Friday, July 31, 2015

Choosing wisely

I've mentioned this before, but as I have completed my clinical hours this year, I have been blessed to work with an MD who is very, very cost conscious. He has been in medicine for over 30 years, he has taught in hospitals, he has done research, he has provided expert testimony in malpractice trials, and he has run his own practice. It may surprise some, but he is fully in favor of a single payer system, and though he admits he might chafe some at changes he believes should be made, he fully believes that the way current doctors practice has a lot to do with why medicine is so expensive.

I asked him directly if he really believed tort reform is that answer, and further if he really believed that doctors order a lot of unnecessary test to just cover their ass. His response to the test part of it was that he really didn't believe that doctors did it out of covering their ass legally, rather, at least in his case, he has a fear of missing something. He also sheepishly acknowledged that providers tend to have big ego's and like ordering a test that confirms what they have already figured out. As for tort reform, he told me that in most of the cases he gave testimony in, he felt there was a clear lack of due diligence. It wasn't a matter that a test wasn't ordered as much as it was a matter that a doctor didn't really make much of a case in their notes for why they did or didn't do something. He has also said to me a few times, "You can be wrong, but you need to have a rational for why you did what you did"

This week, he showed me an awesome article in JAMA that I can't link because those bastards won't let you read anything for free on their site. In a nutshell, a patient started to develop chest pain that was basically a stable angina, IE his chest pain stopped when he sat down and rested. He was told at first he needed to go for a stent. When he asked if it would lower his risk for heart attack and whether he could be treated with just medicine, he was given a "take it or leave it" ultimatum. He went for a second opinion, and was told again to get a test without being given any real rational for what this test would do for him. In the office of a third MD, who wrote the short submission, the patient relayed his story and the third MD addressed his questions and admitted that the research is not there to support getting an aggressive procedure like a stent for his condition. So, the patient diligently worked to lose weight, change his diet, and also started a statin and an aspirin and did just fine.

The moral here, that my preceptor has been drilling into me is that the system orders and pays for countless tests and procedures that have little science to show they improve outcomes. Some maybe to cover their ass legally, but not enough to fully explain the problem. A big part of the problem is that patients are not medically literate, and countless MDs simply don't have the time to explain anything. Just this week, we saw a new patient who has had atrial fibrillation for 15 years, after I explained what that meant, she and her granddaughter said that no one had ever explained that to them. I found an interesting link I wanted to share This link talks a little more about this. For some, I understand that a single payer system will merely be a horseman of the apocalypse that indicates the end of freedom is neigh. For me, I see it as something that is long overdue if for no other reason to start to wring out the enormous inefficiency our system has. On that link, there is a section called "lists" that I think has really good information for patients.


  1. Mike that is exactly what happened to me. Chest pains when I was running around the restaurant during busy times and as soon as it slowed a I could sit for a minute the pain totally went away. From the start the doc called it angina at rest (Unstable angina) although I emphatically told him no when I rest it goes away. Anyway before the stent they went in with the micro camera to have a look see. The left coronary artery was 90% blocked. All the others were fine. What he explained to me was in that particular artery the plaque that we all build up over time had begun to "sag" into the artery causing the blockage so a stent was needed. Of course I am no medical expert but it all sounded reasonable. After reading your piece I don't know that exercise and diet would have changed a thing. I did embark on a diet and exercise regime mostly because I want off the damn pills. When I told him that in April he seemed astonished. this brings me to my next point. I think he was more used to patients wanting wanting wanting then saying hey lets get me off this shit. So I would like to know this next time you have a discussion with the doctor. How much stuff do doctors have to do because their patients are demanding more treatment or a different diagnosis or prognosis? I know some people who absolutely live to go to the doctor.
    My doctor (the general practitioner) also agrees with the single payer system. Both doctors thus far have been very minimal in their treatment, the cardiologist sometimes so minimal it even pisses me off and I don't even like being there. I was lucky in that I drew a cardiologist that could actually place the stent through the wrist so my pain and discomfort was nothing, I left the hospital with a bandaid on my wrist and after a month of no heavy lifting with that arm, I was good to go. I got this done at UNC/REX Hospital which they say is one of the best cardiology depts. in the nation. I dunno I have been satisfied, except still taking pills after all my hard work. Seems this a Standard Operating Procedure of some kind and time will get me off of all meds if I continue to do my part. I have a server who's mother had the same stuff going on. She is about 9 months ahead of me and is slowly dropping off the pills. Hope!

