Re: Single ultrasound
From: Dave Berck (djberck@yahoo.com)
Tue Aug 30 11:11:19 2005
I generally agree. I don't believe the the HMOs are interested in rational resource allocation. Examples of this are too numerous to count. And I do believe there are better systems out there -- namely, those of other 1st world countries who generally allocate funds in a more sensible way than we do.Their citizens are as healthy as we are and are generally satisfied with the care they receive. And it's at a fraction of the cost. True, they don't do so many heart/lung transplants, but they're not blowing their treasuries in the ER like we do. I have no illusions that we could ever implement such a system here. It'll never happen. But it's been done.
James Smeltzer <James.Smeltzer@wellstar.org> wrote:
Dave,
Precisely! No ministry of health means individualized, "irrational" or distorted resource allocation. Emory Univ advertises executive physicals and botique executive suites for therapy on the radio. I even used to take echinacea for Rx of colds. We squander billions on unproven therapies and on drug uses "proven" through studies paid for and monitored for by the drug pushers. We used to take bribes to go to dinners to learn about therapies discussed by "consultants" on payola from drug companies.
Now that avenue is closing down the drug pushers are going directly to the consumers......
Now more than ever we have a fiducial and agency responsibility to our patients.
But it also means freedom, and a marketplace for ideas. As a free people we have always been susceptible to snake oil salesmen. Looking at our government, the results are not much better however, but the issue of choice has been removed.....
There is no such thing as a "free" market for health care, and the HMOs are at least trying to encourage rational resource allocation - & what do we accuse them of? Taking away our freedom to choose therapy to maximize profit - which may be true. Without active exploration and experimentation we are left with a health care system frozen into what worked in the past, and this is far from optimal therapy...
To date there is no economic or utilitarian model to adequately describe our static and dynamic health care system, and certainly no algorithm to make rational choices. In the absence of same, you cannot tell me that you have a better system than the current chaotic one. I can tell you this, any practitioner who says he completely ignores the cost to the patient in making treatment prescriptions to his patient is practicing in "Never-Never Land", and not treating actual people.
On the other hand, if I were the Minister of Health we'd get a lot more bang for our buck - AND the patient/client would not have to go to the mall for their 3-D sonogram. They'd also be a lot less anxious to get one, since they'd all have tapes of their exams...
;^)
Jim S
>>> djberck@yahoo.com 8/29/2005 2:08:26 PM >>>
I don't suggest we stop prenatal care or screening for Rh sensitization etc. I do suggest that proper assessments of cost-effectiveness are few and far-between, and that modern medical practice is not driven by them (I think we all know this already). I don't suggest that we stop routine blood screening for Rh disease. Indeed it is quite rewarding to save those pregnancies. I only suggest that the costs involved (and these change all the time depending on cost of T&S, the cost of rhogam, ultrasound etc.) are incurred without regard to their merit relative to other health values society doesn't pay for. My point is that we don't have a ministry of health making these choices. These choices are driven by other factors -- good medical practice, inertia, tradition, patient desires, MD incentives, pharmaceutical marketing etc.
James Smeltzer wrote:Hi!
If you look at prenatal care, it is MAGIC! Evaluation of the content would lead us to question what in this is beneficial, but EVERY study that has looked at outcomes with vs without prenatal care has shown a clear pay-off of 3:1 or better, not to mention improved outcomes.
When you talk about Rh Ig - the 28 week dose prevents sensitization in about 1% of potential pregnancies, about 1/2 of the treated ones, for a risk of 1/2%. Of these half will get pregnant again, or about 0.25% of doses will have a future preventative effect.
A significantly sensitized pregnancy can run about $75,000 for all the testing and transfusions. I have to report a financial interest in these, as well as the fact that saving babies of sensitized mothers is the coolest thing I do professionally. With this seat of the pants assessment, Rh Immune globulin is cheap if it less than $184 per dose (which it is). It is still better to prevent the problem than to treat it. Federal reimbursement must be close to actual cost at:
J2790 Rho(D), immune globulin, full dose, human, injections, per 300mcg $93.54
(http://www.zlbbehring.com/ZLBB/binary/Reimbursement_Alert_JuneJuly_2005_1.pdf)
The potential for morbidity and mortality with (even the best) treatment makes this one a no-brainer, even though the cost of the full-court-press therapy af a sensitized mother is still cheap for cost of life saved by adult standards. My grandmother lost four boys from this before my mom was born. What was that heartache worth?
