Will My Opt-Out Status Affect You?

Updated 3/2017-- all links (except to my own posts) removed as many are no longer active and it was easier than checking each one.

I opted out of Medicare several years ago.  This means I don’t see Medicare patients other than in the emergency room when I’m on unassigned call.   I don’t submit bills to Medicare or to those patients.  I just let it slide.

Last Wednesday, I received the following letter from a large radiology group in my home town:

September 2010
RE:  PECOS Enrollment
To our referring physicians and their office managers:

At __________we have begun a project to identify ordering physicians who are not enrolled in Medicare’s Provider Enrollment, Chain and Ownership System (PECOS).  Our purpose is to remind physicians of the importance of enrollment to them and to us.

Beginning in January, 2011 those providers filing Medicare claims listing an NPI number on the claim of an unenrolled provider will have their claims denied.  This would apply to any claim you send in and to any claim we submit for services provided to your patients because we are required to list your NPI number on our claims.  This applies both to patients referred to our private offices and the hospitals where we provide radiology professional interpretations or services.

So, you can see our effort is not purely altruistic.  We have a financial interest in reminding you of the importance of PECOS enrollment.  In trying to ascertain whether you are enrolled, we are using an online program you can find at www.oandp.com/pecos.  Simply enter your NPI number in the entry block and press enter.  If you enter a valid NPI number, your name will appear and beside it will be a symbol indicating where Medicare recognizes your PECOS enrollment.

Since Medicare is continually updating the files, we may have accessed the system before your enrollment was completed.  We will continue to monitor the situation in hopes you will enroll if you intend to continue seeing Medicare patients.  If you have already enrolled or have no plans to enroll, please excuse our intrusion.

Sincerely,

This bothers me.  It is not likely that I will be sending them any patients from my office, but that doesn’t mean there won’t be the occasional patient with my name on their chart in the ER.  IF I need to take a Medicare patient to the operating room from the ER, will the hospital not get paid?  Will the anesthesiologist not get paid?

Will my non-participation in Medicare affect my fellow healthcare providers receiving payment?  If so, that is just not right.  I voiced this concern to Senator Blanche Lincoln shortly after receiving this letter.  She agrees with me.

This radiology group is usually correct in their policy interpretations, but I still went searching for more information.  I found this summary:  What You Need to Know about Enrolling and Ordering/Referring in the Medicare Program.  It includes this

Physicians who have validly opted out of Medicare will not need to complete a Medicare enrollment application.

Still, I am not reassured.   The policy doesn’t seem to take into account that I may through unassigned ER call see the occasional Medicare patient.  The policy seems to “assume” that since I opted-out, I never see any Medicare patients.  If this were the case, I would never affect my fellow physicians/hospitals payment.  I’m left wondering if I will affect their payments for that occasional patient I see through the unassigned ER route.

I will tell you that I have gone to the NPI site and reviewed my information.  I have gone to the Medicare (PECOS) site and attempted to registered my information.  I will not be re-enrolling as a Medicare provider at this point in time.  

Insurance Premium Increase

Updated 3/2017 -- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

Physicians aren’t exempt from the struggles with personal health insurance coverage, affordability, denied coverage, etc.   When I finished my training and opened my practice 20 years ago I had to buy individual coverage.   All options included a rider that excluded coverage on my uterus and ovaries due to fibroid surgery during training.  So when I had my TAH & BSO a few years later, the entire cost came out of my pocket.  Fortunately, I knew how to ask for cost reductions, but still…

My husband and I are both small business individuals.   I have always carried our health insurance under my name (office).  Over the years we have gone to a health savings account with a high deductible to keep the cost reasonable.  Fortunately, we have been mostly healthy.

Last month, we received a letter from Assurant Health telling us of a policy change that includes a $75 ER visit charge.  I thought this might be their way of avoiding a policy increase, but no.  Last week I received the notice regarding an increase to our policy.  Currently, our premium is $619.76 per month plus a mandatory $100 deposit into the HSA each month. 

The notice included the “good news”  -- “Congratulation!  You’re a Healthy Discount candidate.”  To determine your eligibility for the Healthy Discount, follow these simply instructions:  1.  Answer all six questions below.  Please consider the last 12 month when answering these questions……”

• Been recommended or scheduled for surgery that has not been complete?
• Been recommended to have or is anyone contemplating infertility treatment or been treated for infertility?
• Received or been recommended to have any treatment for alcoholism, alcohol or drug abuse or addiction or mental or nervous conditions?
• Been cited for operating a moving vehicle under the influence of alcohol or drugs?
• Received a diagnosis for any serious medical condition such as heart disease, stroke, cancer, diabetes, HIV, AIDS, or any other progressive disabling condition?
• Been incapacitated or hospitalized due to an accident or illness?

The “good news” is that since we can answer no to all six of those questions, our new premium will be $761.71 per month rather than $842.87 per month.  The mandatory $100 deposit into our HSA remains the same.
A simple 23% increase rather than a 36% increase. 

Earlier this year policy increases of up to 39% in California, Indiana, etc led The House Committee on Energy and Commerce to summon the chiefs of WellPoint, UnitedHealth Group, Humana and Aetna to the Hill to answer questions.  Policy increases by other companies seem to be flying under the radar.

If you missed them, check out the posts by Shadowfax here and here on Assurant Health.

$250,000 for Loss of Consortium?

Updated 3/2017 -- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

Why should the husband of  a woman who was disfigured by her facelift get $250,000 for pain and suffering?  Actually, his is for “loss of consortium.”

President Barak Obama is scheduled to sign the new healthcare bill into law today.  No tort reform was included.

According to the Georgia Supreme Court ruling

In January 2006, Harvey P. Cole, M.D., of Atlanta Oculoplastic Surgery, d/b/a Oculus, performed CO2 laser resurfacing and a full facelift on appellee Betty Nestlehutt.  In the weeks after the surgery, complications arose, resulting in Nestlehutt’s permanent disfigurement. Nestlehutt, along with her husband, sued Oculus for medical malpractice. The case proceeded to trial, ending in a mistrial. On retrial, the jury returned a verdict of $1,265,000, comprised of $115,000 for past and future medical expenses; $900,000 in noneconomic damages for Ms. Nestlehutt’s pain and suffering; and $250,000 for Mr.
Nestlehutt’s loss of consortium.

