Ethical Health Partnerships Blog

The Hidden Cost of Hospital Owned Physician Practices

2010-05-11T06:56:00.003-04:00

While I always suspected hospitals' rush to establish or buy out physician practices was simply to make more money, I focused in the past on costs of establishing uncecessary practices for the sole purpose of grabbing market share. (See the series on Adventist Health). Now, I have concrete evidence of how hospital owned practice nearly doubles the costs of health care, just by the way they bill patients for services. I'll write an article for the site later, but my proof is a relative's cardiology services bill that shows doubled cost for every standard procedure that she has, even for the same CPT codes after hospital buy out at the end of last year. Something as simple as a finger prick test to check blood clotting time because of Coumadin (a medication that thins the blood to help prevent stroke) went from $31 to $71. Office visit of moderate severity went from $112 to $274. Lack of transparency and doubling costs of care simply for the sake of more money is one more example of the state of ethics in healthcare today.

Independent practice is disappearing as corporate hospital systems grab up more practices or push established physicians out of practice. In the case of local surgeons, if you divert all the referrals to your own hospital-owned surgical practices, it leaves independent surgeons in the situation of having their revenue and patient numbers slashed while their expenses rise to the point where they will either limp along by cutting back staff, cancelling plans to purchase electronic medical record systems to improve patient care, and other cost-cutting efforts -- or end up essentially forced to join the ranks of hospital owned practices. The hospital swoops in like circling vultures aggressively recruiting those practices promising them relief, electronic records, benefits and profit in these challenging times. They do it not for the benefit of the struggling physician, or the patients, but for the money the hospital will make off those physicians.

It makes me sick. What angers me even more is the way every one turns a blind eye to it which allows the trend to continue growing. There is a reason we have laws like Stark, anti-trust laws, anti-kickback laws to protect patients and the integrity of healthcare. Hospitals have found the ultimate loophole that allows them to essentially practice in ways those laws were designed to prevent.

If you have noticed your doctors' office with a different name on the bill, or some other indication they have been bought out by a larger system (it may not be the name of the hospital system) or see your insurance being billed higher amounts for the same procedures you have had in the past, ask questions. Then, help educate your government representatives about what is happening. Until patients rise up to protest this, it will continue to happen under the radar.

Mammogram Screening Vital -- Don't Put it Off

2009-11-21T21:40:00.001-05:00

The new mammography guidelines have created massive confusion for women. First, remember they are one small group’s guidelines. The upset about them is much more widespread. I imagine that the panel tried to come to the best conclusions they could based on the data they had. I don’t doubt positive intent. However, many, with equally good intent, are outraged.

I am not a physician. But I personally know a couple of women who had breast cancer who were under 50. Most were discovered by routine screening. Others were found because the woman, or her spouse/partner felt a lump. It is very disturbing to me that those women would not have gone for screenings if they followed the current recommendations and would probably be dead. And, others would have died because the same panel doesn’t think women need to be taught self-examination of their own breasts.

If anything, I think women need to be better taught how to examine their own breast. I am 59 and once, a very long time ago, a gynecologist told me and let me feel a model that had spots that felt like a BB. So that was better than nothing, but I never felt confident that I really knew or that I could distinguish the general changing lumpiness from something I should be concerned about. I wish physicians had helped me learn and practice regularly in visits.

The panel recommends mammograms every other year for women 50 and over. I personally know probably 8 women who had cancer diagnosed in routine mammograms. One year they were clear, the next year, they were diagnosed. These were not women who skip mammograms – they did them regularly. At least two I know had cancer that was already invasive (had penetrated the wall of the duct and were in the lymph node.

Mammograms are not perfect, but they are a powerful tool for women to find cancer early, and get less traumatic treatment and help women survive.

I for one will continue to get yearly mammograms, and will encourage anyone 40 or over to get them regularly. I also make sure I have a physician give me a clinical breast exam. I’m a big believer in minimizing chances of a bad outcome and maximizing chances of a good outcome. Finding cancer early is a clear way to do just that.

House Passed SGR Fix

2009-11-21T19:35:00.003-05:00

I am quite amazed that any governmental body has actually passed something instead of just talking about the same things year after year after year. A couple of years ago, I watched live proceedings of one of the House committees. The head of the committee, plus a leading member of the minority party, loudly proclaimed how more than talk has to happen, that legislation needs to be passed, and how absurd it is that the SGR hasn't been fixed. Guess what happened! Nothing.

I haven't read the bill yet, but just an attempt to fix it is good news to me. Do you really think a 21% cut to physician reimbursement when they have increasing expenses is going to help healthcare? It is scheduled for 2010 if something doesn't happen to stop it. We are going to lose good physicians who finally give up if that happens. Cutting reimbursement will make it impossible for some to stay in practice, let alone compete against growing hospital employed networks.

Reform: The Health Exchange Idea

2009-09-27T09:10:00.002-04:00

I am very curious about why, in all the media coverage of the health reform debate and drama, why aren't we hearing more about another significant part of most proposals -- the Health Exchange approach? This is was one of the key pieces of President Obama's campaign platform. Variations of it are in his proposal, the House proposal, the Senate Finance Committee proposal, and even the Former Majority Leaders (Senators Howard Baker, Tom Daschle and Bob Dole)

The essence of the Exchange is that private insurance companies would offer plans under the Exchange that were more affordable and more accountable in terms of premium rates, costs, pre-existing conditions and that they cannot drop you because you become ill. Accountability is one of the biggest needs in insurance reform, and the Exchange idea helps promote that and more affordability for middle-class individuals and families.

This is a supplement to a public option that allows private insurance companies to stay competitive, to be included in reform instead of shut out of it by solely a public option, and yet holds them significantly more accountable.

This makes sense to me.

For more information, go to http://www.kff.org/healthreform/7908.cfm and from there, you can download a PDF file of a Brief on the topic of Health Exchanges.

You can also go to their Side-by-Side Comparison of Proposals, select the proposals you want to compare, and then click on the issue of “changes to private insurance” to see at least some of what each proposal says.

Part 4 on Integrated Delivery Systems is up

2009-09-27T09:04:00.002-04:00

Just to let you know that Part 4 of the series on integrated delivery systems is back up on the website. This section is on Community Need vs. Revenue and Market Share as driving forces in hospital employment of physicians.

In the near future, I will add a final section on some of the things I think could bring such systems into more ethical alignment with core values, patients and physicians.

Next installment of series up

2009-09-24T16:09:00.003-04:00

For those of you wanting to read the series, Part 3 on some of the negative impacts on physicians and patients is back up and hopefully Part 4 will be back up by tomorrow -- or at least over the weekend.

Adventist Health/Integrated Delivery Series

2009-09-23T21:37:00.003-04:00

Part 2 of the series is now back up -- The Power of Patient Steering by a Large Hospital System The graphs alone are worth a thousand words!

Series on Adventist Health & Integrated Delivery

2009-09-22T11:35:00.002-04:00

For those of you searching for the series on integrated delivery systems like Adventist Health in Central Florida, I temporarily took down the pages to fix some formatting. They will be going up little by little this week. Right now, you can find the following sections:
Ethical Issues in Hospital Based Healthcare Delivery Systems (Intro to the series)
Part 1: Hidden Ownership/Employment of Physicians
Current Online List of Adventist Health/FPMG Physicians in Central Florida This has questions to ask to help you make more informed decisions when you seek a physician or are referred to another physician. I have also added in some from surrounding counties. (Updated 9-21-09)
Downloadable related items: Report for Physicians on the Impact of Adventist Hiring on Independent Practice and downloadable list of FPMG/Adventist Physicians (As of 9-21-09, does not yet include the updates I did yesterday to the online version. I will be working on that today.

NOTE: On the downloadable report, the front page incorrectly lists my e-mail as dawn@ethicalhealthpartnerships.com -- it should be dawn@ethicalhealthpartnerships.org I will correct that on the PDF this week as well.

Trying to Separate Fact from Fiction in Healthcare?

2009-08-15T16:49:00.003-04:00

Check out the Politifact.com truth ratings on healthcare reform statements. Because this is updated regularly, and not only about healthcare. Each healthcare statement is rated on the 'truth-o-meter' and by clicking on the meter, you can find a more in-depth review of the issue.

Another good one is Kaiser Family Foundation's site on reform, including a section where you can do a side-by-side comparison of major issues in different proposals.

Still another good site is Factcheck.org Several things on healthcare and more.

CNN is broadcasting as I am writing this about truth checking and answering questions on healthcare reform. Their new website checks some of the facts and also has links to download the bills.

Send these sites to your friends so that they too can find out more accurate answers to some of their questions. This debate is too important to resort to reactivity on either side.

The Fears about Ezekiel Emanuel, MD

2009-08-15T08:17:00.002-04:00

Some of the viral chain e-mails quote Rep. Michele Bachmann (MN) or Betsy McCaughey blasting Ezekiel I think misrepresent him, what he thinks, and how that effects healthcare reform.

First and foremost, neither Emanuel or Blumenthal will ‘decide’ what is in or out of a public plan option. It will be a group process as government always is. But I think it is still important to put Emanuel in perspective:

Ezekiel Emanual is a renowned bioethicist and oncologist. He has worked with sick and dying people for over 25 years, of all ages. Interestingly enough, while they portray him as someone who would kill off disabled people, he has a sister with cerebral palsy! He is known as a warm and compassionate physician. (Here is some about him )

And, ironically, Ezekiel Emanuel is actually opposed to euthanasia and forms of assisted suicide!!! In a case about assisted suicide that was going before the Supreme court in 1997, Emanuel wrote a piece in the Wall Street Journal opposing euthanasia. He said,

“For the vast majority of dying patients, legalizing euthanasia or physician-assisted suicide would be of no benefit. To the contrary, it would be a way of avoiding the complex and arduous efforts required of doctors and other health-care providers to ensure that dying patients receive humane, dignified care.”

He is furious about what is being said about him in these e-mails and the protrayal of him in these scare tactics is against what his whole life and career has been about. Here is his response to all the allegations flying around about him.

What I Have Read and Think:

The chain e-mail talks about Emanuel’s remark about changing how doctors think about their patients: "Doctors take the Hippocratic Oath too seriously as an imperative to do everything for the patient regardless of the cost or effects on others" and they cite the Journal of the American Medical Association, June 18, 2008).

In the entire article, he is talking about the factors that have led to overutilization of costly care. I have read numerous other articles that talk about some of the same things. Too many unnecessary tests are ordered – for a variety of reasons: 1) the patient demands it and the doctor is both worried about being sued, 2) It is easier to give in to a demanding patient --
even if the physician does refuse, the patient usually goes somewhere else and gets the test. 2) 3. Another reason they overutilize is that, according to one of my clients in healthcare, many physicians are now trained to rely on tests instead of learning how to really examine and explore for a good diagnosis. It also takes way less time, but significantly raises the cost of care. 4. Emanuel also talks about the way doctors are trained to be meticulous and do everything possible.

THAT is the kind of 'overutilization' that Emanuel was talking about in JAMA. (Read the article online(subscription or payment for the article required unless you access through a university or hospital) OR you can usually find a copy at your local hospital's library, so you can make up your own mind!) Overutilization has been written about extensively by economists, physicians, policy makers, etc in nearly all the major medical journals.

In both the Lancet article and the old Hastings Center Report, that the chain e-mail quotes, he is discussing bioethics and how we make tough decision in healthcare, especially in situations where there is scarcity of resources – vaccines, organs, etc. What he is talking about just happened this past week when the government decided who would get swine flu vaccine first because there is not enough for everyone – pregnant women first because they are high risk, healthcare workers and I forget who comes next – I think children and then the elderly, but I’m not sure. Kids are much more likely to get swine flu than adults.) There is no outcry about that even though the 'government' decided who would get what care and who would not.

Another example would be who gets an organ transplant -- if you have a 6 month old baby, a 21 year old college student, and my mother with dementia – all of whom would die within a week or two without a new liver – and you have only one liver available – who do you give it to? Currently we use a list – and probably other things. Emanuel’s writing about bioethics is primarily about exploring the PROCESS, the HOW of coming to those decisions and creating ways that are the best when none are perfect, as he consistently acknowledges.

In both articles that quote him, he explores different models and where they lead, and in both say that there is no one size fits all that does not raise moral and ethical questions that are extremely challenging. That's why we have a field called bioethics!

In the first article from the Hastings Center Reports (1996) in which he contrasts two constructs in making those kind of decisions and concludes that neither is adequate and that more public discussion would be needed to come up with how those decisions are made.

In the Lancet article (again you can usually read it for free at your local hospital library), he and the other authors look at 6 or 7 models of decision making for things like ‘who do you give the organ to’? He finds them all lacking in and of themselves and thinks it has to be multi-principled with flexibility and considering numerous factors. Even the combined model that uses several of the principles explored that he and the others think would be better than a single principle model, he acknowledges that it still raises important moral issues.

They are tough questions that patients don’t usually think about, unless you or someone you love needs what is in scarcity.

So if YOU had to decide TODAY about that one liver for 3 people who would die in 2 weeks dilemma, what criterion would YOU use to make that decision of who gets the liver? How do YOU think we should make those decisions?

I, personally, --this is just ME talking -- do not think that one liver is best used for my mother who is in her 80s and with dementia, even though I dearly love her and want to enjoy every moment I can with her. Even if I were 80 and with full mental faculties, in one way I would want the liver because I love life. And yet, on the other hand, I would think twice -- I would have lived a long and full life and my getting the liver instead of the 6 month old or the 21 year old, deprives them of that opportunity. I think and hope I would be big enough to give one of those others the chance to have what I have had.

But no matter what I think, someone else will be making those decisions -- whether or not there is healthcare reform. I would hope that they, like Ezekiel Emanuel, would have thought long and hard about how to make the best decision possible in very heart wrenching situations.

Whither Reform?

2009-08-13T23:17:00.002-04:00

Hopefully I will be in a different frame of mind tomorrow, but tonight, I am uncharacteristically disheartened. I am concerned that the dis-information, appeal to the dinosaur parts of brains, and too little too late response from the White House, will result in a very watered down proposal that won't upset anyone because it really won't contain much different than what we have. There are rumors (hopefully they are just rumors) that they may consider taking out the provision to actually pay doctors for their time if patients would like to discuss end-of-life issues, that we won't get the public option -- which I think (and hoped) would be the centerpiece. And now the news, that they copped out, caved in and are not requiring pharma companies to negotiate better prices for Medicare.

I was hoping for visionary, bold, a real improvement. I'm thinking we're getting more of the same old, same old of politics before the good of the people. I hope we don't get saddled with something in name only that costs a fortune and that simply maintains the status quo.

And I'm profoundly disappointed in politicians who engaged and continue to engage in fear-mongering, stirring hysteria and de-railing one of the most important issues of public policy, something that so profoundly affects so many of us. I love disagreement and debate, but that is not what this has been. It's been road rage screaming about 'death panels'. It has been inaccurate statements designed to scare -- like Sen. Grassley, "You have every right to fear." Give me a break! I think it is a sad commentary on what the once respected Republican Party has become. I'm furious with Sarah Palin. I can't help but wonder if her 'source' for her 'information' was a chain e-mail! She loved getting the crowds whipped up about Obama and terrorism. This is like more of the same. I'm disappointed in the media for not addressing the rumors swiftly and with their own fact-checking to put it out to the public. I'm disappointed in the level of non-thinking and effort to read for ourselves the sections people are concerned about.

Wow -- am I in a funk about this tonight! My hope is that I am completely wrong about everything I just said! THAT would make my day!

Viral E-Mail Myths on Healthcare Reform

2009-08-09T08:50:00.003-04:00

Whatever your opinion about the proposed healthcare reform bill, please make sure you check the facts you use to make your decisions AND check your facts before you forward e-mails to your whole address book. With the rapid spread of e-mails, we have an even greater ethical responsibility for what we put out and what we forward to our contacts.

