The sham surgeries aren't done by fraudulent physicians. There have been studies done for knee pain, where patients are randomly selected for traditional arthroscopy versus a sham surgery, where arthroscopy style skin incisions are created, and then sewn shut. When the patient awakens, they don't know if they had actual surgery or not. This is the study's design, and all patients in the study agree to the randomization process. This is quite different that a surgeon "pretending" to do surgery to bill patient. That, of course, would be fraudulent, unethical, and illegal.
http://content.nejm.org/cgi/content/full/347/2/81
(Can't make a link!! My coding-fu is weak this morning)
I'm a family physician, graduated med school in 2001, been in practice since 2004. First, I loved O-Chem, so I'm probably odd. General chem was okay, but it was a much bigger weed-out class. It felt like more rote memorization.
O-chem was interesting and fun, because the reactions made intuitive sense. Once you understood why the electrons flowed the way they did, you didn't have to memorize the Clemenson reaction or the Grignard reaction, you just "got" why they worked.
If you don't understand O-chem, you really will never get biochemistry. Although med students complain about first-year biochem, it's essential. When I decide to prescribe Crestor to someone for their hyperlipidemia, I really ought to know how Crestor works. Specifically, what does Hmg-CoA reductase do, where does it work in the cholesterol synthesis cycle, and why would it be good to take Crestor. Instead, you have doctors or PA/NPs who simply prescribe Crestor because the last drug rep was cute, rather than understanding the underlying pathophysiology.
To the posters who've noted that demand is outstripping supplies of doctors: I agree that we need to lower the barriers to producing more doctors. But, dumbing down pre-med isn't the answer. Moderating the cost of medical education could go a long way. There's a tremendous shortage of Family Physicians and general Internists. But if you're a 4th year med student looking at $250K of student loan debt, you've got to consider your ability to repay it. From an purely economic standpoint, why would I do a 3 year primary care residency and make $170K/year, when I could do a 4 year anesthesia residency and make $400K/year.
Since I am a Family Doc, there must be more reasons than just economics (or perhaps I couldn't get into an anesthesia residency;-). I dunno. I always planned on Family Medicine.
Back to the original question. Next time you get a drug sample, unfold the little packet of paper that folds out to the size of a large map. That's the product insert. Look at the very top. There's a picture of the chemical structure, and the actual name of the molecule.
"Heady forecasts like these energize chip proponents, who insist that RFID will result in enormous savings for businesses. Each year, retailers lose $57 billion from administrative failures, supplier fraud and employee theft, according to a recent survey of 820 retailers by Checkpoint Systems, an RFID manufacturer that specializes in store security devices."
So, a company who makes RFID chips does a study showing the businesses lose $57 Billion every year? That sounds as reliable as some of the Business Software Alliance statements on losses from piracy. To call this self-serving would be an understatement.
Funny thing, the VA system is actually some of the best care in America. Too bad you're too busy paying for your yacht to realize that...
Nice cheapshot there, AC. My yacht is a 1999 Dodge Intrepid with 105,000 miles.
I've worked in the VA system in med school and residency. To be fair, there's a lot to like. You can go to any VA in the country and your doc can pull up your entire chart. That's a huge deal.
However, one can't compare the VA to Medicare in an apples-to-apples comparison. The VA CAN bargain with drug companies. They get tremendous price concessions from the companies. Medicare is prohibited by law to do such things. As long as you're prescribing the drugs on the VA preferred list, costs are contained pretty well, and the patients have relatively cheap copays.
If you want to do anything outside the approved list, heaven help you and your patient. I've spent hours trying to get Prevacid approved for a patient who had failed Aciphex therapy (preferred). They never approved it. The VA is not set up well for emergency care. Sure, they have an ER. But it's usually a major fight to get my patient having a heart attack transferred to the VA ER.
I don't dispute that the VA is more efficient that commercial insurance companies. After all, the VA, hopefully, doesn't have bottom line and shareholder interests as its primary goal.
If you're an optimist, you can view the VA as a good example of how government might do things right. If you're a pessimist, you could say that the VA sucks less than the rest of the government programs. That's a fairly backhanded compliment, similar to, "For a fat chick, you don't sweat much!"
Is it embarassing that we spend so much and get so little for our US healthcare dollar? Yes, it's appalling. Infant mortality in the US is far below most developed countries. I've delivered five babies in the last seven days. It's staggering to think that we can't do better than we're doing.
I'm in favor of a national health care system, at least in principle. However, I don't think the political environment in the US will ever allow it. There's too much money to be made in the levels of bureaucracy. The big health insurers and big pharma contribute too much money to both sides of the aisle to allow that to happen. Maybe I'm just a cynic, but I think I'm also a realist.
We could save billions on pharmaceuticals alone if Medicare was allowed to bargain with the drug companies. If Medicare could tell Astra-Zeneca, "You're gonna supply Nexium to our beneficiaries for $20 a month, or you'll never see another Medicare patient again," AZ would suddenly have some major, firesale pricing going on. To my knowledge, all of the EU countries do this on some level. Hell, even Canada and Mexico get much better pricing. I just wish I lived closer to one of the borders. I'd send patients there all the time.
Heh heh. Personally, I agree with your open source comments. However, I work nearly every day in clinic or the ER and I don't have time to develop/test/compile/support an EMR. I just want something that works (at least reasonably well, most of the time).
I don't think most doctors frequent Slashdot (I could be wrong). They're probably more of the "Nobody ever got fired for buying IBM/Microsoft/etc" mindset.
We have an IT vendor and all of our network is HP. Sure, I could've built a less expensive server than our dual Xeon HPs, but I don't want to support them. Even if I found it personally interesting, I don't want to deal with the server or the wireless when it goes down. I want someone to yell at (the IT company) and a company behind it (HP). And I'm willing to pay for it so that I can focus on my priorities (seeing patients).
