- Del Meyer, MD - http://delmeyer.net -

Fake Smiles

Watch for those fake SMILES. Psychologists report (Science 262:336) that they have separated the smiles that evoke positive emotions from those that don’t. If the smile, even if forced, involves certain muscles around the eye (instead of just those around the mouth) it activates an area in the left hemisphere of the brain associated with positive emotions. So be sure to put that pars lateralis muscle into action before you read the newspaper.

Arthur Hoppe’s (SFChron) recent column “Is the Penis Obsolete?” is a follow up of his previous column condemning the new fad of penile enhancement pointing out that this male organ is the ugliest appendage on the human body. He received a clipping with a very feminine note attached. The clipping recounted how heroic surgeons in a grueling 10-hour operation reattached the penis of John Wayne Bobbitt after his wife, Lorena, had lopped it off. Scrawled across the clipping were the words: “What for?” (Almost as dismissive as was Dorothy Parker when told that Calvin Coolidge had died, “How could they tell?”) Hoppe enumerates all that we could accomplish if we eliminate this organ: wars, fights, divorces, overpopulation. . . Perhaps! But for the record, we’ve always preferred the Greek derivation “phallus.” It sounds so much more masculine and doesn’t remind us of those colonies that house inmates. . . However, if you’re examining an inmate, he may not recognize either the Greek or the Latin derivations. Even if you use a functional description such as “the organ of copulation” or “the organ of micturition” he still may not understand. You may be forced to use the vernacular.

Arnold Relman, editor-in-chief of the New England Journal of Medicine, in his article carried by Newsday and the Sacramento Bee, “Doctors are the Key to Health Reform,” notes that we can’t blame health care costs on futile care which has not increased in the last 12 years, or malpractice insurance which remains a small fraction of the total cost of care, ($12B out of $900B), or the cost of defensive medicine which is not growing, (good physicians rarely feel compelled to practice it). Dr. Relman states, “It is unfortunate that the polls indicate that physicians seem to feel they have no responsibility for containing costs. But they do. If physicians do not take the initiative, they will end up working for the insurance companies now preparing to become medical-delivery plans. That would be unfortunate for all.”

When I arrived at my office recently, I found upon my desk a 240-page “working group draft” copy of The American Health Security Act of 1993, marked PRIVILEGED AND CONFIDENTIAL. Thank you to whomever. . . Looking for something I hope we could all agree with, I found on page 62, “Fee-For-Service Plans.” It states that each Alliance must include among its health plan offerings at least one plan based on a fee-for-service system which may require utilization review, prior approval for certain services, but not a requirement to seek approval through a gatekeeper. Now we must come up with a fee-for-service system that will have it’s own built in controls to provide the clinical incentives so that physicians and patients will direct their health care to the lowest cost basis. Watch for our symposium on National Health Care in February.

Just received the printout from my Delta Dental Plan indicating that they paid the full $54 for cleaning my teeth. The fee goes up every six months when I return for my recommended appointments. It was $30 a few years ago. I guess the dentists haven’t found the maximum that Delta Dental will pay. . . Reminds me of Eskaton American River Hospital some 15 years ago when my technical director informed me that the price of oxygen increased from 75 cents an hour to $3 an hour without any departmental input. We went into the Assistant Administrator’s office to register our concern about this $72 a day our respiratory patients were paying. We were told that Blue Cross, Blue Shield, Medicare, etc. were paying the $3 an hour and he had already authorized a further increase to $3.50 an hour stating “we haven’t yet found the maximum that the carriers will pay.” Oxygen cost at that time was less than 25 cents an hour.

Congress has finally agreed that lectrocardiogram interpretation is a definable medical service and, therefore, should be reimbursed and Medicare actually will do so beginning in January. It must have taken hundreds of physicians thousands of hours to convince the lawmakers what was self-evident. An ECG has no intrinsic value until it is interpreted. But then, we as physicians have always had difficulty in articulating our position. In the early 1970’s, physician and hospitals split the ECG reimbursement. When the ECG charge was $18, we got $9. When it increased to $24, we got $12. When it increased to $38, we received $19. Then the hospital administrators (at that hospital that’s not on the River) convinced the Doctors that they could never recover their costs as long as they were tied to us. They actually convinced the internists that the cost of an ECG, which is less than $1 for the equipment cost and $2 for the technical cost required a higher than $19 hospital portion. (A $4000 machine had a capital cost of about $100 per month; if it did 200 ECG’s per month the cost per ECG was fifty cents; if 1000, the capital cost was ten cents; at that time a technician could easily do, mount, file, and bill 6 ECG’s per hour and got paid about $12 per hour) Why do we have difficulty asserting that we are as valuable as technicians in patient care?

A family reports that their 8- year-old father, who had heart disease, collapsed in a restaurant. The maitre d’ called 911. The EMT told the family their father was dead but they would nevertheless take him to the hospital under CPR. He was pronounced 14 minutes after arrival. The hospital ER bill for those 14 minutes was $4300. That’s $300 per minute. . . I’m sure all internists and cardiologist are pleased the government has agreed that the minutes we spend reading ECG’s do have “some” value. Initial estimates are that it may be as high as $2 a minute for the 5-minute average.

Thanks for all the comments, suggestions, and contributions. Irwin Lyons, M.D., Ph.D., J.D., in his role as a medico-legal arbitrator in health care law disputes, came across a photocopy of an identity card stating that the person was 1/64th Native American and was entitled to all the perquisites pertaining thereto. Does that mean the grandchildren at 1/256 ethnicity will have the same perks? It wouldn’t take too many more generations before all Americans could possibly be Native? There was a time when another minority race had to be out of some towns before sundown. A less diluted racial status was even more disastrously prejudicial. Miscegenation could be lethal. Perhaps Irwin, an analyst, will favor us with an analysis of this trend as it pertains to other minorities in history and the physical and mental consequences to our society.

Sutter’s November quarterly staff meeting continued a high level of relevance with the subject of sexual harassment. A “comment” that four out of five men may take as a compliment, three out of five women would consider sexual harassment and could, if used, destroy your professional career and your family. Although attendance was modest for Gordon Hunt’s swan song, those that came seemed to think the message was timely and important. . . Meanwhile, across town, there was another staff meeting. Ballots had been sent out for the hospital’s chosen candidate for president-elect and a challenge candidate from the staff according to bylaw procedure. An additional candidate was fielded after many of the ballots were returned. We are told that attempts were made to delay the election, to change the bylaws, to allow staff to pick up their ballots and re-vote them. One response was why shouldn’t the hospital control at least 50% of the vote since they pay 50% of the staff salaries. Others began to wonder if medical staff salaries are a conflict of interest?

Kenneth Grant, M.D., J.D., from Georgetown University School of Medicine, was a guest lecturer recently in Sacramento. In his comments on the proposed national health plan, he stated that there are only two people in the whole delivery of health care with any ethics – the physician and the pharmacist. Dr. Grant also showed a cartoon of “Billary’s Garage.” An ambulance had driven up to get a broken headlight replaced. The caption read: “You’ll need a new ambulance.”

Getting back to those Fake Smiles. Be sure to check the smiles on those politicos who are out there allegedly trying to help our patients. We better fix that headlight before we will be forced to buy a new ambulance. . . And one final smile: “non profit” Blue Shield’s try to stitch together insurance, hospitals, and doctor groups into a loosely-knit merger with “for profit” UniHealth America is dead. If it had succeeded, Blue Shield would have lost its traditional allegiance to physicians and probably its membership in the national Blue Cross and Blue Shield organization. Would we then have had to organize a new Blue Plan? Keep smiling.