Paying dearly for mistakes

The lede:

The movement to align patient safety and payment seems to be picking up a full head of steam. Hospitals and payers are coalescing around the idea that no one should get paid for so-called never events — serious reportable events, such as wrong-site surgery, that kill or maim patients.

Perhaps most significantly, the BlueCross BlueShield Assn. announced in November 2007 that its plans will work toward ending payment for never events. The change will be phased in over several years as the Blues alters its coding and claims processes. A spokesman said adoption will vary among the 39 Blues plans, which insure more than 100 million people, because the change requires renegotiating contracts and securing agreements from local physicians and hospitals.

The whole shebang.

Radiant with cancer worries

The lede:

A recent study estimates that between 1.5% and 2% of all cancers can be attributed to radiation from the 62 million computed tomography scans Americans get each year. The finding comes on the heels of earlier, similar risk estimates, and it has some experts saying physicians should think twice about ordering the test.

The review article in the Nov. 29, 2007, New England Journal of Medicine arrives at its estimate by examining the cancer effects on the 25,000 Japanese who survived the 1945 atomic bombs and received radiation doses equivalent to the x-rays emitted by several CT scans.

The authors, David J. Brenner, PhD, and Eric J. Hall, PhD, are professors at the Columbia University Center for Radiological Research and have studied the cancer-causing effects of imaging for years. They write that the evidence of cancer risk from CTs is “reasonably convincing” for adults and “very convincing for children.”

The whole shebang.

Ethical ideals versus reality

The lede:

Doctors agree on the basic tenets of medical professionalism, but they frequently fail to live up to those ideals in practice, according to a survey of more than 1,600 physicians in the Dec. 4 Annals of Internal Medicine.

Nearly all of the physicians surveyed agreed doctors should use medical resources appropriately, tell patients the truth, minimize disparities, see patients regardless of their ability to pay, maintain board certifications, evaluate peers’ care, avoid sex with patients, work on quality initiatives, disclose conflicts of interest, report impaired or incompetent physicians, and report medical errors.

But more than half of doctors told investigators that they failed to report a serious medical error they observed, or a colleague who was impaired or incompetent, to authorities in the last three years. And more than a third of the doctors said they would order an unnecessary magnetic resonance imaging scan to mollify an insistent patient.

The whole shebang.

Medical ethics during the war on terror

The lede:

Medical students get a failing grade on their knowledge of physicians’ ethical obligations during wartime, according to a new study authored by a team of Harvard Medical School physicians.

The authors said their study, published in October in the International Journal of Health Services, should prompt medical schools to educate future doctors more thoroughly on the ethical questions they could face in an age of terror and torture.

But experts said that although medical curricula could cover military medical ethics, such instruction should be folded into discussions about the broader problem of dual loyalty — when doctors’ advocacy for the patient conflicts with other institutional or societal objectives.

The whole shebang.

Saying no to embryos?

The lede:

Two teams of scientists simultaneously announced they have reprogrammed human skin cells to obtain pluripotency, the characteristic hailed in embryonic stem cells as having the potential for therapeutic breakthroughs in areas ranging from Parkinson’s disease to diabetes.

Scientists in Japan and Wisconsin created the so-called induced pluripotent cells by introducing different combinations of genes into skin cells that are normally switched off after embryonic cells differentiate into various cell types. The results were published last month in Cell and Nature, respectively.

Researchers, ethicists, religious leaders and politicians hailed the findings, saying the innovative work could allow society to reap scientific and medical benefits of stem cell research without destroying embryos.

The whole shebang.

Size matters

The lede:

Large physician groups have long had a head start on solo and small practices in the medical marketplace because they can negotiate better health plan contracts. Now, a rising tide of evidence indicates that size also confers a quality advantage.

Researchers admit that the medical literature emerging on the relationship between group size and quality is far from a slam dunk. They argue, however, that bigger physician groups can pool capital to pay for electronic medical records systems and other quality initiatives that help them more reliably deliver guideline-based care.

On the opposite end of the spectrum, a small but growing movement of doctors is experimenting with a leaner model of medicine that they say improves the financial viability of solo and small-group practice and, most importantly, improves patient care.

The whole shebang.

Redesigning informed consent

The lede:

Toni Cordell’s surgery would be “an easy repair,” her doctor said. Embarrassed at being a slow reader, she signed the informed-consent papers she was given without understanding them.

She said no one, including her doctor, explained the procedure in detail beforehand or uttered the word “hysterectomy.” Cordell didn’t discover the nature of her operation until months after surgery when an office nurse inquired about her recovery.

