My Blog

August 22, 2014


Filed under: Uncategorized — Tags: , , — admin @ 11:25 am



“Guess where the coldest place in the country was yesterday?” I asked.
She of course knew the answer, having heard the question many times before; many times, as in every morning for the past five years.
“Uh, Stanley, Idaho?” She replied.
“Yup,” I would say. “Thirty six degrees.”
This being the middle of June in Florida, where heat and humidity could wring sweat out of a corpse, thirty-six degrees was something to be coveted, almost worshipped. For at least the next three months, sweat and outside were synonymous. Even a trip to the mailbox could cause beads of perspiration to envelop the skin.
“You know…” I started to say.
“Don’t say it,” she interrupted. “We should go visit Stanley someday, right?”
“Yes. We could rent an RV and drive cross country and…”
“Forget it,” she interjected again, “You know I don’t do road trips.”

I had practiced medicine for over 35 years, most of it in Florida, and was on the cusp of retirement. One of my goals was to travel more, but my wife, Denise’s profession as an art teacher would at least over the short run, damper that somewhat. She and her daughters had carefully planned a retirement party for me on June 28, 2014. I never expected what ensued.
As music, drinks, and food flowed, my youngest daughter, Emily, tapped a spoon on a glass to get the crowd’s attention. My praises were spoken and then Denise presented me with a colorful folder. She briefly gave the inside story we shared daily about Stanley, and inside the pamphlet were beautiful color pictures of the tiny town with the Sawtooth Mountains in the background. I laughed as I flipped page after page filled with pictures and fun facts, 2010 population 63, elevation 6253′ above sea level, and no stop lights.
“We’re loosing the audience here,” I complained. “I think they got the joke already.”
“Keep turning,” she insisted.
Taking a deep breath, I finally got it. On about page five or six, was a series of reservation numbers for flights, (in and out of Boise, Idaho) and car rentals. She had recently been painting furiously and had made enough money to pay for our “dream vacation.”
What had a first been a “groundhog day” type joke, was now an imminent reality. The crowed laughed and our combined five daughters giggled at my shock and surprise.
Having grown up in rural New York State, I was familiar with small towns. However, Middletown, NY, (pop. ~20,000) was a bustling metropolis compared to Stanley. I had been a boy scout and camped in the woods, cooked my own food over an open fire, washed my mess kit in a stream and even got up at 4 AM to watch beavers build a dam. But since then I have lived in large cities, Cleveland, San Diego, Houston, and now St. Petersburg. My travel was less tent and RV, but upscale hotels, B&B’s and fine restaurants. Was I now ready for almost a week in town with six dirt roads in the middle of a national forest?


The only part of the trip Denise had left to me was lodging. Tapping in hotels for Stanley in Google, yielded eight choices, (not including cabins and guest ranches). Some were even reviewed on Tripadvisor! After a few phone calls, a pattern emerged. The weekend of our trip someone was planning a wedding and most rooms were booked. With sixty-three residents I assumed this was most likely a “destination wedding,” From where? Boise? I finally got room at the Sawtooth Hotel that looked lovely, but there was no TV. The Riverside Motel had vacancies but after two days we would have to relocate from a riverside unit because of the wedding. The temptation to fish off my front porch directly into the Salmon River was irresistible. Reservation made.
My neice in Ann Arbor’s boyfriend knew someone who they said had grown up in Stanley––really. She contacted her and she wrote back to say alas no she hadn’t been born or grown up there, but had spent time there with family and gave up some useful tips. Everyone seemed to mention McCoy’s Bait and Tackle shop and after emailing them we got a reservation with a fly fishing guide Mary Ann Dozier. So we booked her for Sunday August 17, my birthday.
I nervously monitored the temperatures in Stanley daily and saw they were having a “heat wave.” To us however this was wintertime Florida weather with highs in the 80′s and lows in the 40′s. The key was the humidity was less than 40% so no worries.
“I think we should get a Go-Pro for our trip,” Denise said.
“No,” I said. I’m not wearing that thing on my head and besides my small Canon Powershot will be fine. I’d rather spend $300 on fishing then another electronic device.” In truth part of me wanted to do this and then I found out a friend’s son owned one. Could we borrow it? Yes. Eureka!


