Sunday, April 24, 2011

End Medicare As We Know It

The intractable Israeli-Palestinian conflict has been raging and smoldering since I was born, over half a century ago. This suggests that it is an insoluble conundrum, yet all parties to the conflict and others admit that they know what the contours of the final peace would be. This reality heightens everyone’s frustration. The process is frozen within close view of the end zone.

The Medicare crisis is analogous to Middle East peace process. The challenges are well known and the solutions are obvious. Yet, decades go by and politics have kept politicians, and those they serve, out of the end zone. They’ve been fumbling the ball for a generation. Now, it’s 4th down and they want to punt again.

The problem is that the Medicare program is headed toward insolvency. The solution? Here’s three Mensa suggestions:

  • Scale back benefits
  • Spend more money
  • Raise the age of eligibility
Most folks support scaling back benefits, as long as it’s someone else’s benefits that will be adjusted. Similarly, Americans are prepared to pay more to keep Medicare viable, as long as it’s on someone else’s tab. Everyone supports raising the eligibility age, as long as it applies to folks younger than they are.

This is why reformers are proposing that changes in Medicare would apply only to those who are younger than 55-yrs-old. Of course, the proper Medicare reform proposal would be to implement changes on everyone, or perhaps excepting those who are current Medicare beneficiaries. While no one wants their existing benefits to be cut, this is happening in the private and government sectors throughout the country. Consider the new paradigm for public workers’ collective bargaining rights in Wisconsin and Ohio. With regard to Medicare reform, sparing the over 55 crowd is purely a political calculation. This transparent maneuver is designed to insulate politicians from the wrath of those in the Medicare program and those who are on-deck to enter it.

Representative Paul Ryan, Republican from Wisconsin, has proposed a Medicare reform plan where those under the age of 55 would be given a voucher that could be applied toward private insurance. This was the response from Democrats and President Obama.

This would end Medicare as we know it.

This response is clearly a product of Democratic focus groups, as the same phrase is coming out of so many different mouths.

Considering that American are living and working longer, shouldn’t the age that we become eligible for Medicare be raised, particularly since the program in its current form is not sustainable?

Is the Ryan proposal a panacea? It’s hard to judge the proposal on its merits since the Medicare issue is permeated with politics. I credit him and his supporters for a bold opening to a conversation our government needs to have with us. Instead we’ve been given their version of straight talk, which is as straight as the image below.

I’m under 55-yrs-old and I am willing to delay my entrance into Medicare and to accept reforms that will prevent the program from heading over a cliff. If that happens, and the system crashes to earth, wouldn’t that be a worse outcome than accepting some Medicare modifications?

I’ve conducted my own focus group. When folks ask me why I would change Medicare and toss our elderly overboard, here’s my response. If we don’t implement meaningful structural changes in the program, then

Medicare would end as we know it.

Sunday, April 17, 2011

A ‘Never Event’ in Alabama: Did Nine People Have to Die?

Recently, nine patients died in Alabama when they received intravenous nutrition that was contaminated with deadly bacteria. This type of nutrition is called total parenteral nutrition, or TPN, and is used to nourish patients by vein when their digestive systems are not functioning properly. It is a milestone achievement in medicine and saves and maintains lives every day.

What went wrong? How did an instrument of healing become death by lethal injection? What is the lesson that can emerge from this unimaginable horror?

This tragedy represents that most feared ‘never event’ that can ever occur – death by friendly fire. No survivors. Contrast this with many other medical ‘never events’ as defined by the Centers for Medicare and Medicaid Services, such as post-operative infections, development of bed sores in the hospital or wrong-site surgery. Under the ‘never events’ program, hospitals will be financially penalized if a listed event occurs. Many physicians and hospitals are concerned that there will be a ‘never events’ mission creep with new outcomes added to the list that don’t belong there. Medical complications, which are unavoidable, may soon be defined as ‘never events’.

Do we need a new category of ‘never ever ever events’ to include those that lead to fatal outcomes?

The facts of the Alabama deaths have started to emerge.  Apparently, a water faucet in the pharmacy was contaminated. Protocols and processes are violated every day in all spheres of professional life; and we usually get away with them. The absence of serious consequences breeds complacency, which is shattered by an occasional tragedy. Isn’t it after a horrible traffic accident that a local government decides to erect street lights that were requested by local residents for years? I read earlier today that the Federal Aviation Administration is requiring extensive inspections of a few hundred airplanes when small cracks were discovered in a few of them. This followed a near disaster when a 5 foot hole burst open in the roof of an airplane during flight. The plane landed and all survived. Of course, a very different outcome was possible.

