Maggie's Farm

I opted out of Medicare years ago. I felt morally torn about doing so, but finally my bookkeeper refused to do any more of their paperwork. That settled it.

My compromise was to institute a generous sliding fee scale for Medicare-aged folks. (My general policy is to never decline a referred patient because of money.) From a young Doc, in the WSJ:

Here's something that has gotten lost in the drive to institute universal health insurance: Health insurance doesn't automatically lead to health care. And with more and more doctors dropping out of one insurance plan or another, especially government plans, there is no guarantee that you will be able to see a physician no matter what coverage you have.

Consider that the Medicare Payment Advisory Commission reported in 2008 that 28% of Medicare beneficiaries looking for a primary care physician had trouble finding one, up from 24% the year before. The reasons are clear: A 2008 survey by the Texas Medical Association, for example, found that only 38% of primary-care doctors in Texas took new Medicare patients. The statistics are similar in New York state, where I practice medicine.

More and more of my fellow doctors are turning away Medicare patients because of the diminished reimbursements and the growing delay in payments.

Yesterday morning's NJ post on "Quality Care" from the WSJ was enlightening, and just gives me one more reason to stay away from Medicare (besides the fact that they pay me peanuts, and that their paperwork requirements are over my head and take more time than my patients take).

I see how government "Quality Care" works: the academic medical experts take a vote, and that becomes "Quality Care." That's not medical care: that's government policy. Forget the individual patient and his or her unique situation, forget the Doc's experience and skills and insight, forget the Doc's judgement, forget the fact that academic Docs aren't always practical, forget that next week's new data will completely alter the information at hand. Just Follow The Rules and stay out of trouble.

I have seen plenty of cases go bad in the hands of young Docs who strictly follow the rules. It's not a good example of that, but when I was a resident one of "the rules" of the time included strict limits on the use of pain-killers, even for terminal cancer patients. Didn't want them to become addicts, you know. They forgot that pain relief remains one of a handful of the greatest blessings medicine has bestowed on humanity (along with anesthesia, antibiotics - and Lexapro).

One of the best things about seasoned physicians is that they are a cranky bunch who do not take orders, who think for themselves, who feel that rules are made to be broken, and who do not like to take crap from anybody - especially anybody in "authority". Your patient comes first, or you are nothing. There is a "House" inside every Doc. In most lines of work, you can't get away with that sort of attitude.

When government gets involved in things, they tend to screw them up. The article's example of high blood sugars in the ICU was a perfect example. Even I, who have not cared for ICU patients for more than a decade, know that tight sugar control for critical patients is insane and dangerous. Not only that, but it doesn't matter: if the patient survives and gets healthy, a few days of higher sugars with a good margin of error will not have hurt them one darn bit. But I am a Doc with a practical mind.

Expertise always has to be taken with a grain of salt, and government-emitted expertise with a tablespoon-full. I am not disparaging expertise, which I respect enormously. I just distrust the combination of expertise with power over others: anointed experts who want power instead of simply to educate give me the willies.

Non-"experts" often have loads of common sense. We take an ancient oath, too.

Ed. note: Somewhat related: Socialized medicine: A warning from across the pond

That's the latest cardiovascular recommendation for brisk aerobic exercise. (It used to be 20 minutes three times a week, but new data has changed that recommendation.)

I have not asked whether 30 minutes of vigorous sex five times/week counts, but we hope it does.

For some today, and for just about everybody in the past, medical insurance was something everybody bought, just like life insurance or disability insurance, to cover extraordinary expenses. It is called Major Medical, and it is still readily available.

Over the past 20-30 years, governments, businesses, and union contracts began expanding their coverage by reducing deductibles and covering more routine things. Medicare, of course, was the model for that. During the same time, costly medical technology and new drugs were developed in a near-miraculous way, mostly in the US.

With those changes, folks began wanting "insurance" to cover their routine maintenance medical expenses instead of the things that would financially overwhelm them. When that shift was combined with the CYA style of medicine which results in $5000 work-ups for dizzy spells (fed by the ambulance-chasers), everybody expected everything.

That isn't sustainable, and will never happen. Medical technology has grown to an amazing extent, but those machines are expensive.

I have no idea what the folks in power are trying to plan for us, but I know it will be an entitlement disaster, filled with unintended consequences, that people would not be happy with. It will end up with politically-determined rationing.

Our family bought Major Medical insurance many years ago. It cannot be cancelled. It's more important than a cool car. Why everybody does not do that when they are young and healthy is beyond me, because it would seem like the logical and prudent thing to do. Over the years, we have increased the deductible so that it is quite affordable, and we keep a money market savings account specifically for medical bills to the amount of the deductible. As I recall, we began with a $2000 annual deductible, and now we finally have a dirt-cheap $20,000 2-year deductible on the original policy. It does not cover any routine or preventive medical care, which is as I think it should be. Nobody owes me medical care, in my view, any more than anybody owes me auto insurance.