July 7, 2014


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Having just retired on July1, my medical group’s commercial health insurance policy is no longer available to me. However, being past 65, I started a year ago applying for Medicare benefits. Despite my knowledge in this field, I had assumed this would be a snap. I also had assumed that my Medicare patients who enrolled in a Medicare HMO (Medicare Advantage), did so for purely economic reasons. My experience has been nothing short of an eye-opener. I should have of course known better, embarking on any venture with a government agency. I signed up on-line for Medicare Part A, but Part B was more challenging since I didn’t want to start collecting Social Security at the same time and the computer program didn’t like this.

There is of course Medicare Part A, which covers hospital bills, and Medicare Part B that covers other medical and physician service. Then there is Part D that is the drug prescription plan. Medicare HMO’s combine A, B and D for one set fee and are known as Medicare Part C, or Medicare Advantage. However, hospital, physician, and drug choices are severely limited when signing up for Part C, no matter what the insurance company’s marketing advertises. “Medigap” plans can be purchased to fill in the many holes which A and B do not cover, for another premium. This is also called Medicare Part F. Are you still with me?

Now there is also Medicare Parts E, G, H, I, J, K and L. But let’s skip those for now. By late spring of this year, my head was spinning. I threw in the towel and used an insurance expert to help me navigate this alphabetical morass. Within the past two months, hardly a day would pass without some document arriving form Medicare, Social Security, or United Healthcare, the private insurance company that I had chosen for my Part D and F plans. Thankfully, they have an almost 24/7 telephone help line. I was told in writing no less than three times that my Medicare Part B would be higher than normal due to my “high” previous year’s income. I was asked in writing to verify, in writing, why I hadn’t applied for Medicare Part D benefits from the start of the year, etc.

My epiphany was that many of my former patients probably chose Medicare Part C or HMO plans, not just to save money, but also not to have to deal with this endless maze of paperwork and redundancy. This system is so cumbersome, arbitrary, and difficult to understand that only another government agency, the IRS, can make it look simple.

I have come to the conclusion that navigating all of these arms of the Medicare tendrils is almost a full time job. I have a much better appreciation for what my patients have had to endure all these years while I was simply trying to diagnose and treat their heart disease. It is no wonder our Medicare system is such a mess.

May 25, 2014

How the VAH Scandal Applies to All of Us


Whether you are a veteran of not, the recent report of “waiting lists”, and possibly preventable deaths of veterans, has implications for all citizens. There is no large health system which functions perfectly. But I would say that the efficiency of any given system is inversely related to its size. If this is true, then the VAH system is, and has always been, a bureaucratic and wasteful mess. Like most physicians trained in this country, I rotated through many VA hospitals, from Cleveland, to San Diego to Houston.
Many veterans receive important and good care at these facilities. However, many are shorted good care not for lack of funding, but due to layers upon layers of bureaucratic rules, regulations, and officials. Long before there were diagnostic-related groups, or DRG’s, for private hospitals, the VA health system was famous for extraordinarily long lengths of stay. So long in fact, that when I was a house officer at the La Jolla VAH outside San Diego, we had our own admitting diagnosis-IFTW, (in for the winter). Veterans came from the north and Midwest, got admitted for something, and stayed hospitalized for months.

Now the pendulum has swung to the other extreme and patients have a hard time getting admitted and staying long enough to be stabilized. (This is not unique to the VA system and affects private medicine as well.) I have recent first-hand experience with this. A friend of mine, who is a Vietnam War veteran, had to wait nine months for hernia surgery. Admittedly this is not a lethal condition but the story of my father-in-law was. A wounded WWII veteran, he was an insulin-dependent diabetic for over 30 years. He had already lost one leg due to the disease. In his eighties, his diabetes became increasingly brittle. It was not uncommon for the ambulance to appear several times a week at his ALF, for symptomatic blood sugars of 50 to over 500. He was repeatedly “stabilized” in the local VAH ER, and then sent home. Finally, I told my wife to tell the ER staff that she was not leaving the ER, unless her dad was admitted. That worked––at least for three days.

His blood sugar was no better after discharge and two days later EMS was again summoned to his residence for hypoglycemia and syncope. He was readmitted and at this point I intervened. I spent over 30 minutes on the phone arguing with a hospitalist about how he needed an endocrinology consult before discharge. Ultimately she relented. Later I found out that his clinic endocrinologist did not even see him, but only an “endocrinology PA” visited and did a consult prior to discharge.

I called his doctor and asked about an insulin pump. I was told he was “too old.” Later at a nursing home his other leg developed gangrene and he refused more surgery. He and the family chose hospice care, where he quickly died. I have often wondered if his last few years would have been different in a private hospital.

