Brave thinkers!!!! Lies, Damned Lies, and Medical Research

Much of what medical researchers conclude in their studies is misleading, exaggerated, or flat-out wrong. So why are doctors—to a striking extent—still drawing upon misinformation in their everyday practice? Dr. John Ioannidis has spent his career challenging his peers by exposing their bad science.

The Atlantic magazine interview : http://www.theatlantic.com/magazine/archive/2010/11/lies-damned-lies-and-medical-science/308269/

Website traffic at "shoulderelbow.blogspot.com"

Risk of complications after shoulder replacements - ACS risk calculator

It is interesting to see how the ACS risk calculator assesses the chances of a complication after a common surgical procedure performed in the US. The calculator gave a 5% risk of complication for a patient that weighs 220 pounds is 68 inches tall, has type II diabetes, age between 65-74 years, has a history of prior cardiac event (coronary artery disease) and no hx of COPD. Each year 75000 total shoulder replacements are performed. 5% of 75000 is 3750 patients will have a complication.

The bionic arm. Fact or fiction?

I am sure that you all remember the movie "The terminator". Well I have news for you. Today it is possible to implant bionic arms. The cost is extremely high but it will not be too long when the price of this technology drops and will become available to a lot of trauma victims. The following video provides the proof.

https://www.youtube.com/watch?v=FSRsw-b4Nlw

The direct payment model in medicine - The values of free Market

Fed Up With Obamacare, Doctors Increasingly Prefer Cash For Care

Obamacare’s most intrusive changes to the healthcare marketplace — including the individual mandate whereby Americans must secure health insurance or pay a fine and its massive expansion of Medicaid — are less than a year from taking effect.

Many doctors have decided that they’re not interested in seeing how those changes play out in their own practices. Nearly two-thirds of doctors say that they or their colleagues will retire earlier than planned over the next few years, according to a survey conducted by consulting firm Deloitte.

Others are considering a departure from the current system of third-party payment. Instead, they’re exploring direct payment, with patients paying for care on their own.

Patients should welcome this development. Not only does the move toward direct payment have the potential to reduce health costs — it could also yield higher-quality care.

Even before Obamacare, direct-pay practices were growing in popularity. According to the Center for Studying Health System Change, direct-payment practices increased from 9.2 percent of the market in 2001 to 12.4 percent by 2008.

Nearly 7 percent of doctors say they are planning to change to some form of direct-pay care in the next three years, according to a survey of 13,000 doctors done for the Physicians Foundation. The consulting firm Accenture projects that one in three doctors in independent practice will adopt “subscription-based care models.”

One direct payment model that’s growing in popularity is “concierge” care, whereby doctors charge a monthly or annual fee for care — and bypass the administrative headaches associated with insurance and government programs altogether. The American Academy of Private Physicians — which represents cash-only doctors — estimates that the number of concierge doctors has shot up 30 percent in just the last year.

Examples of these practices abound.

Qliance, for instance, offers primary and preventive care for less than $90 a month in several cities in Washington state. In January, the company raised $8.6 million to expand beyond its home state.

One Medical in San Francisco charges patients between $150 and $200 a year for same-day appointments, online prescriptions, and email access to doctors. And in Portland, Oregon, patients at the Multnomah Family Care Center can pay a one-time enrollment fee and then monthly membership and provider fees that average less than $60 a month for preventative care. Others include Atlas MD, MedLion, Simple Care, and Paladina Health.

The direct-pay model does force patients to shoulder more of the upfront cost of their care. But the long-term savings it can generate are substantial. Qliance, for example, says it can trim as much as 30 percent off health costs by combining its services with a high-deductible plan for major medical bills.

High-deductible plans are usually paired with health savings accounts (HSAs), which allow consumers to set aside money tax-free for health expenses. HSAs empower patients to take charge of their care — and can make visits to direct-payment practices even more affordable.

At Access Healthcare, a cash-only practice, fees can be lower than the co-pays a patient would otherwise cover under a traditional insurance plan. The cost-lowering potential of direct-payment practices is heartening because the current third-party payment system has failed to stem our burgeoning health cost crisis.