Several people have forwarded me an e-mail by a man who lists numerous pages and states what horrible things will happen to all of us. Some are highlighted in red so people can be even more scared. I haven't yet gone through each statement this man made, but I did check a few statements related to end-of-life care because I heard fears from one of my dear friends and also read Sarah Palin's characterization of the proposals being 'downright evil' and involving 'death panels'. (Using that kind of language is an issue of it's own and you can read more at What World Do We Create with Our Words? )

Here is what the chain e-mail says (there are several similar versions):

• Page 425: Government provides approved list of end-of-life resources, guiding you in death.

• Page 427: Government mandates program that orders end-of-life treatment; government dictates how your life ends.

• Page 429: Advance Care Planning Consult will dictate treatment as patient’s health deteriorates. This can include a GOVERNMENT ORDER for end-of-life plans.

• Page 430: Government will decide what level of treatments you may have at end-of-life.

Another e-mail goes even further:

On Page 425 of Obama’s health care bill, the Federal Government will require EVERYONE who is on Social Security to undergo a counseling session every 5 years with the objective being that they will explain to them just how to end their own life earlier. Yes…They are going to push SUICIDE to cut medicare spending!!!

If you actually read page 425-430 (the PDF version) OR (the online version by section) (or check it out at FactCheck.org on this issue) you will see that it is listing what will be a reimbursible office visit -- and is now including discussions about end-of-life wishes. The section of the Social Security Act (section 1861(s)(2)) that it is modifying is listing of Miscellaneous Services and includes things like psychiatric care, home dialysis and more -- NONE of which are required. In terms of talking about living wills, health care proxy, etc., it is defining what can be part of one of these session that they will reimburse. It includes discussion of things like living wills, health proxy's so that people can choose to have advanced directives that will be honored in health settings -- or choose not to have them.

After the Terri Schiavo case hit the news, I went out the next week and met with an attorney to set up what I want done and not done if I am incapable of making decisions or if I am brain dead. Other people might make different choices, but I want my choices honored and I do NOT want to end up like she did. This part of the reform reimburses a physician for taking the time to sit down and talk with her or his patient about those things if they so choose. It is not mandated and the government does NOT decide for you. Other people WILL decide for you if you don't have advanced directives.

So my point is, as you decide what you agree or disagree with in this reform proposal, check out the facts for yourself rather than decide based on e-mails or pronouncements (even mine!). And certainly consider your own ethical responsibility to check this and anything else you send out or forward e-mails.

May we come to wise decisions on this very important issue that will affect all of us.

How We Talk About Healthcare Reforem

2009-08-08T10:18:00.002-04:00

After reading yesterday's statement by Sarah Palin on the proposed healthcare reform being 'downright evil" and having 'death panels' to decide whether you get healthcare based on your productivity in society, I wrote in my Build Better Relationships blog about how we use language. You can read it at What World Do We Create With Our Words? (Aug. 8th blog).

Stay Informed About Healthcare Reform

2009-06-30T09:21:00.002-04:00

With all the media coverage of healthcare reform, Kaiser Permanente, who does a great job of publishing daily healthcare news summaries as well as other in-depth reports, has 2 sites worth bookmarking.

The first is their Health Reform site that carries up-to-date news about the issues and resources.
The second is a section of that same site that allows you to perform Side-by-Side Comparisons of Reform Proposals put forth by the President, Congressional committees and individual Senators and Representatives. You can also take a particular element, such as financing, or approach to expanding coverage, and compare those across various proposals.

Well worth your time if you want to stay informed and make your voice heard!

It Keeps Going . . .

2009-06-28T20:21:00.003-04:00

As of past efforts to flood the market and bypass independent surgeons were not enough, FPMG Adventist Health has just hired another breast surgeon in May 2009 that we don't need, but that we will all pay for as we pay her malpractice, benefits and salary. Of course, since they are steering most of the referrals to their own surgeons to bypass independent physicians, it does make sense.

One definition of 'integrated delivery systems' was that they are ways to avoid redundancy. Adventist Health has hired at least 12-13 surgeons that are redundant when there is no wait for the best surgeons in this area. Maybe President Obama needs this information to help cut healthcare costs!

Integrated Delivery Systems - Ethical Issues

2009-06-10T11:23:00.004-04:00

I am finally back! I have spent most of the past year researching the impact of an integrated delivery system in my own community on local independent physicians and the on ethical concerns it raises. Both independent physicians and patients are negatively impacted. I am still in the process of submitting the information to the general council of Adventist Health, but will begin posting some of the issues and concerns online.

Part 1 looks at the practice of deliberately concealing the physician network of physicians employed or owned by Adventist Health/FPMG and the ethical concerns of concealment. Part 2 shows the incredible power to completely shift referral patterns to specialists within 3 months in such a massive system. Part 3 highlights how this way of doing business harms independent physicians and patients. Part 4 explores the stated reasons of 'community need' and the reasons that seem to be the motivating factors, market share and revenue. There is also a list of those physicians that are employed or owned by Adventist Health in Central Florida and questions patients should ask to keep THEIR welfare above corporate goals.

Adventist Health is by no means the only system involved in this type of behavior -- which is all the more reason some of these questions need to be raised and brought to light.

What has been YOUR experience in such a system -- whether you are a physician, healthcare professional, patient or other?

Health Insurance Confesses it Cares More about Itself than Patients

2008-05-19T22:10:00.002-04:00

American Medical News (May 19th) reports that major health insurance plans stated clearly that they do not care if they lose members by raising premiums, as long as they increase profits even more.

Financial data from the 1st quarter of 2008 (only 3 months) shows:

Aetna brought in over $7.5 billion in revenue with a 3 month profit of over $431 million. (But it was down $3 million from the first quarter of last year)
Humana brought in $6.9 billion in revenue and made $80 million profit (actually up from $71 million for the first 3 months of 2007)
UnitedHealth brought in $20.3 billion revenue with a $994 million profit (up from $927 million for 3 months of 2007)
Wellpoint brought in $15.5 billion with profit of $588 million (sadly it is down from $778 million from the first 3 months of 2007)

This is for THREE MONTHS!!!! January - March, 2008.

According to the article, the CEO of Wellpoint states: "We will not sacrifice profitability for membership".
They will give up members as they raise premium prices to perform better on Wall Street. Ironically they will be doing some of it around the time of Cover the Uninsured Week sponsored by the Robert Wood Foundation to bring attention to the problem of the uninsured -- clearly not a concern for insurance companies. Or UnitedHealth's CEO, Hemsley: "We continue to protect our margins. . . ."

Not only do they not care about patients, they don't care about doctors either. The same Wellpoint CEO, Angela Brady, assures investors that because Wellpoint has market power (mostly through gobbling up other companies), it gives Wellpoint "the ability to lean hard on its network doctors to accept lower reimbursement." (AMNews)

I guess it is business as usual -- massive insurance companies, protected by our elected leaders who fail to call them to task (or upset their apple carts) -- raising costs to patients and creating unfair pay reductions for physicians.

I am a self-employed individual who gets to pay high rates, with a high deductibles and who is often just priced out after a few years with a company because insurance decides as I get older I'm more of a risk -- whether or not I use the insurance! More and more companies are dropping benefits or raising the cost to employees.

Until we have leaders who have the guts and the smarts to address the excess of corporate health insurance greed, we will have growing numbers of uninsured -- not just college kids, not just those close to the poverty line, but middle class Americans -- all of us. And we won't have leaders who step up to the task until patients like you and me make noise and demand it.

Hospital (Dis)Honesty

2007-12-31T10:06:00.000-05:00

A recent article on a The Changing Business of Medicine still disturbs me (The Orlando Sentinel strangely requires that you pay for any article over a week old so I can only provide a link to the opening lines). The article is touted on the front cover of the business section as "a new model of medicine' and essentially introduces the Orlando community to some general surgeons now employed by Florida Hospital. Understandably the young surgeons like not having to deal with insurance, overhead, the investment of long hours and all the business-related matters that come with solo or group practice. Their malpractice insurance is paid by the hospitals – no small thing since Florida surgeons usually pay upward of $150,000/year.

One has to ask: why would a hospital pay $150,000 plus salary for 5 surgeons and pay for their office space and all administrative functions? Why would they undermine the surgeons who have loyally supported their hospital and outpatient surgery center?

I don’t think it is concern about patient care, especially when we have so many fine surgeons in the Central Florida area. We are a major city, not a rural area that has no surgeons.

I am concerned about 2 things:
1. that the action, for whatever reason they decided to hire their own surgeons, creates negative consequences for patients and their surgeons.
The general negative consequences are:
a) it undermines those surgeons who DO put up with the hassles of running a practice, dealing with long hours, and usually cannot afford full malpractice premiums – yet who stay in practice because they do care about patients. That includes my own surgeon. And it expects those same surgeons to continue bringing their patients to the hospital and outpatient surgery center while reducing the number of patients they see.

b) it reduces future access and choice for patients. Why would anyone go into surgery with not only the current challenges of malpractice risk and declining reimbursements, but now the fact that they would have to compete with hospitals? If this were the true reason, it reveals the band-aid approach to healthcare issues that tend to make the problems worse instead of better.

c) it creates an unfair competitive advantage for local surgeons since Florida Hospital has the marketing power of it’s 7 local hospitals and the resulting referral network. It also owns all the CentraCare 24 hour centers and major imaging centers. They can funnel patients to their practice.

d) it is potentially a conflict of interest. With a hospital signing a physician’s paycheck, realistically, who will the doctor be most loyal to in a situation where there is conflict between patient interest and hospital interest? What will it mean in terms of necessity and intensity of procedures for patients?

2. My second, and now larger concern is that, whether by deliberate intent or simply by effect, they are being dishonest with patients and the community.

Why would the hospital hire its own surgeons? I could understand it if it were for a very specific focus. For example, if surgeons no longer want to take on-call, or they need surgeons specifically for liver or other transplant teams, or more trauma surgeons for their ER. I could understand it if they needed a couple of surgeons to direct their general surgery residency program.

Yet, when I contacted the hospital, their spokesperson beat around the bush with reasons like “to provide critical services. . .residency . . .access for patients . . . a new blend of community and hospital employed staff . . . .blah, blah, blah -- but most of those reasons simply do not make sense.
• Access for patients is not an issue with so many good local surgeons of all ages and levels of experience.
• Hospital hiring undermines future access and choice for patients.
• Critical services would seem to imply things like on-call, ER, etc., yet I know someone who was referred to the group for a small melanoma, which any surgeon could do. I received a referral to the hospital employed group from one of the hospital’s local women’s centers for a biopsy. When I asked if there was someone in the group who specialized in breast health, I was told that any of them could do it. (By the way, there ARE surgeons in Orlando who specialize in breast care, some of whom are listed as part of the hospital’s own breast care team.)
• A new model of medicine. For what purpose? In the past, hospitals hiring physicians has been a costly enterprise for the hospital. Why is it being resurrected? One reason could be that with the power and size of a hospital, or hospital network, the hospital could negotiate higher reimbursement from insurance companies in ways that an individual doctor or even a small group could not begin to do. Yet it still seems the expenses would eliminate significant profit.

The only reason that makes sense is that they need patients for their residency program and the fact that all of the surgeons are listed as faculty supports that assumption. So, why doesn’t the hospital present the group to the public as the residency program?

My guess is that the ‘practice’ is set up to provide surgical cases for the residents to work with. I could be wrong, but I imagine most surgeons in private practice might be reluctant to have resident involvement with the increased malpractice risk. By the hospital having its own group, it can guarantee those cases and offset some of the expenses of providing supervising physicians for residents by income produced by the doctors in their office and in surgeries done at the hospital and its outpatient center.

And THAT disturbs me even more, not because they have a residency program, but because they are not upfront about it with potential patients in relation to this group of surgeons.

Part 2: Ethical conflict

Insurance Mergers Serve Profits, not Patients

2007-10-29T13:59:00.000-04:00

Insurance Merger Serves Profits, not Patients

I just read that insurance giant, WellPoint is aggressively seeking more insurance companies to absorb, further reducing health competition. Both in the past and for the future, their plans also include buying non-profit companies and turning them to for-profit companies. WellPoint’s spokesman, Jim Kappel, says that “We believe we are in an industry suitable for further consolidation."

According to AMNews that reviewed the transcript, Wayne DeVeydt, WellPoint's executive vice president and chief financial officer, stated at a recent conference.

"If you looked at us 10 years ago, the top 10 companies made up 27% [of the market]. Today the top 10 companies make up 54%. I would venture to say that in the next five to 10 years, the top 10 will make up 75% to 80%. So we are far from being done on consolidation.”

I don’t know about you, but I do not want the top 10 insurance companies, who are already squeezing both patients and physicians while they post record profits, controlling 80% of the whole health insurance industry.

This whole scenario only highlights the need for the federal government to change the historical anti-trust exemption given to insurance. Patients and their physicians become helpless against such giants when there is no competition to turn to if you don’t like how they do business. While insurance already controls so much of our healthcare experience, I don’t want to hand them more on a silver platter.

I understand people need to earn livings and create and maintain profitable companies, but it should not be done at the continued unjust expense and burden of patients and the physicians and other health professionals who provide their care. We keep losing the focus of healthcare – the well-being of the patients and the continued ability to provide quality care by professionals.

Start writing your federal senators and representatives to revoke the anti-trust exemption for insurance (, and in so doing take a step toward more ethical health care. (I’ll try to get more up on the website soon about this aspect of anti-trust laws affecting your healthcare.)

A few notes on Wellpoint:
• Former CEO, Larry Glasscock’s total compensation for 2006: $14.5 million (per Indianapolis Star)
• The company earned $868 million in the third quarter of 2007, and has earned a total of $2.9 billion for the first 9 months of 2007 (total revenue was $15.23 billion)
• At the end of the third quarter it has 34.8 million members (up 615,000 from the year before) (How is a private practice physician supposed to negotiate against THAT!
• In 2006 a federal judge approved a settlement of two lawsuits that alleged Wellpoint deliberately delayed and denied reimbursements for physician services. They were one of the last settlements in findings against several national insurance companies, pointing to industry wide problems in ethical practice.

• In 2005 WellPoint paid $6.5 billion to obtain the parent company of New York’s Empire Blue Cross Blue Shield

Other insurance profits:
** UnitedHealth’s 3rd quarter profit this year rose 26%
Humana’s 3rd quarter profit rose 90%

Personal Injury Litigation by Doctors Offensive

2007-10-24T19:55:00.000-04:00

This week a jury in Tampa, FL awarded a 16 year old boy $4 million because a boy in the private school who had harrassed Danny Heidenberg in the past fell on him during a football game at recess and broke Danny's arm. The offender had bullied Danny and others at school and during the game. The reasoning for the lawsuit and award was that his parents had complained before and the teachers had not supervised them enough. Danny has screws in his arm and his attorney claims there is permanent nerve damage in his forearm. And, he should get $4 million dollars because he wanted to be a surgeon when he grew up. Give me a break.

While it is sad that Danny has damage to his arm, in my opinion it does not come close to deserving $4 million. It is not like he just finished medical school and was about to start his career as a surgeon. His injury does not prevent him from working and probably does not prevent him from a career in medicine -- if he even really wanted or continues to want that career. He was 12 at the time of the injury (16 now). He has plenty of time to pursue his life path in a way that is fulfilling and productive for him.

What makes this case even more offensive to me is that both of his parents are physicians. His father is a DO urologist and his mother is an MD fertility specialist. I find it fascinating (and irritating) when physicians, who are always under the gun of malpractice lawsuits themselves, jump at the chance to file their own lawsuits for the ever vague "pain and suffering" theme. I hope neither of Danny's doctor parents have or ever will complain about medical liability.

I can understand wanting to prevent this from happening to anyone again at that school. I understand wanting accountability. I understand frustration and anger. I could understand mediation to facilitate a constructive process and plan of action for both the bully and the school, including restitution for medical expenses. I understand wanting to stand up for and protect your child. But to me, his parents become just like the personal injury lawyers who go for money or revenge. "Let me hurt you to make my point." Nothing constructive happens to change the situation and they have their $4 million award. Personally, I would never, as a potential patient, go to physicians who thought this was the only way they could make a point or seek justice, or who finally feel some satisfaction because they won.

