Sangry* About Healthcare

Feb 11 2012 Published by under Uncategorized, [Medicine&Pharma]

Many comfortably middle class folks I meet view the uninsured as a great mass of people making bad choices, ignoring their personal responsibilities. Many of them do not believe that anyone they know would be uninsured.

If you fit in that group that that assumes "people like me" have healthcare, you must read Kevin Zelnio's post about his son's recent bout of pneumonia. See, Kevin recently started his own business as a writer and consultant. We keep hearing about small business being the the lifeblood of our economy, and every business starts out as one person trying to make something happen. When you first begin, insurance is an insurmountable expense. You need to put bucks back into the business and (gasp) pay for food and shelter. You have no bargaining power for insurance rates. I have met several entrepreneurs over the years, and all of them have gone uninsured for at least a year (unless they had a spouse with employment-based insurance).

Image from Kevin's son (Click for original)

Kevin shares with the world the gut-wrenching fear of having a critically-ill child while recognizing that a hospital admission could wreak financial havoc for years. He also pulls in the statistics for the uninsured in the United States, illustrating what a wide-spread problem this is. Please read his post now, if you have not; I will wait.

The details and names and locations change, but I hear this same story a lot. In some ways, Kevin is lucky; his son suffered a single acute illness. Most of the families I see must deal with a chronic disease, one that will be ongoing, perhaps forever. In a few weeks or months, Kevin will receive a final bill and know his debt. The number may be astronomical, but it will be finite. If the diagnosis is cancer or asthma or kidney failure, the expenses keep piling up.

Some politicians suggest that charitable impulses will take care of these issues. As a pediatric subspecialist I have donated my care before. However, even if all the doctors and nurses and technicians involved with a patient agree to donate their services, there are still enormous expenses. The hospital must pay for supplies and utilities and documentation. Part of your stay pays for the custodian in the hallway and the folks who change the lightbulbs. They may not touch the patient, and their part cannot be assigned to any particular patient, but without them the hospital could not function. If one patient cannot pay, then those costs must be borne by those who do. Part of the inflated cost of care in this country comes from spreading out uncovered costs this way.

One of the big triumphs of Obamacare thus far is a mandate for dependent child coverage, with no exclusions for preexisting conditions. Before that, I saw families who wanted to buy insurance but could not. One child with a chronic illness excluded them from family coverage; the company would not create a package for two parents and all-but-one-child. See, children are supposed to be cheap for the insurance company. Yes, they get shots and have some illnesses, but major pediatric health problems are pretty damn rare. Create special family plans that exclude one child? "We can't do that."

So what's a family to do? In the current insurance climate, major illnesses cause most personal bankruptcy in the US (at least before the housing bubble burst).  Some families divorce, because the mother and children then become eligible for Medicaid if mom doesn't work - and yes, I have seen mothers quit jobs to get coverage for their children.

The US really does not have a system of healthcare or coverage. We have a patchwork of solutions that have popped up over time, much as our electric grid grew. Obamacare (I do not consider this a derogatory term) provides a step in the right direction; by making all healthy people buy coverage, we spread the costs out and make insurance less expensive. Exchanges should grant collective bargaining clout to the self-employed, so they can negotiate the better rates of larger businesses.

We have a long way to go, but it's a journey we must take. No one should have to break up a marriage to get healthcare for their child. No one should have to choose between bankruptcy or their child's life.

*Sangry = Sad + Angry

If you wish to contribute to a fund for Kevin's son's hospitalization, please click here.

Also, as Scicurious writes, contact your congresscritter about this issue.

 

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Competing Forces in Medical Care

Dec 01 2011 Published by under Life of a Physician

My November travels took me to the Scientific Sessions for the American Society of Nephrology, a huge gathering of we kidney specialists. As I enjoyed an adult beverage with colleagues from across the country, we began comparing notes about our clinical services. We all hear that we fail to see enough patients!

So how do we determine "enough" for physicians? In private practice you fill your clinics. When the load overwhelms the group, a new doctor can be hired. In academia, where our jobs include teaching, research, and administration, the standard is more difficult to determine. One tactic involves Relative Value Units (RVUs) for physician work.

