President Obama's Speech to the AMA

Yesterday President Obama delivered a speech to the American Medical Association (AMA) in Chicago. When viewed it looks like his message was relatively well received, except for his comment on medical malpractice lawsuit caps, and that this reform appears logical to many of the doctors who were present during his speech. However, the media reports a mixed response being supported by some and skeptical by others. I read some comments by other providers and also watched some interviews from doctors who attended and it seemed that many of them have some of the same doubts that I had while reading, and then later watching this speech. The biggest concern I believe was that of a socialistic health care system.
Before addressing the concern of socialized medicine I want to point out one concern that I had with his speech and a concern I know many of my colleagues have as well. He addressed Doctors and Nurse Practitioners yet left out Physician Assistants as providers of health care. Maybe it was an oversight of the president but not recognizing the importance of PA's (who fall under AMA jurisdiction) as providers the president has alienated over 76,000 providers of medicine, a majority who fill the role of primary care providers, in this nation. Is it a bias on my part? Maybe, but still, this is my profession and his changes for reform will affect how I practice in the future and thus I, and every other PA, should be considered in his decisions. Not addressing us in his speech might suggest the contrary. For those PA's out there reading this blog who wish to let the president know of our importance in this nations health care system visit this site.
In his speech President Obama did all he could to assure the AMA that his goal was not a socialistic government, or a single-payer plan. He said, "If you like your doctor, you will be able to keep your doctor, period. If you like your plan, you will be able to keep your plan, period." He then goes on to say that his vision is to create a public plan (run by the government) that will provide fair competition to private insurance companies, but will still be able to cover those who have little to no insurance. This will ensure that every American has health coverage. He calls this Health Insurance Exchange but many skeptics are saying that he's just using semantics to cover up an eventual single-payer, socialized health care. What the fear is that with this new Exchange it will eventually drive the other insurance companies out of business and leave Americans with only one option for health care, this Exchange. The next fear is that with one company calling the shots decisions for medical treatment will then be made by bureaucrats rather than by doctors. Now, even though I see this as a problem with a socialized health care system I also see this already happening in our current system. The insurance companies decide to pay for what they want to pay for and use terms like "pre-existing condition," or,"prior authorization," to limit what they will pay for. I have seen this in my own practice. When having to choose between the two proton pump inhibitors Omeprazole (Prilosec) and Esomeprazole (Nexium) I have to weigh what my patients insurance will cover as first line treatment. Most companies will use Prilosec as first line treatment not because it has been shown to be more effective than Nexium (on the contrary, Nexium has been shown to be superior to Prilosec) but because it has gone generic and is now an over the counter (OTC) medication. In simple terms, Prilosec is first choice because it's cheaper, not better.
Ironically it's the government run system of Medicare and Medicaid that I have to deal with when getting prior authorizations for medications such as Prilosec and Nexium. It's Medicaid that chooses to use the cheaper as first line. This is another part of Obama's speech that I had trouble with. He cited an instance where a doctor spends 20% of his time filling out these prior authorizations forms or dealing with insurance companies rather than taking care of his patients. In my experience, that 20% of my time has been used dealing with similar circumstances...80% being Medicare and Medicaid problems that require prior authorization. Later on in his speech he states how doctors need to practice based off of Evidence Based Medicine (EBM) rather than what insurance companies are willing to pay for. I again will have you reference my Prilosec/Nexium example. EBM shows me that Nexium should be used, but government run Medicaid tells me I should use Prilosec first because it's cheaper. In fact, many of the providers I listened to or read comments from had similar concerns. They are concerned with the way Medicare and Medicaid have been running and see this only an insight to what the new reform will bring, and this scares us. We fear that these problems will only continue to exist in the new reform.
