At the start of next year, the drug companies will no longer be giving pens and pads of paper to doctors.  The rules regarding pharmaceutical sales practices have grown progressively more stringent over the past few years.  The FDA already regulates what the reps say to physicians (they may only assert what is in the PI, or package insert).  Now they will
be very limited on other contact with physicians.

Thank goodness.  Those pens and pads of paper were sending
subliminal messages to me.  I hear them talking to me in my sleep.  I
just have an insatiable need to prescribe unnecessary medications
because of a ballpoint.  It will be good to get out of this marketing
hell these reps have put me in.

Citizens are worried about the influence these companies are having
over us physicians, wondering if their efforts to influence are driving
up the cost of care.  One online petition site states:

Drug marketing is out of control. Help send a message to Congress.
Support the Physician Payments Sunshine Act, which will require drug
companies to publicly report their gifts and payments to doctors.
Drug companies spend at least $25 billion each year marketing to
doctors. We pay for that with every drug we buy. And studies prove that marketing causes doctors to prescribe higher-cost drugs. Some new drugs also have safety risks (like Vioxx). By increasing transparency, the Sunshine Act will help protect patients and help counter the skyrocketing costs of drugs.

Congress is also getting involved:

I was reading Peggy Noonan at The Wall Street Journal, and I wasn't sure where we, the doctors, fit in.

Democrats in the end speak most of, and seem to hold the most sympathy for, the beset-upon single mother without medical coverage for her children, and the soldier back from the war who needs more help with post-traumatic stress disorder. They express the most sympathy for the needy, the yearning, the marginalized and unwell. For those, in short, who need more help from the government, meaning from the government's treasury, meaning the money got from taxpayers...

Democrats show little expressed sympathy for those who work to make the money the government taxes to help the beset-upon mother and the soldier and the kids. They express little sympathy for the middle-aged woman who owns a small dry cleaner and employs six people and is, actually, day to day, stressed and depressed from the burden of state, local and federal taxes, and regulations, and lawsuits, and meetings with the accountant, and complaints as to insufficient or incorrect efforts to meet guidelines regarding various employee/employer rules and regulations. At Republican conventions they express sympathy for this woman, as they do for those who are entrepreneurial, who start businesses and create jobs and build things. Republicans have, that is, sympathy for taxpayers. But they don't dwell all that much, or show much expressed sympathy for, the sick mother with the uninsured kids, and the soldier with the shot nerves.

Peggy Noonan: The Master Has Arrived...

The below story was forwarded to me by a dear friend.

She's a teacher- not a doctor- and she understands clearly the lessons that we, as doctors must learn ourselves.

"Docs Bailing Out of Medicare, Medicaid"
Plummeting Reimbursement Rates Have Some Doctors Looking for a Way Out

Frustration Mounting for Physicians

According to Dr. Scott Nelson, a family practice physician in Cleveland, Miss., the reimbursement cuts have hit doctors in his state very hard.

"There is an unprecedented level of frustration with the government and Medicare in Mississippi," Nelson explained. "I have not heard of any doctors in my area opting out of Medicare, because there are not enough patients with private insurance in the rural Mississippi Delta... we have no choice but to see them, and we are literally at the mercy of the government. I foresee some small practices closing altogether."

Full article:

Politicians are finally hearing the reality of the problems in
medicine.  Some "insiders" have visited various congressmen and folks in CMS who state that their goal is raising the income of primary care doctors.  They understand the fact that costs are much higher if there is a high percent of specialists in relation to primary care doctors. 
The promise is that over the next few years, the income of primary care
physicians will rise through increased Medicare reimbursement. 

So I am told.

My contacts are reliable.

I don't believe them. 

I don't care if I hear it from the head of CMS and both presidential
candidates.  I don't care if I hear it from the guy who personally
authorizes the checks.  We have been waiting so long, only to see
decreased reimbursement for more work. 