Michale Parsons did a study with about the same results a good while back: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=2154307&dopt=Abstract
The sonographic assessment and screening of the cervix has probably saved enough in my practice from all the Neonatal intensive care costs avoided to pay for the entire ultrasound operation.
So far, the only "undiagnosed" Down's Syndrome in this practice have been those who refused amnio despite multiple markers positive - with virtually NO help from serum screening - and this is all comers of all ages.
I have no trouble defending most of what we do on a cost-effectiveness basis. I have no trouble offering one or two sonograms to the working poor at cost. Enoxyparin is an exception....
;^)
Jim
>>> evsono@pipeline.com 8/24/2005 5:12:16 PM >>>
Prescripition Drugs For Neonates!!!
art
Joe wrote:
> Dave: If we had a Ministry of Health I would hope that finally someone
> would realize that the future of our country is in our newborns and
> not on the old and dying on who we spend an enormous amount of money
> for a few extra days of life. Doesn't make sense. But newborns don't
> vote. Joe C
>
> Dave Berck wrote:
>
>> We may be de facto fiducial agents for our patients, but best I can
>> tell the system is run exclusively by market forces. The lovenox is
>> covered by plan A only because it's covered by plan B and for no
>> other reason. Notions of "cost-effectiveness" seem entirely misplaced
>> in American medicine. And let me tell you, I'd hate to have a
>> cost-effectiveness analysis done on lots of standard
>> medical/obstetrical practices, for example, 90% of ultrasounds that
>> we do, virtually all of prenatal care, rhogam administration,
>> diagnosis and management of gestational diabetes, most antepartum
>> fetal testing, to name a few. They'd be pretty far down on the list
>> of priorities for any Ministry of Health (if we had one) if a fair
>> analysis were done.
>>
>> -- Dave Berck, MD
>>
>> James Smeltzer wrote:
>>
>> Hi Art!
>>
>> I just saw today a patient who was approved for enoxyparin
>> (Lovinox-R) which has no proven superiority for Rx acute DVT in
>> pregnancy over heparin. The former costs $2500 per month but has
>> become the de facto standard of care. The latter is $78 per month.
>> At term we have to switch back to heparin because of the shorter
>> wash-out and possibility of epidural anesthesia. Is this indicated?
>> WHo should pay the $2422 difference in cost?
>>
>> Physicians are de facto fiducial agents for their patients. Should
>> we guide them in the appropriate use of their scarce resources? The
>> rational indications for ultrasonography when the cost to the
>> patient is zero may be different than that when the cost is full UCR
>> price, and will be different for different patients for different
>> reasons. The "my way or the highway" approach to medicine is wrong
>> in a free society, IMHO, but then! I'm the guy who tapes on demand.
>> About 1 in 4 patients actually NEEDS a sonogram for a medical
>> problem in pregnancy... Unfortunately we often donot know which one
>> of the four unless we do the scan....
>> ;^) Jim
>>
>> >>> evsono@pipeline.com 8/12/2005 8:15:47 AM >>>
>> bouthina ibrahim wrote:
>>
>> > THANK YOU JAMES NUMBER OF FETUS AND VIABLITY.
>> >
>> > */bouthina ibrahim /* wrote:
>> >
>> > LADIES ABOVE 35YS AND THOSE ITH PREVIOUS CONGENITAL ANOMALS EARLY
>> > 11-14WS LOOK FOR NASAL BONE BRAIN SPINES AS THERE IS INCREASE OF
>> > TRISOMY ESPECIALLY T21.AT 20WS SCANNING GENERAL BODY PARTS FOR
>> > ASSOCIATED ANOMALIS.
>> >
>> > */James Smeltzer /* wrote:
>> >
>> > Hi!
>> > Here in Georgia we are faced with the prospect of medicaid
>> > cutting reimbursement for a normal pregnancy to one sonogram.
>> > Our policy has been two for a normal pregnancy, with a 12-14
>> > week dating, nuchal lucency and nose bone study, and a 20 week
>> > anatomic survey. I can understand medicaid's need to ration
>> > scarce resources with tax cuts and service increases,
>> > especially when some practices are doing four or five
>> > sonograms in a normal pregnancy.
>> >
>> > Which is most important for prenatal screening and diagnosis?