Much of what President Obama said in his discourse was nothing new to providers. We already know that electronic medical records saves not only time and money but also improves patient care. We know that preventing a problem is cheaper than fixing a problem and that preventative health will cut medical costs (it's my belief that preventative health care will not only put just a dent in the problem as the president addressed, but will blast a hole through it. He gave examples of five chronic problems that scourge our health care system which account for most of the cost. If we prevented the majority of these problems will it not then cut a majority of what we spend on health care? Preventative care will not just be a dent people in the system people.) Many of the things the president addressed we already knew, yet he spent a good amount of time discussing them. One of those points, however, I would like to address rapidly because I'm weary at how the president will bring about the change of preventative medicine. How will he get Americans to live healthier without forcing it upon them? I read an article about some of his goals (some I agree with, others I don't) and this change. But again, how will he make this change without forcing it upon Americans? Increase taxing of certain foods, alcohol, tobacco only makes Americans not consume them not because of health benefits, but because of costs.
Now comes the point of paying for all of this. We are a country already in debt and now we're looking to reform our health care by putting $1 trillion over the next 10 years into it. He states that this will be debt neutral and proposes a system of cuts and taxes to pay for it. He states that over the next 10 years he can cut $950 billion from our spending, thus almost covering the $1 trillion needed for reform. I don't know how all of that will play out, if it will work or not. But one thing that I'm concerned with is that this will take 10 years. At most he will only spend the next 7 years in office, maybe only 3. So what happens down the road when the next guy, or Congress decides to reform the reform? One of his proposed cuts was the amount of government money hospitals will receive for treating uninsured patients. He states that as the number of the uninsured go down so will the need for hospital reimbursement. The question at hand is which will come first? Will the number of uninsured go down first or hospital reimbursement? How can you pay for the one without affecting the other?
President Obama was openly opposed, even booed by some, when he said that he didn't support putting a cap on malpractice insurance lawsuits. However, he did recognize that the fear of a lawsuit did affect how providers practiced and that this increased costs. This is true, we do get that extra test just to be sure, even though we're 99% positive in the first place, so as to not be caught off guard by that disease that has an prevalence of 1%. All though he said he understood this as a concern, he gave no alternative or plan of action of how to address this problem, other than stating that he opposes caps. Now, in certain cases I agree, but the majority of malpractice lawsuits are frivolous and cause a huge strain on our system. I don't know how to fix it either, but then again I'm not the one bringing up the issue and then not having a solution for it. One thing the president must know is that providers will continue to practice defensive medicine while the threat of frivolous lawsuits still exist, and this will ultimately raise the cost of medicine.
I was pleased when the president addressed the problem with many insurance companies about "pre-existing conditions" and other hassles they give us as providers. I was also pleased to hear that insurance companies and pharmaceutical companies were willing to discuss what they can do to help stem the rising of health care. Personally I believe that there are some problems with insurance company policies that need changed and I'm glad to see the president take a stand on it. However, again it falls back on the concept of Big Brother stepping in and that worries me to a degree.
Overall I am skeptical of the reform laid out by the president. I agree with the need for electronic based medical records and preventative care, but question the Health Insurance Exchange program he announced. A change needs to be made, but I still maintain the belief that I don't think our government is capable of doing it. I believe that if we want a change then we need to make the change. Americans need to learn to practice preventative medicine and stop being so eager to sue. Insurance companies need to have a major overhaul in their policies about what they will and will not pay for (one theory of mine is that if the policy will not pay for a particular aspect of care then I should be refunded what I've paid to them over the years. At least I can use that to make a dent in my medical costs.) Pharmaceuticals need to change their spending policies so when their new drugs do come out they don't have to charge $200/month for them (spending policies: advertisement, luncheons, etc) I also believe that patents for medications should be shorter thus allowing generics to be made available earlier on. I believe that we in medicine could take a cut in our pay to serve the greater good or, if we are not willing to take a cut, then donate to our communities a generous offering, being money or time. Change is needed, we must be willing to work for it and not have Big Brother bail us out. Comments, opinions?