As a group, primary care physicians are jaded.  We are used to being
the step-child.  Hospitals build big wings for OB and Cardiology. 
Specialists build fancy office buildings and drive the expensive cars. 
We are used to seeing insurance company profits shoot up while our
income goes down.  We are a name to put on a list for the hospital so
they can get contracts, or a source of ancillary income for hosptials.

What is the job of the PCP?  To serve as a conduit to send patients to
specialists so they can make more money than us.  To avoid expensive
procedures and keep costs down so that the insurance company profits
are higher.  Is that cynical?  Sure it is.  But is it wrong?

The difficult irony is that our patients value us far more than they
value the specialist, hospital, or insurance company.  If it were up to
patients, we would have a higher income than the others.  But it isn't
up to them.  It is up to the politicians and lobyists.  It is up to the
shareholders of the insurance companies.

An article in the CMAJ (Canadian Medical Association Journal) seems to suggest that it would be best for this site to shut down, so no one will  be exposed to unpleasant voices of  doctors who want to frankly blog about their profession.

From Mark Otto Baerlocher, MD and Allan S. Detsky, MD in CMAJ:

I have noticed several posts / articles on women (or the lack) in surgery.

Women in Surgery; The Differential: Medscape Med Students; Lucia Li; August 1, 2008

In one of my regional placements, I met a surgeon who said that “women are killing surgery”; what he meant was that as the majority of medical graduates are now women, most of them will shun surgery for its stereotypes. This will reduce the number of good candidates going into surgery, lowering its standards. Surgery needs to attract women for continued excellence in practice. I am uncertain about the benefits, or even the need, for positive discrimination, but educational initiatives which promote surgery as a realistic career option for women are vital.

WSJ article: Women Remain Scarce in Neurosurgery; Jacob Goldstein; August 14, 2008

WSJ article: For Female Surgeons, Barriers Persist; Jacob Goldstein; August 16, 2008

Mothers Don't Let Your Daughters Grow Up to be Doctors; posted by Fizzy, Mothers in Medicine Blog; August 18, 2008 [not just don't let them be surgeons, but don't let them be doctors]

 I was sitting in a conference recently;  the speaker was talking about the Medical Home and how one practice was getting nearly $150K for  managing a patient population using a new computerized tool.  Sounds good.

During the question and answer period I asked the speaker:  "Shouldn't we
wait until insurance companies are willing to pay for this before adopting it? 
If we start giving this care on our own, what motivation will they have to pay
us for doing it?"

The speaker smiled and agreed that the "market would have to mature" before
this technology could be adopted.  If we do adopt too soon, we run the risk of
giving higher quality for nothing.  We do extra work - above and beyond what we
are doing now - and do so "for the good of the patients."  Yet while the
patients and payers benefit, our hourly rate goes down.

Sad.

Here is a technology that improves care and potentially saves lives, and yet
we are waiting for a good business case to do it.  Only in America.

A physician came up to me after the talk and said, "No matter what happens,
we physicians are going to get screwed."

That is the climate we practice in.  Morale has never been lower among
physicians.  We are all tired of bearing the responsibility for change without
sharing in its fruits.  Any new program that comes along is suspect.  Where's
the catch?  How is this "great new idea" going to lower my bottom line?

Why can't we just get paid for doing a better job?

Let me make this clear:  I do whatever I can to maintain the best quality
care for my patients as is possible.  I am proud of the quality I do.  Our
practice has actually surpassed most reported quality numbers by far.  We do
well despite this climate.  But the rank-and file physician is
frustrating with having to choose between good care and good business. 

Dr. Linda Halderman tackles another frequently asked question about nationalized health care:

Q: If socialized medicine is so bad, why do people in countries with government or single-payer healthcare live longer?

Here are excerpts from her answer:

A: Life expectancy in the U.S. compared with that of other countries is often cited to condemn the American healthcare system; the uninsured are dying from lack of health insurance and treatment, it is argued, while countries with universal coverage live longer as the result of their healthcare systems.

But is life expectancy primarily dependent on having health insurance? Is access to healthcare services the main determinant of longevity?