The Georgia Supreme Court ruled the 2005 Tort Reform Act was unconstitutional and that the state legislature may not limit the amount of money that juries award to victims of medical malpractice.   So the above amounts stand rather than being reduced to $115,000 for medical expenses and $350,000 for noneconomic damages.

The 2005 Tort Reform Act was part of a legislative package that capped jury awards at $350,000 for the “noneconomic damages” of malpractice victims.  The Georgia Supreme Court has ruled that the cap improperly removes a jury’s fundamental role to determine the damages in a civil case.

Chief Justice Carol W. Hunstein wrote in the decision,“The very existence of the caps, in any amount, is violative of the right to trial by jury.”

The current healthcare bill to be signed into law today by President Obama fails to address tort reform.

Help Fight the BoTax: Send Your Senator a Letter

 Updated 3/2017--  all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

I am against the Cosmetic Surgery Tax (or BoTax). I feel it is an unfair tax which will heavily affect women more so than men. It will also affect many more in the middle class than in the wealthy class. I’d like to join the Aesthetic Society and all of organized Plastic Surgery in fighting this unfair tax.

For more on how the tax is a bad idea, check out this article Breast-Enlargement Tax That Failed in Jersey Taints U.S. Plan by Nicole Gaouette over at Bloomberg.com (H/T to Jeff Frentzen, PSP Blog)

”It was a real education,” said Cryan, a Democrat who now wants the levy repealed, in a telephone interview. “We essentially discouraged the business from happening at all.”

Susan Hughes, a Cherry Hill, New Jersey, facial surgeon, said her business dropped by 10 percent when patients began crossing the state line to Pennsylvania. Administering the tax strained relationships with patients, and created extra work and costs for her office, she said.

‘You Idiots’

“We become the tax collector,” Hughes said in a telephone interview. “Now you’re going to repeat that on a national level? You idiots!” Hughes’s office manager, Jaime Castle, said she’s also concerned about layering the taxes, making New Jersey residents pay a combined 11 percent. ………….

The following is the template for a letter that patients can use to express their opinion and dissent toward the proposed cosmetic surgery tax:

Dear Senator ______,

HEALTHCARE PLAN IN THE SENATE WILL UNFAIRLY DISCRIMINATE AGAINST US!

I am writing you today about an issue that affects everyone who utilizes plastic surgery services for anything from Botox to Tummy Tucks.

The healthcare bill approved by the US Senate this weekend, Page 2045 Sec. 9017, Excise Tax on Elective Cosmetic Medical Procedures included in the “Patient Protection and Affordable Care Act.

This dense legalese translates to a tax on all cosmetic procedures as partial payment for the healthcare overhaul our current administration is attempting to implement.

The problem is that we would be paying this tax, the FIRST time this country has levied a tax on patients for medical procedures. This Bill is objectionable in many ways, including:

· This is a discriminatory tax. According to the Aesthetic Society Annual Statistics, 91% of all cosmetic procedures are requested by women

· This will not have considerable consequences on the wealthiest patients but, as usual, affects the middle class. We working women, soccer moms, and scores of others who carefully save and budget to improve our appearance and self esteem will be penalized for doing so.

· Procedures such as breast reduction that have been cited in the literature for improving self esteem and quality of life would be taxed as well.

· Our doctor as tax collector: This provision places physicians in the role of tax collector and holds physicians liable should an individual fail or refuse to pay the tax. That is not the relationship we want with our medical provider!

Please, do not allow this portion of the tax bill to pass!

Sincerely,

______________________

You can find your elected representative by clicking here.

Are BPA Products Safe?

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

I love the convenience of my microwave. It is especially good for reheating leftovers like the chili I made recently. I took the chili to the office in a plastic container for lunch the next day. The question is: are the BPAs in the plastic container a health risk? Should I put my chili in a Pyrex or ceramic bowl before microwaving?

Yesterday afternoon, I participated in Better Health's very first blogger briefing. The subject was Bisphenol-A (BPA) plastic safety. The briefing included an interview with Steve Hentges, PhD., Executive Director of the Polycarbonate/BPA Global Group of the American Chemistry Council (ACC), and was moderated by Dr. Steven Novella, founder of the blog Science-Based Medicine and the new policy non-profit, The Institute For Science In Medicine.

Bisphenol-A (BPA) is a chemical widely used to produce polycarbonate, a hard plastic. More than 2 million metric tons of BPA were produced worldwide in 2003. There is an increase in demand of 6% to 10% annually. BPA can be found in a wide range of products, including baby bottles, plastic utensils, and plastic food containers. It has been the focus of some controversy over its safety, and the resulting debate reveals much about how the current system deals with such issues.

The concern is that BPA can leech from plastic containers into the food or liquid it contains, and when consumed can have negative health effects. The debate is over how to interpret existing evidence about BPA safety, which gives conflicting results. Essentially it is a debate about how to weight different kinds of evidence, and where safety thresholds should be.

The Food and Drug Administration is getting ready to look at this question of BPA safety again. The history of the FDA’s stance is as follows (dated Aug 31, 2009):

In August 2008, FDA released a draft report finding that BPA remains safe in food contact materials. On October 31, 2008, a subcommittee of FDA's science board raised questions about whether FDA's review had adequately considered the most recent scientific information available. Most recently, on June 3, 2009, FDA Commissioner Dr. Margaret A. Hamburg testified before the House Committee on Energy and Commerce's Subcommittee on Health (written testimony is available at http://www.fda.gov/NewsEvents/Testimony/ucm164186.htm).

In response to a question about BPA, Dr. Hamburg emphasized that she takes the questions that have been raised about BPA very seriously, and she stated that the FDA's new Acting Chief Scientist, Dr. Jesse Goodman, is working with FDA scientists to take a fresh look at the science of BPA. FDA intends to explain the results of this review in late summer or early fall.

In August 2009, Massachusetts joined Connecticut in taking a stance on BPA. Connecticut has banned the use of BPA from infant formula and baby food cans and jars, as well as in reusable food and beverage containers sold with the state. Massachusetts has considered the same ban, but for now has only told parents of young children to avoid using baby bottles and other food and beverage containers made with the plastic-hardening chemical bisphenol A (BPA). Massachusetts is waiting the FDA’s decision on BPA.

