26 April 2011

The Importance of a Good Left Hook

Outside of work, I practice martial arts -- in particular, karate. We run a dojo which focuses on the traditional elements of the fighting system but also on real-world applications. By which I mean we do all the stereotypical karate "stuff" -- punching the air, conditioning, kata forms, that sort of thing -- but we also try to teach a more holistic self-defense approach including practical street fighting techniques, grappling, and personal safety and security. This differs a bit from many martial arts schools in that we are not sport oriented at all. Our students don't go to tournaments, and we don't teach techniques which are flashy but which would not be useful in a real fighting situation.

Don't get me wrong -- I love to watch the shotokan guys performing their kata with their incredibly athletic low stances, and I love to see the tae kwon do guys with their acrobatic spinning kicks. I mean no disrespect for their styles, and I know many practitioners of these arts are also excellent fighters. But the reality of a street fight is that they are fast, messy, frantic, and incredibly emotional. They do not have the elegant distance and measured timing that a tournament sparring match has, with the complex back and forth of feints, footwork and tactics. If you can pull off a leaping kick in the heat of a real altercation, well, that would be quite an accomplishment. But it would be difficult, since the distance for that sort of thing gets real close, real fast. They say any street fight that lasts more than ten seconds, you're probably losing.

So when I teach self-defense, I focus on close-in techniques: hooks and uppercuts, elbows and knees, wrist locks and arm bars. Simple, easy, high-yield stuff. Not as devastating as a lovely roundhouse kick, but lower risk and more likely to land. 

As you close distance, the punches you can effectively use change. The long straight punch is great from middle distance, as is the back-fist punch. When you're really close, you want your punches to arc under or around your opponent's guard. If you can get your hip into it, a hook to the temple or the jaw can be devastating.

Case in point: I recently saw a young man from the local MMA (mixed martial arts) club. As an aside, I love MMA. It's still a sport, but it's pragmatic and authentic and intense. It's not what I do, but I can really appreciate its virtues. Anyway, this young fellow had taken a roundhouse to the right temple and had dropped like the proverbial sack of potatoes. His mates had not been alarmed by this, perhaps because knockouts are common in some dojos, but they really should have done something when he had a seizure. I guess it was a brief seizure, because they didn't call 911. They propped him up, gave him an ice pack and he started to come around after a while. (I swear, you can't make this stuff up.) In fairness, they were all pretty young, in their late teens and early twenties, and I guess they didn't know any better. 

Our fellow went home and had a restless night's sleep. His headache kept him awake. The next afternoon he was still feeling poorly, with some nausea and a bit off balance. Finally he decided to come in and get checked out. His scan, as I am sure you have now guessed, showed a bleed:

subdural apex
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subdural
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You can see the subtle enhancing rim of bright blood along the left side of the skull around the edge of the brain (remember, the CT image is reversed). More strikingly, the midline is shifted from the left to the right and the dark slits of the left ventricles are compressed. This indicates fairly severe swelling of the brain. 

This patient, fortunately, did great. He did not require surgery -- the amount of bleeding was actually minimal. It was the swelling that was making him so sick. He did not have any more seizures, and neurologically made a complete recovery. (Whether he will have long term cognitive problems from the head injury is an open question.)

The teaching point here, applicable whether you are medical or martial in your interests, is that the vector, the direction, of applied force matters a lot to the brain. The skull is strongest in the forehead and the back of the head, and the brain is designed to rock back and forth in the front-back axis without too much damage. This is not surprising! Evolution is smart, and humans have been falling forward and backwards for eons, so there's a good survival advantage to being able to withstand the most common head injuries. But when the force is directed from the side, the risk of injury goes up dramatically. The brain is closer to the skull in the temporal area, and is tethered in a way that it gets rattled much more violently from an impact to the side. The skull is thinner and weaker there, and the major blood vessels run along the temple. One good whack along the ear can induce anything from a concussion to a lethal hemorrhage.

The take-home points are:

  • If you teach a dojo, I would not allow hooks to be used in practice, or perhaps only very cautiously with mandatory headgear.
  • If you are in fear for your life and wish to inflict injury, this is a great place to hit.
  • If someone in your dojo/ER does take a shot to the temple, you need to have a high suspicion for serious injury.

Also, I suppose I would add that if your buddy has a seizure after a head injury, you should go ahead and call an ambulance. But that's just common sense, right?

23 April 2011

It should go without saying

But, just for the record:

Do not stick your finger into the spinning blades of a lawnmower.

fingeramp
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This wound poses some interesting management issues. As you can see, it's a fairly clean amputation just beyond the distal interphalangeal (DIP) joint. The patient, optimistically, brought in the amputated portion nicely iced, but reimplantation at this level is not feasible. The blood vessels there are too small and distorted to anastomose. Such a relatively long section to re-install requires good blood flow or it will simply necrose and fall off. So I had to disappoint the patient and tell him it could not be made whole again.

However, the technical issue is that with this very clean amputation there was not enough soft tissue left to close around the stump. Ordinarily, I would take a bone rongeur to nibble away at the residual bony stump until there was enough slack in the skin to pull it across the stump and close it. But this guy had just a bit of intact distal phalanx. I would have had to remove the entire thing, which is not preferable since the flexor and extensor attachment points were still intact. Taking out the rest of the bone would have made the finger weaker and less mobile.

So, in the McGyver-like fashion that ER docs must emulate, I improvised. I took the devitalized fingertip and started harvesting. I excised the bone and the nailbed, leaving only the finger pad and a generous fat pad underneath. I thinnned the fat pad a bit, and trimmed the skin to fit the stump, then tacked it on like a cap. It looked pretty good, and I am optimistic that my little graft will survive. If it does, the fact that I left a fat pad will give him a little cushion over the bone and a relatively functional finger.

But still, the principle remains. Fingers and spinning blades of any sort should not mix.

22 April 2011

Are End-of-Life costs avoidable?

One interesting comment I have seen come up over and over is the idea that end-of-life costs are the thing that is spiralling out of control and that if we could somehow find a way to curb the costs of futile care, then that would somehow solve the health care inflation crisis. Andrew Sullivan endorsed such an idea the other day, a "Modest Proposal," which is not nearly as radical or amusing as Swift's. And indeed, there is a modicum of sense in the idea.Estimates are that spending in the last six months of a person's life account for 30-50% of their overall health care costs, and that the spending in the last year of a person's life accounts for 25% of overall medicare spending.So -- simple solution, right? cut down on the futile care, and we're good to go.

