L Gordon Moore

"Institutions will try to preserve the problem to which they are the solution.” — Clay..."

Thu, 22 Apr 2010 06:55:55 -0700

““Institutions will try to preserve the problem to which they are the solution.” — Clay Shirky”

- The Technium: The Shirky Principle

Symptom Checker - Check Your Symptoms - Check Medical Symptoms

Mon, 12 Apr 2010 10:55:24 -0700

Symptom Checker - Check Your Symptoms - Check Medical Symptoms

Doctors Remove Ammunition From Soldier’s Head

Sun, 11 Apr 2010 17:18:59 -0700

Doctors Remove Ammunition From Soldier’s Head:

We shy away from live ammunition in our practice, though we’re happy to help with lacerations and other less dramatic events.

"universal health care will be doomed if there are not enough primary care doctors"

Fri, 13 Nov 2009 10:04:41 -0800

“universal health care will be doomed if there are not enough primary care doctors”

- Doctor and Patient - Primary Care’s Image Problem - NYTimes.com

So true, but not the whole story.

The JAMA study of medical students cited in the article describes medical students looking at the impossible pressures and manifest misery of the typical primary care physician. 98% of those medical students made the logical conclusion to avoid a career in primary care internal medicine.

This is not so much an ‘image problem’ as stated in the headline, but a problem of the typical office practice operating in a broken paradigm. The story is incomplete in failing to note the green shoots of primary care practices discovering new paradigms that free the physician to do what’s right.

My heroes are doctors like Jean Antonucci MD in Farmington ME, John Brady MD in Newport News VA, Aaron Blackledge MD San Francisco, and a host of others who reject the assumptions of the status quo and achieve brilliance in delivering better care.

Medical students who visit practices like theirs come away understanding the potential of high functioning primary care, the better outcomes, the improved satisfaction with care and the satisfaction of living up to the highest ideals of our profession.

Headed to the emergency room? Bring a book.

Wed, 11 Nov 2009 18:34:41 -0800

Headed to the emergency room? Bring a book.:

Is it crowds of poor people using the ER as their source of primary care? No….

“The researchers conclude that poor, uninsured patients aren’t to blame.”

It turns out that while wait times have increased and the proportion of people going to the ER have increased over time, the proportion of poor folks going has remained the same.

So what’s behind this?

“…it appears that decreased access to primary health care for all patients and an aging population are more important contributors to the per capita increase”

Turns out the flip side is true too:

When people have good access to primary care that doesn’t treat them with flagrant disrespect through waits and delays, they end up using the ER less often. (read a study on this)

It’s good to know that a small but growing number of primary care offices know this and can deliver on the promise of good access.

The Rules of Cancer - Well Blog - NYTimes.com

Tue, 10 Nov 2009 18:29:00 -0800

The Rules of Cancer - Well Blog - NYTimes.com:

A wonderful example of someone who totally gets the power of a collaborative relationship in health care.

Health care is so much more than tests and diagnoses; it is about real and complex people. To honor the essence of our profession we must get off the hamster wheel.

Should insurance contracts come with black box warnings?

Sat, 03 Oct 2009 10:00:35 -0700

A colleague wrote:

If your practice is what you want it to be, then do not spoil it by taking (hundreds of) Medicare patients in order to fulfill the criteria for the stimulus money. Doctors have been giving up autonomy for money for years and that is why 58% would quit medicine if given the chance. If you feel your practice is financially faltering and you need an infusion of more patients or you particularly like elderly patients, then go for it. But do not let the beauty of the spinach entice you to taste the toxic stew unless you are starving and there is no other food around.

I know I accept insurance and therefore have been drinking the stew for years, but I realize how it zaps my strength and had initiated a cancerous growth that will almost certainly force me to stop practicing medicine early. Nearly every week I ponder the idea of breaking from the insurance industry. The reality is my practice would not financially survive. My patients don’t want to/can’t pay more than a simple co-pay. The federal stimulus will help my bottom line. Increasing primary care pay will help my bottom line. But, the stupid stupid stupid administrative stuff is what kills and that is what you accept when you sign on the dotted Medicare line. Insurance contracts should come with a skull and crossbones on the front page (open at your own risk). [emphasis added]

John

What an interesting idea. Since more and more primary care physicians are realizing that continued contracting with the insurance industry is forcing them into a downward spiral of more and more ‘productivity’ at the expense of their patients and professionalism, maybe we should be lobbying for black box warnings on contracts?

