Diabetes: Some Good News

Those who suffer from this debilitating and often deadly disease may be in line for some good news for a change. FoIB Holly R sent me links to two potentially wonderful breakthroughs.

First up:

"Surgeons at NewYork-Presbyterian Hospital/Columbia University Medical Center are innovating new ways to treat diabetes using techniques from weight-loss surgery"

There's a sort of "d'unh!" moment here: morbidly obese folks tend to be more prone to developing diabetes. But this technique is sort of the obverse side of the coin, in that the doc's are using treatments that were originally designed to treat weight gain and pointing them at the diabetes itself.

The folks at NY-P/C are looking to use a procedure called "sleeve gastrectomy" to target a side-effect of diabetes, astroparesis. They're also "offering weight-loss surgery for the treatment of Type 2 diabetes as part of an ongoing clinical trial."

So far, things look promising.

Half a world away, Israeli researchers have developed "[a]n implantable gastric stimulator with electrodes attached through laparoscopic surgery to the outer stomach muscles." Basically, it's a little "teaser" that both fools you into thinking you're already full, and promotes the release of certain hormones that suppress your desire for just one more Big Mac.

They've already implanted to little widget in over 200 people around the globe, and seen that "the system reduces blood glucose levels significantly."

Very cool.

Nine Signs You Should Fire Your Patient

This post is a response to the article 9 Signs You Should Fire Your Doctor.

A doctor keeping a patient that is medically non-compliant, or who displays unacceptable behavior, may seem the easier path to tread, but actually such patients are a detriment to one's medical practice as well as a malpractice suit waiting to happen. Here are nine signs that it’s time to fire your patient.

1. You don’t mesh. In today’s contentious legal atmosphere it is important that you have a patient that will listen to and take your medical advice and recommendation. As payments to physicians move from fee for service to payment on outcomes it is even more important that your patient follow your medical instructions. If there is a mismatch, then it's in your best interests to sever the relationship.

2. The patient doesn’t respect your time. How many times have you opened the exam room door to a patient on the cell phone asking you to wait for them to finish the phone call? Or, you have checked your schedule and your patient waltzes in 14 minutes late and still expects to be seen, regardless of the fact that there are other patients to be seen? If your patient does not want to take the time to listen to your medical advice but instead only wants some meds so he can leave, that is a problem. If your patient’s chronic lateness is disrupting the office why keep the patient?

3.The patient keeps you in the dark. A patient should be open and thorough about why he has come to see the physician. A physician learns many facts and techniques, however, mind reading is not found in any medical curriculum. A patient endangers himself when he does not reveal his entire medical history at the first appointment. Without proper medical information, a physician could prescribe a medication that interacts negatively with another medication or prescribe a treatment that would not be as effective if all medical information was known. Your medical practice is too important to feel confused or uninformed.

4.The patient doesn’t listen. Does your patient answer your questions with enough information to make a medical decision? When you ask for medical information does the patient jump to a conclusion about what you want to hear instead of providing you the facts? It all comes down to communicating to the patient and ensuring that the patient fully comprehends the information you are giving.

5.The patient is rude to the office staff. The receptionist is the link between you and the patient. As a physician, you put time and effort into ensuring that your staff is professional, trained and has the correct skill sets to manage both your office and your business. As medical professionals, your staff expects to come to work each day and be treated with the respect that matches their job, education, and experience. Even if your patient is pleasant with you, if the patient is rude to your staff this is a signal that you need to ask your patient to look elsewhere.

6.You don’t feel comfortable with the patient or wonder about his competence. As a doctor you need to know intimate details of your patient’s life in order to offer proper treatment. If the patient is not comfortable sharing this information, this hinders your ability to adequately treat the patient and opens you up to malpractice. A sense of unease as to whether or not the patient will follow you directions is a perfectly legitimate reason for cutting the cord. Beware of sloppy medical decision-making on the part of your patient since mistakes and misinformation in the chart can lead to a malpractice suit.

7.The patient does not coordinate his care with other doctors. As a specialist, the patient’s primary care doctor should be the quarterback of his healthcare team. If the patient does not share with you his primary care physician or does not inform his primary care physician of his treatment with you, then an important piece of your care could slip through the cracks.

8.The patient is unreachable. A good patient always ensures that the physician can reach him in the event of an emergency. If the patient is argumentative over providing correct demographic information or refuses to do the yearly demographic form, then you as the physician are missing a vital piece of that patient’s information. As important as your patient is in your care, it is also important that the patient realize that when the office is closed and they are having a medical emergency, the best place for them is the emergency room or urgent care center. As a physician, your primary duty is general care, not emergency care.

9.The patient is rude or condescending. I attended a workshop many years ago on the proper ways to manage health care information. During that meeting, the speaker asked if we had any Celebrity Patients. I responded no, but a lot of them think they are. Do you have a patient list of CP’s? Does your patient walk away when you are trying to give directions, or simply too important to deal with the policies and procedures of your office. Then it is time to part ways, as this patient will always trivialize both you and your staff.

The article does not have an ending paragraph, but I will include one:

Healthcare is one of the most stressful, busy, and under paid career fields that one can enter. People who enter the healthcare field do so not merely for money, but because of a true empathetic and sympathetic calling to help their fellow man. Many times, this character trait is taken advantage of by people who truly believe that they are the center of the universe. As empathic/sympathetic people, it is in our nature to try to make things right. However, since we are all truly mortal, sometimes things cannot be made right.

The article discusses abrupt behavior by physicians. I do concede that physicians can be abrupt at times; however, it is often due to the amount of information that they must process during the average appointment. The physician is the master of multi-tasking: listening, talking, taking notes, and making decisions very quickly and efficiently. While I am not dismissing the attitudes of physicians, as a patient you need to remember you are seeking a physician for his medical expertise, not as your personal confessor, confidant, or even close friend, but as a professional in the medical field that can treat and mend your injuries and illnesses.

