i bought a swimsuit

And I posted about it for BlogHer.

I won't say the search wasn't traumatic:

I rejected suits that didn't cover my scars, that were two big, too small or both at the same time. I worked up a sweat trying to get tangled bathing suit straps over my shoulders, often resulting in a look that was reminiscent of a wrestling uniform. I cried a little bit. Regular suits left me feeling too exposed and mastectomy suits bagged on the chest when I was not wearing a breast form.

You can read the rest of the post here. I even posted a picture of myself, wearing the swimsuit.

I didn't get to far on my to-do list this month but these are accomplishments (the doing and the writing) of which I am proud.

Accountable Care Organizations: Physician Group Competition, Divided Loyalties, Monopolies & the Risk of Abandonment

The Disease Management Care Blog gave a one hour Category 1 continuing medical education lecture to an independent, very large (more than a hundred providers), multi-site and physician-owned primary care group the other day. It had a chance to chat with the practice administrator and it learned a) recruiting physicians is their biggest challenge, b) once a young physician is recruited, it takes months for him or her to become efficient enough to cover salary and benefits, c) fee-for-service Medicare is their problem payer, d) there is a direct economic link between the money they get from private insurers' pay for performance (P4P) and their willingness to provide disease management: no P4P, no DM, e) they do business in the same core service area as a very large integrated delivery system and are thriving and f) they admit or refer patients to two hospitals.

Each point was savored during the car ride home, but it was the last insight above on two hospitals that dredged up some additional questions about a DMCB favorite: acountable care organizations (ACOs).

It's the end of the week, so the DMCB will keep it brief.

As hospitals respond to health reform and seek to form ACOs, how will they and/or the Federal regulations that govern all of this.....

1) overcome the triple threat of i) large physician owned groups' competitive activities, ii) provider unwillingness to be on call for emergency room consultations/admissions and iii) that many outpatient-based physicians can't recall what the inside of a hospital even looks like, let alone have a business relationship with one?

2) deal with large physician groups that can play one hospital against another?

3) ease inevitable government anxieties that ACOs are really monopolies in health reform's clothing?

4) keep hospitals, if things don't work out as planned, from pulling the plug and leaving large and small physician groups to claw their way back to financial independence?

The Latest Health Wonk Review Is Up

It's East versus West in a wonky tournament-style face off of the top 16 posts in a NBA Playoffs Edition, all arranged for your educational pleasure at the Healthcare Economist Blog. The Disease Management Care Blog is in it and is all (inter)net.

The Busywork Burden of Primary Care Physicians: A Review and What Population-Based Care Management Organizations Already Know

Everyone knows primary care physicians are a legitmately grumpy and depressed lot, but does it really come down to being overworked and not being paid well compared to their specialist colleagues? To get some better insight about what's really going on, check out the April 29 New England Journal article by primary care internist Richard Baron titled "What's Keeping Us So Busy in Primary Care? A Snap Shot from One Practice." The entire manuscript is available on line gratis. There's also this report in The New York Times with some additional interview tidbits.

Using an electronic record's patient encounter database from a five person community-based Philadelphia practice called Greenhouse Internists, Dr. Baron looked at how a typical doc's day gets filled:

24 patient phone calls per physician per day, with 80% of them handled personally and mostly involving medical advice, dealing with insurance issues or talking to other docs about patients.

17 emails per physician per day, mostly dealing with test results or patient inquiries.

12 prescription refills per physician per day outside of a face-to-face patient encounter.

20 lab reports per physician per day. If any are abnormal, they'd need to be attended to, often the same day.

11 imaging reports per patient per day.

14 outside physician consultation letters or notes per physician per day. If there are recommendations, they'd also need to be attended to.

By the DMCB's count, that's 98 paperwork events per day. Even if each took one to two minutes to accomplish (and it doesn't) that's about three hours that are not involved in patient care. It's also important to note that Greenhouse Internists is not a struggling physician-owned practice saddled with poor management. They have Level 3 NCQA PCC-PCMH recognition and are the smart guys behind this insightful 2005 Annals article Electronic Health Records: Just around the Corner? Or over the Cliff?

This snapshot is quite credible and the DMCB suspects most community-based primary care physicians will readily identify with the numbers described above.

What does this tell us?

Quality, Not Quantity: The actual paperwork is not necessarily mentally or physically taxing and the DMCB suspects Greenhouse has money coming in. Rather, it's the mismatch between professional work expectations and the reality of modern practice management. The DMCB can't blame docs for seeking alternatives outside of primary care and doubts more money alone is the answer

Don't Drink the Kool-Aid: While astonishingly disconnected utopians continue to promise that the electronic record and the patient centered medical home (see here and here) will fix all that ails primary care, note that Greenhouse already have both and still have to funnel busy work to the docs. Despite The Time's interview with the author saluting both the EHR and the PCMH, the DMCB notes that the workload described above was happening despite the EHR and PCMH.

Now You Know Why: Care management organizations, quality assurance mavens, non-physician administrators, managed care executives, pharmacy benefit managers, policymakers, politicians, C-Suite types, advocacy groups, electronic record vendors, regulators, academics and anyone else with a good idea that will take just a little bit of a physician's time may now appreciate why docs can be so resistant to taking on another task - no matter how small it is. This is death by a thousand cuts.

Successful disease and care management organizations painfully learned about the importance of physician attitudes long ago. They already know that, to succeed in this environment, their programs need to not only deliver outcomes for their sponsors, but unburden physicians as much as possible with a flexible service mentality. What's more, they're already at work learning to align themselves with the PCMH and EHR to take up even more slack. Their perspective is one of "all hands on deck."

The DMCB has seen disease management nurses aid physicians by getting to patients figure out what to do for themselves, independently communicate and interpret important lab results and run interference with their sponsoring health insurance companies. When done right, physician satisfaction surveys (for example here, here, and here) run counter to the canard that all docs routinely dislike disease management.

Afterall, it's easy to see why they like anything that can help them with 3 plus hours-a-day of busywork.

The Future of Digital Medicine: Smartphones Will Replace the EHR As the Workhorse Informatics Device In Clinical Care Settings

As a former New Yorker, the Disease Management Care Blog has always had an abiding respect for the Big Apple's taxi drivers. That increased considerably after it left its wallet in a Manhattan cab and it turned up in Virginia a year later - in the possession of an individual allegedly involved in organized crime. This and other evidence of the cabbies' shrewd business acumen makes the DMCB wonder why Hizzoner required that they start using hybrid cars. If they're such a gas-conserving and money saving no-brainers, the DMCB figures the cabbies would have figured out a way to get them on the streets all by themselves.