As of the spring of this year, six major companies have agreed to stop selling hard-plastic baby bottles which contain bisphenol-A in the United States. The companies decision was in response to growing public concern. The companies are Playtex Products Inc., Gerber, Evenflo Co., Avent America Inc., Dr. Brown and Disney First Years.

From the FDA Draft Assessment:

Exposure of adults or infants to residual BPA through uses in food additives is relatively low (i.e., no more than 11 μg/person/day for any segment of the population). Traditionally, FDA’s evaluation of chemical migrants to food from the use of food contact materials at exposures of ≤ 150 μg/person/day focuses primarily on carcinogenicity and on genetic toxicity as an indicator of carcinogenicity1, unless data are available (biological or predictive) that indicate a concern for another endpoint of toxicity at this level.
It is well documented that BPA binds to estrogen receptors (ERα and ERβ), although its affinity is orders of magnitude lower than that of endogenous estrogen2,3. In addition, several in vitro studies have indicated that BPA may also interact with other receptors, including membrane bound ER and estrogen-related receptor γ (ERR γ)4. Since the late 1990s, a large volume of research has been generated suggesting a possible ‘low’ dose effect for weakly estrogenic environmental contaminants, such as BPA. The National Toxicology Program (NTP) defines ‘low’ dose for BPA as ≤ 5 mg/kg bw/day5

While BPA may bind to estrogen receptors, its metabolites don’t. The oral route is most important in this discussion. BPA is rapidly metabolized to the monoglucuronide and cleared from the body via urinary excretion. The metabolite, monoglucuronide, is biologically inactive. BPA does not accumulate in body fat or sex organs of either male or female test animals given either 10 or 100 milligrams per kilogram body weight of bisphenol A administered by oral exposure, or intraperitoneal or subcutaneous injection.

So while scientist will continue to look at BPA and its safety, I will feel safe in using plastic water bottles. I will feel safe in storing my leftovers in plastic containers. I will feel safe in reheating my leftovers in those plastic containers.
Listen to the briefing here at Better Health.

Sources
Bisphenol A in Plastics – Should We Worry? by Steven Novella (September 17, 2008)
Bisphenol A (BPA) -- FDA
FDA DRAFT Assessment of Bisphenol A for Use in Food Contact Applications (2008)
Pharmacokinetic Studies and Bisphenol A Metabolism

(Bo)Tax on Elective Surgery

Updated 3/2017--  all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

I agree with all who feel there needs to be healthcare reform (or more honestly health insurance reform), but I don’t agree with Senator Harry Reid who feels one way to pay for it is by taxing elective surgery. 

This proposed tax has been dubbed the Bo-Tax and was first mentioned back in the summer.  Then it was proposed as a 10% tax on elective and cosmetic procedures.  Now it is proposed as a 5% tax on those procedures.

As defined by the Internal Revenue Code of 1986, "Any procedure which is directed at improving the patient's appearance and does not meaningfully promote the proper function of the body or prevent or treat illness or disease."  These procedures would be the target of the proposed tax.

The price tag for the proposed bill (here in pdf ) is reported to be $849 billion over 10 years, according to the nonpartisan Congressional Budget Office.   The costs are reported be offset by reductions in the growth of Medicare and new taxes (including the bo-tax).

Mr. Reid’s bill (text available here) is expected to extend health insurance coverage to 31 million people who currently do not have any and add new benefits to Medicare.  So why should anyone who can pay for elective or cosmetic procedures care?  They are all wealthy, right?

Wrong.

Even though Americans may spend more than $10 billion each year on cosmetic surgery, most of these patients are female (86%) and most of them are middle income not the wealthy.  At least a third of them have incomes less than $30,000 per year.  Many of them have borrowed money to pay for the tummy tuck or breast augmentation or excision of excess skin (after lap band).  Many in this last group (the massive weight loss group) have to pay for the excision of the skin which hampers than hygiene or ambulation because their insurance won’t cover it (usually a rider or the way the policy is written).  Refer back to the definition of cosmetic surgery—surgery for this last group often does improve function of the body by making ambulation easier or hygiene better.

So now instead of borrowing $5000 or $10,000, the patient will need to borrow an added 5% to pay the federal tax.  This then will be subject to the interest on the loan.  It is a tremendous burden added to the wrong population.

I would agree with Malcolm Roth of the American Society of Plastic Surgeons, and a plastic surgeon at Maimonides Medical Center in Brooklyn, N.Y., who feels that such a a tax "would be a discriminatory tax against women."

I also object to the fact this tax would turn me into a tax collector.  If I don’t collect the tax from the patient, then I become liable for it.

COLLECTION.-Every person receiving a payment for procedures on which a tax is imposed under subsection (a) shall collect the amount of the tax from the individual on whom the procedure is performed and remit such tax quarterly to the Secretary at such time and in such manner as provided by the Secretary. "(3) SECONDARY LIABILITY.-Where any tax imposed by subsection (a) is not paid at the time payments for cosmetic surgery and medical procedures are made, then to the extent that such tax is not collected, such tax shall be paid by the person who performs the procedure.". (this section shall apply to procedures performed on or after January 1, 2010.)

If you would like to add you name to a petition apposing the botax, go here.

ASPRS Press Release:  Plastic Surgeons Respond To Proposed Cosmetic Surgery Tax

US Healthcare Reform Photoshop Contest

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

Dr Wes and his wife, Diane, are holding a contest: US Healthcare Reform Photoshop Contest.

Bring us your snark, your wit, your creativity about the health care reform efforts encapsulated in a single photograph. Photographs in support or against the current efforts will be equally considered, and you, dear internet devotees, will be the final judge. The winner receives an iPod Touch.

Full details on the rules can be found at Dr Wes’ blog here.  You must send in your entry no later than 11:59 PM on 30 November 2009.   Dr Wes and Diane will then chose 5 or 6 finalists.

On 2 December 2009 or so, the chosen finalists will be displayed and the polls will open for you to choose the winner. The photograph with the most votes tallied will receive an 8Meg iPod Touch. Voting on the finalists will close 11 Dec 2009 at 11:59 PM. This way,

John Stossel Speaks at Healthcare Town Hall

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

I am not as well educated in healthcare policy or politics as Dr Wes, Dr Val, KevinMD, Movin’ Meat, or Dr Sid Schwab.  I keep reading and listening, trying to understand and decide where I stand.  I seem to be more of a centrist (I think).