It may not be the case at all, but it reminds me of people who are abused becoming abusive themselves, victims who become victimizers. Is this an example of how the oppression of the malpractice system for physicians creates a situation where those same people use the system to beat up someone else? It also strikes me that they use a system that by its very nature is bullying while presenting as victims of a bully.

The personal injury system is out of control. It is not constructive and only creates more harm. We just had a case in Orlando a few weeks ago of a police officer who responded to a 911 call of a toddler found in a pool suing the family because she slipped in a puddle of water in the house after the mother carried her unconscious child in to the bedroom where she called for help. Fortunately public outcry pressured the officer to drop the lawsuit. In personal injury cases (and in life), the only thing worse than people who exploit a bad situation, who go after personal gain at any means, or who are more interested in punishment and award than constructive change, are the attorneys who encourage them.

I keep thinking that maybe, out there somewhere, there are actually ethical personal injury attorneys. I have no idea where, but I do hold hope. I just wish they, and their associations would hold attorneys accountable for more ethical behavior. Just because their actions may not violate the letter of the law, does not mean they are ethical. We need a major attitude shift in this country -- and maybe in the world -- toward ethical standards of behavior that take into consideration the well-being of all parties involved, not just one. What is fair and just for all involved? I wish we could focus on justice AND a process that results in a better school, or a better medical system, how we use a bad situation to help create a better situation for personal and collective justice. That could create the protection and enhancement of others to come after them so that this kind of thing doesn't happen again.

Are Hospitals Betraying Community Surgeons?

2007-10-17T23:15:00.000-04:00

The Orlando Business Journal announced this week in its cover story a 'New Model of Medicine'. The new model means that hospitals are not only hiring more hospitalists, but also specialist. In the article, they featured 3 young general surgeons who are now employees of Florida Hospital in Orlando.

While the article explains the role of hospitalists, it did not really explain the general surgeons. Reference was made to a surgical residency when the new medical school opens within a year or two and an attempt to get a liver transplant program in the future. These 3 surgeons in their 30’s are part of the faculty of the residency program. Perhaps they are the best and brightest of their programs and have 5 years or so under their belts. However, since so much of surgical proficiency comes from hundreds of surgeries, I find it curious that they bring in such young surgeons for a brand new residency program.

My bigger concern is why and how the hospital is employing 3 new surgeons full time right now when those programs are off somewhere in the future. There was no mention in the article that they are trauma surgeons or surgeons to simply take call – which I would think would be a selling point to the public if that’s what they are doing.

I could be wrong, but my take is that they are beginning to set up a hospital based program of general surgery that eventually will pull in residents, but that right now involves these new surgeons. It appears to be a trend around the country. Are these departments doing breast biopsies, gallbladders, hernias – all those procedures that are the bread and butter for community surgeons in private practice? If so, it is a betrayal of those physicians who support the hospitals.

Combine that with the massive marketing and referral system of a large hospital network with satellite hospitals all over Central Florida and I imagine it will indeed impact surgeons in private practice. The article talks about the new surgeons not wanting to deal with the hassles of the business side of practice, reimbursement, malpractice premiums, etc. which is certainly understandable. But what about those excellent surgeons in the community who ARE dealing with all those hassles – and now having the hospital they help support undermine them by creating its own department in competition with them for patients and facility time? The hospitals should be actively finding ways to partner with and assist physicians ‘dealing with the hassles’. Hospital systems could use their size and power to push for insurance reform, standardization and other ways that would benefit their own bottom line as well as support private practice surgeons. Instead they undermine them. The surgeons here deserve better support.

As a patient who has benefited from a private practice surgeon, I am concerned and angered. If surgeons are struggling with declining reimbursements and the ‘hassles’ while trying to provide quality care, what is going to happen with a massive system sucking in referrals and perhaps having priority for facility time?

As a patient, I am also leery of surgeons who would have full responsibility for their patients and yet be beholden to their corporate employer. I want, and have, a surgeon who, if necessary, will stand up to policies, procedures or anything that prevents me and other patients from getting the care we need. Will an employee of the hospital be willing to take on the institution that pays their salary?

If the hospital creates this surgical department in direct competition to our community surgeons, not only surgeons will suffer, so will patients.

Health care multi-millionaire proposes ‘reform’

2007-06-25T21:03:00.000-04:00

Last week experts attended the National Institute of Health Policy meeting in Minneapolis and gave the usual dire warning that the healthcare system will face serious problems in the coming years unless Congress takes action now. Don’t we already have financial problems?

The Minneapolis Star Tribune quoted one of the ‘experts’, former WellPoint insurance Chair and CEO, Leonard Schaffer, who said that we have 8-10 years to avoid the trend of an exploding federal deficit because of an aging population.

And then, he gives his recommendations for change: base payments to physicians and hospitals on the quality of care, make sure that treatments are prescribed based on evidence that they work, and closely monitor technological devices. He said that “everybody is going to have to sacrifice a little bit.”

By their own admission, a big part of the problem is the growing aging population. Along with that population comes record numbers of chronic illnesses, including obesity and its consequences. There are problems of non-compliance with treatment and recommended medications to help control those conditions.

Instead of addressing the problem, Mr. Schaeffer’s approach, and that of the insurance industry and government is to focus instead on micromanaging physicians and trying to tell them how they should treat us. Case managers second guessed doctors decisions and treatment plans. They punish them if they go out of the cookbook guidelines for the welfare of their patient. They penalize physicians for giving what the insurance company decided was too much. You may remember that this was HMOs’ approach in the past. The ones who benefited were insurance companies and their shareholders. The ones who lost were patients and their physicians. The formula being proposed does the same.

In this case, what makes it all even more insulting to me as a patient, and to my physicians, is that the pontificating comes from Mr. Schaeffer whose total compensation in 2002 was over $19 million dollars that year, and who, in 2004, along with that level of compensation, was given $234 million dollars bonus for a merger when WellPoint bought Anthem insurance. “Sacrificing a little bit” has a very different impact for me as a patient, or for my physician than it does for Mr. Schaeffer.

People like Mr. Schaeffer have no credibility when they talk about how to curb health costs – and especially when they nickel and dime physicians while stuffing their own and their company’s pockets. Their purpose is to make money for themselves, the company and the shareholders. UnitedHealth Group publicly estimates earnings of $4.2 billion in 2007. That is over $1 billion in profits in one quarter!

As long as healthcare is run for the benefit of people like Mr. Schaeffer, UnitedHealth Group, and their shareholders, profit will always come first -- at the expense of patients and the physicians who care for them who are supposed to 'sacrifice'. And to me, that is unethical.

The HPV Vaccine controversy -- choice and responsibility

2007-03-27T21:48:00.000-04:00

This morning’s newspaper (Orlando Sentinel) had a column by Susan Reimer of The Baltimore Sun in which she discussed the arguments by some parents against mandatory vaccination for the HPV virus that can cause cervical cancer. Some states have considered making it a mandatory vaccination at 11 or 12 years old before they become sexually active. Groups of parents have protested, saying that it will encourage their children to have sex.

She quotes Sarah Brown of the National Campaign to Prevent Teenage Pregnancy who says that she can understand parents being concerned about their children being required to be vaccinated with a drug that is new and does not yet have long term data on its effects. But, she added that their argument that getting vaccinated will change a young woman’s thinking about whether or not to have sex strikes her as ‘intensely unreasonable.’

And, another part of the issue is that the vaccine does not prevent all cervical cancers, and not even all that are caused by HPV. (It is estimated that it can prevent half of those caused by HPV.)

So what do you do? Do you allow future generations of women to be exposed to a virus that half of men have and that contributes to 7500 cases of cervical cancer per year? She states that 40% of those who develop cervical cancer die of the disease. Do you force those who object because of their beliefs (no matter how you view those beliefs) to comply? Do you force parents who think their daughter will never have sex until a certain age or marriage? (I wonder if they plan to have her vaccinated at 15 or 18?) Do you force parents to take risks of unknown side effects or limited efficacy of a new drug? Do we force parents who wonder if it is just a ploy by pharmaceutical companies to make millions or billions more?

I don’t know that requiring vaccination is the answer. And yet, polio vaccine was required early on. Other vaccines are required for entry to school.

My first thought was ‘if parents choose to NOT have their child vaccinated, and that child later develops cervical cancer associated with that particular virus that the vaccine prevents, they should be required to pay for medical treatment of the cancer, or at least 50% of the cost. In spite of the attitude of entitlement in this country, I think patients bear certain financial responsibility for their decisions. Taxpayers, insured, businesses, hospitals, public health assistance programs should not be required to absorb the cost of something that can be prevented. (On the other hand, where would that lead us if we actually held people financially responsible for their lifestyle choices -- smoking, obesity, unprotected sex with multiple partners?)

Perhaps more importantly, parents have a responsibility to safeguard their children’s health. What will it be like for a child who becomes a young woman and develops cervical cancer when it could have been prevented? What will it be like for her parents, who remember they had a chance to provide some protection, but did not? I wouldn’t want to be either one of them.

Is justice a dream or can it be our vision?

2007-03-23T10:53:00.000-04:00

Democrats vs. Republicans, trial attorneys vs. physicians . . . they are like the fighting couples I see in my office, caught in the power struggle, so caught up in being right and pointing fingers, that they lose what they both most want. The Power Struggle becomes more important than the relationship, than their vision of what is possible. Actually, most of them were never clear about their dreams or discounted their own or their partner’s, which also fueled more of the conflict. Perhaps that’s what has happened between the players in healthcare, and the politicians who play the games of being right by making the other wrong.

What has happened to the dreams, to their vision of what is possible?

Today I discovered a proposed bill (HB 733) in the Florida House of Representatives trying to get around the abolishment of joint & several liability that the legislature voted on last year. The bill seeks to make the named party in the lawsuit responsible for all the damages, even if they were only minimally responsible. (See more on my Legislation page) It’s a great way to go after the most solvent, the deepest pockets and to justify once again the shotgun approach to malpractice claims – naming every possible person in the hopes someone can be found guilty of some responsibility and forced to bear the burden of all the expense. So in the name of justice, we make an unjust law??? It’s like a game to see who will win, no matter who you damage in the process.

It is easy for me to think of trial attorneys as greedy exploiters of misfortune, and some are – as are some doctors, therapists, insurance companies, politicians and even some patients or family members. But I also can’t help but imagine that there are actually some trial attorneys motivated by a sense of justice and fairness, and some who are ethical and some who hold a vision of a more just world.

As I was researching the Florida bill, I found that the Academy of Florida Trial Lawyers has changed its name to the Florida Justice Association, as has the national association (now the American Association for Justice). Wouldn’t it really get interesting if it were all actually about justice?. . .If we looked for ways to be just to both injured patients and physicians who provide care, yet as human beings are not perfect every minute of every working day? Clearly there are some unethical and incompetent doctors. But so many named in malpractice claims are not that. So much energy, time, money, resource is wasted in attacks and counter-attacks, going back and trying to undo the opponents win. And we all end up losing.

What if we all, lawyers, physicians, patients, Democrats, Republicans, insurance industry and others sought justice for all, instead of protection of profit or power or position, or reward for the few? What if we put our combined vision, intelligence, creativity and the best part of our desire for a better world at the service of creating a better way?

Doctors, patient, staff relationships and . . . .

2007-03-21T12:56:00.000-04:00

I received a comment from Tim Dawes on a recent post I did on corporatization of healthcare and it's effect both on physicians and on the physician-patient relationship. I signed up for 2 free e-mail mini-courses that Tim has: 7 Steps to Excellent Service for Patients of Any Culture and How to Uncover the Hidden Opportunities and Risks in Your Medical Group. They are free and just require an e-mail address sign-up. (The second one you receive when you sign up for the special report -- 7 Mistakes Medical Groups Make that Cost Patients & Money)

Needless to say, the two topics are intertwined. Dawes talks about the importance of communicating more effectively, expressing empathy, respect and valuing. As a relationship expert, I certainly agree. The power of relationship is a major factor for quality healthcare, for patient compliance with treatment, for accurate treatment planning and for healing itself. For example, research has shown that trusting one's surgeon can actually lead to less pain after surgery. (I'll plug in links to the studies when I find the articles on my hard drive!) And, on the flip side, when people feel devalued, discounted, disrespected, not cared about, anger increases. Research has also shown failures in relationship between doctor and patient to be a significant factor in patients' decisions to file a lawsuit. (A Mediation Skills Model to Manage Disclosure of Errors and Adverse Events to Patients Carol B. Liebman; Chris Stern Hyman Health Affairs 23(4):23-32, 2004. © 2004 Project HOPE)

I liked what I read and I'm going to order his Healing from the Heart: A Practical Guide to Creating Excellent Experiences for Patients and their Families,

Further Reading:
Why Do Patients Sue Doctors? by Richard J. Andolsen, MD in Sonoma Medicine
How plaintiffs' lawyers pick their targets by Berkley Rice in Medical Economics
Beckman, H.B. et al., The doctor-patient relationship and malpractice. Lessons from plaintiff depositions, Archives of Internal Medicine, Vol. 154 No. 12 (1994)
Hickson et al. Factors that Prompted Families to File Medical Malpractice Claims Following Perinatal Injuries, JAMA 1992; 267:1359.
Levinson, W. et al., “Physician-Patient Communication: The Relationship with Malpractice Claims among Primary Care Physicians and Surgeons,” Journal of the American Medical Association 277, no 7 (1997): 553-559
Young, VC M, Phillips A. Why do people sue doctors? A study of patients and relatives taking legal action. The Lancet. 1994;343:1609-1613
Huycle, K. Characteristics of potential plaintiffs in malpractice litigation. Ann Intern Med 1994; 120:792-798.
Mazor, Kathleen M., Steven R. Simon, and Jerry H. Gurwitz. 2004. Communicating With Patients About Medical Errors: A Review of the Literature. Archives of Internal Medicine 164:1690-1697.

Ethical conduct by US research in India?

2007-03-20T21:35:00.000-04:00

Some of the questions about pharma’s ethics with research in India involve informed consent. To what extent are the people being enrolled truly giving informed voluntary consent rather than just signing a paper. Some are poor, some are illiterate. Some are offered $100, a small fortune to the poor, and therefore possibly undue influence. Some see it as an opportunity to get some treatment when they normally cannot afford to seek treatment. Some point out cultural differences in which most patients blindly trust that anything a doctor gives them or asks them to do will make them better, the legacy of the caste system and more. Experiences of autonomy and freedom are very different in Western culture than they are for many in Indian culture. (Pharma giants risk reputation through clinical trial cost-cutting) Candice Player in her article, Outsourcing Clinical Trials to India, points out that for many women, their role is defined by their fathers, then by husbands, and/or wishes of parents and elders.

Another question is that after determining that a person has the target illness, medication or a placebo is given for the trial, and no attention given to follow-up treatment of the patient. The drug matters more than the patient. Ms. Player makes the point of distributive justice which would make it unethical for one group to bear all the risks and inconveniences of the research, while another group is the one who receives all the benefits. She cites The Belmont Report on ethical principles in human research and the Indian Council of Medical Research’s principles of ethical research. (Ethics in Human Experimentation)

It is not just India’s responsibility to create an ethical environment for research, it is also the responsibility of the leadership of America’s and Europe’s pharmaceutical companies. And it is our responsibility as human beings to call them to ethical relationship and behavior.

Related articles:
How informed are the country's clinical trial participants? In Applied Clinical Trials

India a hotbed for clinical trial (Times of India)

Drug trials outsourced to India BBC News

Fear, Pharma or Ethical Choice?

2007-03-20T21:31:00.001-04:00

Today I received a notice about a Forbes magazine article on the pharmaceutical industry’s plans to fight any moves by Democrats to push for federal negotiation on drug prices for Medicare and to limit direct-to-consumer advertising of drugs. (Democrats Bad News for Big Pharma).