Only problem -- as a doctor, I sometimes have a hard time telling when someone is in their last DAY of life, let alone last year.

Just recently, I saw a guy with dead gut -- ischemic bowel -- a near-universally fatal diagnosis. we worked really hard on him in the ER, because saving lives is "what we do," but it was with a real sense of futility. It was depressing, actually. However, to my great surprise, the patient survived, after many thousands of dollars in expenses and will make a real recovery. He may never go back to work, but he will probably live many more years with good quality of life.

I have a friend whose mother, in her eighties, went in for a coronary bypass, and sadly suffered a stroke and died. Some might well criticize -- what were they thinking doing a bypass in an octogenarian? But consider, she was hale and active prior to the procedure and looked in advance to be a good candidate. And I have seen many nonagenarians who are ten years out from their CABG with good quality of life.

My point is that while some are lucky (?) enough to contract a terminal illness and expire in a planned manner with a clear line drawn on the extent of the interventions, or lucky (?) enough to die quickly and cheaply, many and perhaps most of us will not know in advance which of the several illness we incur as we age is going to be our terminal illness. If you think you can beat it, if your family and your doctor have reason to think you might be able to pull through, then it is difficult to give up. Even if you have an advanced directive, as Andrew suggested (and I wholly agree), in the absence of an established and accepted terminal diagnosis, most patients and families will be reluctant to invoke it and decline care.

So while we may have some ability to reduce costs in the end of life, the simple fact that we tend to get sick before we die, and nobody knows the hour of their death will make them difficult if not impossible to significantly reduce.

21 April 2011

Where do I spend the bulk of my time?

According to the iPhone tracker:

iPhoneTracker
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Yeah, kinda creepy. Maybe not quite as accurate as I have heard -- when I break it down it looks like a grid pattern, not street by street, and some places appear I am pretty sure I have never been. That apparently has to do with the fact that the iPhone uses tower triangulation in logging its location. But the day-by-day log is much creepier:

iPhoneTracker day
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I hear there's a harmless explanation, and I actually believe it. All cell phones d this, and forensic cell phone specialists have been able to access this data for a long time. The Droid does the same thing (though it, sensibly, deletes data after a certain time). This is a technical nerd-level mistake and not Big Brother. 

But still, man, creepy.

 

Why Patients are Not Consumers

Republican budget guru Paul Ryan has a plan to end Medicare as we know it to be replaced with a series of less-generous vouchers. The House of Representatives has voted to implement this plan. The political side of this has been written about a lot, and I am not going to rehash what has been better covered elsewhere. I do want to address what seems to be a persistent fallacy or delusion which is held to a near-religious level by many free-market conservatives: The idea that market economics can have an impact on health care costs.

This concept has underpinned every major Republican health care plan since, well, since Mitt Romney's proto-ObamaCare reforms. The idea is that consumers, when they have "skin in the game," and when they are empowered and incentivized to see that their money is spent efficiently and only as necessary, will change their health care consumption behavior in a way which will force providers to compete on cost and quality and thus drive down costs. This is wrong, mistaken, misguided and inaccurate.

It's undeniably true that markets do work in this way, most of the time. The auto industry and the fall of Detroit is a perfect example of the invisible hand at work. It will not work in health care. Health care is a fundamentally different market for three major reasons:

1. Health care is generally not a refusable or elective service.

By this, I mean that in most cases, the health care costs are driven by medically necessary procedures. You get pneumonia. Your knees wear out. You find a lump in your breast. You notice blood in your stool. Barring the denial/self-neglect approach that some people take, when you develop a medical problem, you need to spend money to remedy it. While the timing of your knee replacement may be elective, whether to do it or not generally is not, if the alternative is being disabled and non-ambulatory. It is an inelastic demand, like the demand for gas. When gas gets more expensive, you still have to fuel your car, and except for very small variations, the demand for gas does not vary with the price. Similarly, the demand for medically needed care is not going to be terribly price responsive. When your doctor tells you that you need chemotherapy, you don't make the decision to proceed based on the cost, but on the need. And the number of recreational colonoscopies performed is actually very low.

It is true that some medical costs are elective and price sensitive -- preventative care, luxury procedures like Lasik, some office visits. These, however are a tiny fraction of overall health care costs. As in my analogy, some people do drive less when the price of gas goes up -- they take the bus instead -- but this does not reduce demand enough to make a difference in the price of oil.

2. There is an asymmetry of information

This asymmetry relates to both price and necessity. When your orthopedist tells you that your knee pain is due to a degenerated meniscus and that the best treatment for that is athroscopy, most consumers are going to simply accept the surgeon's advice. Now, as it happens, there is good evidence that arthroscopy of the knee provides no more benefit than placebo, but 99% of patients are not going to be aware of this and are not going to bother to do the research to find it out. Those that do, might find that the surgeon has an explanation why, in your case, he thinks it will be helpful despite the studies showing otherwise for other people. In most cases, the patient must trust the physician to provide accurate information on what is really needed. And if you should ask your surgeon what the cost of the arthroscopy will be, the answer will probably be "I don't know." Price transparency is poor to begin with but there is the very real fact that based on a patient's individual payer status the cost will vary dramatically, and the surgeon probably does not know what the cost will be for your case. Finally, when consumers make health care providers compete against one another to decide by whom and where the care will be given, they tend to be concerned primarily with quality and with cost as, at best, a secondary concern. 

All these factors greatly inhibit competition and the development of a free market. To some degree it is possible to mitigate these, through, say, all-payer price setting, and mandatory disclosures and publishing outcomes data, etc. However, the third variable, in my opinion, makes the rest all-but-moot.

3. Purchasing power is concentrated in the hands of a very small number of "consumers"

This is the wooden stake through the heart of the idea that consumer behavior can effect cost containment. The functioning of a free market is dependent on the ability of consumers to vary their behavior to force suppliers to compete. However, you and I can be as scrupulous and cost conscious as we like. We are not sick. (Well, I'm not anyway. I hope you're OK.) The driver of cost is the small fraction of people who have serious medical conditions. It's the old 80/20 rule writ large.

cost distribution

Though the data is a few years old, I doubt the distribution has changed. To emphasize, HALF of all health care costs in the US is concentrated in only 5% of the population, and 80% of costs are accounted for by the top quintile! (source: Kaiser Foundation PDF)

So the effect here is that with such a concentration of costs in such a small segment of the population, the ability of the larger population to move the market is highly restricted. You can make 80% of consumers highly price sensitive, but they can only affect a tiny fraction of healthcare spending. And for the generally well, their costs are probably those which are least responsible for the spiraling inflation. They're not getting $30,000 stents or prolonged ICU stays, or needing complex chronic disease management.