I was not able to attend any of the previous town hall meetings held in Little Rock on healthcare, but was able to attend the one today.  It was sponsored by the Americans for Prosperity.   The headline speaker was John Stossel.  I am happy to note it was a civil discourse though that may be due to most of them leaning the same way.

I didn’t come away any clearer than before. 

I do tend to agree with Stossel that “when insurance is paying” (and not the individual) “it changes behavior.”  We aren’t as engaged in the decision making when someone else is paying.  However, it is very difficult to get straight answers or even estimates when it comes to healthcare.  It’s easy to say what an x-ray might cost.  It is difficult to estimate all the drugs, surgeries, care someone might need who has been involved in a major accident.  WSJ Health Blog provides links to sites that can help with cost questions.

I don’t tend to agree with Americans for Prosperity when it comes to pre-existing conditions.  I know it messes with “free market” values that I and others feel insurance companies should NOT be allowed to deny coverage due to pre-existing conditions.  A couple of extreme examples were in the news recently regarding babies – one denied because of overweight, the other due to underweight.  It’s one thing to argue that I as an adult can control my weight, exercise, and not smoke, but it’s another to deny someone like Kerry insurance coverage as an adult due to being diagnosed with Type I diabetes as a 6 yr.

There are too many regulations in medicine for a true free market.  I do worry about adding more. 

There were a few good questions asked, but not so good answers.  Here’s one which many of us have been asking – What in the healthcare reform is addressing the projected shortage of doctors?   Will there be access to care even if there is insurance coverage?  No good answers given.  None.

Movin’ Meat has a good post up today, House Health Care Reform Bill released.  Here’s a portion of it.  Be sure you read the entire post.

The bullet point summary:

• As widely reported, the "Robust" public option is dead; long live the "Weak" public option!  Enough House moderates - citing fiscal conservatism - rejected the cheaper option which would have paid providers at Medicare + 5%, and the bill as released would require the public option to negotiate fee schedules with providers like any other insurance company. IMHO, this is better policy even though it costs more, but hypocritical Blue Dogs get under my skin.
• 96% of legal American residents covered.
• The bill is Deficit Neutral and actually reduces the deficit by $100 Billion over ten years.
• Total expenditures are in the region of $900 Billion.
• Slows the rate of growth of Medicare from 6.6% to 5.3% annually.
• Expands Medicaid to 150% of federal poverty level (and I didn't find the citation but I read the Feds were going to pay 75% of the costs of the expansion).
• Financed though savings in Medicare Advantage, taxes on families earning >$1 million, individuals earning more than $500,000, taxes on the insurance industry and medical device makers.
• The Insurance industry's anti-trust exemption is revoked.
• Curiously, it allows states to make "insurance compacts" which will allow insurers to market policies across state lines -- a long-time conservative goal.
• Closes Medicare Part D donut hole
• All the typical insurance regulations, Insurance Exchanges, etc, with a strong employer mandate (8% of payroll for large companies).

Something mentioned at the town hall which troubles me:  “Nevada is the only state which will not have to match Medicaid funds.”  In my humble opinion, no state should gain at the detriment of another. 

Benjamin Spillman of the  Las Vegas Review-Journal writes this

The changes would provide more health care help for Nevadans without dipping into the state's budget at least temporarily.

Under changes made by the Senate Finance Committee, Nevada would be one of four states to be reimbursed 100 percent by the federal government over five years for the cost of increasing the number of people eligible for Medicaid.

After five years, the federal government would pay 82.3 percent of the cost to provide care to the newly eligible people. Nevada would pay 17.7 percent, said sources who worked on the legislation.

"I promised the people of Nevada that I wouldn't support any health insurance reform proposal that wasn't good for our state, and I meant it," Reid said in a statement.

Dr Wes tweeted this link earlier today.  Read it.

doctorwes

Politico: Must-read supporting documents for new House #hc bill http://tinyurl.com/ygqog89 #healthcare

Shout Outs

Updated 3/2017-- photos/video and all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

Codeblog  is this week's host of Grand Rounds.  You can read this week’s “Trick or Treating” edition here.

Welcome to Grand Rounds!  This is volume 6, number 6…. and the 6th time I am hosting… during the week of Halloween.  Does anyone else find that creepy coincidentally satanic fascinating?!

For this edition, I thought we could go out Trick or Treating on Medblogger Lane.  I’m sure we will find some colorful stories along the way…

………………………….

Better Health highlights’ Evan Falchuk JD  post:  If I Could Fix One Thing About US Healthcare.

………….In response, a friend of mine challenged me:  if the system is too complicated, how should we simplify it?

I wish more policy-makers were asking this question.

For me, the answer is clear: Primary care.  Time was, your primary care doctor was able to serve as the hub of your medical activity.  He or she could spend all the time needed to figure out what was wrong and to coordinate with your specialists.  It’s not true anymore.  Patients are left on their own trying to navigate the system.  In many ways they end up acting  almost as their own primary care doctors.  Patients try to pick their specialists, find out what to do about their condition, decide on good treatment choices……………….

………………………………………

H/T to @EvidenceMatters  for the link via twitter to the Jenner Museum.  What a wonderful website filled with history of Dr Edward Jenner and the story of the smallpox vaccination!

Interested in smallpox vaccination history as mentioned by @badastronomer? Jenner Museum in on Twitter @JennerMuseum

……………………………………….

When is it important for physician’s to tell patient’s about their own illnesses (the physician’s)?  Dr. Anne Brewster has multiple sclerosis.  She writes about revealing this to a patient with the same disease in her essay:  Boundary Issues: A Doctor with MS Confides in Her Patient

I called her at home to give her this news. While I informed her ……., she heard only “Multiple Sclerosis”. “What does this mean?” she asked, but she didn’t wait for my answer. She began to cry. “I am so young. There was so much I wanted to do. I wanted to have a family.”

“I have the same disease,” I told her. I had decided to reach across the space between us and to share a bit of myself. I went on to say that I have four kids, that I still ski, run, play lacrosse and work as a doctor, that I am healthy and energetic. “There is tremendous variability in how people do,” I offered, “and some people do very well. It is the unknown that is scary.”

……………………………..