Why You Need an Umbrella (Liability) Policy, Part II

Because you just never know:

"This was the moment when a woman driver caused a £700,000 five-car pile-up as her Bentley collided with a Mercedes, Ferrari, Porsche and Aston Martin."

Historically High. No, Wait: Historically Low

Do you sometimes (often?) get the feeling that the rocket surgeons in DC have been inhaling again? Take, for example, two emails I received today, just hours apart.

The first one breathlessly exclaims:

"Healthcare spending to reach new heights ... will account for almost a fifth of the nation’s economy by 2020, with government making up almost half of it, Medicare’s actuaries project"

Oh noes, the sky is falling!

Maybe not, as the second one explains:

"Today, the CMS Office of the Actuary released its report on how much the United States spends on health care now and in the future. The report shows a 3.9 percent growth in health spending in 2010 – an historic low."

So which is it?

One possibility is that these actuaries are, in fact, delusional, and that they don't have a clue as to what's really going on, let alone what will happen down the road as ObamaCrap kicks into high gear. While I'm by no means unconvinced that this is the case, a more charitable conclusion is that both reports are accurate.

But how can that be?

Well, we all know the old saw about statistics, and how they can be made to tell whatever story one wishes to hear. So for those who think the sky is, in fact, falling, there's ample evidence that we should be running for cover. On the other hand, those with a more optimistic outlook have plenty to be cheerful about.

As for me, I think it's perfectly obvious where we're actually heading: an aging population, with the chronic and expensive claims that go with it, presages much higher costs; the implementation of ObamaCare© and it's intrinsic rationing will create even greater anguish.

[Hat Tip: FoIB Holly R]

Hips, Knees, Tonsils and the MVNHS©: Oh, my!

Those rascally rationers at the Much Vaunted National Health Service© are on a roll. Not content to deny essential medical care to cancer patients and patients dying in the hallways, they've set their sites on the more mundane.

To wit:

"Hip replacements, cataract surgery and tonsil removal are among operations now being rationed in a bid to save the NHS money."

If memory serves (and it most assuredly does), proponents of ObamaCrap based most of their advocacy on the "fact" that British-style medical "care" delivered excellent care at substantial cost savings compared to our "broken" system.

The truth is: not so much.

Here's a sample of that superior, yet more cost-effective, health care "system:"

■ Cataract operations being withheld from patients until their sight problems "substantially" affect their ability to work

■ Tonsillectomies only to be carried out in children if they have had seven [seven!] bouts of tonsillitis in the previous year

On the other hand, they did get one thing right:

■ Funding has also been cut in some areas for IVF treatment

Paging Dr Berwick!

EMTALA vs DIY

It's not clear from this story, but it appears that the gentleman may have benefited from the services of an emergency room under the auspices of EMTALA:

"A 63-year-old American man with a hernia plunged a butter knife into his abdomen to try to fix the problem, and later put a lit cigarette in the wound."

As the young people say, "you're doing it wrong."

But believe it or not, this was the most eye-opening part:

"Lorenz ... was not under the influence of drugs or alcohol."

The good news is that Mr Lorenz "was taken to Los Angeles County-USC Medical Center ... The hospital was expected to perform the surgery to fix his hernia."

Under the care of a professional surgeon, one presumes.

One can't help but wonder, though, if there's a lesson on the effects of ObamaCare© in here somewhere.

MLR Revisited

In the law, there's an aphorism that goes "he who is his own lawyer has a fool for a client."

I would argue that as regards insurance, and especially health insurance, "he who is his own agent has a fool for a client."

[Click here for a detailed explication of why this is so. HGS]

Basically, the agent is the interface between the carrier and the client, and serves as both advisor to and advocate for the latter. Over the years, we've recounted countless experiences where agents have helped clients, both large and small, out of a bind.

Remember also that deleting the agent from the equation represents little, if any, real savings: after all, carriers still have to pay for Customer Service (such as it is) and marketing. If anything, I suspect that most agents who ultimately decide to "stay in" will move to a fee-only model, and clients without access to professional advice and advocacy are the ones who will be most hurt.

And that's one of the effects of the Medical Loss Ratio (MLR) provision in ObamaCare©. By mandating a specific disbursement threshold, agents' commissions go away, making it impossible for us to continue servicing existing clients, let alone obtaining new ones.

Of course, that's easy for me to say; after all, I have a vested interest in the outcome. What if I told you, though, that Senator Mary Landrieu (D-LA), who voted for ObamaCare© so that she (and we) could see what's actually in it, is having second thoughts about doing away with us? In a letter to HHS Secretary Shecantbeserious, Ms Landrieu writes:

"(A) certain provision regarding [ObamaCare©]'s MLR requirements is unintentionally* harming an important sector of the small business community - health insurance agents and brokers - and may also harm other small businesses that rely on their services."

[ed: it's far from clear that this was, in fact, "unintentional"]

So, contra Mr Rockefeller, agents do in fact bring value to the table.

But then, we already knew that.

[Hat Tip: FoIB P Paule]

Cavacade of Risk #136: Riskiest Sports edition is up!

Jacob Irwin presents this week's collection of risky posts, all centered on risky sports, from horse racing to cave-diving (and don't miss the cheerleaders!).

Weather or not....This is kinda cool [UPDATED]

About two months ago, our little corner of southwest Ohio was treated to a major thunderstorm, complete with "golf ball sized" hail.

As an aside: I had heard the term "golf ball sized hail" before, but never seen it myself. I imagined a roughly 2" diameter sphere. What came from the sky was, in fact, a rather flat piece of ice about 2" in diameter. Very scary.

All the west-facing windows at my office were smashed, and the damage around us was widespread. My brother-in-law was driving home from his son's baseball game and ran smack into the middle of the storm; his windshield was cracked in several places (luckily, there were no injuries).

Now, re-wind that a bit, and consider this: how helpful would it have been to my BIL if he'd had "Live:Wire® HailZone™ data and radar analytics to provide advanced warning of severe hailstorms?" This new program, a joint venture between Progressive Insurance and Weather Central, provides "automatic alerts via text message up to thirty minutes before hailstorms, high winds, or other severe weather."

