Limbaugh after being hospitalized in Hawaii for chest pains. Thanks but no thanks. Headed for Costa Rica?

My guess in even in Canada and even in the UK, doctors have opted out. And once they’ve opted, they can’t see anybody Medicare, Medicaid, or what will become the exchanges. They have to have a clientele of private patients that will pay them a retainer and it’ll be a very small practice. I don’t know if that’s been outlawed in the Senate bill. I don’t know. I’ll just tell you this, if this passes and it’s five years from now and all that stuff gets implemented — I am leaving the country. I’ll go to Costa Rica.

It’s interesting to note that Mr. Limbaugh admits to not knowing particular aspects about the Senate health care reform bill but he is dead set against it. I guess this is an example of that anti-intellectual logic popular among conservatives. In any case, Mr. Limbaugh appears to be concerned that health care reform in the US will effectively do away with private medical practice. But ironically, Costa Rica, a central American country with 1/10th the per capita income of the US, has universal health care that works very closely with its private medical system.

Many of the country’s highly trained physicians and some dentists work in the mornings for the [government health care system] and operate their own offices and clinics in the afternoons and evenings. While private health care in Costa Rica is more expensive than that offered by the same doctors and surgeons through the [government health care system], the price is still far below that of the average office visit in the U.S

So let me get this straight. Mr. Limbaugh is planning to go to a country that already has universal health insurance that is far more socialized than any proposed reform bills in the US where private physicians willingly participate instead of completely opting out because he is concerned about socialized health care reform in the US and the inability of private US physicians to participate? This must be another example of that conservative anti-intellectualism.

In my travels, I have come across many an irate physician who enthusiastically inscribes their opinion upon the official and legal record of a patient’s chart regarding the denial by the patient’s insurance of a test or procedure.

While it is perfectly acceptable and appropriate for the physician to write a note in the chart explaining the reasons for the requested test or procedure, it is almost always not a good idea to express one’s opinion about a denial in the chart. For one, a denial by an insurance company is based on medical information (which may be incomplete or inadequate) and contrary to liberal belief, this is not the insurance company practicing medicine because the decision is about what will be reimbursed and not what will be ordered.

This distinction is important because an insurance denial does not substitute for nor remove a physician’s obligation to care for the patient despite the financial barriers that the patient faces. So if a physician writes in the chart that the insurance company is threatening the life and well-being of the patient by denying a test or procedure then that physician better find a way to get it done, continue to advise the patient to have it done, or do it anyway if able. Doctors cannot transfer the medical liability for a bad outcome from themselves to the insurance company.

Of particular importance is when a physician is able to perform a test or procedure themselves and deems it necessary and states it thus in the chart but does not do so because reimbursement is denied by the insurance company. I.e. if you call the actions of the insurance company “unethical” for denying a procedure that you normally perform and recommend for your patient, don’t be surprised when a court of law uses your own words to describe YOUR ACTIONS in refusing to perform a necessary procedure unless reimbursement is guaranteed.

Nuf, said.

How do you opt out? You would think that it’s as straight forward as informing your Medicare patients and telling the Centers for Medicare and Medicaid Services (CMS) to cross your name off their list of participating physicians with a big, “thanks but no thanks.”

But this is the Federal government we are talking about here! Nothing is simple or straight forward! The actual process includes sending in an affidavit to CMS and signing separate contracts with those Medicare patients who wish to remain in the practice where both the physician and the patient promise not to bill Medicare for services rendered. And the affidavit must be sent in every two years. It’s almost like drug addiction or being a CIA agent. Once a Medicare user, always a Medicare user. Because, if you no longer accept Medicare then the Federal government no longer has the right to control you and your practice with arbitrary audits and unfunded mandates.

Among the millions of Texans jumping on the bandwagon of partisan criticism was Texas Attorney General Greg Abbott, who called Fine’s ruling one of “unabashed judicial activism.” However, it’s unclear whether General Abbott’s use of the term “unabashed judicial activism” refers as well to rulings like Brown v the Board of Education of Topeka Kansas (1957) and Bush v Gore (2000) or to court rulings that he simply doesn’t agree with.

What Judge Fine does not seem to realize is that in order to make an omelet, you have to be willing to break some eggs! Since there is no such thing as a system that is 100% guaranteed accurate in executing only the guilty, the people of Texas have made it clear that they are willing to risk the rare innocent death in return for the greatest system of retribution in the world!

*(How did a Democrat get elected state district judge in execution alley? It’s nice to know that recovering alcoholics and drug addicts can easily get elected to hold office as state judges, governors, and US Presidents . . just as long as they are not doctors and as long as they steer clear of the Texas Medical Board).

DWT laws have light years to go before they begin to even come close to DWI laws in severity of punishment and overall societal condemnation. These days you can be fired for being arrested for DWI even if your job has nothing to do with operating a motor vehicle. And this is just for being arrested for DWI. Never mind any conviction.

But DWT laws will probably never reach the hysterical levels of DWI laws and consequences even if DWT related deaths eventually reach those related to DWI (a distinct possibility in the next few years, as cell phone and other text device usage increases). Americans will always have this mentality that crimes committed while under the influence of a substance are considered to be MORE illegal than braking the law while stone cold sober. I suppose this is because being under the influence of a recreational psychotropic substance is considered to be a grand moral failing while taking your eyes off the road for five seconds before plowing into a crowd of school kids at a cross walk is considered to be just “bad judgment”.

Doctors using e-prescribing with formulary decision support, which accounted for more than 200,000 filled prescriptions in the study, increased their use of generic prescriptions by 3.3 percent, study authors found. These changes were above and beyond increasing use of generics that was occurring among all doctors and the already high rate of generic drug use in Massachusetts . . Based on average costs for private insurers, study authors estimated that the use of e-prescribing could save $845,000 per 100,000 patients per year and generate even higher savings with greater use.

