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Tag Archives: Policy

Political Quote of the Day

“Maybe we should have started with you at the very beginning, talked to the physicians before they started writing a 2,000-plus-page bill that many of them [politicans] didn’t read, yet passed.” – Republican Rep. Scott Tipton, commenting about the Affordable Care Act during a House Small Business Committee meeting last week which showed how “physicians have reached a tipping point” due to overregulation by Congress and insurance companies. Dr. Louis McIntyre does a very good job at putting things into perspective during the included video interview. Not bad for an orthopedist … ;-)  

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Get Your Own X-ray

GruntDoc had a post that illustrates a point I have been trying to make for quite some time. The post is simple enough. It starts out with a Twitter post by a physician named Brett (@EMDocBrett) noting “Ottawa Ankle Rules? People follow them? I try to explain to pts but really, they [just] want an [x-ray].” For those of you not familiar with the Ottawa Ankle Rules, they are a way to predict with high accuracy whether a patient does not have an ankle fracture. In other words, if you don’t meet the criteria in the Rules, it is almost certain that you don’t have an ankle fracture. GruntDoc relayed a story about how, through use of the Ottawa Ankle Rules, he was able to substantially cut down on the number of ankle x-rays at a clinic where he worked. He was proud of the impact he made … until he learned that all the corpsmen drove to the local emergency department to get their x-rays anyway. Then he cited the scholarly Nick Genes (also at @nickgenes) who once said “Canadians get exams, Americans get x-rays.” What’s the simple solution to the problem of everyone wanting ankle x-rays when no injury is present? Deregulation. If people want to have an x-ray, they should be able to walk into any radiology facility and have an x-ray without a doctor’s prescription. Why are we requiring doctors to be the “middlemen” between patients and testing? Common knowledge that if a patient goes to a doctor demanding an x-ray, the patient will get an x-ray. Press Ganey has made it likely that you will get what you want in the emergency department even if it is medically inappropriate. And if one doctor doesn’t write a prescription for an x-ray, then, just as they did with GruntDoc, the patients will just go somewhere else to get their x-ray done. Allowing patients to get their own x-rays would cut down on the number of doctor visits and emergency department visits significantly. How many patients go to the doctor solely because they want a prescription to have an x-ray done? Allowing patients to get their own x-rays would also cut down on medical liability. If patients get an x-ray without their doctor knowing about it, then the doctor doesn’t have to worry about following up on the study or the results. If the patient wants to discuss the results with the doctor, they make an appointment. Otherwise — just like if you choose to fix the brakes on your car — if something goes wrong, you’re on your own. Deregulation would also mean that patients have to pay out of pocket for the x-ray. Patients would then be faced with a dilemma: Do I pay $100 for an ankle x-ray, do I just follow those Ottawa Ankle Rules and save the $100, or do I go get a professional opinion from the doctor? Let’s say that the patient decides to go purchase an x-ray. It’s normal. After a few normal ankle x-rays, then patients may be a little more hesitant to get radiated next time they twist their ankle. Now what? See a doctor for an exam? Go pay for an MRI? Let’s pay $1000 for an MRI and interpretation. Or perhaps we save money on the radiologist’s interpretation and we look up MRI ankle interpretation on the internet. Now what? Want to discuss what to do with the results? Your family doc can probably get you in to the office in a day or two. Or … our emergency department doors are open 24/7. We don’t ...

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The Supreme Curve Ball

The Supreme Court decision on the Affordable Healthcare Act threw us a curve ball. Many people who predicted the outcome of the ruling swung and missed – including me. The Court agreed with the government’s argument that the individual mandate contained in the Affordable Care Act was not a tax … for purposes of the Anti-Injunction Act (which would have prevented a lawsuit regarding assessment or collection of the mandate and forced those bringing suit to sue for a refund after paying it). At the same time, the Court declared that the individual mandate contained in the Act was a tax … for purposes of validating and enforcing the mandate. To me that’s a stretch. That’s like legal argument defending a dog bite lawsuit by simultaneously alleging that (1) I don’t have a dog, (2) you weren’t bitten, and (3) my dog didn’t bite you. President Obama has declared the Supreme Court decision as a “victory” but this victory is largely Pyrrhic. The Supreme Court’s decision will become a rally cry for the 41% of Americans who believe the law should be overturned and the 27% of Americans who believe the mandate should be overturned. Romney’s campaign will emphasize Romney’s commitment to repeal the law – whether or not he truly intends to do so. While some argue that “President Romney” wouldn’t have the ability to repeal the law, President Obama’s decision not to enforce our country’s immigration laws shows that an executive order refusing to enforce laws can have the same effect as repealing a law. A dog with no teeth can’t bite you. In addition, President Obama and all the legislators who supported the ACA have essentially approved the largest tax increase in US history … in an election year. How many voters will be happy at the thought of a new and expanding tax that coerces us to purchase a commercial product which we may not even be able to use? The growing public backlash in this regard is probably the reason that the White House is backpedaling and stating that the mandate really isn’t a tax … even though the same White House stated that the mandate was a tax in the media and during oral arguments on the issue. The mandate stands because it is a tax and now President Obama and our legislators have to live with the consequences of their decision. In case you were wondering, here are how each of the House members and the Senators voted on ACA. But many people will think that the tax … er, um … penalty is OK because our government is going to provide us with insurance. Millions of more patients will be INSURED! If you’ve read WhiteCoat’s Call Room on a regular basis, you know why this is such a false and empty promise. Insurance amounts to a series of promises. First there is a promise that, in exchange for a premium payment, someone else will pay for your medical care. Then there is a promise that someone else will provide your medical care. Finally, there is a promise that you will be provided with the medical care you need when you need it. While the government wishes to expand the number of patients who receive our government-mandated “insurance”, many states are planning to restrict the eligibility for the “insurance” that our government wishes to provide to us. In other words, states don’t want to pay for your insurance. A House Ways and Means survey showed that 71 of the Forbes 100 companies could save a total of $28.6 billion in 2014 by dropping health care coverage for their employees. The Affordable Care Act ...