Currently, this program is available only to Progressive insureds, but don't be shocked when we see the Weather Channel team up with State Farm, or whatever.

Very cool.

UPDATE - MORE COOL (NEW) TECH: Recently, I had some trouble writing a new life insurance policy on a gentleman who was, as we knew upfront, a diabetic. After doing a routine pre-screen, we applied; as part of the process, he had to undergo a brief medical exam. Unfortunately, his A1c "score" came back at 12.3%.

After a bit of Googling, I determined that this was almost twice as high as a "controlled" diabetic; we're still noodling out how to proceed.

But I really didn't know what an "A1c" score actually was or meant, and had to go Googling to find out. Not a huge deal, granted, but still: wouldn't it be nice to have that kind of info at my fingertips? What if I was away from my desk and had no immediate web access?

That's where the "first free mobile app to help consumers decipher their medical tests" comes in. Developed and offered by Lab Tests Online, this little widget "connects consumers to reliable, unbiased information that enables them to have more informed conversations with their doctors."

It seems to me that it would be just as handy as a quick reference for just about any medical test, even when it's just for one's own peace of mind.

Grand Rounds: Good Care edition

The folks at the Prepared Patient Forum host this week's round-up of medblog posts, focusing on what it takes to find good care and make the most of it. Do check it out.

Fraud, Shmaud: Medicare/Medicaid edition

The folks at Cato have just released this video which shows just how rampant and out-of-control Medicare and Medicaid fraud have become. The numbers - our tax dollars! - in play here are truly astounding. What's perhaps more disturbing, though, is the sense one gets that this kind of abuse is considered by leadership to be a feature, not a bug:

Medical Necessity Redux

It's time once again to open up the can o'worms known as "medical necessity." This caused an interesting kerfluffle some years ago when we discussed it as regards IVF. Yet here we go, once more into that (metaphorical) breech.

Last week, Bob wrote about "free" prescriptions, and their true cost. In that post, he noted that the "Institute of Medicine wants women to get free birth control pills ... [w]ith some pills running $90 per month."

That's just shy of $1,200 a year for a "medication" with but one purpose, to prevent a potential consequence of an easily avoided behavior, and for which numerous other "therapies" are available.

Now, it's true that these "meds" are sometimes used for other purposes (eg endometriosis), but again, all of these alternative - "off label," if you will - uses are easily (and often more effectively) substitutable by other protocols.

To put it another way: there is no justifiable medical reason for birth control pills to be covered by insurance. And, quite frankly, asking the 50% of the population who gain no benefit from these little pills to subsidize their cost is unfair, and unjustifiable.

But there's a larger issue here:

"The Obama administration seems ready to force insurance companies to include birth control coverage in their plans. So much for the president's promise of bending health care costs downward."

In fact, it gives HHS Secretary Shecantbeserious the "authority to compile a list of female preventive services that all new health insurance plans will have to cover without employing deductibles or charging co-payments."

These are known as "first dollar" benefits, meaning that there is no deductible, co-insurance or co-pay required of the recipient. It's "free." So much for "skin in the game," as well: we already know what happens to costs when benefits incur no out-of-pocket costs. And again, who's punished by this?

You'll notice that I don't advocate that plans cover Viagra, or prostate exams, or Rogaine. At all.

Those, too, increase costs, and only one can be considered medically necessary. But if we're going to go down this road, how about a little fairness?

Helpful Alzheimer's News

Back in May, we brought to our readers' attention a new online resource for (pretty much) all things Alzheimer's-related. While this horrible disease continues to claim lives (both metaphorically and actually), there may be hope that it can be staved off, if not eradicated:

"A provocative new analysis identifies the biggest risk factors for Alzheimer's disease — and concludes that more than half of all cases are potentially preventable"

Are you kidding me??!!

"Nearly half" of those who have, or might become afflicted with, Alzheimer's could have avoided such a fate?

Okay, I'll bite: what's the magic pill?

Turns out, it's not a "magic pill," but something far more practical:

"[S]imple lifestyle changes, such as exercising, quitting smoking and losing weight."

Really? Who knew??!!

Of course, these steps won't guarantee success, primarily because we still don't know what, precisely, triggers Alzheimer's in the first place. But it's kind of like the old joke, "what harm can it do?"

BONUS NEWS: Can a simple shot prevent heart disease? Maybe:

"An injection could reverse the ravages of heart disease, effectively curing the condition ... The gene injection takes just 12 weeks to start working."

[ed: that link is sketchy, just keep trying]

Based on so-called "gene therapy" techniques, it's still a ways from actual implementation, and of course, who knows if it'll be covered under ObamaCare©. Still, for those interested, more details are available here.

Wait Times in the Medical Office

It seems that wait times in the doctor’s office has been as big an issue in civilizations as food and shelter. The new twist on this age old problem is to have physician’s pay patients for “unusual wait times”. Patient Elaine Farstad told CNN "to date, she's sent bills to six physicians who have seen her more than 30 minutes late, three of which have paid.” As a medical manager I have focused many man hours and extensive resources in our office to assure we stay on time. However, being a medical office, we do have medical emergencies that may cause us to run behind. While we attempt to minimize these emergencies through better triage at the front desk, many patients would rather wait until the physician walks in the room to announce that they have a pain in their chest.

Both as a manager and as a patient I would ask Mrs. Farstad a simple question: When you are in the exam room and you have an irregular, though in normal range blood pressure, what do you want your doctor to be thinking:

1) “This blood pressure is somewhat irregular, maybe I should make sure there are no other issues?"

Or

2) “This blood pressure is a little irregular, but within parameters and if I run late with this patient I will have to pay the next patient. ”

Mrs. Farstad I would definitely want my doctor to think thought number 1. As we explain to our patients, we apologize for the wait but we assure them that the physician will take as long with them as necessary when it is their appointment.