When you see your doctor, s/he bills a level of service that translates to the amount of reimbursement. That level of service can be translated into the sum of several RVUs for Physician Work, Practice Expense, and Professional Liability. The monetary value of each of these gets adjusted by region, and the final value factor varies over time and by payor. (More on Medicare and RVUs can be found here.) Productivity benchmarks for each specialty are generated annually (Medical Group Management Association, for example, publishes standards). Most academic departments expect a full-time clinician-teacher to generate physician work RVUs at the 75th percentile. Roughly one-quarter of a physician's time will be taken up with trainees. The percentile can be adjusted by job expectations in other ways. Someone with 75% of their time protected for research should only be expected to generate one-quarter of the 75th percentile under this model.

So the bean-counters in our departments look at our numbers and tell us we aren't meeting national standards, but none of us know who they are auditing to determine these numbers! Unlike in adults, pediatric kidney disease has a relatively stable prevalence in the population. Many of us exist in sections that provide the only service in our specialty for a state or multi-state region, so we do not have competition from whom to "steal" patients.

So where do we get these additional patients?

Some centers develop new services. Kidney doctors run blood through filters all the time. Buy a machine with a different filter and we can do plasmapheresis. Of course, that means someone else in our center no longer does those patients; this approach is often a zero-sum game. No, the answer much of the time would be to see patients we might otherwise not see.

For example, asymptomatic microscopic hematuria (blood in the urine not visible to the naked eye) is a common pediatric problem. The typical work-up involves a number of tests. If normal, we just watch blood, urine, and blood pressure over time. Primary care physicians could handle this condition with phone support from us. At this time, our inclination is to see all patients referred to us, rather than doing this level of triage for which we receive no RVUs and no payment.

We have two competing forces here. One involves running our clinics like a business, with carrots and sticks for meeting productivity standards and bringing in the bucks. However, this occurs at a time when there should be even more pressure to avoid unnecessary visits to specialists to keep everyone's costs down - but there is no financial incentive for that.

I do not have an answer. Clearly, current capitalist forces are not going to fix our "system."

 

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Where Am I Going?

Nov 21 2011 Published by under [Information&Communication]

A few weeks ago I found an app called Point Inside Maps. This amazing app uses the GPS in iPhones or Android devices and maps of shopping malls and airports to help navigate people around these large, confusing structures. You can follow your progress as a little blue dot in the building. You know quickly if you make a wrong turn.

Point Inside Airport Map

Today was my first day on the inpatient service for my new position. As I wandered about, trying to remember where I came from and where I was going, I wondered why Point Inside hasn't been brought to large medical centers. As major hospitals expand and add buildings, they become far more challenging to navigate than any airport or mall I have ever visited.

True, malls and airports have consumer appeal, and teaming up with the app-maker can make money. Medical centers make money without such endeavors.

Given the number of folks that get lost on our campus, Point Inside for medical centers could be a welcome development.

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Career Advice: Starting with a WhizBANG!

Oct 25 2011 Published by under [Education&Careers]

Have you decided that a tenure tract position at an academic medical center is for you? How does one begin the quest for assistant professordom, especially with a clinical background? What do you need besides an interview-suit?

Must start blogging in a cloud of tulle and peacock feathers (Image courtesy of PhotoXpress)

Yours truly addresses these issues over at BioCareers. This article is the first in a series on academic medical-science job issues they have asked me to write.

The site includes a number of blog posts from those of us in, well, careers in the biological sciences. They also have job boards, and several Major Research Universities have integrated BioCareers into their own websites. It looks like a great resource for students exploring career paths, and I am delighted to be a contributor.

By the way, no one is paying me to write or promote the site. I am participating because:

  1. The site looks useful
  2. I love to write
  3. I enjoy the ego-boost of being a contributor.

So click on over to BioCareers. Click here to go directly to my post.

 

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When Evidence Based Medicine Can't Happen

Oct 04 2011 Published by under Evidence Based Medicine

Today I reviewed a review article over at Stream of Thought that considers current treatment of IgA nephropathy (IgAN), one of the most common glomerular diseases in the world. Despite being common, most studies of its treatment are retrospective, anecdotal, or small. When the KDIGO group releases its report on glomerulonephritis later this year, most of what it reports for IgAN will not reach the level of "recommendation" because the evidence supporting it is so weak. Most treatments will be "suggestions" based on expert opinion.