Conversely, those who are high consumers of health care simply cannot be made more price sensitive, since their costs are probably well beyond what they could pay in any event, and for most are well beyond the limits of even a catastrophic health insurance policy. Once you are told that you need a bypass/chemo/stent/dialysis/NICU etc, etc, etc, the costs are so overwhelming that a consumer cannot possibly pay them out of pocket. Since, by definition, these catastrophic costs are paid by some form of insurance, the consumer cannot have much financial interest in cost containment. For most, when they are confronted with a major or life-threatening illness, their entire focus shifts to survival, and they could care less about the cost. Further, many who are in this sick/expensive category have some diminished capacity with regard to their information gathering and decision-making. I'm thinking particularly of the elderly and those who have had strokes or any one of a multitude of illnesses which impact cognitive function or other functional capacity. These patients struggle with their activities of daily living -- getting dressed, bathing, transportation, housing, taking their meds. Their ability (let alone interest) in price-shopping their doctors is minimal to nonexistent, even if they had an economic incentive to do so. Taking someone who has a serious illness and making them have more "skin in the game" would represent a cruel additional hardship, but would be ineffective in creating an economic environment in which consumer behavior brought down spiraling health care costs.

On a personal note, I've recently acquired some experience with the perspective of someone who is a member of the 1% club. As I have blogged, my wife is under treatment for stage IIb breast cancer. We are pretty highly functional and informed consumers, and we actually have the financial resources to pay for more of our care than most would, so if, hypothetically, we had a stronger incentive to seek out more cost effective care we would be in a position to do so.

So, in our case, would we? No, of course not. My wife's chemo is going to cost >$100,000. I am sure that we could cut down the cost. Herceptin is pretty expensive -- are there less expensive alternatives? Turns out there are not. We spent a lot of money on Neulasta to keep her immune system operational during the intense chemo. Maybe we could have gone without it and just risked neutropenia? Maybe saved some money and used neupogen instead? That would have been quite a risk at minimal savings. Maybe we could have skipped the expensive anti-nausea meds? Not a chance! Chemo is miserable enough that those meds were worth every penny. (not to mention that all these meds might actually be cost-saving in keeping her out of the hospital with complications of chemo.)

What other options do we have in deciding how we treat the cancer? Radiation is non-negotiable, but maybe we could shop between facilities for the best deal. Of course there may not be much price flexibility on radiotherapy given the huge capital costs required. We will be interviewing half a dozen surgeons to determine who will do the mastectomy and reconstruction, and we are 100% focused on quality in making that choice.

So, in the end, if we had the proverbial "skin in the game" in making treatment decisions for my wife's cancer, I doubt it would make one iota of difference in the actual cost, or at very best only a small marginal difference in a very very expensive course of treatment. Bear in mind, we are the perfect test case! I can afford to pay $20,000 or more out of pocket if I need to, and it STILL wouldn't make a difference. If families with more limited means were obligated to pay the same $10-20K, if would mean financial ruin, or inability to access the lifesaving care, but it wouldn't allow the invisible hand to guide the market towards cheaper, more efficient care.

This is, ultimately, why people who believe that passing along the cost of health care to consumers will promote cost savings are wrong, and health reforms which are predicated on this concept will not work.

20 April 2011

Everyone wants to cut Medicare, until it's time to cut Medicare


Everyone knows that the excess growth in health care costs is driving the fiscal crisis in our country. The problem is that while everybody wants to somehow cut the cost of Medicare/Medicaid, in theory, when it comes time to actually make cuts, the courage of our politicians fails in the face of unrelenting public opposition to cuts in Medicare. In a poll just this week, the WaPo found that a staggering 78% of respondents opposed cuts to Medicare, 65% strongly. Surprisingly, despite the fact that it's a "welfare" program with limited constituency, 69% opposed cuts in Medicaid. And this is despite the fact that the poll question was slightly loaded, phrased to trigger the respondents' awareness of the national debt. Gallup found that even of Republicans, only 14% favored an overhaul of these popular entitlement programs, and 61% favored either no change or minor changes.

So while we all see the train heading off the cliff, we all know that something needs to be done, it's hard and politically scary to tinker or roll back such popular programs. You can see that with the fact that Obama's HHS has granted hundreds of "Quality Bonus" payments to the Medicare Advantage plans that he opposes. And now some in Congress are trying to roll back the Independent Payment Advisory Board (IPAB) that was included in the PPACA.

This is disheartening, especially in light of the fact that the critics of ObamaCare are those who often complain that it does to little to contain costs. Yet they are trying to repeal what is probably the single most effective cost-control provision in the health care reform. Apparently it's "rationing" or possibly a "death panel."

I should explain what the IPAB is, before I go any further. Established in the PPACA, it grew out of the MedPAC, Medicare Payment Advisory Commission. MedPAC made recommendations to Congress regarding what services Medicare should pay for, and how much it should pay. However, Congress often (read: usually) ignored those recommendations, especially for medical devices or other services with well-connected lobbyists, and MedPAC has been a very weak influence on controlling the growth in Medicare expenditures. IPAB is a bit different. It will consist of 15 appointed members who are to be experts in health care, economics, research and insurance. Some, but no more than half, are to be health care providers. The president is to consult with Congressional leaders before appointing them, and the chair will have to face Senate confirmation.

The IPAB will have powers more expansive than MedPAC. If HHS determines that the growth of medicare is expected to exceed a certain index (inflation-based till 2020, GDP-based after that), the IPAB is required to submit a plan which would restrict that growth by a certain percent.

IPAB is explicitly prohibited from making any recommendation that would ration care, raise out-of-pocket expenses from beneficiaries, or restrict eligibility in Medicare. It also cannot reduce hospital reimbursement rates till 2020. Any recommendation IPAB makes will become law (or, technically, a rule) unless Congress acts to replace that recommendation with one which can save as much money. Congress may, with 60 votes in the Senate, choose to block the IPAB recommendations altogether. (Interestingly, 60 votes are also required to repeal or disband IPAB.)