Parmy Olson states that David Seemangul, an analyst with S&P Equity Research, sees A Democratic congress as detrimental to pharma. Price negotiation would put pricing pressure, but it would also increase volume and that could mean lower operating margins.

So, if I understand it correctly, he says if we lower health costs for Medicare patients, save the government and taxpayers money, and help people actually get more of the drugs they need, pharmaceutical companies will be upset because their profits won’t be as high.

And then, heaven forbid, we could also address the concerns about direct-to-consumer advertising that many times lead patients to demand drugs from their physicians that may not even be the treatment they need. Patients sometimes switch physicians to get what they want – or perhaps more accurately said, what pharma wants them to want, and continually influences them to want.

To me, drug price negotiation and some boundaries around direct-to-consumer advertising would be a more ethical approach. And yet, Seemungal pulls the fear card that we will lose pharmaceutical business as they look to markets like India and China if we don’t keep feeding their profit margins.

Actually pharma already outsources their research and more to China and India. Turning to India to conduct clinical trials has already saved them billions. Never mind, that ethical questions have been ever-present with the practices associated with those trials. Pharma claims that labor is cheaper and there is a large population of people with diseases and little or no previous treatment. (Watch for another story about some of the ethical concerns.)

To me, the question is what, or who, will make our healthcare decisions that will create our future – fear, pharma profits, or ethical choice?

Corporatization and Motives in Medicine

2007-03-07T08:12:00.000-05:00

In today's Medscape's General Surgery Medpulse news, there was a link to an article that discusses the corporatization of healthcare, the changing motives of physicians, the impact on physician self-esteem and satisfaction and why that should be part of the discussion on universal coverage. The article is:

Pay, Pride, and Public Purpose: Why America's Doctors Should Support Universal Healthcare

Posted 02/28/2007

One of the saddest parts tome was a comment with a physician who was building an oversized luxury home. As he was giving a tour of the construction he said, almost as an apology, that "it gives me a reason to keep working". While there have always been some doctors who have entered medicine for the income, most physicians have found their motivation and passion for medicine in their care of patients, in the service they provide, in their contributions to those patients who come to them for help. Most physicians enter medicine because they want to make a difference in people's lives. That is the core of satisfaction, motivation and continued energy for the profession -- even on difficult days. It is a sad day when the price of a procedure becomes more motivating and more important than the procedure and it's potential for healing the patient.

The article talks about some of the many ways that increasing commercialization and commodification of them and their care impacts not only their morale, but their decisions and motives and how that weakens professionalism and healthcare. Altom states:

But for professionals, the only god worthy of solemn devotion is signified in the etymology of 'profession,' viz., an avowal of service beyond self.^[10] Without this piety technical proficiency may remain intact, and financial rewards may remain plentiful, but professional identity cannot be sustained. As Arthur Okun has remarked, "everybody (but an economist) knows that that money shouldn't buy some things."^[11] Yet to be accurate we need to go beyond the moral realm indicated by "should." One of the things money can't buy is a professional identity; this means that every encroachment of commercialism into medicine makes professionalism more fragile.

She continues:
Whatever else it brings, universal access, even in a system with multiple tiers, is a great equalizing force. Commercialism plays upon, and profits from, disparities in health status and income, and as noted above, makes physicians active players in that collusion against the poor and the sick. It is very likely that any system of universal care, whatever the organization and delivery mechanisms, will promote an environment in which physicians can again take pride in recognizing the skillful execution of their unique abilities in serving, healing, and alleviating suffering. For most doctors, a rise in professional self-esteem will be the result.

One of the places the 'money as primary motive' is clearly evident is in large group practices. While there may be exceptions, the focus tends to be on the bottom line and physicians themselves are evaluated and measured by how much revenue they bring in. In my opinion, one of the minefields for ethical healthcare lies in large group practice. And, it is often one of the places where physicians themselves seem to feel the least satisfaction -- as it is for many patients. As a patient, if I have a choice between a physician or specialist in a solo or very small group practice, versus a large practice, I always go with the small practice. Large practices in so many instances have become like factories. That is not what I want in my healthcare. And I really don't think it is what most physicians want either.

We need to find passion, strategies and ways of galvinizing patients and physicians to demand that the essence and the core of healthcare -- the patient -- AND their physicians and other professionals who give the care are supported, not undermined, to create the environment for the quality care they deserve to receive and to be able to give.

Who Cares About the Doctor-Patient Relationship?

2007-03-04T10:41:00.000-05:00

The doctor-patient relationship is going the way of 8-track tapes, not thinking twice about leaving your doors unlocked, and companies valuing and honoring those who give 30 years of service. But like those good ideas and nostalgic times, no one seems to care. There are a few “yeah, that’s too bad” sighs, but apparently it doesn’t bother us enough to speak out, let alone take action.

“See what you are being persuaded to forget”
Haroon Moghul

What we are being persuaded to forget is that the patient is the purpose of healthcare and that the doctor-patient relationship is both the core of health care and the means of healthcare. (I also include nurse-patient and in some places, physician-assistant-patient relationships. But, without the doctor-patient relationship, you don’t have those relationships.) The physician is our primary point of receiving and accessing the care we need.

Every day in many ways systems, policies, profits, political posturing, and short-sightedness are chipping away at this foundation. They encroach on physician decision-making, they add administrative burdens, they deny care, they market directly to patients who then switch physicians when they don’t get the advertised drug, they cut fees to physicians while padding their own profits. I could go on. They are dissolving the bedrock that supports the entire healthcare system and then politicians and patients moan and groan about the quality of healthcare. Actually, politicians complain more about the efficiency of healthcare – which is a translation for the cost of healthcare – which is a translation for “growing profits of the biggest players.”

The other night I read a great article that I hope many of you will read for yourselves.
From a relationship to encounter: an examination of the longitudinal and lateral dimensions in the doctor-patient relationship
by Sharyn J. Potter (Department of Sociology at the University of New Hampshire ) and John B. McKinlay (New England Research Institutes) (Social Science & Medicine 61 (2005) 465-479)
(Sorry I can't provide an active link. I could not find a place you can access the article online for free unless you go through a university, hospital, library free access system for journals.)

Don’t let the title put you off or lead you to believe it is dry, boring reading. Far from it!

The article talks about the framing of healthcare as a commodity, about the business forces like insurance and pharmaceutical companies, physician employers, and others intruding into, and ultimately defining, the nature of the doctor-patient relationship – and, sometimes literally defining the care we receive (or not). When business defines and directs healthcare, it is their profits, their obligations to their shareholders and their executive benefits and bonuses that become the bedrock of healthcare. That dissolves the very core of quality healthcare.

I am not against people and companies making a profit. I am angry and concerned about greed and business damaging what is most important for good care, and about profit at the expense of patients and their physicians, nurses, and other health caregivers.

I want a wave of voices and actions to grow to reclaim the heart and core of healthcare, the doctor-patient relationship, so that the purpose of healthcare, the well-being of the patient, is primary.

Don’t let yourself be persuaded to forget!

(I’ve been away for some time to focus on my mother’s health and well-being, but she is now in a great place with very good care. So hopefully, I can write more regularly.)

Tobacco, nicotine and ethics

2006-09-03T22:12:00.000-04:00

The other day I read that the tobacco industry, in spite of years of lawsuits and sanctions, continue to knowingly increase the addictive quality of cigarettes by increasing the amount of nicotine.

A study by the Massachusetts Department of Health found the nicotine levels in American made cigarettes has risen about 10% in the past 6 years. That makes it easier to become addicted and harder to stop smoking. They found that the 3 brands most popular with young smokers had more nicotine than 6 years ago. The level in a menthol brand increase 20%. On top of that, there was no significant difference in nicotine levels in brands marked full flavor, medium, light or ultra-light. In addition to the implications for health risks, the study also means that medications, such as nicotine patches, have to be adjusted. (For PDFs of the report and fact sheets, visit the Massachusetts Department of Health page. For the press release, click here. )

To me, this demonstrates lack of any sense of ethical responsibility and the need for a basic ethical context for our relationships and decisions at every level of society. The healthcare system is a network of relationships, not only among the major players in the system itself, but also includes relationships in business and society that impact healthcare. The action of tobacco companies overtly and intentionally places profit above the physical health of other human beings, and actually contributes to the detriment of their health. Nicotine use can contribute to developmental delays in babies whose mothers smoke while pregnant. It raises blood sugar levels and raises risk for diabetes, or makes diabetes harder to control. It can reduce effectiveness of some medications used to control blood pressure and other chronic conditions.

Profit at that expense is unethical.

So far, it appears that no action has been taken. I hope there will be. Tobaccos actions lack consideration for others, and are a glaring example of self taking primacy over the good of many. . . .profit at any price. While there are wonderful things about individualism, and the ideas that we can be whatever we want and achieve whatever we want, it cannot be at the undue expense of others, we cannot lose sight of the common good, the care for the fundamental well-being of others as much as our own.

How can we begin to change the thinking that makes this possible?

Prevention Matters!

2006-06-28T10:55:00.000-04:00

I could barely believe it when I read it. Finally, Medicare is going to focus efforts on prevention of chronic disease. According to Kaiser Network reports, Medicare administrator Mark McLellan said,

"If you take a big step back and look at Medicare spending, 90%-plus of what we are spending is going for the complications of chronic disease. . . .We can get healthier beneficiaries and a lot lower costs related to complications if we can get more prevention.

Reports have consistently shown that chronic disease is one of the main drivers of health care costs. However, both Medicare and private insurance have simply increased patient premiums or reduced physician reimbursement in response to rising costs instead of tackling the problems driving costs.

But . . . better late than never. I hope that the private sector will follow Medicare’s efforts to address preventable conditions.

The Surgeon General is also acknowledging the problem in his recent statement to the American Water Works Association conference. According to reports he sees costs increasing while health diminishes unless energy is shifted to prevention. Rightly so, he specifically mentioned obesity-related illnesses like diabetes, hypertension, cardiovascular disease and cancer. Apparently he brought up the same theme at a presentation at the University of North Carolina where he said:

"We are largely a nation that doesn't practice prevention. Most of the disease burden and the cost for health care is preventable. Seven of every 10 deaths in the U.S. are due to preventable chronic diseases, such as heart disease, diabetes and many forms of cancer.” NBC17

The savings in health costs, both in government programs and in private insurance plans, is significant. See our testimony to the House Ways & Means Committee (see section toward end on drivers of health costs.)

The LA Times article on the prevention story states:

A Medicare analysis using data from 2001 found that the program paid nearly $13 billion that year for potentially preventable hospitalizations for a variety of illnesses, including pneumonia and uncontrolled diabetes. A reduction of as little as 5% in the hospitalization rate would produce more than $500 million in savings, the analysis showed.

Will Medicare create meaningful change?
The Medicare announcement mentions that Medicare has already added a number of new preventive services, including blood tests for cardiac risk factors. However, if you go to the Medicare website, the preventive service consists of a blood test every 5 years to check cholesterol. Here is the current statement from Medicare:

“Medicare covers cardiovascular screenings that check your cholesterol and other blood fat (lipid) levels. High levels of cholesterol can increase your risk for heart disease and stroke. These screening tests will tell if you have high cholesterol. You might be able to make lifestyle changes (like changing your diet) to lower your cholesterol and stay healthy. Medicare will cover these tests every five years.”

We will need to do much better than that for prevention to be successful. At least it is entering the consciousness and conversation at higher levels. Now all of us need to make sure the conversation and consciousness continues so that action will take place in both public and private sectors.

Transparency: A Cure for Health Care Costs?

2006-06-02T10:11:00.000-04:00

President Bush is joining others (or maybe it's the other way around) on the transparency bandwagon as the way to address increasing healthcare costs. To me, it only illustrates why we struggle to create meaningful reforms, whether that be for cost, safety, physician payment, covering the uninsured, or even restoring and strengthening the physician-patient relationship. Transparency is one more example of failing to address the real causes of the problem, touting a ‘quick fix’ that won’t fix anything, and then wondering why both patients and clinicians are more and more fed up with healthcare.

Transparency, as it is most often used by politicians and insurance leaders, is focused on posting the prices physicians charge for their services. The focus is almost completely on physicians, although it is now beginning to spread to hospitals. Proponents believe that by doctors and hospitals posting their prices on the web, patients can make informed choices about purchasing healthcare and reduce their healthcare costs.

Here are some of my objections:

For those who DO have health insurance:

1. Most insurance pays a flat fee no matter what the doctor or hospital charges.
For the majority of people who DO have health insurance, it really does not matter what physicians or hospitals charge, because nearly all insurance plans no longer pay a percentage of the usual and customary charge. They pay a flat fee that THEY decide upon, based on a percentage of the current Medicare rate. Some pay a little more than Medicare, some pay 80-90% of the Medicare costs.

2. Insurance-determined payment makes doctor fees almost irrelevant to the patient.
Anytime a physician accepts insurance, they are required to accept whatever insurance has decided for the reimbursement rate and cannot bill the patient for more than that. For example, my surgeon can charge $3000 for gallbladder surgery. She will get paid about $800, whether paid by my insurance, by me as an out-of-pocket payment, or by the combination of both. She could charge $1000 or $5000 and it does not change the amount she will be paid. AND, she cannot bill me for any part of the unpaid difference of $2200.

3. Choosing healthcare based solely on cost is dumb.
Why would I, as a patient, choose a surgeon who charges the least? I am not buying a loaf of bread. I am buying expertise, knowledge, skill, clinical judgment, conscientious care, nurse-to-patient ratios, comittment to quality care. Cheap is not the way I would decide who will be holding my life in their hands!

For people who do NOT have health insurance:
The story is different because the actual charge for services DOES affect them. They would benefit more by seeing prices up front.

4. Obtaining healthcare based on price targets the uninsured and puts them at risk for lower quality care:
The uninsured, and insured patients who have no clue how insurance pays their physicians or hospitals, may shop for healthcare by price. And precisely because of that, transparency expects primarily the uninsured to choose healthcare by cost, not quality. That is not fair. I don’t have any sympathy for people who fail to act responsibly to obtain healthcare insurance just because they assume someone will take care of them and they rather spend their money on fun things. But I have a lot of sympathy for people who are struggling to support themselves and their famililies and truly cannot afford health insurance, a group that is increasing because of the continual premium hikes by insurance companies (who are still managing to make healthy and growing profits). Do we relegate them to the cheapest healthcare providers? Or do we search for ways to make healthcare more affordable?

So should there be transparency? Yes. As patients we need to get a better sense of cost and be more judicious. But focusing solely on provider charges is not the way to do it. Nor will it reduce healthcare costs.

Stay tuned for Part 2 on Transparency . . . what should be transparent, why, and what effects will it have? Is it even legal?

Applause for initiative of some drug companies

2006-04-26T08:20:00.000-04:00

I was pleasantly surprised to read about an initiative by five large pharmaceutical companies to partner with the American Cancer Society to create employer-based programs to actually do something to promote health and prevent cancer, among employees. The companies include AstraZeneca, GlaxoSmithKline, Novartis, Johnson & Johnson, and OSI Pharmaceuticals.

Their goals are to reduce the risk of cancer, to detect it early and to ensure the best care if cancer occurs. Known as the CEO Cancer Gold Standard, the project focuses on 5 areas:

Tobacco use: Creating and enforcing tobacco-free worksite policies, ensure that health benefits include evidence-based tobacco treatment with counseling and medication, and create workplace initiatives for helping people stop smoking.
Diet & Nutrition: Sustain a culture that supports healthy food choice, provide access to nutrition and weight control programs.
Physical Activity: Sustain a culture that promotes physical activity and eliminate barriers to active lifestyles.
Screening and Early Detection: Promote behaviors leading to recommended cancer-screenings as recommended by the American Cancer Society Guidelines or the US Preventative Services Task Force Guidelines. They also seek to provide health benefits to cover screening costs and eliminate cost as a barrier to regular screenings.
Access to Quality Treatment & Clinical Trials: Educate and promote clinical trials for cancer treatment. Create health benefits that stop people from entering clinical trials and that provide access to cancer care at Commission on Cancer-approved or NCI-approved cancer centers. (I hope that this includes information on ALL current clinical trials and does not unduly influence patients only toward trials of specific drugs manufactured by these companies.)

