Social Programs, The Federal Budget, and Your Future Health Coverage

This post is to celebrate **cough cough** our government's new budget deal this weekend.

Ever wonder what is devouring up our tax dollars to the tune of 5+ trillion dollar debt (last I checked, though admittedly this number could be drastically higher)? Would it suprise you to find out that currently 76% of it goes directly towards paying just FOUR governmental expenditures?!

1) Social Security
2) Medicare
3) Medicaid
4) Paying down our national debt

What's even more suprising? The expected percentage of budget projected by the Governmental Accountability Office prior to tonight's deal.

Prepare yourself...

92%

Imagine looking at your family budget and realizing you have 8% of your monthly income left after paying your debtors, your health insurance, and your retirement. Doesn't compute. You'd be homeless, starving, and naked in less than one month's time!

Here's a perfect illustration of the deep financial problems facing our gonverment without budget and social program reform.

Currently Medicare provides services for every individual over 65 years of age or about 47 million Americans. Medicaid services are extended to an additional ~46.8 million. In fact, according to the U.S. Department of Labor's National Compensation Survey, only about half (or 162 million) of the nation's current population has commericial insurance. With an ever-aging population and an ever-expanding lower class, Medicaid/Medicare numbers will only continue to expand rapidly.

So why make it on my medical blog? THIS BUDGET DECISION AFFECTS ME AND IT AFFECTS YOU! Just looking at one issue, healthcare, and you will see that at the current expense rate, america cannot sustain/afford this system of health coverage. Unfortunately, when Obama healthcare package goes into effect, it will only further centralize insurance coverage and place greater burden on the federal budget. Please, read my post last year on Obama's plan for more information on that subject.

This is meant only to bring this remarkable information to your attention. I hope it astonished you as much as it surprised me.

A New Way to Take Tylenol?

This week I saw something new that may change how your pain will be managed during your next hospital stay. After nearly 60 years of Tylenol as you know it...there is a new player on the market:

Injectable Tylenol.

Why you might ask did it take that long for them to crush the pills and put them into saline? Good question, but it has actually been around for quite along time, under the name Paracetamol, and has been approved for use in Europe for years. So perhaps the better question is: What took so long for the FDA to approve it for use here?

From what I have gathered, the FDA has balked over the years because it can be easier to overdose when using the injectable form. Not that it is anymore potent, just that it is easier to give a rapid dose, which can overwhelm the liver into failure. Interestingly, the number one cause of liver failure in the U.S. is from tylenol misuse.

There is undoubtedly a lot more to the FDA's prior concerns, and I am not sure what exactly this new medication has done to prove itself safer. Regardless, it is now approved for use now under the name OFIRMEV (I know, crappy name).
What so nice about it? Well, it will virtually take the place of narcotic pain relievers as firstline therapy straight out of surgery when one is not awake enough to take oral meds (incidentally how I saw it used today). From the anesthesiologists that I have worked with that have used it, most feel strongly that it works very well to keep initial post-operative pain low and overall decreases the need to turn to heavier duty narcotic medications like Fentanyl, Dilaudid, or Morphine itself. Remember to ask about it the next time you go for surgery, to see if it is in use at your hospital yet.

One more thing: Cost?.....It is 100x's the price of a single dose of oral Tylenol!! What??? Well, that might sound like a lot, but that is actually only $10/dose. Oral Tylenol is just that dirt cheap, folks. I guarantee it is actually a cheaper option than most injectable narcotics being used today. Let me know if it happens to be given to you at some point in the future. I would love to hear what your experience was with it.

FYI: Package Insert

What's Wrong With This Picture?

For now, unlike originally announced last week, this product will not yet be available at your neighborhood Walgreen's...but it is only a matter of time, believe me. The proposed product: a home genetic test...check that, a home saliva test (self dubbed: "health risk assessment kit") which you can send to a California company for a DNA analysis. And their promise? A risk report for a plethora of medical issues - all within the confines of your home. Great, right? Wrong. I have spent 3 years in med school and 4 more years studying genetics/developmental biology for my B.S. degree, and I have not even the first clue what gene data they are using to tell you your risk for: (off their own website mind you): Asthma, Atrial fibrillation, Coronary artery disease, Diabetes - Type 1 & 2, Glaucoma, Hypertension, Melanoma, Myocardial infarction, Obesity, Osteoarthritis, Peripheral arterial disease, and a number of cancers too.