Church and State

Today I read an online article that touched on the subject of the Church of Jesus Christ of Latter Day Saints and Proposition 8 that was passed. The main emphasis of the article, to me as a reader anyway, was a protest to religious supported laws, or laws that are enacted not based on "civil rights" but a matter of what particular voters consider as being moral or not. In his argument, the author expresses his belief that laws cannot and should not be passed based on their considered morality but rather on civil rights and then uses examples of other such instances (i.e. beliefs during the civil right movement in the 50's-60's) to further his opinion. While reading this article some questions came to my mind.
The first thing I thought about was the old statement "separation of church and state". This was instituted in the days of our fore fathers. The concept behind it was that no church could have Constitutional power to impose it's beliefs on any person. However, many of the laws that organized and enacted had basis on some religious belief. Laws enacted then and laws existent now are based on a principle of right versus wrong, good versus evil, protection of the innocent and justice for all. We have laws against murder, stealing, rape, abuse, kidnapping, extortion, and a plethora of other laws that, one can look at it this way, limit what we can and cannot do. My question now is where did these laws come from? Or where does the concept of good and bad come from to perpetuate the need for such laws?
Who are we to say what is right and wrong? Does not enacting a law against murder take away the freedom I have to chose to take the life of another? Yes I might be infringing upon the right of another and the Constitution grants us the right to Life, Liberty, and the Pursuit of Happiness (originally property), but who decided that we have those rights in the first place? Who decided that humans have a right to anything? Are we not just another organism belonging to the animal kingdom? Does not the gazelle have a right to life? If so, then why is there not a law in the animal kingdom that prohibits the lion from killing the gazelle for the lion's personal gain? If this is a world inhabited by the product of evolution then "survival of the fittest" is our adage and rights be damned!
Yet, we do have rights. Our founding fathers outlined a system of laws based on what they believed our rights to be...those beliefs stemming from what their own personal, religious beliefs were. They were Christians who followed the 10 commandments, and thus implemented many of those commandments as law (murder, stealing, etc). Again, the laws they enacted were based on what they considered to be good or bad. And thus even though there was a call for separation of church and state we see that the original laws of this land were taken from the religious beliefs of it's organizers.
So today we have laws being written, proposed and voted upon by the people. Those who feel strongly opposed to certain laws because of religious beliefs are ridiculed and labeled as bigots, racists, closed minded along with an innumerable amount of other terms. Those who support laws that are widely opposed by the majority are seen as heroes, visionaries, free thinkers, progresivists and other highly acclaimed accolades. They use terms like "civil rights" as their swords and "racism, sexism, and oppression" as their shields when it suits their needs. I would like to see these people argue for civil rights when the pedophiles of America argue that it is their "civil right" to sexually assault young children because "it's who I am, I was born that way" or when serial killers argue that because they have a psychiatric condition (antisocial personality disorder, conduct disorder, borderline personality disorder, narcissistic personality disorder) they have a "civil right" to carry out their acts of violence. My question is where is the call for civil rights when a doctor in Kansas is allowed to perform more than 60,000 late term abortions for reasons other than medically necessary? We have laws and activists that protect against animal cruelty and yet proponents who believe that a woman has the right to chose to keep or terminate a creature that that looks human, has human tissue, and genetic material that establish it as human because it's her body, her life and her right. Where are the rights of the fetus?
In other words, civil rights are based upon what we consider to be good or bad. You cannot establish laws that protect the rights of others without first establishing the concept of what is good and what is bad. Where do you get your sense of good or bad? For me, I get it from what I believe to be a true religion and so I will be guided by those beliefs. If I believe gay marriage to be bad then I will vote against a law that looks to allow it. If I believe murder to be bad then I will vote for any law that punishes murder. Men and women are entitled to their separate opinions and beliefs and they will vote based on the beliefs, and seeing how there will always be separate beliefs there will continue to be a never ending struggle about, that's right folks you guessed it, what's RIGHT and WRONG.

Boundary Trail - FAIL!