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The Expense of Saving Money

Our state government, just like every state government, is trying to save money. One of the largest targets for this attempt at savings is the health care system, since health care is one of the largest expenses in any state budget. In order to save money, the state government has several options: It can raise revenues, cut services, or cut payments. But unless these options are well-thought out, the attempt at saving money may have the opposite effect. Which brings me to the topic of this post. In the emergency department, there are certain patients who we see on a regular basis. Some are present so frequently that they should literally have their mail forwarded to the hospital. Others, upon investigation, rotate from hospital to hospital and doctor to doctor for some type of secondary gain. And some are attempting to survive in a system that can be stacked against them. It was one such patient’s fourth visit to the emergency department in two weeks. Each time she had difficulty breathing. She had a long history of asthma and has been hospitalized several times for asthma in the past. During one of those hospitalizations, she had been on a continuous albuterol nebulizer for an hour. She developed supraventricular tachycardia (a fast heart rate) which was presumed to be from too much albuterol and one doctor emphatically told her that she was thereafter “allergic” to albuterol and that the next time she ever used albuterol she would most certainly die. Therein lies problem #1. A fast heart rate is not an “allergy” to albuterol any more than diarrhea is an “allergy” to antibiotics. A fast heart rate is a documented side effect of using albuterol. But the seed had been planted in the patient’s head.From that point forward, the patient was only able to use Xopenex. Xopenex is structurally very similar to albuterol. In theory, Xopenex has fewer cardiac side effects than albuterol, but from a practical standpoint, there isn’t much difference in side effects between the two. Rapid heart rate is also listed as a documented side effect of Xopenex. For a long time, the patient received her prescriptions for Xopenex for free from the state. Then the state decided to save money. It stopped paying for Xopenex for people on public aid. Albuterol was now the only approved rescue medication for patients with asthma. But since the patient was “allergic” to albuterol, there was no way for her to pay for the “only” medication that she could take. And her doctor left the state because of increasing taxes and decreasing reimbursement for seeing Medicaid patients. So when she had an asthma attack, the patient simply came to the emergency department. She informed the staff that she was allergic to albuterol and so the respiratory department had to find some Xopenex to use in the emergency department. She felt better after a couple of treatments and was discharged with a prescription for steriods and a Xopenex inhaler, but she never filled the Xopenex because she could not afford it. She was also referred to the county hospital for specialty care, but the trip was long and the waiting list for appointments was longer, so she never made an appointment. So during the spring months, we sometimes see Joanne Doroshow several times per week. She fills her prednisone prescriptions and sporadically fills other prescriptions for maintenance medications, but she still ends up in the emergency department every time that she feels “tight.” The amount of money that the state saves in withholding Xopenex from Joanne is more than surpassed by all ...

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Bye Bye Generic Vicodin

Let the wailing and gnashing of teeth begin. Vicodin pills are about to get a lot more expensive. You see, according to this Abbott Vicodin Announcement (.pdf file), Abbott Labs is very concerned about the Tylenol content in its combination pain medications. After all, too much acetaminophen per dose in prescription medications may cause “severe liver injury from acetaminophen overdosing.” In bowing to pressure from the FDA, Abbott decided to stop making the combination pills containing hydrocodone with 325 mg Tylenol or more and decided to start producing all of its combination pills with 300 mg Tylenol, instead. Phew. I’m glad they took care of that. I’m sure that the extra 25 mg of acetaminophen in the current formulation was just causing an untenable overload of all the liver transplant centers throughout the country. The other thing that creating a new formulation and discontinuing the current formulation does is create a new patent on the medication. Which will undoubtedly mean that, much like how the cost of colchicine went from 10 cents per pill to $5 per pill, the cost of brand name Vicodin will soon skyrocket as the medication goes “non-generic”. Since states don’t like spending a lot of money on medical care, it is also likely that the “safer” brand name Vicodin will no longer be covered under state insurance plans. I’m sure there will still be generic versions of hydrocodone/acetaminophen available along with Oxycontin and Tylenol with codeine — until the remaining manufacturers also create their own “safer” versions of the medications. For now, any time that a physician writes a prescription for the brand “Vicodin”, patients are going to not only have pain in their body, but they will also have pain in their wallets. I’m predicting $2.50/pill price point. Look for lots more hassles to both pharmacists and to the doctors writing the prescriptions.

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Microbial Armageddon

Any patient who demands a ZeePack for a runny nose, who wants amoxicillin for sinus congestion, or who wants Levaquin to “keep this bronchitis from developing into pneumonia” needs to read this Bloomberg article. We are heading toward a situation where people die from infections that no antibiotics can treat. The article discussed one infant in a pediatric ICU that died because the infection that the child developed was resistant to all antibiotics used for treatment. Six similar incidents occurred during the course of 16 months. Estimates are that 100 million people in India have been colonized with organisms carrying the genetic mutation. Medical tourism in India is decreasing as a result. Even the director of the CDC cites the situation an example of why we have to limit antibiotic prescriptions: “We are looking at the specter of untreatable illness.” Oh, and remember how the Centers for Medicare and Medicaid Services assert that if hospitals don’t give antibiotics to every single pneumonia patient within 6 hours of arrival – even though a large proportion of pneumonias are viral in nature – that the hospitals are falling outside of “quality” guidelines? Our government’s own “quality” guidelines may be contributing to the looming microbial Armageddon in this country.

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