You see, as much as scientists have discovered when it comes to genes and disease, they are not even close to understanding how your DNA dictates your propensity for certain illnesses. For example, there is the concept of epigenetics stating that many or our bodies cells 'override' the DNA code contained within their nucleus, sometimes temporarily and sometimes permanently, to produce gene products in response to the local extracellular environment. Genetic tests will only tell you what the sequence of your DNA compared with the so-called "normal" or in other words, how the majority of the population's DNA sequence reads. These gene tests do not take into account a whole balderdash worth of medical genetics concepts: paramutation, bookmarking, imprinting, gene silencing, X chromosome inactivation, position effect, reprogramming, transvection, carcinogenesis, teratogenic effects, histone modifications, and heterochromatin changes. All this means that one's cells can change frequently by a whole number of mechanisms and all those changes might not be reflected in the actual DNA sequence.

Not only are there a whole slew of post-DNA production changes, most mutations seen in a DNA sequences do not directly correlate 1:1 to disease states. Some you've heard of do...like with cystic fibrosis (CFTR gene), however most don't, like with obesity (or any of the other above diseases). So next time you are at your doctor's, and they hesitate to recommend genetics testing bought at your local Walgreen's....now you know why. Spend your $200 on quit smoking classes or a personal trainer at least that will help extend your life.

Oh Please, Not Again!

For those of you true Darwinists out there, you will fully understand what I'm a about to roll out with this post. You see, working the frontlines of medicine places me in a position at times to greet those who have survived their own stupid decisions long enough to seek help at the local emergency room. Helping patients get through some of their unintelligent decisions can be quite a surreal experience. As a health care worker, I attempt not to pass judgement, but that doesn't mean I can't crack a smirk, or shake my head in amazement at some pretty poor choices. Recently, I had the priveledge of caring for a young man who 'accidentally' detonated the homemade ammonium nitrate bucket bomb in his back yard while he was standing only a few feet away. His clothes blew off and landed some 15 feet past where he eventually landed. Though he literally lost most of the skin on his backside, he was stable when he arrived to the emergency room. My job was to help pick the pieces of melted plastic bucket out if his exposed posterior leg muscles before cleaning what was left of his legs with warm saline. Not exactly something you dream about when you imagine yourself being a doctor as a kid.

Ahh...but the point of this post...a whole new experience for me: rectal foreign body removal. I come from the school of thought that believes that rarely should things go in your butthole, and even then there must be a great reason to do so, such as a suppository for extreme constipation or a gloved finger to check for an enlarged prostate. Maybe an old school view of the world, but one that I ascribe to nevertheless. So when I am called upon to help assist an rather unfortunate soul who lodged a 4 inch in diameter slippery ball, inserted using a foot and a half long pole, it can be difficult not to be somewhat judgemental. After a procession of medical personel attempted without success to dislodge this object out the way, this person bought themselves an exploratory surgery complete with a large abdominal incision, loss of necrotic bowel, and a colostomy bag placement. The really unfortunate thing...this exact surgery had been done to excavate a lodged FB nearly a decade ago. Some will never learn, no matter the consequences...right Darwin?

No Surprises There!

What does your health insurance company and a Quarter Pounder with Cheese at the local McDonald's have in common...besides a vested interest in the state of your coronary arteries????

Turns out more than meets the love handles. A study just released by Harvard Medical School in the American Journal of Public Health, confirms what we have suspected all along....your health insurer is in it for the money, not your health. Notably, researchers found that 11 large US/European-based insurance companies own ~ $1.9 billion in stock in the five largest fast-food companies (including McDonald's, Burger King, and KFC/Taco Bell) as of June 2009. These same researchers found last year that 7 insurance companies held ~$4.5 billion in tobacco-company stock! WHAT?? That seems to me to be quite the double standard.

Shocking, yet predictable. The sad part, it is quite an effective way to invest if you ask me. They make money off of you during the fattening-up phase and then charge higher premiums to insure your fat-self when you seek out their insurance.

To steal an applicable line from The Italian Job: "I trust everyone. It's the devil inside them I don't trust." -John/Stella Bridger


The Medhead.


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Obama, Can You Hear Me?

President Obama-

As I know you are a causal reader of my freshly-minted blog, I thought perhaps I could direct this message to you, Mr. President. My question is related to the passing of our (note: although it was purely a one-sided congress affair, it is all of ours for good or for bad) new health care reform bill. As a current doctor-in-training, one who will be making a decision in the next couple of months on my residency/future medicine path, I am in need of a little bit of guidance from you.