Which brings the DMCB to smartphones and healthcare. How can this be, you ask? Read on.

Thanks to the Covering Health blog and their link to this report from the California HealthCare Foundation (CHCF), the DMCB not only got to delight in the new term 'techfluentials,' it learned that these little electronic mini-slabs have remained remarkably recession proof. They're now in use by 42% of consumers. Even more impressive, however, is their uptake among supposedly tech-wary physicians. Fully two thirds of providers currently possess smartphones and that's projected to exceed 80% by 2012.

There are over 5000 iPhone health-related apps and about a third have been designed for physicians and other providers. They include medical and drug reference libraries, dosage calculators, clinical alerts, decision support tools, viewers for lab and radiology reports (including the x-rays themselves), communication portals designed for patients as well as physicians, patient status monitors (for example, in the emergency room and labor suite), continuing medical education (CME) tools and the means to access a patient's personal health record (PHR)

In the meantime, the Feds continue to promote a stubbornly expensive and unwieldy electronic health record (EHR). With their usual complex web of financial and regulatory sticks and carrots, Washington's bureaucrats remain fixated on the big boxy multifunctional and proprietary personal computer-based systems with screens and keyboards populating every clinic room and hallway.

In contrast to that orthodoxy, the DMCB agrees with it's colleague Vince Kuraitis. He predicts the EHR will evolve into a PC-centric platform of distributed cross-functional and plug-and play devices. Yet, thanks to the California Foundation report, the DMCB wonders if things may become even more complicated than that. It could be that the handheld smartphone, not the screen and keyboard, turns out to be the central hub of digital care. In other words, the iPhone won't be slaved to PC-based EHR systems, it'll be vice versa. What's more, there won't necessarily be a desktop or a hallway. In fact, the clinic's boundaries may turn out to be even more fluid than we ever anticipated.

And it's all happening without Federal intervention.

Which brings the DMCB back to the New York City cabbies. Despite the best intentions of the Mayor, there have been problems, suits and delays. The DMCB also recalls reading that the involvement of NYC government in the first place may have ironically led some cab companies, pending better understanding the law, to delay buying any hybrids.

And, despite similarly good intentions extending back through several administrations, Federal meddling in the promotion of EHRs have also caused many physicians to delay the purchase of an EHR. Unlike the NYC cabbies, however, the docs have had another smaller, nimble, cheaper and remarkably functional option. It's the smartphone, which may have been partially spurred by the continuing travails of the Fed's love affair with the EHR. It seems that while providers have been waiting for Dr. Blumenthal et al to clarify just how good the EHR can be, physicians have apparently turned to the next best thing.

In fact, based on CHCF's report, it may be turning out to be the better thing.

('’)

Dietary Counseling for Obesity As A Covered Benefit In Medicare: Is It A Good Idea?

In its past lives, it wasn't unusual for a C-Suite type to ask the Disease Management Care Blog to take a look at the outcomes of a care management and/or clinical and/or disease management and/or quality improvement program. The typical intent was to get the DMCB to prove that the initiative really worked as advertised, get the results published in a peer reviewed journal and help garner some marketing mojo.

Alas, the DMCB quickly learned these types of post hoc analyses are not only beset by numerous data flaws, they can also fail to show the program really worked. While the initial C-Suite response to the DMCB's pessimism was to find a more cooperative geek, what typically followed were instructions to adjust the program and then find the necessary proof to get it published.

Which is why the DMCB has some sympathy for whoever is going to be running the Center for Medicare and Medicaid Innovation. Even with the impressive name and all the zeros in its budget, one unspoken purpose of the CMMI may turn out to be eerily similar to what the DMCB went through. Policymakers, politicians and bureaucrats may assume that the CMMI exists to do the research that can justify covering something we already assume works.

Case in point? Ask the average health care provider, policymaker, regulator, politician or person if Medicare should cover dietary counseling for weight loss among obese persons, the answer will probably be a resounding yes. When confronted by the lack of any research showing that weight loss services actually work, the same average health care provider, policymaker, regulator, politician and person will respond that better research is needed. Once that's over with, we can get Medicare to cover it.....right?

Unfortunately, when it comes to dietary counseling and weight loss, more research may never get the answer we want. Check out this recently published review of every study ever published involving weight loss interventions for persons over age 60 years. A total of nine good studies were found mostly involving community dwelling overweight and obese elders with a chronic condition such as diabetes or arthritis. While there were methodologic problems involving blinding, intention-to-treat analyses and handling the drop outs, the studies were generally performed well and were also disappointing: the average weight loss amounted to a measly six to seven lbs. What's more, no significant improvements were detected in cardiovascular risk factors, exercise capacity or quality of life. The authors indicate that the lack of high quality studies doesn't preclude the possibility that dietary advice may work. The DMCB thinks they're being overly generous.

This is a useful review because it focuses on the Medicare-eligible population. The DMCB also suspects that it's likely that additional research - even if it's done by CMMI as part of a broader study of wellness, prevention and primary care - will simply replicate the outcome of modest weight loss that doesn't appear to translate into meaningful reductions in risk.

One last thought: dietary counseling in Medicare as well as younger populations is probably necessary but insufficient to lead to significant and meaningful weight loss. It's greatest potential is when it's combined with other interventions in the context of disease management or the patient centered medical home. Stay tuned.

Medical Homes & CMS' Chief Actuary: The Mirrored Gazing Globe of Health Reform?

The Disease Management Care Blog believes a gazing ball would be a handsome addition to our yard. In its opinion, a mirrored globe would be a festive compliment to the property and introduce a distinct classiness that is absent around our neighborhood. Yet, the DMCB spouse's opaque logic has inexplicably vetoed the idea. What gives?

And the same cold water could end up being splashed on the equally good ideas behind the various pilots and demos in the recently passed Patient Protection and Affordable Care Act (APPAC). In Section 3021 (p. 271), the yet to be formed Center for Medicare and Medicad Innovation is charged with testing various models of care including medical homes. The HHS Secretary may, 'through rulemaking,' expand the models if:

"...the Chief Actuary of the Centers for Medicare & Medicaid Services certifies that such expansion would reduce program spending under applicable titles."

Egads. Getting the CMS Chief Actuary to certify there is reduced program spending may be a tough hurdle. According to this news report, this is the same equally hardnosed Chief Actuary that recently calculated that the newly passed health reform bill will lead to "increased costs associated with the expansions of health insurance coverage" and that "the longer-term viability of the Medicare ... reductions is doubtful."