Indeed, third-party payment is largely to blame for the untamed growth of health costs. Back in 1960, only about half the nation’s health spending was paid for by a third party, according to the Centers for Medicare and Medicaid Services. By 1980 that had risen to 77 percent. Today, it’s 88 percent. Not surprisingly, as consumers’ out-of-pocket share of health costs has declined, their demand for care has exploded.

Our tax regime encourages such over-consumption. Employer-sponsored insurance benefits are not taxed. So a worker receives a full dollar’s worth of health benefits for every dollar his employer pays for insurance — compared to less than 85 cents for every dollar his boss spends on wages.  As a result, health costs have grown at double the rate of inflation elsewhere in the economy.

That’s not sustainable. Direct-payment could check that cost growth, particularly in the primary care realm, by empowering doctors and patients to negotiate mutually agreeable prices, free of interference from insurers or the government.

Reason magazine recently profiled Dr. Ryan Neuhofel, a Kansas doctor who posts his prices online and doesn’t accept insurance. A 30-minute house call runs $100. That may seem high to those used to $30 co-pays. But that $100 house call may end up being cheaper, after taking into account sky-high monthly insurance premiums, steadily rising annual deductibles, and out-of-pocket maximums — not to mention the time and expense that both doctors and patients have to devote to filing claims.

Obamacare will only add to the cost-inflating administrative burden that third-party payment places on doctors. Direct-payment allows physicians to reject that burden and focus on what they do best — treating patients.

Dr. Samir Qamar had a “concierge” practice in Monterey, California, where he charged a few very wealthy patients as much as $30,000 a month to keep him on retainer. But last year he changed his business model drastically, taking advantage of what he saw happening to healthcare in the United States. In an interview with Mary Pat Whaley, Qamar explained:

I became obsessed with finding other models that would not necessitate daily high-volume traffic which, in my opinion, led to poorer quality care....

I wanted to design an affordable membership model for those [patients] with little or no health insurance.... I realized that this model [also] appealed to employers as well, and our company began to grown.

His company, MedLion, now has 16 offices located in five states, and is negotiating a contract with a large employer with 9,000 employees to open a facility close by to serve as its primary care physician. Qamar explained his “model”:

“Direct Primary Care” is when individuals or employers pay “directly” for “primary care.” Because of this “direct” care, excessive overhead, such as insurance claim processing costs, prior authorizations, billing and coding, extra office space, and unnecessary staff is removed from the business equation.

The savings attained are passed on to the patients in the form of lower fees. Doctors are less dependent on third party payers, and end up working in the best interests of patients, not insurance companies…

Direct Primary Care is able to make primary care relatively affordable, and thus eliminate the need for costly insurance. Health insurance is reserved for rare, expensive events, like in all other industries.... [As a result] costs are driven down.

Just the costs of managing the paperwork involved in insurance claims, billing and obtaining approval for procedures can run up to 40 percent of a practice's revenues. It’s a treadmill that the traditional physician finds himself on: running harder and harder just to stay in place. With ObamaCare, the treadmill is speeding up and many physicians are falling behind, leaving patients with more delays, poorer care, and a lower overall quality of medical care.

Business is so good for Scott Borden’s Direct Pay Consulting business which helps doctors make the transition from traditional treadmill practices to direct pay that he is limiting himself to helping just 20 practices at a time. He is on the cutting edge of dissatisfaction with medical care in the United States, driven by at least three forces: decreasing reimbursements, more and more time spent writing letters and filing claims rather than practicing medicine, and increasing demand from more and more patients. What Borden is finding is that more and more people are willing to pay a little extra to get a lot more.

The potential market is large and could be immense. As ObamaCare falters and ultimately fails to cover the millions originally promised back in 2009, citizens will be more and more willing to pay a little more for direct access to a doctor who can now spend more time with them. When they are forced to buy insurance through one of the ObamaCare exchanges, the low-premium high-deductible plans will likely make the most sense. With a $5,000 annual deductible that most citizens might face, they will promptly discover that rather than paying that deductible out of pocket, it makes more economic sense to pay $100 a month or so to cover ordinary medical costs such as office visits, blood tests, urinalysis, and the like.

