Archive | January 2010

Health Care Reform ICU Update and Implications

So the ICU metaphor has unsurprisingly been used after the recent developments surrounding the reform effort.  Incredibly, it appears that despite a year of work, the healthcare reform effort might not survive.  If in fact, there is a post-mortem, and its not completely clear yet that there will be, it will be a sad and unfortunate development.

The system as currently configured, is on a financially unsustainable path.  That is very clear.  But without real reform, access to care will be denied for millions who are stuck between not having  “good” coverage (in the form of a decent employer-sponsored plan or Medicare) and “okay” coverage, in the form of Medicaid.   Those are people earning too much for the latter and lacking access to (or the ability to afford) the former. 

If it is decided to “pull the plug” on the healthcare reform effort (keeping with the ICU metaphor), it will represent a tragic missed opportunity and the blame must be shared by both parties.   Nearly every stakeholder in the sector was asked to make sacrifices in order to facilitate reform, except for one.  Nothing at all was done to trim the ineffectual medical malpractice system, for fear of angering a substantial constituency.  Howard Dean himself admitted that the Democrats were taking on so many stakeholders, that they could not also take on the trial lawyers if they hoped to get anything done.   Yet making some degree of substantial reform to this flawed system was the one olive branch that might have secured some degree of Republican cooperation on the overall effort.  Instead of that, states were given language that would punish them if they tried to undertake tort reform on their own.

If something cannot be done to pass meaningful reform, the issue will be so politically untouchable that who can guess when it will be approached again?  The system will continue to react and change in other ways, possibly by large companies coming up with other ways to provide care for their employees in a more cost-responsible model.  So far, cost-shifting has been a large part of companies’ efforts.   The number of uninsured will continue to climb, and the withdrawal of providers willing to service them will continue to increase, likely mitigated as many providers are incorporated into hospital employed situations.   That will further increase the burden on hospitals who will be shouldering even more of the uninsured problem. 

Can there be real bipartisan work that will save the effort?  This seems unlikely if a “back to the drawing board” approach is taken, since its hard to believe that there is energy left for another 8-12+ months of hard work.

Healthcare Reform Effort Transferred to Intensive Care

I came across a good article  on NPR.com that describes what has gone wrong so far with the healthcare reform effort. Arguably, one could say that the backlash culminated in the election of Scott Brown; a Republican who will now succeed Ted Kennedy and represent Massachusetts in the U.S. Senate.

The long and short of it is this:  healthcare reform is a topic so complex,  that even folks that have spent years within the sector have difficulty grasping all of it.  Another problem is that the various elements of the sector (hosptials, insurers, device companies, providers etc.) do not all have interests which are aligned.   So cost reductions for some,  result in income and coverage loss for others.  Covering those without insurance is a laudable goal, but it should be clear that expanded coverage will definitely increase costs in the short term.    So after expanding coverage, something must be done to contain the cost growth. 

As Charles Krauthammer pointed out in April, “In the end, the spinach must be served.” 

For now, the reform effort clearly is in Intensive Care.  It’s not dead, but it is at risk.  Perhaps at this point, some real bipartisan effort can take place to salvage the endeavor.  From a policy standpoint, it is almost always to pass something rather than nothing, and then improve it around the edges as time goes on.  If nothing is passed, this issue will be toxic to handle in the future.   It wasn’t touched from 1994-2009.  Now, it will be 2010 until [?]. 

Offering real reform of the tort system would be one thing most physicians would like to see.  Under the current wording, state efforts to reform their tort systems would result in penalties, which clearly will discourage this from happening.  It does seem that the tort system is the one stakeholder which was left untouched under the current bills, although insurers, pharma, and hospitals all were asked to make concessions.  Realistically, a challenge to the medical malpractice system at this point in the game is unlikely, but should be explored if it is needed to get a bill passed. 

From the provider standpoint, regardless if  anything passes, the story remains the same;  the gradual slow squeeze of the private practice model will continue.  So for now all eyes are on the ICU, and its star patient.

External Tissue Expansion (Proxiderm)

I wanted to talk about a method of wound closure that deserves to be in the toolkit of any trauma or reconstructive surgeon who faces difficult wounds.   I have no commercial involvment with Progressive Surgical, which is the company that makes the Proxiderm external tissue expansion device. 

Each Proxiderm device has two opposing tissue hooks which are separated on tension and inserted away from the wound edges.  The device applies a specific amount of tension on the tissue (460g) which causes steady expansion of the tissue without pressure necrosis.  Technically, a similar procedure is possible using a serial-suturing technique with rubber bolsters, but the disadvantage of this is the variability of the tension being applied.  With Proxiderm, it is designed to provide the right amount of force every time.

By placing these devices every 2-3 cm along the wound edges, and changing them every 2-3 days, wounds can be gradually closed with good skin, not needing grafting or flap procedures.   Wounds need to be well debrided prior to beginning the procedure, and are generally recleaned with each stage, when new Proxiderms are applied and the old ones discarded.  The following photos (from the company website at www.proxiderm.com)  show a tough lower extremity wound closed at 16 days without the need for grafts or flaps.