WARNING TO PHYSICIANS: Used as intended, this contract could lead to direct patient harm in the event we choose to deny needed care or delay care through endless paperwork. This harm may in some cases lead to premature death or permanent disability. Signing this contract could force your practice into financial penury and increases the risk of career burnout. Numerous studies have demonstrated that this risk is particularly high for primary care physicians. Physicians should seriously consider the ethical and professional implications of signing this contract.

WARNING TO PATIENTS: Signing this contract in no way obligates the insurer (us) to provide insurance coverage for the member (you), though it does obligate the member to provide monthly payment to the insurer. If the member becomes ill and needs significant help* (*’significant’ is a subjective term that will be interpreted solely by the insurer’s employed clerks) we reserve the right to continue to collect monthly premiums while denying services. Signing this contract means the member has waived forever the right to sue. If there is ever a disagreement, the member must use our designated and beholden stable of arbitration lawyers in a complete sham of legal justice.

Primum non nocere

A peek at the tip of the iceberg of paperwork sinking the great...

Fri, 02 Oct 2009 10:12:03 -0700

A peek at the tip of the iceberg of paperwork sinking the great Titanic of US healthcare.

"We really need a national conversation about how we measure quality. The Cartesian verbatim approach..."

Fri, 25 Sep 2009 12:24:08 -0700

“We really need a national conversation about how we measure quality. The Cartesian verbatim approach is missing the forest for the trees.”

- Ideal Medical Practices: Clinical gist and what we measure

An interesting commentary from JAMA on verbatim and gist memory & implications on how we measure medical quality.

Painter/physician Dr. Sam brings affordable health care to...

Fri, 25 Sep 2009 10:31:20 -0700

Painter/physician Dr. Sam brings affordable health care to Minneapolis artists

Why aren't teabaggers fired up about socialized finances? Why do bankers keep getting more taxpayer protection?

Thu, 24 Sep 2009 13:01:00 -0700

A top White House economic adviser says the Obama administration’s proposed overhaul of financial rules preserves the policy of “too big to fail,” and could lead to future bailouts. Former Federal Reserve Chairman Paul Volcker said Thursday that by designating some companies as critical to the broader financial system, the plans create an expectation that those firms enjoy government backing in tough times. That implies those financial companies “will be sheltered by access to a federal safety net,” he said. From HuffPost

I wonder if it has anything to do with the revolving door between these institutions and major governmental policy positions?

This is not a democratic or republican issue. This smacks of the corporate takeover of our republic.

We’re #37 in the world for health systems but at least we...

Wed, 23 Sep 2009 16:50:51 -0700

We’re #37 in the world for health systems but at least we spend 40% more per person! Take THAT, rest of you better-health-system-countries!

Protect Insurance Companies PSA from FOD Team, Will Ferrell, Jon Hamm, Olivia Wilde, Thomas Lennon, Donald Faison, Linda Cardellini, Masi Oka, Ben Garant, Jordana Spiro, lauren, Drew, and chad_carter - Video

Tue, 22 Sep 2009 14:54:21 -0700

Protect Insurance Companies PSA from FOD Team, Will Ferrell, Jon Hamm, Olivia Wilde, Thomas Lennon, Donald Faison, Linda Cardellini, Masi Oka, Ben Garant, Jordana Spiro, lauren, Drew, and chad_carter - Video

“As a nation, we first need to answer the question as to whether health care is a right or a...

Mon, 21 Sep 2009 08:46:36 -0700

“As a nation, we first need to answer the question as to whether health care is a right or a privilege before we jump into the details of fixing it. If health care is a privilege, then we need to decide unapologetically who should die unnecessarily (certainly letting the old, poor, and sick die would be the most financially advantageous) . If that seems a bit harsh and we can’t determine who we should discriminate against, then perhaps we feel health care is a right. If it is a right, then by definition it has to be universal. So then all we need to do is figure out the most cost effective way to provide universal coverage. Interestingly, by simply getting to this point in the conversation, the us vs. them begins to go away and it is just an us—how do we cover everyone and what is that coverage going to be? Heck, that is almost a simple conversation compared to where we are now.”

John Brady MD writing about conversations he has been having with some of his patients about the need to step back from rhetoric and dogma to address the real underlying issues in health care in the US.

"Are health insurance companies generally being fair and honest when they reject claims from policy..."

Fri, 18 Sep 2009 17:29:38 -0700

“Are health insurance companies generally being fair and honest when they reject claims from policy holders?”

- In Health Care, Number Of Claims Denied Remains A Mystery

Lemme take a crack at this. Um, I seem to recall some recent posts from colleagues that tell a pretty grim tale regarding rejections.