(You can read more about each of these at the CEO Cancer Gold Standard website. )

The hope is that the effort will save lives, improve employee productivity and reduce health costs.

Since cancer is one of the drivers of high health costs, this major effort at prevention is to be both applauded and used as a model or springboard for other initiatives in every area of healthcare. Medicare, every insurance company, hospital corporations, medical supply companies, patient groups, and others can do so much more in reducing health costs by addressing the real causes of increasing health costs. This makes much more sense than the usual approach of penalizing physicians and patients financially as a band-aid that solves nothing because it doesn’t address the roots of the problem or the real drivers of costs.

I applaud these companies who are leading the way toward more positive and effective steps to improving health and reducing costs. As long as the information on clinical trials is inclusive of other companies' medications or procedures, this represents an ethical relationship approach that benefits patients, physicians, and reduces health costs.

May the trend continue! And may it be successful.

More interesting points on Garza Vioxx case

2006-04-26T07:19:00.000-04:00

I came across some other interesting points related to the Vioxx lawsuit in Texas (see entry of April 22). These are focused more on evidence and testimony and can be found at Pointoflaw.com's April 23rd entry on the case -- The Garza Vioxx case and the jury system

Celebrate Successes in Healthcare

2006-04-24T13:49:00.000-04:00

This past week the National Center for Health Statistics reported that the annual number of deaths in the United States dropped by almost 50,000 in 2004. It is the biggest decline in 70 years. Some commentators guess that when the final report is released later in the year, the numbers won’t hold up.

One of the reasons for surprise is that the number of deaths most often increases each year. The last decrease was in 1997 when it dropped by 445 deaths. This time it dropped by almost 50,000.

Another reason for the surprise is that we are growing in population, growing the number of older citizens and getting fatter.

The Center said the data shows decreases in death rates for cancer, stroke and heart diseases which comprised the biggest portion of the drop.

Whether or not the numbers hold up exactly, I think it is important to give credit to advances in medicine and quality of care. There will always be room for improvement, but we also need to celebrate successes, to recognize and acknowledge what’s right, to hold in one hand the positives about healthcare, while in the other hand we hold those things we all want better. Otherwise we walk around with skewed views believing the lack of perfection is all there is. We make the negative the primary reality.

I, for one, want to walk forward with both – to build on the best we already have in order to take steps to bring the rest to what we want.

This is justice?

2006-04-22T14:48:00.000-04:00

Today I read in my local newspaper that in Texas a jury found Merck liable in the death of a 71-year old man who took Vioxx. They ordered Merck to pay – are you ready? -- $32 million. They ordered $7 million in non-economic compensatory damage for mental anguish and loss of companionship to someone. They ordered $25 million in punitive damages. No economic damages were awarded because Mr. Garza was retired.

But get this . . . Mr. Garza, the deceased, had documented heart disease for more than 20 years, had already had one heart attack and died of a heart attack. And yet, in spite of that and the fact that one might expect someone who had chronic heart disease to eventually die of heart attack, Merck is to blame. To make it even more absurd in my mind is that the man took Vioxx for less than one month. What is known about it is that it increases the risk of heart attack for people who took it 18 months or longer. But never mind those details. Once again, we have a jury dispensing so-called justice based on . . . . what?

Perhaps this is a great example of why health courts might provide a more reasonable, consistent, fair alternative to emotionality and sympathy verdicts. I do believe there are people who should be awarded damages because of stroke or heart attack caused by longer term use of Vioxx when it has been shown in 2004 that Vioxx increases those risks significantly. But I also believe in justice – for patients, for companies, for physicians, for anyone and everyone involved. A man dying of a heart attack after over 20 years of heart disease who had had a previous heart attack, combined with the fact he took Vioxx for a few weeks just doesn’t do it for me.

In the New York Times report on the ruling, a few other facts were noted and seemingly disregarded. Not only had the man had a previous heart attack, he had had a quadruple bypass, was overweight and smoked. Oh yes, he also had high blood pressure. Could any of those things possibly have anything to do with the fact that he died of a heart attack? I guess the jury didn't think so. (Did I mention maybe we need specialized health courts?)

The New York Times also pointed out that local plaintiffs who have suits against companies with out-of-state headquarters typically get large awards in South Texas. Mr. Garza was well known in the county where the case was heard.

Maybe there are significant other facts that were not reported, but from what I read, I think this is miscarriage of justice, not just for Merck, who is no friend of mine, but for patients and healthcare in general.

The only redeeming factor in this situation is that Texas has some caps on damages and so the award is reduced from $32 million to $7.75 million. Only 11,500 more Vioxx lawsuits to go. This is better than the lottery when they rule in favor of cases like this one. . . and then give large awards.

Happy Doctor's Day!

2006-03-30T12:26:00.000-05:00

If you have not done so, right now write a note, buy a thank you card, create a fax, order flowers -- do something to express to YOUR physicians how much you appreciate them. Today is Doctor's Day -- but you can say thanks any day!!!

A couple of thoughts about this day:

1. Throughout this week, every morning from 8am-9am and a couple of evenings from 5pm-6:15pm, I and various friends have stood on corners of busy streets with a 7 foot banner that reads "Thank YOUR doctors this week --- March 30th is Doctor's Day."
As I stood there waving each time, I wished that every doctor could have been standing there with us to see and hear the response of people driving by. So many people waved, many honked their horns, some gave thumbs up, others yelled 'thank you' out the window. Some even did those things while talking on their cell phone and driving! They were teenagers and senior citizens, black, white, Hispanic, people driving Jaguars and Hummers, bikers (motorcycle and regular bikes!), repairmen, bus drivers, city workers, dumptruck drivers -- every type of person expressed their appreciation and support of doctors. I just wish all physicians could have heard and seen it! (I think even the nurse and PA who were with me some days may have felt a little more appreciated!)

2. I have been so struck and saddened over the past year or two as I've heard from physicians not only how discouraged they are, but how deeply so many feel unappreciated by patients. I've heard some of the same from, nurses, physician's assistants and others. And I've wondered "How can they not know that they are appreciated and valued by patients, when so many of us are so grateful for the care we have received?" Why don't people express their appreciation?

My guess is that there are a couple of reasons.
• Patients assume doctors and other pracitioners know they are grateful. (How could we NOT be?) Some might even say 'thank you' at the end of their visit and believe that communicates their gratitude. But 'thank you' can sound automatic and is not often received by the person hearing it.
• Patients feel awkward and even a bit embarrassed about expressing gratitude more fully, especially to a professional. I remember when I first wrote a 'thank you' to my surgeon. I remember thinking "she's going to think this is so silly". I had to remind myself that it was important to say, that I wanted her to know how grateful I am, and if she thought it was silly, that was up to her. If I, who often express my appreciation of people, have second thoughts, I can only imagine how those who don't do it often can easily talk themselves right out of it, even if they really want to express their gratitude.
• People don't know what to say. For some people giving compliments and expressing themselves seems to come easily. For others, it seems stuck inside without words or ways to express it. I think of that great scene with Jack Nicholson and Helen Hunt in the movie 'As Good as it Gets'. She has asked him for a compliment after feeling insulted. You can see his agony and difficulty in coming up with just one compliment. At the end of the movie, there is another great scene in which he tells her easily some of the qualities he has noticed about her. You see how deeply it touches her heart and soul as she hears it.
You CAN say thank you for qualities and behaviors and care even if doing so seems awkward. When you do, it transforms both you and the person hearing it. We sure need more of that in our healthcare relationships!
• Sometimes patients just feel rushed at a visit. The physician, nurse, PA are in and out of the room and it is clear they are rushed. (To my fellow patients -- it is NOT because doctors or other practitioners don't care or are just trying to get money for a nice vacation -- it's usually because they are trying to make up for declining reimbursement and increasing office and professional expenses. They hate it as much as we do. But that's another whole story, -- you can read a little about it here.)

So, right now, whether it is March or October when you read this, write a few words, or find a Thank You card that helps you say want to say, or send a couple of flowers, a balloon, or a box of chocolates with "I just want to say thanks for being my doctor." You will make their day, you'll feel great, and you will have done one thing to support healthcare professionals in this age of discouragement.

And in that same spirit, I want to thank YOU-- all our physicians and practitioners -- for even staying in practice this days, and for trying every day to be the best doctor to your patients that you can while facing so many obstacles. I, and many more of your patients, wave, honk our horns, give you thumbs up, and are yelling 'Thank You!!!' out our windows because we want you to know we value you and appreciate all you do.

Defensive Medicine is Not a Problem?

2006-03-09T11:34:00.000-05:00

I frequently read comments, most often by personal injury attorneys or their organizations that say that there is not a significant problem with defensive medicine as a result of the fear of litigation. They usually go on to say that defensive medicine does not contribute that much to rising health costs and that no one has been able to supply a valid study or report about the extent or cost of defensive medicine.

A couple of weeks ago, I went to physician for a yearly follow-up and at the end of my visit asked if I could have a couple of annoying skin tags (little protruding benign skin growths) removed from my neck area and one under my arm that would get irritated with jewelry or some clothes. The doctor said he could remove the bigger one under my arm, but I would need to go to a dermatologist for the others because they were too small. A little Lidocaine and a quick snip later, my skin tag was removed.

As he was documenting what he had done in my chart, he asked the nurse about my insurance, I said it wasn't necessary because I have a high deductible HSA and would pay out of pocket anyway. The doctor replied, "Oh, I'm not charging you for removing the skin tag, I'm determining which lab to send it to." I laughed and said, "You and I both know it is a simple skin tag, it's not a mole, it's a little skin tag. We all know it's not malignant!" He replied that he knew it was not malignant, but needed to send it to a lab for verification. He knows me and knows I'm not looking for a way to sue him. He has no interest in the lab, and he didn't even care which one it was ultimately sent to. But he cared about protecting himself and documenting that he had been diligent in sending it out for pathology.

I know this doctor. I know he is a person of integrity and honesty and values giving the best possible care for his patients. I know he is experienced, brilliant, and has seen thousands of skin tags and knows, like I do, that they are not malignant. But I also know he has been sued more than once although never found guilty.

I know this was defensive medicine, that I will end up paying for, because he understandably needs to be so careful. I didn't feel angry at him. I felt sad -- sad that this highly competent, thorough, excellent physician had to be hypervigilant each and every moment to dot the i's and cross the t's just to protect himself should it ever come to court. And he has made it standard procedure in his office that he does not deviate from. It made me wonder how many more tests, not just by him, but by any doctor or hospital are done for exactly the same reason.

Here's the definition:
"Defensive medicine occurs when doctors order tests, procedures or visits, or avoid high-risk patients or procedures, primarily (but not necessarily solely) to reduce their exposure to malpractice liability. (2. U.S. Congress, Office of Technology Assessment." Defensive Medicine and Medical Malpractice. Washington, DC: U.S. Government Printing Office. 1994: 13)

Don't tell me that defensive medicine is not a problem. But telling physicians or hospitals not to do it is like telling them to walk across a tightrope without a safety harness and just hope they don't fall and kill themselves. If I were a physician, I would do the same thing. And that is a sad state of affairs. And it costs all of us.

It costs financially:
"Everyone complains about the constantly rising cost of health care," he writes, "but there is something we physicians can do right now that would save billions of dollars: Stop practicing defensive medicine." Sharzer, Sidney. "Defensive Medicine is Worthless - On Two Counts." Medical Economics. March 22, 1993; 70(6): 41)

". . .system-wide savings from aggressive malpractice reform could approach $41 billion over five years."
Rubin RJ and DN Mendelson. "How Much Does Defensive Medicine Cost?" Journal of American Health Policy, July-August, 4(4): 7-15.

In a study done by Studdert, Mello, Safe, Brennan and others of the Harvard Health Policy group that has studied various aspects of malpractice extensively, they report:
A total of 824 physicians (65%) completed thesurvey. Nearly all (93%) reported practicing defensive medicine."Assurance behavior" such as ordering tests, performing diagnosticprocedures, and referring patients for consultation, was verycommon (92%). Among practitioners of defensive medicine whodetailed their most recent defensive act, 43% reported usingimaging technology in clinically unnecessary circumstances.Avoidance of procedures and patients that were perceived toelevate the probability of litigation was also widespread. Forty-twopercent of respondents reported that they had taken steps torestrict their practice in the previous 3 years, including eliminatingprocedures prone to complications, such as trauma surgery, andavoiding patients who had complex medical problems or were perceivedas litigious. Defensive practice correlated strongly with respondents’lack of confidence in their liability insurance and perceivedburden of insurance premiums.
Defensive Medicine Among High-Risk Specialist Physicians in a Volatile Malpractice Environment David M. Studdert, LLB, ScD, MPH; Michelle M. Mello, JD, PhD, MPhil; William M. Sage, MD, JD; Catherine M. DesRoches, DrPH; Jordon Peugh, MA; Kinga Zapert, PhD; Troyen A. Brennan, MD, JD, MPH JAMA Vol. 293 No. 21, June 1, 2005

It costs in patient trust and satisfaction.

It costs in physician satisfaction and well-being.

It costs in allowing something besides the well-being of the patient and the context of the physician-patient relationship to determine healthcare.

It costs me!

Resources:
GAO-03-836 Medical Malpractice: Implications of Rising Premiums on Access to Health Care (PDF)
Defensive Medicine and Medical Malpractice (HTML or PDF)

The Hijacking of the Legal System: Legalizing Theft

2006-02-05T20:35:00.000-05:00

I saw that two lawsuits were filed in Manhattan courts early this week to try to make a buck, and some large bucks, off the revelation that the book A Million Little Pieces by James Frey and promoted on Oprah, is not all true. Oprah took him to task on her show and also personally apologized to her viewers. She took responsibility for minimizing the initial revelation that some things may not be true and fully apologized to her audience.

Besides James Frey who had to lie to make money, now we have two lawsuits by others trying to make money from the event. According to the Orlando Sentinel, there have other lawsuits filed in Chicago, Seattle and Los Angeles.

One is a federal class action suit filed by Jimmy Floyd and Susan Gardiner against Random House and Nan Talese of ‘gross negligence’ for not checking the facts. They are seeking cash, of course, a full accounting of book sales and an injunction to prevent Random House from marketing the book as a non-fiction memoir.

One even more ridiculous is filed by Jennifer Cohn, a social worker (I’m embarrassed to acknowledge!). She claims that as a ‘health care professional’ she recommended the book to people with substance abuse problems because the book had a ‘redemptive theme.’ Now Cohn is claiming that consumers were injured by the lies and she is seeking, $10 million on behalf of these poor injured people. It reminds me of a lawsuit filed against numerous physicians, including a surgeon sought for a second opinion, by a woman who failed to comply with repeated instructions by that very surgeon to have a biopsy. She claimed 'failure to diagnose' a cancer that ultimately claimed her life and she won millions.

Are we becoming a nation of wimps? Or of greedy attention seekers, or in some cases, thieves, hoping to subvert the legal system to essentially steal someone else’s money? My only comfort is that for the most part, these people are the minority, although I see more and more people failing to take responsibility for their lives and continually making themselves helpless by blaming someone else for the state of their lives. But that is another story! If people are injured because some guy embellishes the truth in his memoir, they are indeed pathetic. Maybe all of us could sue our politicians for misleading us and therefore ruining our lives! Victimhood and greed are two things for which I have no patience. People need to get a life, and to get one by their own work, by fulfilling their own purpose of being on the planet, instead of trying to leech off someone else.

Will we see outrage by the majority at this hijacking of the legal system? I’m not holding my breath, but I hope so. And I hope that the legal profession is just as embarrassed about the attorneys who would file such absurd claims as I am that Cohn is a member of my profession. I hope both professions would take disciplinary action. No one held the woman accountable for her actions in the failed diagnosis cancer case I mentioned and I doubt anything would have happened had she lived.