I doubt that ACA will make this any better for non-veteran patients. Simply insuring millions of patients with a Medicaid-like product does not guarantee access to care. In fact, a recent survey of thousands of doctors estimates a least one-half will not accept patients in the future with Medicaid or ACA-insurance. Wait times for potentially life saving care will become the norm and unnecessary deaths a reality.

Do I believe that there were secret “wait-lists” at VA hospitals. I’m not sure, but I wouldn’t be surprised. Surely Washington administrators and executives had to have known. And if they did not, then they should be fired. In fact, I have longed argued that the government could save billions, and veterans could receive better care, by simply giving health insurance vouchers for their care in the private system, instead of a VA hospital or clinic. Do I think this will ever happen? No.

It is unrealistic to expect a monumental bureaucracy like the VAH to deliver timely and efficient medical care routinely. It is laden with career government employees who sadly care more about their jobs than good care for our veterans. At the bottom are wonderful and giving nurses and other staff, but at the top are people whose only goal is to preserve the status quo and keep their job until retirement and secure a government pension. Efficient care is an anathema to such a system.

I predict we are headed for a two-tiered system of healthcare in our country––those who wait for care, and those who don’t. And in this respect, what happens in the VA health system has implications for all of us.

January 18, 2014

The Death of the Progress Note

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I am not sure of the date or time of death. However, I am reasonably certain of the cause. Death was by electronic data and formatting. The victim was the time-honored physician’s progress note. To be sure, these notes, even the now “ancient” written ones, were far from perfect. Shortcuts such as “as above” or AVSS (All Vital Signs Stable) littered the pages of the now nearly extinct hospital chart. Yet, what now replaces it more resembles “computer vomit” than anything readable or coherent. The EHR is drowning in data excess where the truly pertinent information is at best lost is a sea of cut and paste gobbledygook, and at worst, repetitive false information.

The designers of the EHR sowed the seeds of this mess. Initially computerized health records were created to more accurately bill medical procedures, CPT codes, and hospital services. Clinical information was added out of necessity, but layered on a framework of billing and coding, making a very imperfect marriage as the final product. Having used our office EHR now for ten years, and learned four different hospital systems over the past few. Thus, I have seen more than my share of this landscape, and trust me, it isn’t pretty.

I have worked with IT personnel to try and make my notes more readable and coherent, and have used everything from larger fonts, to SOAP formats. But in order to comply with coding requirements for mid-level and higher coding, I am forced by Medicare to throw in stuff that is redundant and clinically useless. For example, “No change in PMH/FH/SH/ROS.” (Translation: Past Medical History, Family History, Social History and Review of Systems.) Since it is unlikely that my patient with CHF or atrial fibrillation will remember a new symptom, or discover a family member had a stroke, between day one and two of his hospitalization, this exercise is a waste of time, but required by CMS if you want to be reimbursed for a complex visit.

I review my patients’ medication administration record, (or MAR), daily. However, if I document those medications in the record, the end result may be a morass of unorganized and scattered drugs. The worse offender here is the Meditech system used by HCA hospitals. When incorporated into the progress note, the list is neither alphabetical, by date or route of administration. In other words, it is a disorganized mess. This quirk has been pointed out to the Meditech IT staff, and they say they have forwarded the doctors’ “concerns” to the programmers, who say they are “working on it.”

The other issue with the electronic progress notes is the “carry forward” features. The Meditech physical exam auto-fills from the previous day, unless you specifically change it. This is nice for the time pressed doctor, but leads to false and inaccurate documentation. I have seen patients who days following extubation still have noted an ETT in the mouth. In order to keep the physician “honest,” you must fill in “General Appearance” daily, but the rest can be an all too easily repeated. Ditto for the Impression and Plan. Again I have noted plans like, “For bypass surgery” a day after the procedure was completed. In its defense, you can free text anywhere, but that takes work and typing skills, and many older doctors simply are lacking here. And the local HCA hospitals have refused to install voice recognition software to make the docs’ jobs easier.

Other hospital systems force the doctor to refill the H&P daily, but there are auto-click buttons, which when repeated daily are obvious cookbook catch phrases. You can free text for sure, but again that takes more time. Local Baycare hospitals have thankfully installed proprietary voice recognition software to accommodate the “keyboard-challenged” physicians.

The end result is often a misleading and unhelpful recording of the day-to-day patient’s progress. There seems to be more than enough information in the notes, it’s just that the “forest in lost inside all of the trees.”