...Motor vehicle fatalities are the leading cause of death for Americans aged 1-29. Driving under the influence of alcohol is the most common factor in fatal crashes. For every reported death related to a motor vehicle crash, it is estimated that thirteen individuals are injured severely enough to require hospitalization.

...Supporters of government-provided healthcare often attribute longevity to healthcare access without considering the impact of other factors. Healthcare access in the U.S. has less of an impact on mortality statistics than trauma.

She also discusses obesity, smoking and crime, concluding:

It seem like healthcare can easily derail the speaking skills of even the most gifted orators. Watch this:

Massachusetts blogger Paula Hall dissects the latest problem with Massachusetts' universal health care -- lack of dental care -- in her recent blog post, "A Pocket Full of Insurance and no Dental Care to Buy".

Here are some excerpts she's selected from the following article in the August 7, 2008 Boston Globe. Again, it highlights the fact that "coverage" is not the same as actual care:

Call me old fashioned, but I am not alone. I often believe that patients don't have the capabilities to make proper decisions about their clinical options. When the issue is childbirth, excuse me, patients
are often nuts. Just witness the epidemic of home childbirths!

S.W. McFee, M.D. from Parkville, Missouri goes even further. Read the
following letter from this clinician to the latest American Society of
Anesthesiologists Newsletter:

I'd like to comment on the recent Boston Globe article on surgeons' outbursts and also on Maggie Mahar's post, Surgeons and Other Physicians: A Cultural Divide.  Both seem to be painting surgeons as the ogres or bullies of the medical community.  I'd like to think that I am neither.  There are better examples of surgeons than the Alex Baldwin character in the movie Malice. 

I agree it is not good form or good for the patient for these outbursts to occur, but generalizing to the point that most of your readers would think that 90% or more of surgeons behave this way is wrong. I have never thrown any equipment and rarely gotten angry to point of raising my voice or screaming in the OR. Each time I did, the nurse told me I was right.

I have witnessed some of the examples given in the article. Yes, those surgeons should be counseled and most likely should even be required to go to anger management classes. BUT maybe the reason for their anger should also be sought.

Was the faulty equipment putting the patient at risk? It is very frustrating to try three pair of scissors before you get one that will cut tissue or to have the electrocautery machine not work so the circulating nurse (bless her) has to go find one that does. Perhaps the hospital is at fault for not updating and replacing defective instruments and equipment.

American Health Care in Critical Condition

The Case for Putting Individuals, Not Employers or Government, in
Control of Health Care

By JOHN STOSSEL and ANDREW SULLIVAN

"Most everyone agrees, America's health-care system is a mess.

Millions of Americans lack health insurance and still our annual
health-care costs exceed $2 trillion — that's about the size of the
entire economy of China. For the country with the world's "best"
medical care, a lot of people seem unhappy.

Many hate the insurance industry.

Employers have seen insurance premiums rise 87 percent over the last
seven years. General Motors now spends more on its employees' health
insurance than on steel. Doctors are fed up, too; the average
physician's office spends 14 percent of its income filling out
paperwork.

No one seems angrier than the patients who have been denied care....

The more people control the money they spend on their own health
care, the more people shop around and the more providers compete to
attract patients by lowering prices while improving quality.

It's putting individuals in control that could turn our health-care
sector into the vibrant, competitive marketplace that we see in
nearly every other area of our economy.

After all, it's our body and our health. Shouldn't we be in control
of how our health-care dollars are spent?

Harvard's Herzlinger said:

"Who should decide whether you live or die?
Do you want the government to decide?
Do you want a health insurer to decide?

Who's gonna make that decision?
Is it gonna be a government?
Is it gonna be an insurer?

Or is it gonna be you and me?"