The real issue is why do doctor’s run late. The answer is time. Physicians normally work more than 8 hours a day. In my office, one physician has 42.5 hours a week of patient time and the other has 46.25 patient hours a week. These patient hours do not include paperwork, charting, or any other medical or business matters. The standard patient appointment time is 15 minutes. How many of us could do our entire job in 15 minute increments, 25 to 28 times a day? Physicians do their jobs each day, every day in 15 minute increments, without mistakes and with measurable evidence of medical treatment. For this they receive a whopping $65.00 from contracted insurance companies.

The next time you are in a medical office and getting angry about the wait, remember there is a patient in the room right now, being treated by an exceptional professional who in 15 minutes must determine what is wrong, make a diagnosis, explain that to the patient and present a treatment that will take care of the issue. I am sure you would want nothing less.

Cavalcade of Risk #136: Call for submissions

Jacob Irwin hosts next week's CavRisk. Entries are due by Monday (the 25th).

NB: We're now using this submission tool: The BC WorkAround

Once there, you'll be asked to provide:

■ Your post's url and title
■ Your blog's url and name
■ Your name and email
■ A (brief) summary of the post ("Remarks")

At the bottom of the form, you'll see a drop-down menu; simply select "Cavalcade of Risk" then press "Submit" and you're good to go.

And PLEASE remember: ONLY posts that relate to risk (not personal finance tips and the like).

Captain Obvious meets ObamaCare©

Breaking hard:

"Healthcare law could leave families with high insurance costs"

In related news:

■ The sun may rise in the East tomorrow morning.

■ Putting your hand on a hot stove may cause discomfort.

■ Drinking water may avert thirst.

[Hat Tip for ObamaCare© item: FoIB Holly R]

Health Wonk Review: Get it while it's HOT!

HWR co-founder Julie Ferguson presents this week's red-hot round-up of healthcare wonkery, sizzlin' with great posts on everything from Medicaid in Oregon to cost curves and EMR. It's so hot, it's cool!

ObamaCare© kills jobs, too

It's not just Grandma and Grandpa being pulled off life support, it's our jobs:

[Hat Tip: Ace of Spades]

More On (Moron?) Those Exchanges

Even as Ohio voters look to shield the state from it, our new Governor has announced that "plans are moving forward to create a statewide marketplace or exchange for health insurance, as mandated by [ObamaCare©] ... the state has received federal money to plan for building an exchange."

Um, John: what part of the word "No" don't you understand?

But it gets worse:

"Taylor, who also heads Ohio's Department of Insurance, is to apply soon for a second round of federal cash."

Um, Mary: same question.

This is really maddening; it's okay to leave money on the table if the purpose of said funds is counter to the wishes of the people. It's also okay when the end result will be less choice, less competition, and higher costs, as the Exchanges will, in fact, produce:

"Health and Human Services Department released draft regulations telling the states how they must run these organizations, which are the core of the new entitlement and are where people will receive heavily subsidized coverage ... HHS, unsurprisingly, envisions the exchanges as 50 (or more) new regulatory agencies designed to let politics run health markets."

Spot on.

Oh, you doubt that last bit?

Heh.

But surely the Exchanges will "afford States substantial discretion in the design and operation of an Exchange," right?

Well, no:

"This is the exchange model that prevails in Massachusetts, where Mitt Romney's "connector" has become a tool for controlling the insurance industry and picking health-care winners and losers."

And we've seen how well that's worked out.

No surprise there, of course. The truth is, the gummint is competent to run a select, specific group of programs. But it is run, after all, by human beings (really!), and we humans are not immune to corruption, greed and failure.

Okay, Henry, that may be true, but what evidence is there to support that claim as regards health care?

I'm so glad you asked:

"For the second time, a federal audit has charged the Louisiana state health agency with mismanaging a $50 million post-Hurricane Katrina grant intended to restore health care access to the New Orleans region."

This wasn't a national program. This wasn't even a state-wide effort. It was focused, laser-like, on one city, and they couldn't even get that right. Earlier today, Bob asked (as regards "waste, fraud and abuse") why in the world we do "we need a new law or program to take care of something that SHOULD BE standard operating procedure?" The answer, of course, is that we don't. What we do need is protection from "our betters."

And just to pile on, HHS Secretary Shecantbeserious sent out new "proposed" rules for the Exchanges. What caught my eye is this (from a Cigna email):

"The regulation does not address all the requirements of Exchanges. Additional guidance is expected later this year regarding:

■ Standards for individual eligibility to purchase Exchange coverage, including premium subsidy information

And

■ The process for receiving an exemption from the individual mandate

And

■ The definition of essential health benefits

So, um, about those subsidies: how're those working out so far?

I can guess about how one receives an "exemption from the individual mandate."

And those "essential benefits?" One can safely assume.

[Hat Tip for Ohio item: FoIB Holly R]

Another 1,000 Words...

From IWV:

<Click here for details>

Grand Rounds go virtual (touring, that is)

Elaine Schattner is on staycation, so she decided to take her 'Rounds on a beautiful tour of medbloggers' home towns. Great pics accompany even better posts, so don't miss out.

There IS a difference...

Both health and disability insurance are (like auto and home) based on the concept of indemnification . That is, they are designed on the premise that one can both identify and quantify a given risk, and then offload some portion of that risk to an insurer.

Health insurance bases these quantities on the cost of health care; car insurance on the cost of a new vehicle (among other things); and disability insurance is based on one's wages.

Not exactly rocket surgery.

Most people have health insurance of one kind or another, most folks do not own disability insurance (more's the shame). But most intelligent, reasonably astute folks know the difference: health insurance pays the doc, disability insurance pays me (and, hence, the mortgage).

Apparently, our Rocket Surgeon in Chief (RSiC) is unaware of these differences:

"During the 2008 presidential campaign, Barack Obama often discussed his mother's struggle with cancer ... fighting with insurance companies that sought to deny her the coverage she needed to pay for treatment."