    1. Interesting they called it unstable when it went away with rest. That wrist entry method is interesting, I have to admit, I never saw that in the ICU, but considering how far behind the times medicine is here in Vegas, that's not surprising. Getting off the pills may be tougher, even if you do the right things. We use a calculator provided by the American Heart Association and you can click on the web version and put in your numbers and see whether the recommend statin or not. They recently changed the threshold on when to initiate statins and being male and getting older are, unfortunately, two unmodifiable statistics. :(

      On the plus side, change in diet can make a big difference, depending on genes. Some people are just stuck no matter what they do. I think it runs a little high naturally in my family, because even with eating meat, mine was still normal high. When I started to cut out more dairy, I finally started to move it down. I like the AHA calculator because it lets you manipulate the numbers to see what effect you can have by lowering BP and cholesterol. It kind of gives you some targets.

    2. Whoops, that should read even without eating meat my cholesterol was high normal.

    3. Single payer system

      A great idea the only part is the payer, government.
      Reference the fraud, abuse of medicare, medicaid.
      Reference government incompetence with the VA.
      Reference the reality of cost.
      People want every thing and no one wants to pay for it.
      Should we have a national sales tax or VAT tax? Everyone uses it, everyone pays?
      Perhaps make all of business pay for it? Unintended consequences?
      Add a 20% tax hike on all taxpayers and think that will do it? Unintended consequences.

      The problem with giving government more to spend is they don't care, it's not their money.

    4. And there we have it. Government sucks, therefore we can never have a single payer. What frustrates me about hearing this repeated so flippantly Lou is that private insurance is not any better. I was going to address each one of your points, but then thought, why bother?

    5. Fraud in private business costs you nothing as it falls to the stock/bond holders.

      Fraud in government falls to the taxpayer who pays the bills.

      Government does suck because they don't care, it's not their money. There's more where that came from.

      You call for a single payer system today without a way to implement it unless we use our bloated broken government.

      I call for fiscal responsibility first before we further trash the healthcare system.

  2. The stories there suggest to me that crackdowns are increasing. The size of healthcare spending is gigantic and no matter who is running the payment stream, which is all that insurance does, there are going to be people who try to find ways to scam the system, just as there are thieves who steal identities, and get cash with stolen credit card numbers.

    You ask for fiscal responsibility, and I tried to post one thing up top that actually addresses some of the problem. I see a lot of waste from the inside and while the government isn't perfect, I just don't think you are willing step an inch from the position that anything the government manages by design has to be a failure.

    1. The stories suggest that fraud is more common that people like you would like to believe.

      Are you ready to become a government employee?

      As far as government, at one time they had great accomplishments. Sent a man to the moon. The creation of nuclear power.

      Those days are gone. We spend 1 trillion a year on medicare and medicaid. 25% of all spending

      Both programs were created back in 1965. Congressional budgeters at the time thought Medicare, the healthcare program for the elderly, would cost about $12 billion by 1990. The actual cost that year was $90 billion.

      We should have seen it coming. After all, it didn’t take decades for actual Medicare and Medicaid costs to overrun projections. That pretty much happened right away. In 1965, the House Ways and Means Committee estimated that Medicaid, the jointly funded federal-state program originally meant to cover the poor, would cost $238 million in its first year. It actually cost more than $1 billion. By 1971, Medicaid spending had reached about $6.5 billion, blowing away all previous estimates.

      Here's the issue.
      Why give government more responsibility oversight of our healthcare until they clean up the mess they currently have. Why give them all our healthcare dollars when they cannot get fraud and abuse under control?
      Single payer, how to pay for it. Everyone wants it, no one wants to pay for it.