I place the blame at the feet of CMS and insurance companies. They are the ones who have created this checkbox and laundry list approach to medical documentation. That is if the doctor wants to get reimbursed for anything above the simplest visit level. I review others notes and have to search for nuggets of informative prose. Emergency department notes are even worse. It takes effort to sometimes find out why the patient even sought urgent care.

There must better information systems around. Unless we can free ourselves from being reimbursed by the number of words in a note, I fear the valuable physician progress note will continue to drown in mountains of data and illiteracy.

October 23, 2013

Guess What Might Just Save Healthcare

Filed under: Uncategorized — Tags: , , , , — admin @ 2:30 pm


If you are like millions of Americans, at some point in your adult life, your doctor will order you to have a CT or MRI scan. Quick, easy, and painless, (unless you have claustrophobia), these invaluable imaging tests provide a vast amount and array of diagnostic information about illnesses, and direct treatment paths. However, the real pain usually begins when you receive the bill. It is not uncommon for the charges, including radiological interpretation, to run into the thousands of dollars. However, as those of us in the medical field know, “charges” do not = “costs.” So what exactly is the cost of these tests? Good question.

It is not uncommon for a MRI, (Magnetic Resonance Imaging), to cost $2,000-$5,000, depending upon where it is done. So how about charging just $275 for the test? Sound like a myth or joke? It isn’t, if you go to Affordable Medical Imaging, ( So here’s the catch: they do not accept insurance or fill out insurance forms. Neither do they wait for payment. The patient pays the bill at the time of service, and the company gives the interpretation results and billing information to the patient. The patient may then submit it to his or her insurance company for payment.

How can they do that and still make money? The answer is easy. Without having to bill insurance companies and wait for authorizations and payments, the supplier to consumer short cut saves thousands of dollars in overhead costs. It may come as a shock to many, but health insurance is in large part the problem, and not the solution, to not only skyrocketing health care costs, but also access to care in this country. Insurance sets the rates of payment, including Medicare, (which by the way is the worst offender), and thereby increases overhead for hospitals and doctors. Since Medicare “rules the roost” over how providers get paid, and how much, they have no competition. One of the immutable laws of economics is that no competition=increased costs. This is true whether you are selling hamburgers or imaging tests.

One of the problems with health insurance in the US is by its history and very nature; it functions like no other insurance product. Imagine if your automobile insurance was forced to pay for preventive maintenance and oil changes. Or your homeowner’s policy covered a couple of shingles knocked off a roof in a storm. If they did, then how affordable to you think those policies would be? Every time insurance is excluded form the equation in medicine; prices go down––think LASIK and plastic surgery. Insurance, by its very nature, is meant to cover episodic large, often unpredictable, events; not everyday minor problems.

The difference however between health insurance, and others, is the implicit belief that everyone, no matter how rich or poor, is entitled to basic coverage for illness and accidents. Although still somewhat controversial, it is this essential belief that makes that coverage either very expensive, or not accessible, as in rationing. Unless this paradigm changes, and I doubt it will, medical insurance will continue to escalate and health care more difficult to access.

To be sure, not everyone can afford high deductible health insurance plans. Although the Affordable Care Act, (a.k.a., Obamacare), will reduce premiums for some, it will raise them for many more. Yet, if the truly free market were permitted to grow in health care, prices could only come down for everyone. Imaging is the easiest place to have price competition as Affordable Medical Imaging demonstrates. But there is absolutely no reason why it couldn’t be done in other medical and surgical fields as well.

Medicare, as an arm of the government, changes reimbursements for often arbitrary and political reasons. As an example, up until a few years ago, there were 100′s of freestanding cardiac catheterization labs across the US. That was until Medicare decided to reduce payments to these labs below the actual level of costs. No matter that most labs could do a heart cath, charge between $1,000-2,000, (including facility fees and professional charges), and still make a profit. Instead, and due solely to favored payments, outpatient heart caths went back to the hospitals where charges for the same procedure are typically between $5,000-$10,000. That is an example of how preferential pricing can be a major driver of health care costs.

The roadblocks are substantial. The medical insurance and hospital industries have vested interests in keeping costs high. And as long as we view the holy grail of medical care being equated with having similar insurance for all, costs will never become significantly lower, and access will be come more two-tiered. Sometimes the simplest solutions are the best ones.

