Saturday, December 15, 2007

Pennsylvania's Ed Rendell Playing Games With Mcare Abatement

The Governor of my state, Ed Rendell, has decided he wants to spend any surplus from the catastrophic malpractice insurance fund (which pays awards and settlements over $500,000) on providing insurance for uninsured adults in Pennsylvania. He wants this so much that that he's threatened not to renew the Mcare program unless he gets what he wants. Thought he State Senate has voted to extend the abatement, the House adjourned before voting.

Here's an interesting quote from Rendell:

"We're not going to go through the pain initially of having the doctors send in their checks, and then having to return them if we continue the (subsidy)," Rendell said after speaking at a nurses' conference in Hershey."

What about the pain of the physicians who will have to figure out how to get the money to pay the full amount in January rather than April? Does the Governor think it's harder for the State to issue a refund than it is for doctors to get their hands on that kinds of money?

There should be no linkage between renewal of Mcare abatement and funding of the Cover All Pennsylvanians insurance program. Mcare funds should be used to cover the program's unfunded liability and make it easier to privatize later. The Governor's Cover All Pennsylvanians should get funding in a way that does not impact Mcare's ability to retire unfunded liability and he should stop playing political games to fund it otherwise.



Tuesday, July 3, 2007

Muslim First, Doctors Second

The news that several Muslim physicians were allegedly involved in the UK and Scotland bombing plots did not surprise me as much as it did some others. It made me think back to a conversation I had with a Muslim anesthesiology resident shortly after September 11th.

This resident physician was from Iraq, was a doctor in Saddam's army , surrendered to Canadian troops during Gulf War I and was granted political asylum in Canada. He was very well trained and was a wonderful resident to work with--good work ethic, felt responsible to his patient, a pleasure to teach, a natural in many respects. I'd like to think we became friends during those years. In fact, he gave my an anesthetic for my own appendectomy.

We'd had several conversations about Islam previously and I asked him what he would do if Grand Ayatollah al-Sistani instructed all Shia Muslims to kill Americans? Without even a pause he answered 'I would do it.' Muslim first, doctor second.



Thursday, June 28, 2007

Pennsylvania CRNA Scope of Practice Bills Withdrawn

The two House bills dealing with CRNA scope of practice have been withdrawn by their sponsors due to 'lack of support' in the House Professional Licensure Committee. Good news for now but I'm sure we'll see these efforts again...



Thursday, May 24, 2007

Pennsylvania CRNA's Are After Independent Practice (Again)

Currently pending in the Pennsylvania Legislature is House Bill 1256 to amend the state law that currently requires CRNA's to be supervised by physicians. If enacted, Certified Registered Nurse Anesthetists would no longer be 'supervised' but 'shall administer anesthesia in collaboration with a physician or dentist' (emphasis mine). Furthermore, such collaborating physician only needs to be available electronically (i.e. a phone call away). I'm told that this new language would essentially give CRNA's the ability to practice independently in the State of Pennsylvania.

I think this is a very, very bad idea. In a year when the Governor has made patient safety a centerpiece of his legislative agenda, telling CRNA's that they can practice without supervision seems to me to be a step in the wrong direction. CRNA's are nurses. Highly trained (and the most highly paid) advanced practice nurses, yes, but still nurses. The proposed legislation seeks a substantial change in the status quo and should not be enacted without clear proof that the quality of care Pennsylvania's residents receive will not be adversely affected.

The CRNA lobby is arguing that you really only need anesthesiologists in teaching institutions. I hope our legislators will pause to consider how silly this assertion is. I know a lot of CRNA's. A few of them are very, very good. I would let any one of my physician colleagues (that's about forty people) give my family members an anesthetic. I would only let a handful of CRNA's do the same, and then only with physician supervision immediately available.

Perhaps we should amend this bill so that only the Governor, and members of the legislature and their families will receive anesthesia only from CRNA's and without physician direction for, say, the next ten years and see how good an idea they think this is.

Pennsylvania's citizens are aging. They need physicians to evaluate them before, during, and after their surgery and anesthesia. If you're in favor of this bill, you're probably also in favor of RN First Assistants doing routine cholecystectomies and other surgeries. Those performing surgery have to try really hard to kill a patient. We just have to not pay attention for one minute.



Friday, March 30, 2007

Counterinsurgency in Congress

Professor Arthur Herman

"I think in some ways here, what you are really seeing is that we’ve got a general who finally understands and gets it about the counterinsurgency in Iraq. What we need is an administration that’s going to deal with the counterinsurgency at home, which is taking root in the Democratic Congress."


[Hugh Hewitt]


Thursday, March 29, 2007

Which is more important? Iraq or Afghanistan?

Charles Krauthammer: The wars against radical Islamic insurgents

"Thought experiment: Bring in a completely neutral observer -- a Martian -- and point out to him that the United States is involved in two hot wars against radical Islamic insurgents. One is in Afghanistan, a geographically marginal backwater with no resources, no industrial and no technological infrastructure. The other is in Iraq, one of the three principal Arab states, with untold oil wealth, an educated population, an advanced military and technological infrastructure which, though suffering decay in the later Saddam years, could easily be revived if it falls into the right (i.e. wrong) hands. Add to that the fact that its strategic location would give its rulers inordinate influence over the entire Persian Gulf region, including Saudi Arabia, Kuwait and the Gulf states. Then ask your Martian: Which is the more important battle? He would not even understand why you are asking the question. "



Thursday, March 8, 2007

Why Are C-Section Rates Still Going Up?