    2. The Soviets had single payer. Until it collapsed.

    3. As I read your stuff here Lou, here is what I take awake. You make a case that is simplified to meet a political view. Medicare and Medicaid are expensive, this is a fact. Medicare and Medicaid patients are also way more sicker, collectively, than those in private insurance who are younger and have jobs. The government may suck, but it has nothing to do with this reality that these patients are a lot sicker and with or without fraud, their healthcare is going to cost a lot more than the healthcare of a younger patient who is not yet chronically ill.

      There is a perfect conundrum in what you are asking. Why give the government money if they can't run what they have? This is a statement that doesn't want a solution, because if a solution is put forward and the government does run it efficiently, this will only begat more government. I think that whether it works or not, you don't want single payer. I don't want more government control per se, but I just see an enormous inefficiency in the fact that private insurance gets healthy people, tax payers get the ones who are sicker. Private insurers do not want sick people. THIS is what I am interested in solving.

      Do I want to work for the government?
      Essentially, I already do. As a hospice nurse, I would say 80 odd percent of the people I care for are insured by the government one way or another. Frustrating as it may be to deal with the government at times, I don't buy your premise that the government just takes money and doesn't give a shit about being defrauded. there are many interests at play here, the interests of those who to see every government program ended and hence act to make sure said programs stay dysfunctional. there are the interests of those who want to scam and embedded in this is that a big part of the problem is that the government gets defrauded because the scammers prey directly on the seniors, there are interests of private insurance who want to make sure they keep their franchise above all else, and yes, there are those who blindly want single payer without really addressing some of the few legitimate concerns you raise.

    4. I get it.

      You want single payer.

      I also get it, Americans want everything and don't want to pay for it. The poor say, us, we can't afford it. The middle class says we pay to much already. The wealthy, what ever that is pay the majority of Federal Income Tax. Business, some actually pay for healthcare for their employees. The solution, let government hand out healthcare? I hope not. Perhaps when we finally address government and government employees and the way government does business we could have government handout healthcare. Until they prove they are responsible with our healthcare dollars, no thanks.

      Healthcare costs to much. Are healthcare workers all ready to take a 50% pay cut? Are Americans ready for a no when they demand a MRI? Are Americans ready to accept death instead off extraordinary measures to extend their live by 3 months? Healthcare costs what it does because Americans demand more not to mention their insatiable appetite for food.

      No you don't work for the government. They do not set your wages, benefits, retirement.

    5. For what it's worth, I want single payer as a consequence rather than a love of government. The dichotomy of for profit cherry picking health patients while leaving sicker patients for tax payers seems ridiculous to me. Do you think this is even an issue?

      Your second para there is what really gets to what I am talking about. Independent of whatever incompetance government control may or may not bring, you start to hit on very real things that need to be addressed. The original link I posted addresses some of this, but you ask the key question, are Americans ready to hear the word NO when they demand an uneccesary MRI? How would you address this? Doctors like the one I am doing clinical with are taking it upon themselves to be gatekeepers to keep the system solvent and reduce cost. I guess, while people like you and I can have an honest disagreement about a single payer system, I would hope that on a bigger scale, people could agree to disagree on that issue while still agreeing to go after things that clearly are independent of government incompetence.

      What is probably going to happen is that there will be an effort to drive down wages of healthcare workers rather than tell Americans they should consume less unhealthy products while consuming unecessary healthcare. We are built on a premise that consumption and market forces are the answer to everything and I think this is a bad framework to shape discussions on healthcare. A discussion I have frequently with others in healthcare is that if a resource exists, it will be used and likely overused to justify its existence. And yes, I see the irony of that when it comes to government programs.

      As to your last sentence there, it's a matter of degree. Medicare already sets the price it will pay for services, and respectfully, I think you underapprciate how much medicare does to try and reduce unecessary costs. My wages here are only minimally set by "the market" and are much more driven by the reality that so many of our patients are medicare patients. I left the for profit hospital environment where I was literally making 15k more a year.

