Nearly a quarter of the Texas population lacked health insurance in 2010, according to the most recent data released by the American Community Survey, which the U.S. Census Bureau conducted. That’s more than 5.7 million Texans.It’s likely that someone you know — and probably one you wouldn’t have guessed — doesn’t have health insurance. More than half of the uninsured are employed. More than a third have an annual household income above $50,000. And more than 1 million have college experience or post-secondary degrees.

via Interactive: Who Are the Uninsured in Texas?.

Very nicely done.

If I get a lesson from this, it’s “Stay in School. kids!” (If you live that long).

Sustainable. They keep using that word. I do not think it means what they think it means…

Permanent repeal of the flawed Medicare payment formula known as the Sustainable Growth Rate just got a lot more expensive….

via Doc Fix Just Got More Expensive – Margot Sanger-Katz – NationalJournal.com.

So: the 2011 winner of the worst quackery award is: battlefield acupuncture. This bizarre practice, invented just 10 years ago, offers a trifecta of ills:

It offers no medical benefit and carries a real risk of harm for some patients.

The U.S. government is wasting tens of millions of dollars per year on it, and plans to increase its spending next year.

The patients are wounded combat veterans who have no choice about where to get treatment.

In battlefield acupuncture, the “doctor” (no competent doctor would do this) sticks needles into the patient’s ear to relieve pain.

via The Worst Quackery of 2011: Battlefield Acupuncture – Forbes.

Incredible. And infuriating.

(Found on Twitter, but I cannot recall who tweeted it).

Wow. Short, and sweet, and painful.

…peddling the same tired phenomenon of magical thinking regarding the diagnostic miracle of highly sensitive troponins…

via Emergency Medicine Literature of Note: Yet Another Highly Sensitive Troponin – In JAMA.

Nice! Go and read.

via @nickgenes on that Twitter thing…

This article and its graph (from the NEJM), and its interesting, informative but probably useless graph, was referenced today on twitter, via the Washington Post’s Wonkblog,

Recently, the Centers for Medicaid and Medicare Services announced a scheduled cut in Medicare physician fees of 27.4% for 2012. This cut stems from the sustainable growth rate (SGR) formula used by the physician-payment system. …
To illustrate the level of inequity in this system, we broke down the national spending for Medicare physician services by state and by specialty and determined which states and specialties have contributed most to the SGR deficit between 2002, when the program was last balanced, and 2009. Although SGR spending targets are set on a national level, we computed state targets by applying the SGR’s national target growth rate to each state’s per capita expenditure, using 2002 as the base year. Our analysis is an approximation, because, unlike the SGR, we do not adjust for differential fee changes. …

We compared the state targets for the years 2003 to 2009 to actual state expenditures and added the annual difference between these figures to get a cumulative difference between the state’s spending and the SGR target. This cumulative difference was then divided by the 2002 per capita expenditure to determine the percentage growth since 2002.

via The Sources of the SGR “Hole” — NEJM.

Here are the graphs, and my attempts at explanation, and the questions I have:  Read the rest of this entry »

I got a nice email form someone who stumbled across this Humble Blog, and had the following questions; my replies follow. Those who have something constructive to add, please do so in the comments.

1. I’m most interested in EM. Given that I have no prior military service/experience, am I basically going to have to do a GMO tour to get this specialty?

Well, it depends on a lot of factors. Your branch of service is probably the biggest determinant (AF is best, Navy is historically worst at going from Internship straight to residency without a GMO tour), but there are several reasons you might not want to go straight to residency.

Honestly, residency is easy compared with being a GMO, at least the first year of a GMO tour. I finished a Basic Surgery Internship, and went to the fleet as a Battalion Surgeon (honorary doc title). I could spit out the Ddx of hypersplenism but had no idea how to treat musculoskeletal back pain, an ankle sprain, or PFPS. I’ll get into the rest of this later.

2. Did you do a GMO tour? If so, how was it?

Yes, GMO for 4 years. Fortunately for me it was between conflicts. To plagarize some guy, it was the best of times, it was the worst of times. Seriously, if I could have my GMO job 1/2 time and my real job 1/2 time I’d be a very happy person, and a happy doc.

3. What made you ultimately decide to stay in military post-active duty or leave for private practice?

I wasn’t a career type, and I knew I wanted to work in the real world. At the time new EM grads were going to boats, and while they’d be very useful there were there a shooting war, it would be a punishment tour otherwise.