csectionrate.gif

As an anesthesiologist I provide anesthesia for cesarean sections quite often. In fact, when I'm on overnight call it's what I spend most of my time doing. Usually, anesthesia for c-section consists of a spinal anesthetic, or using a pre-existing epidural catheter, or (more rarely and usually only in emergencies) a general anesthetic. I am therefore quite interested in the subject of cesarean section rates and what effects how often they are done. I learned some things from this article [free full text]:

Cesarean Delivery and The Risk-Benefit Calculus

1. Parturients are different--they are heavier and older.
2. The number of premature and low birth-weight babies has grown.
3. Vaginal breech deliveries are no longer recommended.
4. Operative deliveries (forceps or vacuum) are less common due to better data describing their risks.
5. More labors are induced (20% in 2003 vs 9.5% in 1990) and induced labors are more likely to result in C-section.
6. Changes in provider behavior

"At least one study found that physicians' malpractice premiums, the number of claims against physicians and hospitals, and the physician's preception of the risk fo being sued were all positively correlated with the likelihood of cesarean delivery. Many in the field defend the rising cesarean rates by citing concern about legal jeopardy, and indeed lawsuits often allege a failure to perform a timely cesarean delivery."

Look at John Edwards' list of law cases (thank you, Google). Notice the medical malpractice cases:

MEDICAL MALPRACTICE CASES
Another specialty Edwards developed was in medical malpractice cases involving problems during births of babies. According to the New York Times, after Edwards won a $6.5M verdict for a baby born with cerbral-palsy, he filed at least 20 similar lawsuits against doctors and hospitals in deliveries gone wrong, winning verdicts and settlements of more than $60M.
Case Summary of Facts Case Type Result
Griffin v. Teague, et al.
(Mecklenburg Co. Superior Ct., NC, 1997)
Application of abdominal pressure and delay in performing c-section caused brain damage to infant and resulted in child having cerebral palsy and spastic quadriplegia. Verdict set record for malpractice award. Medical Malpractice $23.25M
verdict
Campbell v. Pitt County Memorial Hosp.

(Pitt County, NC, 1985)

Infant born with cerebral palsy after breech birth via vaginal delivery, rather than cesarean. Established North Carolina precedent of physician and hospital liability for failing to determine if patient understood risks of particular procedure. Medical
Malpractice
$5.75M
settlement
Wiggs v. Glover, et al. Plaintiff alleged infant's severe cerebral palsy was caused by negligent administration of pitocin, failure to use fetal monitor, or timely intervening in baby's fetal distress. Medical
Malpractice
2.5M
settlement
Cooper v. Craven Regional Med. Ctr., et al. Infant suffered severe brain damage after obstetrician failed to moderate use of Picotin after baby displayed clear fetal distress. Medical
Malpractice
$2.5M
settlement
Dixon v. Pitt County Memorial Hospital
(Pitt County, NC)
Birth-related injuries including cerebral palsy and mental retardation allegedly caused by obstetrician's failure to diagnose fetal distress, including umbilical cord wrapped around baby's neck prior to delivery. Medical
Malpractice
2.4M

settlement


Despite the increase in c-section rates nationwide, we have seen no reduction in the cerebral palsy rate...



Monday, February 26, 2007

Lieberman on Iraq

OpinionJournal - Featured Article

"We are at a critical moment in Iraq--at the beginning of a key battle, in the midst of a war that is irretrievably bound up in an even bigger, global struggle against the totalitarian ideology of radical Islamism. However tired, however frustrated, however angry we may feel, we must remember that our forces in Iraq carry America's cause--the cause of freedom--which we abandon at our peril."



Wednesday, February 21, 2007

CRNA Independent Practice: Deciding Which Question to Answer

In doing some more reading on the CRNA independent practice issue, I found what I thought was a curious quote in a Centers for Medicare and Medicaid Services press release from January 17, 2001. The press release is an announcement that Medicare will leave decisions on whether physician supervision of CRNA's is necessary to the States. Here's the quote from the second to the last paragraph:

"There is no evidence that CRNA independent practice would cause adverse outcomes."

I think asserting that there is no evidence that CRNA independent practice would cause adverse outcome is the wrong question to address. I think the question should be, 'is there evidence that CRNA independent practice would be as safe for patients as the present system?' (we're a six sigma specialty, remember).

The Safe Seniors Assurance Study Act of 1999 was to address the issue but it never made it out of committee:

"(1) The Secretary of Health and Human Services shall conduct a study of mortality and adverse outcome rates of medicare patients by providers of anesthesia services. In conducting the study, the Secretary shall analyze the impact of physician supervision of providers of anesthesia services, or lack thereof, on such mortality and adverse outcome rates.

(2) In conducting the study, the Secretary shall consult with appropriate national professional organizations with respect to the methodology of the study, and shall use medicare operating room anesthesia data, adjusted for patient acuity and other relevant scientific variables."

Sounds like a good starting point for this discussion, however...



Monday, February 19, 2007

Is CRNA Independent Practice Coming to Pennsylvania?

Governor Rendell's 2007 budget document includes a section titled Prescription for Pennsylvania on page A3.32. The first paragraph of that section states:

"Ensuring that all licensed health care providers – including nurses, advanced nurse practitioners, midwives, physician assistants, pharmacists and dental hygienists – can practice to the fullest extent of their training. Pennsylvania consistently lags behind other states in fully utilizing health care providers who are not physicians. Prescription for Pennsylvania will seek to eliminate the barriers in existing laws, regulations and insurance reimbursement policies that limit the ability of health care providers to practice to the fullest extent allowed by their training and education."

Sounds like independent practice to me. Rather than write a knee-jerk reaction right now, I'd like to take some time to educate myself and consider the ramifications...

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