The new BO health care plan

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Subject: RE: The new BO health care plan

PennState - 2009-06-26 1:53 PM

Brock Samson - 2009-06-26 2:47 PM

Specifically to DerekL:

I'm not advocating taking or capping doctors salaries. I'm not blaming the medical profession for the health care crisis. That would be like blaming solely the insurance industry or the drug companies or the legal profession. The point I was trying to make is that all sectors of the "Health Care" industry are to blame. Focusing on one part or the other as the central "cause" of the problem is disengenious.

For years people have been pointing at the legal profession and arguing or asserting that it is the cost of med. mal. suits that is driving up the cost of health care. The reality is that it is not true. At least it is not true to extent that this portion of the puzzle is the major contributing factor. The number and amount of successful med. mal claims is infentesimally small compared to the other pieces of the puzzle.

As an attorney I would agree to tort reform if the medical provider industry (Doctors, hospitals) also agreed to reform. Also you shouldn't agree to reform unless the insurance industry agrees to reform. Likewise the insurance industry shouldn't agree to reform unless the drug companies agree to reform. It's all interwoven. Each part plays against each other, and in turn each part plays one another against each other in the court of public opinion. And all of the industries do so in an attempt to protect their own self interests ($$$$$$)

My previous post may have come off snarkie and as a personal attack on you and your profession. I didn't mean it that way. Iwas simply trying to look at the component numbers.

well said Brock. I agree that lawyers are not the main problem. I have objections to a very powerful political lobby group called the American Society for Justice... but the issue is not lawyers... it's the litigious nature of the people in our society. Lawyers would not be able to mount malpractice suits if they didn't have interested clients (patients) would they?

Whos forcing the lawyers to take said cases?

Of course the pressure to be the next John Edwards is pretty extreme

Edited by Imjin 2009-06-26 5:49 PM

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Subject: RE: The new BO health care plan

csibona - 2009-06-26 5:12 PM

PennState - 2009-06-26 1:10 PM Also, it has worsened in the 9 years I have been in central PA... no-one goes the the ER with 'belly pain' without getting a CT first... the cost is staggering, but they are afraid to miss that appendicitis.

Also would like to point out that this is a pretty civilized discussion on a contentious topic. Good job.

I'm not sure who "requires" the CT scan. When I've interviewed physicians about tests some will say that one of the reasons some physician do tests is that they get reimbursed for the test. I couldn't for the life of me figure out why when I went to see a physician about knee pain that the first thing the office did before the physician ever met me was to do multiple x-rays of my knee. I would have preferred to see the physician first so they could do an evaluation and determine if the x-rays were necessary. I am fairly certain that evidence-based medicine would mean that there would be a determination if a test was necessary and not simply a standard operating procedure. I've talked to others about similar situations and they have stated similar physician procedures where it is test first then meet the physician. I've also interviewed physician about the conditions on which they give tests and the majority of answers do not match evidence-based medical practices. There is some pretty good evidence that physician are reluctant to follow best practices (such as the Goldman prediction rule on myocardial infarction) and rely on their own past experiences instead. See: Impact of a clinical decision rule on hospital triage of patients with suspected acute cardiac ischemia in the emergency department Reilly. 2002 JAMA - Journal of the American Medical Association, Vol. 288, No. 3, pp. 342 (ISSN: 0098-7484)

That's sorta the point. Tests are ordered to cover our tails regardless of the appropriateness of doing them. It's what defensive medicine is.

A patient comes in with completely atypical chest pain and is sent home by the ER doc only to go home and have a heart attack. You think the patient is going to say, "Well the doc did the appropriate thing for the situation."? No, that doc is going to get sued in many situations like that. That's why probably a quarter of my admissions are chest pain these days. We can't win for losing these days, and it's driving a lot of docs out of the practice of medicine.

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Subject: RE: The new BO health care plan

PennState - 2009-06-26 4:27 PM

csibona - 2009-06-26 6:12 PM

PennState - 2009-06-26 1:10 PM Also, it has worsened in the 9 years I have been in central PA... no-one goes the the ER with 'belly pain' without getting a CT first... the cost is staggering, but they are afraid to miss that appendicitis.

Also would like to point out that this is a pretty civilized discussion on a contentious topic. Good job.