4. What kind of leadership opportunities did you have in military medicine that you feel would have been impossible/unlikely in civilian medicine?

I got to lead, really lead, some excellent Navy Corpsmen, I got to advocate for some Marines and Sailors who needed it, and I got to go places nobody gets to these days. (2 trips to Iwo Jima, try booking that on Kayak).

5. Would you have decided to still do HPSP if the scholarship amount was significantly smaller? (ie, <50% what it is).

It was that then, I did it because I wanted to serve and it served by desires and interests. In general, if you’re considering HPSP just to pay the bills you won’t be a happy camper, and you’re signing on the line for a lot of years.

6. Is it possible to find out how many GMOs the Navy needs? (Currently, there are rumors that the Navy is going to change the GMO program).

No idea. But, don’t consider GMO time punishment, or time lost, it’s just something different, and I still think of (parts of it) fondly. The bonus of being a GMO and re-applying to a military residency? Time in Service is weighted on your app. So, if you want to be a brain surgeon but were bottom of your class, after a few GMO tours you’d most likely be in (YMMV).

Best of luck with your decision, and please let me know how it goes!

Aah, the French:

The idea of putting maggots into open flesh may sound repulsive, but such a therapy might be a quick way to clean wounds, a new study from France suggests.

via Maggots Clean Wounds Faster Than Surgeons | Wound Healing | LiveScience.

I kid. I think this is a good idea, and it’s natures’ way of saying ‘cleanup on aisle three’. Patients not infrequently will be brought to the ED with awful, non-healing wounds infested with maggots.

We typically kill them off, more because a) the staff is completely grossed out and b) if you’re living at home and have maggots in your wounds, let’s just say your personal hygiene is deeply suspect. Rank, in fact. Needs a decon level bad.

However, there is a legitimate role for biological wound cleaning; I have a WWII surgical book with a chapter in it on growing your own sterile maggots. It’s not an ER thing, but it’s yet another tool in the armamentarium of bad wounds.

You. Don’t. Say.

Thanks to a $374,000 taxpayer-funded grant, we now know that inhaling lemon and lavender scents doesn’t do a lot for our ability to heal a wound. With $666,000 in federal research money, scientists examined whether distant prayer could heal AIDS. It could not.

The National Center for Complementary and Alternative Medicine, or NCCAM, also helped pay scientists to study whether squirting brewed coffee into someone’s intestines can help treat pancreatic cancer (a $406,000 grant) and whether massage makes people with advanced cancer feel better ($1.25 million). The coffee enemas did not help. The massage did.

…

“Some of these treatments were just distinctly made up out of people’s imaginations,” said Dr. Wallace Sampson, clinical professor emeritus of medicine at Stanford University. “We don’t take public money and invest it in projects that are just made up out of people’s imaginations.”

via Studying alternative medicine with federal dollars – latimes.com.

For those who are curious about homeopathy:

I read that headline and said, “Wow!, finally I won’t need to CT all those patients’ heads!”

FDA permits marketing of the first hand-held device to aid in the detection of bleeding in the skull

Helps to determine if immediate CT scan is needed

The U.S. Food and Drug Administration today allowed marketing of the first hand-held device intended to aid in the detection of life-threatening bleeding in the skull called intracranial hematomas, using near-infrared spectroscopy.

via Press Announcements > FDA permits marketing of the first hand-held device to aid in the detection of bleeding in the skull.

But then, wait, said I, is it any good? Apparently Not:

The FDA granted the de novo petition for the Infrascanner Model 1000 based on a review of data comparing results from 383 CT scans of adult subjects with Infrascanner scan results. The Infrascanner was able to detect nearly 75 percent of the hematomas detected by CT scan. When CT scans detected no hematoma, the Infrascanner detected no hematoma 82 percent of the time. The Infrascanner Model 1000, however, is not a substitute for a CT scan.

Anyone considering purchasing one of these based on those numbers? If so, I’ll sell you a random number generator for 1/2 of what they’re asking.

Stated another way, this device will miss more than 25% of intracranial hematomas that are present, and will tell you it’s there when it’s not 18% of the time.

Not ready for prime time. I feel bad for the detailers who are sent out to see this thing, and worse for the patients it’s used on.