Good for fellow bloggers for taking on Suzanne Somers!  (photo credit)

• Suzanne Somers carpet bombs the media with napalm-grade stupid about cancer – Orac at Respectful Insolence
• Suzanne Somers’ Knockout: Dangerous misinformation about cancer (part 1) -- David Gorski at Science-Based Medicine
• Suzie's At it Again – Margaret Polaneczky,MD (aka TBTAM)
• Suzanne Somers, Larry King and Cancer - Enough is Enough (TBTAM)

………………………………..

I just recently signed up for Skype (haven’t used it) but have wondered about using it as Shrink Rap suggests:  Skype Therapy.   I think HIPAA may prevent us from making the most of Skype, texting, etc.  Too many privacy/legal  issues for now and that’s a shameful waste of good technology.

So what do you think about the idea of videochatting with your shrink on the computer? Patrick Barta is a psychiatrist in Maryland who has started having some of his sessions (5 percent or so) on Skype. He's blogging about his experiences and talking about the good and the bad aspects. Do visit his blog: Adventures in Telepsychiatry and let him know what you think about Skype-Therapy!

……………………………..

If you live in or near Washington DC, you may want to Bring your kids! Halloween at the Medical Museum, Sat. 10/31, 10am-1pm.  It’s a free event, but photo ID’s are required.

The National Museum of Health and Medicine and Family Magazine will host family-friendly Halloween activities for ages 5 and up. Children will be able to participate in a costume contest (with prizes!) and make skeleton crafts (a dancing macaroni skeleton, a medieval plague mask, and a skeleton wall hanging) as well as join in a Halloween-themed family yoga demonstration by Shakti Yoga.

……………………………………..

H/T to Dr Isis for this video on Polaroid.  I am a Polaroid fan and was saddened when they quit making the film.

Also, check out this post at Cocktail Party Physics:  images from supernovae to supermodels by Diandra Leslie-Pelecky

A brief review: Light can be modeled as photons, which are characterized by a wavelength λ and a frequency f. …………..…

The camera obscura, a system of lenses used to project images, was known in the 1000's CE, but it was an aid for drawing – there was no way to save the images. Daguerre developed a process in 1839 that employed copper plates and mercury vapor;…………..

Before film, photographs were taken on glass plates, which produce much more durable images, but are very difficult to carry in your wallet or purse………..

Eastman Kodak is credited with the first flexible (although not transparent) film in 1885…………..

…………..…………………

There has not been an announced guest or topic for this Thursday night  Dr Anonymous’ show.   The show starts at 10 pm EST.   Dr. A has a couple of nice videos up of his appearance on local TV news giving his take on H1N1.

Abortion Coverage and Health Insurance Reform

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

I’m going to wade right in here.  I am not a fan of abortions, but neither am I of amputations.  Both are sometimes necessary.  To me, too often abortion opponents forget the mother.  She is a life present before us.  Her care should not be forgotten.

I have been listening and reading the discussions over how the abortion coverage may sink health care reform.  I think it would be a shame if this one issue does sink reform.

If my understanding of the Hyde Amendment (and it’s amendments over the years) is correct the Federal Government covers the cost of abortions in cases of rape or incest or when the life of the mother is at risk.  It does not cover the cost when the health of the mother is at risk:

With these bans, the federal government turns its back on women who need abortions for their health.  Women with cancer, diabetes, or heart conditions, or whose pregnancies otherwise threaten their health, are denied coverage for abortions.  Only if a woman would otherwise die, or if her pregnancy results from rape or incest, is an abortion covered.  The bans thus put many women's health in jeopardy. 

I agree with opponents who do not wish to cover abortions for simple any reason (ie the timing for a pregnancy is not good, etc).  Abortion should never be used for birth control.  That should be done using birth control pills, condoms, abstinence, etc.

Currently, the only abortions available under Medicaid are the ones mentioned above.  I think it a shame that distinctions can not be made to provide coverage for a woman who’s HEALTH would be negatively affected by her pregnancy.  All insurance policies should do so in my opinion. 

Opponents of abortion want language that would prohibit any private insurance company that accepts federal funds from offering to policyholders abortions other than those already eligible under Medicaid.

Sources

How Abortion Could Imperil Health-Care Reform by Michael Scherer; Monday, Aug. 24, 2009; Times.com

What is the Hyde Amendment? (July 21, 2004); ACLU

Shout Outs

Updated 3/2017--  all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

DrRich, The Covert Rationing Blog, is this week's host of Grand Rounds. You can read it here (photo credit).  It’s the “cost containment in healthcare” edition.

Critics of the Obama health (insurance) reform plan have been formally served notice that they are under observation, ……….. So, as he embarks on this week’s edition of Grand Rounds, DrRich would like to welcome any visitors who are here on behalf of such important surveillance efforts, and hasten to tell you that DrRich is on your side. Indeed, this version of Grand Rounds is dedicated to exploring the many ways in which the proposed health (insurance) reforms will succeed in all its goals, and most especially in achieving cost containment…….

The latest edition of Change of Shift (Vol 4, No 3) is hosted by Man-Nurse Diaries who used a video game theme!   What fun!You can find the schedule and the COS archives at Emergiblog.  (photo credit)

It's August and school is looming around the corner, so kids everywhere are scrambling to waste time and do as much nothing as possible. What better way to dampen your brain activity than with video games? So here it is, your video game themed Change of Shift Vol 4 No 3: The Revenge!

H/T to  @EvidenceMatters for the link to this article:  A new superbug found in Britain is major concern: Government scientists by Rebecca Smith, Medical Editor.  The article talks about an un-intended consequence of medical tourism – the global spread of antibiotic resistant bacteria.

A new superbug that is resistant to all antibiotics has been brought into Britain by patients having surgery abroad, Government scientists said.

Doctors are urged to be vigilent for a new bug that has arriving in Britain with patients who have travelled to India and Pakistan for cosmetic surgery or organ transplants and is now circulating here.

Great show on NPR yesterday on “End Of Live Decisions And The Health Care Bill.”  You can listen to it here.

A portion of one health care bill in congress states that the cost of consultations between patients and doctors over "end-of-life" issues would be covered. The proposal has sparked fears that the bill promotes euthanasia.