I'm not sure who "requires" the CT scan. When I've interviewed physicians about tests some will say that one of the reasons some physician do tests is that they get reimbursed for the test. I couldn't for the life of me figure out why when I went to see a physician about knee pain that the first thing the office did before the physician ever met me was to do multiple x-rays of my knee. I would have preferred to see the physician first so they could do an evaluation and determine if the x-rays were necessary. I am fairly certain that evidence-based medicine would mean that there would be a determination if a test was necessary and not simply a standard operating procedure. I've talked to others about similar situations and they have stated similar physician procedures where it is test first then meet the physician. I've also interviewed physician about the conditions on which they give tests and the majority of answers do not match evidence-based medical practices. There is some pretty good evidence that physician are reluctant to follow best practices (such as the Goldman prediction rule on myocardial infarction) and rely on their own past experiences instead. See: Impact of a clinical decision rule on hospital triage of patients with suspected acute cardiac ischemia in the emergency department Reilly. 2002 JAMA - Journal of the American Medical Association, Vol. 288, No. 3, pp. 342 (ISSN: 0098-7484)

I think you mis-understood me a bit... patients who present to the ER are being assessed and then having a CT scan. It is the frequency of the scan that is of concern... they do see the doctor first.
By all means continue on with your 'education' of American physicians and their lack of EBM practices...

I think there are misunderstandings all around. You mention chest pain and ER I mentioned a different situation requiring tests. Related, but different. I then went on about EBM and some of the issues with EBM and adoption. Personally, I think that EBM will protect physicians (to a large extent) from lawsuits.

But, um, I think you're being a little condescending when you remark about continuing to educate American physicians about EBM. I am a researcher in health information technology. Just as your education as a medical doctor informs you about this topic my background informs me. I'm providing a JAMA article as evidence not some wacky fly-by-night journal article.

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Subject: RE: The new BO health care plan

DerekL - 2009-06-26 4:56 PM

csibona - 2009-06-26 5:12 PM

PennState - 2009-06-26 1:10 PM Also, it has worsened in the 9 years I have been in central PA... no-one goes the the ER with 'belly pain' without getting a CT first... the cost is staggering, but they are afraid to miss that appendicitis.

Also would like to point out that this is a pretty civilized discussion on a contentious topic. Good job.

I'm not sure who "requires" the CT scan. When I've interviewed physicians about tests some will say that one of the reasons some physician do tests is that they get reimbursed for the test. I couldn't for the life of me figure out why when I went to see a physician about knee pain that the first thing the office did before the physician ever met me was to do multiple x-rays of my knee. I would have preferred to see the physician first so they could do an evaluation and determine if the x-rays were necessary. I am fairly certain that evidence-based medicine would mean that there would be a determination if a test was necessary and not simply a standard operating procedure. I've talked to others about similar situations and they have stated similar physician procedures where it is test first then meet the physician. I've also interviewed physician about the conditions on which they give tests and the majority of answers do not match evidence-based medical practices. There is some pretty good evidence that physician are reluctant to follow best practices (such as the Goldman prediction rule on myocardial infarction) and rely on their own past experiences instead. See: Impact of a clinical decision rule on hospital triage of patients with suspected acute cardiac ischemia in the emergency department Reilly. 2002 JAMA - Journal of the American Medical Association, Vol. 288, No. 3, pp. 342 (ISSN: 0098-7484)

That's sorta the point. Tests are ordered to cover our tails regardless of the appropriateness of doing them. It's what defensive medicine is.

A patient comes in with completely atypical chest pain and is sent home by the ER doc only to go home and have a heart attack. You think the patient is going to say, "Well the doc did the appropriate thing for the situation."? No, that doc is going to get sued in many situations like that. That's why probably a quarter of my admissions are chest pain these days. We can't win for losing these days, and it's driving a lot of docs out of the practice of medicine.

I'm just trying to figure out who "requires" the test, is it the physician who is protecting themselves or is it the hospital, insurance company, patient, attorneys, "society," etc? It seems to me like it is self-imposed. Indeed, I think that is part of the problem it is difficult to draw the line when a test is "required" to cover one's behind and when it is not required.

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Subject: RE: The new BO health care plan

csibona - 2009-06-26 6:31 PM

DerekL - 2009-06-26 4:56 PM

csibona - 2009-06-26 5:12 PM

PennState - 2009-06-26 1:10 PM Also, it has worsened in the 9 years I have been in central PA... no-one goes the the ER with 'belly pain' without getting a CT first... the cost is staggering, but they are afraid to miss that appendicitis.

Also would like to point out that this is a pretty civilized discussion on a contentious topic. Good job.

