New Orleans Saints

Who knows in what fortunes and misfortunes God chooses to intervene but yesterday he/she must have felt compelled to support the Saints in their efforts to bring forth a miracle. The city of New Orleans, a city of great tenacity in the face of great adversity, will be uplifted by this miracle and we should all celebrate, even those from Indianapolis, the efforts of strong and determined people to acheive their loftiest goals.

Helping in Haiti

My partner and I volunteered immediately after the earthquake to offer our expertise in Haiti. We tried to do so through multiple organizations as well as the White House. We were placed on a list but I am certain that there were many physicians throughout the world who also volunteered to provide assistance. The problems, of course, were many. Getting to Haiti was at first a major challenge and planes with doctors could not even land. Furthermore, there were no facilities initially for providing medical care for the seriously injured. The first physicians to arrive were those who already had disaster management experience. Sadly, any patients requiring neurosurgery due to head injuries would have had to receive attention within hours. Certainly, individuals with spine injuries may still require stabilization procedures and many are being transfered to the USS Comfort or to Miami. We know, however, over the coming months and probably for next couple of years there will be individuals in Haiti who suffer injuries and illnesses that require neurosurgical intervention. I hope that all who have offered their expertise in the acute phase of this disaster will be willing to help as future needs arise.

Poem of the Day

Two Cats and Me

There are two Cats in my room and Me
One is a small, gray and white ceramic cat
Fiddling atop a round, yellow box
For tiny mementos
The other is a great big gray one
Just now lying in the doggie bed licking his paw
Sometimes he lies on top of me when I lie in bed
Purring as I stroke his chin and chest and
That spot just behind his ear
The three of us
Sharing this room


Ezriel Kornel

1/30/10

Insurance companies once again trying to increase profits on the backs of consumers

Well, the health insurance companies in New York have a new trick up their sleeves. Until very recently, insurance companies have been paying doctors who are "out-of-network" fees that are based on usual and customary rates (UCR). They usually pay 70 to 80% of these UCR and the patient is responsible for the difference between what the doctor charges and what the insurance company pays. The insurance companies used to determine UCR based on numbers established by a company they themselves set up. Attorney General Andrew Cuomo felt this was not appropriate or fair to the consumers because there was a conflict of interest and because the UCRs they set were lower than the actual UCRs as determined by analyzing true physician's fees. Under this old scheme patients had to pay more out of pocket. With the new methodology, insurance companies will have to pay more and consumers less. So the insurance companies decided to pull a switcheroo and stop basing reimbursements on UCR . They have been sending letters out to their subscribers telling them that they will now make payments based on medicare rates, the maximum pay-out being 140% of medicare fees. Medicare fees are woefully inadequate especially for reimbursement of surgical procedures. There is no way that physicians, especially surgeons can lower their fees to a fee anywhere close to 140% of medicare. Therefore, the consumer will now be out-of-pocket for far, far greater an amount then they had been with a UCR based fee.
If the insurance companies think that by pulling this switcheroo they will be able to force more doctors "in network" they are mistaken. Groups such as ours, will, in fact have to close the office doors if reimbursements are based on Medicare rates. We have far too great an over-head to be able to cover this over-head and still make an adequate living.
So, some physicians will move or retire and those left will have to try to maintain fees adequate to provide the revenue they require, leaving the patient to pay more out-of-pocket. The only way this miserable scenario can be avoided is for consumers to inform their insurance companies and their elected officials that this is unacceptable.
Both the insurance companies and the government want to change the way health-care is delivered, each for their own purposes and in the end, it seems, to the detriment of most patients.

Ignorance is bliss---not

Oh, how loudly people are screaming (the pundit Palin once again expressing opinions without comprehension of the facts) that now the government wants to decide who lives and who dies. First, its "the government wants to provide health-care to one and all" and suddenly its "the government wants to withhold health-care from the old and sick." Well, it reminds me of the old joke about the Ignorantans vs the Jesuits but its a long joke and I won't repeat it now. Suffice it to say that there are complex and appropriate arguments on both sides of the health-care debate but ranting against the one unequivocally appropriate and important provision in the health-care bill brought forth by the House is an accolade to ignorance. There are governments that believe they have the right to determine how money is spent when they are giving away "free stuff." Both Great Britain and the state of Oregon, for example, have made decisions not to treat certain illnesses that have an extremely low likelyhood of recovery. But this is not what our legislature has in mind, it wants to educate people, a seemingly radical idea. Who wants to remain ignorant about what treatment options we have when we get really sick and are likely to pass on to the next world? The answer should be "no one." Someone may want to be on a ventilator with IV's and catheters and multiple medications if it allows them a few more hours of life even if they are comatose. Another person may choose to have no treatment and even withhold nurishment if they are in a condition that will not allow them to live a life which allows them a measure of independence along with normal cognition and communication. Both have the right to their exit strategy but unless they know how to communicate their wishes to the health-care system, they will all be kept alive to the very end and sometimes even beyound. The bottom line is when an individual understands their choices, expresses those choices clearly to someone else and then identifies that person to their health-care provider than there is a high likelyhood that their wishes will be honored. This empowers the individual and is that not the core of conservative ideology? We have the added benefit of not having to waste large sums of money on unwanted treatments. Is this a case of everyone wins? Yup, it sure is.