This body was created basically because Congress failed to act, and shows every likelihood of continuing that gridlock on the hot-button item of health care cost control. And when Congress has in the past tried to put health care cost controls into law, it hasn't worked out so well. (See: SGR) So the PPACA took the initiative away from Congress and creates a dynamic in which health care experts, including doctors, will be making recommendations that will automatically go into effect. This takes the "default" mode from "nothing happens" to policy changes which will happen unless Congress can rouse itself to block them. Is that a possibility? Sure! (See again: SGR) Will it happen routinely, if the rules proposed are limited in scope and well-targeted? Hard to say. We won't know that until IPAB is actually constituted and has made some recommendations. There are as yet no appointees.

The advantage of this is that it takes policy and puts it into the hands of actual health-care experts, including doctors and nurses, patient advocates, and other industry experts, instead of our venal and corrupt politicians. The disadvantage of this is that it takes policy and puts it into the hands of unaccountable bureaucrats instead of our democratically-elected representatives. In the end, I think this is a good thing. Something need to change. Costs need to be controlled. Congress does not seem able to manage this problem. Peter Orszag described the IPAB as "the largest yielding of sovereignty from the Congress since the creation of the Federal Reserve." That was in praise of the IPAB, by the way.

So why is the IPAB being opposed in Congress now? I think there are a variety of reasons. Some legislators may be regretting the cessation of that power to an outside agency. The GOP has a vested interest in opposing everything about ObamaCare, both ideologically and electorally. And Republicans have never been comfortable with bureaucrat-run, centralized decision-making bodied in the first place. There are electoral advantages to members of both parties in posing as defenders of Medicare. Some of both parties may be influenced by the financial support of the health care industry. (Industry sources have a vested interest in health care costs not being controlled -- remember that one man's waste and abuse is another's paycheck.)

In the end, I think Congress will leave the IPAB alone, and they'll be glad they did. When the time comes for the cuts we all know are needed, IPAB can do the hard work and the politicians won't have to get any blood on their hands. They can decry the cuts as misguided and lament their inability to block them. Everybody gets to evade responsibility, and the policy can actually be set by experts. Whether they will get it right, or whether they will have the scope of authority to bend the curve of health care costs is at this point still an unknown. But changes are needed, and at this time the IPAB is the only credible mechanism we have in place or under consideration.

(image credit: The Incidental Economist)

15 April 2011

Wow oh wow this is great

I'm too tired to write about malpractice insurance tonight, so I offer you this sample of pure refined awesomeness:


I want to be that guy SO MUCH I CANNOT EXPLAIN IT.

14 April 2011

Malpractice Self-Insurance -- Why would you want to, and why you might not

I wrote at some length yesterday about the prerequisites for a medical group to self-insure. What I didn't go into in detail was the why -- the benefits and the risks. I'm going to tackle that a bit today.

Potential Benefits to self-insurance 

Those who have been around a few years can testify that the medical malpractice insurance market is highly cyclic. It seems that about once a decade a crisis hits. Whether this is a rational market is another question entirely. Some have attributed these crises to macroeconomic factors, like the market crash of 2002, after which insurers had to recoup investment losses, or hurricanes and natural disasters in which insurers cost shifted onto other product lines. Other obervers cite skyrocketing medical malpractice losses as the driver of these intermittent price spikes. I don't pretend to know the reason, but it's a reality that prices go up, and sometimes rapidly so, for no apparent reason. Additionally, during these times of market disruption, it's common for carriers to drop clients, leave states they perceive as too risky, or leave the med mal market altogether.

One big advantage of self-insurance is that you can control your own destiny and insulate yourself from these market forces. You set your own premium and it only has to go up if you deem it necessary and prudent. You have a carrier that can is guaranteed to issue a policy, and that will never leave the market. These are not small considerations. I know a group that liquidated because their insurer dropped them and they could not find insurance; a contract management chain picked up the contract. I know several groups whose insurer stopped writing med mal and they were left high and dry. They had to purchase a group tail at an exorbitant mark-up and scramble on very short notice to find a new carrier, whcih was excruciatingly stressful. So to have carrier permanence, guaranteed issue, and premium stability is a huge benefit of self-insurance.

Owning your own insurance carrier is also nice because you get total flexibility over your plan. You want to offer D&O insurance? You want to cover your walk-in clinic, too? Do your docs provide medical back-up at the local marathon? You want to set your policy limits obscenely high? No problem. You have to price it in, of course, but the option is yours.

Of course, you are not going to take on the whole risk yourself. You will, as your own insurer, gain access to the reinsurance market. You have the flexibilty to decide how much of each claim you will handle in house, and what financial level you will outsource the risk. Reinsurance, as a rule, is much cheaper than first-dollar insurance, so you can gain significant savings here. As your company matures and your loss reserves grow, you can adjust the reinsurance limits upward and save yet more. On the other hand, if you are inherently cautious and prefer not to take on too much risk, you can keep the limits lower, for a price, and have peace of mind. 

You have complete flexibility to determine where your premium will be. This is a dangerous freedom, by the way. You do need to be prudent and to ensure that you are funding the plan adequately. But you can fiddle with the numbers -- your actuarial confidence level, your reinsurance level, the amount you want to keep in your loss reserves -- from year to year to at least keep the premium stable. However, this is where excess risk tolerance might not be a good idea. If you starve the plan to keep your premiums low, that can kill you should claims materialize. But properly and carefully managed, the ability to maintain your premium at a consistent level is great for running your business.

Another beneift is the ability to actualize the returns on investments. A self-insurance company maintains capital reserves, loss reserves, and incurred but not reported reserves. This money needs to be invested carefully, but will generate returns over time. Your carrier gets that profit under commercial insurance, but as a self-insurer, you will be able to have your money working for you. There are also many esoteric tax benefits involved in your own insurance company, but they are highly dependent on plan design and other variables, and I am utterly unqualified to do more than note their existence.

As your own insurer, you also have the ability to develop your own approach to claims management. You can decide which cases you will internally review, and which will be outsourced to expert reviewers. You have the autonomy to take a stinker of a case and offer to settle up front before the lawyers get involved. You can ensure that your docs will have the power to consent before any settlement (or the converse, if you prefer). You may find your partners take a much more calculating apporach to the settle-or-fight question, when it is their money to defend a case. But how aggressive you want to be is also under your control. The CW is that plaintiff's attorneys are less enthusiastic about suing a self-insured doc, since they expect more defensive engagement and fewer easy settlements, but that's anecdotal. There are, of course, third-party administrators who will coordinate and assist in claims management. And the claims experience you have, and the information you develop from it will inform your prospective apporach to risk management in your practice.