The process that KDIGO uses to evaluate evidence is explained here. Two major groups participate: world leaders in the condition at hand (the working group or WG) and a separate professional evidence review team (ERT, practitioners of statistical black magic). The WG takes the output of the ERT and makes recommendations or suggestions in support of various treatments; public commentary occurs during the process as well.

I will not repeat the treatment algorithm for IgAN here at WhizBANG! (you can click over and read the other post). This article and post demonstrate the uncertainty that physicians deal with daily: how do you treat a patient when there is little or no evidence of what you should do?

For kidney diseases, a number of nonspecific treatments can generally be pursued. If the blood pressure is high, we make it normal, usually by inhibiting angiotensin II. If a study ever shows that this is bad for a kidney disorder, I won't believe it. If the patient has protein in the urine, lowering it is good. If cholesterol and other plasma lipids are increased, fix them. Encourage the patient to be active, maintain normal body weight, and avoid tobacco products.

There is value in expert opinion based on anecdotes and case reports as well. We have to have a starting point for valid clinical trials. Some prospective trials in IgAN may suggest "recommended" treatments in the next 4 to 5 years, in part because they expanded on smaller, less rigorous studies. However, telling a patient to wait 5 years for evidence before beginning treatment is impractical. Published guidelines help us choose a rational approach while we wait for evidence.

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Screening for Disease: A Primer

Sep 13 2011 Published by under General Health, [Medicine&Pharma]

Yesterday I reviewed a paper that raised the question of screening urinalysis for adolescents and young adults, showing that asymptomatic isolated hematuria (blood in the urine) indicated almost 20-fold increased risk for development of end-stage kidney failure over twenty years. Does this alone make this a good screening test?

The best discussion I found on screening for disease is a PDF from the National Institute of Occupational Safety and Health (NIOSH) regarding mining-associated lung disorders. A screening test must:

  • Have acceptable sensitivity, specificity, and predictive value
  • Be valid and reliable
  • Be able to identify disease early and lead to treatment that impedes disease progression

So we want a test that is sensitive. This means that it will identify affected individuals at a high rate (essentially 100%), producing very few false negative results (subjects have the condition but test negative). Specificity, or a test that produces few false positives (subjects do not have the condition but test positive), is also nice; however, since we are screening an at risk population who will be subjected to confirmatory tests, it is usually more important to make sure we have no false negatives.

Valid and reliable seem to speak for themselves.

The third point sparks discussion. What if our screening tests do not identify a treatable disorder? Or if treatment can be administered, what if it makes no difference in survival or quality of life? Mass screenings under those conditions make little sense.

Two other points from the NIOSH PDF fall into this same general area:

  • Adequate follow-up, further diagnostic tests, and effective management of the disease must be available, accessible, and acceptable
  • Benefits of the screening program must outweigh the costs

Most patients who screen positive for something must then undergo further confirmatory tests. The purpose of screening is to identify all affected individuals; some false positives can be acceptable in a screening test. Screening for a disorder for which there is no treatment available seems cruel, unless there are other benefits. Knowing one had HIV could prevent spread of the disease, even before we had anti-retroviral therapies.

Finally the benefits of screening must outweigh the costs. All costs, not just the monetary ones, must be considered. The brouhaha over annual mammograms a few years back addressed not just the monetary costs of breast biopsy for false-positive lesions, but the pain, psychological distress, lost wages, and other human costs of those tests.

A screening test ultimately must identify affected individuals who would benefit from early (asymptomatic) detection and treatment of a condition. As in everything in medicine, benefits must outweigh risks and costs. Sometimes the answer is clear (determining maternal Rh blood type early in pregnancy); other times, as with screening UAs, it is not.

 

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Fashionable Medications

Jul 07 2011 Published by under Pharmaceuticals

Image courtesy of PhotoXpress.com

The July 7 issue of New England Journal of Medicine includes an article on Trade Dress of medications, something I never gave much thought. Greene and Kesselheim discuss the concept in their article, Why Do the Same Drugs Look Different? Why do companies go to the expense of coloring their pills?