October 19, 2013

You might want to be a doctor if

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You are young and bright and starting to think about a career. Maybe you are graduating from high school or in college, or floundering around part-time in some tech job. Here are 10 questions to ask your self:

1. Do you love spending lots of time everyday on a computer, Smartphone, or tablet?
2. Do you have a high level of frustration?
3. Do you enjoy making life and death decisions, but also don’t mind having them reviewed by a bureaucrat or regulating body?
4. Can you excel at multi-tasking and don’t mind being interrupted dozens of times a day?
5. Are you flexible enough to learn new rules and regulations at work daily?
6. Can you type or keyboard really fast, (say like at least 50 WPM)?
7. Can you handle someone else telling you how long you can spend with a customer? Whoops, I meant patient.
8. Are you challenged by a lifetime of perpetual course taking for re-certification of things you already know and do well?
9. Do you consider it a challenge to learn an EMR designed by a non-clinical programmer?
10. Do you consider it stimulating to diagnosis and cure disease but at the same time try to avoid a malpractice suit in case you are wrong or err?

If you answered yes to most of these questions, then I’ve got the career for you, young man or woman––become a doctor. Yes, some of the above is tongue-in-cheek, but my observations of the present state of medicine, tells me it is not too far from the truth. I have the advantage of the long view, having graduated from medical school in 1974 and been in private practice since 1979. A lot has changed––some for the better, and lot of it not.

What I do see is many of the doctors my age are choosing to retire early out of sheer frustration. The younger doctors don’t know any better, and seem to accept many of these roadblocks to good patient care as “normal.” They even seem to enjoy the challenge. But herein lies the paradox. As a general rule, many of us chose medicine because it offered autonomy and the satisfaction to heal the sick. Yes, it has paid well, but we delayed entry into the labor force by 10-15 years. And the salaries are only headed downward.

Sadly now a typical physician spends more time on a computer than talking to, or examining, a patient. Ditto for the nurses. The trend in public policy is to expand healthcare coverage to more people, which is a lofty goal indeed. However, within the thousands of pages of ACA (Affordable Care Act, AKA, Obamacare) are no provisions for increasing the number of doctors to care for new patients who sign up. (That is assuming the Health & Human Services actually creates a functional website.) What I foresee is a perfect storm for shortages in healthcare providers.
Older physicians, like myself, will give up in disgust, and less young people will choose this profession. More care will be provided by “physician-extenders”, like nurse practitioners or physician assistants. More hospitals will sponsor marginal quality “teaching programs” with questionable community doctors as the instructors, so the hospital can rake in millions of federal Medicare money. In October of 2014, ICD 10 will be implemented making a coding nightmare for doctors and their office staff. As an example, envision 12 ways to code for infections of the hand. Solo and small group offices will be forced to close, collapsing under the weight of bureaucratic and regulatory rules gone wild.

I would like to be more optimistic, and hope that I am wrong. After all, peers, my family, and I will need more, not less care as we age. However, unless something fundamental changes, we are headed to a homogenous and less available system of health care in this country. Increasing the number of medically insured does not guarantee increasing their access to care.

August 19, 2013

The Schizophrenia of Hospital Discharges


A long time ago, in a bygone era, hospital discharges were simple. As a physician, you decided when to admit and discharge a patient from the hospital. Unfortunately, this process was often inefficient, costly, and subject to the whims of doctor and patient. Medicare, and other third-party payers, ultimately realized that this format made little sense and motivated keeping patients in the hospital too long. Many unethical doctors gamed the system by ordering questionable consults, insuring excessive lengths of stay, (LOS). As an attending physician, the longer the LOS, the more money they made for daily hospital visits. Sadly, to some extent, this practice still exists today. In the early 1980′s, Medicare instituted its Diagnostic Related Group, or DRG payment method, which capped hospital reimbursements by a given diagnosis, rather than upon a per diem basis. So the longer the patient stayed in the hospital, the more money the hospital lost. Conversely, the shorter the stay, the more money they reaped. Doctors, except for surgeons who did an operation, were excluded. Thus doctors and hospitals became entrenched on polar ends of the incentive equation.

This misalignment of financial incentives was a major factor in the birth and popularity of the new Hospitalist specialty. Of inpatient Medicare claims for internists, the proportion handled by hospitalists jumped from about 9 percent in 1995 to about 37 percent in 2006. The percentage today is much higher. Often employed by the hospital, the latter now had the muscle to hurry the patient out of the in-patient setting, which increased the facility’s profits. Alternatively a hospital group could be contracted for services by a hospital. If it’s LOS profile was less than satisfactory, the contract was not renewed or voided. But the hospitals faced another thorny issue. That was how to get the majority, if not all, of their in-patients admitted to the hospitalist’s service, and not that of a community physician. To mandate this would be in direct violation of many medical staff bylaws or rules and regulations. Some have done so by so-called “economic credentialing”, pressuring credentials and Medical Executive committees, to not renew admitting privileges of “over-utilizers.”

