So Dr. Rangel’s got a piece talking about taking away Medicaid benefits if people don’t use the ER correctly:

With states now allowed to make changes on eligibility requirements for Medicaid, West Virginia will be requiring many beneficiaries to sign a contract in which they promise to use the ER only for emergencies and to keep their doctors’ appointments. Failure to do so will result in loss of benefits. And why not?

Medicaid spending is out of control and is squeezing state budgets. ER visits for non-urgent conditions are hundreds of dollars more expensive than an office visit so that seems like a good place to start to try and control costs.

He goes on to note that low-income people disproportionately make up a good percentage of ER visits, and goes on to say that “only about 16% of ER visits among all patients are considered to be true emergencies so the potential exists for a substantial reduction in unnecessary ER visits among Medicaid beneficiaries.” In the comments, another doctor, Flea , agrees.

I’ll throw another mess into the pot here before drawing my conclusions. A retired orthopod, Dr. Thompson, frequently comments on my blog, and left this zinger today : “I personally see nothing wrong with health savings accounts and allowing patients to be in charge of their health care decisions.” Wha-wha-what?

What is it with these doctors? I’m at a loss. We’ll go point by point here:

1. Medicaid is broke. Check.
2. Poor people use the ER more often. I’ll assume for the sake of argument this is true. Check.
3. Only 16% of ER visits are truly emergencies. Now things get murky. The study Dr. Rangel is quoting seems to be looking at end-diagnoses , not symptoms. In my 4 ER shifts, maybe out 20% of the people I’ve seen have been truly emergencies or urgencies. However , the people’s symptoms have been a much higher percentage of possible emergencies! Sure, you see 10 chest pains for every 1 heart attack, but how the hell are our patients supposed to know that? A patient got poked in the eye pretty bad. Should he wait until morning? Or go into the ER? A patient feels nauseous and light-headed, and has one episode of shaking. We find nothing wrong with him, but I’d get myself to an ER immediately, too!
4. Next up: If we follow the “poor people” line, we’ll go ahead and assume they’re probably also the least educated, too. So now we’re asking the least educated of our population to properly differentiate between emergent and non-emergent. (Some things are “duh,” but honestly, most of them aren’t.) The rich get richer, and the poor get sicker. (As a commenter noted on Dr. Rangel’s site, perhaps Medicaid patients go to the ER more often because so few doctors see Medicaid patients anymore.)
5. If we want incentives and disincentives (carrots and sticks), let’s make an actual, viable system. If you go to the ER now with your Medicaid or whathaveyou, you may get a bill for several thousand dollars. Ha! That’s what you make in 3 months! What a joke! In a perverse system like this, people will respond just as perversely. No doctors at clinics? Ridiculous bills? Might as well just use the ER when I need it, since the whole system’s a joke.
6. And finally for Dr. Thompson’s doozy: of course you don’t have a problem with Health Savings Accounts and people making their own health care decisions. You know exactly what decisions to make–you’re a doctor ! That’s what you’re supposed to do–make health care decisions. But as I’ve said before , people that need health care urgently pick the closest hospital; no one bargain shops (as if you could get prices anyway). And which patient has the time and energy (and background) to research the costs and benefits of a certain study, and to interpret what the research actually means clinically?

Can we please, please, PLEASE stop with the patchwork nonsense where we try to eliminate limit health care for the poorest and sickest and drive all the burden onto our already-burdened-with-their-illness patients? Can we see the forest amongst those trees? Can we see that hitting one group with this policy or that one will only create more burden in the long run, and that the only real solution is one that affects us all? Single-payer, multi-payer, I don’t even care at this point–I just wish people would see the big picture. (And no, not the big picture of your specialty. Zoom out one more time. The big picture of everyone.)

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One reason we’re getting nowhere quickly in health care reform is that Bush is focusing primarily on health savings accounts and “consumer-directed health care,” which basically puts people in charge of making their own health care decisions. This is a ridiculously terrible idea for many reasons, not limited to the fact that 1% Of Americans Account For 22% Of Health Care Spending , and the top 5% account for basically half of health care spending.

These are the people that spend 10 months in the ICU, or have 23 vascular surgeries for peripheral vascular disease. These are not people that are trying to decide whether to get that lab test or that colonoscopy. These people are not using health savings accounts. So Bush is putting all his effort into these accounts, when, very likely, it might put a teeny, tiny little dent in health care spending. The wool’s pulled over his eyes for the giant elephant in the room.

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This is definitely good news ; sugar sodas will be removed from schools, but “the beverage industry said its school sales would not be affected because it expected to replace sugary drinks with other ones.”

Mark my words, folks. Juice is already a problem, and now that soda is out, and people have a notion that juice is healthier, it will take over as a big cause of unnecessary calories.

And most juices are not 100% juice. Product standards say that a product cannot be called “juice” unless it is 100% juice, so these products will be called “juice drink,” “nectar,” “beverage,” or “cocktail.” All these drinks are not healthy just because they’re from fruit. They’re not nutricious, and are loaded with calories–often just as many as soda. And if they don’t contain pulp, they don’t even contain any fiber benefits. Sure, you get a healthy whopping of vitamins from some juices, but that’s a reason to drink some juice, not gallons.