The story (and I stress the term story) became the centerpiece of his push for ObamaCrap.

Unfortunately, our RSiC misunderstood the very simple, obvious difference between health insurance and disability insurance:

"[ObamaMom]'s compensation for her job in Jakarta had included health insurance, which covered most of the costs of her medical treatment ... [ObamaMom]filed a separate claim under her employer's disability insurance policy." It was that claim, with the insurance company CIGNA, that was denied."

So let's get this straight: we are now facing an unprecedented limitation on our economic freedom because the RSiC misunderstood (and consistently misquoted) the difference between health and disability coverage?

Wow. Just wow.

Civility at the Medical Office

Over my 8 years as a medical practice manager I have had my share of patients not on their best behavior. I often have to tell patients no, we cannot do that because of 1) office policies, 2) federal policies, or 3) legality. It is at this point that the abusive language begins and I am accused of no customer service, being mean, and other colorful remarks. (The best question was, “Do you work at Wal Mart?" Still trying to figure out that insult.) Customer Service is not to do everything that the patient/customer wants, but to provide the best service/product at the best price with the best staff/employees. I have had many discussions with patients who are not happy with the answer, but I have never had to call 911 to get an abusive patient out of my office. Well, that streaked ended this week.

The Joint Commission released a report June 3, 2010 citing increased violence in the workplace.

After my encounter I found this article, which states that “Nationwide, health care is one of the most dangerous industries to work in, especially if you work in an ER.”

What caused this outburst on this particular day? The patient was 15 minutes late for her appointment and by office policy I informed her we could not see her today and that I would be happy to reschedule. The vast majority of all medical offices have a policy that if you are late for your appointment you are rescheduled. Most people are upset that they missed the appointment, but understand, reschedule and move on. I told her we could not see her and I would be happy to reschedule. She would have none of it. She insisted on being seen. I offered three times to reschedule her appointment. After the third time I asked her to leave. I told her if she did not leave, I would call 911. She said go ahead, and I did.

I have puzzled over the years why normal people become raging idiots in a physician’s office and I believe I have developed a theory. It is because people have been told for several decades and very recently that healthcare is a right. Thus if healthcare is a right, then people are relieved of the obligation of civility. Healthcare is a service, provided to the general population by educated professionals. We are guided by the ethics of our profession, the legality of our profession, federal guidelines, and general good business practices. Yes, medicine is a business and as such my policies are designed for optimal customer service. In this case, the late patient told me that my response was bad customer service and as such she should be seen. However, there are other customers we service in a day; approximately 50 patients are treated on a daily basis. All the other 49 patients made it to their appointments on time, so it would be poor customer service to allow the late patient disrupt their appointments because she was unable to make it to her appointment on time.

I realize that the bad behavior will not stop because I will not be able to accommodate every patient’s desire, needs, and perceived rights. I am able to only do what is ethical, legal, and in the best interests of the business. This is an anathema to the current trend that healthcare is a right, but healthcare is not a right. It is a privilege and as with all privileges patients must be more responsible in regards to their behavior in healthcare settings, or there will be no healthcare because professionals like me will simply leave and go to a less stressful profession, like selling shoes.

Welcome Aboard!

It's our pleasure to welcome long-time guest-blogger Kelley Beloff as a regular contributor. Regular readers know her as our resident Medical Office Maven (here, for example, or here); we're looking forward to showcasing her interesting and unique insights on a more regular basis.

Her first post as an official blogger is coming up shortly, so stay tuned...

Lest We Forget: ObamaWaiver© Mania Rolls On...

Last time we checked (about a month ago), ObamaWaivers© appeared to have peaked at about 1400. That seemed to be the saturation point for these little political nuggets.

Or so we thought.

Turns out, HHS Secretary Shecantbeserious still had a few burning a hole in her purse:

"The Health and Human Services Department granted 39 new waivers last month from part of the healthcare law, bringing the total to just shy of 1,500."

But let's say you're not a union or other major Dem contributor. Is there any hope for a change for you?

Well, maybe so:

"Sen. John Barrasso (R-Wyo.) said he will introduce a bill next week to let every American apply for a waiver from the healthcare law."

No word yet on the cost, but if you have to ask...

Flying AirHealth

FoIB Michael Cannon, the Cato Institute's Director of Health Policy Studies, alerts us to this outstanding video that perfectly illustrates how health care will work under ObamaCare©.

I'd say "enjoy," but...well, you'll see:

HSA News

First, courtesy of UHC, we learn that next year's Health Savings Account contributions and policy regs have been published by the IRS.

Some highlights:

■ The max annual contribution limit for single coverage is up $50 to $3,100; family max is also increased to $6.250 (a $100 step up)

■ The max OOP (out of pocket) limit for underlying High Deductible Health Plans (HDHPs), which includes deductible and co-insurance, goes up to $6,050 for singles and $12,100 for family plans (increases of $$100 and $200, respectively)

■ The minimum deductible for singles is $1,200 and $2,400 for families That's the same as this years'.

And speaking of HSA's, our own Alternative Benefits gurus as FlexBank point out that "HSAs have rules - LOTS of rules. Technically, it is the HSA owner's responsibility to know and abide by all of the rules. How in the world is this possible without help?"

That's where having access to a local, professional practice that focuses solely on these kinds of benefits comes in. Being able to pick up the phone (or get a quick reply by email) is, to coin a phrase, priceless.

AustraliaHealth© meets Mustang Ranch

Australia's national health care system (which is called, interestingly enough, Medicare) seems to have a problem. Although "(p)rimary health care remains the responsibility of the federal government," said government isn't actually keen on providing it.

Which leads to, um, interesting personal solutions:

"The day after Rachel Rohrlach and her soon-to-be-husband, farmer Chris Rohrlach, announced they were expecting their first child, Rachel suffered a debilitating stroke that left her a quadriplegic ... so Chris and two friends came up with the controversial solution to build and manage a brothel."