>> >
>> > Jim S
>> >
>> > James S. Smeltzer, MD, FACOG, SMFM
>> > Consultant, Maternal Fetal Medicine
>> > Wellstar Physicians' Group
>> > Northwest Women's Care
>> > 787 Campbell Hill St
>> > Marietta GA 30060
>> > James.Smeltzer@wellstar.org
>> > VM 678-290-3035
>> > Off 770-528-0260
>> > Page 404-318-3451
>> >
>> > >>> evsono@pipeline.com 8/10/2005 11:41:14 AM >>>*Allen
>> > Worrall wrote:
>> >
>> > > Unfortunately many large radiology departments cannot get the
>> > > administration to spend the money! getting new machines,
>> > space to put
>> > > the machines, and doctors and sonographers to examine the
>> > patients.
>> > > Resources are often less than required, particularly when the
>> > > radiology department is in a large hospital.
>> > >
>> > > I am sure Terry can expound on that subject much more than I
>> > can.
>> > >
>> > > Allen
>> > >
>>> > > ----- Original Message -----
>> > > *From:* Latha Natarajan
>> > > *To:* Multiple recipients of list ULTRASOUND-HISTORY
>> > >
>> > > *Sent:* Tuesday, August 09, 2005 8:44 PM
>> > > *Subject:* Re: consulting
>> > >
>> > > More number of cases, if unavoidable, should be tackled with
>> > > more machines and the appropriate man-power.
>> > > That is what my "guru" Dr. Suresh, mediscan sy! stems,
>> > Chennai does.
>> > >
>> > &! gt; Logical solution.
>> > >
>> > > LN.
>> > >
>> >
>>
>> ------------------------------------------------------------------------
>> > >
>> ------------------------------------------------------------------------
>> > >
>> ------------------------------------------------------------------------
>>> > > ----- Original Message -----
>> > > *From:* Allen Worrall
>> > > *To:* Multiple recipients of list ULTRASOUND-HISTORY
>> > >
>> > > *Sent:* Wednesday, August 10, 2005 8:11 AM
>> > > *Subject:* Re: consulting
>> > >
>> > > Terry, I think I saw you at that lecture in Orlando, a GE
>> > > supper event, in which a young woman radiologist from
>> > > Boston,(I think) related that her ultrasound department was
>> > > bogged down with too many cases, and one of the things that
>> > > helped them was 3D ultrasound. The volumes can be obtained
>> > > quickly, and looked at later by the radiologist.
>> > >
>> > > Has this speaker published her lecture anywhere? I thought it
>> > > was very good and very thought-provoking.
>> > >
>> > > Allen
>> > >
>>> > ! > ----- Original Message -----
>> > > *From:* Terry DuBose
>> > > *To:* Multiple recipients of list ULTRASOUND-HISTORY
>> > >
>> > > *Sent:* Tuesday, August 09, 2005 6:27 PM
>> > > *Subject:* Re: consulting
>> > >
>> > > Dr. De Lancer, you ask a question that many have asked.
>> > > In general sonography (Abdomen and OB/GYN) usually no more
>> > > than two an hour in peak rush times. It depends on how
>> > > detailed the studies are, but at bottom line, two an hour
>> > > average is too much if it is all day every day. This is
>> > > based on my experience of 29 years and not on any
>> > > scientific study.
>> > >
>> > > For you second question I would say anytime the
>> > > sonographer is rushed enough to not be able to focus on
>> > > the diagnosis, that is too many. There needs to be a bit
>> > > of fle! xibility to allow for the unexpected twins ! or other
>> > > ! detailed study.
>> > >
>> > > Also do not forget that over work, continuously over a
>> > > period of months or years can injure the sonographer.
>> > > Repeated Stress Injuries are well documented now. See:
>> > >
>> > > http://www.sdms.org/msi/default.asp
>> > >
>> > > Hope this helps. Terry
>> > >
>> > > */jose de lancer /* wrote:
>> > >
>> > > Hi, i am Dr. Jose De Lancer from Dominican Republic.
>> > >
>> > > I am obstetrician, gynecologist and sonologist.
>> > >
>> > > We have troubles in our hospital sonografy department
>> > > for the "overdemand" in ultrasound studies.
>> > >
>> > > What is your opinion in the following isues:
>> > >
>> > > 1-How many studies are reasonable for each sonographer
>> > > in one day?
>> > >
>> > >! 2-How afect the excesive number of patients in the
>> > > individual and department quality?