A few weeks back, an airline pilot was puzzled and perturbed when he couldn’t make contact with an air traffic controller at Ronald Reagan Washington International Airport. This wasn’t a mechanical failure but was a matter of zzzz’s. The controller simply nodded off. I suppose it’s preferable for the controller to take a catnap than for the pilot, but there is a process defect in the tower. Afterwards, the Secretary of Transportation announced a new policy that middle school kids could have devised. Air traffic controllers shouldn’t be manning the fort solo. Wow! Real genius advice here from our government. Are these the same brainiacs that make me take off my sneakers before I board an airplane?  (No, these Mensa folks are Department of Homeland Security experts.)

In past years, several people have contracted hepatitis C after undergoing medicine’s most elegant medical procedure – a colonoscopy. These events were not Acts of God but were Acts of Man. They occurred when established procedures were breached for various reasons, none of which are defensible.

While we often cut corners with impunity, on occasion a small and seemingly innocuous deviation can result in unforgiving consequences. The concept of Universal Precautions means what it says. It means do what you are supposed to do every time without exception. Here’s what a list of Partial Precautions might include:

  • Wear seat belts on long car trips only.
  • Physicians should wash their hands only before seeing ICU patients.
  • Do not leave infants alone in the bath on odd numbered days.
  • Give your children two-thirds of recommended vaccinations.
  • Never drive under the influence of alcohol during daylight.
So, the water faucet was dirty.My kitchen faucet isn't sterile either. However, while I'm no TPN expert, should tap water be used to clean a container that would be used for preparing TPN, which must be 100% germ free?  Similar mistakes are made daily throughout society without causing harm. Lighting a match won’t lead to havoc and destruction. But, when the same match lights a fuse, then the world can go dark.

Any corner cutters out there who want to come clean?

Sunday, April 10, 2011

IPhone Apps for Physicians: Medical Apps I Want

Your humble Luddite Whistleblower has leapt across the sea to reach the Isle of Technology. I now own and operate an iPhone, which identifies me as groovy, hip and cool, three adjectives that none of our 5 kids ever use to describe their technophobic father. I’m told that my text messages are too long and too frequent. I am admonished that it is not necessary for me to photograph moments of high drama, such as a kid eating breakfast, and then to disseminate the image to my contact list. I am reminded often that I am slow to grasp the mechanical intricacies of the device, such as switching from ring to vibration mode.

You may wonder how it was possible that I, who consider using an ATM to be a high level computer operation, could make the iPhone, my phone. I knew I couldn’t fail, despite my trepidation of all things cyber. I had a secret weapon, a ‘Plan B’. Actually, I had Plan Z, the most powerful asset that anyone in my situation could hope for. Z stands for Zachy. One sentence will explain all and may provoke screams of envy from those who have no available similar resource.

Zachy is our 14-yr-old kid!

Zachy is our youngest son and lives and dreams in the cyberworld. Like his contemporaries, he relies on computers to communicate and interact with the world. He is excited to devise new mousetraps that seem unnecessarily complex. When he receives a phone call, he can reroute the call so that it the caller’s voice will emerge out of a speaker from another techno-contraption in his room. Is this cool? Yes. Is it easier than simply answering the phone? You decide.

Of course, the real appeal of the iPhone is the Apps. Since App to me means appendectomy, I assumed that the iPhone was a well-designed physician’s tool. Relax readers, I have since become educated and have increased my Apptitude. I can now spend time I don’t have searching for cool Apps that will solve problems I don’t have.

Some Apps I Have

Dragon – This is a must-have App and is well worth the price. It’s free. It permits you to dictate directly into the contraption and then transforms your voice into text with reasonable accuracy. This is great for TWD, or texting while driving, an act that no responsible physician has ever committed.

Epocrates – Another gratis App, although the company hopes you will upgrade to one of their premium products. I’ve used Epocrates for years, and consult it nearly every day. It’s a quick and easy resource for all medications, including dosage, adverse reactions, drug interactions, contraindications and cost. How many medications do we really need to take care of patients? Probably, 2 dozen or so.

Liver Calc – My partner is always showing off when he rounds on liver patients and calculates the MELD score in his progress notes. Who can remember this stuff? It reminds me of the Ranson criteria for pancreatitis that we medical students were forced to memorize. (I remember Dr. Ranson from my medical school days. He was warm & fuzzy – NOT). Do these liver scores help actual patients or merely provide grist for board examinations? With this App, I can now calculate on the spot a variety of scores for liver patients, most of which this board certified gastroenterologist has never heard of. Anyone out there heard of the RUCAM criteria?

Medscape – This is a very comprehensive site, but seems to cruise more horizontally across the medical landscape than vertically. Will I ever use it? Not sure. The goal, I am learning, is not to use Apps, but just to collect ‘em.

Epocrates Disease Game – This is a cool way to spend time in the airport when your flight is delayed and the smiling airline personnel will not divulge the updated departure time regardless of threat or bribery. Tap the App and a medical image appears in stages, until the entire screen shows the finding. Choose the correct diagnosis among the 3 given choices. For those who were born during the Eisenhower era, this game reminds me of solving the rebus in the classic TV game show Concentration.