The policy response from the White House and its Favored Chosen, of course, is spin. Given the Chief Actuary's uncanny similarity to the DMCB spouse, however, the DMCB isn't sure that spin will meet "reduce program spending" muster.

In the meantime, the DMCB is moving on. Inspired by the release of the movie Avatar on DVD, its latest pilot ornament idea is to festoon our shrubbery with solar powered glo-in-the dark Pandora-like butterflies. The DMCB looks forward to the DMCB spouse's analysis and the expansion of this meritorious landscaping model.

Specialist Physicians and Patient Centered Medical Homes: Here's How To Make It Work

Should specialist physicians be allowed to hop on the Patient Centered Medical Home gravy train? That's the topic of an interesting New England Journal article by Larry Casalino (Cornell), Diane Rittenhouse (UCSF), Robin Gilles (Berkley) and Stephen Shortell (Berkley).

Several organized specialist physician groups as well as the AMA have supported the notion of specialist (for example, urologist) medical homes. Dr. Casalino et al explored this with a telephone survey of randomly selected cardiology, endocrinology and pulmonary specialty practices. Unsurprisingly, 81% of the respondents described themselves as providing primary care services for 10% or less of their patients. Endocrinologists averaged higher, with about 10% providing primary care to up to 50% of their patients.

In response, Dr. Casalino and colleagues posed four open ended questions for health care policymakers:

1. Is it called 'primary care' if specialist physicians refer patients to other physicians for primary care services?

2. Are some specialty physicians, compared to others, better able to provide 'primary care?'

3. Is the extensive practice transformation necessary to become a PCMH possible or even worthwhile for specialty physicians when primary care only occupies a fraction of their practice?

4. Assuming specialty physicians are an important societal resource, should we be even encouraging the notion of them providing primary care?

While the few policymakers that actually read the Journal may ponder those questions, regular readers of the DMCB can go one step further and note:

1) how little mention the self and commercial insured markets get in this article. If there is a business case or consumer demand for cardiology, pulmonary, endocrinology or even urology patient centered medical homes, the purpose of policy makers should be to figure out how to get themselves and government out of the way.

2) that the answer to specialist-run medical homes may be sorted out in the coming Accountable Care Organization programs that were part of the health reform PPAC Act. In fact, the DMCB suspects, depending on how the regulations are sorted out, that the infrastructure of well managed ACOs will provide virtual and transorganizational PCMH services, blurring the distinction between physician 'owned' versus "rented" elements that make up a medical home.....

...which brings up a third wrinkle and possibly some answers to the questions poised by Casalino et al. Inside or outside of ACO's, the DMCB thinks - depending on market forces and the degree of Federal meddling - that the smarter commercial disease management organizations (DMOs) are already positioning themselves to provide many of the services that would fulfill the spirit and the letter of medical homes, including those run by specialists. DMOs can prompt patients to meet their primary care needs with shared decision making, level the playing fields between different types of specialists, reduce the need for a wholesale practice transformation and enable specialists to still function as specialists for an appropriate percentage of their practices.

(There's lots more on Accountable Care Organizations here)

How Not To Answer The Question

Now that the spotlight has moved onto other issues of great national import like financial services reform, legalizing weed and Kate's status on Dancing With The Stars, the real work of implementing the health reform bill has begun. Based on the interchange below, one way to accomplish this is for a HHS Secretary is to respond to questions with dissembling, vague non-answers. Let the games begin.



Hat Tip: HealthHombre

The Latest Cavalcade of Risk Is Up!

Veteran hoster My Wealth Builder has the latest Cavalcade of Risk at this "Stars Edition." Don't let the number of stars assigned to each link fool you, because it's based on prior participation. The Disease Management Care Blog currently has one star.... which is sure to increase. There is lots of good stuff on insurance, economics and finace - well worth your time.

all clear

I got my CT results yesterday - via a very casual voice mail message:

"This is A. calling from the Cancer Centre. Your scans were normal. Thank you."

So there you have it. That's almost three years clean now.

And now on to making two birthday cakes (D. is 7 today), cleaning the house and doing the myriad things one needs to do before going away for a few days.

I'm not living the life I imagined for myself, but I'll take it.

really random news

1. According to an article in the Globe andMail, women and men respond very differently when they are on the recieving end of an apology:

“Women who are starved of an apology for rude or hurtful behaviour suffer an increase in blood pressure which can raise the risk of a heart attack or stroke, a study found,” The Daily Telegraph reports. “But those who hear a well-timed ‘sorry’ calm down more quickly, with their blood pressure returning to normal 20 per cent faster, the research showed. Conversely, a man’s blood pressure takes 20 per cent longer to recover after an apology – suggesting men become more worked up after hearing an admission of guilt.”

2. My sister sent me an article from the CBC web site this morning, about a colossal cookbook typo with the subject line "Oops." I've made some pretty big errors by not proofreading properly but this tops it all.

3. My friend, O. posted a story to Facebook today, with the headline "Woman with parrot perched on face arrested after throwing inhaler." Note to self: Don't throw an inhaler while a parrot is standing on your face. You will be arrested.

4. I'm still waiting for my CT scan results, which could be why I'm letting myself be distracted by all this silliness.

Not Filling Prescriptions After Hospital Discharge: Here's How To Fix It

The Disease Management Care Blog remembers the thick carpeting on the way to the hospital's flourescently lit and windowless administrative conference room. Copy machines were whispering in the background while photos of past Board members smiled at us from behind their ground-breaking spray-painted shovels. No, said the Vice President, we can't require our discharge planners to notify your disease management program about patients' going home. They're too busy and we're understaffed. Have a nice day.

Fast forward to the Disease Management Care Blog giving the Booster Shots Blog a hat tip for the timely alert about this just released article by Michael Ho and colleagues about the prescribing patterns of clopidogrel (a.k.a., the generic name of the drug "Plavix") for patients sent home after getting a coronary artery stent.

Stents are used to treat blocked coronary arteries. Yet, while they work great at opening arteries, the stents themselves are prone to thrombosis. The surfaces of these spring-like scaffolds can be irritating to the blood platelets which, in turn, can lead to clotting.

That's why persons with stents should generally take blood thinners every day. The most widely prescribed blood thinner for stent patients is clopidogrel. It's typically started in the hospital and continued for at least a year after discharge. That's because it's been known years that stopping clopidogrel in the weeks or months after getting a stent leads to thrombosis which, in turn, causes another heart attack or stroke.