All this I already cited, of course, is gravy, but not the real killer reason to consider self-insuring. Presuming that you do have exceptional risk management, and that you really can manage your practice such that your claims experience will be better than the actuaries expect, you will have the ability to recapture your premium costs. Commercial malpractice insurance is like life insurance: a gamble in which if you are unlucky enough not to die, you lose your bet and forfeit the premium. Only the lucky stiffs who croak get their money back. Similarly, in the commercial med mal market, if you are unlucky enough to not get sued, you still lose your premium dollars. But if you insure yourself, and you do well in the claims department, you get to keep the premiums as profit. You can do what you like with it -- issue dividends to your partners, reduce future premiums or even take a premium holiday. 

Having said that, my definition of success for a self-insurance med mal plan is more modest; if you can go five years with no significant increase in premiums, you are probably ahead of your brethren in the traditional professional liability market. If you recapture your premium investment, that's like winning the lottery.

Down side to Self-insurance

It ties up your capital. When you buy insurance from a traditional insurer, you are essentially renting the use of their capital and bond rating. As a self-insured group, you need to set aside the capital yourself. You may even need to pay a fronting insurer to provide the rated bonds to satisfy your hospital that your insurance is sound. Depending on how robust your cash flow is, this can be a small burden or a substantial one.

You are also at risk of needing to recapitalize your self-insurance company. A capital call is not the end of the world, not even the end of your self-insurance program. But it is an indication that something is not going as planned, and an excess expense at a time when you may not have planned it.

You are dependent on contractors. Your self-insurance plan will need a plethora of consultants: a captive manager and prgram manager, actuaries and lawyers, auditors and claims managers. It's symbiotic. You are their meal ticket, but your livelihood depends on their getting their job done right, and you have no way of evaluating how well they are doing their job. It's scary. You need to carefully select the people you are working with based on price as well as quality and reliability. Badly done, your plan will be more costly than it need be and may never pay off the dividends you hope for. Worse, it puts you at risk for plan failure.

One thing which is a very small risk but tends to assume an outsize importance in the eyes of many docs is the possibility of a huge verdict -- the newspaper-headline $5- and $10-million jury awards. This really worries docs, that a single lightning strike could wipe out the whole plan. That is, in actuality, not impossible but so improbable that it's barely worth consideration. So long as your insurer (which is you) defends your doc in good faith, its exposure ends at the plan limits, just like a commercial insurer's would. If you are insured by AIG and you lose a case for $10 million, the plan pays to $1 million or $2 million or whatever the policy limit is, and the doc is on the hook for the rest (or the hospital, or other co-defendants). A big award can't come in and wipe out your entire loss reserves. Better yet, of the $1 or $2 million that you are on the hook for, most will be paid by reinsurance. Say you have configured the plan to have re-insurance kick in at $150K, and you get hit by the big verdict. The reinsurer pays $850K and you pay $150K. So your loss reserves and capital are well-insulated from the single big case.

Conversely, the little-appreciated risk is that of numerous small-dollar cases. Four smallish cases where you spend $100K in defense and payouts are much more injurious to your plan than the one big one. In this event, all the money is being paid out under the "deductible," so to speak, and the re-insurance is never kicking in. All of that comes out of loss reserves.

Now if you have losses which exceed expectations, this will result in higher future premiums. You need to recapitalize your loss reserves, maybe recapitalize the plan. Your actuaries will take the losses into account in setting future premiums. Your reinsurers will charge you more in the future if you have cost them a lot. But -- and this is the key point -- the exact same thing applies in the commercial market. If you have losses, the insurer will hike up your premium just as AllState will if you get a speeding ticket. So while it is a risk, it is not a risk unique to the self-insurance market.

Similarly, if the markets tank and you experience investment losses, you also are exposed to that. Hopefully prudent investing will mitigate that risk, but ultimately it cannot be completely avoided.

 

I alluded to this above, but the decisions you make in the plan design can impose excess risk of failure on your plan. For example, when you fund your loss reserves, the actuaries are going to say "we think your losses this year will be $200,000. The 75th percentile confidence level is $325,000, and the 90th %ile is $500,000." And so one. That means that out of every four years, one year will have losses of >$325K, and out of every ten years, one will exceed $500K. You need to decide in advance how much money to set aside for losses. There's a huge spread between the expected loss and the 90th%ile. It's tempting to try to low-ball the plan, and go with a cheaper confidence level for cheaper premiums early on. But if that one year out of four is the first year, you're dipping into capital right away. The set-point for reinsurance is also important. The higher the point where reinsurance kicks in the cheaper it is, and that makes a huge difference in your costs. But if you don't account for the higher deductible in your funding, you can get wiped out with a series of smallish cases.

Summary

The whole basis for self-insurance is that you are accepting risk which has previously been outsourced. Overall, the benefits far outweight the risks (which is why insurance companies exist and are profitable). As long as your group is large enough to encompass the risk, practices solid medicine and is otherwise ready to take on the challenge, it should be a no-brainer. The obligate risks of self-insurance can be mitigated with good plan design, adequate funding, and may well exist even in the traditional insurance market. Moreover, if the whole thing blow up, you can always walk away and re-exit to the commercial market. Self-insuring does not mean that you have to self-insure forever. If there are wrap-up costs, however, they may not be avoidable. but in the end, if your medical risk management is not there and you are getting sued and losing left and right, you were probably not right for self-insurance in the first place.

I've beaten this to death enough for today. I've covered the "who" and the "why," so tomorrow, if I have time, I'll tackle the "how." Meaning I'll address the practical considerations of plan design and implementation.

13 April 2011

Medical Malpractice Self-Insurance -- Is it right for your group?

One of the more painful elements of running a group practice is the ritual abasement before the god-like executives at the insurance company annual malpractice insurance re-bid. It's kind of like a visit to the dentist: guaranteed to be uncomfortable and with the potential for a very unhappy surprise. Also, it leaves your face numb and drooling. The only thing that matches it in pain is writing the check every quarter, year after year, and then looking back at your actual, you know, losses, and seeing that you have paid for insurance way way more than you ever lost in liability claims. It's got the all visceral satisfaction of lighting a pile of money on fire.

But what can you do? You need insurance. What if John Ritter walks into your ER and dies and you get sued for $65 million? So what if we are paying way more than we actually should cost. At least we have that peace of mind that we are covered, right?

There is an option, though. It's not for everybody, and it's not easy, but there is an option.

You can self-insure.

