8 Minutes Per Patient

The New York Times medical writer Dr. Pauline Chen discusses how doctors in training are now spending on average only 8 minutes per patient each day.

Some excerpts from her piece, "For New Doctors, 8 Minutes Per Patient":

[R]esearchers found that interns were devoting about eight minutes each day to each patient, only about 12 percent of their time...

The dramatic decrease in time spent with patients compared with previous generations appears to be linked to new constraints young doctors now face, most notably duty hour limits and electronic medical record-keeping. The study found, for example, that interns now spend almost half their days in front of a computer screen, more than they do with patients, since most documentation must be done electronically...

When finally in a room with patients, they try to speed up their work again, but by limiting or eliminating altogether gestures like sitting down to talk, posing open-ended questions, encouraging family discussions or even fully introducing themselves.

“We have to ask ourselves if spending more time on electronic medical records than with patients is time well spent,” said Dr. Leonard S. Feldman, senior author of the study and assistant professor of medicine and pediatrics at the Johns Hopkins School of Medicine. “If you’re only spending eight minutes talking to and examining a patient, something is certainly going to be missing.”

The article also notes that this will set a pattern for how these young doctors practice in the future:

A young doctor’s experiences during training strongly influence how he or she treats patients once in practice. In addition, because observation of diseases and their myriad manifestations is critical to building a doctor’s clinical skills, some worry that today’s young doctors won’t have had enough interactions with patients to be able to recognize the more subtle signs and symptoms of disease or of impending emergencies when they begin practicing on their own.

The newest generation of doctors may thus be more reliant on standardized protocols, and less adept at independent clinical judgment.

The combination of government-mandated work hour limits and mandated electronic medical records could change American medicine for decades to come -- and not necessarily for the better.

(Read the full text of "For New Doctors, 8 Minutes Per Patient".)

The Direct Pay Model Spreads

The Bangor Daily News reports: "South Portland doctor stops accepting insurance, posts prices online".

Some excerpts:

...[T]he decision to do away with insurance allows Ciampi to practice medicine the way he sees fit, he said. Insurance companies no longer dictate how much he charges. He can offer discounts to patients struggling with their medical bills. He can make house calls.

"I'm freed up to do what I think is right for the patients," Ciampi said. "If I'm providing them a service that they value, they can pay me, and we cut the insurance out as the middleman and cut out a lot of the expense"...

Even with the loss of some patients, Ciampi expects his practice to perform just as well financially, if not better, than before he ditched insurance. The new approach will likely attract new patients who are self-employed, lack insurance or have high-deductible plans, he said, because Ciampi has slashed his prices.

“I’ve been able to cut my prices in half because my overhead will be so much less,” he said.

Before, Ciampi charged $160 for an office visit with an existing patient facing one or more complicated health problems. Now, he charges $75...

You can see the prices he charges on his website.

Another benefit to patients:

That time is crucial to Ciampi. When his patients come to his office, they see him, not a physician’s assistant or a nurse practitioner, he said.

“If more doctors were able to do this, that would be real health care reform,” he said. “That’s when we’d see the cost of medicine truly go down.”

(Read the full text of "South Portland doctor stops accepting insurance, posts prices online".)

For more on benefits of this "direct pay" model (or related "concierge" model), see my Forbes piece: "Is Concierge Medicine The Correct Choice For You?"

Quick Links: UK Whistleblower, IRS, Tyranny

Express & Star: "Stafford Hospital whistleblower forced out of town by hate campaign".

David Catron: "An IRS Scandal Inseparable from Obamacare".

Milton Wolf: "Tyranny in our time"

Cochrane on Doctor Owned Hospitals

University of Chicago economist John Cochrane makes some great points about crazy pricing in traditional hospitals. And why ObamaCare has restrictions on doctor-owned hospitals. (Hint, it's at the insistence of traditional hospitals who want to suppress competition).

Read the full text of his post, "Doctor-owned hospitals".

(Via Marginal Revolution.)

Hsieh PJM OpEd: Is Obamacare's Fatal Flaw Taking Effect?

Yesterday's PJ Media has published my latest OpEd, "Is Obamacare's Fatal Flaw Taking Effect?"

I discuss how ObamaCare requires voluntary cooperation of people who will be harmed by the law -- which gives Americans a powerful weapon.  Don't be a willing accomplice to a law you don't support!

I'd also like to thank Dr. Megan Edison for allowing me to quote her.

Update: I'm also encouraged by the fact that some former supporters of the law appear to now be having second thoughts: "Unions break ranks on ObamaCare" (The Hill, 5/21/2013)

Trusting the Navigators?

WSJ: "Role of Health-Law 'Navigators' Under Fire":

At a private briefing with federal officials last month, committee aides say they were told there would be no criminal background checks for navigators or requirements that they hold a high-school diploma.