>> > >
>> > > Thanks for your cooperation!!
>> > >
>> > > */"DuBose, Terry" /* escribió:
>> > >
>> > > Congratulations to everyone on another landmark
>> > > event. Good work. Terry
>> > >
>> > > Terry J. DuBose, M.S., RDMS, FSDMS, FAIUM
>> > >
>> > > Associate Professor & Director
>> > > Diagnostic Medical Sonography Program
>> > > University of Arkansas for Medical Sciences, CHRP
>> > > 4301 West Markham St. Mail Slot #563
>> > > Little Rock, Arkansas, 72205 USA
>> > > 501-686-6510
>> > > DuBoseTerryJ@UAMS.edu
>> > > http://www.io.com/~dubose/
>> > >
>> > > http://www.uams.edu/chrp/dms/default.asp
>> > > http://www.obgyn.net/us/panel/panel.htm
>> > > ---------------------------------------------------------------
>> > >
>> > > ---------------------------------------------------------------
>> > >
>> > > ---------------------------------------------------------------
>> > >
>> >
>>
>> ------------------------------------------------------------------------
>> > >
>> ------------------------------------------------------------------------
>> > > *From:* Dale R. Cyr [mailto:cyr@ardms.org]
>> ------------------------------------------------------------------------
>> > > *Sent:* Tuesday, August 09, 2! 005 7:18 AM
>> > > *To:* ALL STAFF; BOARD MEMBERS; All EDTF Committees
>> > > *Cc:* Thomas Magallanes; steve_tapp@promissor.com
>> > > *Subject:* Success in Hong Kong ARDMS Exam Delivery
>> > >
>> > > Hello Everyone:
>> > >
>> > > ARDMS began delivering examinations at the
>> > > University of Hong Kong on August 8th. Two
>> > > candidates sat for ARDMS examinations (Neuro and
>> > > CPI), which were routinely and securely delivered
>> > > with all data safely transmitted back to
>> > > Promissor as per normal procedure. The ARDMS Hong
>> > > Kong exami! nations and processes are exactly the
>> > > same as here in the United States and Canada.
>> > > Several other Candidates are scheduled to sit for
>> > > ARDMS examinations in Hong Kong over the next
>> > > couple of weeks.
>> > >
>> > > Congratulations everyone as ARDMS continues to
>> > >! increase the number of credentialed individuals to
>> > > promote qual! ity and patient safety through
>> > > credentialing and continuing competency of
>> > > ultrasound professionals.
>> > >
>> > > Also, a big thank you to Promissor who has been a
>> > > great partner in assisting ARDMS in meeting our
>> > > strategic initiatives, particularly in the global
>> > > expansion program.
>> > >
>> > > Regards,
>> > >
>> > > Dale
>> > >
>> > > Dale R. Cyr, MBA, CAE
>> > >
>> > > Chief Executive Officer/Executive Director
>> > >
>> > > ARDMS and the Breast Ultrasound Foundation
>> > >
>> > > 51 Monroe St., Plaza East One
>> > >
>> > > Rockville, Maryland 20850-2400
>> > >
>> > > 301-738-8406, x223
>> > >
>> > > cyr@ardms.org,
>> > > cyr@breastultrasound.org
>> > >
>> > > http://www.ardms.org
>> > > http://www.breastultrasound.org
>> > >
>> > > //You should always make sure. Verify the Registry
>> > > status of employees - current and potential.
>> > > ////ARDMS offers an _online directory of its
>> > > Registrants.
>> > > _//////
>> > >
>> > > *NOTICE:* This e-mail may contain information that
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>> > > Espacio para todos tus mensajes, antivirus y antispam
>> > > ¡gratis!
>> > > Regístrate ya - http://correo.espanol.yahoo.com/
>> > >
>> > Allen
>> >
>> > Falling reimbursements and rising expenditures is not an optimal
>> > business model.
>> >
>> > Art
>> >
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>> James
>>
>> One of the specious exercises in medical logic today is "practice by
>> insurance." If a physician feels a procedure or scan is medically
>> indicated, then it should be performed. Conversely, if it is NOT
>> indicated, then it should NOT be performed. To the best of my
>> knowledge,
>> the fact that a procedure is covered by insurance is not
>> pertinent to
>> what should be medical decisions.
>>
>> Just my opinion - I could be wrong.
>>
>> Art
>>
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>> David J. Berck, MD, M! PH
>
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