But how about persons who fail to fill their clopidogrel prescripion on the day of discharge from a hospital?

Ho and colleagues looked at the records of approximately 7400 patients who 1) had at least one coronary stent placed and 2) who also had health insurance and a pharmacy plan through Kaiser of Northern California, Kaiser of Colorado or Health Partners of Minneapolis. The study authors were interested in how much time elapsed between the day of discharge and getting the clopidogrel prescription filled. About 1200 or 16% or about 1 in 6 discharged patients went at least a day without their medication. For those who went without, the median was 3 days. What's more, 165 patients or about 2% never filled any prespription for the drug.

Any delay in filling the clopidogrel prescripiton was associated with an increased likelihood of death or heart attack during the median of 664 days of follow-up. Even after adjusting for the use of other medications, the difference, compared to persons who filled their prescriptions right away, remained statistically significant.

What does the DMCB think?

While medication use for persons with chronic illess is a common quality measure, the DMCB doesn't believe measures of medication use focusing on persons just discharged from the hospital has been widely adopted. That needs to change.

The authors noted that during January 2004 to December 2007 period of study, medication co-pays ranged from $20-$35. Even small out of pocket expenses for high-value and life-saving medications can make a difference in medication compliance. In the meantime, value-based insurance designs for pharmaceuticals are one answer to addressing a one-size-fits-all pharmacy benefit. Those inflexible benefit plans need to change.

While the absence of any health insurance is certainly a formidable barrier to accessing good health care, this article shows that simply getting persons insurance is not a health reform panacea. We still have our work cut out for us. Formulating health care policy that doesn't recognize that needs to change.

While policy makers, providers and insurers have lately been hostile to the role of pharmaceutical companies having any role outside of manufacturing and selling their products, companies like sanofi-aventis (which makes clopidogrel) have a wealth of information on how to incent consumers to take their product. Maybe our national unwillingness to engage with big pharma on issues like this needs to change.

We have a comparative effectiveness boondoggle headed our way, but in the meantime, there are entities like Kaiser and HealthPartners that can access their huge data bases today to come up with insights that are immediately useful. While not mentioned above, the authors identified some patient characteristics that seemed to be associated with not getting a prescription filled. This information can be used prior to discharge to focus on persons at special risk. The low use of the databases that are already at hand needs to change.

The Feds have obviously declared war on avoidable readmissions by not paying for them. Their willingness to pay for the readmission of a patient that a) should have been taking their clopidogrel and b) went without any documented outreach by the hospital or the insurer may be something that needs to change.

While physicians are also responsible, their good intentions in the absence of systems changes in partnership with hospitals and insurers is not enough. That's why disease management's and the patient-centered medical home's track records of remotely communicating with patients and deploying state-of-the-art interventions that optimize self-care are so important. Many DMOs already emphasize medication management in their patient engagement strategies. Not recognizing how powerful this is among policy makers is something that needs to change.

Last but not least, the unwillingness of hospital leaders - especially those outside of the few integrated delivery systems - to play nice with disease management organizations, pharmacy benefit managers and outpatient physicians is intolerable. If it were up to the DMCB, insurers would be allowed to deduct a percentage of the hospital payment if they were not notified on the day of discharge about a patient over and beyond the no-payment "nuclear option" described above. Traditional discharge planning has got to change.

*Image of stent from Wikipedia

The Goldilocks Approach to Insurance Design with Out Of Pocket Expenses

In a prior post, the Disease Management Care Blog touched on the complex economic trade-offs that need to be considered in insurance benefit designs. It likened the topic to the double edged sword of possible appendicitis, where maintaining too low a threshold for going to surgery means some people will have an unnecessary operation, while too high a threshold and waiting will lead to complicated rupture. Good surgeons and hospitals know the best is a middle-of-the-road "Goldilocks" approach that manages and minimizes both extremes.

And so it is with the design of health insurance and the degree of out of pocket expenses. Articles like this and this would have unsophisticated readers believe that the best approach is a "low threshold" approach to health insurance that pays for every health care need, both great and small. On the other hand, the DMCB has encounted C-Suite executives who embrace the "high threshold" style of insurance that pays for precisely defined covered services using a simplified and rigid one-size-fits-all benefit - and not a cent more. In between these two extremes is a curious mix of politics and insurer tone deafness has resulted in national health care policy tilted toward paying for every need.

Critics of the health insurance reform passed by Congress say that that level of generosity cannot continue. Supporters respond by pointing to a host of study pilots, commissions, tax policies and comparative effectiveness research (CER) that will point the way to a more enlighted approach that still manage to pay for every health need. The DMCB is not optimistic that that will be enough. Our expanding Federal bureaucracy is unlikely to execute well on the pilots, get any commission's recommendations past Congress or credibly mainstream any CER findings.

There is good news, however:

1) Disease management organizations (DMOs have a wealth of experience in not only helping patients choose among competing care options but, in many instances, also understanding how to navigate through their insurance benefit. The "Goldilocks" trick is to present the risks, benefits and alternatives to getting a mammogram or going to the emergency room and help the patient make the right decision. Why else would Congress be so interested in Shared Decision Making (SDM)?

2) Value based insurance designs (VBID) are also making good headway. While it there are significant administrative challenges, toggling out of pocket patient expenses according to the value of the medical service - as defined by market demand or government fiat - is another Goldilocks approach. Why else would the Feds be so interested in Value Based Purchasing (VBP)?

The DMCB predicts that when the current Administration's approach to the pilots and comparative effectiveness research proves unable to tame health inflation, there will be even more renewed interest in DMOs, SDM and VBIDs.

buckets of pink sh*t

If you've been reading this blog for a while, then you know how I feel about corporations selling pink crap in the name of "breast cancer." I even have a "don't buy pink crap" tag that use pretty regularly, especially in October.

There have been some pretty awful pink products sold over the years but in launching "Buckets for the Cure," KFC and Susan G. Komen for the Cure have sunk to what may be a new kind of low.

This stupefyingly bad idea was brought to my attention by Clergy Girl, in a post called "Buckets Of Saturated Fat For The Cure" over at Mothers With Cancer. She writes:

This was a sell-out Komen.  Did you ask anyone with breast cancer how they would feel seeing that big pink greasy bucket of chicken?  Was someone going to lose their job if you didn’t raise cash quick?  I really don’t get it?  Research also shows smoking and alcohol consumption are clear links to cancer, so why not team up with Marlboro or Bud Beer?  It’s not just about money, and quite frankly, don’t raise money on the backs of research that is clearly linking to cancer promotion.  Please!

