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How Medicare will pay doctors

Wednesday, September 29th, 2010

UPDATE: Those interested should read this article in the WSJ today about the rapid consolidation of American medicine taking place right now, not in 2014.

Across the country, providers are building giant hospital systems and much tighter doctor alliances like multispecialty groups to get out ahead of a concept known as “accountable care organizations,” or ACOs. To modernize the delivery of medical services, ACOs would encourage doctors to work in teams to use resources more efficiently, streamline treatment and improve quality. The model is the Mayo Clinic and other large integrated systems.

Of course, the Mayo Clinic has concluded that it cannot treat Medicare patients and survive, as many of its Medicare members learned a few months ago.

At the moment ACOs are only a gleam in some bureaucrat’s eye, and no one has a clue how they’ll operate in practice until the government releases a working regulatory definition next year. Yet the percussive effects are already being felt across medicine.

Hospitals are now on a buying spree of private physician practices in the rush to build something that will qualify as an ACO. Some 65% of doctors who changed jobs in 2009 moved into a hospital-owned practice, while 49% of doctors out of residency were hired by hospitals, according to the Medical Group Management Association. In its 2010 census, the American College of Cardiology reports that nearly 40% of private cardiology groups are currently integrating with hospitals or merging with other practices.

Doctors are selling because complying with the ever-growing list of mandates has become more cumbersome; and while staff physicians on salary do gain predictability, they also lose the autonomy of independent practice. The other problem is price controls in Medicare, which are about 20% below private payments for doctors and 30% lower for hospitals. Hospitals are also scooping up practices to lock in referral sources and make up for ObamaCare’s Medicare cuts. As it is, two-thirds of hospitals lose money today on Medicare inpatient services, according to Medicare.

I get these e-mail articles from several industry sources, some of which sell practice management, others supported by ads. This one looks interesting for those who are wondering what Obama will do to Medicare. This is not Obamacare but Medicare will be heavily affected since his plan intends to take $500 billion from Medicare to pay for the Obamacare new enrollees.

Physician Payment Reform: What it Could Mean to Doctors – Part 1: Accountable Care Organizations

Kenneth J. Terry, MA

Introduction

The fee-for-service method of payment is wearing a bulls-eye target. It’s been blamed as a major factor in high healthcare costs, and as a result, Medicare and private insurers are exploring new ways to provide patient services and to pay doctors for those services. The new models vary, and some will be more appealing — or less unappealing — than others. This series will explore proposed payment models, what they could mean for doctors, and how they may affect physician incomes. We’ll start by looking at accountable care organizations.

Quick Summary: An accountable care organization (ACO) is a contracting group accountable for the quality and cost of care provided to a defined population. It may be led by a hospital or a physician organization, and may be a single business entity or include multiple entities. An ACO must include primary care doctors, must manage care across the continuum of care settings, and must measure and provide data on the quality of care.

This is nothing new in California where they are called IPAs (Independent Practice Associations) and are run by a board of directors. They contract with insurers as a single entity, subtract a healthy management fee and then pay the individual doctors by various formulas. I was involved in this although avoided being a board member pretty much because, as a surgeon, it is easy to alienate the treating doctors and surgeons rely on referrals. The GPs make out fairly well but there are lots of perverse incentives. For example, there are bonuses for meeting goals for keeping cost down. Some of the GPs ended up with 50% of their income from the annual bonus.

How Doctors Get Paid: There are 2 reimbursement models. In risk-taking ACO arrangements, organizations take financial responsibility for all inpatient and outpatient care and can profit by meeting quality goals and by keeping the cost of care under budget. Under the shared-savings model that Medicare will use, physicians get paid fee for service and can split savings with Medicare if they reach benchmarks on quality measures. A single ACO can have both kinds of contracts.

The IPAs were conceived as an alternative to HMOs, first seen in the Competitive Practice Act from its first incarnation in 1974. It was the model of Paul Ellwood, who liked the Kaiser HMO and tried to make that the national model. He had only non-profits in mind and has become disillusioned in recent years. The for-profit HMOs figured out that they did not have to build a large infrastructure like the Kaiser system. They could simply set up their own “HMO without walls” and go around offering terrible contracts to local physicians who were afraid of losing all their patients. The IPA was created as an attempt to control this race to the bottom. The results have been spotty but better thann the alternative.

Pros: As reimbursements decline, ACOs offer an alternative source of revenue for physicians while giving them the infrastructure and the information systems they need to improve the quality of care across the board. Primary care doctors should do especially well financially because they’re key ACO players.

