Monday, February 11, 2008

Aetna, Colonoscopy, and Money

I suspect that there is much more to Aetna's recent decision (pdf) to stop paying for Propofol for all (exceptions exist) colonoscopies than either Propofol or colonoscopies. At first glance it just look like they're trying to save themselves the additional cost the anesthetist or anesthesiologist that is needed if endoscopists want their patients to receive propofol adds. But I think there's more to it than that.

Let me state at the outset that my practice does not derive significant income from providing anesthesia for colonoscopies. The vast majority of colonoscopies done with propofol use RN's with anesthesia training (CRNA's) to provide the service. I point this out because it seems that having any financial involvement at all is cause for discounting ones opinion--it should not be, but it is.

Using propofol allows colonoscopies to be done without patient awareness of discomfort, true, but the real advantage is that patients recover from the drug fast. By way of example, if a colonoscopy is done the 'old fashioned way' using the sedative midazolam and the narcotic demerol or fentanyl, the patient will likely need to remain in the center for one to two hours before they meet discharge criteria (assuming they don't have any nausea). Propofol allows them to go home in about 30-45 minutes. Roughly twice as fast from completion of colonoscopy to discharge. That means they occupy a recovery bed for less time and that's the limiting step for many centers. Once all the recovery beds are full, you can't do any more procedures until one opens up. Being able to quickly discharge patients after their exam allows much greater throughput in terms of exams per day that can be done .

Here is where I think the policy change will have its real effect. Either endoscopy centers will continue to provide the option of propofol sedation but charge the patient for it (in which case the insurance company will pay less), will provide it as part of the facility fee as a way to compete more effectively for patients (in which case the insurance company will pay less), or centers will go back (and I do mean back) to using older drugs but sacrifice throughput (in which case the insurance company will pay less).

Is having a colonoscopy easier with propofol? Don't take my word for it. Ask any endoscopy nurse which way he or she would prefer having a colonoscopy done.

Aside from cost and cost savings there's the issue of who decides what appropriate care is. If insurance companies are allowed to dictate who can and cannot get a certain kind of anesthesia, what will they do next? Get rid of anesthesia payments for cataract surgery? How about for trigger finger releases and carpal tunnel surgery. Vasectomy? See where I'm going with this?

Saturday, February 2, 2008

iPods and Pacemakers

iPods and Pacemakers: "

(Via Medgadget.)

Good summary on BIS

Is there a consensus concerning the routine use of BIS monitoring during general anesthesia?

Wednesday, January 30, 2008

My MacBook Air shipped!

Shipment Date: Jan 30, 2008
Delivers by: Feb 04, 2008 "

Sunday, January 20, 2008

George Carlin, 'A Place For Your Stuff', and the MacBook Air

My uber-cool sister-in-law gave me the George Carlin Reads To You boxed set. George Carlin's "A Place For Your Stuff" exactly summarizes my dilemma about how to keep my computer 'stuff' handy. Thanks to Apple, 'there's all different ways of carrying your stuff.' Let me explain.

All my 'stuff' is on my 24" Core2Duo iMac. That stuff is automatically copied every hour to an external hard drive via Time Machine so my stuff is safe from a computer hard disk problem. My really important stuff is backed up online using dotMac. Every night at 2 in the morning. Really.

I want to take some of my stuff with me wherever I go. I use my 60 GB video iPod to carry stuff around on but I need to plug it in to another Mac to see my stuff and, let's face it, there aren't a lot of Macs around in the workplace. Right now I use my iPhone to carry important stuff, but there's lots of stuff I can't carry on my iPhone, like the article on how to use Google Reader that I'm working on, or the PDF files I'd like to read.

Going from my iMac to the outside world means I have to leave a lot of stuff behind.....until now. Thanks to the MacBook Air I can now take most of my important stuff with me and it will only weigh three pounds!

Saturday, January 19, 2008

OpenID for Non-SuperUsers

OpenID for Non-SuperUsers

Tuesday, January 15, 2008

MacBook Air

MACBOOK AIR 13/1.6/2GB/80GB-USA  MB003LL/A $1,799.00

Ships by: Feb 6
Delivers by: Feb 11

Thursday, January 10, 2008

16,707 SPAM E-mails In One Month

My group uses Google Apps for Your Domain for one of our domain names. That particular domain had been compromised before it went to GAFYD. A trojan had infected an unprotected office PC and harvested our addresses.

I logged in to the account for the first time in a month today. In one month, Google's SPAM filters blocked 16,707 spams from getting to our inboxes. Thanks, Google.

Tuesday, January 1, 2008

My Predictions for Apple's New Laptop--3G Wireless

The one feature for Apple's new laptop that no one has mentioned but that I'm hoping for is the option to add a 3G wireless card. Give me a 3 pound, 13", solid state memory, 12 hour battery life (or even 8) laptop that is connected anywhere ATT has 3G wireless and I'd pay a premium to get one.

Monday, December 31, 2007

Clark Venable, M.D.

Lifehacker suggested setting up a nameplate site way back in February of 2006. This post is my attempt to get Google to index it:

Friday, December 28, 2007

Pay For Performance: Physicians Pay For Insurers Better Financial Performance?

I've always been suspicious of the pay for performance movement. Thinking cynically (which I do more and more these days), it seemed to me that pay for performance has the backing of the insurance industry because they could use it as an excuse to pay physicians less. Show me a pay for performance program that actually increases costs to insurers and I'll show you an out-of-work actuary.

Mark Vonnegut, a pediatrician, has a perspective article in the December 27, 2007 issue of the NEJM titled Is Quality Improvement Improving Quality? A View from the Doctor's Office. I found the following a much better statement of the issue than I could ever come up with:

"I can't help suspecting that underneath all these quality-improvement and pay-for-performance initiatives lies yet another scheme that will work out very well for insurers and very badly for providers and patients."

Unfortunately, it's not free full text, but it should be (meaning you'll need a subscription to read the whole piece).

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