Others, like one local hospital, simply ignored the medical staff’s rules and regulations, and instituted a policy of all “unattached” emergency room patients needing to be admitted by a hospitalist. Faced with declining hospital reimbursements for visits, may family doctors quickly figured out they could make more money by seeing office patients and reluctantly, or gladly, relinquished admitting duties to the hospitalist. As a result, patient care has not always improved, and in others, actually suffered.

Studies found that although the hospitals saved money with hospitalists in charge, Medicare didn’t. Often hurried out of the hospital before stabilized, re-admission rates began to climb. This “revolving door” consequence cost Medicare, and other insurers more, but increased the hospital’s profit. You see, even if a patient was discharged, and re-admitted one day later, the meter would be reset and a new DRG payment to the hospital was initiated. Perhaps slow and inept, Medicare is not completely dumb. On October 1, 2012, they started to financially penalize hospitals for “excessive” readmissions. The penalties involved are not small. If the readmission rates go above a certain percentage, the fine can be in millions of dollars. And the readmissions are for anything and anywhere. So if a patient in Miami is discharged from a hospital with congestive heart failure, and then is admitted in Michigan within 30 days of discharge with pneumonia, the Miami hospital is dinged. The actual rules of Medicare’s Hospital Readmission Reduction Program, which was birthed as part of ACA or Obamacare, are too complex to detail in this blog.

However, suffice it to say that now the “shove them out the door” policy perfected by hospitalists may backfire, and cost the institution more money than it saves. This schizophrenia of hospital discharging gets even more complicated when you consider that realistic fears of litigation drive many ER physicians to err on the side of admitting, rather than discharging patients. In answer to this, some hospitals are now experimenting with utilizing hospitalists in the emergency room

This has left a muddy picture for patients, and their families, caught in the middle of what is in essence more of a monetary, than quality of care, battle. Ultra-short, or long, hospital stays are often not in a patient’s best interest. Sadly, we may have replaced a costly and at times inefficient system, with one driven purely by the “best reimbursement profile” of the day. Ideally, it would be great if third party payers supported and preferentially directed its patients to centers of excellence, where patient discharges are neither too early not late, and can prove good clinical outcomes. How to measure and evaluate this will not be easy, but it is certainly not impossible with today’s metrics and wealth of health outcome data.

July 27, 2013

Another French Paradox

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The French Paradox is the observation that French people suffer a relatively low incidence of coronary artery disease (CAD) despite having a diet relatively rich in saturated fats and cholesterol The term French Paradox was coined by Dr. Serge Renaud, a scientist in France and made popular when described on the CBS news show “60 Minutes” in 1991. The theory goes that the French people’s large consumption of red wine helps to decrease the incidence of CAD by as much as 44% compared to other Western countries, in particular the United States. Other theories such as low genetic predisposition to CAD in the population and generous consumption of fresh fruits and vegetables were largely ignored. Also not mentioned was the leading cause of death in adult French males––cirrhosis of the liver.

But this is a curious topic for another time. I have recently observed something else about the French while my wife and I traveled for two weeks in Europe. We were in five countries: Germany, Switzerland, France, Belgium, and the Netherlands.
My wife made the interesting observation that most of the obese people we saw were Americans and not the natives. Our friends, who live in Amsterdam, also said many were Eastern Europeans. Nonetheless, I too was struck by the relative slimmer size of the Western European people. As a cardiologist, I started to ponder the paradox. Here were people who lived on bratwurst, beer, pretzels, chocolates, and pastries, and yet compared to pot-bellied Americans, you would think they were all Vegans.

Maybe it was because so many of them smoked I mused. Then I envisioned all of my obese patients who were smokers, and tossed that theory out. Next was the portion theory. Sure our portions are huge here, but what we ate at restaurants in Europe was far from tiny. There were some other clues. Here in the states, I suffer, as many adults do, with lactose intolerance. Yet, in France, I ate cheese, butter, and cream with little indigestion or flatus––yet another puzzle.

My wife, the artist, has a theory. She is convinced that food additives and preservatives are the culprit. Indeed a quick Internet search revealed that there are over 1,400 man-made chemicals added to the American food supply today. There are “natural sweeteners” as in high fructose-corn syrup, artificial sweeteners’, and “natural flavorings”, meaning annatto or guar gum, etc. A whole cottage industry of “chemical cuisine” has taken over much of our foodstuffs today. In my mind, the health impact and contribution to our obesity epidemic is unknown, undefined, and suspect.