This week our journey through the hills of Idaho takes us to the eastern part of Caribou National Forrest and along the west slope just down from Pebble Creek Ski Resort. This trail is known as the Boundary Trail and is an 18 mile double track ride from Pebble Resort, along the ridge of the mountain, back behind Crystal Springs and then comes out just north of Lava Hot Springs. It is rated at a difficult to very difficult level as compared to most of the other trails around the Pocatello area. This is due to the constant change in elevation and the terrain that you must traverse. The trail is covered, and I do mean covered in rocks, and not just your little pebbles or the occasional golf ball sized rocks, I'm talking rocks the size of large watermelons. And these rocks are evenly disbursed throughout the trail or organized to make for a smooth ride. No, at times these rocks covered the trail like sprinkles on a doughnut, just not as tasty. There are sections of the trail where it's pure rocks for 100 yards or more. Now, the rocks are one thing...but add in rain and mud and the trail becomes absolutely unbearable (hence the FAIL in the title). This is the first time we've had to turn around because there was no way that we were going the full 18 miles alive. In fact, I believe we got 2.5 miles into the ride before we decided to turn back, and we probably should have turned back sooner...or maybe postponed the trip all together.
So this ride started out in planning the night before. Looking at the terrain on Google Earth and checking the profile with Mapsource. I also checked the weather report because it has been cloudy and rainy in Pocatello for much of the week, and Friday wasn't looking any better. The report said that there was a 40% chance of rain during the day with a higher chance at night. With that we still decided to go tackle this beast. So Friday morning rolls in and the sky is cloudy with a mixture of white, grey, and black clouds; no rain however. We load the bikes up and head down to Lava to drop off the Jeep. Heading back towards the start of the trail head we run into some rain along I-15. I check the weather report again and notice that the storm is just rolling over us, moving in a north-eastern pattern with more storms off the the west and south that look to be intensifying. One would think that with the current rain, future weather report, and current Doppler radar we would have scrubbed the adventure in the first place. Well as someone once put it, "common sense isn't so common." No this information didn't deter us at all. We continued to head up the mountain to the Pebble Creek Ski Resort. Once arriving there the rain had disappeared but plenty of clouds still covered the sky, many of them heading towards us. And yet, we still decided to hit the trail, knowing that we would probably get wet and ride straight into those storms. A little rain never hurt anybody, right?
So we started out on the trail. Immediately hit mud and had a good time trying to keep up enough speed so as to not get mud everywhere and also keep the back tires from slipping out beneath us. The mud wasn't that bad at this time and we were able to push through. The scenery from this altitude was absolutely beautiful. I was able to appreciate this part of the valley from a whole new perspective. I've driven through it every time I go between Ogden and Pocatello and its part of the plain where the original Lake Bonneville drained into the Snake River Valley Plain. From here you can see as far as Malad Summit (if the clouds aren't covering it) and over to the West Caribou National Forrest. It was an awesome sight to see Scout Mountain and Old Tom Mountain with there peaks covered as low flying clouds sat on top of them.
We continued on pedaling through rock, rivers, and mud...plenty of mud. About 2 miles into the ride I took this picture where you can see the rain coming.

