Wednesday, August 20, 2014

Edison on Narrow Networks

Pediatrician Dr. Megan Edison recently described what it's like to be on the receiving end of patients who lose their doctors because of ObamaCare: "Confessions of a Narrow Network Doctor".

She describes the problems patients faced by the loss of choice.  And she offers some solutions:
The solution seems so clear in my little corner of the world. I want my patients to have control over their own health care dollars regardless of employment status or political party in power. I want to work directly with my patients to help them choose how to best use those dollars in a price transparent healthcare environment. I want them to choose me. I want competition to push me to provide the best care at a good value, knowing that my patients always have a choice to see another doctor if I’m not doing a good job. In short, I’d love folks to own a high-deductible HSA for life, in a healthcare system that is transparent and competes for those dollars.

But that would give power directly to the patient and all the healthcare choices between the patient and the doctor. Turns out, there are more powerful players that want control over what happens in my office...
I recommend reading the full text of "Confessions of a Narrow Network Doctor".  If you like what you read, check out the rest of the RebelMD site!

Monday, August 18, 2014

Hughes On VA, FDA, and American Health Care

Monica Hughes recently gave an excellent talk on, "The Transformation of American Healthcare: Lessons from the Veterans Administration and Existing FDA Standards of Care" to Liberty On The Rocks at Flatirons.

Her talk is now available on YouTube (3 parts).

Part 1

Part 2

Part 3

Disclaimer and synopsis:

DISCLAIMER: The speaker is not a medical doctor or health care practitioner. The ideas in this video are not intended as a substitute for the advice of a trained health professional. All matters regarding your health require medical supervision. Consult your physician and/or health care professional before adopting any nutritional, exercise, or medical protocol, as well as about any condition that may require diagnosis or medical attention. In addition, statements regarding certain products and services represent the views of the speaker alone and do not constitute a recommendation or endorsement or any product or service.

Synopsis: In January 2014, Robb was diagnosed with glioblastoma multiforme (GBM), one of the deadliest brain cancers in existence. Nicknamed "The Terminator" the median survival time is around 11 months. Robb had brain surgery on January 16, which was performed by a team of surgeons while Robb was awake. The surgery was a success.

Monica's research into the post-surgery treatments that worked best for other survivors showed that they were not approved by the Food and Drug Administration, so they'd have to go to a cancer center that sprouted up in Tijuana, Mexico for treatment which included a 100 year-old immune system booster called Coley's Vaccine.

Bio: Monica Hughes has bachelor's, master's, and PhD degrees in biology and has taught college biology since 2006. Previously, Monica served as a medical writer for National Jewish Health, a premier research hospital for respiratory and immune disorders, and is now a patient advocate specializing in literature research.

Robb LeChevalier has served in the Air Force and has a bachelor's degree in electrical engineering. He designed his own home situated in the foothills outside of Denver, and currently develops high speed electronics for his own company, Astronix Research. He has been an Objectivist for 40 years.

More: Robb was given 2 months to live without surgery, a maximum of 6 months to live with surgery only, and an unspecified amount of time with additional therapy due to the unusually aggressive nature of his particular tumor. He and his wife Monica faced seemingly insurmountable hurdles by the Veterans Administration along the way, including timely care from the VA and a delay of emergency surgery that could have cost Robb his life had they not pushed for a special dispensation from a panel of VA doctors within the 48 hours leading up to his scheduled surgery. They are currently contesting 58 claims denials by the VA totaling nearly $250,000 in unpaid medical bills.

In the days following Robb's surgery, they discovered that immunotherapy held the best chance of long-term and quality survival for this cancer. Historical 3 year survival with FDA-approved standard of care for GBM is around 7%. 3-5 year survival for some GBM patients in clinical trials using cancer vaccines is between 20%-50%, depending on the vaccine. Yet they discovered that due to FDA regulations, it is impossible to enter these clinical trials without first or concurrently undergoing FDA-approved standard of care, and that such care would greatly reduce his likelihood of responding to immunotherapy, if he was lucky enough to meet the criteria for the study and be placed in the treatment arm of such a trial.

Given these poor odds, Robb chose to forego all standard of care therapy after surgery, and opted for an immunotherapy protocol abroad that, according to current MRI results, has left him without evidence of disease. As of June 10, 2014, their new low deductible PPO health insurance policy, purchased on the Obamacare exchange, has not paid out a single penny of reimbursement for Robb's cancer treatment.

(Note: I also discussed their case in my 5/28/2014 Forbes piece, "VA Denies Coverage For US Air Force Veteran With Malignant Brain Tumor".)

Wednesday, August 13, 2014

Quality Is In The Eye Of The Beholder

Dr. Saurabh Jha has penned a great essay, "Who is the better radiologist? Hint, it’s not that easy."

A couple of comments:

1) "Quality" is in the eye of the beholder.  And as the federal government starts setting more payment rules to govern "quality", that beholder will increasingly be the government.  Which won't necessarily be what patients would regard as "quality".

2) This is one of the best discussions of ROC and the trade-off between sensitivity-vs-specificity, without the jargon.

Tuesday, August 12, 2014

Dr. Brian Forrest on How To Start a Direct Primary Care Practice

Dr. Brian Forrest recently gave an interview with Concierge Medicine Radio on "How You Can Start a Direct Primary Care Practice for less than $10k".