I would think that all citizens and professions would want to prevent such abuses of the system from occurring and to create meaningful and consistent consequences for those who would try to take what is not theirs and/or cause damage to others by their greed.

Thoughts from the Citizen's Group Healthcare Meeting

2006-01-28T22:49:00.000-05:00

We started our discussions at the town meeting on healthcare (see previous post on the Citizen's Working Group in Healthcare) by exploring the core values we thought were important to frame our discussion and approach to healthcare reform. From the group, the top values chosen were:

Affordable
Ever improving quality
Equal access for basic services
Fairness
Empowered and educated consumers
Prevention as a core component

When talking about ways of cutting costs, one suggestion was that we require that new technology should demonstrate proven benefit over previous equipment or methods before we adopt it. A good portion of the group stressed the need for prevention and wellness education in light of the fact that 50% of the population with chronic illness represents 75% of medical costs.

Discussions also explored what a basic plan of service coverage would include if we were to design something that would provide coverage to everyone. When asked who should decide what such coverage for all should include, the initial vote based on groups decided by the Citizen’s Group before the meeting was as follows:

Medical professionals 31%
Government 17%
Employers 7%
Insurance industry 2%
Other 43% When ‘other’ was discussed the group overwhelmingly (76%) supported a proposal of an entity, like a federal board of appointed experts, that would include medical professionals, employers, insurance, government, consumers, and perhaps others that would present a package of core services and advise on other ways of impacting health costs.

We were asked to discuss problems we have experienced in getting healthcare, whether for ourselves or a family member, and factors that contribute to problems.
The most common problem getting care in the group was getting past gatekeepers to get specialist or sometimes basic care.
The second biggest problem was cost.

Some of the health cost concerns reported:

Failure to address core drivers of healthcare like obesity, lack of patient compliance in chronic disease management, etc.
Unproven technology.
The failure of people to get off programs like Medicaid.
The uninsured clogging emergency rooms and raising the costs of care delivery.
Defensive medicine – unnecessary tests and procedures to cover oneself or one’s facility out of fear of litigation.
Too many 3rd parties and resulting administrative costs.
Excessive and diverse regulations that add to costs of providing services for doctors, clinics and hospitals.

When asked what tradeoffs people would be willing to make to create a healthcare system for everyone, people wanted to be sure to keep the following:

Access and choice
Quality
Service and choice based not just on cost, but on good care
Timeliness of access
Less bureaucracy for physicians and facilities.
Respect for patient.

Concerns were:

Negative impacts on the doctor-patient relationship that we all want to preserve and restore.
Address the core drivers of health costs instead of band-aid approaches.
Reducing administrative and regulatory costs.
Insure everyone and eliminate 3rd parties.
Need to invest in public health programs for preventive services and basic care.

74% of the group believed that everyone should be required to obtain basic coverage, with costs based on income. A large majority voted for a single-payer system, either created from scratch, or building upon the current Medicare and federal employees health benefits program (would be opened up for everyone.)

One of my concerns about the core group’s approach was that much seemed to be focus on how do we find creative ways to pay for rising health costs, when I believe a big part of the question is how do we address the core drivers that create excessive and wasteful costs? To me that must come first and then the problem of paying for it is a more manageable one. By addressing the core drivers, not only do we address cost issues, we create a healthier America.

Town Hall Meetings on America's Healthcare

2006-01-25T07:34:00.000-05:00

Yesterday I had the opportunity to be part of one of the community meetings of the Citizen’s Health Care Working Group talking about Health Care that Works for all Americans. I happened to see a small story in the local newspaper the day before and decided to attend.

The Group is part of a mandate in the Medicare Modernization Act of 2003 (yes, THAT one!). Meetings will be held across the country and from that, recommendations will be submitted to the President and Congress at the end of September, 2006. They have created a document entitled, “The Health Report to the American People” that grew out of meetings with experts on healthcare. (The report and transcripts from the meetings are available on their website, Citizen's Health Care Working Group )

The mandate itself is important – whether or not anyone attends a meeting.

“In order to improve the health care system, the American public must engage in an informed national public debate to make choices about the services they want covered, what health care coverage they want and how they are willing to pay for coverage.”

What I think is so important about it, is that it is a challenge to all citizens to become better informed about policies and trends impacting their lives AND to take responsibility for making their voices heard. I was just saying to a doctor the other day that patients are essentially, and often totally, ignorant about health care policies impacting their access and care. Staying ignorant keeps people disempowered. Of course, then we can all moan and groan and blame someone else, so it does have it’s advantages. But I think there are a lot of us out here who DO want to do something, but nearly all people feel helpless. And in our helplessness, we feel hopeless about possibilities for change. And I think that is true for both patients and providers. While doctors, nurses, and others may know first-hand some of the issues, they are swamped and feel like they can’t do one more thing. They are also discouraged because they feel betrayed by the AMA and other professional organizations that are supposed to represent them because change has not occurred. Nor have those groups effectively educated the public. But that’s another story. The point is, for patients, ignorance is disempowerment and letting our healthcare happen by default.

These town hall meetings are an opportunity to learn and to voice concerns. In my opinion, even if that’s ALL they do, that is success. Clearlym, I hope they come up at the end with at least some recommendations of promise, but to me, the journey is part of the possibility for our future. If more people hear about some of the issues and the complexities, if more people say, “here’s how this impacts me” and “this is what I want, this is what I think we need”, we are further ahead than we are now. We need to find ways to get people engaged.

Next time, I'll let you know about some of the responses of our Orlando meeting.

To double-check upcoming meetings in your state or region, visit their website. www.citizenshealthcare.gov As of today, January 25, 2006, here is the schedule:

January 2006
January 17	Kansas City, MO	The Kauffman Foundation
January 24	Orlando, FL	Leu Gardens
January 26	Baton Rouge, LA	LSU Lod Cook Alumni Center

February 2006
February 11	Memphis, TN	Bridges
February 18	Charlotte, NC	Harris Conference Center
February 25	Seattle, WA	Seattle Center- Northwest Rooms
February 27	Denver, CO	Colorado History Museum

March 2006
March 4	Los Angeles, CA	Los Angeles Convention Center
March 6	Providence, RI	TBD
March 9	Miami, FL	Grand Bay Coconut Grove
March 11	Indianapolis, IN	Butler University
March 18	Detroit, MI	Northwest Activities Center
March 25	Phoenix, AZ	Crowne Plaza Hotel

April 2006
April 8	Des Moines, IA	Des Moines Botanical Center
April 22	New York, NY	TBD

May 2006
TBD	Chicago, IL	TBD

Insurance Profits Underscore the Need for Insurance Reform

2006-01-23T12:04:00.000-05:00

A January 19th, 2006 MarketWatch updates states that UnitedHealth Group, Inc., one of the nation’s largest health insurance companies had an 18% increase in just their 4th quarter profits of last year. This was after a 21% increase for the 3rd quarter. The December quarterly net income was $870 million bringing their 2005 revenue to $12.1 billion, almost $2 billion more than in 2004. Market analyst, David Shove of Prudential, said: "We remain bullish on UnitedHealth's 2006 prospects." (Market Watch News report Jan. 19, 2006)

It sounds like the health insurance industry is doing quite well!

But there’s more. UnitedHealthcare also just completed its merger with PacifiCare Health Systems at the end of December. $230 million in accelerated stock options and payments to PacifiCare executives, plus an additional $85 million in signing bonuses to the executives who remained with the company, were part of the deal. (Health Policy Report, Kaiser, Dec. 20, 2005)

This abundance of cash flow occurs while my individual insurance premium rates go up an average of 25-30% each year without having used my insurance until last year. It occurs while my surgeon gets paid less than Medicare paid for the same surgery 10 years ago; and while many of surgeon’s reimbursements for their most common procedures have dropped double-digit percentage points.

Insurance should make a profit, but not in ways that cause damage to patients or their physicians.

A huge factor in the ‘problem of the uninsured’ are the insurance companies themselves. They are pricing more and more individuals out of insurance coverage, and causing employers to reduce benefits. It is inconceivable to me that states, the federal government, and patients are not uniting their voices to call for significant reform of the insurance industry. In December I wrote an opinion piece in my local newspaper about insurance profits, increasing premiums, reduced reimbursements to physicians and the need for reform. There was a deafening silence from the general public. Will it take 40 million more of us to become uninsured before this is addressed?

For more info on insurance company profits, see these articles:
Insurance Reform for Healthcare Opinion piece I wrote to local Orlando Sentinel
UnitedHealth misses some expectations, Reuters

(More article links coming!)

Give Thanks for Your Doctors -- They Need It

2005-11-20T09:57:00.000-05:00

This morning’s paper contained two stories that push all my buttons about unethical relationships in healthcare. When people think about ethical or unethical relationship, they focus on physicians. But as I’ve tried to make clear on my website, patients can be unethical with their physician, or the office staff, or their insurance company. Insurance companies can be ethical or unethical in their behavior toward patients and toward physicians. And the same is true for all individuals, groups, professions, and industries that form what we call healthcare.

As Thanksgiving approaches, I hope every single adult in America gives thanks for physicians and nurses who work exceptionally hard, often under difficult circumstances, with little support, to take care of us. I know I am exceedingly grateful for mine, in particular my surgeon who provided such exceptional care for me last year; for a cardiologist who probably saved my best friend’s life.

One of today’s articles was on the planned cuts in payments to physicians by Medicare and the administration’s views on the cuts. Most reports I have read over the past year say the cuts will total 30% over the next 6 years. Now Medicare is claiming 25% cuts, and say physicians’ practice costs will go up 15%. If you include medical malpractice insurance costs in practice expense, 15% is an absurdly low estimate designed to make the cuts more acceptable, not just to physicians, but to the public.

Administration puts out the usual ‘fear’ tactic (as it seems to do with most of its decisions these days). If the government treats physicians fairly and ethically, poor seniors will be burdened with the cost. No mention is made about changing the payment structure that has led to the problem in the first place. No mention is made of the billions of dollars the ridiculously complex drug program will cost, much of which will go into the insurance industry’s pocket. And once again, we here the stupid thinking espoused by Grassley earlier. The administration (un-named source) said that “doctors often respond to cuts by performing more services, so their income does not necessarily fall.”

As Representative Norwood said the other day in the House Energy & Commerce Committee hearing on physician pay by Medicare, this approach “expects doctors to work twice as hard for half the money and be happy about it.”

This amounts to nothing less than the administration’s blatant willingness to exploit the care and commitment of physicians. In what other profession or industry could they even be considering such action? Would THEY work twice as hard for half the pay? Would you? No wonder doctors are so demoralized.

Then, to add insult to injury, administration officials say that doctors should not be paid more unless they cooperate with the governments effort to link fair payment to them to the governments standards of quality care, most of which has not been defined yet. Their initial efforts to create standards brought objections from physician groups, even those who support measuring quality. The AMA said that many of the 36 measures were invalid or inappropriate for doctor’s offices. Many doctor’s associations have been saying from the beginning that many would support some type of measurement of quality, but ones that are fair, that are designed to measure according to the practice type and specialty since there cannot be a ‘one size fits all’ approach.

They aren’t discussing the costs to physicians to implement electronic records to be able to even collect the data, while they are supposed to be working twice as hard at half the pay and other expenses going up.

So on Thanksgiving, give thanks for your doctors. Write them a note – even the mediocre ones. They are struggling under increasing burden, are more and more discouraged, and do not feel supported by we patients. It’s time for all of that to change. We don’t have healthcare without them and without their commitment to us. They could use a little support and appreciation. Better yet, make your support known in Washington. (Contact your legislators and take action here.)

I’ll tell you about the other article later.

Hoping you and your family have much to be thankful for this Thanksgiving.

Patient Safety Success -- We Need More

2005-10-19T09:32:00.000-04:00

Yesterday I read a notice from Modern Physician about a patient safety effort in the Intensive Care Units of 77 hospitals, primarily in Michigan. The project was organized by Michigan Health and Hospital Association and Johns Hopkins University Quality and Safety Research Group. The study reports that over 1500 lives were saved, 81,020 hospital stay days were eliminated and over $165 million were saved.

As part of that improvement, central-line infections were reduced by almost 50%, 68 of the ICUs reported no cases of bloodstream infections and no cases of ventilator-associated pneumonia for at least 6 months.

Efforts like these are not only to be applauded, but made into a template for ready implementation in hospitals across the country (and the world!) Hospitals do not need to reinvent the wheel. No doubt they can refine it and continually improve it. I’m curious about why things like this don’t spread like wildfire.

I don’t know about the hospitals in your area, but the three major hospitals in my community all have safety committees. I don’t know if they are staffed by any full time employees whose job description IS the committees work of assessing and meeting patient safety goals, or whether they are volunteer committees that are fit in between other duties and demands.

Is there one databank where successful programs can be made easily and freely accessible to everyone? If not, who would be the logical institution to create one? I have read in the past about successful efforts to reduce medication errors in hospitals. I personally sent that to the committees in my area. I will send this notice or any other information I can find about the study. But there has to be a more consistent and efficient way. Maybe I’ll e-mail Donald Berwick to see if his Institute for Healthcare Improvement will sponsor it, or maybe the JCAHO or AHRQ.

In the meantime, I hope you will get the info to the patient safety committees in the hospitals where you live. Not only do they need the information, they need to know that physicians, patients, nurses, administrators, insurance executives and government leaders all care enough to make a statement.

Note: After writing this, I searched for more information about the initiative to send more specifics to my local hospitals. According to a report in Nurse Week reports that “a physician faculty member of the university, Sanjay Saint, MD, MPH, has written evidence-based safety standards for AHRQ, including interventions the Keystone project uses.”

Recommended Resources:
Keystone Program — a Foundation for Patient Safety – Summary Article in Nurse Week by Lisette Hilton August 01, 2005

MHA Keystone Center for Patient Safety & Quality – the site of the Keystone Project

Simple hospital reminder system reduces urinary catheter use, cutting risk of infection, and cost -- focuses only on infections related to catheter use. Medical News Today (Section: Urology/Nephrology News) Article Date: 31 Jul 2005

The Ultimate In Shortsighted Thinking About Quality Healthcare:

2005-10-14T11:21:00.000-04:00

A recent update on the status of the proposed Medicare cuts in reimbursement to physicians discussed pay-for-performance and possible legislation that would postpone the pay cuts for two years to study the impact of quality improvement. The update reported a remark by Rep. Pete Stark (D-Calif.) who is alleged to have said that if the scheduled cuts go forward, doctors could see a reduction in payments per service, but they could offset the cut by increasing service volume (that means squeezing in more patients or unneeded services). (CQ Healthbeat 9-29-05)

So, if our physicians squeeze in 10 more patients, when they already don’t enough time to spend with us, or work 14 hours instead of 12, maybe they can keep up with their current income level (never mind that their cost of living will continue to rise as does ours, their practice expenses will go up as they have in the past, and malpractice premiums increase each year.)

Does Rep. Stark and legislators or patients like him think about the consequences of simply squeezing in more patients? Do they think or care about quality of care and patient safety? Do they care about a physician taking time to do a thorough examination, make an accurate diagnosis, and treat the patient? Do they care about what that attitude does to physicians?

Patients and physicians both suffer from such shortsighted thinking. The entire healthcare industry, including much of our Congress, suffers from shortsighted thinking that continues to bury collective heads in the sand about the real drivers of healthcare costs. Repeated research shows that the rate of pay of physicians is NOT a big driver. (Physician care has historically been the slowest growing category of health care spending and has increased very little in recent years. Source: Tracking Health Care Costs, Strunk, BC and Ginsburg, PB, Center for Studying Health system Change, December 2004.)

We all suffer from continuing weakening of the doctor/patient relationship. We all suffer when neither patients nor their physicians are valued enough to put creativity, effort and vision into finding ways to work together to support the well-being of all of us.

