Richard Rathe, MD

The US Supreme Court is about to hear arguments for and against the recent healthcare insurance reform law enacted by Congress. (aka The Affordable Care Act, aka Obamacare) At issue is the constitutionality of the individual mandate to buy health insurance. It is unclear whether they will set new precedent or rule on a much narrower basis. Their decision could have profound effects on the current law and future legislation. Partisans on both sides of this issue should welcome a broad decision and be ready to accept the consequences!

If the mandate is found to be constitutional, this strengthens the notion that private insurance has a significant role to play in our mixed healthcare system. It bolsters popular components of the law that limit insurance companies’ ability to deny coverage for pre-existing conditions, place lifetime caps on benefits, and allow young adult children to remain on their parents’ insurance. The real challenge—reining in the exploding costs of healthcare—is still ahead of us.

If the mandate is found to be unconstitutional, this is the best argument yet for a single payer system in the US. You cannot have a viable healthcare insurance system if a significant number of citizens have the ability to opt out when they’re young and healthy. Beware the law of unintended consequences! If it turns out to be unconstitutional to force broad participation in private insurance, can a public option be far behind? Careful what you wish for!

March 26 Update: Nice Summary of What’s at Stake on ProPublica!

I recently updated my lecture on cough, given to third-year medical students and residents. It presents an algorithm I developed based on the omnibus supplement published in the journal Chest and other sources. Here is a quick summary of key points that are often missed  by primary care physicians…

1. Acute cough is largely due to viral infections and therefore antibiotics are NOT indicated.
2. There is growing evidence that first generation antihistamines are the drugs of choice for undifferentiated acute cough.
3. Post-infectious cough is the most common etiology for cough lasting between 3-8 weeks.
4. Secondary causes of cough (reactive airways, GERD, post-nasal drip) should be considered based on symptoms and time course.
5. In areas of high TB prevalence consider testing for active disease in any patient with a cough lasting more than two weeks (WHO recommendation).

I concise version of the lecture is available as a podcast.

The lecture handout is available in PDF format.

Always start with the standard questions applied to the patient’s Chief Concern(s): Location/Radiation; Quality/Severity; Duration (total/episode)/Frequency; Aggravating/Relieving Factors; Associated Symptoms/Effect on Function.

It is useful to think of the secondary history as a Focused Review of Systems (ROS). These questions often bring out information that supports a certain diagnosis or helps gauge the severity of the disorder. Unlike the primary history, a certain amount of interpretation (and experience) is necessary.

The tertiary history brings in elements of the Past Medical and Family History that have a bearing on the patient’s condition. By the time you get to the tertiary history you may already have a good idea of what might be going on. Read More…

This is a great documentary from 2008 that explores how other wealthy countries deal with healthcare. The corespondent T.R. Reid visits five capitalist countries that provide affordable, nearly universal coverage for their citizens. How do they do it? He observes that here in the US we have the British model for veterans, the Taiwanese model for seniors, the German model for workers with insurance, but for the rest we are “just another poor country”. His conclusions…

1) Insurance companies must accept everyone, and cannot make a profit on basic care.

2) Everybody is mandated to buy insurance, with the government paying the premiums for the poor.

3) Doctors and hospitals have to accept one standard set of fixed prices.

Being able to handle emotional situations is an important interviewing skill. It is safe to assume that every patient has some form of emotional response to significant illness. There is also growing evidence that an individual’s emotional state can effect or even cause physical disease. The patient will often give you several clues that should be followed up. Read more…

At the most basic level, insurance is all about sharing risk. For example, a group of one thousand homeowners band together to create an insurance pool to protect against fire. If homes are worth $100,000 and there is one fire per year, they would have to chip in $100 each. Fortunately the risky event is rare, so the cost of insurance is low.

Now let’s compare this with insuring health. We have the same thousand people, of which five hundred consume an average of $10,000 in healthcare services each year. Illness unfortunately is not a rare event and the annual premium jumps to $5,000 per person! Many of the younger, healthier people ask why they should be paying for somebody else’s infirmity? They withdraw from the pool and premiums skyrocket. Eventually the pool collapses and those who actually need care loose their coverage, and in many cases financial ruin ensues.

The key difference is that almost everyone will utilize healthcare services at some point in their lives. It’s as if fifty houses burn down every year, not just one. The insurance model breaks down under these circumstances. We are no longer sharing risk but rather sharing the cost of something that is deemed essential by a large number of our peers.

The two obvious solutions are controlling costs and enlarging the pool. Recent mandates to buy health insurance are an attempt to address the latter. Controlling the cost of healthcare continues to be a conundrum.

One of the biggest fears facing Americans is loss or denial of health insurance. This recent analysis concludes that up to half of adults under age 65 are at risk of being denied due to a pre-existing condition. Note that the dark blue bars on the graph below are based on criteria provided by the insurance companies themselves.

Source: healthcare.gov

Article: http://www.healthcare.gov/center/reports/preexisting.html

Analysis: http://www.slate.com/id/2281588/ (podcast)

Canvass ARS is a flexible and scalable program for polling a live audience. Instructors have the choice to use it as a stand-alone presentation tool, or integrate it with presentation software such as Powerpoint. It blends easily with other instructional technologies such as teleconferencing, streamed video events and Webinars. The audience is not limited to a single physical location. You can also use it to record votes during a meeting. In fact, you could run an entire presentation with audience responses from your smartphone! Read more…

Source: Am Scientist

While searching for something else, I came across this important article from 2001 by Clyde Hertzman concerning the relationships between wealth, society, and health. One graph from the article says it all—the United States is deep in the “worse outcome, higher expenditure” quadrant. The author begins by defining the Socioeconomic Gradient as the relationship between social status and health…

The average health status of members within every society on earth increases in a stepwise fashion as one ascends from the bottom of the social ladder (defined, variously, by income, education or occupation) to the top.

He argues that the slope of this gradient depends on several non-healthcare factors within each society. The specifics of healthcare delivery and healthcare systems are less important!

Here is a summary of his conclusions with respect to wealthy countries…

1. Increased life expectancy and other measures of health do not correlate with increased wealth.
2. The character of the socioeconomic environment has a strong effect on health outcomes.
3. Societies that are more socially just and egalitarian have better overall health outcomes.
4. These factors determine the slope of of the socioeconomic gradient (the “spread” in health outcomes).
5. To be effective, health policy should focus on flattening this gradient.
6. In the modern world, socioeconomic boundaries are much more important that geographic boundaries when it comes to disease.

Food for thought as we move forward with “Healthcare Reform” in the US.

I recently created a style guide for our Epic EMR project focused on their so-called  ”SmartText” and related documentation tools. It is based on my experience with the default (“model”) tools, many of which are available on userweb.epic.com under Community Library/Spring 2008. The recommendations are intended to balance the need for efficient, effective documentation tools with the costs of development, validation, training and maintenance. They emphasize keeping things simple and promoting as much end-user autonomy as possible. The link to the full posting is: http://emr.med.ufl.edu/training/smarttool-style-guide/ Access is limited to local users unfortunately. Those from outside UF who are interested should contact me directly via the form to the right on this page.