Wednesday, August 29, 2012

Reducing Health Care Costs

ACEP, the professional association for Emergency Physicians has established a "task force" with a goal to see where we ED physicians can reduce healthcare costs. The focus of the group seems to be on "clinical decision" rules that are used by ED physicians to guide our decisions about when to order more invasive or expensive tests.

I am all about treating DVT as an out-patient with the appropriate setting. I treat and street lots of things like chf, afib, copd if the pt improves and can see their doctor the next day. I also think its important to know the various managed-care derived Canadian C-spine rules, Ottawa knee and ankle rules, and straight leg raise/hip fracture and various other clinical decision tools (San Fransisco Syncope, CENTOR criteria, PORT Score, TIMI/Grace Risk, PERC, NIH Stroke, etc)

However, when it comes to lowering healthcare costs, there is nothing more expensive than missing a diagnosis as well as missing the expectation of the patient. In many cases, I may suggest my initial impression based on a clinical tool to the patient. However, because the patient is not paying, their anxiety about their symptoms may exceed their trust of the ED Physician and our clinical opinions. The Media and other phycians don't help ED Physician public perception. ED docs are the least trusted and respected physician.

If the person is anxious enough about their symptom and clinical decisions and therapeutic/diagnostic treatment is not helping the symptom or the patient anxiety, the patient is going to probably get the X-ray, or the GI referral for the EGD/HIDA scan or be admitted to the Obs unit for a cardiac stress test (unless age 24 and low TIMI risk).

Using clinical rules to save money is great but a failure by the physician to validate/address patient concerns and expectations will result in greater healthcare costs by the patient going to another ED saying "the other ED did nothing for me". Or the patient bringing legal action against the ED doctor for a missed diagnosis and bad outcome because "that ED doctor didn't do anything for me". The jury rewards the plaintiff for any bad outcome (regardless of clinical rules).

Ignoring patient anxieties and mistrust of doctors clinical decisions negatively affects patient satisfaction scores. "they didn't do anything for me" perception will earn a poor evaluation score regardless of the quality of the clinical decisions.

Furthermore, many clinical decision rules depend on history and clinical signs. Patients are routinely very unreliable in giving a history anpanicking good effort in the physical exam. Therefore, clinical rules have limited application in many patients. Sometimes you don't know who is giving an incomplete history or who is not giving good effort on exam.

Finally, patients that can be successfully treated conservatively and discharged from the ED without testing need to have an availible primary source of care. Again, many times patient anxiety and perceptions and discouragement and not having access to usual source of care (frustration at not getting am appointment with their PCP) is projected onto the ED doctor resulting in greater mistrust and worse patient satisfaction with the ED.

Radiological testing and invasive diagnostics can be excluded in Patients who are triaged to main ED in referral-center Hospital with high pre-test probability of disease where their anxiety about having to pay for the radiological study and their trust of the ED physician and the clinical decision rule outways their anxiety about their symptoms and a clinical rule rules out the need for the more invasive/expensive test. The patients have to be dependable, have an available primary source of care, and give a good history and good effort in exam.

Radiological testing and invasive diagnostics should not be excluded in Patients who are triaged to main ED in referral-center Hospital with high pre-test probability of disease where anxiety about their symptoms outway their trust of the ED physician, the clinical decision rule, and the financial burden of paying for the radiological or other expensive diagnostic procedure. Tests may be ordered if patients are not dependable, have no primary source of care, and fail to give a good history and good effort in exam.

The answer to saving healthcare costs does not rest with the ED. We are the safety net. Yet it seems too much responsibiliy for patient satisfaction vs clinical decision is being placed on our shoulders. Give ED docs a break. We only have a few clinical labs, a few X-rays and a CT scanner at our disposal anyways. In a majority of cases, considering the incidence and pre-test probability of patients in my ED who are triaged to be seem by the ED physician vs ExpressCare/minor tx, I don't consider any ED test to be causing more harm than benefit. Also, if the patient is triaged to the main ED, getting the labs and CT doesn't prolong their stay. What prolongs a stay is to not order the labs and studies initially and have to reorder later.