I'm not sure who "requires" the CT scan. When I've interviewed physicians about tests some will say that one of the reasons some physician do tests is that they get reimbursed for the test. I couldn't for the life of me figure out why when I went to see a physician about knee pain that the first thing the office did before the physician ever met me was to do multiple x-rays of my knee. I would have preferred to see the physician first so they could do an evaluation and determine if the x-rays were necessary. I am fairly certain that evidence-based medicine would mean that there would be a determination if a test was necessary and not simply a standard operating procedure. I've talked to others about similar situations and they have stated similar physician procedures where it is test first then meet the physician. I've also interviewed physician about the conditions on which they give tests and the majority of answers do not match evidence-based medical practices. There is some pretty good evidence that physician are reluctant to follow best practices (such as the Goldman prediction rule on myocardial infarction) and rely on their own past experiences instead. See: Impact of a clinical decision rule on hospital triage of patients with suspected acute cardiac ischemia in the emergency department Reilly. 2002 JAMA - Journal of the American Medical Association, Vol. 288, No. 3, pp. 342 (ISSN: 0098-7484)

That's sorta the point. Tests are ordered to cover our tails regardless of the appropriateness of doing them. It's what defensive medicine is.

A patient comes in with completely atypical chest pain and is sent home by the ER doc only to go home and have a heart attack. You think the patient is going to say, "Well the doc did the appropriate thing for the situation."? No, that doc is going to get sued in many situations like that. That's why probably a quarter of my admissions are chest pain these days. We can't win for losing these days, and it's driving a lot of docs out of the practice of medicine.

I'm just trying to figure out who "requires" the test, is it the physician who is protecting themselves or is it the hospital, insurance company, patient, attorneys, "society," etc? It seems to me like it is self-imposed. Indeed, I think that is part of the problem it is difficult to draw the line when a test is "required" to cover one's behind and when it is not required.

If you're looking for a hard and fast requirement, you're not going to find one. Of course it's self-imposed, but it takes into account the circumstances of previous lawsuits and potential ones. Most of us would rather stay out of the courtroom if at all possible. The problem is that you never know what patient is going to file a suit, so you cover yourself in all situations.

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Subject: RE: The new BO health care plan

DerekL - 2009-06-26 12:02 PM

Brock Samson - 2009-06-26 1:56 PM

Is there a cost to the health care system for litigation and tort issues: Yes. Is it the major cost....Not even close. Blaming the lawyers for the high cost of health care is a smoke screen and subtrafuge.

I certainly don't blame it solely, but I can tell you for a fact that the way I practice is directly linked to fear of lawsuits. Far more tests are ordered than are necessary. Patients are kept in the hospital far longer than they would be otherwise at times. For those who have actually been sued for malpractice previously, this practice of defensive medicine is even worse.

Does the drunk guy who comes in after falling and hitting hit head need a $700 CT scan of his head? Nope, but he gets it. Does everybody with an inkling of chest pain need to be admitted to be observed? Nope, but they do. I could go on all day about similar situations. We're all looking for the rare exception to the rule, because that's the one that inevitably comes back to bite you.

Would we automatically revert to "common sense" medicine if we suddenly had no fear of lawsuits? Not completely I'm sure, and I acknowledge that freely. I do know that my practice habits would change significantly were that the case. I can only speak for me.

Well put, excellent post.

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Subject: RE: The new BO health care plan

As Gov. Daniels said recently,

"If you gave me a lifetime of free pizza, I can guarantee... I will be eating a lot more Pizza. The US has healthcare that is largely free to the consumer. Is it any different".

For most Americans, Healthcare is an all you can eat buffet with someone else paying. Is it any wonder that we are fat with healthcare?

Ultimately, that is what is driving the cost of Healthcare in the US.

Edited by Indiana_Geoff 2009-06-28 2:43 PM

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Subject: RE: The new BO health care plan

Indiana_Geoff - 2009-06-28 1:41 PM

As Gov. Daniels said recently,

"If you gave me a lifetime of free pizza, I can guarantee... I will be eating a lot more Pizza. The US has healthcare that is largely free to the consumer. Is it any different".

For most Americans, Healthcare is an all you can eat buffet with someone else paying. Is it any wonder that we are fat with healthcare?

Ultimately, that is what is driving the cost of Healthcare in the US.

Except that pizza is a "sought" good and health care is, essentially, an unsought good. You want health care when you need it but you don't want it if you don't "need" it. I believe that health care estimates are that approximately 50% of health care costs are lifestyle related. Obesity, for instance is estimated account for cost 5-7% of annual health care costs.

Obesity and the Economy: From Crisis to Opportunity
DS Ludwig, HA Pollack - JAMA, 2009 - Am Med Assoc

Obesity-attributable costs account for 5% to
7% of annual health care expenditures—currently amounting
to more than $100 billion per year. The direct economic
effects of obesity may be twice this figure, when missed workdays
and other costs outside the medical care system are considered.

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Edited by PennState 2009-06-29 6:08 AM

The new BO health care plan (Page 7)

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