So as we made our way through a veritable gustatory journey of overtly high fat and high caloric food, my thoughts turned toward my waistline. Since age forty I have added about a pound a year, and my self-image as a “slim” person has been in jeopardy. I weighed myself before leaving for Europe and two weeks later upon return.

Despite sinful indulgences such as pretzels, beer, Belgian French fries, (or pom frites, minus their traditional mayonnaise), French bread, pastries, and hot chocolate so thick you could stand a spoon up in the cup, I was stunned at my weigh-in. I had gained only one pound!

I don’t think I’m any closer to an answer about this paradox than I was before our trip. However, I am starting to agree with my wife––the food industry is poisoning us. I can’t back this up with science but my anecdotal travel experience has me concerned that something seriously wrong is happening with our food supply on this side of the pond.

So now I read labels like a detective, shunning anything that is packaged with more than five ingredients. And if you think that is easy to do, then just try grocery shopping sometime and reading all of the food labels. It will be a real eye-opener. In the meantime, we will continue to shop at Farmer’s markets, grow veggies out back in our Earth Boxes, and eat out as little as possible. I don’t care if it is high fat, lo carb, no fat, etc. What might be more important is and how and where our foods are produced than anything else.

July 8, 2013

Misplaced Medicare Incentives Are Driving Healthcare Costs Upward



For all of those out there anticipating the 2014 official role out of Obama Care, officially known as ACA (Affordable Care Act), here is a cautionary tale. Many years ago, as I was growing my cardiology practice, it became evident that diagnostic services for my specialty, like stress tests, echocardiograms, etc., were done less efficiently and cost more at the local hospital, then in the office. This stimulated many groups in the 1980′s and ’90.s to install their own “ancillary” diagnostic services. Patients loved not having to deal with the long waits and higher co-pay prices at the hospitals. And yes, the cardiologists did increase their revenues with these tests. However, lower costs to patients, insurance companies, Medicare, and improved patient satisfaction were just as powerful a stimulus to the explosive growth of these diagnostic tests, and later even cardiac catheterization labs, when integrated into the physicians’ offices.


As the growth in testing spiraled upward, the hospital industry saw their slice of the outpatient revenue pie nosedive. Hospital lobbyists and policy-makers cried foul and complained of greed and self-referral, which they said was spiking the rapid rise in healthcare costs. Studies laying blame on self-referrals being the major culprit for escalating healthcare costs, have been inconclusive. However, after years of lobbying and the passage of ACA, the hospital industry finally had the weight of the Federal government on their side. It did not take long for Medicare to start dialing back the reimbursements for in-office ancillary tests and procedures, and outpatient cardiac catheterization labs were one of their main targets. Hospitals had lost millions of dollars to the burgeoning growth of these labs inside the cardiologist’s office.


Our twelve-man group had a safe and successful lab for about ten years. Then after ACA was passed, Medicare began to cut the reimbursements for global and technical fees in this area. The cuts were so Draconian that it became impossible financially to continue the service. Never mind that we could provide the same service as the hospital more efficiently, with better patient satisfaction, and at a third of the cost.


Other diagnostic tests are being similarly placed under the reimbursement gun. Fiercely independent as a group, cardiologists have finally given up and began selling their practices to hospitals where they could be reimbursed based upon their work, (or RVU), and not worry about reimbursement from insurance and Medicare. So powerful has been this incentive that at the end of 2012, it was estimated that more the half of US cardiologists had sold, or were in the process of selling, their practices to hospitals.


But now Medicare and Congress realize they may have made a mistake. A federal advisory panel just said that Congress should move immediately to cut payments to hospitals for many services that can be provided at much lower cost in doctors’ offices.


So after taking measures to increase the cost of care and testing, it has finally dawned on them that they have incentivized the wrong entity. Unfortunately the Genie has left the bottle, and it is unlikely that the steady tide of cardiology groups selling their practices to hospitals will be stemmed. The end result will of course be higher costs to patients, insurers, and Medicare.


How bad is it? For example, Medicare pays $58 for a 15-minute visit to a doctor’s office and 70% more, $98.70, for the same visit in the outpatient department of a hospital. The patient also pays more: $24.68 rather than $14.50. When a patient receives an echocardiogram in a doctor’s office, the government and the patient together pay $188.  They pay TWICE as much, $452, for the same test in the outpatient department. From 2010 to 2011, the number of echocardiograms provided to Medicare beneficiaries in doctors’ offices declined by 6% while those in hospital outpatient clinics increased by 18%. Perhaps ACA should be renamed the “Unaffordable Care Act.”