And this was only with a seemingly small increase of 3.3% in the use of generic medications in an area that already uses a ton of generic medications (the liberal intellectual northeastern establishment appears to be less susceptible than the rest of the nation to the bright, shinny colors of newer brand name medications that are heavily promoted by the pharmaceutical industry).The authors noted that e-prescribing was only used about 20% of the time so these number estimates are very conservative.

There are several hundred million patients in this country with some time of government or private health insurance plan and so much greater adoption of EMRs and use of e-prescribing with the ability to interface with drug formularies could reduce overall prescription usage by tens of Billions of Dollars!

You would think that the Federal government and private  health insurance companies are rushing to help physicians adopt EMRs and e-prescribing but you’d be wrong. Right now, private insurance companies use the rather low tech, caveman method of throwing up bureaucratic barriers in the form of requiring “prior authorizations” to force physicians and patients to use cheaper alternative medications by making it as inconvenient and ineffective as possible to get brand name meds.The drug formulary with its various cost tiers is an understandable concept but the use of which is often impractical. Patient’s almost always defer to their physicians as to what medications to take and busy physicians usually defer to whatever medication they are most familiar with prescribing rather then take 5-15 mins to find a formulary and look up a certain medication.

An EMR that instantly gives the physician lower cost alternatives based on a formulary that is tied into the patient’s listed insurance would make this process far easier and increase compliance. This is exactly what this study showed but the idea of cooperating with or even financially assisting physicians in getting set up with e-prescribing must be a totally foreign concept to private health insurance companies. But then again, spending short term money to increase long term savings is not a concept that is endemic to American businesses.

For its part, the Federal government appears to be too plagued by special interests (i.e.the pharmaceutical industry a la the disaster that is Medicare Part D) and bureaucracy to properly and promptly act on the proven safety and cost reduction benefits of electronic prescribing. The paltry $44,000 promised to physicians who convert to EMR systems is the government’s idea of a joke since payment comes only after several years and a ton of bureaucratic hassles. If there were only some way for physicians to tell the Federal government that they are too big to fail!

So called “e-prescriptions” make use of a practitioner’s office electronic medical record system (ER) to send new prescriptions and prescription refills directly to a local pharmacy. It’s a system that’s analogous to email but it’s even better in that it’s more direct and is encrypted as a protection from unauthorized access. Security is important since a paper prescription containing the patient’s name, date of birth, home address, prescribing physician information, and medication information can easily be lost, stolen, copied, altered, and observed by unauthorized persons.

E-prescribing should also be much safer for at least three reasons. 1.) E-prescriptions eliminate bad handwriting that can lead to errors. 2.) E-prescriptions should eliminate reading and transcription errors at the pharmacy that can occur even if the handwriting on the prescription is pristine. 3.) Since it utilizes an EMR, e-prescribing can reduce errors a the point of origin by using  systems to automatically ensure that the dosage for a prescribed medication is correct and that there are no significant interactions with the patient’ other listed medications or medication allegies. I.e. the EMR will not allow me to send out a prescription for a medication with the incorrect dosage unless I over-ride the system (and even then it will fag the prescription for the pharmacist).

These improved safety assumptions have now been proven to be correct in a recent study from Weill Cornell Medical College:

To evaluate the effects of e-prescribing on medication safety, researchers looked at prescriptions written by health care providers at 12 community practices in the Hudson Valley region of New York. The authors compared the number and severity of prescription errors between 15 health care providers who adopted e-prescribing and 15 who continued to write prescriptions by hand. . . the authors reviewed 3,684 paper-based prescriptions at the start of the study and 3,848 paper-based and electronic prescriptions written one year later. After one year, the percentage of errors dropped from 42.5 percent to 6.6 percent for the providers using the electronic system. For those writing prescriptions by hand, the percentage of errors increased slightly from 37.3 percent to 38.4 percent. Illegibility problems were completely eliminated by e-prescribing.

These results are stunning. Even though the vast majority of prescription errors are either minor or caught and corrected by the pharmacist before the medication gets to the patient, there will still be a tiny though significant number of errors that will get through and potentially cause harm. By massively reducing the total number of errors, the potential for a harmful error that gets through to the patient is also massively reduced. And from a practical stand point, this reduction in errors significantly improves efficiency by eliminating most of the phone calls by the pharmacy back to the physician’s office for incorrect or problem prescriptions. This also improves convenience for the patient since it eliminates the extra step of having to drop off the paper prescription for processing at the pharmacy and may improve patient compliance (though this study did not look at the issue of patient compliance).

If a new medication reduced the potential for significant side effects from 42% to 6% it would make national news. And yet, only 43% of all US physicians utilize an electronic medical record system and fewer use the e-prescribing option. There are various reasons for this; tradition, ludditeism, but expense is one of the main hurdles for a system that often costs tens of thousands of dollars up front and does not directly generate any income (as opposed to, say, an ultrasound machine). And it doesn’t help that, thus far, the Federal government is more interested in giving Trillions to Wall Street schemers than they are in improving the health infrastructure of this country.

The 2009 Recovery Act did have a provision to give physicians $44,000 to purchase and convert to an EMR but as with everything else with the Federal government (not connected to muti-Billion dollar banks)  this money will only be made available after several years and only after going through a ton of bureaucratic hoops. This amount is paltry and laughable considering that the initial purchase price and start up costs of an EMR can be far more than $44,000 and ongoing licensing, use, and “maintenance” costs can easily be several hundred to several thousand per year per provider. It’s like winning the lottery but only having the option of collecting a few cents of it a day over several years. Yea, it sounds like a lot when considered in a lump sum but the way it is delivered makes it financially impractical.

Read more about my own experiences with e-prescribing.