T1 and T2 differences in cancerous tissue was a Eureka moment for Paul Lauterbur. After seeing Dr. Damadian's experiment repeated by a graduate student, Mr. Lauterbur dined at a hamburger joint, where he had a flash of brilliance.
He realized he could subject the nuclei to a second magnetic field that varied in strength in a precise way. Though the idea of a "magnetic field gradient" was not new, Mr. Lauterbur was the first to see how it could be used to reconstruct an image. He wrote his idea in a notebook and had it witnessed the next day. His work, with later contributions from Peter Mansfield, forms the basis for modern MRI imaging.....

I see no mention of Dr. Damadian's demise in his biography (a Nobel cannot be awarded posthumously) so the Nobel committee did not feel that his contribution was signifigant. Interesting
The winners of the 2003 Nobel prize in medicine were announced today. They are Paul C. Lauterbur and Peter Mansfield, "for their discoveries concerning magnetic resonance imaging". MRI is becoming an indispensible tool in modern diagnosis, like CT scanning (which also netted a Nobel for its developers). Over the years nine surgeons (4 general or vascular surgeons, 2 ophthalmologists, 1 each of urology, orthopedics ,and ENT) have won the Nobel prize.
The winners are....
Theodor Kocher "for his work on the physiology, pathology and surgery of the thyroid gland"
Allvar Gullstrand "for his work on the dioptrics of the eye"
Alexis Carrel "in recognition of his work on vascular suture and the transplantation of blood vessels and organs" The father of vascular and transplant surgery.
Robert Barany "for his work on the physiology and pathology of the vestibular apparatus"
Frederick Grant Banting "for the discovery of insulin" The orthopedist of the group.
Walter Rudolf Hess "for his discovery of the functional organization of the interbrain as a coordinator of the activities of the internal organs"
Werner Forssmann "for ... discoveries concerning heart catheterization and pathological changes in the circulatory system" . This is what he did:
...he was the first to develop a technique for the catheterization of the heart. This he did by inserting a cannula into his own antecubital vein, through which he passed a catheter for 65 cm and then walked to the X-ray department, where a photograph was taken of the catheter lying in his right auricle....
Pretty impressive.
Charles Brenton Huggins "for his discoveries concerning hormonal treatment of prostatic cancer"
Joseph E. Murray "for..... discoveries concerning organ and cell transplantation in the treatment of human disease" . The only living surgeon laureate.
Interesting that an imaging technique wins the medicine award, since the person who started it all Wilhelm Conrad Rontgen won the prize in physics.
The Nobel website is here.
Seems as if the .."means testing" effort is picking up some steam....

With unexpected support from some Democrats, Republican negotiators from the House and the Senate say they are seriously considering a change in Medicare that would require elderly people with high incomes to pay higher premiums than other beneficiaries.

Quite a difference from just a few months before....

Only a short time before, the Senate came perilously close to a meltdown of its own. On a procedural vote, senators indicated they would approve an amendment to provide less of a government subsidy for affluent Medicare recipients in paying for doctor visits and other medical services. This prompted a furious response from Sen. Edward M. Kennedy (D-Mass.), who adamantly opposes such means-testing of Medicare.

As 20 or more senators huddled in the well of the chamber, Kennedy returned to his seat and hauled out charts and a lectern -- signaling he had every intention to filibuster the bill until he got his way. The proposal's sponsors finally backed down and the provision was jettisoned by voice vote.

I posted about this several months ago. While I think the government gets too much of our money anway, I believe this is a good option to sustain Medicare. It sure beats cutting reimbursements again.

Sunday, October 05, 2003

Good sports blog:The Bleacher Seat. If you're into that sort of thing.

Saturday, October 04, 2003

Hope no one gets shot at tonight.
34 year-old as college quaterback

Friday, October 03, 2003

From the CBS Marketwatch a story about the author's open heart surgery and the workings of the fee structure in medical care. Or, the difference between the "usual and customary fee" and what insurance will pay:

The surgeon in charge of fixing my heart billed $6,000, but insurance paid an agreed rate of $2,875. The hospital billed $42,000 for the surgery and my first three-day stay, but accepted $7,000 less. One specialist billed $699 for a weekend emergency consultation but was paid an agreed insurance rate of $80.

Here at the Acme Surgical Corp. is how it breaks down:
For a lap gallbladder (CPT 47562) our fee is $2,550. A managed care plan in our area pays about $2,000 while Medicare pays $600.
For construction of an A-V graft (36830), we charge about $2,600, Uncle Sam coughs up $671
Why the difference?
It goes back to the time when private insurance rates were not tied so closely with Medicare. Often private insurance would pay your usual fee, or just a little less. This was back in the days of "balance billing" where the fees from insured patients would subsidize the uninsured. Now managed care plans set fees just above or even below Medicare, depending on procedure and geography. So reimbursement is tighter and physicians start thinking about admin fees to try to improve things.
Why continue to set fees that you know will never be met in full? There is this fear that if we reduce our fees to bring them closer to Medicare, they (meaning Medicare and managed care plans) will reduce our reimbursement even lower because we have cut our fees.
Silly, isn't it?
via The Health Care Blog
Where is Dr. Rangel?