The federal advisory panel now realizes that the hospital buyouts of doctors, which have turned independent practitioners into hospital employees, has led to higher spending by private insurers and higher co-payments for their policyholders.


So where is the accountability here for the original poor judgment and decision to attack the cost-saving independent doctors’ offices and labs? No one has been named in this advisory panel’s report cited above, and I doubt anyone will ever be held responsible.


This is the kind of government snafu we have to look forward to with ACA­­––skewed incentives based solely upon lobbying and misinformation. Truly free market forces, which we have never had in medicine since the passage of Medicare, restrain costs. It is unlikely that the clock can be turned back, but I am betting that more increases in cost will result from ACA then savings.




March 2, 2013


Filed under: Uncategorized — Tags: , , — admin @ 5:05 pm

Juan Gonzales, (not his real name), is a somewhat demented elderly Hispanic male, who I met last week in an intensive care unit. He spoke little English, and I spoke limited Spanish.  His devoted family was at the bedside, and fortunately his daughter was able to provide some history. He was admitted with palpitations and dizziness and atrial fibrillation with a rapid response. His family had just moved him from Miami, where they said he had three prior strokes. As I went over his medications, all seem appropriate except for two antibiotics ordered from the ER, azithromycin and ceftriaxone. He had no fever, a normal white blood cell count, no cough or dyspnea, and benign urinary sediment. His lactic acid level was also normal. His chest X Ray did show heart failure and the report also said “cannot rule out lower lobe pneumonia.” By all clinical and objective criteria, this man did not have an infection that needed to be treated. However, the ER team is so sensitive to missing sepsis that I guess any reason to give empiric antibiotics is not missed.


I have witnessed this trend before, and have to wonder how much this over use of antibiotics has contributed to drug resistant bugs in the hospital.  As a physician in training, we had a fraction of the drug resistant problems encountered in most hospitals today. I can’t believe that our hand washing and sanitizing was that much better in the “old days.” I am no infectious disease or public health specialist, but I do believe that the unintended consequences of this, and other mandated core measures and protocols, have created as many problems as they have solved.


There certainly is a role for guidelines and workflows. I am sure that more post-MI patients are discharged on aspirin, beta-blockers, and statins, than before they were instituted. Yet, the cookbook approach to medicine also makes us clinically lazy and treating problems where none existed. I have had to wage a campaign at some of my local hospitals to educate the coding folks, (not so fondly referred to be one nurse as the “clipboard people”) to not say a patient has congestive heart failure, because his B-NP level was 102 (normal being 1-100).  And therefore I don’t need to order beta-blockers, ace-inhibitors, or an echocardiogram.


Speaking of echocardiograms, if the patient had one last month and returns again in heart failure, he really doesn’t need another one, unless of course he has had an MI. Probably one of the most abused and over-ordered cardiology tests, doctors and coding staff seem too rushed to even look if the patient has had an echo in the recent past. And oh by the way, Medicare won’t reimburse us for reading more than one every six months, without an appeal and extra documentation.


Another time I was approached by a core measure nurse, to ask why a patient had not gotten aspirin within 24 hours of his admission. The answer, which of course I had to document in the chart, was because the poor soul was in shock and on a ventilator, and his enzymes did not turn positive until 36 hours after admission.


The Joint Commission has now recommended no less than 14 different “National Hospital Quality Measures”, ranging from Myocardial Infarction to Tobacco Treatment. So expect the ranks of the clipboard team to swell in the future. Some of these make sense and are useful, like a “timeout” before surgery or an invasive procedure, to make sure the correct patient and site of operation are confirmed. But do I really need a timeout before I administer a treadmill stress test?


All of these policies are well intentioned. However, once Medicare started supplying financial incentives, and disincentives, and the Joint Commission penalized hospitals for poor compliance, you knew abuses weren’t far away. I suppose as doctors, we had this coming for not remembering to do all those little things that make patients better, and avoiding those that make them sicker. It just seems that common sense has once again taken a back seat to bureaucracies and insurance companies.


I do what I can, albeit small, to make application of these guidelines more rationale. But sometimes, I feel like Don Quixote, tilting at windmills. As for Mr. Gonzales, I stopped his antibiotics, treated his atrial fibrillation, and he did just fine.



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