Dr Rob has made his local paper, “Doctor 's humor is a hit on iTunes!"  Check out his podcast,  “House Call Doctor.” You can find the list of his podcasts here.  Enjoy!

Did you know that approximately 200 people die each year in the U.S. after being struck by lightning?  H/T to @laikas  for the link to this article: ER Doc explains how to avoid or respond to lightning strike

Prevention begins by seeking cover at the start of a storm. “Lightning seems to be concentrated at the forefront of a storm,” according to Zinzuwadia, “so there tends to be a greater risk of being hit by lightning at the beginning of a storm.”

WhiteCoat raises an interesting question in his post Charity Care Tax Exemptions. 

If exemption from federal income and/or state property taxes for non-profit hospitals is based upon providing “charity care” to their surrounding communities, how will hospitals qualify for income tax and property tax exemptions if health care coverage becomes “universal” and there is no longer a need for “charity care”? ………….

Crazy for Quilts Contest Gallery is up!  The quilt I did is #4.  

All contest quilts will be auctioned via eBay. All proceeds will support AAQ.
All auctions begin and end at 9:00 PM Eastern

On eBay search keyword "Alliance for American Quilts." Never used eBay? No problem! View a great tutorial on the eBay website.

                            

This week Dr Anonymous guest will be  The Hollums Adoption.  Come joint us.  The show starts at 9 pm EST.

Upcoming Dr. A Shows 

8/20: Dr. Rob & House Call Doctor podcast
8/27: Dr. A Show 2nd Anniversary & BlogWorldExpo
9/3 : Dr. A Show (9:30pmET)

Shout Outs

Updated 3/2017-- all links removed as many no longer active and it was easier than checking each one.

 

Captain Atopic is this week's host of Grand Rounds. You can read it here.  He calls it the “Grand Rounds 5:45 - Le Tour de France Edition!”

Where Grand Rounds is the Grand Tour of Medical Blogging, the Grand tour of Cycling is undoubtedly Le Tour de France, which concluded on Sunday in Paris. After three weeks of cycling, nearly 3,500km at an average speed above 40km/h, the peleton will ride up Paris' Champs Elysee's to the finish. Throughout the race, certain riders and teams will have reached their goals, revealed their future potential and achieved great triumphs. This week's Grand Rounds features some sterling examples of writing, all capable of Stage Victories, and some, much more. Welcome to the Tour...

The latest edition of Change of Shift (Vol 4, No 2) is hosted by Ross at Nurse in Australia! You can find the schedule and the COS archives at Emergiblog. 

The beautiful sunshine coast in Queensland, Australia is where I call home, so I’ve themed this edition the Sunshine Coast Edition. So welcome, thanks again for visiting my corner of the world!

Close your eyes for a moment and take a deep breath of that coastal air, and get ready to invigorate yourselves with some great posts for this edition of change of shift

You can read Movin' Meat’s  interview of Dr. Nick Jouriles, President of ACEP, over at The Central Line.

• Interview with ACEP President Jouriles (Pt 1)
• Interview with ACEP President Dr Jouriles (Pt 2)

Several bloggers come to Dr Regina Benjamin’s defense.  I agree with them.  It is much more important to look at her impressive qualifications.

• Dr Rob – Stone Throwing
• KevinMD  -- We should not care about Regina Benjamin’s weight
• Emily Walke -- Critcism of Regina Benjamin's Weight Nothing But Sexism

I’d like to direct you to Buckeye Surgeon’s post “The Meaning of Life.”  Be sure you read the comments.

Our purpose, our meaning is driven by the concept of "life"--- making it better, richer, less intolerable. If we admit this, then we are obligated to define what we mean by "life", because that is the fulcrum upon which we operate. What is life? What is it exactly that we are trying to save, to alleviate, to improve?

H/T to @MedicalQuack who tweeted the following. 

Nice Mention of @GruntDoc in Houston Chronicle http://tinyurl.com/mvoymy

Interesting NPR interview of Michael Ruhlman on cooking and his new book, Ratio.

His new book, Ratio, is about learning basic ratios. For example: 3:2:1 — three parts flour, two parts fat (like butter) and one part water — makes a basic pie crust. Add a dash of salt, and it's a savory base for a quiche. Add some sugar, and you've got a shell for cherries, chocolate cream or fresh peaches.

Dr Rob is now doing podcast as the “House Call Doctor”  giving “quick and dirty tips” to help you take charge of your health.   You can find the list of his podcasts here.  Enjoy!     

Shout Outs

Updated 3/2017-- all links removed as many no longer active and it is easier than checking each one.

Doc Gurley is this week's host of Grand Rounds. You can read it here.

Welcome to Grand Rounds Vol. 5 No. 44.  A Grand Rounds full of plot twists, drama, melodrama and yes, death (this is a medical blog roundup after all).

Just for fun, I am going to group the submissions under acts whose real names you’ll have to guess (pick from: The Hunt Is Afoot, The Law Gets Involved, Death Arrives, Clues Are Discovered, The Plot Thickens, and All Is Revealed).

Suggestions/nominations for the acts’ titles can go in the comments and the people who get the closest to the right answers can wear their imaginary Sherlock Holmes deerstalkers with pride. The rest of us can instead wear our Doctor Watson designation (also with pride).

Here are some posts on the "Patients First” meeting Dr Val put together at the National Press Club this past Friday.  I hope I didn’t miss any.

• Congressman Paul Ryan’s Speech To Medical Bloggers At The National Press Club (Better Health)
• KevinMD Addresses Crowd At National Press Club About Primary Care Crisis (by KevinMD)
• My Comments At the National Press Club, Washington DC (by Dr Wes)  
• Washington Wrap-Up  (by Dr Wes)
• Someone Who Actually Knows How to Put Patients First (by DrRich)
• Washing Tons for Boggers (by Dr Rob)
• Patients First: Twitter Transcript (by Robin)
• Better Health in D.C.: the Panel, the Politics and the Ce-Ment Pond (by Kim)
• Reflections on health-care reform (by Dr Edwin Leap)

H/T to scanman who tweeted this:  “RT @precordialthump Trick of the Trade: IO line for failed IV access http://bit.ly/4qfUl Awesome post & video. Hats off to the volunteers!!!”  This link is to this article, Sneak Peak "Trick of the Trade": IO line for failed IV access, which has a very nice video showing IO (intraosseous access)

In the video below, 3 brave (a.k.a. crazy) volunteers get an IO drilled into their proximal tibia. Apparently, the insertion is only mildly painful and the infusion of fluids is actually the more painful part of the procedure. You might consider priming the IV tubing with 1% lidocaine to minimize pain in awake patients.