More Riffs on Health-Care

Everyone is talking about the need for change in the health-care system but the system is constantly changing. It is a huge enterprise responsive to many factors ranging from economics to new scientific discoveries and developments to new illnesses making sudden appearances to changes in personal views on life and death. Some changes have been taking place with relatively little notice from the public. One big shift is the movement by many hospitals to employ hospitalists to care for hospitalized patients. Hospitalists are physicians trained in internal medicine with particular focus on the needs of hospitalized patients. These, of course, tend to be the sickest individuals and require the most time and attention. What this means for you, the "customer" is that your primary care provider will care for you when you are well , have a relatively minor illness or when you have illnesses that are chronic and generally not severe. When you get really sick and have to be hospitalized your primary care provider, most often your "family doctor," will not be the one caring for you. Someone who probably has never met you before and who has a number of sick patients to care for will be in charge of your medical management. On the positive side, you will be taken care of by someone who keeps up-to-date on the management of serious illnesses and who is being paid to take the time to care for you. They are not in a rush to get back to the office to get through a busy office schedule. They are responsible to the hospital and also responsible for providing information about your condition to your primary care provider. Therefore, their management is closely scrutinized and if they do not meet the high standards generally set, they have to find another job. On the down side, the medical professional who knows you best and who you feel most comfortable with is not the one who will be taking care of you when you are at your most vulnerable and want to know that the person caring for you knows you well and cares deeply about your well-being. The truth is that most primary care physicians would like to take care of you when you are really sick in the hospital but they just can not afford to do so. The system has dictated that in order to be able to stay in business and make a living (and we are not talking about a fortune) primary care providers need to see many patients in a day. There is just not enough compensation for the time physicians spend in the hospital caring of one,two or three hospitalized patients. Taking care of two hospitalized patients can easily take a couple of hours and in that time the doctor could see six or more patients in the office. The hospital is able to bill for the services of the hospitalists they employ and pay these physicians a reasonable salary. Of course, the large teaching hospitals utilize residents as hospitalists and they have been a source of cheap labor for many years but as residency work hours are restricted, hospitals have to employ more expensive health-care providers including physician extenders such as physician's assistants and nurse practitioners. As sicker individuals are being cared for by hospital-employed personnel, primary care physicians spend more of their time providing well care and managing chronic illnesses. Much of this type of medical management can be handled by physician extenders who command lower salaries than physicians. By expanding on this army of health-care providers and leaving physicians to oversee these health-care providers and directly manage the care of more complex problems that specialists generally manage we can hold down the number of primary care physicians needed and keep health-care costs from rising further. If we want the highest quality of care for the money, we will want more specialists and more physician extenders, not more primary care doctors. This is how I see it , from my perch.

The Future of Medicine as Perceived by a Working Neurosurgeon

Health-care reform has taken center stage in the national political debate in America. In truth, it has been center stage for years. I recall when I completed my residency in neurosurgery in Washington, D.C. in 1984 the talk was all about the escalating and out-of-control health-care costs. Government had to control medicare costs, limiting expenditures with the assistance and complicity of physicians. The government gained support of physicians by a monetery redistribution, taking money form "proceduralists" who were the minority and giving more to "cognitive" specialists, physicians in the majority. In other words, they took money from surgeons and gave more to internists, general practioners and the like. In the end, of course, everyone got less. The "cognitive" specialists had to see many more patients to make ends meet and the "proceduralists" could never make enough with the reimbursements the government provides. In the end, private insurance had to subsidize the medicare system to keep "proceduralists" in the medicare program. Surgeons, unless they are employed by a hospital, make their living from private insurance reimbursement. If the government begins to provide a medicare-type insurance policy to the currently uninsured at reimbursement rates similar to medicare rates, "proceduralists" will drop like flies. They will simply be unable to remain in business. The truth is that we already have a shortage of "proceduralists" and we will have a major crisis in access to care if the number of "proceduralists" drops further. As the population grows and ages, more people require craniotomies for subdural evacuations, hip and knee replacements, laminectomies, thoracotomies, abdominal operations, prostectomies, organ transplants, mastectomies, colonoscopies, arterial stenting procedures, etc, etc.. Though much is being spoken of primary care shortages, the solution lies not in more primary care physicians but in more physicians extenders. It does not make fiscal sense to pay highly trained physicians to provide well-patient care. In truth, one physician can oversee several nurse practioners and physician assistants. These physician extenders can provide care for many routine medical problems ranging from colds to diabetes management. More complex disorders which require more expertise and more time can then be managed by internists and medical specialists such as cardiologists, neurologists, endocrinologists, oncologists and the list keeps expanding because medicine keeps becoming more complex as more is learned about each medical disorder and treatments become more refined and diverse. It has become nearly impossible for one physician to know all the crucial management issues for every medical disorder. Furthermore, individuals are becoming more involved in their health-care and as information becomes more abundant on the internet, the majority of Americans will be playing a significant role in their health-care. In fact, patients may be required to become more active in "doctoring" themselves. It will improve the quality of health-care and save a substantial amount of money. Patients will be required to fill out forms on-line that ask questions about their medical history and symptoms of illness. Based on these answers a differential diagnosis will be generated. Patients can then review these diagnoses to understand more about their illness and also review possible treatments. When they then go to their health-care provider a differential diagnosis will already have been generated saving the health professional a considerable amount of time. It will also reduce errors of diagnosis and treatment because the health-care provider can choose a treatment course based on the recommendations the program generates. If the treatment plan does not match an option, the health professional will need to provide a justification/explanation for why they have choosen this particular approach over another. The patient can review the treatment plan to whatever depth they wish in order to feel comfortable with the plan that has been recommended. In the end, the quality will have been maximized. This type of program could be created now (and probably is being created by some clever health-care organization) and patients who are willing to complete it before seeing their health-care provider should be offered a discount since they are saving their health-care professional and the health-care system time and, as they say, time is money. More ruminations on health-care to come.