Cordell’s story of being bewildered by medical-legal jargon is not unique. According to a 2005 National Quality Forum report, between 60% and 70% of patients do not read or understand informed-consent documents and nearly half cannot recall the exact nature of the operation to be performed.

Now a growing number of hospitals and physicians are moving to redesign informed-consent protocols. They are using new computer technology and education techniques to improve safety and ensure that patients understand a surgery’s risks and benefits. Informed consent is a process, they say, not a piece of paper.

The whole shebang.

Regulating drug industry gifts to physicians

The lede:

Thirteen states this year have seen legislative proposals aimed at limiting financial relationships between physicians and drugmakers. Most bills failed to pass, due to heavy pressure from pharmaceutical lobbyists, experts said, but new efforts are afoot.

The latest proposals include a Michigan bill that would make that state the second in the nation after Minnesota to place a limit — $100 — on the total value of gifts a drugmaker can give a physician in a year. Michigan and Massachusetts are considering so-called sunshine laws requiring drug companies to publicly disclose any gifts, payments, subsidies or incentives worth more than $25.

The whole shebang.

Who’s a good doctor?

The lede:

The Robert Wood Johnson Foundation is pouring $15.9 million into a new effort to give doctors and the public a more accurate assessment of physician performance.

The plan is to combine national Medicare and private health plan claims data and then use the data for public reporting of physician performance on quality and cost measures. Reporting in select areas is set for 2010.

The initiative comes on top of criticism that the nation’s dozens of quality measurement and reporting efforts are redundant or rely on widely varying metrics. For example, a 2005 Institute of Medicine report on performance measurement called for a new office in Health and Human Services to coordinate and fund the development of metrics for pay-for-performance and public reporting programs.

The whole shebang.

Doctors and executions

My stories for American Medical News are now freely available for about 90 days after they go live on the Web site. So, I’ve decided to start posting the first few grafs and links to the stories here in case you’re interested in reading.

The beat — medical ethics, patient safety and health care quality — is pretty interesting because quite a few of the stories are of great interest to many people who are not physicians. A great example is this story.

The lede:

The only state medical board in the country with policy declaring physician participation in executions “a departure from the ethics of the medical profession” and grounds for discipline was rebuked in state court late last month.

Wake County (N.C.) Superior Court Judge Donald W. Stephens ruled that the North Carolina Medical Board overstepped its authority in threatening to punish doctors who take an active role in the death chamber. But executions in the state will not resume due to the pending cases of five North Carolina death-row inmates on lethal injection protocols.

Read the whole shebang.

“Politicians don’t amount to much. Ideas do.”

Thus spake Ron Paul, in today’s surprisingly fair piece in The New York Times. I don’t agree with Paul about everything, and reporter Christopher Caldwell is certainly right to note that he attracts a lot of nuts.

But if you don’t like nuts, stop being a libertarian now because it’s just part of the package.

I like the guy. Note that whenever Paul is asked about why he’s getting so much attention, he says something along the lines of, “People are interested in the freedom message.” It’s always about the message, not about him.

(Also posted to Sinners in the Hands of an Angry Blog.)

The Iraq war was never prudent at any juncture

Randy Barnett’s Wall Street Journal column, “Libertarians and the War,” makes two indisputable points: Ron Paul is not the be-all and end-all of libertarianism, and not every libertarian opposes the Iraq war. At the same time, it lays bare the fantastical chain of logic a libertarian must traverse to come down in favor of this tragic misadventure.

On the first point, Ron Paul is a conservative libertarian of a certain stripe. I think he’s very wrong on immigration, for example. If his recent notoriety had come thanks to his strident opposition to birthright citizenship, I too would probably be writing missives noting that “Ron Paul doesn’t speak for all of us.”

It is a demonstration of how little understood libertarianism is — and how much disagreement there is among libertarians — that we are so concerned that a single figure could forever freeze in amber the public’s perception of what it means to be a libertarian. The truth is that anyone who insists on judging the whole of a political movement by the beliefs and character of one person is probably uninterested in really understanding libertarianism.

Comprehending this movement of ours means appreciating the diversity of viewpoints on even the most apprently black-and-white issues of the day, such as the Iraq war. But then why would we expect anything different? Liberals disagreed about Iraq, and so did conservatives. If it does nothing else, Brian Doherty’s “Radicals for Capitalism” illustrates that libertarians are a motley crew.