In reality, incidence of disease and pre-test probability is such that most people triaged to the main ED in some future time I predict all patients will be getting a level-1 diagnostic which would include a noninvasive full body scan and finger-prick capillary action lab panel on a chip. A doctor wouldnt need to order anything.

If you want to save healthcare costs, then focus on primary prevention. We need stronger families because it's mommy and daddy that do real primary prevention and not your doctor. If your talking to your doctor (except ob or peds) about prevention then it's probably too late.

Second, we need to stop poisoning and abusing ourselves with pornography, recreational sex, alcohol, cannibis, tobacco, illicit drugs, fluoride, etc.

Various rules have already been compiled by MedCalc 3000

There are no institutional barriers. This is how I currently practice. The barriers in the way of my current practice are "socialist/liberal progressives" who have have been fooled by the "Bohemian Grove/Fabian/Bilderberg/Davos/New-World-Order/Global Governance elite" into forming all these "sustainable task forces" which are designed to destroy the foundations of self- and local-government established by the US Constitution. It's these same "special interests" who wrote Obamacare and have established physician reimbursement which will now be based on some arbitrary quality factor. Instead of focusing on the wealthy elite who profiteer off of healthcare, they turn us against ourselves by having "sustainable task forces" impose burdensome regulations such as penalties for ordering too many CT scans.

Sometimes clinical decision rules are wrong. I routinely look for at risk factors in addition to history and physical exam when deciding to order a test. many times a vague complaint "I feel bad" can turn out to be a silent MI. Missing the MI because the patient didn't say they had chest pain or were short of breath is what adds to health care costs. ED Labs are a very small cost in comparison. All ED labs are done on automated machines. Again, high incidence of disease in main ED reduces harm by false positives.

Most importantly, the largest contributors to the rising cost of healthcare is the federal government via inflation and then a steady decrease in federal and state government reimbursement. As government reduces reimbursement, healthcare increases costs to keep pace. Since when can anyone walk into a Walmart and walk out with a $500 TV and tell them they will take $250 and like it. Secondly, the beuracracy between the patients and the doctor adds to the costs. Why can't communities get no-interest loans to build their own non-profit hospitals? Why do hospitals need a board of wealthy investment capitalists to profiteer off physician labor and disease? It's these same wealthy globalist investors who turn our attention away from their profit taking and fool us into turning against ourselves to penny pinch in the name of "sustainable growth"

The way to reducing cost in healthcare is the same way you reduce costs in industry. The secret is to reduce the number of people involved in the process. The more people involved, the more inefficient and expensive the process. Just consider how many extraneous people stand between the patient and the doctor. The key is using technology to reduce the number of people required in the process.

I have made the point that if we really wanted to reduce healthcare costs, after first reducing overall visits to the ED by providing patients with readily available sources of care, it is my opinion that every patient seen in a major referral ED could have some sort of non-invasive head-to-toe body scan and micro-capillary blood and urine panel. You may argue, that indiscriminately running a panel of tests on every main ED patient would cause harm due to false positives. I would remind you that false positives are only significant when there is a low prevalence of disease in the population. But when it comes to ED patients, the prevalence of disease is much higher than the general population.

If you don't believe me that the prevalence of disease in the ED population could justifies panel testing. This is exactly the reasoning the CDCis using to support HIV screening of all patients in the ED. If the CDC can justify screening ED patients for HIV, then any other ED diagnosis is justifiable. But until we have the technology to do it, well just have to decide what few ED tests to order on an individual patient basis.

Factors Required To Apply Clinical Decision Rule to exclude additional test.
1. Accurate, precise and valid clinical decision rule.
2. Patient trusts physician clinical judgement.
3. This is not 2nd visit where clinical decision rule has already been applied.
4. Patient can give good history
5. Patient gives good effort on physician exam.
6. Patient has low pretest probability for disease.
7. Patient has availible primary care follow up.
8. Patient anxiety about disease does not exceed anxiety about cost or invasiveness of procedure or test.