This is a concept that scares the bejeezus out of a lot of doctors, and perhaps for good reason. For one, it's way out of the comfort zone for someone who spent half a lifetime training in clinical medicine. There are lots of foreign concepts and terms and laws and regulations. It involves entrusting the health and future of your practice into the hands of some people that you barely know. It means taking risk onto your own shoulders and with your own money.

So, how do you know if it is right for you?

I look at this through the lens of the doctrine of comparative efficiency. You should not do something, in business, unless you do it better than anybody else can. Otherwise, pay someone better to do it and focus your attention on your core competency. Hopefully you have one. As an analogy, I pay my mechanic to fix my car because there's very good evidence that he can do it better and cheaper and faster than I could. He's probably ripping me off by overcharging for the oil filter, but that's a more or less inescapable friction loss for me. The overpriced oil filter is still cheaper than trying to do it myself. But -- if you happen to be handy with cars, then the equation shifts and maybe it is better for you to maintain your own car.

So, what is it that an insurance company does that you can do better? To answer that, you need to know what it is that an insurance company does in the first place. (Itself an education for many docs.) In short, greatly simplified:

  • They assume the risk inherent in your medical practice.
  • They navigate state insurance regulations and laws, and they employ actuaries to estimate risk and set premiums.
  • They shop and purchase reinsurance. Any decent broker can replicate that function.
  • They sit on a huge pile of money (loss reserves) and invest it. You probably are not going to be much better at investing than the typical insurer. (AIG may be an exception to this.)
  • They review and manage claims and litigation. YMMV, but you'll probably not do this much better or worse than a big insurer.

But there is one thing that a doctor (or group of doctors) can do that an insurer cannot: they can assess their practice internally and take steps to control their risk and create an organization that will have a lower risk profile than the industry average.

We hopefully all do this anyway. We all want to provide high quality care, better patient outcomes, and we want to not get sued. When we take steps to do this, we are generally making money for our insurer. Nothing wrong with that, but if your practice is well run, and if you really are better than the industry average, then maybe it might make sense to reap the financial rewards that come with a lower risk profile.

This is one of the big stumbling blocks for a group that is thinking about self-insuring. You need to apply some serious introspection and self-knowledge to your group before you embark on this sort of project:

Can you cold-bloodedly assess your practice and ask yourself if you are really a better risk than the actuaries think you are? Not all doctors are better than average, though most think they are. If you've had some runs of bad cases, maybe it's just bad luck, but maybe you would still be better off paying someone else to shoulder that risk for you. Get a professional to run the actual numbers to get a gauge on this. It may only make sense if you really have a superior loss history.

You also need to know your organization. Are you staffed with flexible docs who are willing to change their personal practice style, to adopt best practices and to minimize variability? Are your docs willing to adapt to the party line in documentation and use of new technology?  Or do you have a bunch of prima donnas who are not really receptive to suggestions on how they could do things differently?

 

Is your practice willing to enforce standards to the point of firing "Old Bill," the doc that everybody loves but who just isn't at the level of quality that you need? Every group has an "Old Bill," who keeps his job despite the bad outcomes (or whatever) because he's such a great guy and patients love him and he's so earnest about trying to improve. If you and your partners can't bring yourself to pull the trigger on Bill, you shouldn't self-insure.

What's your level of comfort with risk? Are your partners at the same place? There's a chance a self-insurance program could go bad. Are you prepared to face that possibility? Have you gotten a consensus from everybody that the benefits of self-insurance is worth this risk? The risk may be less than you think, and I'll go into that later, but better to worst-case it before jumping in.

How long is your time horizon and how robust is your cash flow? Are you willing to pay higher levels of premiums up front to reap lower premiums or return on your investment later? A short-sighted focus on this year's bottom line can lead to disastrously underfunded plans.

How comfortable is your group with a collectivist approach to equity? Some practices are loosely-confederated bunches of independent contractors, with an "every man for himself" mentality. A group which does not hold assets in common or have a means to calculate shareholders' relative stake might be poorly suited to this sort of collaboration. 

How stable is your contract? This is a medium-to-long-term endeavor. If your contract is up for renewal and the hospital CEO is rattling his saber, now might not be the best time for you to explore this sort of project. 

How deep is your bench? Do you have several partners who are bright and enthusiatic about a self-insurance plan?  Are they willing to dedicate a lot of time to learning about the various facets of how to run one, and then doing so? This will take a lot of administrative mind-space, and if there's just one person who will take responsibility for the administration of a self-insurance plan, it's probably not going to turn out well.

Finally, and perhaps most importantly, is your group big enough to support a self-insurance plan? There is an economy of scale, below which the internal costs of a plan may never really work out for you, financially. I've heard a lot of estimates, and there are too many variables in terms of how you construct the plan, but if your premium base is less than $500,000 a year, the numbers may not work out. (You definitely need professional advice in answering this question.)

 

I think I mistitled this post -- it should read "Medical Malpractice Self-Insurance -- Is your group right for it?" This is a hugely complex issue, so I am going to break it down into several separate posts. Tomorrow I will address "Self-Insurance -- why would you want to, and why not?"

12 April 2011

Happy Birthday EMTALA?

Apparently it was 25 years ago that President Reagan signed the COBRA bill into law, which contained the EMTALA provisions. How time flies!

EMTALA has been an incredible double-edged sword for Emergency Departments and for the healthcare system in general. It has by far been the most transformative piece of healthcare legislation since medicare itself was enacted. Off the top of my head, for better and for worse:

It's protected patients. There were rampant abuses of patients who were less lucrative prior to EMTALA. Patients were turned away at the doorstep, refused care, wantonly dumped on neighboring facilities who operated on a "Good samaritan" basis, if there were any. It's given patients the ability to choose the institution they will get their care at, knowing they can't be railroaded against their will, and that needed care will be provided. That's an unmitigated good thing.

Created de facto universal health care, albeit limited, inefficient and incomplete. Any person, of any economic or legal status can walk into an ER and know they will get necessary emergency care, if there is a need. Not so great for chronic or non-emergent conditions, and not great for preventative care or post-acute care. Obligates not just ER doctors but specialists to provide needed care.

Indirectly increased access to emergency care by knocking down barriers raised by insurers. This was not immediate, but EMTALA was the club wielded to limit requirements for pre-authorization of ER services, and ultimately paved the way for the national "Prudent Layperson" standard.