Shame on Komen for lending it's name to this outrage.

Wellpoint, Goldman Sachs, Policy and Political Theater: A Bad Movie Part 2

The Disease Management Care Blog used to tell its patients it was a good sign if you had insight about your mental illness. That's why it readily admits to an abundance of paranoia over the timing of the Security and Exchange Commission's civil suit against Goldman Sachs and the Democrats' push for major financial reform legislation. By taking the abstract (hopelessly complicated financial instruments that were hopelessly outside the understanding of everyone, including the regulators) and putting a face on the alleged villainy, the Dems have simultaneously increased the likelihood of passage of a bill, energized their base and once again painted their Republican opponents into the Corner of the Party of No.

If this sounds like a bad movie that DMCB readers have seen before, it should. Recall that in weeks leading up to the showdown vote over health reform, HHS Secretary Sebelius unloaded a perfectly timed broadside at the the infamous Wellpoint, even though its proposed rate increases and administrative costs were known months before. Now that the Wellpoint has served its purpose, Ms. Sebelius and the White House have moved on, leaving State officials in California to deal with the inconvenient truths of an informed Board of Directors' decision about CEO compensation and the apparent likelihood that, effective May 1, the rate increases will stand. This mugging is the White House's style of victory?

The contrarian DMCB is not defending corporate piracy at the expense of the little man. But it knows that the time necessary to formulate good policy based on all sides of the issues takes a lot longer than the political cycle. It seems the White House has learned to manipulate both. That makes for good political theater and victories, but does not bode well for the business of government.

Tell The Feds What You Think!

Do you think patients getting timely copies of their electronic records, after-care summaries for each encounter, discharge summaries for each hospital stay and patient reminders for preventive as well as follow-up care are what it takes to provide state-of-the-art care for patients with chronic illness? '

The Disease Management Care Blog doesn’t think so either. The good news, however, is that it and you have an opportunity to let the Feds know why those elements are a good start and are necessary but are still insufficient. You can do so at the Health Information Technology “Federal Advisory Committee Blog” here.

That’s right, the Feds have posted a series of questions that are calling out for your on-line input. The questions range from use of the PHR, leveraging the EHR as a means of collaboration, workflow and data management.

Comments placed today will be used by the Feds in their ongoing deliberations, including an April 20 hearing.

Trade Offs in Health Insurance Benefit Design

Appendicitis can teach us about the trade-offs in health insurance.

Not all abdominal pain is from appendicitis. So, when physicians worry about appendicitis in an emergency room patient with severe belly pain, they also worry that its rupture can lead to complications. However, they also know that unnecessary surgery should be avoided. So, should doctors: 1) arrange for that person to go to the operating room right away, because waiting can lead to rupture, or 2) should they sit tight and see if the pain gets better because it might not be appendicitis and unnecessary surgery could be avoided?

The best - yet imperfect - answer is that "it depends." This JAMA article shows us that the the rate of ruptured appendices in the U.S. is around 35% and that the rate of normal appendices being taken out is 2-3%.

Which leads to the trade-off. If we collectively decided as a society that we wanted to really reduce the rate of appendicial rupture, we'd need to have a lower threshold for taking people to the operating room. We could a) educate people to seek medical care ASAP for suspicious abdominal pain, b) require insurance companies to only sell benefit plans that encourage persons to get emergency and hospital care for any pain that mimics appendicits and c) economically incent hospitals and physicians with "no payment" if there is a complicated rupture. However, the problem is that there will be more people going to the emergency room and then onto the operating room and there will be more normal appendices being taken out.

The Disease Management Care Blog keeps this kind of economic trade-off in mind whenever it reads articles like this one that was just published in April 14 JAMA. Briefly, the medical records of 3721 consecutive heart attack patients in 24 U.S. urban hospitals were reviewed to determine insurance status and how much time elapsed between the onset of symptoms and getting medical care. The patients were also interviewed about their "financial concerns" when they decided to go to a hospital. Patients were placed in one of three categories: 1) insurance present and no concerns, 2) insurance present but concerned and 3) no insurance. Persons with no concerns were more likely to make it to a hospital within two hours: it was 36.6% vs. 33.5% (among persons with concerns) vs. 27.5% (among persons with no insurance). The conclusion of the authors was that economic barriers are associated with delays in seeking care for heart attack.

They're right.

It has been known for a long time that relatively small changes in out-of-pocket expenses can have an important impact on the decision by patients to seek medical care. That's why increasing consumer payments through co-pays, co-insurance and benefit limits have been widely used to address the perfect storm of medical as well as emergency room overutilization that can, in turn, can make employer-based health insurance less unaffordable.

Which leads to the appendicitis-like trade off. Decreasing the financial barriers to accessing timely health care could lead to 10% more patients seeking timely heart attack care. On the other hand, that could also lead to emergency room overcrowding and overuse by persons who would otherwise have second thoughts and their belly pain. On the other hand, by increasing "skin in the game," patients can be more cautious and savvy consumers of health care even though it could cost lives.

The DMCB isn't sure there is a right answer here. However, it figures there are smart ways and dumb ways to configure an insurance benefit that navigates between open unfettered overutilization and inappropriate economic barriers.

This is still very much a work in progress. More on that in a future post, but here's a preview: don't count on the traditional doctor-patient relationship to figure it out.

You Could Win A DMAA Leadership Award. Here's Why.

The Disease Management Care Blog feels your pain.

Your demanding customers bear an uncanny resemblance the skeptical and frugal DMCB spouse. Her attitude about the DMCB's obviously valuable blogging is undoubtedly similar to the tough mindset you're encountering about the veracity of your decreased emergency room utilization and hospital admissions data. Unfortunately, unlike the DMCB, pretending you didn't hear won't work, so you need another way to quell the criticism and gain a competitive advantage.

The DMAA, the Care Continuum Alliance to your rescue with its nationally recognized and highly covered Leadership Awards. Once again, the competition has been opened for organizations just like yours.

Should you go for it? The DMCB says yes, but to help you answer the question for yourself, the DMCB is happy to offer this exclusive for readers only self-assessment questionaire:

Has your company:

1) partnered with a community health program, causing an insurer's claims expense to drop lower than a D.C. incumbent's approval rating, or

2) changed its branding, emphasizing how it does really the same stuff but now calls it "empowering consumer-based self care to drive optimal outcomes," (or is it branding health consumerism by optimizing outcomes based driving...? - whatever)... or

3) developed an app that cures diabetes when you hold the iPhone against a person's forehead?

