Criminal Penalties For No Insurance Possible Under Pelosi Bill

From a letter from the the non-partisan Joint Committee of Taxation from Rep David Camp to explain penalties for not carrying insurance under the Pelosi Bill (H.R. 3962):

Americans who do not maintain “acceptable health insurance coverage” and who choose not to pay the bill’s new individual mandate tax (generally 2.5% of income), are subject to numerous civil and criminal penalties, including criminal fines of up to $250,000 and imprisonment of up to five years.

Is this what American's want, criminal penalties including jail time?

If not, I'd suggest you call, fax, or e-mail your Congressman today.

-Wes

Reader Poll: Should House Health Care Bill Pass?

With the US House of Representatives set to vote on the ‘‘Affordable Health Care for America Act’’ (H.R. Bill 3962) this weekend, should the bill pass?

Vote in the sidebar and feel free to leave any comments you'd like to make below.

-Wes

P.S. I'm not tracking URL's nor marketing - promise - just interested what others who read this blog think.

Cardiology Consolidation Continues

This time, in Kansas City:

Cuts of the magnitude envisioned by Medicare, Holkins said, would present “a significant problem for the revenue side of our business model.”

The 14-physician practice, which has roughly 80 employees, has been independent since its founding in 1975.

So, Holkins said, the decision to affiliate was not taken lightly.

“I have really liked the idea of being independent,” he said. “But I also like to be able to pay our employees well and have enough left so our physician partners make a comparable salary to their peers in Kansas City, and I saw that as something I would not be able to do going forward.”

-Wes

Reading the Fine Print of Government-Run Comparative Effectiveness Research

This week, the New England Journal of Medicine published the comparative effectiveness research trial "ROOBY" comparing conventional cardiac bypass surgery to off-pump bypass surgery. The study was conducted at VA medical centers and randomly enrolled 2203 patients between conventional bypass and off-pump bypass surgeries. The study concluded "At 1 year of follow-up, patients in the off-pump group had worse composite outcomes and poorer graft patency than did patients in the on-pump group. No significant differences between the techniques were found in neuropsychological outcomes or use of major resources." Excellent reviews of the trial (with associated surgeon commentary) are provided at theHeart.org and at MedPageToday.com.

What I found interesting was the fact that over half of the operations in the trial were performed by surgical residents. (Admitedly all surgeons had to have a minimum experience of 20 off-pump procedures, but the median off-pump experience by surgeons in the trial was 50 procedures.)

I wonder, where were the senior surgeons at the VA?

-Wes

Cancer's Miracle

It's a strange thing, cancer.

It renders the greatest intellect impotent.

Families coalesce, grapple, then muster their courage to confront the reality, their angst cloaked in platitudes and favors. Certainly there must be something we can do!

Slow. Gradual. Relentless. And yet it's moving too fast.

I wake at night to my wife's restlessness, the thoughts of her mother circulating. Why her? Why now?

A sniffle, a sigh. There is little I can do.

The relentless march goes on, the cadence quickening.

We realize now what's important; her mother's gifts to us a gem.

-Wes

One Special Operation

Real life is so much better than Grey's Anatomy.

-Wes

A Cardiology Fellow Saves a Life on the Subway

Dr. Sonia Tolani, 32, a first-year cardiology fellow at NewYork-Presbyterian/Columbia, notches her belt with another save after 20 minutes of CPR on the subway...

"Stayin alive, stayin' alive, ah ah ah ah..."

Nice work!

-Wes

Do the Ends Justify the Means?

John Cassidy of the New Yorker thinks so:

So what does it all add up to? The U.S. government is making a costly and open-ended commitment to help provide health coverage for the vast majority of its citizens. I support this commitment, and I think the federal government’s spending priorities should be altered to make it happen. But let’s not pretend that it isn’t a big deal, or that it will be self-financing, or that it will work out exactly as planned. It won’t.

Many Democratic insiders know all this, or most of it. What is really unfolding, I suspect, is the scenario that many conservatives feared. The Obama Administration, like the Bush Administration before it (and many other Administrations before that) is creating a new entitlement program, which, once established, will be virtually impossible to rescind. At some point in the future, the fiscal consequences of the reform will have to be dealt with in a more meaningful way, but by then the principle of (near) universal coverage will be well established. Even a twenty-first-century Ronald Reagan will have great difficult overturning it.

Regretably, this analysis is where we're heading: who cares what it costs, just enact it!

God help us when the check comes due.

-Wes

Health Care Insurance Gift Cards

... for Florida residents, they're just in time for the holidays!

Starting this month you can find these gift cards at any Winn Dixie and in November you can find them at CVS pharmacy stores.

There are two types of gift cards available. One is called "the blue health care card" It acts like a temporary health insurance. For $59.00 it gives you health insurance coverage for one to 2 1/2 months based on your age. Here's how it works. You buy the gift card at the store, and the person receiving the card activates it. Then they enroll in a variety of plans offered. After that, you'll receive a package in the mail with a member id card.