"Because navigators and assisters will have access to personal and sensitive information such as Social Security numbers and tax returns, we believe they should be held to the same hiring standard as U.S. Census and [Internal Revenue Service] employees," who get Federal Bureau of Investigation background checks, wrote Rep. Darrell Issa (R., Calif.), the chairman of the committee, and two other Republican members in a letter to the department.

In light of recent events, perhaps the government "navigators" should be held to even higher standards than IRS employees.

Catron on IRS and Medical Records

David Catron asks, "Has the IRS Already Seized Your Medical Records?"

I was particularly struck by this section:

You will note that the person from whom these records were stolen was not a doctor or a nurse, but a data analyst who was carrying around huge amounts of medical information on a laptop. And this is where you should begin to have real fears for your privacy. Your medical records, once the province of highly trained medical professionals, are now routinely accessed by all manner of individuals uninvolved in your medical treatment. And many of these individuals are not closely supervised by medical professionals. Indeed, many of the people who have access to your medical records are not supervised by anyone.

For example, if you visit the ER tonight, the hospital will send a claim to your insurance company. Before that happens, however, a diagnosis code must be assigned to your record. Who does that? Typically, it is someone in her pajamas who uses a laptop to remote into the hospital’s IT system from home after the kids are in bed. She is not a physician or a nurse, yet she peruses your records, interprets your doctor’s notes, and then chooses an ICD-9 code from a drop-down box. It is likely that no one employed at the hospital has ever met this person in the flesh. Hospitals increasingly connect with such contract coders via outside agencies.

Assuming this coder is completely honest and very productive, as are most of them, what happens if her eldest son is addicted to narcotics and knows that she has routine access to the names, dates of birth and Social Security numbers of thousands of people? He has a golden opportunity to commit identity theft. All he has to do is wait until she forgets to lock her screen when she gets up to toss a casserole into the oven or run to the bathroom. If he is computer savvy, and what adolescent isn’t, he can access and steal your information in a matter of minutes. Such opportunities arise every minute of every day, all across the nation.

The point here is not that electronic medical records are inherently bad. It is rather that, in their mad rush to pass Obamacare and the stimulus package, the President and his accomplices on Capitol Hill mandated clunky, insecure systems that can be abused by politicized government agencies, mismanaged by innocent but incompetent bureaucrats, or even breached by the kid next door...

(Read the full text of "Has the IRS Already Seized Your Medical Records?")

More IRS-Health Record Problems?

Health Care IT News: "IRS faces class action lawsuit over theft of 60 million medical records"

 Scott Gottleib (Forbes): "The IRS Is Accessing Your Health Records. You Trust Them?"

Also from Gottleib: "Suit Alleges IRS Improperly Seized 60 Million Personal Medical Records"

In the second piece, Gottleib quotes from the complaint:

“These medical records contained intimate and private information of more than 10,000,000 Americans, information that by its nature includes information about treatment for any kind of medical concern, including psychological counseling, gynecological counseling, sexual or drug treatment, and a wide range of medical matters covering the most intimate and private of concerns,” the complaint states.

“Despite knowing that these medical records were not within the scope of the warrant, defendants threatened to ‘rip’ the servers containing the medical data out of the building if IT personnel would not voluntarily hand them over,” the complaint reads.

(Of course, the validity of these complaints presumably still needs to be established in court.)

Hsieh at PJM: Did the White House Try to Get a Conservative Columnist Canned?

PJ Media published my latest short blog post, "Did the White House Try to Get a Conservative Columnist Canned?"

I appreciate Dr. Milton Wolf's willingness to let me quote him in this piece. As he notes, what once seemed implausible, today seems possible.

I applaud Dr. Wolf's tireless advocacy efforts and always enjoyed reading his columns.  (We differ on some issues, but I agree with much of what he writes, especially on health care policy.)  I also want to give the Washington Times credit for ignoring that kind of government "hint".

Plus, it's in my self-interest to ensure that other radiologist-activists don't draw the wrong kind of government attention.  Hence, I very much appreciated today's Instapundit link.

If you haven't done so, you should check out Milton Wolf's website!

Quick Links: York, Samuelson

Byron York: "IRS scandal raises fears about enforcing Obamacare".

Robert Samuelson: "Overselling ObamaCare".

Catron on Grand Old Poseurs

In his latest American Spectator piece, David Catron explains why advocates of free-market health reform should not regard Republicans as their unconditional allies.

His piece, "The Grand Old Poseurs" discusses problems with positions taken by federal and state Republican officials including Speaker of the House John Boehner and Senate Minority Leader Mitch McConnell and Ohio governor John Kasich.

Catron is more optimistic about some new blood such as Senators Ted Cruz and Rand Paul. (For me, the jury is still out.) 