Certainly, these are excellent points. You're quite correct that there are ethical dilemmas when business and medicine cross. I would love to be paid a reasonable salary (you can debate what is reasonable) and not worry about the business side of things. However, I've got staff to pay, supplies to buy, rent and utilities, etc., etc., etc. Only after these expenses are paid do I take anything home.
You can make the same argument about health insurance. There's an ethical conflict of interest at work when you take people's money (insurance premiums) and contract to pay for their health care costs. Since you already have their money in hand, you, the insurer, have every incentive to deny or delay payment whenever possible. The longer you do this, the more money and interest you make. If you deny coverage for that MRI, that's another $1500 that stays with your company, instead of going to the radiologist or the hospital.
Of course, I have the incentive to perform more procedures on a patient. The more I perform, the more fees I generate (or so the theory goes). Or, you can pay doctors a flat fee per month per patient (capitation). Now, the doctor has every incentive to not do anything extra for the patient, because they won't get paid any more. No matter which side you choose, there are always potential conflicts of interest. The goal is to develop a system or framework where these conflicts are minimized.
For what it's worth, most doctors are very uncomfortable thinking of themselves as businessmen/women. We are not comfortable talking about fees with patients, and you feel like you're lowering yourself to the used car salesman level. But, you've gotta stay in the black, or the clinic closes.
I'm a Family Physician in rural Utah. There are several points in the article and posts worth commenting on:
First, technology will help, but certainly not fix the system. Yes, there are inefficiencies. My clinic, with 3 MDs, has about 20,000 total charts. Of those, probably 5-10,000 are active patients. The cost and time involved to maintain, file, refile, and add to these charts is enormous. Having said that, we are stilling making a somewhat greater income than the average family doc. We switched to an electronic medical record system in November 2006. It has saved us time spent in chasing charts and making copies. But, we had to upgrade out entire office network AND buy the EMR system. That's about $120K to start, and about 15-20%/year in maintenance fees. So, we're more efficient in many ways, but it's certainly not making us more money. I'm now more efficient and I make less money. I would never, ever go back to paper charts, but most docs won't pony up the $40K/doc for a system that costs them more money. If it comes down to money or efficiency, efficiency be damned is the mindset. And before everyone starts complaining about overpaid doctors, please realize that nearly all businesses would make the same decision.
Second, the US spends far too much money on the ends of life. Okay, most of us are willing to allow our taxes to go towards saving pre-term babies. However, is it really worth spending another $200-500K on pacemaker and cardiac bypass surgery for an 85 year old man with end-stage emphysema, congestive heart failure, renal failure, and alzheimer's dementia? No, it's not. We need to tell Americans, "Sorry. There's not money available to pay for that." We could immunize thousands of kids for the cost of that pacemaker and surgery. But Americans currently demand "the best healthcare system in the world". In their minds, it's worth "any cost" to spend another week of quality time with Grandma before she inevitably dies.
Third, health insurance and copays obscure the real cost of healthcare. If the patient knows that he's going to pay $20 for his office copay, he doesn't really care if the doctor submits a $60 or a $120 charge to insurance. There's no incentive to search for a lower price. If you're on a high deductible plan, that person with usually try to bargain with the physician. At the least, they'll question why I might bill a level 3 office visit charge vs. a level 4 office visit charge.
Similarly, patients don't have any incentive to use a cheaper, but similarly effective medication. As long as my copay is $25, why should I care whether I'm on Effexor XR ($140/month) or generic Celexa ($10/month).
Fourth, the process of submitting claims to insurance is encrusted with bureaucracy at every level. Each company has you submit the claim to a different address, with different information and codes. Their claims software is designed to reject certain claims immediately. Now I can file an appeal and often get them paid, but that may cost $20-50 in staff time. If it's a $40 claim, it's not worth it-and they know it.
I'd like to think that a government mandated, standardized submission process would be more efficient. But even under heavy sedation, I would never believe that the government that brought us Medicare, Medicaid, and the VA could possibly get it right.
Hoo-friggin-rah we don't have socialized medicine. I'll pay and see a doctor instead of getting on a waiting list governed by some governmental schmuck. Exactly when were these halcion days for which you pine?
Okay, I can't pass on this one. I think you mean "these halcyon days". Halcion is a sleep medication is the same family as Valium and Xanax.
I'm going to assume that you knew that and you were making a outstanding pun!
Okay, your response is that of the pharmaceutical researcher. My response is that of a family doctor:
I have no doubts that Pfizer, Merck, Novartis, AZ, and all the others are researching all sorts of interesting things that would be a great benefit to society. As you pointed out, if (some drug company) invents a real cure for AIDs, they will make a bazillion dollars and their stockholders will be able to hire Trump and Gates as their shoe-shine boys.
As a researcher, I imagine that you have personal, social, and ethical reasons to motivate you to find a new treatment for major diseases. Good for you. (that's not sarcasm-I really mean that).
However, the marketing and PR departments and the army of drug reps out there present a different perspective. There's not a day that goes by that a drug rep doesn't try to convince me that I should be prescribing Diovan/Cozaar/Benicar/Micardis, etc., for blood pressure instead of Lisinopril. Diovan and friends are a class of drugs called ARBs that have are very effective for lowering blood pressure and thereby lowering the risk of stroke and renal damage. However, Lisinopril, belonging to an older class of drugs called ACE inhibitors, is just as effective, and it's dirt cheap. The irony is that Lisinopril was once marketed like crazy as THE go-to drug for hypertension. But once it's off patent and generics are available, you never hear about it again. The implication is that if I want to be an up-to-date physician, I'd be prescribing the latest and greatest. Never mind that it doesn't work any better.
The most recent, blatant, insulting example was Zocor. For years, Zocor was pushed as god's gift to lowering cholesterol. And yes, it has some great studies showing decreases in heart attacks. However, Zocor became available as a generic this year. I had two visits from the SAME Merck rep about 3 months apart. At the first visit, the message was, "Zocor. The drug of choice. Blah, blah, blah. Nothing new here."