    6. Lou I don't want government healthcare for free. I think probably Max doesn't want it for free either. I am willing to pay a premium just as I do for my insurance now. As for the poor we pay for them already. you know Lou there was a time not all that long ago that our VA system was held up as a model healthcare system for efficiency and the care it provided. A decade and a half of getting guys blown up and maimed has now overwhelmed it. My father in law when he was alive would go no where else except the VA.

    7. The Huffington Post recently reported that “238,000 of the 847,000 veterans with pending applications for VA health care have already died.” And that’s on top of coast-to-coast wait-time scandals that literally cost lives (at least 42 facilities have been investigated) and other scandals including sexual misconduct, drug rings run from VA facilities, and thefts from dying patients. VA employees even “fail to show up for work” at a rate “exceeding every other department and agency.”

      Against the backdrop of unrelenting scandals, how much job security do VA employees currently enjoy? This much: The VA recently claimed that it fired a grand total of 60 people in connection with the wait-time scandals that implicated dozens of its facilities. Yet this was manifestly untrue. The Washington Post’s Fact Checker gave the claim four Pinocchios: Disciplinary actions for 75 employees have been proposed since June 3, 2014. . . . The proposed actions included removals, admonishment (a written letter of censure), reprimand (a stronger letter of censure), suspension of less than two weeks and probationary termination. . . . Of the 75 employees, only eight employees have actually been removed, as of February 13, 2015. Twenty-three cases were pending. Five employees resigned before a decision was made on their case. Others were demoted, were on probationary termination, had some other disciplinary action, or had no action taken at all.

      Not only is the VA broken but our government is broken.

      People do not get fired they retire on a cushy pension, just ask Lois Lerner.

  3. Rick,
    You, Max and I are not like the rest of America. Not all of the 45% of Americans riding the free ride are not the, oh the poor, poor people, many are just like you and Max except they want FREEE. Obama added 10 million middle class Americans to the Free role when he made most of the Obama/Bush tax cuts permanent.

    Here's to your BS about the VA.

    There are hospital doors at the half-built ­Veterans Affairs medical center outside Denver that were supposed to cost $100 each but ended up ­running $1,400. There’s a $100-million-and-still-rising price tag for an atrium and concourse with curving blond-wood walls and towering glass windows. And entire rooms that had to be refashioned because requests for medical equipment changed at the last minute and in other cases the equipment didn’t fit. No one had bothered to measure.

    Not even completed yet, this $1.7 billion facility is already among the most expensive hospitals in the world, and it’s just one of several VA hospital projects that are greatly over budget and behind schedule, according to the Government Accountability Office, the investigative arm of Congress.

    “Everything that could have gone wrong did. It’s just an astounding price tag,” said David Wise, who wrote in a GAO report about the Aurora project and VA construction problems in Orlando, Las Vegas and New Orleans.

    The hospital construction woes are the latest in a long line of troubles that the Department of Veterans Affairs faces, from accusations of retaliation against whistleblowers to a backlog of compensation benefits to reports that wait times for appointments in some parts of the country still haven’t improved. Wait times range from 30 days to more than six months.

    As a side note they forgot to add parking. The cpst of the parking structure, 180 million dollars. It will exceed the 2 billion dollar mark before it's finished. The amazing thing about a government job, incompetence is rewarded with a cushy retirement and no one in government is ever held responsible. Ask Lois Lerner.

    A Department of Veterans Affairs executive is “stepping down” after reports that he received nearly $64,000 in bonuses despite overseeing $2 billion in cost overruns at four troubled VA hospital projects, including one in Aurora, Colo., that is now the most expensive hospital in the VA’s history.

    Glenn Haggstrom, principal executive director of the Office of Acquisition, Logistics and Construction (OALC), is no longer an employee of VA, a VA statement released Wednesday evening said.

    Haggstrom “retired” from federal service in the “midst of an investigation, initiated by VA, into delays and cost overruns associated with the design and construction of the medical center in Aurora,” the statement said. “Haggstrom had recently been relieved of any decision-making,” the statement said.

    The VA called the situation with its Aurora hospital “unacceptable.” But Haggstrom is still entitled by law to apply for federal retirement benefits, officials there said.

    This is a great example of gross government incompetence. Need more? The internet is filled with government waste corruption bloat.