So when Barnett asks, “Does being a libertarian commit one to a particular stance toward the Iraq war?” the “No” answer should be pretty uncontroversial, in spite of Justin Raimondo’s contention that Barnett is a “fake libertarian.”

Even Jim Henley, in his harsh assessment of Barnett and other pro-war libertarians as, simply, “morons,” never denies them their libertarian credentials. Henley is on the right track, though. Barnett rightly notes in his column that “devising a military defense strategy is a matter of judgment or prudence about which reasonable libertarians may differ greatly.”

It was clear to most libertarians in 2002 and early 2003 that attacking Iraq was not a prudent form of self-defense and that in fact it was more likely than not to greatly add to the anti-American terrorist problem. Back then, the waters were muddied by baseless assertions that the Hussein regime was actively collaborating with Al Qaeda — really the only grounds on which a prudent libertarian would have jumped aboard the Iraq war express.

Any libertarian worth his salt asked, “Where’s the evidence?” and when it was not provided simply disregarded the argument. Barnett avoids that line, which by now has been so thoroughly debunked that he cannot even give voice to it on the Wall Street Journal’s opinion page. Instead he opts for the Iraq-the-model line. OK, so it’s a theory. I’ll give it that much. I don’t believe it is inherently inconsistent with libertarianism.

But that theory asks libertarians to ignore or discount the certain dangers of war — greater government spending, the deaths of soldiers and innocent civilians, blowback from at least a solid minority of the country — in exchange for the slim possibility that an invasion will yield a peaceful liberal democracy and reliable ally.

Real dollars paid by real taxpayers go to fund these wars. Real soldiers die. Real innocents are massacred. There’s no such thing as a free war, and you’ve to meet an incredibly high threshold before committing to the prospect. Elective war is a speculative act, and libertarians are not usually in the habit of supporting massive and deadly government programs for no better reason than … Gee willickers, they just might work!

The point is not that Iraq was bound to fail spectacularly, but that like any war it was a crap shoot and very well could blow up in our faces. And so it has — literally and figuratively. And why do that — why take that risk — for no damn good reason?

(Also posted to Sinners in the Hands of an Angry Blog.)

Mother of exiles

It’s estimated that about one-tenth of Iraq’s population has fled that most dangerous place on Earth since the United States & Co. liberated it in 2003. In the last seven months, The Wall Street Journal reports, the U.S. has admitted 69 Iraqi refugees.

Since 2003, the U.S. hasn’t even come close to admitting 1,000 Iraqi refugees in a single year. Why such pitifully low numbers, given that the U.S. helped unleash Iraq’s bloody civil war?

The refugee wave is tricky for an administration eager to portray the recent troop “surge” as a boost to improving security and curbing the sectarian killings in Iraq. There’s also genuine concern that encouraging large-scale flight from Iraq will compound the coutnry’s many challenges, by luring its most talented citizens to the U.S.

Uh-huh. Well, this is no surprise. So it has ever been. The asylum program has played second fiddle to the politicians’ foreign-policy whims since time out of mind. What’s especially galling is this notion that talented Iraqi individuals ought to be, for all intents and purposes, sacrificed for the hypothetical good of Iraq as a whole.

Wasn’t that the kind of idiotic dogma Dubya & Co. were hoping to dethrone in their quixotic, tragically misguided effort to socially re-engineer the entire Middle East?

Dubya is likely to sign a refugee bill that will increase to 500 a year the number Afghan and Iraq military translators allowed to come to America. A Democratic-sponsored bill to welcome a measly 15,000 Iraqis a year hasn’t even been scheduled for a vote. Not only are the Democrats unwilling to stand up to Dubya on the war itself, they won’t even vote on a bill to do a small favor for just a few of the people whose lives their own votes helped to make a living nightmare.

Hawks are fond of arguing that regardless of one’s prospective position on the war, since the U.S. government invaded Iraq it took on a moral obligation to help the country transition into a place resembling something other than the eighth circle of hell. I’d say we’ve already given them plenty of opportunities, including repeated elections that were largely free and fair, to determine their own course. Whatever obligation the U.S. took on has been discharged, in my view, especially given that two-thirds of Iraqis want American troops out.

But if there is some kind of moral obligation incumbent on the U.S. today, doesn’t it include opening its doors to at least a few of the huddled masses yearning to breathe this country’s free and peaceful air?

Or should they have to sneak in through Mexico?

(Title reference explained; also posted to Sinners in the Hands of an Angry Blog.)