At the second visit by the exact same rep, she tells me, "Well, you might use Zocor for your patients who need mild cholesterol lowering. But for patients needing robust lowering, you really should avoid Zocor and prescribe VYTORIN (trumpets sound in the background). Coincidentally, Vytorin is simply Zocor plus Zetia combined into one pill. Wow!! That's some great innovation there! At least the stockholders would see it that way.
This happens again and again with me-too drugs. Claritin and Clarinex? Floxin and Levaquin? Prilosec and Nexium? Celexa and Lexapro? Albuterol and Xoponex? The second is simply one isomer of the first, which is a racemic mixture. These drugs are already invented and patented. Why should separating a racemic mixture justify a new patent? It's absurd. It may be technically challenging, but not patent-worthy.
As for the HPV vaccine: it's a great shot series, but Merck isn't selling it cheap. I understand that they've got to cover R&D costs, but if they were as altruistic as they'd have us believe, they'd be giving it out as cheaply as possible.
Perhaps if the NIH were probably funded and could support large, ongoing studies, we'd see some real breakthoughs in new drugs. As long as pharmaceutical companies foot the bill, they will always take the easier route of slightly modifying an existing drug, re-patenting (is that a word?) the "new" drug, and selling it just barely below the current market leader. They may stumble onto new, innovative compounds that are actually a breakthrough, but as the article points out, this is the exception, not the rule.
I notice that TFA is actually about sponges. As many previous posts have mentioned, these are much harder to detect when they've been left in surgery. Here's my perspective:
I'm a physician and the most common major surgeries I perform are C-Sections (I've done two in the last 36 hours, BTW). As already noted, the nurses do sponge, needle, and blade counts before the surgery, and they count more than once, and two nurses participate. Each surgery packet has a standard number of certain instruments, and these counts are also verified.
During the surgery, the surgeons obviously use up a fair number of sponges. As the sponges get bloody, the scrub nurse takes them from the surgeon and hands him/her a new one. The bloody sponges are placed in groups (usually of five) on a sticky mat on the floor (like flypaper), and the circulating nurse keeps a running total. As the surgery nears conclusion (for example, I've finished sewing up the uterus, but not closed the abdomen), the nurses start a sponge, needle, and blade count. If it's not correct, they count again, and again. Unless the surgery is at a critical stage, the surgeon(s) will stop and look everywhere in the surgical area, in the folds of the drapes, etc., until the missing item is found. In the case of sponges, they're usually hidden in a drape fold, or two bloody sponges are stuck together and counted as one. If a blade or needle can't be found, the portable X-Ray machine is brought in and the patient is X-rayed to make sure nothing is in the surgical field.
Only the most callous, stupid, and arrogant surgeon would knowingly say, "Oh, I'm sure you miscounted all six times. Lets close up anyway."
These mistakes are bad and avoidable, but they're certainly not the most common. It makes a big headline and lawyers start to salivate like Pavlov's dog when they hear them. But, wrong patient/wrong surgery/wrong side/sponge-left-inside events are much less common than other errors. For example, if we (the medical profession) could eliminate medication errors (wrong dose, wrong drug, wrong time, wrong patient, allergies), we would drastically reduce the number of errors and patient injuries and deaths.
This is an interesting technology, but it's going to cost an inordinate amount of money. I think it would be better spent trying to reduce or eliminate the most common errors first.
Just my 2 cents. Of course, I could be wrong (with apologies to Dennis Miller).
The Law School story is different. You, the Law Student, are paying money for an education. Sure, they can grill you with questions and generally embarass you, but you're not actually doing something against the rules. If your behavior hurts your productivity (your ability to learn and graduate law school), that's only hurting you.
This contrasts with someone who is paid to perform a job and has an acceptable use policy as part of their contract. If you're not doing your job, you're not upholding your end of the contract. You are breaking the rules that you agreed to as part of your contract, and you can be fired.
Yeah, it stinks to get fired over a stupid game like Solitaire, but the principle still holds. (Freecell might be worth getting fired;-)
I was in the market for a Digital Rebel XT and read a few of the magazine ads. They all seem somewhat questionable, and most of them say "call for prices", thereby allowing them to bump up the price whenever possible. I ended up using a couple of coupons from Dell and bought the Rebel XT with lens kit ($999 retail) for $790 shipped. Dell may get some black eyes from time to time, but I had the camera on my front door in 5 days and I didn't have to worry that it was a grey market model.
(Disclaimer: I'm a primary care doctor in the USA. I have a few type I diabetics, and many type IIs.)
First, I think it's great that the researchers have demonstrated a potential way to identify pre-clinical type I diabetes. If these patients could be easily identified and the pathologic process halted or reversed, this would be one of the greatest feats ever accomplished in medicine.
However, this approach has several problems. Another poster has already mentioned that health insurance companies could start denying coverage to kids(and adults) who don't have diabetes, but might get it. If you're a health plan administrator, diabetes is a very, very expensive disease and you want to avoid these patients.
(Whether health insurance companies should even be in the business to make a profit is a topic for another debate. Short answer: It's absolutely wrong.)
More importantly, who do you screen with MRI? Do you screen every child at age 5 (or another pre-defined age)? Do you only screen them once? It's true that most type I patients are diagnosed by the early teens, but a significant portion develop the disease in their later teens or twenties. I have a 20 year old patient who was just diagnosed with type I after the birth of her first child. I also had a medical school classmate who was diagnosed while in his residency.
Once you've decided who you'll screen and at what age and interval, how do you pay for it? This cannot be ignored. An abdominal MRI can cost $1-3,000, and you often need to sedate patients because it's quite claustrophobic. If you were to screen every child only once, the cost would skyrocket into billions of dollars almost immediately.