You can use the temporary insurance gift card to see a doctor, a dentist, at the pharmacy, or for lab work.

The other gift card is called the family blue discount card. It's $19.00 but unlike temporary insurance, this one gets you 3 months worth of discounts on dental, prescriptions and vision services.

Just be sure you know when you're going to get sick!

-Wes

Are Pharmacies Getting Flu Shots Before Doctors?

From the Chicago Tribune:

"I am a pediatrician in suburban Cook County. We signed up to receive the vaccine, and have yet to get it. I hear it is going to go to local pharmacies before we get it. They only vaccinate children 9 and above. ... Who is going to ensure that infants and asthmatics get vaccinated?"

The response from the Illionois Department of Public Health's spokeswoman Kelly Jakubek was telling:

"We currently are only placing orders for hospitals and health departments, which we consider the front line of health care," she said.

Chicago vaccine providers are under a similar system in which the first shipments go to places that serve the most at risk, said Dr. Julie Morita, medical director of the Chicago Department of Public Health. Her department places the orders and selects the providers to get the first H1N1 vaccine shipments.

"Our priority is to get the early vaccine to high-risk providers," Morita said, "and once the majority have gotten vaccinated, then it can go to retail providers. We can't guarantee a limitless supply, so there may be breaks in supplies for a time, and then get orders filled later on."

It is difficult to know whether Dr. Morita bases her decision on places that have a high incidence of the disease (the frequency of development of a new illness in a population in a certain period of time), or a high prevalence (current number of people suffering from an illness in a given period of time). Pediatricians offices might have a high incidence, but very low prevalence, of flu relative to large chains stores, and if prevalence is what matters to the health department (and politically this would seem so), then pediatricians might be last in line for the shots.

-Wes

A Little Electronic Health Record Satire

SEEDIE (The Society of Exhorbitantly Expensive and Difficult to Implement EHR's) (the same organization that certified Extormity) issues it's definition of "meaningful use:"

"What is meaningful use?" asked executive director Sal Obfuscato at a recent SEEDIE executive retreat in Belize. "We believe the question is the answer, as man has always struggled to find meaning in this world."

This insight led SEEDIE to suggest that certified EHR vendors should embed quotes from well known philosophers in their applications. This approach will prompt physicians and other caregivers to actively seek meaning as they document patient encounters.

"When I am treating a patient, a thought-provoking quote from Jean Paul Sartre or Voltaire is far more valuable than the ability to e-prescribe or adhere to evidence-based guidelines," said Dr. Timothy Farragut, a Vermont pediatrician and SEEDIE board member. "You get so caught up in diagnosing a condition that you forget to ask yourself the important questions - why am I here, what does it all mean, can I still make my tee time?"

These recommendations are part of a SEEDIE effort to be designated as an ARRA certification body. "Unlike certification organizations that focus on subjective functional requirements, our innovative approach to meaningful use is focused on a much deeper meaning of the word meaning," said Obfuscato.

Heh.

-Wes

EP Woo: Electrohypersensitivity Syndrome

Do you have headaches, difficulty concentrating, insomnia, heart irregularities and headaches, fatigue, poor short-term memory, difficulty sleeping, skin problems, tinnitus, nausea, and dizziness? You might have electrohypersensitivity syndrome, a variant of "cell-tower blues!"

Yep, conclusive data gleaned from a study of twenty-five whole patients out of 100 to be studied has discovered at least one example of a "DECT" (aka Digital Enhanced Cordless Telecommunications in the 1.9-2.4GHz band) cell phone causing increased heart rate and irregularities!

Never mind that actual signals are not included in the data, but only a graph of "R-R intervals."

(Um, in case you were wondering, noise will cause variations in surface EKG signals and shortening of RR intervals.)

But don't pay attention to details. It is now clear that electrohypersensitivity syndrome clearly affects a significant proportion of America's teenagers...

-Wes

When Hoop-Jumping Becomes Patient Care

"Doc, I've got good news and bad news."

"What's that?"

"Well, I've lost six more pounds!"

"Wonderful! What's the bad news?"

"Well, you know that new-fangled drug you gave me that works so well for my atrial fibrillation?"

"Yes."

"We'll, I'm part of that AARP Medicare Advantage Part D drug plan, and I just got the "partial" approved drug list for 2010 in the mail. My drug's not on the list, so I called and found the drug's been moved from a Tier II drug to a Tier III drug. That means it will cost me twice what I paid for it this year. That's gonna be tough, doc. I can't afford it.

But I also read that if you call this '800' number and speak to them, they'll allow me to obtain an exemption to keep the drug on Tier II for next year."

I called the number as I typed his note. The patient seemed pleased that I'd be so attentive to his needs during their office visit. A sophisticated voice-recognition triage prompt answered:

"If you're calling about an injectable insulin question, say 'insulin,' drug issue say, 'drug,' if not part of this list, say 'other,'..."

"Drug," I said. a brief pause occurred, then:

"Just a moment..." (Soft music played in the background.)

