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The Price of Certainty Print E-mail
Written by David H. Epstein, MD, FACR   
Friday, 28 January 2011 00:00


 As the debate over health care reform is assured to continue into the next congress, questions about the role of tort reform will undoubtedly also persist, as we, physicians, will assert the centrality of tort reform to the control of medical care costs.  While the cost of defensive medicine is real, quantifying it is difficult and risky, and any attempt to profess that tort reform will produce prompt measurable reductions in the cost of health care provision may imperil our credibility where and when tort reform is accomplished.

In our zeal to communicate to the non-medical population our belief in the imperative of tort reform, we must also be realistic about the many causes of the progressive rise in the cost of medical care, the extent to which defensive medicine contributes to the cost, and the ability of tort-reform to stabilize or reverse these increases in the near term.

Contributors to the excessive and increasing cost of medical care are legion, and are mostly well recognized, if not necessarily their exact proportion.  For some, such as the felonious operators of non-existent Medicare and Medicaid clinics and the bogus personal injury rackets, better law enforcement is needed.  Greedy insurance companies, avaricious drug and durable medical suppliers, and inefficient wasteful hospital administrators, are all substantial participants that need in some way to be dealt with.  At some point, however, we must also confront those parts of the medical cost conundrum that are ours.  By that, I am referring first to that part of our community that has placed financial gain above the welfare of our patients.  In some cases this behavior can be quite blatant; with others it occurs only at the margins of our practices and is justified, erroneously, as good, thorough practice.  Unfortunately, where good medical practice is usurped by greed is probably more frequent than we would like to believe, and is inviting ever greater and unwanted scrutiny and interference by non-medical entities into our day-to-day practices.

Secondly, we have to look at how the nature of patient/physician interaction, along with its irrationalities, fears, habits, and quirks, has changed, and what this means to the future of the practice of medicine.  For example:  Susie comes to the ER with her perky 5 year old son Bobby who had just fallen off a piece of recreational equipment striking his head on a padded floor.  After a few moments of dizziness, he returns to his normal pre-event status.  Despite his apparent normalcy, Susie takes him to the ER, where Bobby is evaluated thoroughly by the ER physician, who can find nothing disconcerting.  Based on the history and physical exam, the doctor recommends observation and Tylenol as needed.  Susie, though somewhat reassured, mentions that a friend of hers knew someone who knew someone else that had a cousin whose daughter had a similar fall and got a CT scan.  That she thinks showed something.  And therefore, shouldn't Bobby get one? 

Ten, maybe twenty years ago, we would have confidently said no, and that would have been the end of it.  But now the discussion slips into the realm of "can you be sure?" and "would it hurt to..." and...You get the idea.  Knowing the severe penalty our legal system exacts if the highly unlikely but not impossible has happened, in all likelihood Bobby will get the head CT to assure that there is no intracranial injury.  While this can be called "defensive medicine," in reality what has happened is the result of a generation of interactions between physicians and patients that seek, no, make that demand, an absurdly high level of diagnostic certainty.  And usually just to prove that nothing is wrong.  We aren't seeking disease where we expect to find it as much as we are confirming the absence of disease where we don't expect it.  The latter, of course, is much more expensive.

Besides my concern that this style of practice is totally unaffordable, there is the peril that it places us in as a profession as we seek legitimate relief from the litigation drenched society in which we must function.  If we claim that 40% of the "excess" utilization is driven by defensive medicine, the logical conclusion is that once the burden of impending litigation is magically lifted off our shoulders, there will be a commensurate decrease in utilization.  My specific concern is that there is no such one-to-one correspondence.  In reality the practice patterns that have developed in the US are not just a response to mal-practice, but also to the profusion of and consumer demand for highly accurate but expensive tests and procedures which has conspired to create in our nation an unparalleled intolerance for uncertainty.   And while we must immediately and continuously advocate for tort reform, I believe with the utmost certainty that there will be little measurable change in patient/physician behavior until we have a new generation of physicians trained in a tort-restricted environment under the umbrella of respected and followed practice guidelines, and a generation of new patients that live in a world where the level of certainty that is attainable is commensurate with that which is affordable.

As we seek changes in medical tort law, we must not mistakenly suggest that tort reform will have an immediate payout in the form of recovered medical expense dollars.  If we make this mistake we are certain to disappoint, and are likely to suffer a backlash that may reverse any hard fought gains made in tort-reform and substantially delay the institution of meaningful and long-lasting improvements in medical tort law. 

Dr. David H. Epstein, MD, FACR, a partner with Radiology Associates of Hollywood,  is a senior attending with the Memorial Health Care System, member of the Florida Medicare Contractor Advisory Committee and Blue Cross/Blue Shield Physician Advisory Panel, and former Florida Radiology Society President.