Trade dress refers to nonfunctional properties of preparations that could lead to confusion if imitated. In addition, the property must have a secondary association with the product. One example in the paper is the Coca-Cola bottle. Its unique shape does not affect the formulation or flavor of the beverage, but it is strongly associated with the drink. If a similar cola were packaged in a similar bottle, consumers could be deceived into buying an imitator.

Originally trade dress received protection to protect consumers. They would be able to tell if a substitution had been made in a drug, either for a generic or a similar but not-the-same agent (so-called palming off by pharmacies). Trade dress is serious business; Viagra will lose its patent, but "the little blue pill" is protected by law forever. Will generic sildenafil also be blue? It's hard to know; in the 1950's the "soothing" pink color of Pepto-Bismol was declared to provide "therapeutic value" so was not protected as trade dress!

So why is protection of trade dress potentially harmful? First, as patents expire, a number of bio-equivalent generic preparations become available. As pharmacies negotiate for better prices, the supplier and the appearance of the drug may change over time. The article illustrates four drastically different generic forms of the drug commonly known as Prozac. Having a drug change its appearance could confuse patients, perhaps leading to issues with treatment adherence.

Synthroid

Standardization of colorization and packaging could also improve patient care. For example, Synthroid (the major brand of thyroid hormone) cleverly colored each dose differently (see figure). Instead of remembering the size of the pill, patients could relate the color to confirm their dose. Exploring a couple of web sites reveals that generics also color code their doses to roughly the same shade as the Abbott product, but shapes vary.

The authors also cite an effort in the United Kingdom to standardize color of asthma inhalers. All bronchodilators became blue, while steroids were colored brown, orange, or burgundy. Patients could then be told to use the blue unit for acute attacks, and to take the other colors on a regular schedule.

Since the 1970's federal law has provided regulation of generic drug production and assurance, for the most part, of bio-equivalence with brand name pharmaceuticals. Some degree of standardization of appearance may help patients adhere to treatment plans, especially as chronic diseases requiring long-term use of multiple medications dominate the practice of medicine.

The article addresses an important but overlooked issue in the care of patients. Click on over and read the whole thing. The authors make a strong argument for legislation to promote standardization of drug appearance as well as activity.

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Is Volume Toxic? Part 2

Jul 06 2011 Published by under Journal Club

Over at the blogspot place in May 2010 I reviewed an article for journal club showing that children requiring continuous renal replacement therapy did worse with greater volume overload at the start of therapy. Query: Is saline toxic?

The current New England Journal of Medicine reports a trial of children in Africa who presented with a febrile illness and impaired perfusion who were randomized to first receive a bolus of saline or albumin or to proceed directly to maintenance fluid therapy. Bolus therapy is given to rapidly restore circulating volume. Children with hypotension (low blood pressure) were assigned to either bolus group, but not the maintenance fluid group. Children with gastroenteritis were excluded from the study; 57% of participants had malaria. The primary endpoint was 48 hour mortality, with secondary endpoints including pulmonary edema; increased intracranial pressure; 4 week mortality; or 4 week neurologic sequelae.

The trial stopped ~500 patients before the initial estimated enrollment on the advice of the Data and Safety Monitoring Board (DSMB). In stratum A (patients with impaired perfusion but without frank hypotension) bolus therapy of either type increased 48 hour mortality (Relative risk 1.45; 95% confidence interval, 1.13 to 1.86; p=0.003) and mortality at 4 weeks (12% vs. 8.7%; p=0.004). No other secondary endpoints showed any differences. Stratum B (patients with frank hypotension) included only 29 patients, and no difference between albumin (69% mortality) and saline (56% mortality; p=0.45) was demonstrated.

Impaired perfusion can be diagnosed by physical exam. Prolonged capillary refill time (after skin compression, blanching should resolve in 2-3 seconds; see figure) provides the most common assessment of this state, although cyanotic extremities may also be a sign. In the presence of normal blood pressure, bolus therapy appears to be contraindicated in children with these signs, although generalizing the findings from this study of children primarily affected by malaria may not be valid to children in countries such as the US where the underlying conditions may be different.