I'm definitely all in favor for holding our elected officials' feet to the fire on this issue, regardless party affiliation.

(For more details, read the full text of "The Grand Old Poseurs".)

Diana Hsieh Podcast on EMTALA

Diana's internet radio segment on the EMTALA law went well yesterday! For those interested in listening to the segment, here's her description and the links:

Do people have a right to emergency medical care?

On Sunday's Philosophy in Action Radio, I answered a question on emergency medical care. The question was:

Do people have a right to emergency medical care? EMTALA (a.k.a. the Emergency Medical Treatment and Active Labor Act) is a federal law that requires emergency rooms to stabilize any patient with an emergency medical condition, regardless of the patient's ability to pay. Is that proper? Is that the same as a right to medical care?

My Answer, In Brief: EMTALA violates the rights of doctors, based on the false premise of a "right" to health care. In practice, it's a disaster for doctors, hospitals, and the working poor. Ultimately, only scammers and advocates of government-controlled medicine benefit by it. Download or Listen to My Full Answer:

• Duration: 22:21
• Download: MP3 Segment

Tags: Altruism, Charity, Egalitarianism, Emergencies, Ethics, Free Society, Justice, Law, Law, Medicine, Politics, Poverty

Links:

• FAQ on EMTALA
• Cato Institute: Medicare's Origin: The Economics and Politics of Dependency by Charlotte Twight
• American College of Emergency Physicians: On EMTALA and The Uninsured
• Health Care Is Not a Right by Leonard Peikoff
• The Objective Standard: Moral Health Care vs. "Universal Health Care" by Lin Zinser and Paul Hsieh
• The Objective Standard: Health Care and the Separation of Charity and State by Paul Hsieh
• Freedom and Individual Rights in Medicine (FIRM), particularly its articles
• The History of Health Care Costs and Health Insurance by Linda Gorman

To comment on this question or my answer, visit its comment thread.

A podcast of the full episode – where I answered questions on taxes versus slavery, infanticide after abortion, emergency medical care, and more – is available here: Episode of 12 May 2013.

You can automatically download podcasts of Philosophy in Action Radio by subscribing to Philosophy in Action's Podcast RSS Feed:

• Enhanced M4A Feed: Subscribe via iTunes or another podcast player
• Standard MP3 Feed: Subscribe via iTunes or another podcast player

About Philosophy in Action Radio

Philosophy in Action Radio applies rational principles to the challenges of real life in live internet radio shows on Sunday mornings and Wednesday evenings. For information on upcoming shows, visit the Episodes on Tap. For podcasts of past shows, visit the Show Archives.

Upcoming Diana Hsieh Podcast on EMTALA

My wife Diana Hsieh will be covering the EMTALA law (Emergency Medical Treatment and Active Labor Act) as one of the topics in her "Philosophy In Action" radio show tomorrow morning.

Here's the question she'll be answering:

Question 3: Emergency Medical Care

Do people have a right to "stabilizing medical care"? EMTALA (a.k.a. the Emergency Medical Treatment and Active Labor Act) is a federal law that requires ERs to stabilize any patient with an emergency medical condition, regardless of the patient's ability to pay. Is that proper? Is that the same as a right to medical care? Does it matter that EMTALA only applies to emergency rooms that accept Medicare patients?

The other topics she'll be covering include "taxes vs. slavery", the Gosnell infanticide case, and how to work with an uncommunicative boss.

For more details on how to listen live (or listen to the podcast later), go to her page.

McArdle on Medical Innovation

Megan McArdle asks, "Has Medical Innovation Slowed Down?"

The teaser sentence:

The good news is that health care costs aren't rocketing away like they used to. The bad news is that drug discovery has slowed down too.

Benjamin Rush YouTube Channel

The Benjamin Rush Society (soon to be renamed the Benjamin Rush Institute) has a new YouTube channel.

According to executive director Dr. Beth Haynes:

You can now access all of the debates from the 2012-2013 academic year - the latest of which is on the issue of Maintenance of Certification. The full video of this particular is debate lengthy -- 2 hours. A volunteer is preparing a transcript from which I will work on creating an abridged version - but as that won't be available for several weeks, I wanted to make the full length version available now...

This topic is picking up steam, sparking initiatives in state medical societies(one example attached), a law suit, and news articles, a survey of physicians asking them to report actual costs for recertification, and vigorous discussion on various internet platforms.

I am thrilled that the work of BRS is relevant beyond medical school campuses, and able to provide medical students a place to get involved now.

 Kudos to Dr. Haynes for her great work!

Hsieh Forbes OpEd on 3D-Printed Guns

This isn't directly related to health care policy, but it's a hot topic that's been in the news lately.  Plus it's one of my other public policy interests, so I'm exercising blogger's privilege to post about it anyways!