Putting individuals in control of our health — rather than our
employers or the government — is a better way to cure what ails
America's health system. "

Dr. Brian Schwartz, health care blogger for the Independence Institute, takes on the latest NY Times opinion piece by Paul Krugman singing the praises of government-run "universal" health care. Here are a few excerpts from Dr. Schwartz's piece:

If citizens of these other wealthy countries have guaranteed care, can Dr. Krugman explain to me to following instances of people in these countries not getting needed medical care:

I am a primary care physician - in the crosshairs of the mess we call healthcare in the US.  I see about 30 patients per day.  I answer a ton of phone calls, look at labs, x-rays, consults, and fill out forms every day.  If I take time off from work, I am not paid.  I am the source of most of my income.

I bear the weight of the current healthcare crisis, but am to caught up in the mess to have any time or means to do anything about it.  I can't take time away to advocate for myself, nor can most of my colleagues.  Instead, we are represented by academics and other physicians who are conspicuously "out of the trenches."  It is the classic catch-22 - those with the most to lose have the least voice.

But I can blog.

I can say what I think and have others read it.  The voice of the rank-and-file of healthcare is now out there.  Doctors are starting to understand that this new medium gives us access to much larger audiences.  We have a soap box.  We no longer have to get others to advocate for us - we can do it ourselves.

So those who can listen: pay attention to the bloggers.  They are the real voice of healthcare.  The lobbyists and big organizations may think they understand, but most of them don't have to pay rent, support a payroll, and negotiate contracts with insurance companies.  They make their points, advocate for their bosses, and go home without living with the consequences.

We live with the consequences.

Listen to us.

More on the New Medicare Auditors:

From the CMS's own Feb 2008 press release:

"Approximately 96 percent of the improper payments identified by the RACs in 2007 were overpayments collected from health care providers; the remaining 4 percent were underpayments repaid to health care providers.

The demonstration program began in California, Florida and New York in 2005 and expanded into Massachusetts, South Carolina, and Arizona in 2007. The first three states are those states with the largest number of Medicare claims.>>

1. Though glibly marketed as a measure designed to identify “improper” payments and ensure “accurate” Medicare billing- by attempting to identify equally both under- and overpayments to providers, it is hardly coincidental that fully 96% of the “improper” payments were “overpayments”

2. RACS incentivized by a cut of the money they recover might explain the gross imbalance between over-and underpayments, but if the true motive was to equally identify “underpayents”, why then structure the program in such a manner to reward RACs with a personal cut of any Medicare money they recover, rather than paying them a salary?

3. I think it then becomes obvious that, rather than being designed to identify “improper” payments, and it merely being “more difficult” to identify underpayments, the true motive for the program- hidden transparently behind euphemistic, bureaucratic jargon- is nothing more than to recover money already paid out from Medicare for services rendered by health care providers to stick back into a Medicare trust fund which is rapidly approaching bankruptcy.

They *are* after all, aptly named  RECOVERY  Audit Contractors- and not by accident.

A Short Course in Brain Surgery highlights the plight of an Ontario man with a cancerous brain tumor who crossed the border to the U.S. to get the medical care that is rationed in his home country.

Written, Directed, Produced, Edited and Narrated By: Stuart Browning. (From FreeMarketCure.com.)

I recently read the following e-mail about Medicare from a US medical student, which I am quoting with his permission:

From David Catron:

Here's a chart showing U.S. survival rates for breast and prostate
cancer compared to the survival rates of four countries whose health
care systems are often touted as superior to ours.

Wait a minute. How can the U.S. have better survival rates
than France? Wasn't the French system rated the best on the planet by
the World Health Organization?

And what the hell are Norway's survival rates doing so far behind
those of the United States? According to WHO, the Norwegian health
care system is WAY better than ours."

And John Goodman summarizes the latest study in The Lancet:

Cancer survival varies widely across the developed world and within the United States. However, in almost every category Americans survive cancer at higher rates than patients in other developed countries. American cancer patients have a higher survival rate for every major form of cancer than patients in Canada and Britain -- two English-speaking countries with which the U.S. is often compared.

The Telegraph.uk reported similar findings last year.

(Via Patient Power.)