Forced hospital ERs to embrace their role as community service centers and as the ultimate social safety net. This was accepted eagerly by some hospitals, more reluctantly by others. It has, however, given EM as a specialty the ability to wear the white hat, has given ER docs tremendous credibility and respect as the guys who will always do the right thing for the patient.

It's been an enormous unfunded mandate, which has forced many individual docs to work for free, and hospitals to provide charity care. The (un)fairness of this is one matter, but the practical effect has been that ERs where the EMTALA burden is higher are underfunded, poorly staffed and poorly capitalized. The requirement, without real funding to support it, has created a two-tier healthcare system where hospitals in less affluent areas struggle to provide critical and necessary services, and patients experience tremendous delays in care and poorer outcomes. Additionally, the unfunded mandate puts stress on specialists who are needed to provide on-call backup. On-call duty by its nature is unpleasant and disruptive, and the fact that it often becomes unpaid work increases this stress, to the point that many ERs can no longer maintain adequate specialist back-up. This affects all patients, regardless of insurance status, if there is no specialist to provide needed care.

Enabled the abuse of the ER for non-emergent complaints. Under EMTALA, if a patient presents with a clearly trivial or chronic complaint, the ER cannot turn them away, at least not without providing the mandated medical screening exam. While it is possible to short-change the exam and redirect/rebuff the patient at the front desk, this is infrequently done and fraught with risk. The practical matter is that the patient has to be registered, triaged and screened by a medical provider no matter what. At that point, in most cases, it's easier to finish treating the patient for their hangnail, medication refill or what-not. It has created a situation where the patient reasonably expects that they can receive care for anything at any time in the ER, thereby transforming our function from acute and critical care into convenience care. I cannot count how many times I have seen people in the ER who had access to more appropriate venues of care just because they didn't want to wait for an appointment or overcome with the hassles of dealing with office staff. It doesn't help that ACEP, in its efforts to justify our work as lifesaving and critical, falsely minimizes the tremendous amount of non-emergent care provided in the ER by repeating and publicizing misleading factoids. EMTALA, while it opened the ER to all, also precluded ERs from filtering out the patients who didn't need to be in an ER.

I could go on, but I won't. I'm sure you all can provide some other unanticipated effects of EMTALA in the comments. On the whole, I'd judge EMTALA as a good and successful law, though grievously flawed and in need of amendment.

Now don't even get me started on HIPAA.

09 April 2011

Beat Poetry

Ordinarily, a nine-minute animated beat poem is something I would subject myself to only under extreme duress, and not willingly. So recently when I began seeing links to this pop up, my eyes immediately glazed over and I hit the "next" button in my RSS reader.

Then I looked a little closer and realized it was Tim Minchin. That changed things a lot. It's nine-minutes of sheer unadulterated brilliance.

Watch it. If you only watch one nine-minute animated beat poem in your life (and one may be all that I have in me), this is the one to watch. It tells the story of a dinner party where he confronts a credulous hippie. Good stuff.

07 April 2011

How things change -- CT scans and radiation

There was an interesting study published this week in the journal Radiology: 

Rising Use of CT in Child Visits to the Emergency Department in the United States, 1995–2008 (Abstract)

The results are not surprising to anyone who has been working in medicine in the US over the last fifteen years. Basically, in 1995, a kid visiting the ER had a 1.2% likelihood of getting a CT scan, and by 2008, that number was 5.9%.

I had written about this general phenomon not too long ago, in defense of the general increase of CT utilization in the ER, largely on the basis that CT is a better tool: it provides diagnoses in a rapid and timely manner, and excludes many potential life threats, saving lives and mitigating malpractice risk. That was largely relevant to the adult population, though, and kids are not, as they say, just little adults. The increase in scanning children is more dramatic, especially given the generally lower incidence of disease in kids compared to adults and the chonrically ill.

The experience I have had in the ER was comparable to the study findings. When I started training in the mid '90s, CT scans were time-consuming, offered less than excellent images and were relatively uncommon to get in general, let alone in pediatric populations. By the time I started practice in 2000, things had changed dramatically. The image quality and diagnostic information a scan provided was way better. The development of high-speed helical scans made it much easier to get them on kids without sedation, which greatly lowered the operational barrier to getting them. The overall accessibility and use of scans were rising and the pediatric use rose in lockstep. There was little concern about the risks of radiation or the downside of getting a scan on a kid if there seemed to be a clinical indication. This was largely (but not entirely) driven by percieved malpractice risk, especially in the hot-button liability scenarios of head injuries and potential appendicitis. The feeling was that the consequences, both human and financial, in missing an epidural hematoma in a child were so gargantuan, and the risk inferent in the radiation so trivial, that why not do it? We ordered scans willy-nilly, it seems in retrospect.

Appendicitis is a little different. There is the fact that you had other options, including ultrasound, observation, and surgical consultation. So CT was not used quite as profligately for potential appendicitis. But for some cases (and some docs) it did become the test of choice. Ultrasound is frustratingly insensitive, time-consuming and operator dependent. Surgeons are difficult to get to come to the ER for a consult. And, especially in the malpractice insurance crisis in the early part of the decade, many docs were uncomfortable with the risk inherent in watchful waiting. This is not to excuse, but to explain why CT rates shot up, at least in my experience.

But a very welcome countervailing trend has definitely arisen over the past four years or so, especially in but not limited to the pediatric population, as the risks of radiation with regard to lifetime cancer incidence have become better understood and better publicized. This has spurred a change in practice in our ER, driven by the clinical leadership in concert with our radiologists and pediatricians. I don't have numbers, but it seems like the use of scans for kids has slowly dropped and dropped over this time frame. 

We have been assisted in this by the development and validation of some good decision-making rules for selecting the kids with head trauma who are likely to benefit from a CT scan. There's also increased awareness and acceptance amoung patients and their families. It used to be that parents had an expectation of and even advocated for CT imaging. I've always been more of a diagnostic minimalist, and back in the day I would have to really go out of my way to convince some parents that a CT scan was not necessary. Now it seems all I have to say is that "We have learned that this is a lot of radiation to focus on a growing brain/set of genitals," and the parents are nodding and very accepting of my explanation that their child is not likely to benefit from a scan. We have also developed algorithms for the evaluation of abdominal pain which make it pretty clear that CT scans are discouraged unless there is a darn good reason. So things are changing, and for the better.