For those of use who are members of the Mormon population in Utah (like me), this is still blatant pandering. My Utah-based ISP, xmission.com offers full, unrestricted access. I choose to use this ISP, and I monitor my kids' internet access. There are several ISPs in Utah that already filter questionable material. You can choose one if you want. As it is, I work in health care, and there are plenty of legitimate medical sites that are filtered out because they mention STDs, HIV, etc.
On the other hand, this law isn't that big of a deal. You have to ask the ISP to turn on your filtering. It's like the V-Chip. If you don't want it, ignore it and continue to get your unfiltered access.
As far as Orrin Hatch goes, I have no good answer except that I've voted against him twice now. Every now and then, he'll do something really creative and interesting, and he can selectively work well with the Democrats. But, he drives some of us crazy most of the time. Obviously, a lot of Utah still likes him.
On the same lines: Do you want to go to your doctor and have him/her walk in the room covered with piercings and tattoos? Maybe a few of you do. But, medicine is very conservative. I work in a doctor's office in a town of 8,000 which is very conservative. Tattoo's and piercings wouldn't fly.
You raise some good points. Is 40K a lot? No. It's actually low. I did live in Washington State where the OB/GYNs were paying 60-120K. As a family doctor, my premiums are lower. But, I deliver fewer babies than an OB and gain less revenue from deliveries, so it's proportionally very similar.
I mean 500 dollars for insurance on something that can affect the rest of a persons life? Agreed. But why do I have to pay all of it? How about society paying it, or the mother and father? It makes some sense if the injury is due to my neglect or incompetence. But what if it's a birth defect beyond my control? The old adage "shit happens!" applies in medicine too, and it's not always the doctor's fault.
Actually, some practices are instituting something similar. They're charging the mother an extra $500 or so to cover their increased costs. Whether or not this is appropriate is probably beyond the scope of this post, but it's something to think about.
oh, and alot of late nights..what on earth did u expect in ob/gyn? I fully expect the late nights. I don't mean to suggest that I'm bitter about that. But, when I look at my derm/radiology colleagues who pay a small fraction in malpractice and sleep at night, AND make more (sometimes a lot more) money than me, you start thinking about how much you really like delivering babies.
Anyway, it will probably remain a problem for a long time. The doctors' lobby and the lawyers' lobby and the insurance lobby all have big stakes (and money) in this, and I don't see any easy solution.
There are a few bad doctors out there, and bad outcomes happen at times to all doctors. We could do better at policing ourselves.
However, the lawsuit-jackpot mentality is not helping the patients or the physicians. It helps the lawyer who gets to take his 30-50% off the top of a big judgement. As a rural family physician, I deliver 30-40 babies a year, but my malpractice premium is about $40,000/year. If I didn't deliver babies, it would be about $12,000. Disturbingly, 40K is actually pretty low for delivering babies. It helps that I live in a rural area.
I have to deliver about 30 babies a year just to cover my malpractice premium and office expenses. That's a lot of late nights, weekends away from home, etc. If I have a bad outcome, even if it wasn't my fault and the jury finds in my favor, my premium will still jump a good 25-50% or so. If you don't love delivering babies for the sake of delivering babies, you start asking yourself why you're exposing yourself to all this litigious risk, missing sleep, and paying higher premiums even if you're right. Then you start seeing physicians retiring or stopping high-risk procedures, and that doesn't serve anyone.
It's an easy sound bite to just blame doctors, or just blame lawyers. All the involved parties need to sit down and work out a solution. I'm afraid that this won't happen until enough pregnant women can't find a physician and end up being delivered in the emergency room.
My father, a physician, got his LASIK done about two years ago. He's 55. He'd been wearing half-frames for reading since age 40. At 50, he needed glasses for distance vision too. He saw the opthalmology group where he refers patients and they did it for him. And yes, it cost a lot more than $299/eye. He's now 20/15, and only wears his half-frames for reading, once again. He refers his patients for LASIK if they ask, but he and the eye docs are very up front about the risks and the percentage of poor outcomes and complications.
Since I have stable 20/100 vision, I asked him last month about it. He has absolutely no regrets, and I'm planning to get it done within the next couple of months. For a properly selected set of patients, it's definitely worth considering. You've just gotta go in with your eyes open! (Couldn't help myself)
Residents outweigh attending physicians 2-to-1 in this study. Wouldn't residents be more likely to be younger? Aren't younger people much more likely to have significant video game experience? I can find no place in the report that shows they controlled for age. Might the study simply be showing that "younger people have better eye-hand coordination than older people?
I'm completing residency this year. I'm not a surgeon, but I do perform colonoscopies and upper endoscopy. I played a fair amount of Doom in College and Half-Life in Medical School as well as Nintendo since age 12. My anecdotal experience agrees with this study. The colonoscope uses two wheels to go left-right and up-down, as well as another button for suction, a button for water, and a button to take pictures. You could think of it as a mutated Nintendo controller. After performing a certain number of scopes, you can intuitively guide the scope down the tunnel without thinking about the controls, just like a Nintendo's control pad. Actually, a colonoscopy is just a trip down a long tunnel, and it reminds me a bit of Descent and Descent II.
As I perform colonoscopy with my attending physicians (45 and older), they often comment that they have difficulty manipulating the controls to make the screen image move the way you want. The issue might bear more study, but it seems reasonable to see a connection.
As far a vision goes, if you can see the TV screen, that shouldn't be an issue. It's more a matter of learning the hand-eye coordination with frequent repetition.
For the record, I still play a little Half-Life now and then.
I appreciate the comment. Delivering babies is easily one of my favorite parts of the job. I'd much rather stay awake at night stressing over a sick pregnant woman than lose sleep worrying about who's going to sue me next.