Yesterday's Forbes published my latest OpEd, "Why 3D-Printed Untraceable Guns Could Be Good For America".

Here is the opening:

In the past few days, Forbes writer Andy Greenberg broke a pair of dramatic stories on Cody Wilson’s quest to build an untraceable plastic gun using commercially available 3D-printing technology. First, Greenberg published exclusive photos of the completed firearm, then he reported on a successful test firing of a live .380 cartridge.

Although the technology is still in its infancy, Wilson’s innovation has already sparked heated debate. Some gun rights advocates (including Wilson) argue this means current gun laws will soon be obsolete. They welcome the fact that home hobbyists may soon be able to build functioning firearms without any background check or government record. Others are alarmed, concerned that this would enable criminals to more easily obtain firearms. Congressman Steve Israel has already stated his intent to modify current laws to ban such guns.

However, Congressman Israel may be too late. Once thousands of motivated hobbyists start downloading open source gun designs and posting their refinements, we’ll likely see rapid technical advances. But Cody Wilson’s real impact on America may not be technological but political — and in a good way...

(Read the full text of "Why 3D-Printed Untraceable Guns Could Be Good For America".)

Update: I've gotten some helpful feedback on this piece.  I should make clear that I don't support government overreach with bad laws.  But neither do I support the anarchists who wish to misuse this technology to violate individual rights either. Instead, I regard this as a good opportunity to promote limited government as the proper alternative to both statism and anarchism. If I was insufficiently clear on this earlier, I apologize!

More Reactions to Oregon Study

Some more worthwhile commentary on the Oregon study:

David Catron: "Obamacare Pimps Smear Lipstick on Another Pig"

Megan McArdle: "How the Oregon Study Should Change Our Thinking"

More Lessons From the UK

Diana Furchtgott-Roth writes in RealClearMarkets: "For An Obamacare Preview, Look To England"

Oregon Surprise

Slate has just reported, "Bad News for Obamacare: A new study suggests universal health care makes people happier but not healthier".

Here's opening to the Slate piece:

In 2008, the state of Oregon initiated an ambitious health care policy that allowed researchers to shed light on the effects of guaranteeing Medicaid coverage for low-income adults. The results have been closely followed in large part because insurance for the poor is a major component of the Affordable Care Act—aka Obamacare—that will soon be rolled out across the country.

A study published on Wednesday in the New England Journal of Medicine reports that—at least as far as health outcomes are concerned—the Oregon Medicaid experiment hasn’t lived up to the hopes of many universal care advocates. Two years after getting randomly assigned to Medicaid coverage, recipients fared no better than a control group of uninsured, low-income Oregonians in tests for hypertension, cholesterol, and diabetes treatment—all medical conditions that can be managed with proper care. The Medicaid recipients did report much lower rates of depression and—perhaps relatedly—were much less likely to be on shaky financial footing than those in the control group. But the Oregon study’s findings indicate that the claim that universal health care on its own will make Americans healthier, at least in these particular dimensions, may be wishful thinking.

Here's the direct link to the NEJM article: "The Oregon Experiment — Effects of Medicaid on Clinical Outcomes".

Haynes: Almost All Americans Lack Health Insurance

Dr. Beth Haynes of the Benjamin Rush Society has a nice OpEd in the 4/29/2013 Huffington Post, "Almost All Americans Lack Health Insurance".

She adds much-needed conceptual clarity in the discussion over health policy by discussing the nature of genuine insurance, as opposed to our current system.  From her piece:

What is insurance? Think about your auto, life and homeowner's insurance. Each of these is designed as a means to pay for unexpected, unpredictable, very expensive occurrences outside of the control of the policyholder. Insurance is a means of financially protecting people from the risk of unlikely but high-cost events. To build up sufficient funds, the insured pays a premium calculated on their specific chance of experiencing a covered event. Insurance companies can only stay solvent if what they take in as premiums is greater than what they pay out in claims (plus business expenses and a competitive profit).

So what is it we have that we call health insurance but isn't? We have the prepayment of medical expenses. We expect our "insurance" to cover predictable, relatively inexpensive events like health maintenance checks, minor illnesses and injuries -- and to pay for them with minimal out of pocket spending. Under Obamacare, these expectations will be mandated by law. The new law actually makes it illegal for insurance companies to charge individuals premiums equal to their risk of making claims. It's like having a law requiring homeowner's insurance to pay for lawn care, house painting and water heater replacement, while at the same time prohibiting the companies from operating an actuarially sound business.

Instead of genuine insurance, we are moving towards a system of bad pre-paid care.

For more details, read the full text of "Almost All Americans Lack Health Insurance".

And by the way, under Dr. Haynes' leadership, the Benjamin Rush Society has been sponsoring an excellent series of debates on important health policy issues.  Go check out their website for details and videos!