Friday, August 24, 2012

Ron Paul vs LDS Attack; Terahertz Scanners

I thought Ron Paul would need to run 3rd-party to hurt Romney. However, the RNC's blatant persecution of Ron Paul supporters is doing the damage on its own without Paul having to run at all. The LDS piece on NBC Brian Williams last night was much more of a subtle attack beginning by saying the Angel Moroni appeared to Joseph Smith in the First Vision. Conversely, the attack on Ron Paul is obvious. They want Ron Paul supporters to take sides against the RNC. When it comes to attacking the LDS Church, the attack must be subtle to prevent people from taking sides.

Question: why is government ramping up surveillance when a future EMP attack will eventually wipe out all the infrastructure? Is surveillance what they want or is it division? Or are they sending info to China?

Alex Jones generates considerable fear and suspicion over possible health effects of the airport body scanner. While I am no fan of body scanners, I wanted to address any fear over possible health effects from Terahertz radiation. First off we should first realize that all CCD cameras potentially can see through clothing. To prevent embarassing pictures, CCD chips use IR filters to filter the terahertz/Infrared light that passes through clothing but not water. These airport scanners are based on the same technology. There is no good evidence that terahertz/infrared light causes any physical harm. Terahertz/Infrared light is non-ionizing and cannot penetrate through liquid water. Conversely, 2.45 GHz/915 MHz microwaves (microwave oven) cause heating from dielectric effects/ absorption by water. In the case of Terahertz radiation, the scanner works because water reflects these wavelengths rather than absorbing them.

Thursday, August 23, 2012


Hollywood, with movies like the "Terminator", and "I, Robot" tell terrorizing stories about robots with artificial intelligence taking over the world. In my view, robotics and technology is not a problem but a grand solution. Much of our agriculture, industry, manufacturing is done by unskilled labor. Recently, the US has off-shored these unskilled jobs to China and the third world. In the US, undocumented migrant workers stream across the border to do this unskilled/minimal skill work.

In my mind, unskilled labor should be done by machines and robots. All production and manufacturing should be automated and robotic from start to finish. The only human workers should be the skilled and well-paid engineers and technicians who keep the machines and assembly lines running smoothly 24/7. There is no reason in my mind why my iPhone and many other devices couldn't be made by a automated robot from start to finish (Eg Lego Factory). Human labor is the most expensive and inefficient component of the manufacturing process.

Robert Welch, JBS and Morality

Robert Welch was the founder of the conservative John Birch Society in 1958. JBS is dedicated to the mission of protecting traditional American Constitutional government from the encroachment of socialism by the progressive left and erosion of individual rights and freedoms as well as the protection of national sovereignty from international governance.

Amazingly. way back in 1958 Robert Welch articulated the exact agenda of the progressive socialist left and neocon right to surrender national sovereignty to international governance, grow the federal government, institute numerous expensive socialist programs, increase taxes, create overwhelming federal budget deficits, weaken the national currency through inflation, establish federal price controls, and federalize the education system.

Unfortunately, Robert Welch left out 1 critical area of attack which omission doomed his planned education remedy to complete failure. Mr. Welch forgot to mention the Fabian Socialist plan to attack and debase traditional American morality, values, and virtue. This was the critical omission.

Why was forgetting virtue so critical ? Mr Welch missed the immoral revolution of the 1960s that had already started in the 1950s. He should have realized that the JBS could not effectively educate an immoral generation. "Darkness cannot comprehend light" (John 1:5). Ideas of self-government, responsibility, individual liberty, don't make the same kind of sense to an immoral person like they do a moral one.

Immoral people tend to want what they see as best for themselves now. Moral people tend to choose that which is best for the most people in the long term. Moral people will choose that which benefits the majority even if it means they must make personal sacrifice in the short or even the long term. A moral person lives their life or gives their life for the good of their country. And immoral person would not and cannot comprehend why others would or could behave against their own self interest let alone understanding why they should.