Slashdot Mirror
The sham surgeries aren't done by fraudulent physicians. There have been studies done for knee pain, where patients are randomly selected for traditional arthroscopy versus a sham surgery, where arthroscopy style skin incisions are created, and then sewn shut. When the patient awakens, they don't know if they had actual surgery or not. This is the study's design, and all patients in the study agree to the randomization process. This is quite different that a surgeon "pretending" to do surgery to bill patient. That, of course, would be fraudulent, unethical, and illegal.
http://content.nejm.org/cgi/content/full/347/2/81
(Can't make a link!! My coding-fu is weak this morning)
cheap Blu-ray players that cost less than $200
Keep going. I can still get a no-name DVD player for $30, region free as well.
I'm a family physician, graduated med school in 2001, been in practice since 2004. First, I loved O-Chem, so I'm probably odd. General chem was okay, but it was a much bigger weed-out class. It felt like more rote memorization.
O-chem was interesting and fun, because the reactions made intuitive sense. Once you understood why the electrons flowed the way they did, you didn't have to memorize the Clemenson reaction or the Grignard reaction, you just "got" why they worked.
If you don't understand O-chem, you really will never get biochemistry. Although med students complain about first-year biochem, it's essential. When I decide to prescribe Crestor to someone for their hyperlipidemia, I really ought to know how Crestor works. Specifically, what does Hmg-CoA reductase do, where does it work in the cholesterol synthesis cycle, and why would it be good to take Crestor. Instead, you have doctors or PA/NPs who simply prescribe Crestor because the last drug rep was cute, rather than understanding the underlying pathophysiology.
To the posters who've noted that demand is outstripping supplies of doctors: I agree that we need to lower the barriers to producing more doctors. But, dumbing down pre-med isn't the answer. Moderating the cost of medical education could go a long way. There's a tremendous shortage of Family Physicians and general Internists. But if you're a 4th year med student looking at $250K of student loan debt, you've got to consider your ability to repay it. From an purely economic standpoint, why would I do a 3 year primary care residency and make $170K/year, when I could do a 4 year anesthesia residency and make $400K/year.
Since I am a Family Doc, there must be more reasons than just economics (or perhaps I couldn't get into an anesthesia residency ;-). I dunno. I always planned on Family Medicine.
Back to the original question. Next time you get a drug sample, unfold the little packet of paper that folds out to the size of a large map. That's the product insert. Look at the very top. There's a picture of the chemical structure, and the actual name of the molecule.
Damn right O-chem is needed!!
My favorite quote from the article is:
"Heady forecasts like these energize chip proponents, who insist that RFID will result in enormous savings for businesses. Each year, retailers lose $57 billion from administrative failures, supplier fraud and employee theft, according to a recent survey of 820 retailers by Checkpoint Systems, an RFID manufacturer that specializes in store security devices."
So, a company who makes RFID chips does a study showing the businesses lose $57 Billion every year? That sounds as reliable as some of the Business Software Alliance statements on losses from piracy. To call this self-serving would be an understatement.
Funny thing, the VA system is actually some of the best care in America. Too bad you're too busy paying for your yacht to realize that...
Nice cheapshot there, AC. My yacht is a 1999 Dodge Intrepid with 105,000 miles.
I've worked in the VA system in med school and residency. To be fair, there's a lot to like. You can go to any VA in the country and your doc can pull up your entire chart. That's a huge deal.
However, one can't compare the VA to Medicare in an apples-to-apples comparison. The VA CAN bargain with drug companies. They get tremendous price concessions from the companies. Medicare is prohibited by law to do such things. As long as you're prescribing the drugs on the VA preferred list, costs are contained pretty well, and the patients have relatively cheap copays.
If you want to do anything outside the approved list, heaven help you and your patient. I've spent hours trying to get Prevacid approved for a patient who had failed Aciphex therapy (preferred). They never approved it. The VA is not set up well for emergency care. Sure, they have an ER. But it's usually a major fight to get my patient having a heart attack transferred to the VA ER.
I don't dispute that the VA is more efficient that commercial insurance companies. After all, the VA, hopefully, doesn't have bottom line and shareholder interests as its primary goal.
If you're an optimist, you can view the VA as a good example of how government might do things right. If you're a pessimist, you could say that the VA sucks less than the rest of the government programs. That's a fairly backhanded compliment, similar to, "For a fat chick, you don't sweat much!"
Is it embarassing that we spend so much and get so little for our US healthcare dollar? Yes, it's appalling. Infant mortality in the US is far below most developed countries. I've delivered five babies in the last seven days. It's staggering to think that we can't do better than we're doing.
I'm in favor of a national health care system, at least in principle. However, I don't think the political environment in the US will ever allow it. There's too much money to be made in the levels of bureaucracy. The big health insurers and big pharma contribute too much money to both sides of the aisle to allow that to happen. Maybe I'm just a cynic, but I think I'm also a realist.
We could save billions on pharmaceuticals alone if Medicare was allowed to bargain with the drug companies. If Medicare could tell Astra-Zeneca, "You're gonna supply Nexium to our beneficiaries for $20 a month, or you'll never see another Medicare patient again," AZ would suddenly have some major, firesale pricing going on. To my knowledge, all of the EU countries do this on some level. Hell, even Canada and Mexico get much better pricing. I just wish I lived closer to one of the borders. I'd send patients there all the time.
Heh heh. Personally, I agree with your open source comments. However, I work nearly every day in clinic or the ER and I don't have time to develop/test/compile/support an EMR. I just want something that works (at least reasonably well, most of the time).
I don't think most doctors frequent Slashdot (I could be wrong). They're probably more of the "Nobody ever got fired for buying IBM/Microsoft/etc" mindset.
We have an IT vendor and all of our network is HP. Sure, I could've built a less expensive server than our dual Xeon HPs, but I don't want to support them. Even if I found it personally interesting, I don't want to deal with the server or the wireless when it goes down. I want someone to yell at (the IT company) and a company behind it (HP). And I'm willing to pay for it so that I can focus on my priorities (seeing patients).
Certainly, these are excellent points. You're quite correct that there are ethical dilemmas when business and medicine cross. I would love to be paid a reasonable salary (you can debate what is reasonable) and not worry about the business side of things. However, I've got staff to pay, supplies to buy, rent and utilities, etc., etc., etc. Only after these expenses are paid do I take anything home.