Brought to my attention by @EMNews on twitter. (In case you missed it, I’m getting a lot of my bloggable stuff from Twitter. I don’t blog most of what I comment on. Imagine what you’re missing! Get to twitter, and follow me @gruntdoc).

As the original twitterer ( @NickGenes ) said, “…because there wasn’t enough bureaucracy & expense in healthcare yet”.

The U.S. Department of Health and Human Services (HHS) Office for Civil Rights (OCR) has begun the process of notifying covered entities that they are among the unlucky few who have been selected for the first Health Insurance Portability and Accountability Act of 1996 (HIPAA) privacy and security audits under the Health Information Technology for Economic and Clinical Health (HITECH) Act. …

While the first twenty covered entities have been selected, approximately another 130 remain in this audit round. HHS has indicated that it hopes to continue with proactive audits in the future and expects to become more aggressive in its enforcement of complaints.

via HHS Audits the 1% … and the Rest: First HIPAA Privacy and Security Audits Begin – Davis Wright Tremaine.

Yes, this is HITECH, the Son of HIPAA, but it all started with HIPAA.

Is it worth pointing out that HIPAA exempted itself from the unfunded mandate and paperwork reduction rules when it was enacted? I pointed out then that their assertion that it wouldn’t cause an increase in paperwork, nor was it an unfunded mandate was really unlikely.

How many Millions of dollars and man-hours are we pouring down these regulatory holes?

Well, this is good news. Remember that we were assured the information in the NPDB would be protected? Yeah, me too.

And, I don’t understand this move at all.

Law enforcement can access data bank without doctors’ knowledge

The rule, a response to the expansion of the National Practitioner Data Bank, is intended to help prevent evidence tampering.

By Carolyne Krupa, amednews staff. Posted Dec. 13, 2011.

Physicians and other health professionals no longer will be notified if someone accesses information about them through the National Practitioner Data Bank for an investigation, according to a federal rule that takes effect Dec. 23.

The rule, an exemption to the Privacy Act, is meant to prevent tampering with evidence and is limited to law enforcement agencies, said David Bowman, a spokesman for the Dept. of Health and Human Services’ Health Resources and Services Administration, which administers the data bank.

Umm, prevent tampering with WHAT evidence? by the time something’s being put in the NPDB, it’s know about by a lot of folks, and there isn’t any realy opportunity to ‘tamper with evidence’. This sounds exceptionally fishy to me. I need a better explanation than this. (I know I won’t get it).

Oh, and spot the problem with this logic (which I’ll point out after the quote):

Law enforcement agencies are authorized to see information on adverse actions against physicians such as medical board disciplinary actions and peer review sanctions. Such queries make up less than 1% of NPDB queries, with an average of 20 by law enforcement annually, according to the rule (www.gpo.gov/fdsys/pkg/FR-2011-11-23/pdf/2011-30292.pdf).

via amednews: Law enforcement can access data bank without doctors’ knowledge :: Dec. 13, 2011 … American Medical News.

When Law Enforcement was required to notify people they’d had a look at their records, their query rate was less than 1%. Now that they can do it secretly, what will that rate be? We’ll never know.

And, it’s not a tiny company with very limited resources, either…

He can’t talk to us because Apple fires employees who talk with the press without permission, but also because the company must walk a fine line in the medical arena. Right now, the U.S. Food and Drug Administration seems set on regulating the software that runs on the iPad, not the device itself, but if the FDA were to decide that Apple is marketing the iPad for regulated medical uses, it could unleash a regulatory nightmare on the company.

Apple has to carefully watch what it says when it talks about the iPad in medicine, says Bradley Thompson, a partner with the law firm Epstein Becker Green and an expert on FDA regulations. As long as they promote it as a general-use computing device, Apple should be fine. But “if they were promoting it for specific medical device uses,” he says, “they would cross a line.”

via Apple’s Secret Plan to Steal Your Doctor’s Heart | Wired Enterprise | Wired.com.

For those who wonder why many of us are against the regulate-everything environment…

I really like this idea, but …  well, see after the quote.

It’s easy to compare prices on cameras, vacations, and homes. But in the United States, patients fly blind when paying for health care. People typically don’t find out how much any given medical procedure costs until well after they receive treatment, be it a blood draw or major surgery.