Have any of your overpaid consultants pointed out that....

1) you miraculously got a special insurance rider past the actuaries and finance people upstairs and, if others knew about it, it would make health insurance a lot better for persons with chronic illness, or

2) you need to counter those big boy competitors that are hogging all the limelight by cluttering the internet with press releases, e-mails, tweets, white papers and discussion-board chatter, or

3) no health care professional's life is complete without regularly checking out the Disease Management Care Blog?

Do any of the following pertain to you?

1) your evidence-based approach has been used by a government Medicaid program and the State Medical Director is very happy, or

2) you have outcomes results that have been validated using a contemporaneous propensity-matched and quasi-experimental design using age, gender and the number of Lady Gaga tunes on a person's iPod as variables, or

3) you have data that shows liberal use of a chrome-plated handgun to noisily fire some plugs into the ceiling is an effective means of engaging providers?

Alternatively, have you discovered that.....

1) your enrollees' use of terms such as 'like,' 'good' and 'want' speaks louder than anything published in the New England Journal of Medicine, or

2) you have a physician leader in your organization that is truly rare because he or she is only occasionally an insufferably obnoxious know-it-all, or

3) your marketing employees'/consultants'/partners' use of terms like 'robust,' 'groundbreaking,' 'evidence-based,' 'unparalleled' and 'unique' is an embarrassment to the industry?

Do you....

1) agree that an awards venue for you to showcase these and other talents at a national meeting that is attended by important policy makers, potential customers and widely read bloggers is a good thing, and

2) know that the DMAA awards committees make their choices regardless of a company's size or market penetration and

3) realize that those crystal trophy baubles would sure look good in a your reception area when potential customers come-a-calling?

That's why the DMCB is happy to let you know that if any of the above is true, you should compete for a DMAA Leadership Award.

Seriously, the awards are a great way to showcase you or your company's accomplishments in the increasingly crowded of population-based health care. While the application process is rigorous, your company is worth it. While you think about applying, you should also ponder the luster of an extra added bonus: if you win, it's highly likely that you or your company will be mentioned in a certain widely admired blog that has thousands of readers and would be a leading candidate for the Best Disease Management Blog Award if only the DMAA would see fit to offer it.

A good start is to check out the DMAA Leadership Awards' web site. The deadline is June 11, so you have plenty of time to familiarize yourself with the various categories and the nifty on-line submission process.

The Latest Health Wonk Review Is Up!

It's a metaphor and anniversary laden Health Wonk Review at David Harlow's Health Care Law Blog. Sharply written and with great commentary, this HWR has, er, hit one out of the park. And you thought the Great Leader's birthday and this focus on health reform was only a coincidence?

The Detritus of Physicians Copying and Pasting in the Electronic Health Record

"Detritus."

Not only was that a chance for the Disease Management Care Blog to refamiliarize itself with an underused noun (and, er, its spelling), that was the telling term used today by a DMCB colleague to describe the output from a local health system's electronic health record (EHR). He had received a copy of a lengthy consultant-physician's documentation involving one of his patients and was astonished by the blob of past data, prior notes, test results, excerpts, quotes, interpretations and correspondence that had been replicated word-for-word in the course of "seeing" his patient. The terse portions describing what the patient actually said, what the consulting doctor actually examined and what the diagnosis and plan were were inconspiculously buried toward the end of the EHR document.

This was a classic case of electronic record "CoPaGA" i.e., Copy 'n Paste Gone Amok Syndrome. Characterized by repeated highlighting, copying and pasting text from past EHR notes into current notes, the physician-victim attains several goals simultaneously: 1) avoiding the time-consuming work of having to talk to a human being, 2) building a long trail of documentation that portrays faux work effort and 3) justifying a maximally remunerative fee.

Other symptoms of CoPaGA are well described in the medical literature such as JAMA here in the Archives here. They include the crowd-out of useful information by gluts of useless data-text and the endless zombie-like propagation of inaccuracies that refuse to go away. The problem is significant enough that a methodology exists to measure just how severe it is. Last but not least, it's also important to recognize that the words "seeing" and "patients" in context of CoPaGA is a contradiction in terms, since afflicted docs typically spend little time actually looking at patients. They're too busy looking at the monitor!

Contrast this with these New England Journal authors' promise of EHRs preventing diagnositic errors through....

."..serving as a place where clinicians, together with patients, document succinct evaluations, craft thoughtful differential diagnoses, and note unanswered questions. Free-text narrative will often be superior to point-and-click boilerplate in accurately capturing a patient's history and making assessments, and notes should be designed to include discussion of uncertainties...." (italics DMCB).

Will the proposed 'meaningful use' HITECH regulations (which can be seen here) be able to combat CoPaGA and solve the problem of the substitution of input for insight by EHR addled physicians? That remains to be seen, but given the incurabilty of CoPaGA and the eternal nature of detritus (spelled with two t's), the DMCB thinks the prognosis is bleak.

We'll see.

questions

Have you ever blogged about the search for a bathing suit?

Are charcoal barbecues worse for our health and the environment than gas barbecues?

How do you organize your time and set priorities so that the most important things get done?

Did you watch Glee last night? Did you think that it wasn't as good as you remember?

How much do you need to spend on a bicycle if you plan to use it to boot around town, a few days a week from spring to late fall and you want it to last a really long time?

How do you take care of coloured hair when you swim regularly?

Also, I dreamed that my cat came back from the dead. Do you remember your dreams? What do you think this one meant?

Reports of the Death of Physician Private Practice Have Been Greatly Exaggerated

When it comes to the survivability of physician owned practices, is the Disease Management Care Blog being a naive, starry-eyed simpleton? After reading yesterday's DMCB linkfest, it'd be easy to think so.

Yet, the DMCB thinks it's being a contrarian realist about the 'death' of private practice and the rise of salaried physicians. Here's why.

At a past national meeting of the American College of Physicians, the DMCB ran into a elderly doc. Over libations, it mentioned how much things had changed for the worse. That wise doc disagreed. Things are always changing he said, and the profession and patients are better off for it.

That was 25 years ago.

The pace of change has increased, but the fact is that there are still plenty of smaller and physician-owned practices that also continue to adapt. The DMCB has run into these docs at countless meetings, seminars and meals. They are working very hard, are very cynical, are not happy with their current income levels compared to the past, but they're also far from walking away from their practices. The DMCB suspects the same is true in countless towns and cities across the U.S.