So how much does it cost to treat an Australian quadriplegic?

$25 (AU), same as in town.

Along the Oregon Trail

As we noted Monday, "you are more likely to die if you are on government insurance than if you have no insurance at all." And, of course, Oregon's health care "system" is an exemplar of this result.

Well, Cato's Michael Cannon reports on a yearlong experiment on Beaver State citizens, and the results aren't pretty:

"Oregon decided to enroll an additional 10,000 people in its Medicaid program via lottery ... Medicaid coverage led to higher medical consumption."

No surprise there: make pretty much anything freely available at low (or no) cost, and odds are you're going to have a lot of customers.

But is "free" health care worth what you pay for it?

You be the judge:

"Though the president has claimed [ObamaCrap] will “save lives,” the [Oregon Health Insurance Experiment] detected no evidence that extending Medicaid to 10,000 adults did so in the first year."

Granted, one year is hardly long-term, but shouldn't there have been some indication of improved morbidity (if not mortality) even in the short-run? Michael also points out - and this is important - that "the OHIE extended coverage to the most vulnerable population of uninsured Americans, yet the improvements in health and financial security are so far apparently modest."

Talk about damning with faint praise.

Barbara Wagner was unavailable for comment.

Cavalcade of Risk #135: Independence Days Edition now up...

Celebrate your own independence from the mundane with Notwithstanding's unique take on this great collection of risk-related posts. BONUS: A cool sideshow game featuring the flags of countries with national holidays in July.

Speaking of Exchange Policies

One of ObamaCare©'s major pitfalls is the so-called Exchanges. As we've seen with RomneyCare©, these may look good on paper, but their real-life implementation leave much to be desired. We've long been proponents of state-based experimentation, of course, so if the Bay State's happy with them, fine. But that doesn't mean that turning over their basic structure to the likes of HHS Secretary Shecantbeserious portends well:

"[T]he Obama administration unveiled standards on Monday for insurance marketplaces that will allow individuals, families and small businesses in every state to shop for insurance, compare prices and benefits and buy coverage."

As Bob noted here, putting the gummint in charge of these kinds of efforts leads only to heartbreak. Of course, it's literally "your tax dollars at work," since "[t]he Congressional Budget Office predicts that by 2019, about 24 million people will have insurance through exchanges, with four-fifths of them getting federal subsidies that average $6,400 a year per person." [emphasis added]

Let's do some simple math, shall we?

Eighty percent ("four-fifths") of 24 million is about 19 million souls. At $6,400 a pop, that's over 12 billion in taxpayer subsidies. Something about "robbing Peter...?"

I'd perhaps feel better about how this will all work out if it weren't for the fact that the whole shebang was conceived, and is being implemented, by folks like this.

Grand Rounds: "It's Up To Us" edition

Our theme this week is "Personal Responsibility" - only posts that address this issue have been included. I was quite impressed with the creativity that potential contributors brought to the table to make sure their posts fit the bill.

We like outside-the-bun thinkers.

The concept of personal responsibility (or accountability, if you prefer) has been a consistent meme here at IB since our earliest days some 6+ years ago. So it seemed appropriate to use that as the theme for this edition of the venerable Grand Rounds:

■ As the Happy Hospitalist notes, "personal responsibility doesn't have to be only about the patient. It can be about doctors and hospitals, too." Here's his take on how to hold providers accountable to their patients.

■ Ryan DuBosar, the ACP Internist, reports on a new study claiming that "obesity is filling in for smoking as a cause of death in working class women." Doc Ryan observes that "people need to take personal responsibility for their health, even as they drop one bad habit." Picking up a substitute one isn't moving the ball forward.

■ Can interpersonal communication help us understand our relationships and the social world in new ways? Will Meek thinks it can, and makes the case that "when we have this knowledge we can be more responsible in how we interact with others." A potentially great first step towards personal accountability.

■ Continuing the Happy Hospitalist's point that personal responsibility also rests with providers, Bob Coffield avers that "health care providers and staff have a “personal responsibility” under HIPAA to not snoop in the records of patients not under their care." But he goes even further, making a great case that "health care lawyers have a personal responsibility to understand how their health care clients are implementing and using social media tools in health care." These include Twitter and Facebook (and, presumably, blogs and bloggers).

■ The always entertaining (and enlightening) Dr Roy Daviss asks "should patients take personal responsibility for how their health information is shared and with whom?" In answering the question, he notes the "risks and benefits of your data going through a Health Information Exchange (HIE)." And don't miss the lively conversation in the comments.

■ Glenn Laffel provocatively suggests that "folks with chronic diseases would tend, all things being equal, to take care of themselves somewhat better than ‘healthy’ folks, since they have been taught the tough lesson that their behavior is indeed linked to poor health outcomes." One would think so, notes Glenn, but "alas, that’s just not the case."

■ Our colleague Louise Norris observes that "health insurance is not where personal responsibility ends." She backs this up by noting that, oftentimes, "a large claim on a health insurance policy can be the result of a chronic condition or one that will need extensive long-term treatment." One might well have coverage at the outset, but what happens if that changes during the course of the condition?

■ So how to avoid (or at least mitigate) such chronic conditions? Dr Ed Pullen suggests that "choosing a healthy hobby is one of the things we can all do to take personal responsibility for our own health," and even offers some helpful suggestions on which ones to consider.

■ Private practice cardiac electrophysiologist [ed: try saying that 10 times fast] Dr John Mandrola believes that "wellness requires more ownership," and laments that this message seems to be (increasingly) falling on deaf ears.

■ I confess to a guilty pleasure: DrRich (not a typo) is my favorite President of the Future Old Farts of America (FOFA). This is a lot more prestigious than it sounds: as of this writing, total membership in the FOFA exceeds zero. In this post, DrRich discusses what other OF's need to know about "Medicare as we know it," and their responsibility to ensure and/or prevent its demise.

■ Dr Charles offers us this Ode to Dads, and their child-feeding responsibilities.