That didn't stop us though, oh no. Another 0.5 miles and the we hit the front of the storm. It was a light rain to begin with and we were prepared for it. Yes, we had bought a box of Western Family garbage sacks to use for ponchos at a gas station just before the trail head. Dressed in trash we thought about heading forward, but the rain starting coming down harder. Also, the GPS calculated that we had a moving average of 5.0 mph but an overall average (moving + stopped time) of 2.5 mph...thanks to rock and mud. So with 15 miles still left and only moving at 2.5 mph we decided to turn back around (yes it wasn't the fact that it was raining but the fact that we were just going too slow is why we decided to turn back.) Of course, I don't think we would have made it much farther because of what this heavier rain did.
With the ever increasing and never ending rain our trail got to a point of pure unrideability (word?). The mud was so thick and expansive that trying to push through it was almost impossible. It caked everything it touched: forks, spokes, cogs, crankshafts, derailleurs, and chain. Instead of falling off it just kept growing. Most of the time I spent trying not to let my back tire slip out from under me. Eventually, and unfortunately, after 0.25 miles of this Stella had enough. Yes, while trying to push through the pure cake batter that was this mud all of a sudden I heard a pop and felt no resistance while I pedaled. I looked down to see Stella wounded in battle, her chain hanging limp and transected from the cogs. Now I have spare tires, patches, a multi tool, and a chain tool, but what I didn't have was an extra chain or at least a couple of extra links. There I was, stranded in the rain and mud. With only a 1/4 of a mile down that meant I had 2.25 left to hike-a-bike back through that horrible mud of Satan! Just going another 1/4 of a mile probably took 30 mins of pushing, pulling, carrying and everything short of cursing and abandoning my bike. A little under a mile (0.8 miles to be exact) from where we had to turn back we had reached a point where a Jeep trail had crossed ours and looked like it headed back down to the valley. Once we got back to this point I told my buddy that I was going to coast down the mountain until I got to a main road then I'd call him to let him know where I was at so he could come pick me up. There was absolutely no way I was making it back to the trail head in this mud and without a chain. After looking at the map and GPS he decided to come with me down the trail and get back to his Land Cruiser along the main roads. Even though it was longer in mileage wise it might go faster because he would be able to ride instead of push his bike through the mud, seeing how it was that thick and deep that he couldn't pedal either.
So we head down the Jeep trail. It wasn't much different in its mud consistency than the trail we were just on. The difference was now we are sliding down a mountain side trying to just keep the bikes under us and not get thrown into the foliage. The rain had picked up and was now falling harder, colder, and sideways with the wind. As the speed increased on this descent my buddy soon realized that regular bike clamp breaks do absolutely nothing in the mud. My disc breaks help out a lot, but only to an extent. They at least slow down the wheel rotation. My friend didn't have that luxury as he is sliding down the mountain and then loses control of his rear tire. As it fish tails behind him the trail eventually just slides out from under him all together and he is thrown from the biking and goes sliding down the mud mountain with his bike coming in a close second. It was just like a giant slip'n'slide we all use to play on as kids (and still do as adults). Eventually the two stopped, he regained his composure, picked up the bike, jumped back on and started the ordeal again. My laughing didn't help my cause at all because the same thing happened to me just a little way down the mountain. I don't think Stella was too happy with me at this point.


Eventually we made it down to an old highway that would take us back to his Land Cruiser. This was pretty much a dirt road as well, but a kept dirt road so it wasn't too muddy. My buddy started riding but soon realized his chain was too caked in mud and debris that if he kept pedaling it would eventually snap. So we both ended up riding the bikes like those push razor scooters that were popular a few years back. We came to the intersection that would take us back up the Land Cruiser. There was a stream near by so we stopped to wash off, well, what we could. Oh, as a little side note the weather had improved and was now sunny and warm (I swear mother nature was toying with me that day). The final stretch back up to the Land Cruiser was all uphill and my friend really didn't want to push his bike up it. The consensus was that I would stay at the creek with the bikes while he ran up to get the Land Cruiser. According to his story that ran quickly turned into a tiring walk up the switchbacks that lead to the ski resort. He said that the whole time he could see the ski lifts and radio towers at the resort and they looked close, but never seemed to get closer because of all the switchbacks. When he got back we then calculated that distance from the creek to the trail head and it was a good 1.5 miles. Oh well, hindsight is 20/20 isn't in.
As tortuous as this day has been, I'm still glad I did it. There's something to be said about experience gained, be it good or bad (see my other blog for further discussion). The scenery was breathtaking, parts of the ride were fun, and I now know what to expect when I go to tackle that trail again. I only got 2.5 miles into an 18 mile ride so yes, I will ride that trail again. It will not beat me. Next time I'll take a different approach to it, a dry one!

Here are a few other shots from the day. Remember you can see these along with the rest of the unpublished photos, as well as all the photos taken from my other rides at http://picasaweb.google.com/tjdhulst






Until we meet again Boundary...