Some of the topics he discussed include:
  • The shockingly simple math behind how reducing overhead and eliminating collections allows primary care physicians to spend more time providing better care while improving their take home pay. 
  • How Brian kept his total operating expenses to $50k in the first year and how you can too. 
  • The rule of thumb Brian uses to make all his purchasing decisions. 
  • The two most effective forms of advertising for Brian’s direct pay practices. 
  • How to choose your billing software and Brian’s recommendations. 
For more details, listen here.  Here's more information about his particular practice, Access Healthcare.

Friday, August 8, 2014

Doug McGuff on Government Controls In Emergency Medicine

On Thursday's episode of Philosophy in Action Radio, Diana Hsieh interviewed emergency medicine physician Dr. Doug McGuff about "Government Controls in Emergency Medicine." The podcast of that episode is now available for streaming or downloading. You'll find it on the episode's archive page, as well as below. You can automatically download podcasts of Philosophy in Action Radio by subscribing to Philosophy in Action's Podcast RSS Feed:
Podcast: Dr. Doug McGuff about "Government Controls in Emergency Medicine" The practice of emergency medicine is heavily regulated by the government. What is EMTALA? What are its effects? What have the effects of ObamaCare been so far? How do these laws compromise patient care and make the practice of medicine more difficult? How could emergency medicine be made more free? Dr. Doug McGuff is an emergency medicine doctor practicing in South Carolina. He graduated from the University of Texas Medical School at San Antonio in 1989, and then trained in Emergency Medicine at the University of Arkansas, where he served as Chief Resident. From there, Dr. McGuff served as Faculty in the Wright State University Emergency Medicine Residency and was a staff Emergency Physician at Wright-Patterson AFB Hospital. Today, Dr. McGuff is a partner with Blue Ridge Emergency Physicians. Diana interviewed Dr. Doug McGuff about fitness, weightlifting, and high-intensity exercise in December 2012 and about avoiding the emergency room in May 2013. Listen or Download:

  • Emergency Medicine
  • EMTALA and the history of government controls in medicine
  • ObamaCare and its Accountable Care Organizations
  • Practicing under ObamaCare
  • Quality measures
  • Government versus private insurance


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Friday, August 1, 2014

Concierge Medicine Article in Med Monthly

The medical professional magazine Med Monthly has reprinted (with permission) one of my Forbes pieces in their August 2014 issue: "Is Concierge Medicine The Correct Choice For You?"

Thank you, Med Monthly and creative director Tom Hibbard, for the wider circulation!

(Original Forbes link.)

Thursday, July 31, 2014

Unintended Consequences of FDA Regulations

Eye surgeon Dr. Brian C. Joondeph described a crazy "unintended consequence" of FDA rules designed to "protect" patients.

Here's an extended excerpt from his blog post:
In my medical specialty of retina surgery, compounded and off-label Avastin is used in the treatment of macular degeneration, diabetic retinopathy, and other retinal conditions. At a cost of 40 times less than the FDA approved options, using compounded Avastin instead of the on-label expensive alternatives could save Medicare $3 billion per year. Studies have shown the lower cost Avastin is equivalent to the much more expensive Lucentis in treating macular degeneration. Many physicians will try Avastin as the first line of treatment in their patients and continue using it if it is working well.

As Avastin is being used “off-label” in a much smaller dose than used for its approved use in cancer treatment, it must be divided into extremely small doses suitable for injection into an eye. This is done by a compounding pharmacy. Most patients receive injections every four to six weeks for many years, with many physicians deciding at the time of the eye exam whether or not to give an injection. Most patients are elderly and/or visually impaired, meaning that a friend or family member brings them to their eye appointment.

Back to the FDA, which recently issued guidance in response to the new, compounding law. Specifically they “will require a patient-specific prescription for all drugs compounded.” While this may allow easier tracking of the rare cases when drugs are contaminated, it won’t alter the actual compounding process and won’t reduce the chance of contamination.

But once the retina surgeon examines the patient and determines that they need an injection, instead of using a preordered syringe from their inventory, they will instead have to send a prescription to the compounding pharmacy and have the patient return on a separate day for their injection. For a patient receiving monthly injections, this translates to 24 office visits rather than 12 each year. Depending on insurance, there may be a copayment for each visit. Not to mention the friend or family member doubling their driving duties and the physician further loading their already busy patient schedules. Imagine going to the family doctor for a flu shot and after a quick exam, having to return a week later for the shot after the doctor writes a prescription for it rather than simply pulling a vial of flu vaccine from the refrigerator and giving the injection.

The simple alternative for the surgeon is to abandon any intention of being a good steward of societal and patient monies by simply using the FDA approved, but far more expensive, drugs. This avoids the hassle of writing several hundred injection prescriptions each month and making patients return a week later for each injection. Good financial stewardship of government money loses appeal when the government complicates the physician’s business processes by such mandates. And when the government threatens physicians with a 30% cut in reimbursement via the SGR cuts, why should physicians jump through hoops to save Medicare a few dollars?
These FDA rules increase the "hassle factor" for patients and doctors. And cost more money in the long run.