H/T to MedGadget for this:  For Tender Feet, Shoes Simulate Barefoot Running Safely.   I’d love to have a pair of these FiveFingers from Vibram.   Maybe I’ll ask for a pair for my upcoming birthday. 

Check out this cake from a former ophthalmologist turned pastry chef  -- Reaching New Heights.  You should check some of her others at her blog Charmaine’s Pastry Blog.

Dr Rob is now doing podcast as the “House Call Doctor”  giving “quick and dirty tips” to help you take charge of your health.   You can find the list of his podcasts here.  Enjoy!

       

This week Dr Anonymous will be taking July off. You might want to use this time to listen to some of the shows in his Archives.

Don’t Forget HIPAA Privacy Rules

 Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

As we move towards EMR’s, the ability to know who has looked at the medical record may get more and more in trouble. While we are all curious about our friends, neighbors, and celebrities (local or global), it is important to respect each others privacy. This local Arkansas story (3/2017-- link no longer active) shows the importance of this respect.

Hospital emergency room coordinator Candida Griffin, patient account representative Sarah Elizabeth Miller and Dr. Jay Holland, a family doctor who worked part time at the hospital, each face up to a year in prison and $50,000 fine if convicted of the misdemeanor charge.

I would hope that all three of the people listed above would have “known better.” When this story broke earlier this week, the staff in the OR and I had a nice discussion on who gets HIPAA training and how much each get.

I think as part of their punishment, they and perhaps the facility (St Vincent Health System) should have to do refresher courses on HIPAA privacy rules.

The hospital said in November that it fired up to six people for looking at Pressly's records after a routine patient-privacy audit showed that as many as eight people gained access to them.

It was not immediately clear whether others fired from the hospital would face charges. U.S. Attorney Jane Duke declined to comment about the charges Tuesday.

With paper charts, there isn’t a trail proving you or I accessed the chart without need to do so. With EMR’s there is but this trail is not fool-proof. If I haven’t logged off and you look over my shoulder, then ….

If you haven’t logged off and I ask for a quick look at patient 007’s lab work and you do me a “favor” of checking quickly. See, not perfect. No harm was intended and patient 007’s info may never be “leaked” to the press, but someone who perhaps had no need to access it did so.

My circulating nurse in the OR during the discussion revealed that she had heard a lot of talk about the Ann Pressley case which she admits she should not have. She didn’t access the chart. She was working in another hospital’s ER. It was the police and EMT’s doing the talking. There is no trail to “prove” those violations of patient privacy trust.

We need to be more careful in discussing patients and cases. We still need to be able to discuss difficult or unusual cases, but this can be done without breaking a patient’s trust or privacy. Names and identifiers don’t have to be used when stumped by a rash or odd presentation.

Dr Holland had no malicious intent, just curiosity. Be careful.

Arkansas Democrat Gazette article Doctor, ex-hospital employees charged over Pressly records (subscription required) written by Linda Satter

3 charged with getting TV anchor's medical records by Jon Gambrell (no subscription required)

Healthcare Discussion

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

I was in the “audience” of the phone conference today organized by Dr. Bob Goldberg, President, Center for Medicine in the Public Interest Advance (CMPIA).  In addition to him, Dr. Val Jones (Founder and CEO Better Health Network) and Dr Gary Puckrein (President, National Minority Quality Forum) were on the panel of speakers.  The focus was to be on the risks of government-run healthcare.

It seemed to me that many good points were made, but the main one was that the focus of the healthcare discussion needs to be refocused on the patient and the care given rather than simply on the high cost of care/insurance and any cost savings to be gained short-term.  As Dr Wes pointed out in his recent post (The $400 Billion Dollar Question), patients aren’t at the “table” of many of the discussions of healthcare reform that are taking place.

Should America understand precisely what is being cut when we see $400 billion suddenly disappear from the health care reform budget?

I would argue we must know.

After all, it's we the patients who are not at the policy table, and you can bet that it's the patients who will ultimately be paying the tab, be it directly through health care premiums, or indirectly by taxation or deficit spending.

There were two links given by the CMPIA as sources for factual information on the healthcare discussion: publicplanfacts.org and biggovhealth.org.

I went to both, but in an effort to keep this post at a reasonable length will highlight only a few from the first link.  First this one --

• Public plan proponents are advocating a $1.25 per hour per employee tax to pay for the public plan. The Commonwealth Fund, “The Path to a High Performance U.S. Health System”, p. 29, February 2009.

I won’t comment on that one, but will this next one:

• Under the public plan, doctors and hospitals would see their reimbursements for providing medical care cut by as much as 30%. The Commonwealth Fund , “The Path to a High Performance U.S. Health System”, p.33, February 2009.

This decrease in reimbursement troubles me as I have watched the struggles many hospitals have experienced over the past several years with the current reimbursements.  I think this trend will only get worse.  Check out Barbara Duck’s series at Medical Quack on desperate hospitals.  Here’s an excerpt from the May 24, 2009 post:

In Chicago, Illinois

The Loyola University Health System in west suburban Maywood on Tuesday said it will eliminate more than 440 jobs, or about 8 percent of its workforce, amid the recession and an economic downturn causing an influx of patients who cannot pay their bills.

The cost of patients who cannot pay has increased 73 percent, to $31.3 million from $18.1 million, from a year earlier for the nine months ended March 31.

"We have been hit by a number of things," Dr. Paul Whelton, chief executive of Loyola University Health System, said in an interview. "We are having more trouble with charity care, and the money we are getting [from patients] is more slow to come in. But we have a mission to provide care in our communities and we are going to stick to it."

In all this talk on healthcare reform, it seems to me and others at the phone conference that the quality of patient care rather than simply cost containment needs to be put back at the front of the discussion.   Healthcare should provide care without being hampered by more and more rules and regulations in an effort to contain costs.  We don’t need more rules like the Medicare’s 75% rule.

Saving money by providing an inferior “product” isn’t what any of us want.  Is it?