Monday, August 13, 2012

Example of how MPE would generate inflation

Beware the false dichotomy here: Keynesian economics vs Austrian School is a false dichotomy. Keynesians say that money supply (M) doesn't matter but only velocity (V). Austrian economics like Maudlin say that inflation is all about money supply (M) and not velocity (V). This article is misleading by saying Milton Friedman supported money supply (M) over Velocity (V) "Friedman concluded that “inflation is always and everywhere a monetary phenomenon.” And that has been that ever since." Friedman was not an Austrian economist. Friedman's monetarist equation: dM/dt + dV/dt = dP/dt + dQ/dt accounts for both Money Supply (M) and Velocity (V).

The truth is that both Velocity and Money Supply play a role in inflation and economic growth. Anyone who argues one vs the other is just playing into the historic false dichotomy set up my the Keynesians vs the Austrians.

Velocity can very independent of money supply or production. This is why the economists track consumer confidence. Some of what this writer is saying is because we live in a "just in time" economy. But the reality is that people spend more if they have more. However, on rhe other hand we could easily produce more than we could consume. Just consider the problem of too much commercial real estate in Atlanta. This also is why the US government pays farmers on occasion to not harvest their crop.

The following is an example of how MPE would lead to inflation and fails to account for velocity of circulation. If you don't like my numbers, feel free to substitute numbers you like

Imagine a city with 1000 families. Each family makes $75,000/yr, $6250/mo.
All 1000 families bring in a total town imcome of $75,000,000/yr
Each family lives in a house that cost $250,000.
Each family has a fee-based 30-yr loan and pay $700/mo, $8400/yr
This means the economy retires at least $8,400,000/yr
This means builder will need to build and sell at least 34 houses/yr to replace the retired money
34 new home loans will cover the annual salary of 112 workers/yr
The velocity of currency $75,000,000/$8,400,000 = 9
Local Builders can build at least 1000 houses in 30 year

Repaying at rate of depreciation on $250,000 house is $208/mo, $2500/yr.
1000 families would retire $2,500,000/yr
Builders could replace this retired money building 10 new houses/yr
10 houses/yr will cover the salary of 33 employees/yr
Velocity begins at 30.

However, since only $2,500,000/yr is retired. Town builders are likely to build more than 10 houses/yr. Therefore, the excess money will circulate in the economy until retired. Let's say that builders build 20 houses/yr. this means that an extra $2,500,000 more is added to the money supply each year than is retired. After 50 years, the economy will be circulating $125,000,000. This is 1.667 times over the salary of all 1000 families/yr. however, only $2,500,000 is retired each year. And if builders build 30+ houses, that means even more new money is injected into the system and this doesn't even take into account velocity that $1 dollar can do the work of at least $3, if not more.

The problem with MPE is not that the money created is akways backed by the value of a depreciating house. The problem is that money is not retired fast enough from circulation and therefore new money will continue to build up in the economy year after year causing inflation. After several years, there will be too much money chasing too few things for sale.

Wednesday, August 08, 2012

The Fundamental and Fatal Flaw of MPE (Mathematically Perfect Economy [tm])

[You are correct that Capitalism is as bad a Communism. We dont need unelected capitalists making all the economic decisions any more than we need the government making all the decisions]

MPE is based on the assumption that you need money circulating that represents total value of all assets in the economy. Loan money to build or purchase 1000 houses is created and then repayed and retired from circulation at the rate of depreciation of the 1000 houses over 50 years. However, all this time (50 years) that currency for the 1000 houses is circulating in the economy (velocity) and going towards the purchase of other things. The consequence of all this circulating currency is that money supply actually exceeds GDP resulting in inflation.

SSS (Safety Society System) is very similar to MPE but its much better thought out and controls for inflation and currency velocity. MPE does not. The issue here is that to control inflation, It is important that there is currency availible on demand to make purchases for ONLY those assets that are on currently for sale. There doesn't need to be cash availible to purchase everything in the economy all the time.

MPE generates and injects cash into the economy to represent all the total value in every real asset in the economy whether its for sale or not.

SSS only generates and injects cash (on demand) into the economy for those assets in the economy that are for sale. In this way, SSS is not inflationary like MPE. MPE ignores velocity.