With the new health care bill passing, ensuring another 32+ million Americans
insurance coverage, what measures have you taken in this bill to ensure that there will be enough trained physicians to help provide basic care to these individuals and families? I see a system currently that requires medical students to undertake a big financial and time risk to attend medical school and then residency- a sacrifice that mostly attracts those with a true passion for helping those in need. If we expand the number of individuals that can receive care on a regular basis, protected by the blanket of this new insurance plan, shouldn't we make it our number one priority to train individuals to match this new population seeking care? Any action taken now in 2010 will, at the earliest, result in changes 7-10 years down the road, well after this new bill takes effect. I celebrate your ability to organize this effort and accomplish this much-needed reform, but we must do more on this front.

I have gathered a few of my thoughts on some things that you left out of your reform bill (how is that possible with 2,074 double-spaced pages?), so please take careful note as you plan your next big 'bipartisan' bill formulation.

1) Encourage shortened Pre-Med undergrad programs - Allow students to go to 2 years of undergrad and then straight into medical school (cutting out 2 full years of training- adding these years onto the end of these individuals careers). Brown University has such a program- one of very few across the nation. I started medical school @ 25...meaning I'm for sure in my thirties before I can actively participate in the workforce, as is the case with most of my classmates.

2) Subsidize medical education - Easier said than done, but essential if you expect to have us students to really go into our career decisions in medicine with open minds/hearts. I have a wife and children, I do not have the luxury of incurring $120,000 of debt at a public med school, and then chose to pay $80-100,000/yr. for malpractice insurance if I go into OB/GYN or risk 21% medicare cuts (a future blog about this!) if I go into family practice/internal medicine...all of which are primary care specialties essential to the success of this new bill.

3) Expand medical school classes - Starting a medical school requires millions upon millions of dollars, which most states cannot afford now (a future blog about this too!). I am from a state without a med school, but luckily a neighboring state's medical school invites me to attend their school on subsidies from my state. I am one of only 20 and every year my medical school attempts to expand that number to double for a price of only tens of thousands per student...yet my state's government refuses. I would recommend to you, Mr. President that this be an easy way to expand classes NOW. The applicants are out there....the national acceptance rate to medical school is only ~60%...that leaves 40% out there that can help with the physician shortfall we are currently experiencing.

Well I have other ideas, but you have other more important things to do, like securing nuclear disarmament from Chile, Mexico, and Canada...among others. I thank you for reading this entry and look forward to seeing your comments below, Mr. President.

Sincerely,

The Medhead

Health reform and you!

So part of my job as a future doc, is to figure out how decisions made by the government now...when I am incurring thousands in debt...will affect my future practice. The most pressing of course is our newest health care legislation that passed through congress earlier this past year.
The highlights for those of you who might not already know:

- 32 million more Americans to receive health insurance through government organized co-ops/'exchanges'- and as a side note, to make it cost-effective for insurers, a mandatory coverage requirement for everyone by 2014!
- stoppage of preexisting conditions clauses,
- no more lifetime/annual limits on coverage
- kids can remain on parents insurances until they are 26 (Oh yeah baby, one whole year longer!)
- subsidies for insurance for low-income individuals/families to buy health insurance.
- Closing of the 'donut hole' for prescription drug benefits for seniors
- medicaid reimbursement schedule must match the medicare reimbursement schedule
- 0.5% incentive bonus for primary care physicians


The list is actually more extensive, but these are the few salient points worth discussing, which discussion I will include in a future post. For now...I thought you might like to see what was proposed originally by Senate Democrats, that took a lot of lobbying effort and money spent by the AMA (American Medical Association) to prevent their inclusion into this bill:

- Medicare/Medicaid enrollment fees for physicians...AND as if it wasn't already a losing effort to afford caring for patients on government health assistance...
- Mandatory physician participation in medicare and medicaid (That's right, they wanted to force docs to participate and then charge them a fee! Classic Washington politics)
- 0.5% payment cut in all non primary care physician's payments to fund primary care...as you can see from above, they were able to finagle the bonus,without the cuts
- Tax on elective cosmetic surgery and medical procedures...that's right those dental caps, laser hair removals, and boob jobs were going to force major price increases for the patrons of the 'service industry'...how sad!

Well, enough on that. There are some misgivings that I have with this current reform, and that will be tomorrow's blog subject.....a letter to Mr. Obama himself.

-The Medhead