Shout Outs

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

Barbara Olsen, Florence Dot Com,  is this week's host of Grand Rounds. You can read it here (photo credit).  Great edition!

Welcome to Grand Rounds! It's officially summertime, and Flo & Bo are taking you out to the ballgame! At Florence dot com, Bo, a seasoned nurse with an engineer's mind, channels Florence Nightingale, a systems thinker whose interest in public health and service gave rise to modern nursing. (Flo favors cricket, but this is Bo's gig.)

From Better Health comes “A Medical Transgender Primer”  written by DrJonLaPook.   Very nice article.

Step one in reaching the public is defining terms. The terminology surrounding gender issues can be confusing. “Transgender man,”, “transmale,” and “affirmed male” have all been used to refer to a biological female who transitions to a male. I found a glossary of transgender terminology offered by the NCTE to be extremely helpful……….

See DermDoc for the Proper Way to Pop a Pimple

As a dermatologist, I am obligated to tell you: “Do not attempt to pop your pimples.” But I know you are going to do it anyway, so here’s how to do it properly:

1. Pick only pimples that are ready to be popped………..

If you deal with head injury patients, you’ll find this list of resources by VP Medical useful

We here at VP Medical Consulting are currently working on a life care plan for a young lady with a traumatic brain injury. In developing the plan we consult many resources and thought I would share them here. If you have a resource I have missed, please let me know and I will be sure to add it…….

VP Medical has also put together a list of resources for care givers.

From @drval (on twitter):  For those interested in what was discussed at the HC reform meeting at BIO today (June 17): check out the blog: http://tinyurl.com/nqowbm #hcrmtg

TBTAM brings to our attention “Folic Acid Supplementation – Too Much of a Good Thing?”     I must admit, folic acid is one of those vitamins (water soluble) that I never thought of as ever having a problem of too much.  I associate the water soluble ones which our bodies don’t store as having the problem of deficiency.  I stand corrected.  I hope you will read her entire post.

Folic acid supplementation of breads and cereals has led to a decline in the incidence of neural tube defects like spina bifida and anencephaly in the United States and other nations that have implemented similar measures.
But too much folic acid may lead to an increased risk for colon cancer……………….

If you are already taking a multivitamin with folate in it, you might want to avoid high folate cereals and breads. And vice-versa.

This week Dr Anonymous will be  doing a “summer vacation” show.  I hope you will join us. The show begins at 9 pm EST.

Bundling – What will it mean?

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

In a lot of the healthcare policy talk I feel like an outlier.  Most of the healthcare policy talk is directed more towards the primary care specialties.  As a “potential” patient and as a medical specialist, I watch and read with interest.   Often I am unsure as to the definitions being thrown around in the discussion.  Take bundling for example.  Currently, many of the surgical payments are already “bundled” in that the surgery and the first 90 days postop are linked or “bundled” together. 

When I do a breast reduction on a patient, the fee I receive covers the surgery itself and any visits during the first 90 days postoperative.   I see each of these patients the morning of surgery to do the preop marking and answer any new questions.  I then do the surgery and check on them in recovery.  Most breast reduction surgery is outpatient these days so there isn’t hospital rounds to make.   I call each of my patients the evening of surgery.  I see each of them at 5-6 days postop.  I try to get them to return at one month postop and then again at 3 months.  So the average patient will be seen 2-3 times in that post-operative time frame.  All this patient interaction, including all the office work for the insurance billing, is “bundled” into one fee.  If the patient needs or simply wants to be seen more often, it would still be included in the one fee.

So what are the policy wonks discussing in this new bundling talk?  I apparently am not the only one wondering as evidenced by this:

James Bentley, senior vice president of strategic policy planning at the AHA, says that to debate the merits and drawbacks of bundling, we need a clear definition of what bundling really is.

"Most people who talk about bundling talk about combining the physician payment and the hospital payment," but currently, the focus is on combining the acute payment with the postacute payment, he says. Bentley says fundamental questions like this spring up due to the lack of detail in the president's budget proposal, which Congress has already approved in principle. Details are expected to be worked out in conference between the two houses over the summer.

"Our membership is asking a lot of questions that we can't answer," Bentley says, including whether a new system would include all diagnosis-related groups, or just some, or whether the new formula will incorporate the historically wide disparity in Medicare payments per capita by region, for example.

One big potential problem with bundling payments is the assumption that much of the anticipated savings come from the idea that chronic care patients use lots of services and are high cost; but such chronic care services are the hardest to describe for bundling.
"If there are a lot of comorbid conditions, what's the primary condition, where does the bundle start and where does it end?" Bentley asks.

Are the new bundling talks aimed at the family practice doctors and internists?  Surgeons have been living with “bundling” for a while now.
How the policy wonks decide to “bundle” medical care for diabetics will be interesting.  What will that mean to the family practice clinics?

This next part is still on the health policy issue, but has nothing to do with bundling.  It is just interesting to me.
I am like Dr Bruce Campbell  who wrote in his post --Health Care, House Building and Ethics:

I am a novice in policy; every time I read a new editorial or column that proposes how to best pay for health care yet keep the costs under control, I am swayed. It seems that many commentators say something that seems to make sense to me. 

Read Dr Campbell’s entire post on his viewpoint of the recent article in the The New Yorker by surgeon-writer Atul Gawande, MD.

Finally, and potentially most important, Dr. Gawande shows us that HOW we pay for medical care will ultimately be less important than having a "culture of medicine" that is, above all, consistently ethical. If every test or procedure directly benefits the person who orders it, there is too much temptation. 

Then read this one (Gawande) by Dr Jeffrey Parks (Buckeye Surgeon) on his perspective of the same article by Dr Gawande:

I obviously think Dr Gawande has gone off the tracks just a bit with his analysis. In the beginning of the article, he chats with a family practice physician who says "...young doctors don't think anymore". But that line of thought is truncated. Instead, we wander off down the pathway of physician greed and intransigence and we never return. I'd like to revisit the idea of physician thinking…..
But I truly believe that this sort of unprincipled practice represents the exception rather than the rule. (Remember, McAllen itself is an outlier; most hospital systems hover around the mean in terms of health care expenditures.) Also, these proceduralists don't materialize out of thin air. Someone has to consult them. And this gets me to my point……….
But places like McAllen are rare. We've tripled the amount of health care spending in America since 1985 even without the McAllen model being common.