OK, not all claim rejections are such horror stories. I had claims rejected because I forgot to fill in a box on the form correctly. I found the number of the insurer, waited on hold, had to provide a bunch of codes to prove who I was, then the clerk would look up the claim in question and tell me why it was rejected “You didn’t put a modifier on the procedure code.”

“Oh. What modifier should I have used?”
“We’re not permitted to tell you that.”

That kind of thing is an every day occurrence. It is why doctors have to hire more and more staff to deal with with the minutia that makes the difference between being paid & not being paid.

The rules change every year. They are different for each insurer. They differ for each benefit plan the insurer offers.

“Oh, you have Blue Million with the preferred rider from employer X? That means you have only a $5 co-pay if this is a sick child visit first visit without a procedure and not on an emergency basis or after hours.”

I asked an insurance guy about what seemed like a systematic delay or denial of payment:

“Oh, we make a lot of money through short term investing of the pool of money we take in before we send it out. It’s called the ‘float.’ The longer we hold on to the float the more we make.”

All I can think of in reply is how messed up this system is where they do better financially by screwing me.

"The signal to public policymakers is that to attain more health with less health care spending,..."

Fri, 18 Sep 2009 12:23:13 -0700

“The signal to public policymakers is that to attain more health with less health care spending, health plan enrollment must be tilted toward those plans that vigorously reward PCPs and physician groups that excel in low total annual per capita health care spending and clinical outcomes.”

- Ideal Medical Practices (quote from Milstein & Gilbertson Health Affairs article)

The shocking depths to which some insurers will stoop

Fri, 18 Sep 2009 09:08:05 -0700

From a colleague :

I did see a rather ruthless preexisting condition denial today.

A [bleeped] y/o male came to see me as a new pt. He had a plate and screws put in his jaw 9 years ago after a mugging and jaw fracture. He developed a non-healing fistula in the floor of his mouth from infected hardware. [Major Insurer], with whom he’s been insured for 5 years denied a removal proceedure for infected hardware several years ago and again this year. The guy has been living with a hole in the floor of his mouth for 5+ years. Going to work every day, not living off welfare. Two screws have spontaneously come out of the hole along with pus. Several more screws remain along with a metal plate. The company keeps taking his premium but won’t cover the main health issue that he has.

B

I hear stories like this almost every day.

This is wrong.

We can do better.

"In an important victory for the insurance industry, Senator Max Baucus’s legislative proposal does..."

Thu, 17 Sep 2009 13:44:15 -0700

“In an important victory for the insurance industry, Senator Max Baucus’s legislative proposal does not call for a government-run health plan that would directly compete with private insurers. Insurance stocks rose on that news Wednesday.”

- Guarded Optimism Among Insurers, but Some Health Sectors Remain Skeptical - NYTimes.com

Somethings about this makes me nervous for doctors, patients, the public, employers……

"Yes, we invent disease, we invent new therapies to treat invented disease…and then we mandate that..."

Wed, 16 Sep 2009 20:04:49 -0700

“Yes, we invent disease, we invent new therapies to treat invented disease…and then we mandate that all people should be forced to pay into this system that’s fundamentally designed to increase costs as much as possible.”

- Tumblr - Jay Parkinson

And a “mwah-hah-hah-hah-haaaa!” to all!

Just picture me standing over you with a big syringe: “Go ahead. Make my (pay)day!”

The incentives in health care are so freaking sick!

What family physicians are reading today in Family Practice...

Tue, 15 Sep 2009 09:04:59 -0700

What family physicians are reading today in Family Practice management: how to help their uninsured patients get the care they need.

Here are the issue highlights posted to the web:

The goal of FPM is to support practicing docs in their everyday professional lives. What’s depressing is how much time and effort we have to pour into problems like “Offering financial assistance to the newly uninsured” and “New and noteworthy codes.”

None of that is about being a family physician - it is all about trying to slow the flow of those our society chooses to let go down the toilet.

I hear that Senator Olympia Snowe is suggesting we don’t have to rush in with a public option to stem the excesses of the insurance industry - we can wait to see if they clean up their own act and ‘trigger’ the public option if necessary.

Senator, please forgive my bluntness, but we hit that trigger more than a decade ago. The excesses are rampant. Unchecked by realistic options they will continue ad infinitum.

The promise of ‘cooperatives’ fails to sway me. I live in Seattle now with the truly excellent Group Health Cooperative. That venture took decades to get rolling and while it provides excellent care it has not changed the landscape of health care in the US.

The trigger has been pulled.

Real options, right now please.