This lack of transparency has contributed to huge disparities in the cost of procedures. According to Castlight Health, a startup based in San Francisco, a colonoscopy costs anywhere from $563 to $3,967 within a single zip code. EKGs can range from $27 to $143, while the price for a set of three spinal x-rays varies from as little as $38 to as high as $162.

When someone else is picking up the tab, mystery pricing is not much of a problem. But these days, even the 59.5 million Americans who get health benefits through large self-insured employers are increasingly expected to pay a percentage of the costs for their medical care.

Castlight aims to do as its name suggests: cast light on the actual costs of medical care, so that people can make informed decisions…

via Exposing the Cost of Health Care – Technology Review.

Finally! Some price transparency! Huzzah! I WANT people to recognize that spending money when there’s no clue to the charge (not cost, charge) is directly responsible for a ton of the runaway cost in medicine.

This is better then nothing. It is, and while I don’t begrudge people making money on their great idea, is this the best model?

The company sells its tool to self-insured employers, who pay a fee per covered member per month, and in turn offer employees access so they can become more responsible users of their benefits. It has raised $81 million in venture funding to date. Current customers include Safeway and Life Technologies, a leading maker of genomics tools.

“Castlight is further along than anybody else in helping big employers show their employees that the individual decisions they make on health care actually do have a cost that affects benefits and wages,” says Matthew Holt, co-chairman of Health 2.0, a health-care consultancy firm.

Okay, better than nothing, and a start in the right direction. Good for them.

Update: this happened 2 years ago. So, I wrote this thinking it was a new development, but it isn’t. Anyone know how this experiment has played out?

I’ve wondered for years if hospital organizations (and big organized clinics) had done the math on whether they could do without Medicare, and apparently Mayo has. More after the quote

President Obama last year praised the Mayo Clinic as a “classic example” of how a health-care provider can offer “better outcomes” at lower cost. Then what should Americans think about the famous Minnesota medical center’s decision to take fewer Medicare patients?

Specifically, Mayo said last week it will no longer accept Medicare patients at one of its primary care clinics in Arizona. Mayo said the decision is part of a two-year pilot program to determine if it should also drop Medicare patients at other facilities in Arizona, Florida and Minnesota, which serve more than 500,000 seniors.

Mayo says it lost $840 million last year treating Medicare patients, the result of the program’s low reimbursement rates. Its hospital and four clinics in Arizona—including the Glendale facility—lost $120 million. Providers like Mayo swallow some of these Medicare losses, while also shifting the cost by charging more to private patients and insurers.

via Medicare and the Mayo Clinic – WSJ.com.

First thought: the docs at the Mayo Clinic must have gotten some amazing assurances from the clinic to drop Medicare for 2 years. (If a physician opts out of accepting medicare, and it’s an all or nothing proposition, and under current law they cannot get their medicare billing back for 2 years. No doubt this was done to keep docs from using their opt-out as political leverage, and then get it restored when payments went the way they wanted).

Second thought: Mayo just became a Concierge Clinic. Interesting.

Third: I’m very interested in knowing what administrative advantages would follow dropping Medicare. EMTALA would no longer apply, but this is a clinic, not a hospital/ED, so I’m not sure that would affect them much. (I may misunderstand the role and capabilities of this Arizona Mayo Clinic, so let me know if I’m wrong here).

There are always strings attached with taking Uncle’s money, and they don’t lessen over time, they compound. I think HIPAA is linked to Medicare, too, so that gigantic unfunded mandate could stop.

Interesting…

Let’s say, hypothetically, you could design the ED of the Future. I say hypothetically as there may be a new (like New) ED in my future. Maybe; it sounds like a heck of a challenge. Considering we’re a Trauma Center and currently see nearly 100K/year in volume, and have an admission rate that’s between 18-35%,

What would that new ED look like, from the following viewpoints :

• the patient
• the triage nurse (is there one?)
• the treating nurse
• the ED doc
• the consultant
• the hospital admissions team (billing)
• the OR
• the Tele units
• the Floor units
• ED discharge areas
• physical plant

I have a few ideas, but am frankly hamstrung by a lack of ‘out there’ imagination. Let’s hope you’re not similarly limited. Don’t feel like you need to answer all of these, but I’m interested in your ‘out of the box’ ideas…which you’ll get full (if ephemeral) credit for.