■ Meanwhile, Dr Paul Aurbach offers this "brief introduction to helping persons with a medical disability safely enjoy an outdoor adventure experience, which may come with more than the "usual" amount of risk." Since assessing and managing risk is most definitely a matter of personal responsibility, this one's spot on.

■ So, should folks in Glass Hospitals stow thrones? Or ban smokers? University of Chicago's general internist and medical educator Dr John Schumann likes the idea that employers have the "right not to hire smokers." He notes that this is already the case at the Cleveland Clinic. But he's also concerned that it's a potential "slippery slope, and that all of us, especially those of us in the health care workplace, have a responsibility to set a good example."

■ Over at Calling the Shots, breast cancer survivor Beth Gainer knows better than most the value and importance of personal accountability. Her post "focuses on ordinary people who did the extraordinary," helping her through her "medical crisis of breast cancer because they felt a personal responsibility to do so." Talk about True Heroes.

■ e-Patient Dave [ed: gotta love that handle!] continues the cancer-survivor theme, offering this post that "articulates the best framework I've ever seen for what constitutes patient engagement." It's about 4-time (!!!) cancer survivor Jessie Gruman, whose recent address to the Institute for Clinical Systems Improvement recounts her own struggles and triumphs.

■ From Canada's West Coast, Carolyn Thomas wonders why "some heart attack survivors remain emotionally wounded for life as they relive and re-experience their catastrophic cardiac events again and again." She thinks it has to do with the fact that anyone who's undergone such a traumatic event can't help but be transformed, and then points out ways in which those most successful in moving on are those who understand best their own role in their recovery.

■ The Health Business Blog's David Williams brings us full circle, noting that providers also need to take a bit more personal responsibility. In this case, it's pretty simple: take the time to find out how much things cost [ed: sing it, brother!].

■ Finally, our own Bob Vineyard has the touching/disturbing story of a gentleman who took personal responsibility (perhaps) a bit too far.

Next week, please stop by Dr. Elaine Schattner's place for another romp through the medblogosphere.

Monday LinkFest

As is so often the case, these are items of interest which don't seem to merit their own, dedicated post. Still, we'd hate to miss mentioning them:

■ Buckeyes Buck BambiCare©?

Maybe so:

"More than 540,000 voters in the state have signed petitions in favor of a ballot initiative to amend Ohio’s state constitution to directly conflict with Obamacare’s individual mandate."

Assuming those half-a-million-plus signatures prove valid (and sufficient), there's a good chance that we'll see this on the ballot in a few months. The initiative is doubly-interesting: in addition to contesting the (Evil) Individual Mandate, it's worded to prevent the state from passing its own version of the federal train-wreck. Not that there's any great rush to do so: just check out our last item (below).

■ One of the major "accomplishments" of ObamaCare© is to move more folks off of their own private (and group) health plans and onto Medicaid. Whether or not that's such a great idea economically is, of course, a matter of great debate. What's not so debatable, though, may be whether or not it's good for our physical health:

"[S]tudies that show big mortality impacts from being uninsured show even bigger mortality impacts from being on Medicare and Medicaid, even after controlling for age and income: you are more likely to die if you are on government insurance than if you have no insurance at all." [emphasis added]

Ooops!

■ Clunkers and Insurance

Government Motors has added a new "service;" in addition to selling, servicing and financing your new car purchase, they'll even throw in free insurance:

"To spur sales, General Motors is offering a year's worth of car insurance along with any new GM car purchased in the states of Washington or Oregon ... The insurance ... includes both liability and physical damage coverage."

I'm reminded of an old saying.

■ Slow and Easy Does It (Not)

Whether or not Ohio voters are successful in blocking implementation of ObamaCare© here, at least one piece is facing an uphill battle in at least a few of the other 57 states:

"State insurance exchanges are not being set up fast enough to meet the 2014 deadline set by the healthcare law ... a number of state legislatures are at risk of handing over the central component of the reform effort to the federal government."

If your state hasn't set up its version of the notorious Exchange by '14, HHS Secretary Shecantbeserious is set to do so, like it or not. How that would play against any state-specific law barring such a move I'll leave to the lawyers to ponder.

ObamaCare©: Another Victim's Tale

As previously noted (here and here), very few weeks go by without at least one of us having to help a client deal with the consequences of ObamaCare©. This time, it's an old friend of mine whose family is quickly exhausting their COBRA coverage, and who need to find a place to land once it's gone later this summer.

Fred and Ethel are in their early 50's, and both have health issues serious enough to earn them declines in the open market. Their 13 year old daughter, in perfectly good health, is ineligible for her own plan because neither Mom nor Dad are insurable.

Or is she?

Bob recently pointed out two potential plans that might work: the first is a Short Term Medical, the other is a quasi-limited benefit plan. Both are from the same carrier, which has apparently decided that it will continue to offer child-only plans in these configurations.

So what's my beef?

First, the Short Term Medical plan is, well, only good for a short term (6 months at a time, to a maximum of two years in Ohio). And, it excludes coverage for pre-existing conditions (including those that develop during a previous STM's term). On the other hand, it's inexpensive and it does provide some coverage.

The other plan, which we'll call HA, may cover pre-existing conditions (depending on whether they were disclosed and underwritten), and doesn't have a built-in time limit. It's basically a limited benefit plan with some additional bells and whistles. It, too, is relatively inexpensive.

Fred and Ethel, though, are basically SOL: once COBRA runs out, their only real option is a (so-called) HIPAA Plan. This is expensive, mediocre coverage, but it does cover pre-existing conditions. Another option might have been the richer benefits and lower premiums of the ObamaPool©, but they're ineligible for that because they actually played by the rules and made the responsible decision to remain insured.

Oh, Brave New System.

Grand Rounds: "It's Up To Us" edition (Here at IB!)

Next Tuesday, InsureBlog hosts Grand Rounds, the prestigious compendium of the best the medblogosphere has to offer.