I recall a couple of years ago I blogged about a difficult diagnosis of appendicitis and the need to scan a young boy. It was complicated by the fact that the parents, from the Ukraine, has a remarkable fear of radidation, due to the Chernobyl incident. I had reassured the parents that "I had a five-year-old son, and if it were my son with the same pains, I would not hesitate to put my son in the scanner." At the time, that was true. I'm not so sure that I would make that assurance today. Now, I am much more likely to treat kids with observation (either in house or at home).

The pendulum swings, but ever so slowly.

Laugh out loud



they got me

04 April 2011

Pride (in the name of love)

U2 remembers MLK

God I miss the old U2, before Bono became an international brand...

Back -- to the Future!

Turn on your wayback machines, and dial them back to the summer of 2009, a wild and crazy time when Ugg boots and "Epic Fail" were fresh and hip trends. The US Congress adjourned for the season and went home to an unanticipated frenzy in their districts, as enraged citizens mobbed their townhall meetings to rant against nonexistent death panels, demand that government stay out of their medicare, and decry government-run health care as the greatest affront to personal liberty since, I dunno, the minimum wage or internment camps or something. It didn't make much sense at the time, and makes less sense when view through the filter of posterity, 21 months later.

 

Anywho, here we are in the dystopian future under ObamaCare and surely as FreedomWorks predicted, we are seeing unprecedented infringements on individuals' autonomy with regard to healthcare and lifestyle choices. Did you know that the federal government is now going to be attaching a special healthcare tax (or penalty or fine or or "premium adjustment" or whatever euphemism for a tax you choose to use) on people who choose to disregard the orders of their assigned healthcare provider? Yes! If your doctor says you should stop smoking, and you don't, or if your doctor suggest that you're getting a little chubby and maybe you should lose some weight, then Obama will levy a fine on you for refusing to kowtow to the PC wisdom of the day. Yes, you read that right: you will be taxed for being fat, and you will be taxed for smoking if the government in its paternalistic wisdom decides that you should not. Next thing they will want to put a special tax on soda pop and sugary drinks!

 

If that isn't an governmental intrusion into the personal liberty of private citizens, then I don't know what is.

 

Oh, wait, did I say it was Obama and the federal government? Sorry, that was a typo. Or a pun. Possibly an anagram. My bad. In fact, it's the republican governor of Arizona who is advocating these new rules, and they only apply to poor people. So all that about "individual liberty" and "freedom of choice" and all that -- you know, never mind. "Personal responsibility" or something. It's only an affront to liberty when it's proposed by a Democrat, or when it applies to people who matter with money.

 

Move along. Nothing to see here.

 

01 April 2011

Bizarre Juxtaposition

My last couple of posts reminded me of another interesting situation I once found myself in when I was in training at the Big Hospital in the Inner City.

It was a routine day. I was seeing a young inner city youth who had been administered some street justice in the form of a "punkin head." We'd done the primary survey and were moving on to the next segment of the trauma exam when the charge nurse told me that she had put another patient into one of my rooms. It was an old lady named Mrs. B_________ and I needed to go see her right away. She was being evaluated for fainting. Perplexed as to why I was being asked to leave the trauma for an apparently stable elderly syncope, I instructed her to get an things started with the trauma and I'd be right back. I went over as soon as I could and introduced myself to Mrs. B_________, took a brief history of what sounded like garden-variety old lady syncope, and did a quick exam. Nothing seemed out of the ordinary, and I ordered an ECG and labs and went back to my trauma.

Now this young man who had been beaten had assured me that he did not do or have anything to do with drugs, and he had seemed earnest. Since, in that neck of the woods, there was so little stigma involving drugs most users/dealers freely admitted their involvement. So I took him at his word (I know, I know -- rookie error, but I was still in training), and I was really mad when I took off his shoe and a couple dozen vials of high-grade purified heroin fell out and into my hand. (No needles, fortunately) The vials were neatly packaged for sale and probalby represented several thousand dollars worth of inventory. I was really angry at being lied to, and I needed to walk away to cool off. At that time, the nurse brought me the ECG from Mrs. B_________, and I reviewed it. The heart rate was quite slow, probably from her beta-blockers, and that was, I surmised, the cause of her syncope. I wandered back over to her room while the techs were doing x-rays on the trauma kid. I stopped by my attending to show him all the heroin and to see if he knew what I should do with it. He opined that I should find a cop in the ER and give it to him. A nurse volunteered that I should just flush them. Someone else said I should put it back in his shoe or the kid might get killed for losing the drugs.

Still musing, I walked into the room to check on Mrs. B_________. She was okay, and I explained what we had found on the ECG. In walked her husband, whom I immediately recognized and greeted as Senator B_________. It was a delight and an honor to meet him, a famous and historic national politician, and I eagerly shook his hand. He was warm and personable, and I explained that we had a good idea why his wife had fainted. I wanted to show him the ECG, but I had been forced to juggle the packages of heroin and the ECG in my left hand while I shook his right hand. So, I said, "Well, Senator, I think we know why your wife fainted," while holding out a fistful or heroin vials towards him. At least that's what he saw! His eyebrows went up quizzically, and I quickly moved the ECG back onto the top of the pile to show him the tracing. I dropped the vials into the pocket of my scrubs and reviewed the situation with him. He was polite enough not to mention it further, though during the rest of our interaction I couldn't help but notice his eyes kept going back to the pocket of my scrubs with a curious expression.

So eventually it all worked out. The kid went to the OR for his facial fractures, Mrs. B_________ went to the CCU, and the heroin was placed in the custody of hospital security (and I never found out what they did with it). But it was a, how shall we say, unique experience, that I was shaking the hand of a US Senator while clutching a fistful of heroin (insert politician joke here).

Ah, I miss life in the Big ER. It was pretty crazy there. But I don't miss it too much; I'll not be leaving my lower-middle class suburban paradise anytime soon.

Sarah Palin must be smiling

Ah, it's April Fool's Day (as I am sure you all figured out by now, having seen the Google logo for the day), and yet again, some dirty bloggers have managed to get egg all over the face of the bastion of the Lame-Stream Media, the Gray Lady herself, the New York Times.

This isn't the first time the NYT has been snookered by bloggers on April first, and in fact the same crew last year managed to pull off a less impressive version of today's epic pranking. For context, last year some law blogger claimed he was named the official White House law blogger, and made a brief appearance in one of the sort-of-blogs in the Times before they got wise and pulled it down. This year, though... wow! Front page, and with a photo! Better check it out quick before they pull it down.

UPDATE: I seem to be having trouble linking with the NYT's new suicide machine paywall. Ramona has the goods over at Suture For A Living.