You can make the same argument about health insurance. There's an ethical conflict of interest at work when you take people's money (insurance premiums) and contract to pay for their health care costs. Since you already have their money in hand, you, the insurer, have every incentive to deny or delay payment whenever possible. The longer you do this, the more money and interest you make. If you deny coverage for that MRI, that's another $1500 that stays with your company, instead of going to the radiologist or the hospital.
Of course, I have the incentive to perform more procedures on a patient. The more I perform, the more fees I generate (or so the theory goes). Or, you can pay doctors a flat fee per month per patient (capitation). Now, the doctor has every incentive to not do anything extra for the patient, because they won't get paid any more. No matter which side you choose, there are always potential conflicts of interest. The goal is to develop a system or framework where these conflicts are minimized.
For what it's worth, most doctors are very uncomfortable thinking of themselves as businessmen/women. We are not comfortable talking about fees with patients, and you feel like you're lowering yourself to the used car salesman level. But, you've gotta stay in the black, or the clinic closes.
I'm a Family Physician in rural Utah. There are several points in the article and posts worth commenting on:
;-)
First, technology will help, but certainly not fix the system. Yes, there are inefficiencies. My clinic, with 3 MDs, has about 20,000 total charts. Of those, probably 5-10,000 are active patients. The cost and time involved to maintain, file, refile, and add to these charts is enormous. Having said that, we are stilling making a somewhat greater income than the average family doc. We switched to an electronic medical record system in November 2006. It has saved us time spent in chasing charts and making copies. But, we had to upgrade out entire office network AND buy the EMR system. That's about $120K to start, and about 15-20%/year in maintenance fees. So, we're more efficient in many ways, but it's certainly not making us more money. I'm now more efficient and I make less money. I would never, ever go back to paper charts, but most docs won't pony up the $40K/doc for a system that costs them more money. If it comes down to money or efficiency, efficiency be damned is the mindset. And before everyone starts complaining about overpaid doctors, please realize that nearly all businesses would make the same decision.
Second, the US spends far too much money on the ends of life. Okay, most of us are willing to allow our taxes to go towards saving pre-term babies. However, is it really worth spending another $200-500K on pacemaker and cardiac bypass surgery for an 85 year old man with end-stage emphysema, congestive heart failure, renal failure, and alzheimer's dementia? No, it's not. We need to tell Americans, "Sorry. There's not money available to pay for that." We could immunize thousands of kids for the cost of that pacemaker and surgery. But Americans currently demand "the best healthcare system in the world". In their minds, it's worth "any cost" to spend another week of quality time with Grandma before she inevitably dies.
Third, health insurance and copays obscure the real cost of healthcare. If the patient knows that he's going to pay $20 for his office copay, he doesn't really care if the doctor submits a $60 or a $120 charge to insurance. There's no incentive to search for a lower price. If you're on a high deductible plan, that person with usually try to bargain with the physician. At the least, they'll question why I might bill a level 3 office visit charge vs. a level 4 office visit charge.
Similarly, patients don't have any incentive to use a cheaper, but similarly effective medication. As long as my copay is $25, why should I care whether I'm on Effexor XR ($140/month) or generic Celexa ($10/month).
Fourth, the process of submitting claims to insurance is encrusted with bureaucracy at every level. Each company has you submit the claim to a different address, with different information and codes. Their claims software is designed to reject certain claims immediately. Now I can file an appeal and often get them paid, but that may cost $20-50 in staff time. If it's a $40 claim, it's not worth it-and they know it.
I'd like to think that a government mandated, standardized submission process would be more efficient. But even under heavy sedation, I would never believe that the government that brought us Medicare, Medicaid, and the VA could possibly get it right.
Okay, take your best shots
Hoo-friggin-rah we don't have socialized medicine. I'll pay and see a doctor instead of getting on a waiting list governed by some governmental schmuck. Exactly when were these halcion days for which you pine?
Okay, I can't pass on this one. I think you mean "these halcyon days". Halcion is a sleep medication is the same family as Valium and Xanax.
I'm going to assume that you knew that and you were making a outstanding pun!
Okay, your response is that of the pharmaceutical researcher. My response is that of a family doctor:
I have no doubts that Pfizer, Merck, Novartis, AZ, and all the others are researching all sorts of interesting things that would be a great benefit to society. As you pointed out, if (some drug company) invents a real cure for AIDs, they will make a bazillion dollars and their stockholders will be able to hire Trump and Gates as their shoe-shine boys.
As a researcher, I imagine that you have personal, social, and ethical reasons to motivate you to find a new treatment for major diseases. Good for you. (that's not sarcasm-I really mean that).
However, the marketing and PR departments and the army of drug reps out there present a different perspective. There's not a day that goes by that a drug rep doesn't try to convince me that I should be prescribing Diovan/Cozaar/Benicar/Micardis, etc., for blood pressure instead of Lisinopril. Diovan and friends are a class of drugs called ARBs that have are very effective for lowering blood pressure and thereby lowering the risk of stroke and renal damage. However, Lisinopril, belonging to an older class of drugs called ACE inhibitors, is just as effective, and it's dirt cheap. The irony is that Lisinopril was once marketed like crazy as THE go-to drug for hypertension. But once it's off patent and generics are available, you never hear about it again. The implication is that if I want to be an up-to-date physician, I'd be prescribing the latest and greatest. Never mind that it doesn't work any better.
The most recent, blatant, insulting example was Zocor. For years, Zocor was pushed as god's gift to lowering cholesterol. And yes, it has some great studies showing decreases in heart attacks. However, Zocor became available as a generic this year. I had two visits from the SAME Merck rep about 3 months apart. At the first visit, the message was, "Zocor. The drug of choice. Blah, blah, blah. Nothing new here."