Last Updated on Wednesday, 30 March 2011 16:05
Skepticism Regarding ACO's Print E-mail
Written by Name Withheld   
Thursday, 27 January 2011 16:26


Regarding ACO's A Viable Concept? By Michael Casanova Click here to view original article

As a practicing physician, I see ACOs as just another administrative layer that siphons off funds that could be used to pay for healthcare. Since hospitals and hospital systems are infinitely better financed and unified, physicians will unfortunately probably become the junior partner, meaning more profits for hospitals and smaller profits for physicians.  Politics within the medical community may also play a part. For example, a surgeon may take much more time to perform various procedures than others of his specialty and he may even have more complications all of which increase costs, but he is chief of staff, chief of surgery, or even a share holder in the ownership of a hospital. It would be difficult to remove him from an ACO.  Likewise, a particular surgeon may have all the most difficult high risk cases referred to him, so that his complication rate seems higher. As he runs the risk of being dropped by an ACO because his costs for care are higher, he may choose to refuse these difficult cases, though he may be the most qualified in the community to accept them.

In South Florida, we had a system called capitation, in which the primary care physician got a fixed payment each month based on how many of that HMO's patients were assigned to him and he had to pay for those patients.  If none or few of the patients needed care, he made a lot of money.  If many patients needed care, and in particular surgery, he didn't make any or very little.  By slowing down the process, delaying or denying consultations with specialists, scheduling tests or procedures, and other gimmicks, he could insure a better profit at the expense of his patient population.  This could and did happen.

There are so many other ways in which Medicare could save huge sums of money that ACOs aren't really necessary.  What is necessary is for politicians to take appropriate steps and stop protecting powerful groups like trial attorneys and insurance companies.  I have a number of ideas that I think would work.

-Name Withheld by Request

Last Updated on Wednesday, 30 March 2011 16:06
Pollice Verso: How State Legislators try to revive an ancient custom Print E-mail
Written by Bernd Wollschlaeger, MD   
Wednesday, 19 January 2011 10:24

IN MY OPINION                        

A recent article in the Wall Street Journal, Health Studies Cited for Transplant Cuts Put Under the Knife, highlights the looming issue of cost control.  Faced with skyrocketing healthcare costs, states will be forced to make tough decision on care allocation and coverage. 

Arizona already has taken drastic steps to drop Medicaid coverage for some organ transplants as the state tries to plug a $1 billion gap in its health-care budget for next year.  The state agency that recommended that Arizona stop paying for transplants of lungs and, for certain patients, hearts and livers, has defended the move by citing studies and figures that it says demonstrate the ineffectiveness of the procedures.   But the state agency has gone a step further by selecting studies that prove the point that certain transplants are ineffective.  To make its case for cuts, the Arizona agency cited several sets of numbers.  In dropping coverage of liver transplants for patients with hepatitis C, the state said liver recipients suffer recurrence of the disease at a rate of 100%.  And the state argued that candidates for lung transplants would live just as long with other medical care, citing data from university studies.    

Several transplant experts, however, point to flaws in the data and the way the state's Medicaid agency, called the Health Care Cost Containment System, has used the figures.  Arizona "used data that were outdated or data that made no sense, or they misinterpreted or misrepresented what experts said," says Michael Abecassis, director of Northwestern University's comprehensive transplant center and president of the surgeons' group. For lungs, a crux of the state's position was a 1995 study of 49 patients at the University of Washington, 25 of whom received transplants; the rest were waiting at the time of the study. The study concluded that transplant recipients would live half a year longer than those who didn't get a new lung, but the difference wasn't statistically significant-in part because the sample size was so small. Also, researchers didn't wait to track patients' survival, instead extrapolating long-term mortality rates from deaths and sickness in the short run.

So, what's the solution? States should not be permitted to arbitrarily decide what services can be covered under the state's Medicaid program. Instead, they should follow evidence-based data and, most importantly, comparative effectiveness research data.

Otherwise, we will revert to the Pollice Verso (thumbs turned) used in ancient Rome by the crowd to indicate if the defeated gladiator should be condemned to death.  Soon we do not need gladiators to revive this custom.  We just need legislators who will decide the fate of condemned Medicaid recipients.

Last Updated on Wednesday, 30 March 2011 16:06
Government Takeover Concern Print E-mail
Written by Reader   
Sunday, 02 January 2011 17:56


In response to Challenging conservative truisms about HCR by Bernd Wollschlaeger, MD

Click here to see original article

First things first; "PolitiFact Lie of the Year" has about as much journalistic credibility as "Pravda Lie of the Year".  PolitiFacts progressive/socialist editorial bias is unbridled and undeniable.