Thursday, October 02, 2003

DB links to this paper (full article free!!) in the Canadian Medical Association Journal about the risk of emergent cholecystectomy while waiting for elective cholecystectomy. The conclusion from the abstract reads:
The probability that a patient on a waiting list will be admitted for emergency cholecystectomy consistently increases with the duration of wait, particularly after 20 weeks.
The median length of stay on the list was six weeks, but some patients waited for up to a year. I've never had an attack of biliary colic, but I don't think I would want to wait six, twenty, or fifty weeks to get my bag out. (My patients usually get theirs out 5-10 days after they see me)
Two things:
The criteria for inclusion seem to be onset of cholecystitis:
Surgeons on call made the decision to operate on patients who presented to the emergency department by evaluating (a) the clinical presentation for symptoms of increased pain or fever and signs of persisting or worsening abdominal tenderness, guarding or rebound or (b) the ultrasonographic finding of a thick-walled gallbladder with pericholecystic fluid or a positive finding of hepatobilary iminodiacetic acid on radionuclide scan or (c) both (a) and (b).
They make no mention of biliary pancreatitis, or common bile duct obstruction as being indicators for admission.
The other: They tried to remove them via the laparoscope initially, but opened them if the dissection was unsafe. It would be interseting to compare conversion rates (lap to open) to wait list time
In their conclusion they describe other conditions that may require emergency surgery on while on the waiting list:
.....include inguinal hernia, spinal cord conditions, abdominal aortic aneurysm or the need for coronary artery bypass grafting.....
The emergent AAA repair alone carries a fifty percent mortaility (if ruptured)
This study shows how an outpatient procedure can be turned in to easily 4-5 days in the hospital with the usual increase of expense. Talk about being penny wise and pound foolish.
Article in todays Wall Street Journal (requires subscription) about the expanding costs of renal dialysis in the U.S. Currently all dialysis patients are covered under Medicare. Dialysis access is a good portion of the practice at Acme Surgical Corp., and one of the few (if not the only) reason we participate in Medicare. Some of the data presented in the story were pretty amazing:
Costs of dialysis has risen from about $5 billion in 1991 to $15 billion in 2001
One percent of Medicare enrollees are on dialysis, but they account for six percent of expenditures.
In 2001 292,000 people on dialysis and 114,000 with transplants.
(Doing the math that comes to $51,000 per patient per year for dialysis, $37,000 per patient per year if you include the transplants)
Five year life expectancies:
Breast cancer 86%
Heart transplant 71%
Renal dialysis 34%
Pancreatic cancer 4%
I'm not surprised by that number, but agree with the conclusion in the article that, for the most part, dialysis patients have little idea how sick they are.
The figures above reveal the large sums associated with this dialysis. Dialysis rationing always comes up when discussion of a single payer system comes up. Those systems frequently use age as a determining factor as to allow dialysis or not. Given the rising age of dialysis patients in the United States, is that something we would be willing to use to determine care?
Loads of information on dialysis may be found here.

Wednesday, October 01, 2003

As the news out this week reported the Census Bureau's report of the number of Americans without health insurance has increased by 2.4 million people (or 14.6 percent) to a total of 43.6 million or 15.2 percent of the population of the United States. This is accompanied by a decrease to 61 percent of persons covered by health insurance at work. I wish everyone could become insured not only for the altruistic reasons, but because I do enough work for free as it is. While one can debate the scope of the numbers or how many of these millions are ininsured by choice, something is going to come of this I hope (or fear)
Everybody has a solution for the problem, but the Checkhov quote on Dr. Smith's main page hits the nail right on the head. No solution is going to make everyone happy. I think that two aspects of the problem are:
Health insurance is too expensive
Patients are insulated too well from the cost
This is why fewer businesses are offering coverage, it's eating up too much of the bottom line. Insurance is forced to be all things to all people, driving up the cost. I am of the opinion that health insurance should be like insurance for your car or house, available for unforseen emergencies, but not used for routine maintinance. Here is my simple plan for fixing things:
1. Disassociate health coverage from employment. Individuals should be able to purchase insurance themselves, and take it from job to job. They should get the tax benefits that companies get now on the premiums.
2. Individualize plans. Why should a young, healthy twentysomething have a plan with drug coverage? One reason why plans are so expensive is that they all have to include coverage for things that a person may never need.
3. Require some level of basic coverage to be purchased. This applies to auto insurance in my state, and will help spread the risk pool.
Simple plan from a simple man. I'm sure a "Fisking" will poke quite a few holes in my master plan. (What about those who can't pay for a basic plan....what about the elderly) But other plans have their faults too...

Medicare and Medicaid are caught between a rock and a hard place. They are underfunded and in the case of Medicare are going to have solvency problems in the future. They pay so poorly that physician participation is decreasing, and those covered by those plans are going to have a harder time finding a physician. So just saying "Medicaid for everyone" a'la Howard Dean won't work.

The single payer advocates seem to think that by eliminating the insurace companies they can come up with enough money to provide coverage for everyone. Physicians for a National Health Program want a system where everyone has the same coverage, and it is all funded by taxes. No co-pays or deductibles. You have to put some responsibility on the patient to ensure that resources are appropriately used. Even with seniors having to pay 20 percent, they are milking Medicare for all its' worth. A system such as this would either go bankrupt, or become like Canada's or Great Britian's with the waiting lists. It would be difficult to initiate co-pays after you have been giving it away. The lack of a private insurance market is also a problem. Americans are not going to take lightly being told that they can't get private insurance, especially if the national system is facing cutbacks. But won't that create a two-tiered system? you ask. I reply: is the goal to provide everyone with insurance, or to provide everyone with the same insurance? (I posted some comments on the PNHP report in August but Blogger seems to have lost them).

While I don't like always dividing people into two groups over an issue there are two camps with reasons for supporting universal coverage: the idealists who view it as society's job to insure coverage for all concerned, and the pragmatists who view the loss of productivity caused by sick people who can't get insurance. Or as put in Lawrence of Arabia :
With Major Lawrence, mercy is a passion. With me, it is merely good manners. You may judge which motive is the more reliable.
Back to work.
Lots of stuff I've been meaning to post about but my copy of Medal of Honor Allied Assault : Breakthrough came in and it's getting played pretty hard.
More to come..
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