The procedure can be done as an outpatient, and it is necessary to secure each device with a suture across the wound and tied over the top.  A well-padded, bulky dressing is also a must. 

For more information, head to www.proxiderm.com, which is filled with detailed information and many more case photos.

Concierge Medicine

Concierge medicine was in the news again today.  Concierge medicine is not yet a widespread phenomenon, but has been increasing in popularity as primary care doctors find it increasingly difficult to provide attentive care to their patients, and maintain a worthwhile lifestyle at the same time.  For those unfamiliar with the concept of concierge medicine, it works as follows:  doctors charge each patient an annual retainer.  The fees vary, but $1000-3500/yr appears to be a commonly quoted range.  In return for this, the patient receives 24/7/365 access to the practice via email, cell phone, etc.  They receive on-time appointments without delay, and appointments are not the typical 10 minute one so common to rushed primary-care practices today. 

Not surprisingly, concierge medicine has generated debate as to whether this system is ‘fair’ for patients who are unable to afford the retainers.  Also, it must be  pointed out that concierge medicine is not insurance.  That is, patients will still be responsible for other healthcare services such as hospitalizations, surgery, diagnostic imaging, etc.  Concerige patients need to maintain their regular health insurance in order to be properly covered. 

One line of attack against concierge medicine is that it is acting as a form of insurance, and concierge practices are in effect operating as an unlicensed insurance company.  It is still too early to be sure how this will play out,  but these arguments miss the overall point that the concierge medicine trend illustrates. 

Is healthcare a fundamental right?  Or is it a service provided by professionals with fees set by market forces?  If it is the former, than a national health system, or a private system with a foolproof ‘safety net’ for those unable to afford private care, makes sense.  If it is the latter, than concierge medicine reflects an effort by private-sector primary care  to provide this service in a fashion that makes more sense than the current system does.  

The system has not determined what the answer to this question is, although it is clear that the administration as well as many prominent politicians, such as the late Sen. Kennedy,  believe that it is a right.  For now, individual providers are deciding for themselves, and adjusting their own terms of participation in the system.

Corporate Medicine (and Physician Productivity)

Get used to hearing that term.  There is no doubt that the trend is increasing for doctors to be employed.  Right now, about half of America’s physicians are in solo or small group private practices.  By the end of this decade, I would expect that 25% or fewer will be, as the pressures on managing a private practice continue to build.  On the one hand, all the overhead is determined by market forces, yet the reimbursements are determined by Medicare fee schedules, which are not keeping pace with inflation.  Even physicians willing to add discretionary services such as cosmetic surgery and injectables (Botox, fillers) only helps so much, since these are becoming more competitive – with resulting downward price pressure.

The physician-employment trend was seen in the 1990’s, but it was gradually unwound as productivity tended to suffer.  Now, most employment involves compensation tied to productivity.  The problem with this however, is that under such a situation overutilization and procedural activity is not going to be reduced.  Reduction of excess is one of the tenets of the current healthcare reform effort.  Tying compensation to productivity makes sense for the hospital.  But for the system as a whole, it does little to change the so called “perverse incentives” that drive the overall volume of services.  What makes sense is for each medical department to be evaluated on overall outcomes.  The problem is that good outcomes may not come with high revenue.  This problem will be passed along to the employed physicians in the form of lower pay.  At some point, physician compensation will have to be tied to the market supply/demand of each specialist, rather than the productivity achieved by that specialist.  The more that reimbursement continues to lag increases in inflation, the more likely this will become.

Sermo: Powerful Collaborative Tool, Place to Vent

If you are a doctor and you have not signed up for Sermo, you should do so.  What is Sermo?  It is a website founded by former surgery resident Daniel Palestrant, M.D.   Sermo is presently opened exclusively to physicians holding a U.S. medical license.  It is a discussion forum where physician-users can post topics, interact with peers, participate in surveys and otherwise engage in discourse with their colleagues.  Some of the interaction between peers concerning medical topics is very informative, sort of a virtual multidisciplinary Grand Rounds; a very powerful collaborative tool.

There is a lot of value to this interaction, but it is striking how negative the tone of many discussions can be.  These are almost exclusively related to the negative changes in the business of medicine, or related issues such as the medical malpractice system.  When the focus of discussion is not clinical medicine, but something related to the business side of medicine, some these posts can be utterly cringe-inducing. 

Why is there such venom?  It is not the fault of the contributors.  It appears to be related to the severe changes that have been gradually, but steadily, imposed upon the practice of medicine.  Ever-increasing bureaucracy, reimbursements that do not keep pace with the costs of running an office, and increased hassle in maintaining licenses and board certifications (such as the Maintenance of Certification program), are all combining to drive practitioners to vent their frustrations in formats such as Sermo.  The pressures on the healthcare system have reached a critical mass, and the system is beginning to change.  Physician dissatisfaction is a major feature in this, and it is getting worse.  The discussions on Sermo are being repeated on a smaller scale across America in thousands of backrooms, lounges, and conferences.  So far, this dissatisfaction hasn’t led to any major changes in the role of the physician in the healthcare system.  It does make for some interesting reading though.