  • Unelected federal government bureaucrats will define up to (possibly fewer than) five plan definitions.  All American citizens will be obligated to purchase one of the plans that the federal government has designed.  Real lie of the year: "You will be able to keep your insurance coverage".
  • As dictated by the federal government, these plans may be sold only on exchanges constructed by State governments, under the criteria designed by federal government bureaucrats.
  • Purportedly free American companies will be prohibited from selling plans of their own design, even if there is strong demand for those designs from purportedly free American citizens.
  • Half of the current uninsured citizens will be enrolled in Medicaid, which will increase those rolls by approximately 50%, thereby dramatically increasing the number and percentage of citizens who are dependent on government run healthcare.  This is in spite of the fact that approximately 50% of primary care physicians' offices today will take no new Medicaid patients, and approximately 30% of primary care physicians' offices will take no Medicaid patients at all.  And, Medicaid is the largest budget item by far in nearly every State in the country, and is breaking the budgets of the majority of States in the country, before the planned 50% increase in enrollment. (Yes, the federal government will pay a disproportionate share of the increased Medicaid expense for a few years.  However the increased expense is permanent, not just for a few years,)
  • Half of the remaining uninsured are young, healthy people who can afford healthcare insurance, but have made the free choice not to purchase it.  They will no longer have that free choice, they will be required by the federal government to purchase this product that they don't want.
  • The other half of the remaining uninsured will be paid for by increased taxation on the 53% of American citizens who actually pay federal income taxes.
  • Federal bureaucrats have been empowered to design reimbursement schemes that they will be able to enforce upon the payors and providers of healthcare services.

Regulating with great specificity and dramatic impact the activities that private companies and citizens are permitted to engage in under penalty of law ("at the point of a gun"), and taking money from some of the citizens to give to those who pay nothing, for the purposes of achieving objectives that a self-appointed elite class has decided is in the best interest of the people, is textbook socialism/fascism, otherwise known as Government Takeover of Healthcare!

James "Jim" Craig


Last Updated on Wednesday, 30 March 2011 16:07
Is it possible to de-politicize the health policy discussion? Print E-mail
Written by Jeff Herschler   
Sunday, 02 January 2011 17:45

        Probably not. That said it might be a good idea to temper our rhetoric a bit.  Although popular with politicians, health policy is not easily formulated against a political backdrop.  Countervailing values push and pull the debate and an ideological solution appears remote.  Meanwhile the polarization so evident in the broader community is apparent in our own ranks.  See Nurses, doctors at odds on politics, 10-13-10 - Health News Florida.  Progressives and Conservatives do agree on at least one aspect of health policy.  There is a general consensus  that significant change must be applied to our health system to cope with healthcare inflation, unfunded liabilities and an aging demographic.  But gridlock might be the result if a middle ground cannot be found. 

Healthcare is a bit of a policy conundrum.  On the one hand civilized society must provide as a basic humanitarian duty.  On the other, personal responsibility is critical for resource allocation efficiency. Progressive insist that government must underwrite healthcare as an essential resource/infrastructure investment in the same way it finances/operates schools, bridges & roads, law enforcement & the courts, and national defense.  Then Conservatives remind us that runaway costs demand a market solution and market price discipline.

And it's not as if the health policy riddle is a new one.  Allen D. Spiegel, Ph.D. describes a healthcare system created by King Hammurabi of Babylon: "AT THE DAWN OF CIVILIZATION, about 4,000 years ago, nomadic Semite tribes developed a managed health care system. Using cuneiform, a hieroglyphic writing, they inscribed the concepts on clay tablets and chiseled them into stone between the 17th and 21st centuries B.C.  Adapting the existing edicts, King Hammurabi of Babylon incorporated ... managed care precepts in the Codex Hammurabi, a huge stone stele erected about 1700 B.C."

Meanwhile, Wikipedia describes the Healthcare system in Ancient Rome: "The importation of the Aesculapium established medicine in the public domain. There is no record of fees being collected for a stay at one of them, at Rome or elsewhere. The expense of an Aesculapium must have been defrayed in the same way as all temple expenses: individuals vowed to perform certain actions or contribute a certain amount if certain events happened, some of which were healings. Such a system amounts to gradated contributions by income, as the contributor could only vow what he could provide. The building of a temple and its facilities on the other hand was the responsibility of the magistrates. The funds came from the state treasury or from taxes."

Or consider this passage from All Quiet on the Western Front, by Erich Maria Remarque describing the health system in World War I Germany:  "The dressings afterwards are so expensive" says my father.  "Doesn't the Invalid's Fund pay anything towards it, then?" I ask.  "Mother has been ill too long."  Sounds like mom hit the policy limits or perhaps is the victim of a pre-existing condition clause. 