At the second visit by the exact same rep, she tells me, "Well, you might use Zocor for your patients who need mild cholesterol lowering. But for patients needing robust lowering, you really should avoid Zocor and prescribe VYTORIN (trumpets sound in the background). Coincidentally, Vytorin is simply Zocor plus Zetia combined into one pill. Wow!! That's some great innovation there! At least the stockholders would see it that way.
This happens again and again with me-too drugs. Claritin and Clarinex? Floxin and Levaquin? Prilosec and Nexium? Celexa and Lexapro? Albuterol and Xoponex? The second is simply one isomer of the first, which is a racemic mixture. These drugs are already invented and patented. Why should separating a racemic mixture justify a new patent? It's absurd. It may be technically challenging, but not patent-worthy.
As for the HPV vaccine: it's a great shot series, but Merck isn't selling it cheap. I understand that they've got to cover R&D costs, but if they were as altruistic as they'd have us believe, they'd be giving it out as cheaply as possible.
Perhaps if the NIH were probably funded and could support large, ongoing studies, we'd see some real breakthoughs in new drugs. As long as pharmaceutical companies foot the bill, they will always take the easier route of slightly modifying an existing drug, re-patenting (is that a word?) the "new" drug, and selling it just barely below the current market leader. They may stumble onto new, innovative compounds that are actually a breakthrough, but as the article points out, this is the exception, not the rule.
I notice that TFA is actually about sponges. As many previous posts have mentioned, these are much harder to detect when they've been left in surgery. Here's my perspective:
I'm a physician and the most common major surgeries I perform are C-Sections (I've done two in the last 36 hours, BTW). As already noted, the nurses do sponge, needle, and blade counts before the surgery, and they count more than once, and two nurses participate. Each surgery packet has a standard number of certain instruments, and these counts are also verified.
During the surgery, the surgeons obviously use up a fair number of sponges. As the sponges get bloody, the scrub nurse takes them from the surgeon and hands him/her a new one. The bloody sponges are placed in groups (usually of five) on a sticky mat on the floor (like flypaper), and the circulating nurse keeps a running total. As the surgery nears conclusion (for example, I've finished sewing up the uterus, but not closed the abdomen), the nurses start a sponge, needle, and blade count. If it's not correct, they count again, and again. Unless the surgery is at a critical stage, the surgeon(s) will stop and look everywhere in the surgical area, in the folds of the drapes, etc., until the missing item is found. In the case of sponges, they're usually hidden in a drape fold, or two bloody sponges are stuck together and counted as one. If a blade or needle can't be found, the portable X-Ray machine is brought in and the patient is X-rayed to make sure nothing is in the surgical field.
Only the most callous, stupid, and arrogant surgeon would knowingly say, "Oh, I'm sure you miscounted all six times. Lets close up anyway."
These mistakes are bad and avoidable, but they're certainly not the most common. It makes a big headline and lawyers start to salivate like Pavlov's dog when they hear them. But, wrong patient/wrong surgery/wrong side/sponge-left-inside events are much less common than other errors. For example, if we (the medical profession) could eliminate medication errors (wrong dose, wrong drug, wrong time, wrong patient, allergies), we would drastically reduce the number of errors and patient injuries and deaths.
This is an interesting technology, but it's going to cost an inordinate amount of money. I think it would be better spent trying to reduce or eliminate the most common errors first.
Just my 2 cents. Of course, I could be wrong (with apologies to Dennis Miller).
The Law School story is different. You, the Law Student, are paying money for an education. Sure, they can grill you with questions and generally embarass you, but you're not actually doing something against the rules. If your behavior hurts your productivity (your ability to learn and graduate law school), that's only hurting you.
;-)
This contrasts with someone who is paid to perform a job and has an acceptable use policy as part of their contract. If you're not doing your job, you're not upholding your end of the contract. You are breaking the rules that you agreed to as part of your contract, and you can be fired.
Yeah, it stinks to get fired over a stupid game like Solitaire, but the principle still holds. (Freecell might be worth getting fired
I was in the market for a Digital Rebel XT and read a few of the magazine ads. They all seem somewhat questionable, and most of them say "call for prices", thereby allowing them to bump up the price whenever possible. I ended up using a couple of coupons from Dell and bought the Rebel XT with lens kit ($999 retail) for $790 shipped. Dell may get some black eyes from time to time, but I had the camera on my front door in 5 days and I didn't have to worry that it was a grey market model.
(Disclaimer: I'm a primary care doctor in the USA. I have a few type I diabetics, and many type IIs.)
First, I think it's great that the researchers have demonstrated a potential way to identify pre-clinical type I diabetes. If these patients could be easily identified and the pathologic process halted or reversed, this would be one of the greatest feats ever accomplished in medicine.
However, this approach has several problems. Another poster has already mentioned that health insurance companies could start denying coverage to kids(and adults) who don't have diabetes, but might get it. If you're a health plan administrator, diabetes is a very, very expensive disease and you want to avoid these patients.
(Whether health insurance companies should even be in the business to make a profit is a topic for another debate. Short answer: It's absolutely wrong.)
More importantly, who do you screen with MRI? Do you screen every child at age 5 (or another pre-defined age)? Do you only screen them once? It's true that most type I patients are diagnosed by the early teens, but a significant portion develop the disease in their later teens or twenties. I have a 20 year old patient who was just diagnosed with type I after the birth of her first child. I also had a medical school classmate who was diagnosed while in his residency.
Once you've decided who you'll screen and at what age and interval, how do you pay for it? This cannot be ignored. An abdominal MRI can cost $1-3,000, and you often need to sedate patients because it's quite claustrophobic. If you were to screen every child only once, the cost would skyrocket into billions of dollars almost immediately.
Wow. Just like that, all of my spam problems are now solved. I'll be you all wish you lived in Utah too!