Apps I Want

Colon Cleanse App – This is a double plug in App. You plug in the device into the headphone jack of the iPhone and plug the larger end into the rectum. Attach the accessory funneled cleansing tube to a standard faucet, and watch the toxins disappear.

Medical Coding App – This turns your iPhone into a high voltage device, similar to the Invisible Fences that are used to restrain pets to a given area. Tap the App and then place the iPhone in your front pocket. After seeing a patient, if you code higher than you should on your EMR, you will get a light shock. The intensity will increase until you have expressed remorse, atoned and coded properly. I expect that Medicare will provide incentives for using this technology in the coming years.

Formulary App – This will be fun for the entire office. When the physician guesses the drug that is on the patient’s formulary, carnival music starts blaring from the iPhone. Since this occurs rarely, do not worry that this App will be disruptive to your office routine.

Am I getting just a bit slAPP hAPPy? Probably, so. The APPendix may be a vestigial structure, but the iPhone Apps are like the oxygen drive. You can try holding your breath, but how long can you hold out?

Sunday, April 3, 2011

Medical Turf Wars: Truth vs Turf

Prototype 'BS' meter. 

So many folks express views that are obviously self-serving, but they try to masquerade them as altruistic positions that benefit some other constituency. These attempts usually fool no one, but yet these performances are common and ongoing. They are potent fertilizer for cynicism.

Teachers’ unions have been performing for us for decades. Their positions on charter schools, school vouchers, merit pay and the tenure system are clear examples of professional advocacy to protect teachers’ jobs and benefits; yet the stated reasons are to protect our kids. Yeah, right. While our kids are not receiving a top flight education, the public has gotten smart in a hurry on what’s really needed to reform our public educational system. This is why these unions are now retreating and regrouping, grudgingly ‘welcoming’ some reform proposals that have been on the table for decades. This was no epiphany on their part. They were exposed and vulnerable. They wisely sensed that the public lost faith in their arguments and was turning against them. Once the public walked away, or became adversaries, established and entrenched teachers’ union views and policies would be aggressively targeted. Those of us in the medical profession have learned the risk of alienating the public. Teachers have been smarter than we were.

The medical profession is full of ‘performances’ where the stated view is mere camouflage. For example, there is a turf war between gastroenterologists (GI) and anesthesiologists whether GI physicians can safely administer the drug propofol to sedate our patients before colonoscopies and other glamorous procedures. This drug may be familiar to ordinary readers as it was involved in the death of a superstar pop music legend in 2009. GI doctors insist that with proper training we can safely administer this drug to our patients. Indeed, there are numerous scientific publications that support this view. Anesthesiologists have pushed back hard and they have prevailed. “It’s too dangerous,” they warn. “No one can use this drug unless you have advanced anesthesia training,” Of course, the only physicians who have ‘advanced anesthesia training’ are anesthesiologists. I’m not claiming that my anesthesia friends don’t have a legitimate point. But, let’s be clear. Their position is not merely an effort to protect patients, it is also meant to protect their turf. See the equation below for a mathematical depiction of this issue.

Protecting(Turf) = $$$

Gastroenterology, my specialty is in the game also. This is transparent when our GI professional societies issue ‘guidelines’ for recommended GI procedure volumes and training for obtaining hospital privileges. For example, if these societies, who are dominated by academic physicians who work at medical schools and teaching institutions, issue procedure volume standards that are unreasonably high, this will serve to siphon procedures toward their medical centers where they work, and away from community gastroenterologists like me. In other words, if I do 20 procedures a year, but the ‘guidelines’ state that at 40 cases annually are required for competency, then I may be denied hospital privileges for this procedure and must then refer these patients to an academic center. The argument, of course, is to protect patients, but I suggest that there may be an unstated agenda. Interestingly, these medical centers and academicians do not issue ‘guidelines’ and volume standards for treating patients with cirrhosis, Crohn’s disease, irritable bowel disease or gastroesophageal reflux (GERD)? Why does my procedure count matter so much, but my case load for specific diseases doesn’t? Is it really only about safety?   Perhaps, physician readers will offer views on this point.

National leaders in gastroenterology are very concerned about surgeons and other physicians performing endoscopic procedures, which represent a major proportion of our incomes. Of course, we don’t want untrained physicians performing colonoscopies. But, there is a turf issue at play here also.

Everyone is grabbing for a piece of turf. Politics is so rife with turf protection that it is nearly impossible to divine what someone is really thinking. So much of what these guys and gals say and do have little to do with the merits of the issue, and plenty to do with elections and self-preservation. Wouldn’t it be nice if all of our elective representatives were equipped with a B.S. (barnyard epithet) meter that could distinguish truthfulness from turfulness? Could our best engineers design such a device? I doubt it. After 2 or 3 sentences, the needles would all snap.