Other questions arise. First, do boluses help children with frank hypotension? Perhaps they might do better with pressors rather than volume expansion? What about children with gastrointestinal volume losses, a common cause of shock? A recent Clinical Pathological Conference from NEJM demonstrated the apparent benefits of intravenous fluid boluses in a child with cholera. Are these benefits real for children with all gastrointestinal illnesses?

Volume expansion, with saline or colloid, has been a mainstay of therapy for as long as I can remember. Restoration of circulating volume has a place; however, in other cases, additional volume could be toxic. Further studies are needed to define the risk:benefit ratio and conditions of fluid resuscitation.

Performing these studies in the US may be extremely difficult. First, getting informed consent for critically ill children can be fraught with difficulty, especially when one might get randomized to nonstandard care. Do I want to take that chance with my child's life on the line? For a condition like infant diarrhea that is far less likely to lead to death in this country than in Africa?

I am afraid that the initial exploration of these questions will have to happen in other countries with fewer resources and laxer protection of research subjects. Perhaps once we have more information we can perform a meaningful study in a "first-world" country.

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Unkind But Not Illegal Behavior

Jun 16 2011 Published by under [Medicine&Pharma]

 

From today's New England Journal of Medicine:

 

Auditing Access to Specialty Care for Children with Public Insurance by Joanna Bisgaier, M.S.W., and Karin V. Rhodes, M.D from University of Pennsylvania

This study examined barriers to specialty care for children with public health insurance, both Medicaid and Children's Health Insurance Program (CHIP). They studied Cook County, IL, the second most populous county in the US, and had trained graduate students posing as mothers make phone calls to clinics to schedule new specialist appointments for the following patients:

Click to enlarge

They selected specialists that see children using the following sampling method:

We constructed an exhaustive list of providers, using state-provided physician-licensure data, cross-referenced with lists of physicians submitting specialty claims for children in Cook County and lists of specialists provided by children’s hospitals and the American Academy of Pediatrics. The final sample included all specialists for whom there was any evidence that they provided care to children (0 to 18 years of age) residing in Cook County. Because several specialists may practice at the same clinic and some specialists practice at several clinics, we did not sample providers; rather, we sampled clinics, defined by unique (unduplicated) telephone numbers used for scheduling appointments. Random samples of 40 clinics per health-condition scenario were stratified according to two key variables (provider licensure reporting acceptance vs. nonacceptance of Medicaid–CHIP and urban vs. suburban location) with the use of a computer algorithm. During the study, physicians’ licensure data regarding Medicaid–CHIP acceptance were not publicly available.

No data is reported on the nature of these clinics. Were the doctors pediatric sub-specialists, or adult specialists who were willing to see children? Were these private practice offices, or were they satellites of an academic center or children's hospital? The latter are more likely to be staffed by us pesky pediatric subspecialists. Unfortunately, the investigators did not plan or power their study to address these differences.

At any rate, the study found that children with public insurance were less likely to have an appointment scheduled (I don't believe you will have trouble figuring out which bar is which):

 

Click to enlarge

 

 

Waiting times for appointments were also longer with public insurance:

 

Click to enlarge

Expansion of Medicaid-CHIP programs were promoted to increase access of poor children to high-quality medical care, and they do allow these children to be seen by specialists eventually. However, choices in specialty care may be limited, and waiting times may be longer, in part because there are fewer providers taking that insurance.

Click to enlarge

 

 

The first tweet I saw this morning regarding this article suggested that something about these practices was illegal; however, as far as I can tell, it is not.

In our capitalist healthcare system, no practice can be forced to take on every payor, especially those that reimburse at much lower rates.

The authors point out that Illinois Medicaid reimburses ~$100 for a visit for which Blue Cross Blue Shield pays $160. When my department discusses ways to increase our revenue, improving payor mix always comes up. However, for us subspecialists, the kids on Medicaid -CHIP use our services at a higher rate than their suburban counterparts. That I cannot change.

I do not believe my own nephrology group has a problem with this issue. We do ask about insurance during the intake, mostly to figure out what sort of precertification hoops must be jumped since our kids often need laboratory and imaging studies with their appointments. As the only two practitioners in our specialty for a multi-state region, we see them all; delaying appointments just would not matter in the long-run.