Also: a great way to learn about blogs you've never heard of (but should get to know).

Our theme will be "Personal Responsibility" - only posts that address this issue will be included (BUT: feel free to reach back into your archives - any relevant 2011 post will do). Submissions MUST be received no later than Sunday (7/10/11) to be considered.

Potential contributors can submit their entries to insureblog (at) mail (dot) com, and please include the following:

■ Your post's url and title
■ Your blog's url and name
■ Your name and email
■ A (brief) summary of the post

Thanks!

Cavalcade of Risk #135: Call for submissions

NotWithStanding blog hosts next week's CavRisk. Entries are due by Monday (the 11th).

NB: We're now using this submission tool: The BC WorkAround

Once there, you'll be asked to provide:

■ Your post's url and title
■ Your blog's url and name
■ Your name and email
■ A (brief) summary of the post ("Remarks")

At the bottom of the form, you'll see a drop-down menu; simply select "Cavalcade of Risk" then press "Submit" and you're good to go.

And PLEASE remember: ONLY posts that relate to risk (not personal finance tips and the like).

Risk Management and Cell Phones

I have a long-running dispute discussion with a colleague regarding the argument that driving while talking on the cell is the same as drunk driving.

[ed: We have no disagreement vis: texting and driving - we both agree that this warrants the immediate application of the death penalty]

My take is that talking on the phone using a hands-free device is no more risky than listening (and talking back) to the radio, or to one's spouse in the passenger seat. Bill thinks that pretty much any use of the cell while driving is inherently more dangerous than either of those two activities.

So, who's right?

Well, score one for the good guys me:

"A comprehensive study on distracted driving has found there is no conclusive evidence that hands-free cell phone use while driving is any less risky than hand-held cell phone use ... there is no evidence that cell phone or texting bans have reduced crashes."

Is this dispositive? No, not really: the study itself contained enough contradictory findings that the case is still open. But it does recommend that states without such bans hold off a while before enacting them, which also tells you something.

CORRECTION: Bill M begs to disagree: He thinks that the study actually proves his point that there's really no difference between hand-held and hands-free in terms of risk, and that the study actually supports his position.

What say you, dear readers?

Food Pyramid Update: Pass the Salt!

(Yeah, we're old school like that)

Just two months ago, we noted a study of 4,000 Continentals and their intake of salt. The surprising results?

"People who ate lots of salt were not more likely to get high blood pressure, and were less likely to die of heart disease than those with a low salt intake ... The findings "certainly do not support the current recommendation to lower salt intake in the general population."

Now, one might be tempted to discount those results as a "one-off," but one would be wrong to do so. Researchers at Exeter University took a peek at "seven published studies involving 6,489 people. Some had high blood pressure, others had normal blood pressure and they had all been put on salt-reduction diets." Their results mirrored those of the one we cited in May:

"[T]he authors found that there was no evidence that cutting down reduced deaths or heart disease in either group."

In fact (and as noted in that previous study), folks who did cut back on their salt intake were actually more likely to die prematurely than those who didn't alter their diet.

Bon appetit!

Is this drug worth it? Is it rationing if the answer is "no"?

On July 1, the Wall Street Journal reported that Medicare had decided to cover Provenge, a new drug for treatment of advanced prostate cancer.

According to the article, men with advanced prostate cancer and treated with Provenge in clinical research lived a median of about 26 months, or about four months longer than patients who received a placebo.

Translated into English, this says half the Provenge patients lived at least 4 months longer than patients treated with sugar water. The other half lived fewer than 4 months longer.

The punch line is the cost--about $93,000 per course of treatment. (Not a typo.)

I have a question. Why shouldn't Medicare allow patients a choice between Provenge - and a cash payment of $50,000?

Why ask? Well, for starters because this drug delivers minimal benefit, patients might not want it especially if another option were available; the cash option might be a much more welcome way for the federales to help families cope with the loss of a loved one; having no choice means taxpayers will shoulder much higher costs; there's no telling WHAT Medicare was really thinking anyway; and the only party that clearly benefits seems to be Dendreon, the drug manufacturer.

So - is this drug worth it? Is it rationing if the answer is "no" ?

Colorado Burnin'...

Through the ObamaBux©, that is:

"The federally sanctioned high-risk insurance pool for Colorado is signing up fewer patients and burning through its limited cash faster than expected, as the plan attracts the sickest of the sick."

So let's get this straight: you set up a program specifically designed to attract uninsured folks, and are then surprised to learn that the overwhelming majority of them are uninsured because of chromic and/or severe medical problems? And are then further surprised when said programs racks up major costs because you've not only underpriced the plan, but then put it "on sale?"

As Bob says, "Poppa Washington: buncha rocket surgeons."

Friday LinkFest

■ First up, FoIB Jeff M tips us to some cancer-related good news/bad news:

"A group of new drugs is promising to prolong the lives and relieve the symptoms of men with advanced prostate cancer, but could also add billions of dollars to the nation’s medical bills."

In a sense, this is sauce for goose/gander, since we've already seen how politicized the battle over breast-cancer treatment Avastin became. These are, of course, valid and important debates to have, but we mustn't lose sight of the very real bottom line: peoples' lives are at stake.

■ Next, we consider the case of Dr. Susan Rutten Wasson. Is she a "renegade" or just ahead of the curve:

"[She's] a throwback to a time before HMOs, electronic health records and hospitals with fountains in their lobbies. She sees patients the same day they call if ... and usually charges only $50 for a consultation. She takes cash or check, but no insurance — and sometimes accepts gratuities of a dozen fresh eggs or a pie."

■ Finally, RandCorp's Lisa Sodders alerts us to a new Rand study on Medicare's new reporting thresholds:

"Effective January 1, 2012, Medicare will require insurers and self-insured companies to report settlements, awards, and judgments to a Medicare beneficiary to the Centers for Medicare and Medicaid Services."

Big Brother, or Concerned Agency?

You be the judge.