“But if an 8-year-old child took in 45 less calories per day, by the time he reached high school, he would weight 20 pounds less than he would have weighed otherwise.” Now that’s impressive. I hope I’m wrong about the juice thing.

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(Before or after you read this, please, please take action . Especially physicians–Congress listens to you!)

I don’t know how I missed this disaster of a possible policy decision, but luckily Kate informed me of the bill. It’s supposed to allow small businesses to band together to buy health insurance together, but in the process also cancels many states’ required coverage items –that is, areas of health care that the state requires all insurers to cover. (The thinking being that small businesses could purchase cheaper plans if the plans don’t have these required restrictions. And this is big; small businesses employ half the work force in the US. ) By a wide margin, these items are prevention programs . And what are prevention programs? Screenings that catch disease early so that it doesn’t cost us orders of magnitude more down the line–either in health care, education, long-term care, etc. Here’s how I view these programs, as a future provider (and likely future pediatrician). I’ll use California examples. If we cancel…

• Alcoholism Treatment: We have more drunk drivers, more deaths and more permanent disabilities. We have more fetal alcohol syndrome, which leads to learning disabilities and more costs for special ed. We have more lost workdays.
• Blood Lead Screening: We have more children with learning disabilities, permanent brain damage and mental retardation.
• Bone Density Screening: We have more women break their hips and require surgery.
• Colorectal Screening: More men and women get colon cancer, the second most common, deadly cancer in the US. In most cases, if you detect it early, you remove a polyp and STOP a possible cancer completely.
• Contraceptives: More teen births, more unwanted pregnancies.
• Diabetic Supplies/Education: Education and supplies are absolutely key to diabetes care. The complications: early heart attacks, amputations, blindness, non-healing ulcers, infections, more ICU stays.
• Emergency Services: People with these plans will pay 4 times as much for ER visits .
• Hospice Care: People die shitty, painful, scary deaths. Sigh.
• Mammography Screening/Prostate Cancer Screening: Hi breast and prostate cancer, the second most common of cancers in women and men, respectively.
• Metabolic Disorders (PKU): Near and dear to the Pediatrician’s heart, the newborn screening. This picks up diseases like PKU and hypothyroidism, which if caught early, can be treated and the patient can have a normal life. If not treated, kids die early, mentally retarded. (The treatment for PKU? Avoid certain foods, especially those with the artificial sweetener, aspartame–this is why diet drinks say “Phenylketonurics, contains phenylalanine.”)
• Off-Label Drug Use: This requires companies to pay for drugs that doctors prescribe for non-approved uses. For example, some drugs for seizure disorders also work for mental illness or chronic pain; doctors are allowed to prescribe it for seizure disorders as well as other diseases it might work for.
• Well-Child Care: When you take your healthy kid to the doctor to make sure he or she is growing and doing well. In these visits we look for hearing problems, cataracts, childhood cancers, hip deformities, brain problems, broken bones, child abuse, undescended testes, and other signs of possible abnormalities.

I can’t believe some of the stuff that I just wrote that Congress is considering allowing people not to cover. And I can’t believe we’re willing to go this route–allowing companies to provide crappy, inadequate insurance to maintain an already broken, patchwork, pathetic health care system.

(Before or after you read this, please, please take action . Especially physicians–Congress listens to you!)

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And all the other people that don’t get single-payer. Single-payer is not the UK system. So please, please please stop calling out
“single-payer woes” on UK health issues . As I’ve said before, NHS Isn’t NHI .

Phew, I feel better.

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Donorcycle brings up organ donor policy , and reminds me of the Spanish model of organ donation: if you want an organ, you have to be willing to donate one when you die. You have the right to opt-out, but this automatically places you at the bottom of the donor list.

18 people die each day waiting for an organ, and countless others spend months and years on waiting lists with incomplete lives.

I have to admit, the Spanish idea sounds appealing, but maybe a little too punitive. We could probably save all those people if we just had an opt-out rule, where you’d put a sticker on your driver’s license if you didn’t want to donate.

And by the way, the sticker isn’t proof, people. Discuss your organ donation status with your family, because ultimately they decide.

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Not anymore, at least. 40% of businesses do not offer health insurance to their workers, and that’s up from 31% in 2000. How can people possibly think this is working?

• More than one-third (34%) of adults ages 19 to 64 (both insured and uninsured) either had medical bill problems in the past year or were paying off accrued medical debt.
• The $10,880 average annual premium for a family of four in 2005 surpassed the yearly gross earnings of $10, 712 for a full-time minimum-wage worker.
• Forty-one percent of adults with incomes between $20,000 and $40,000 a year did not have health insurance for at least part of 2005.
• 51% of women without health coverage have not had a mammogram in the past two years, compared to just 9.2% of women with coverage.

What an utter disaster. We should be ashamed of this level of care.

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And it’s snowing in hell. A doctor columnist in the Wall Street Journal has made the case for single-payer . 301 health plans, and look where he works , nowhere near Chicago or Springfield. I give him props just for being able to keep up with 301 different health plans.

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