Anecdotes alone, however, don't tell the whole story. These 2008 data show the majority of U.S. physicians remain committed to their businesses and their patients and are not about to become salaried: 61% of docs are self-employed and only 21% work in "institutions." In fact, 59% work in settings with 9 or less physicians.

That being said, however, there is a trend away from physician owned practice settings that began decades ago. According to the AMA link above:

"....the proportion of patient care physicians who were owners fell from 75.8 percent to 57.7 percent between 1983 and 1994. Liebhaber and Grossman (2007) report a decline from 61.6 percent in 1996-1997 to 54.4 percent in 2004-2005 using data from the Center for Studying Health System Change’s Community Tracking Study Physician survey."

What accounts for this? Again, according to the AMA:

First, [younger] physicians tend to enter practice as employees. Also, older physicians ... started practice at a time when ownership was more common among all physicians regardless of age. Finally, the great influx of women into the profession of medicine over the past few decades also contributes to the observed age difference in ownership data.... Because women physicians are—at every age—more likely than men to be employees, this also drives the difference in ownership between the youngest and eldest age groups of physicians.

The DMCB interprets this to mean that while there's been a long term demographic trend away from small private practices, it's hardly been the wholesale stampede that's been portrayed in the media or apparently wished for by the Commonwealth Fund.

Last but not least, this downward trend could stablize to a new equilibrium. There are several reasons why:

1) the rise of the "concierge" private physician business model, where a hefty annual fee is charged in exchange for highly personalized care.

2) the persistent income gap between private practice and large academic group practices combined with opportunities for entrepreneurship.

3) the growth of larger yet still independent physician owned practices, especially in specialty areas.

4) the economic impact of the recently passed health reform legislation.

Based on these trends, it would appear the death of private practice has been greatly exaggerated.

The Decline of Small Physician Owned Practices Explained.... and a Prediction That Private Practice Will Hang In There

Are small physician-owned practices, along with Theodoric of York's long discredited leeching, cupping and poultices, destined to go extinct? Check out this article in the American Medical Association's AMNews, describing how private practice docs are selling out to joint ventures and agreeing to outright ownership. Or, according to the New York Times, they're becoming salaried employees of their local hospitals. And this article says the rest are just going to quit altogether.

It seems physicians are unable to make a business of tight-fisted insurers and debtor patients.

The Disease Management Care Blog agrees something is happening, but it thinks this picture is more complicated. Much like an impressionist painting, stand too close and you will miss the picture for the dots. The DMCB stands back and sees:

This Is a Stick-Up (and the Stick Is Getting Bigger): The reason physicians can be pushed around by increasingly dominant regional payers is that the insurers have even greater control of their markets, which is only destined to grow thanks to reform-powered mandates and subsidized premiums. In the meantime, consolidations have made hospitals more powerful, leaving physicians as the next best target for insurers' quality and cost-control efforts.

A Hostile Work Environment: Not only is it easy to blame them for quality shortcomings, physicians have to put up with the SGR monkeyshines, dreaded RAC audits and constant threats of litigation.

Throw In the Towel: The return on investment from a 7 to 9 year medical education is being battered by decreasing incomes with increasing debt, practice hassles, an unfavorable trade-off between life-style and hamster-wheel hustling, variable cash flows, and having to run the business like... a real business.

Bowling Alone: Organized medicine is struggling to maintain its allure. The DMCB thinks singled minded focus on reimbursement isn't helping. As a result, what's left of any physician community is fractured and unable to fight back with a coherent voice.

You Must Be Kidding: And spending $30K per doc on electronic health records will fix this? A lot of docs may be willing to take the incentive payments but have little doubt about what the impact will be on their practice environments.

As for the hospitals... the DMCB thinks that they, thanks to their consolidated market power (see above), are feeling quite bullish and want to grow their way out of their perenially thin margins. Plus, the warm after-glow of health reform has them hankering for capital. It's so good, even the dogs are looking like good investments.

Which is why more dots on the canvas are needed to see why hospitals view docs as bull market opportunities. They are more than happy to joint venture and hire or own more physician assets because:

The Best Defense Is a..... Not only do the existing revenue streams need to be protected, but new ones have to be developed. The means ever more services by ever more physicians.

Integrated Delivery System (IDS) Lust: Hospital administrators are not immune from succumbing to the fantastical visions from our national addiction to IDS Kool Aid. They dream that by getting their own critical mass of docs, they too can some day be invited from their new born IDS to another IDS to talk about how wonderful IDS' are!

A Rose By Any Other Name Smells As Sweet: Let's call it an ACO! If it includes the Patient Centered Medical Home, that's even more reason to bring the docs on board. Oh, never mind, the more physicians, the better, whatever you call it.

Never Mind the Not-for-Profit Status Either: Hey, they're running a business and they have bills to pay also. Don't like it? Well, they're probably also the biggest employer in your county and would be happy to hire even more people. That includes docs.

Those Who Read About the Past Are Condemned to Repeat It: The DMCB suspects the current crop of hospitals execs have forgotten the '80's Physician-Hospital-Organization (PHO) debacles. While some PHOs succeeded in managing episodes of care, most were unable to achieve the most important part of making this work: cost-effective utilization.

All of which leads to a DMCB Prediction:

Despite the dire circumstances, there are still plenty of practices out there that are and will continue to be profitable. They are owned by savvy, hard working and entrepreneurial physicians that know how to manage overhead, maximize cash flows, hire the right kind of office help, keep their customers satisfied, document things to satisfy any audit, vigorously defend against any allegation of malpractice, show their unsatisfied customers to the door, work with their local medical society, handle bad debt, minimize the percent of Medicaid in the practice, aggressively refuse to be pushed around by insurers and, most importantly, keep the local hospital at arms length. While the Wal-Marts and Kaiser Permanentes are currently in the ascendancy, there will always be smaller and moderate size businesses in their shadow who can profitably service a sizable market segment. They won't go away and many will thrive. What's more, some of the reborn PHOs-ACOs will struggle and the bloom will come of the rose of physician-hospital integration. The only question is where the market will equilibrate over the short term. It will not be 0% private practice.

As for over the long term, who knows? That will be the topic of a future post (which is here) .... and maybe a different allegory.