</sarcasm>
ps - don't you mean "the major University in the state"? ;p
;-)
Once again, our brethren from the south are confused. I think your statement refers to THE University of Utah (in Salt Lake)
U of U Grad (twice)
For those of use who are members of the Mormon population in Utah (like me), this is still blatant pandering. My Utah-based ISP, xmission.com offers full, unrestricted access. I choose to use this ISP, and I monitor my kids' internet access. There are several ISPs in Utah that already filter questionable material. You can choose one if you want. As it is, I work in health care, and there are plenty of legitimate medical sites that are filtered out because they mention STDs, HIV, etc.
On the other hand, this law isn't that big of a deal. You have to ask the ISP to turn on your filtering. It's like the V-Chip. If you don't want it, ignore it and continue to get your unfiltered access.
As far as Orrin Hatch goes, I have no good answer except that I've voted against him twice now. Every now and then, he'll do something really creative and interesting, and he can selectively work well with the Democrats. But, he drives some of us crazy most of the time. Obviously, a lot of Utah still likes him.
On the same lines: Do you want to go to your doctor and have him/her walk in the room covered with piercings and tattoos? Maybe a few of you do. But, medicine is very conservative. I work in a doctor's office in a town of 8,000 which is very conservative. Tattoo's and piercings wouldn't fly.
Check out the AP story here. Notice the statue in the background. I hope everyone appreciates the irony.
You raise some good points.
Is 40K a lot?
No. It's actually low. I did live in Washington State where the OB/GYNs were paying 60-120K. As a family doctor, my premiums are lower. But, I deliver fewer babies than an OB and gain less revenue from deliveries, so it's proportionally very similar.
I mean 500 dollars for insurance on something that can affect the rest of a persons life?
Agreed. But why do I have to pay all of it? How about society paying it, or the mother and father? It makes some sense if the injury is due to my neglect or incompetence. But what if it's a birth defect beyond my control? The old adage "shit happens!" applies in medicine too, and it's not always the doctor's fault.
Actually, some practices are instituting something similar. They're charging the mother an extra $500 or so to cover their increased costs. Whether or not this is appropriate is probably beyond the scope of this post, but it's something to think about.
oh, and alot of late nights..what on earth did u expect in ob/gyn?
I fully expect the late nights. I don't mean to suggest that I'm bitter about that. But, when I look at my derm/radiology colleagues who pay a small fraction in malpractice and sleep at night, AND make more (sometimes a lot more) money than me, you start thinking about how much you really like delivering babies.
Anyway, it will probably remain a problem for a long time. The doctors' lobby and the lawyers' lobby and the insurance lobby all have big stakes (and money) in this, and I don't see any easy solution.
Diclaimer: I'm a physician who delivers babies.
There are a few bad doctors out there, and bad outcomes happen at times to all doctors. We could do better at policing ourselves.
However, the lawsuit-jackpot mentality is not helping the patients or the physicians. It helps the lawyer who gets to take his 30-50% off the top of a big judgement. As a rural family physician, I deliver 30-40 babies a year, but my malpractice premium is about $40,000/year. If I didn't deliver babies, it would be about $12,000. Disturbingly, 40K is actually pretty low for delivering babies. It helps that I live in a rural area.
I have to deliver about 30 babies a year just to cover my malpractice premium and office expenses. That's a lot of late nights, weekends away from home, etc. If I have a bad outcome, even if it wasn't my fault and the jury finds in my favor, my premium will still jump a good 25-50% or so. If you don't love delivering babies for the sake of delivering babies, you start asking yourself why you're exposing yourself to all this litigious risk, missing sleep, and paying higher premiums even if you're right. Then you start seeing physicians retiring or stopping high-risk procedures, and that doesn't serve anyone.
It's an easy sound bite to just blame doctors, or just blame lawyers. All the involved parties need to sit down and work out a solution. I'm afraid that this won't happen until enough pregnant women can't find a physician and end up being delivered in the emergency room.
My father, a physician, got his LASIK done about two years ago. He's 55. He'd been wearing half-frames for reading since age 40. At 50, he needed glasses for distance vision too. He saw the opthalmology group where he refers patients and they did it for him. And yes, it cost a lot more than $299/eye. He's now 20/15, and only wears his half-frames for reading, once again. He refers his patients for LASIK if they ask, but he and the eye docs are very up front about the risks and the percentage of poor outcomes and complications.
Since I have stable 20/100 vision, I asked him last month about it. He has absolutely no regrets, and I'm planning to get it done within the next couple of months. For a properly selected set of patients, it's definitely worth considering. You've just gotta go in with your eyes open! (Couldn't help myself)
Residents outweigh attending physicians 2-to-1 in this study. Wouldn't residents be more likely to be younger? Aren't younger people much more likely to have significant video game experience? I can find no place in the report that shows they controlled for age. Might the study simply be showing that "younger people have better eye-hand coordination than older people?
I'm completing residency this year. I'm not a surgeon, but I do perform colonoscopies and upper endoscopy. I played a fair amount of Doom in College and Half-Life in Medical School as well as Nintendo since age 12. My anecdotal experience agrees with this study. The colonoscope uses two wheels to go left-right and up-down, as well as another button for suction, a button for water, and a button to take pictures. You could think of it as a mutated Nintendo controller. After performing a certain number of scopes, you can intuitively guide the scope down the tunnel without thinking about the controls, just like a Nintendo's control pad. Actually, a colonoscopy is just a trip down a long tunnel, and it reminds me a bit of Descent and Descent II.
As I perform colonoscopy with my attending physicians (45 and older), they often comment that they have difficulty manipulating the controls to make the screen image move the way you want. The issue might bear more study, but it seems reasonable to see a connection.
As far a vision goes, if you can see the TV screen, that shouldn't be an issue. It's more a matter of learning the hand-eye coordination with frequent repetition.
For the record, I still play a little Half-Life now and then.
I appreciate the comment. Delivering babies is easily one of my favorite parts of the job. I'd much rather stay awake at night stressing over a sick pregnant woman than lose sleep worrying about who's going to sue me next.