The authors correctly conclude that there is a discrepancy in specialty care for these children. They discuss issues to consider, but they do not address the most obvious way to eliminate these disparities, a single-payor system.

Of course not; that would be socialist, even if it would be more fair.

 

 

 

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Prescription for Profit

May 27 2011 Published by under MedicoLegal Concerns

The May 26 New England Journal of Medicine includes an editorial on Prescriptions, Privacy, and the First Amendment. The free full-text article discusses a recent Supreme Court case about data mining in Vermont, specifically the practice of selling information about individual physician's prescribing practices to drug companies  for targeted detail visits:

This is the way it works: Retail pharmacies retain information about all drug prescriptions that they fill, including the patient’s name, the identification of the prescriber, the name, dosage, and quantity of the prescribed drug, and the date the prescription was filled. This information is collected, along with the patient’s age, sex, and drug history, and sold, with the individual prescribing doctors identified but the patient’s names encrypted, to data-mining companies (IMS Health is one such company). The data-mining companies then further process the information by collating each physician’s prescribing history for each patient, and they sell it to pharmaceutical companies. The prescribing information of individual doctors can be linked to the Physician Masterfile of the American Medical Association (AMA), thereby enriching the data on prescribing physicians (the Masterfile, which is sold by the AMA, includes information on every physician’s education, licensure, certification, hospital privileges, and practice details). The companies’ marketing departments use the information to develop strategies to sell drugs to individual doctors, and the schemes are applied by pharmaceutical sales representatives (“detailers”) to make pitches to the doctors in their offices. These solicitations are not intended to communicate evidence-based information to doctors; they are intended to sell expensive drugs.

It is a very successful business. When drug detailers have the prescribing history of the physicians they are visiting, they sell more drugs. This is one of the principal reasons why the Pharmaceutical Research and Manufacturers of America (PhRMA), the trade organization of the pharmaceutical industry, joined the data miners as a party to the lawsuit. It is quite clear who profits from the sale of the prescribing information: retail pharmacies, data-mining companies, drug companies, and the AMA. In the end, the costs are passed along to patients, and physicians’ prescribing practices are manipulated by drug salespeople who know the details of their interactions with their patients.

Personally, I find this practice abhorrent. Until this lawsuit, I did not realize that my information could be sold in  this manner. Being one of the more than 80% of physicians who has not joined the AMA, I was also unaware that I could opt out of the use of my prescribing data by salespeople, although I cannot prevent the sale of my data to drug companies via this mechanism. The opt-out site has been minimally effective (<3% of prescribing physicians), in part because so few belong to the AMA and because this service is not exactly front and center on their web site.

Click for source

If you are a physician reading this post, you can opt out by clicking here.

Vermont tried to make the sale of data to the mining companies an opt-in requirement; only if you allowed it would your individual data be shared. The fact that data-mining companies and PhRMA have paid lawyers to take this all the way to the Supreme Court tells me something:

Those data are worth a lot of money.

So what is the legal argument here?

At issue in this important case is the conflict between the privacy of physician-identified drug- prescribing information and the First Amendment right of a business to communicate about its products (“commercial speech”). In contrast to public discourse, which is protected by the First Amendment as a fundamental part of the democratic process, protection of commercial speech under the First Amendment is a relatively recent development in the law. According to the Supreme Court, government regulation of commercial speech must directly promote a substantial governmental interest and must be no more extensive than necessary to meet that interest.

The law in question does not prevent drug companies from advertising the hell out of their products in any way. It will prevent drug companies from using individual physician prescribing habits to tailor a marketing campaign for an individual physician. An opt-in program will produce less data from which the mining companies and the AMA may profit. Given the role of the government in financing and regulating so much about healthcare in the US, the government has a compelling interest in speech that increases healthcare costs - as this sort of data-mining certainly must - or influences the health of the nation.

It will be interesting to see how the Supremes come down on this case. I fear the same group that gave corporations the same protections for political donations as individuals will not see the logic in Vermont's law. Be sure and read the NEJM article in full; the authors make the point in more detail and with greater eloquence and expertise than I can.

In the meantime, let's all opt out of the scheme via the AMA's little-known site. It's the least we physicians can do.

 

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