(There's lots more on Accountable Care Organizations here)

More on Back Surgery Rates and What Physicians Can Do To Support Health Reform

Regular Disease Management Care Blog readers may recall two recent posts here and here on a) physician involvement in health care ('not enough,' sniffed the DMCB) and b) lumbar stenosis ('not as bad as the media would have you think,' opined the DMCB).

Thank goodness for careful readers like c3, who has provided some insightful responses on each posting. Rather than file them away on the "Comments" section, the DCMB thought they deserved more attention and is copying them here.

Recall that the lumbar surgery posting was about a freshly minted JAMA article that found that while the overall rate of back surgeries among Medicare beneficiaries was unchanged, the relative proportion of complex and expensive surgery had increased. The authors concluded that this was an example of profits being put before patients. The DMCB was less sure about that and pointed out that there may be some sources of research bias.

c3 also looked at the article and pointed out.......

The confidence interval, EXCEPT FOR COST (and rehospitalization in 30 days), for most complications generally overlapped (Readers can look at the data table here)

All of the surgeries (CPT codes) are covered by Medicare. And since Medicare doesn't do prior auth, its all a moot point.

It sure would have been nice to know the "positive outcomes" (i.e. improvement in pain and/or function). If there was no difference then why would we pay more for more risk and no additional benefit?

The DMCB totally agrees.

Even though the confidence intervals for overlapped, the authors based their conclusions on p values. This is outside the DMCB's statistical expertise, but suspects this has something to do with non-normal distributions involving odds ratios. That being said, the conclusion that the complication rates for more complex surgery are lower may be not quite correct.

Readers may recall that 'prior auth' (or 'authorization') is the "1-800-mother-may-I" style of managed care. This requires doctors to call ahead of time to get approval for a treatment, otherwise it won't be paid for. While c3 is correct that Medicare fee-for-service doesn't "do" prior auth, the DMCB isn't sure if that will always be true.

And last but not least, until we can understand the link between complex back surgery and patient centered outcomes (less pain, greater mobility), all we can do is guess about the likelihood that taxpayers are getting their money's worth. Unfortunately, it doesn't look like this is a priority topic for Comparative Effectiveness Research.

As for the other DMCB posting on what docs can do to improve the health care system, c3 turns to the same seven point system used in the article and provides additional commentary:

1) Work Daily to Provide High Quality Care

But be prepared to prove it

2) Control Costs

At its core no business is in the business of reducing revenue. As much as I'd like docs to always be pre-disposed to save the system $$ I know they're not inclined to do so. However, if they provided pricing transparency and the patients had a financial stake in the game, that would make difference.

3) Improve Communication

Amen. But EHR's need to talk to each other. And we still haven't mastered the management of so much more info

4) Become Involved Locally

A nice sentiment but it feels pretty mom and apple pie

5) Help Implement Creative Payment Reform Solutions

As physicians consume 25% of every health care dollar (not to mention much of the 31% that hospitals consume) I think the "creative solution" is to make less (or better yet shift from costly specialists to less costly PCP's)

6) Talk About Reform With Patients

In one sense noble; in another sense creepy. It sounds kind of like "patients need to understand!". If patient have more "skin in the game" they will quickly understand the need for reform. What did LBJ say "When you have them by the b**ls, their hearts and minds will soon follow"

7) Minimize Conflicts of Interest

Again, people don't naturally reduce their income so this seems more like a system change than an individual physician change.

I do agree with your overall sentiment that physicians needed a better "system-sense" but that's a long term training issue

All good points. Thanks c3.

how it's done

Everyone makes mistakes. And sometimes things go wrong that are not anyone's fault but someone has to take responsibility for making things right.

Over the last couple of years, I have come to realize that this is a deeply held value of mine, one I am trying to share with my kids. Mistakes don't necessarily make me angry but I can get royally pissed off profoundly annoyed when anyone - adult or child - tries to shirk responsibility. On the other hand, when people step up, acknowledge their mistakes and make a genuine effort to make things right, my resentment tends to evaporate entirely.

Some examples:

1. A few weeks ago, a received a notice from the Ottawa Public Library that a digital book I had ordered was ready for download. The same day, the library's new web site went live. When I tried to download my book - one I had requested months before - I found that all my requests had been deleted from the library site.

I was extremely disappointed. I immediately (and without much hope) sent an email to the library's tech department. The next day (a Saturday), I received an email informing me that they were aware of the problem and attempting to fix it. I was impressed with the rapid response.

The following Monday, I was sent another email explaining what had happened and that the problem had been fixed and informing me that I would be put to the top of the list for this book.

I was thrilled.

2. Last week end, my family ordered takeout from the Foolish Chicken. We have eaten there many times. Every experience has been extremely positive. This time, however, there was a mistake with our order.

We had ordered a ceasar salad with our family meal. When T. went to pick it up, he was asked if ours was the order with the ceasar salad and had confirmed. When we opened the boxes at home, though, we had a green salad.

I was tempted to let it go (the salad looked just fine to me) but S. had really wanted a ceasar salad, so I called the restaurant. My call was immediately transferred to the owner. He apologized profusely, explained what had happened (an order that was virtually identical - but for the salads - had gone out at the same time) and said that if T. were willing to come back and get the right salad, he would throw in some free dessert.

We were thrilled.

3. As I wrote in yesterday's post, I have asked for and received permission to cancel my chemo and herceptin treatments for April. However, when I arrived at the cancer centre last week, I discovered that my treatment for March had inadvertently been cancelled as well.

I went ahead with my bloodwork while staff attempted to figure out what had happened. Each person with whom I spoke (the staff on reception and the nurse who was trying to contact my doctor) made me feel as though they were working hard to get things sorted. A short while later, the woman who does the chemo bookings (someone I know to be extremely competent and accommodating) came to find me in the waiting room. She admitted, in front of a room full of people, that the mistake had been hers and that she had corrected it.

I was both relieved and impressed.

4. When I had my treatment that afternoon, the nurse administered the vinorelbine (the chemo drug, known in the US as Navelbine) right after the Demerol and Gravol (US readers know this as Dramamine). I promptly fell asleep. I woke up more than an hour later, thinking it would soon be time to go home.

Then the nurse came to hang my Herceptin, which takes ninety minutes.

Since the vino only takes ten minutes, I wanted to know what had been happening while I was sleeping. The nurse (not the same one who'd set up the vino) just shrugged and looked at me like she didn't understand the question.

I was too stoned and tired to push matters but I'm pretty sure that they'd just forgotten about me for a while. No one tried to explain or apologize and I was inordinately annoyed.

Mistakes happen. How we deal with our mistakes is what matters.