Last year there were an estimated 4,400 physicians who had already made that jump to direct pay, while current estimates place that number at more than 5,500 — an increase of 25 percent in just one year. But making that jump can be unnerving for the doctor, who could face a serious, although temporary, decline in his income

One year ago. The Boston marathon, the athletic values and the medical profession

The athletic spirit is  strongly connected to the values of peace and brotherhood. It is unfortunate that one year ago innocent people sustained severe injuries at the Boston Marathon bombing. The heroic work of the surgeons should be recognized and valued in todays society where the medical profession has been undervalued and extremely regulated.

For those in the medical field you can watch the interview the world renowed general surgeon George Velmahos about what happend and how the hospitals responded to the extremely high number of injured people that arrived in the hospitals.

http://www.wcvb.com/chronicle/Interview-with-Dr-George-Velmahos-of-Mass-General/19785534#!FWjZ3

Of note the The mission of Olympic Spirit is "to build a peaceful and better world in the Olympic Spirit which requires mutual understanding with a spirit of friendship, solidarity and fair play - Olympic Spirit strives to inspire and motivate the youth of the world to be the best they can be through educational and entertaining interactive challenges. Olympic Spirit seeks to instill and develop the values and ideals of Olympism in those who visit and to promote tolerance and understanding in these increasingly troubled time in which we live, to make our world a more peaceful place."

More generally, the term "Olympic spirit" is an oft-referred-to but perhaps vaguely defined concept associated with the Olympic Games. Some media equate it with Pierre de Coubertin's statement that "The important thing is not to win, but to take part", and view athletes who try their best but finish last as epitomising the "Olympic spirit". Thus the Agence France-Presse wrote: "True Olympic spirit is often found away from gold medallists with their agents and sponsorship deals -- it is found in its purest sense in those that come last."^[3] It cited Eric Moussambani, Paula Barila Bolopa, Abdul Baser Wasiqi, Pyambuugiin Tuul, Charles Olemus,Mala Sakonninhom, Luvsanlkhündegiin Otgonbayar, Mira Kasslin and Samia Hireche as incarnations of the Olympic spirit. In 2000, CNN published an article on Eric Moussambani entitled "Olympic spirit: Swimmer competes for love of sport".^[4] In 2008, a press officer with the Chilean Tennis Federation described Nicolás Massú as having "really demonstrated the Olympic spirit: the effort, the struggle, his refusal to give up"

Calculating major surgical risks of complications and the surgical consent

A lot of times we as physicians have to explain the risks and benefits of a surgical procedure to patients. Some patients want to know what are the common risks and also want to know the severity of complications. On the other hand the hospitals are currently interested in providing information to the public and to insurance companies about outcomes. Some hospital are planning to create programs that provide financial bonuses to physicians that prove that their outcomes are better compared to the outcomes of other surgeons. In addition, the Medicare and Medicaid governmental agencies are looking into penalizing hospitals that have higher rates of complications and readmissions.

The American College of Surgeons has introduced a Web based application where physicians and medical providers can calculate the risks of complications related to surgery. It is a valuable tool that I have been using when I consent patients for surgery and explain to them the "main risks" of surgery. It can be found at:

http://riskcalculator.facs.org/

I believe that this is a very valuable tool. The application was developed after studying 1,414,006 patients encompassing 1,557 unique CPT codes. A universal surgical risk calculator model was developed that had excellent performance for mortality (c-statistic = 0.944; Brier score = 0.011 [where scores approaching 0 are better]), morbidity (c-statistic = 0.816, Brier score = 0.069), and 6 additional complications (c-statistics > 0.8). Predictions were similarly robust for the universal calculator vs procedure-specific calculators (eg, colorectal). Surgeons demonstrated considerable agreement on the case scenario scoring (80% to 100% agreement), suggesting reliable score assignment between surgeons


It is interesting that not too long ago Dr Codman lost his appointment at Harvard University when he insisted in looking at outcomes, complications and introduced the morbidity and mortality conferences. Codman wrote, “We believe it is the duty of every hospital to establish a follow-up system, so that as far as possible the result of every case will be available at all times for investigation by members of the staff, the trustees, or administration, or by other authorized investigators or statisticians.” I guess sometimes looking into the too distant future can have "adverse reactions".

For those interested in learning about Codman's short biography please visit http://www.aaos.org/news/bulletin/janfeb07/research1.asp