Finally, a woman answered. he was quite pleasant as I explained the situation. Finally, I got to the part about the patient's drug not being on the 2010 drug list.

"Oh, 2010?" she asked.

"Just a moment."

On hold again. We continued our office visit. "So, how often are you having those episodes of..."

"Dr. Fisher?"

"Yes?"

"What other drugs has the patient failed?"

We listed them: "Atenolol, Sotalol, Amiodarone..."

"And when were those drugs used?"

"Um, seriously?"

"Yes, I need dates."

"Well, according to the fancy-schmancy electronic record, he's been on this Wonder Drug since November 12, 2007... his Amiodarone was stopped then."

"But the other drugs, when were they started and stopped."

I made up some dates. I was not about to spend time culling the record for these dates, but it was clear that data entry fields were being placed on the opposite phone line. I suggested to my patient he write down those dates.

"And why was the Amiodarone stopped?"

I looked at my patient. He quickly reminded me about the lung findings and liver toxicity he had experienced. I spewed the information to the inquisitor in hopes of expediting the interview. It was taking entirely too long. I looked at my patient. This would be his visit. His priorities were set: money talks after all. So I continued. After submitting the answers, she responded:

"Just a moment while I give this information to my supervisor."

Soft music played again. I looked up at my patient. "Um, where were we? Oh, yes, how often have you been..."

"Dr. Fisher?"

"I've given the information to my supervisor."

"Okay, will he receive his Tier exemption?"

"Oh, we've not received the final list yet for 2010."

"But my patient called and discovered this drug was moved from Tier II to Tier III. Why does he know the information and you seem puzzled by the list?"

"As I said, we're still waiting for the final list..."

It was obvious that the discussion was going nowhere.

"So how will Mr. Smith know if he's been granted the exception?"

"My supervisor will review the application for the Tier review and make a decision. Is there anything else you need?"

Realizing that there was no way I was going to get an answer, I acquiesced. "No, I think we've handled the application. Thanks for all you help. By the way, in case my patient would like to check on the application, what's your name?"

"Christine."

"Thanks, Christine. And your last name?"

"It's just Christine."

"Uh, okay. And how about your supervisor's name?"

"Jericho."

"Jericho who?"

"There's only one Jericho here," she said.

I could only think one thing at that point as I hung up:

... I bet he's a "wall."

-Wes

Not Seeing the Forest for the Trees

Congress, in their efforts to be conciliatory to specialists, is now working to alienate primary care physicians, too:

(Medicare payment) Reductions will be made over four years rather than imposed at once in 2010, the U.S. Centers for Medicare and Medicaid Services said yesterday in a statement. In July, the agency said it planned to slice $1.4 billion, or more than 10 percent, in payments for each of the two specialties, triggering what an advocate promised would be a “tooth and nail” battle.

The administration argued that the lower reimbursements for specialists would make more dollars available for lower-paid non-specialists who can focus on preventing expensive, chronic illnesses. That would tame the growth in medical costs, one goal of President Barack Obama’s effort to remake the U.S. system of care. Under yesterday’s plan, family doctors and nurse practitioners would get half the proposed increase.

So while specialists won't be cut quite as bad, primary care will not see their efforts rewarded significantly either.

And yet, any real effort to look for simple ways to cut costs in health care system is ignored by Congress. One only has to look at the waste of health care dollars implicit in pharmaceutical direct-to-consumer advertising - and the fact that only two countries in the world (the U.S. and New Zealand) permit it - to see the hipocracy of the reform efforts underway. Instead, doctors are the easy target for "reform" as more and more ads for Viagra, Lipitor, and "P.A.D." flash accross our TV screens.

Sure it's not the only place costs can be cut. But how about ridding our system of such bloat before biting the hand that cares for us?

-Wes

Could Statins Be Protective Against H1N1 Flu?

In a retrospective study, it's a definite maybe:

Of the patients studied, 801 were taking statins anyway and continued taking them while hospitalized. Seventeen patients who were taking statins died while in the hospital or within a month afterward, compared to 64 who were not taking statins, Vandermeer said.

Overall, 2.1 percent of patients taking statins died, compared to 3.2 percent of patients not taking statins. That means patients taking statins were just under 50 percent less likely to die.

Turns out this is from a press release regarding reports being presented this weekend at the annual meeting of the Infectious Diseases Society of America (IDSA) in Philadelphia, so while the data are intriguing, they are by no means conclusive.

-Wes

Significant Digits

I find it interesting that the Congressional Budget Office's House health care bill budget estimate was posted to four significant digits ($1.055 Trillion dollars) even though CBO Director Doug Elmendorf, in a Thursday letter to House Democratic Chairmen, cautioned that his estimates are preliminary and "subject to substantial uncertainty."

Why is that so?

Could it be that the "estimate" looks better as $1.055 trillion when reported in the press than $1.1 trillion?

I guess these days, what's a few hundred billion dollars among friends?

-Wes