You only have to talk with physicians one on one to hear their deep discouragement. They love medicine. They want to provide quality care. They care about their patients. And thinking like that of Rep. Stark buries them under more work, less pay, more hours, less time, more unhappy patients, less quality, more paperwork. Many feel beaten down and physically and mentally exhausted. Is that who Rep. Stark and others want providing their (and your) care?

I can’t help but wonder how anyone who thinks like Rep. Stark would react if Washington told them “We will cut your pay 30% over the next 6 years even though your expenses will continue to rise. But – no problem – just work longer and harder to make up the difference to just maintain your current rate of income. I guess you’ll have to do without to make up for the increased cost of living.” I can’t think of a legislator or ANY worker who would just sit back and embrace that concept. How dare they expect that of physicians!

I believe that the mindset that Rep. Stark represents on this issue is an insult to all of us. As patients we have an obligation to correct it, to further educate ourselves and to hold our elected officials accountable for supporting quality physician/patient relationships and the care that takes place within that context.

Contact Rep. Stark and your own Senators and Representatives to help educate them about increasing costs and decreasing reimbursement – with a 30% cut planned. Even if they don’t care, hopefully they can see it is not sustainable from a business point of view! (You can contact your legislators here and also find points you might want to include in your letters or calls.)

For information on the proposed Medicare cuts, impact on ALL patients and physicians, the biggestl health cost drivers and more, click here.

The norm of healthcare is positive

2005-09-25T10:07:00.000-04:00

I felt heartened by the good news stories of physicians, nurses and other healthcare professionals during the television coverage of Hurricanes Katrina and Rita. Their dedication, care, and commitment to patients even at great cost and risk to themselves was not only evident, but was the story. They were working with nothing, short on food and water, worried about their own families and property and stayed the course with their patients. In Galveston that was thought to be the bullseye for Rita, a group of dedicated professionals stocked up on food, water, and plans to care not only for the few who could not be evacuated, but in case people were injured in the hurricane.

We don’t usually hear or read about the heroic side of healthcare, which is 90% of the story. Like with world events, new media tends to cover the absolute worst. Those negative incidents are presented as the story of healthcare, when they are a story precisely because they are not the usual. Good news about healthcare is usually related to breakthroughs in technology, procedures, or medications –– again because it is something apart from the usual. Even these stories were ‘exceptions’ to the death, destruction, rioting that was occurring. They were not the ‘norm’ that we were viewing, even though they are norm in healthcare. News is news because it is a study of contrast –– what stands apart from the larger background.

I know I, and I think most of America, as we are bombarded with negativity –– whether about doctors, terrorism, scandals, and various horrors –– need to continually remind ourselves that those things are the exception. We don’t need to become Pollyanna’s, but we do need balance. I wish the media thought the same way.

The absurdity continues . . .

2005-09-25T10:01:00.000-04:00

I don’t want the main topic of this whole blog to be medical malpractice, but sometimes there are things that I can’t resist. Have you ever asked, “What are the factors in our society that create this mentality?” What values do we promote or fail to instill?

1. An article in Medical Economics described a situation involving a woman he had treated for years for a variety of illnesses. She was in an unhappy marriage and came in about once a month and often did not follow-up with recommended referrals, lifestyle changes, or treatment. During one visit, the doctor notice a mass and suspected lung cancer due to her history of smoking. He was right and referred to her to a surgeon and oncologist. She continued under their care and that of other specialists. He received reports and talked with the other physicians when he felt it necessary.
Because of difficulties related to treatment of the cancer, the patient decided she would not agree to any more chemo, radiation or other aggressive therapies. She became more and more confused and both her husband and family members said something needed to be done because she couldn’t care for herself. Brain metastases was suspected. With her continued decline and family pressure, the doctor suggested a hospice program. She said she knew she was going to die and he did not dispute it, suggesting she get things in order. Long story short, the hospital said she didn’t qualify for hospice because there was no brain metastases. The husband informed the original treating doctor, the author of the story, that he planned to sue.
Two years later, the doctor received a notice of intent to file a claim. It claimed negligence for “failing to properly diagnose her cancer, for not consulting with other physicians, and for enrolling her in hospice when her condition wasn’t terminal.” Of course there were experts, claims for pain and suffering, fright, shock, humiliation, and loss of consortium.
Before the first deposition, the woman died. The lawyer dropped the case since one of the main complaints was that the patient had not died!

2. I read in the paper yesterday that a woman was selected for a possible appearance on Extreme Makeover. She visited the specialists who told her the various things she needed for the makeover – breast implant, chin implant, jawbone broken and re-set for dental work, etc. Even her attorney acknowledges that “she knew that they could drop her at any time, but she didn’t believe they would.”
Hours before the dental procedures, she was dropped from the program because of the recovery time that would be needed for the dental work. Of course she was disappointed and upset and now claims she was subjected to needless humiliation. Four months later, her sister, who had a history of bipolar disorder (manic-depressive) committed suicide. This woman sued ABC related to the death of her sister. She claimed a breach of contract complaint, willful infliction of emotional distress and negligence. She and the lawyer claim the show drove the sister to kill herself.

3. I read a comment by a physician who reported an incident in which a woman was seen at an ER and told to follow-up with a gynecologist. A week later she came back with a worse problem. She was treated and survived. Her insurance company allegedly wrote the hospital and said that if they did not drop the charges they had billed, they (the insurance company) would send a letter to the patient suggesting she contact an attorney about inappropriate treatment on her first visit.

I have nothing to add. They speak for themselves.

The AMA -- Cosmetic Surgery or Real Change?

2005-09-09T21:42:00.000-04:00

One of my big questions is, “What is the AMA not doing, that doctors most need?” Maybe I should ask, “What have they done that has frustrated and angered so many doctors?” With membership declining steadily and rapidly over the past several years, the AMA is in trouble. I read the other day that they are giving themselves a facelift, a new logo, a marketing campaign and more focused agenda to bring doctors back into the fold. (AMA gets facelift to attract new members By Stokely Baksh)

In the article there was mention of member surveys that it seemed were an attempt to begin to prioritize issues. I wonder what all the people who have dropped out of AMA think the important issues are.

My hope is that there is a genuine desire and effort to better support the majority of physicians, including those who have ‘dropped out’, to be the kind of physicians they long to be for their patients.

What I hear from most doctors at this point is a sense of futility and betrayal by people and entities they have supported and trusted in a variety of ways. They love medicine, they love their patients, but they are burned out and burned by the systems.

Whatever the combination of reasons for AMA’s mistakes, I hope that it does take an honest look at itself, cleans house, and becomes the vibrant voice for physicians that it has the potential to be. How does it begin to regain the trust of physicians who feel betrayed by it? I don’t know. But I think that asking themselves “what is the AMA NOT doing that doctors most need from us?” is a good start. A second might be, “how can we become a voice that embodies the best of our values as doctors, a voice for visionary change to co-create a better healthcare system for both patients and for the physicians who care for them?”

Medicare Payments to Physicians -- to cut or to cure?

2005-09-07T07:54:00.000-04:00

Yesterday I read an article in the Philadelphia Inquirer on the proposed cuts to Medicare reimbursement for physicians. It echoed the familiar theme that if we care about the well-being of our physicians and treat them fairly, we as patients will suffer. I am SO tired of reading variations of that theme – whether it is about Medicare, insurance, malpractice, payment of physicians, or anything else. I can’t help but wonder who benefits from making patients and physicians adversaries. It’s not patients and it’s not physicians!

I firmly believe that if we as patients and our physicians band together, we CAN improve both healthcare quality and cost. Patients are the purpose of healthcare, but the physician/patient relationship is the core of healthcare. Without that, we don’t have healthcare. So thinking in ways that seek to undermine that just seems stupid to me.

If let’s take the proposed cuts to Medicare that will lead to a 30% decrease in payments to physicians over the next 5-6 years.

Medicare is indeed faced with the huge challenge of figuring out what to do with drastic cuts in their budget (partially to pay for the new drug benefit), continually increasing costs. They are grasping for anything that will help. Their primary solution is physician pay cuts. Why? Not because it is the problem, but because it is the easiest to control. The other easy thing to control is increasing patient premiums. Yet both put undue burden on the ones already struggling under the weight of short-sighted thinking – patients and physicians.

Did you know that some of real drivers of increasing costs for both Medicare and private insurance are:
• obesity and its related problems (diabetes, some forms of cancer, cardiovascular problems, etc.) The combined prevalence of both overweight and obesity averages 53.6% across all categories and is largest for those enrolled in Medicare (56.1%) Obesity-attributable expenditures by state totalled $75,051, 000,000 from 1998-2000. Since the rate of obesity has increased significantly in over the past 5 years, the costs are significantly higher. Estimated Adult Obesity-attributable Percentages and Expenditures by State (BRFSS 1998 to 2000). . Also: National Medical Spending Attributable to Overweight and Obesity. Finkelstein, EA et al, Health Affairs. May 14, 2003.)
• non-compliance with treatment in chronic conditions (like diabetes, high blood pressure, etc.) In 1992, the cost of medication noncompliance alone was $100 billion ($45 billion in direct medical costs). $31.3 billion was spent on nursing home admission due to noncompliance, $15 billion was spent on hospital admissions due to noncompliance, $1000 was spent per year per non-compliant patients versus $250 dollars spent on per compliant patient (Source: Compliance in Elderly Patients, University of Arkansas College of Pharmacy ;Also, Schering Report IX: The Forgetful Patient: The High Cost of Improper Patient Compliance. Also Standberg, LR, Drugs as a Reason for Nursing Home Admissions, American Healthcare Association Journal 10, 20, 1984) )
• costs of defensive medicine which are estimated at $23.6-42.5 billion per year (Source: Confronting the New Health Care Crisis, U.S. Department of Health and Human Services, July, 2002.)

Each of these cost more per year than the entire amount Medicare spends in physician payment! In contrast, physician care has historically been the slowest growing category of health care spending and has increased very little in recent years. (Source: Tracking Health Care Costs, Strunk, BC and Ginsburg, PB, Center for Studying Health system Change, December 2004.)

The other significant increases are:
• rising costs of drugs
• increased utilization of services
• costs of uninsured.

When you look at these factors and remember that the amount spent for Medicare reimbursement of physician services was $36.9 billion in 2000 and an estimated $54.2 billion for 2005, it is clear that addressing the biggest drivers of increasing costs makes more sense than penny-pinching with the providers of healthcare. (Source: MEDICARE PHYSICIAN PAYMENTS Information on Spending Trends and Targets— May 5, 2004 Testimony Statement of A. Bruce Steinwald Director, Health Care—Economic and Payment Issues, Testimony Before the Subcommittee on Health, Committee on Energy and Commerce, House of Representatives )

These are the problems that need to be addressed with vision, creativity, strategic planning and commitment across sectors of the healthcare system, including patients, physicians, government, insurance industry, pharmaceutical companies, and more.

Only by patients and physicians joining together to push for solving the real problems in healthcare, can we protect our health, our access to care, and quality of care. Promoting the well-being of one at the expense of the other is unethical, no matter which way it is done.

For a more in-depth discussion of this issue, go to:
Statement on Reimbursement for a hearing of the House Ways and Means Committee

Possibilities for action:
Write to your legislative leaders (some suggested points included)
Encourage Congress to support current legislation to prevent the cuts
If you work in healthcare, share information with patients. I have a flyer on my website that I used in Central Florida with names of people to contact, points to make in calls or letters, and why it is essential that patients take action. You can download it here, and I will be happy to modify a copy with YOUR local information (senators, etc.). I will also be updating it to include current legislation.

The Vioxx Ripoff of You and Me

2005-08-28T15:43:00.000-04:00

While I appreciate pharmaceutical companies developing and making available so many drugs that help people heal and manage illness, I am not a fan of their business practices. Another day I will talk about that. But today, part of what burns me up, is that once again we have a perfect example of the absurdity of our current tort system.

The wife of Mr. Ernst, who died of heart failure after taking Vioxx, was awarded $24 million for mental anguish and loss of companionship. They had been married less than ONE YEAR!!! She had known him a couple of years before they married. (See the article at: Widow's Suit to Set Tone for Rest)

Is it just me that thinks there is something wrong with this picture? $24 million for suffering and loss of companionship in a 1 year marriage. I have no doubt that she loved her husband and will grieve his loss. The death of someone you love is by its nature painful. I just don't think she deserves $24 million for it. I cannot tell you how much that angers me. It demonstrates everything that is wrong with the system. Besides the absurdity of that award, they awarded another $255 million in punitive damages--to HER. What a heydey for personal injury attorneys who will get about half and for people who see a once in a lifetime opportunity to cash in. And this is just the first case! A Washington Post article reports that approximately 7500 more cases are expected!

"Litigators and plaintiffs [are] likely to come out of the woodwork," analyst David Moskowitz of Friedman Billings Ramsey warned investors in a note. "The number of lawsuits filed against the company will increase dramatically in the coming months." Los Angeles Times

And, it is only Vioxx – we still have Bextra and Celebrex.

I am not saying there should not be punitive damages. Merck allegedly some suspicious withholding of information in the Vioxx case. Apparently the jury was swayed by documents indicating concern as far back as 1997. They also had resisted putting warning labels on the product. (See Bad Facts May Keep Costing Vioxx Maker) So I'm not feeling sorry for Merck and I agree that some punitive damages should have been awarded if the allegations are true, additional legal sanctions should be considered. But awarding these amounts to an individual or family is not right. It does not just punish Merck, it punishes all of us. If punitive damages are justified, I think Merck should be required to pay that amount, or even more, not to the family, but to something that will benefit patients or physicians -- for example, provide more advanced equipment for diagnosing and treating cardiovascular disorders to clinics in rural areas. That would make sense, and create a more ethical and just award.

Fortunately, Texas has caps on punitive damages, so Mrs. Ernst will probably only get a measly $26 million, minus the chunk her attorneys will take. But the fact is, you and I will be paying for this for years to come as more cases come forward. Pharmaceutical companies, like most other businesses, are not going to lose. Costs will be passed on to consumers. That leads to increases in our medications, increases in insurance premiums, which then will probably lead to further reductions in reimbursements to physicians, and on and on the cycle goes.

At the moment I don't have references for the costs of litigation specifically related to drug companies, but the same principles are shown in the following articles related to litigation against physicians and hospitals: Addressing the New Health Care Crisis: Reforming the Medical Litigation System to Improve the Quality of Health Care From the US Department of Health and Human Services explores the impact of the current system on the injured patient, insurance premiums, health care costs, access to healthcare and quality of healthcare. You can download a PDF version of the report.

Malpractice Crisis Affecting Patient Care
Medical Malpractice: Implications of Rising Premiums on Access to Health Care GAO (Government Accounting Office) August 2003
Caring for Patients in a Malpractice Crisis: Physician Satisfaction and Quality of Care Health Affairs 23(4):42-53, 2004. © 2004 Project HOPE Michelle M. Mello; David M. Studdert; Catherine M. DesRoches; et al.
Medical Malpractice Takes a Toll on Hospitals from Oncology Issues, October, 2004.
Medical Liability Survey Reaffirms More Ob-Gyns Are Quitting Obstetrics July 2004 survey on reduction of services in both obstetrics and gynecology, reduced number entering specialty for 3rd year in a row.
Liability insurance premium hikes take bite out of physicians' income (especially in Florida!) Graphs give you the picture. Source: MANAGED CARE May 2003 with the source being the Medical Liability Monitor
Defensive Medicine: Definition and Causes Older study from Princeton.
Understanding the US Medical Malpractice Crisis Looks at impacts on hospitals, patient care, and options for reform.
An Analysis of the Impacts of the Medical Malpractice System from the Washington Policy Institute
Testimony of GAO to House Ways & Means Committee on Medical Malpractice. Even though this is from 1995, it gives a sense of the scope of impact.

This case should be used by anyone seeking to have caps on damages in their state. But most of all, it should inspire all of us who are not personal injury attorneys to band together to demand that alternative methods to the tort system be encouraged in demonstration projects across the country. If patients don’t take responsibility for demanding it, it will never happen.