We have kept this policy whether or not I or my husband had some form of insurance through work, because you never know how long you will want to keep a position - or when you will be let go.

Off-topic: Around 30% of Medicare expenditures occur in the last year of life. In other words, on failing and terminal people. Interestingly and unsurprisingly, when docs hold end-of-life conversations with these patients (as we should), the costs go way down.

General hospitals are increasingly relying on "hospitalists" to care for inpatients, freeing up office practitioner's time for their (steadily less lucrative) outpatient practices.

I have yet to be a hospital inpatient except for childbirth, but I think that, if and when I am, I'd like to see the face of my own Doc daily. 

This is a new model for medical practice. More time-efficient? Probably. Less comforting? Probably. Overall, better or not? I cannot say.

Internists, and what few GPs still exist, are having a tough go of it these days: Medicare, which is the bulk of their work, compensates them now at a rate lower than a plumber or electrician in Boston.

Your doctor may be so concerned about protecting you from alcoholism that he or she might not tell you that current research indicates that 1-2 drinks per day appears to reduce the risk of heart and arterial disease by 18-30%.

More is not better, however. Details at Medscape.

We have posted on statins in the past.

Here's further evidence that statins are helpful, regardless of your triglyceride levels. Maybe all guys should take them (per your Doc's advice, of course.)

A piece on the subject in the NYT notes:

The myth is that like magic, preventive medicine will simultaneously reduce costs and improve health.

Read the whole thing. Sadly, except at the margins, there is little we can to to prevent disease. The wishful thought that we can control fate and the gods never quits, though.

Yet one more manufactured, over-hyped  crisis is being debunked.

Nowadays you can define anything you want as pathological. And this whole new fashionable category of "at risk" silliness expands things to include everybody.

For example, at middle-age I am "at risk" for obesity. Not wanting to be fat, I decided not eat carbs and I do a tough daily workout. It's not too complicated.

Prosperous nations have lots of fat people. More of them than poor nations, although poor nations have plenty of them too. The reason is that humans have a weakness for carbs. Thus being trim and fit is a sign of self-control, but being heavy is a time-honored sign of prosperity.

If you want to see fat people, go to Disneyworld and get grossed out. There are Americans there so fat that they have to ride around in motorized chairs, like King Kamehameha. God bless 'em. The world needs more fatties, in my opinion. It means people have plenty to eat, but I don't like to have to look at them. To be evenhanded, however, I find anorectics even more disturbing.

I happen to feel that excess fat in women is unattractive, slovenly, and unsexy. Somewhat less so in men: some stout men are cool, like Teddy Roosevelt was. Anyway, we have been subject to much brouhaha about obesity in recent years. Big health crisis, etc.

You have surely read the news that being overweight is not such a big deal, from a medical standpoint. Even the WSJ covered the story, amusingly. Obesity - and that means much more than ordinary fatness and pudginess - is often quite benign.

And being overweight is fine, from a health standpoint.

Just like the the AGW fad and all such fads that governments are suckered into, there is fat money to be made from the obesity silliness. Follow the money: you know that somebody always wants some of yours. Careers. Respect. Pensions. Fat City.

Fact is, when I was an intern in NYC, I saw plenty of skinny, athletic guys in their 40s come into the ER and crap out with massive heart attacks. Also, skinny guys with insulin resistance. The reasons to be relatively thin are to be fully functional - and aesthetic. If an American lady wishes a decent sex life, it behooves her to be trim. Not so in some countries, however, where they prefer us gals Biggie-Sized.

Here's a good food story, from the Englishman:

His typical breakfast order from Pete's Grille in Baltimore, Maryland:

Start with three [white bread] sandwiches of fried eggs, cheese, lettuce, tomato, fried onions, and mayonnaise; add one omelet, a bowl of grits, and three slices of French toast with powdered sugar; then wash down with three chocolate chip pancakes.

According to his autobiography, growing up, lunch also consisted of 1 pound of pasta, 2 large ham and cheese sandwiches with mayo and 1,000 calories of energy drinks. Dinner’s another pound of pasta and a whole pizza and 1,000 calories more in energy drinks. No food hang-ups with him. He gets it. Food is fuel, not endowed with magical or evil effects.

What a fat slob he must be, bet he can barely get up from the sofa to get to the fridge, something ought to be done to prevent our youths ending up like him...

Let's all be relaxed and tolerant: being fat is a "life-style" choice. Let them eat cake.

Addendum: At Pajamas, Fast food restrictions fatten government

Here's an answer. Are men's nipples "sensitive"? Yes they are. Gals take note, for when in a playful mood.

There's a book with that title too: Why Do Men Have Nipples? Hundreds of Questions You'd Only Ask a Doctor After Your Third Martini