A reader recently complained that "we (seemingly) inexorably evolve toward socialized medicine".  But a pure market based solution is unthinkable.  Could you imagine this scenario: "I am sorry sir, we can't treat you following your life threatening diagnosis; we were unable to get an approval code on your AMEX".  So some sort of government involvement including safety nets and income redistribution is mandatory.  We just need to figure out to what degree.

The Conservatives believe the Healthcare Reform of 2010 goes too far.  Some Progressives believe that it is woefully short of what's necessary.  The discussion will continue and we will evolve towards, I am sure, a uniquely American solution.  The fact is both extremes have valid points so compromise is the only reasonable outcome.

Healthy debate is a good thing and I encourage it in the pages of FHIweekly and (See LAST WORD article where Jim Craig engages Bernd Wollschlaeger on Government Takeover of Healthcare.)  But polarizing, ideological rhetoric is counterproductive.  As the sun rises on 2011 and we continue to emerge from the Great Recession, our challenges are enormous.  So gratuitous talking points are out.  Discussion and debate are encouraged. 

About the author:  Mr. Herschler is the Publisher & Editor of FHIweekly and
Last Updated on Wednesday, 19 January 2011 17:11
Setting the Record Straight Print E-mail
Written by Jeffrey Herschler   
Monday, 27 December 2010 12:24

  On the evening of Wednesday, December 15th, I was up late (as usual) putting the finishing touches on that week's issue of FHIweekly.  I was scanning the digital headlines for breaking news to post to my newsletter.  I spotted a juicy one:  Jackson Health holding secret meeting... in the Miami Herald.  I scanned it briefly then made a quick decision to post and link it to my newsletter.  The next morning FHIweekly went out on schedule and, as usual, I immediately received several messages from readers.  One caught my eye. "Jeff, of all of the articles to run about Jackson...frankly do you think this one is in good taste?" the reader inquired.  I clicked through to the offensive article to find out.  

It's a short article and the main point is delivered in the final three sentences:

"Tuesday, Jackson executives will offer the report on security video cameras -- in secret. That portion of the audit committee meeting will be closed to the public.

A Jackson spokeswoman said Monday afternoon that the meeting will be closed under a section of the Florida Sunshine Law exempting details about government security systems."

-Miami Herald 12.15.10 

Sounds reasonable to me.  If I was meeting with my banker to change my PIN, I'd have the meeting "in secret".  Similarly, if I was conferring with my attorney regarding my last will and testament, I'd insist on a private setting.  Jackson officials made a prudent decision when they decided to close a meeting on sensitive security issues.

That headline was inflammatory and misleading in the sense that it implied that Jackson officials were committing some ethical breach by conducting a closed meeting.  Frankly this headline was not in good taste and had no place in FHIweekly.

Jackson faces an uphill battle against flat revenues and limited resources to meet increased demand for charity care.  It will continue to be under the public spotlight. As a journalist I will report the relevant and timely Jackson stories - good and bad.  However I won't post the inflammatory and misleading ones.   

About the Author:  Mr. Herschler is the Editor and Publisher of FHIweekly and

Challenging conservative truisms about HCR Print E-mail
Written by Bernd Wollschlaeger, MD   
Monday, 27 December 2010 11:47

     An article published recently in the Miami Herald entitled, PolitiFact Lie of the Year: 'Government takeover of health care', summarizes the falsehoods attributed to the overhaul of America's health insurance system.

PolitiFact editors and reporters have chosen ``government takeover of health care'' as the 2010 Lie of the Year. Uttered by dozens of politicians and leaders within organized medicine, it played an important role in shaping public opinion about the health care plan and was a significant factor in the Democrats' shellacking in the November elections. The Patient Protection and Affordable Care Act, also falsely called "Obama Care", was passed  by Congress, and relies largely on the free market:

  • Employers will continue to provide health insurance to the majority of Americans through private insurance companies
  • Contrary to the claim, more people will get private health coverage. The law sets up ``exchanges'' where private insurers will compete to provide coverage to people who don't have it.
  • The government will not seize control of hospitals or nationalize doctors.
  • The law does not include the public option, a government-run insurance plan that would have competed with private insurers.
  • The law gives tax credits to people who have difficulty affording insurance, so they can buy their coverage from private providers on the exchange. But here too, the approach relies on a free market with regulations, not socialized medicine.

PolitiFact reporters have studied the 906-page bill and interviewed independent health care experts. They  concluded it is inaccurate to call the plan a government takeover because it relies largely on the existing system of health coverage provided by employers. It's true that the law does significantly increase government regulation of health insurers. But it is, at its heart, a system that relies on private companies and the free market.

I encourage you to  respond accurately to your patient questions regarding this law and impact on their lives and our profession.  Let's remember that facts should rise above cheap talking points and ideological gibberish.

Last Updated on Saturday, 15 January 2011 15:00
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