Tort reform is seen and described by the media as a fight between doctors and lawyers. Even if that were true, who would YOU want to ‘win’? What the media repeatedly fails to do is to investigate and report on how healthcare-related liability cases (and fears of litigation) directly impacts the quality and costs of our healthcare as patients. They have ripple effects throughout the system.

How can we as patients work to change this?
What are the partnerships we need to develop?
How can we encourage not only the pharmaceutical companies, but all of us (including attorneys and plaintiffs) to act more ethically and responsibly?

For recommendations on alternatives to the current system: Patient Injury: An Ethical Health Partnership Approach
Patient Safety and Medical Malpractice: A Case Study Troyen A. Brennan, MD, JD, MPH and Michelle M. Mello, JD, PhD, MPhil, 19 August 2003 | Volume 139 Issue 4 | Pages 267-273 Annals of Internal Medicine
Malpractice Liability and Medical Error Prevention: Strange Bedfellows? Paper Prepared for the Council on Health Economics and Policy Conference on Medical Malpractice Practice in Crisis: Health Policy Options March 2003 Michelle M. Mello, J.D., Ph.D., M.Phil. Article is linked on Kaiser's site at: http://www.kaisernetwork.org/health_cast/hcast_index.cfm?display=detail&hc=796
Policies to Foster Patient Safety Michelle M. Mello, J.D., Ph.D., M.Phil. Assistant Professor of Health Policy and Law Department of Health Policy and Management Harvard School of Public Health
Can the United States Afford a "No-Fault" System of Compensation for Medical Injury? David M. Studdert, Eric J. Thomas, Brett I. W. Zbar, Joseph P. Newhouse, Paul C. Weiler, Jonathan Bayuk and Troyen A. Brennan.Ý Cited: 60 Law & Contemp. Probs. 1 (Spring 1997)
Expert Medical Courts: An Idea Whose Time Has Come Editorial in Contemporary OB/GYN on an alternative to the current system of addressing patient injury.
Development of an Early Identification and Response Model of Malpractice Prevention from Law and Contemporary Problems

Malpractice Case Shows Flaws of System

2005-07-01T16:41:00.000-04:00

In my local newspaper yesterday there was a story about a medical malpractice case that, in my opinion, illustrates the flaws of our current tort system. Click here for article.

The Case:
The case involved a 7 year old girl with cerebral palsy who was in the courtroom in her wheelchair. She suffered oxygen deprivation and cannot walk, talk, use her arm and has very limited use of her head and neck. She communicates through eye movements. The attorneys for the family managed to circumvent the no fault birth injury provisions in Florida, claiming that the provision did not apply to her because there was only moderate mental impairment. She was just trapped in a body that doesn’t work.

The family agreed to a settlement with the hospital in the amount of $10 million dollars. The family would receive $4.6 million, while the attorneys would receive more than $5 million. AND, the lawyers are reportedly planning to ask the judge to order the doctor to pay millions more in legal fees and costs.

A jury somehow determined 3 weeks earlier that the girl would need over $18 million to cover past and future medical expenses. So the jury ordered the obstetrician to pay the family $24 million. The final order, under joint and several liability, required that the doctor pay $16.4 million and other defendants (not sure who) to pay $9 million. That is in addition to the $10 million settlement by the hospital. Then the payments will have added 7% interest per year.

The mother was awarded $351,000 for lost income in caring for the child. For her ‘pain and suffering’ she was awarded $3 million. The father was awarded $1 million for pain and suffering.

The Cost of Excessive Awards:
It is indeed tragic for her and for her family, not only for what she has been through, but the fact that she faces a lifetime of complete disability. No one can argue that. Providing for her medical expenses and expenses for her daily care make sense to me.

Maybe I’m wrong, but it seems that a completely disabled child would receive disability income and medical care through Social Security/Medicaid. I’m curious how the jury determined such a high award. An article on a personal injury attorney site that reported on the case, said that the family’s attorney told the jury that she could live to be 80 years of age. Others claimed she could live to 50.

Either way, with $18 million allegedly needed for care, an award of $34 million dollars seems absurd to me!!

We all pay the cost of such awards. Physician and hospital fees rise to cover loss. Defensive medicine increases. That causes out of pocket costs and health insurance premiums to rise for patients. Malpractice premiums go up for all physicians in Florida, not just negligent ones. Physicians here in high risk specialties like ob-gyns, general surgeons, are expected to pay over $200,000 per year for only $250,000 of malpractice insurance. As a result, good physicians stop delivering babies. Surgeons stop doing procedures that have more risk. Most doctors are more and more discouraged. Some retire early. Others move to a friendlier state. It affects all of us.

Taking Advantage of the Inherent Risks of Birth and Other Risks:
The doctor in this case may have indeed been negligent. On the other hand, cerebral palsy cases are a favorite of personal injury attorneys. Do a search on Google using “cerebral palsy” AND “medical malpractice” and you will actually find attorneys who advertise themselves as “a dedicated medical malpractice and cerebral palsy lawyer”. It’s as if any case of cerebral palsy automatically means malpractice. Attorneys say it is due to failure of adequate fetal monitoring, failure to perform timely C-sections. Even though hospitals across the country report significant increases in C-sections, which carries risks of major surgery to the mother, that has not reduced the rate of cerebral palsy.

William Brody, President of Johns Hopkins wrote in a Washington Post article last Fall:
“And a recent study by Harvard University researchers found that 80 percent of malpractice claims were filed against doctors who had made no error whatever. For instance, recent articles in scientific journals have documented that many, if not most, cases of birth-related cerebral palsy -- cases in which juries tend to be highly sympathetic to plaintiffs -- are not the result of malpractice by obstetricians. Juries often deliver sizable awards against providers who commit no errors for what are unfavorable, but random, outcomes of nature.” Dispelling Malpractice Myths

The current tort system is flawed. It is a system that works very well for personal injury attorneys, but only a very few patients. A small minority of doctors do commit malpractice. But there are many more injured patients who have medical expenses and loss of income, but have no recourse because there was truly no malpractice. So yes, some people are greedy and will screw anyone to get money. But, some are not, are injured, and have no other way to get help with injuries resulting from medical treatment. Attorneys opposing tort reform are right when they say many people are injured and never have justice. They fail to say that the reason for that is that many of those cases don’t involve malpractice, and the ones in that group that do, aren’t considered lucrative enough for attorneys to represent.

Time to Try Something Different:
There is a saying I really like: “If you keep doing what you’ve been doing, you’re going to get what you already have.”

Of course, we need to do everything possible to improve patient safety. But safety alone will not and cannot eliminate all injury. Surgery has inherent risks. Birthing has inherent risks. Medications have risks.

We need to try alternatives to the tort system – things like health courts, or no-fault approaches used in other countries that function like Workman’s Comp. Perhaps we need to look at a different payment system for attorneys than contingency fees – one that would allow access as now, but reimburse attorneys for expenses and hourly rates (even if they are higher than the usual attorney fees.) We need to look at more ethical and impartial expert witnesses, clear and consistent guidelines for courts and juries, other tort reform, and insurance reform.

I’m sure that there are other ideas, but this absurd amount says to me that we need to get busy and do something now.

Non-Standardized Appearance of Medications Endanger Patients

2005-06-29T10:41:00.000-04:00

I recently submitted a refill prescription to a large pharmacy on-line for generic minocycline capsules. The pharmacy is located in the United States, is certified and reputable. I have ordered numerous medications from them for myself and other family members over the past two years because they are cheaper than my corner chain pharmacy.

I had two prior prescriptions for the same medication from the same pharmacy. The capsules were yellow and white and had Minocylcine 75 stamped on them. I did not need the medication right away, but decided to look at it. Much to my surprise, I found capsules that were gray and white and slightly larger. They were stamped with 93 7300. To me, it looked like I had the wrong medication. I e-mailed the pharmacy and still haven't heard. In the meantime I did my own research and discovered that they are indeed the same medication.

Today, my friend picked up her refill of Amiodarone 200mg. Instead of the usual yellow tablet, she now has a pink tablet. One said E-144 and the new one is 93-9133. The pharmacist gave her a heads-up that the color had changed, but it was the same medication. She got on the Internet and after some time confirmed it.

With all the uproar over patient safety, especially related to medications, why would they make different versions of the same medication, same strength without stamping the name of the medication and dosage? I firmly believe that we as patients are obligated to take our part of the responsibility for making sure we check our medications. In fact, most information sheets or articles on medication safety encourage the patient, whether at home or in the hospital, to speak up if they are given medication of a different color or shape.

It seems to me, that the pharmaceutical industry should be required that a drug made by any company should still be the same shape, color, size and have the name of the medication stamped on it. Companies could stamp their own company name or ID number on the back.

Whatever method they come up with, it is essential that as patients we can easily identify our own medications, without having to look them up by ID number.

I would not take the medication until I could be sure that it was the same thing. I could certainly imagine someone else in the same situation either not taking the medication at all because they don’t know how to identify it -- or taking whatever is in the bottle even if they notice it is different, blindly trusting that no one will make a mistake. To me, that is playing with fire.

Is there a group seeking to create standardized appearance of medication? If so, let me know. I have not found one.

I urge you to do your part in contacting your government officials, pharmacy associations, leaders of drug companies, healthcare quality organizations and the media to promote a universal system in which the same medication will always appear to be exactly the same, no matter what company makes it.

Media and the medical community

2005-04-18T14:24:00.000-04:00

I am curious about the position the media, and in particular, our local newspaper (Orlando Sentinel) takes on reporting healthcare issues. They do publish a significant number of timely and informative articles on medical treatments, new medications or tests, problems like obesity, and others related to actual conditions and medical treatment.

What is glaringly absent to me, is information on health care policy issues, both on the state and national levels. I have had letters sent in to the editor published on most occasions I have sent them, but none I have sent related to healthcare legislation have ever been published. Longer opinion pieces have been published, but never anything I sent related to healthcare policy. I don't think it's personal. I think it has something to do with editor's preference or policy. If the director of medical staff at a hospital writes an opinion piece, that will normally be published . . . and that is good! Occasionally, you will see a physician's view published, but rarely.

Is it because the Sentinel does not agree with positions that support the view of the medical community? Is it that they think people don't care about issues affecting their healthcare?

They reported extensively on a fight between firefighters and the city about alleged malpractice, but have said nothing about legislation that could impact malpractice insurance and access of care for Floridians in this current session of the Florida legislature. The only reference this entire year that can be found in searching the newspaper's site is the opinion piece from the director of medical staff at Florida Hospital.

I am not bothered that my personal letter has not been published. I don't care if the editors state their personal views on the issues (as long as they report it as a personal view). But I am bothered by what seems an exclusion of information and views related to important health policy issues that affects every person in Florida (and in some cases, in the entire nation.) They serve no one by contributing to the ignorance of patients about issues that will impact their healthcare.

Florida Malpractice Premiums

2005-04-16T11:16:00.000-04:00

In early March, Florida Senator Dennis Jones and Representative Frank Farkas proposed identical bills in the Florida House and Senate that would double the malpractice insurance requirements for all Florida physicians and eliminate the option they have had for about 15 years to 'go bare'. (HB 665 and SB 972)

Going bare means that the physician does not carry malpractice insurance, but agrees to be financially responsible for the amounts currently required for malpractice insurance. They must post notices prominently in their offices informing patients. If they were to have a judgement againstthem and fail to pay, they would lose their license. Most of the physicians who 'go bare' are specialists in high risk areas like general surgeons, neurosurgerons, thoracic surgeons, ob-gyns, and now a growing number of orthopedic surgeons and radiologists. Florida currently has the highest malpractice premium rate in the country, with even general surgeons expected to pay over $180,000 per year (In 2003, the average was $179,000).

Sen. Jones office reported that it was to protect patients and that going bare wasn't fair to other physicians who paid malpractice insurance!

If the second point is even true, there is a difference in physicians who pay $30,000 a year and high risk specialists who are paying $180,000 per year! In Miami in 2004, the premium for general surgeons topped out at $277,000!!! Who can pay that and stay in practice? A surgeon would have to bring in $500,000 just to break even . . . no salary. . . if you figure in malpractice premiums and the average cost of running a surgical practice ($220,000 nationwide, with it being higher in the South East region.)

As to protecting patients, what is it protecting them from?
* Jury awards in malpractice claims are not based on the amount of insurance a physician carries (most carry the minimum because of the cost), nor whether or not a physician has malpractice insurance or self-insures.
* Physicians are required to pay claims and will lose their license if they don't. In the 8 years the Florida Department of Health has kept records of financial responsibility, 5 doctors were disciplined for not paying claims, three of which ultimately paid. The other 2 who did not pay lost their license.

While the two patients whose doctors did not pay suffered (assuming they were legitimate claims without collateral sources of payment), punishing every physician in Florida for the sins of TWO in 8 years, is ridiculous. It's like requiring all teachers to carry malpractice insurance because a few abuse children.

What is astonishing to me is that instead of looking at what's wrong with the insurance system that causes such absurd premium rates that physicians have to take the risk of going bare, they want to double the burden. I sit here asking myself, "who is really going to benefit from this legislation?" Not patients. Not physicians. In fact, it would make it impossible for some solo practitioners or those in small practices, especially high risk specialties, to stay in practice, thus jeopardizing access to good specialists. My own surgeon has 'gone bare'. You couldn't find a better, more conscientious, thorough, meticulous and caring surgeon. She is brilliant, exceptionally skilled and experienced. Even though she is highly respected in the medical community, has a steady practice, I wonder if she could continue if those bills passed. She and other physicians are already trying to absorb continual decreases in reimbursement from insurance, while their operating expenses increase (not including malpractice premiums).

As I see it, the only beneficiaries of this legislation are the malpractice insurance carriers in Florida. Last I heard, there were only four.

Florida does not have the highest losses, nor the highest number of malpractice cases, but we far outpace other states in the cost of malpractice insurance. Why?

It is high time Florida looks at insurance reform, instead of placing undue burden on physicians, and ultimately patients. To file these bills instead of addressing the real problems is an insult to the people of Florida and a failure in ethical health partnership.

Current status of these bills:
On March 30th this legislation passed the House Health Care Regulation committee, 6 to 4. On April 12th it was referred to the House Judiciary Committee.
The Senate version hasn't made it past the first committee yet. They have postponed the hearing.

For more information on this issue, go to the section on my website about these Bills.

Launching of this blog

2005-04-16T11:13:00.000-04:00

I am moving this blog from tBlog where I was having trouble adding posts, so I'm starting with my original message from there to tell you what I envision for this blog:

It's a new year and a new blog!
As part of my commitment to helping co-create ethical health partnerships, I am starting this blog with the purpose of:
* strengthening the core of healthcare -- the patient/physician relationship
* exploring ways to create ethical relationships at every level of healthcare
* empowering myself and others to increase the quality and availability of healthcare I will say more about ethical health partnerships as I go along.

I also encourage you to visit my website: Ethical Health Partnerships (www.ethicalhealthpartnerships.org) for information on healthcare issues and on what I mean by that kind of partnership.

What I will say is that each of us, whether patient, physician, nurse, insurance company, legislator, attorney, pharmaceutical company, media, medical board, doctor's office staff, technician . . . ALL of us, by each thing we say or do, are like the drop of water in the image at the top of this page. Each thing has ripple effects for the whole healthcare system. . . . and either supports and builds it, or distresses and weakens it. My purpose is to call all of us to mindfully strengthen it, to do our own part and to urge others to do theirs. What I want from myself and anyone who posts here is to create a blog relationship where each of us are mindful about:
* the kind of ripple effects we create with what we say and how we say it
* an effort to not react or tear down what someone says if you disagree, but rather to express what you agree with, what your concern is with something you disagree with, how you would build on their idea or statement in a way that addresses both their concerns and yours . . . and why.

Let's keep the focus on building better relationships and better healthcare at every level and doing so in a constructive way that builds upon each person's contribution.

I believe we have more power than we think we healthcare and it's time to use it.