Cons: The ACO model is set up to gradually transfer more financial risk to providers, forcing doctors to become more efficient. They will also have to follow clinical guidelines and have their quality measured continuously. In some markets, a shift to ACOs will accelerate hospitals’ employment of physicians, hastening the demise of private practice in those areas.

I think this is where this will go. Hospitals are employing more and more doctors and, especially in smaller population areas, this will be the only viable model for Medicare. Hospitals will run clinics for Medicare patients run by nurse practitioners.

Where ACOs Stand: Many large medical groups and independent practice associations (IPAs), especially in California, are ready to become ACOs. Some hospital systems with large employed groups could do the same fairly rapidly. This activity will undoubtedly grow before Medicare launches its ACO program on January 1, 2012.

Physician Payment Reform: What it Could Mean to Doctors – Part 2: Global Payments

Leslie Kane, MA

Introduction

Quick summary. Doctors in a solo practice, group practice, or large organization would be evaluated on the cost of the resources they use to manage their patient population. The premise is that by paying attention to the total cost of patient care instead of payment for each individual service, physicians can focus on ways to manage the cost and quality of patient care more effectively. Global payment plans would address the financial risk that plagued earlier capitation plans by taking into account the healthcare resource needs of patient populations. Global payment plans also require data reporting and quality measurements.

Ever heard of death panels ? The global payment for a large population will force medical groups to concentrate resources on some of those patients and triage the rest.

How doctors get paid. There are variations, but typically, insurers pay claims as services are rendered. If doctors keep total healthcare costs under the annual target for overall patient care, they get to share in the savings. For large provider organizations, in some proposed global plans, insurers make estimated advance payments to the physician or group; withhold payment for services that the group doesn’t provide; and periodically reconcile with the group.

Pros. Global payments help address the problems of rising healthcare costs. Some proponents believe that physicians will make greater use of email, telephone calls, and care teams involving mid-level practitioners for patient communication and management, which doctors previously rejected because those activities did not get reimbursed. Global payment plans place a strong emphasis on primary care. Insurers say doctors can focus on improving a patient’s health instead of being concerned with how many patient visits or services are involved.

This is the end of seeing the doctor for Medicare patients. They will be seen in clinics as noted above. “Improving a patient’s health” is mostly BS although there is a model that can do that. I once wasted a lot of time trying to get a university hospital to adopt it. It involves very elderly people, often called the frail elderly, who are often living in assisted care homes, not nursing homes. Many are couples. There have been pilot programs in which these 85 year olds going through an intensive evaluation involving an internist, a pharmacist and a psychologist. Many of them are taking medications that interact with each other. They may have other chronic problems. The theory, and it has been tested several times in pilot studies, is that you spend more money the first six months or so and the care of these people costs less money after that. They are also in better shape. The barrier is spending more money that first year and, if you think the Obama people are going to go for a program like that, I have a bridge to sell.

Cons. Most physicians will need to plan more carefully how to proactively manage their patients and will need to retool their practices away from the current focus on patient visits. They will also need to pay more attention to the cost of care that they are delivering or referring. Doctors who don’t pay attention to costs and to the avoidance of admissions and complications are likely to earn less than they did under fee for service. They will have to consciously try to limit costs and, in most cases, aim for specific quality targets. The larger concern is that doctors may find themselves pitted against patients who want care that involves the most costly treatment alternative or that may be unlikely to improve patient outcomes.

Doctors’ incomes from Medicare are already so low, they are dropping out of the program.

Physician Payment Reform: What it Could Mean to Doctors – Part 3: Bundled Payments

Shelly M. Reese

Introduction

Summary. Unlike the current fee-for-service system in which each provider who cares for a patient is paid for the different services he or she provides, a bundled payment — also known as an “episode of care” or “case rate” payment — is a single payment covering a particular episode of care, such as a myocardial infarction or a hip replacement. Multiple providers in multiple settings may share in the payment for a patient’s episode of care. An episode of care could encompass a period of hospitalization, hospitalization plus post-acute care, or a defined time frame of care for a chronic condition.

This is already the way IPAs work and I have negotiated methods of payment for surgeons. There are some benefits to this system if the global payment is fair. In our IPA, we instituted a system in which surgeons were paid a monthly fee that was shared among all the other surgeons of that specialty in the IPA. The share for each surgeon was determined by the number of new patients he/she saw each month. That made it easy for GPs and internists to get their patients seen quickly. The surgeons were NOT paid by the number of surgeries they did each month. When that system went into effect, back surgery dropped by 40%; General Surgery, my specialty did not change. The implications are pretty clear. Not all of this stuff is bad.

How doctors get paid. A bundled payment is made to a hospital, which divides the payment between the hospital and all of the providers who cared for the patient. If the cost of an episode of care is less than the bundled payment amount, typically the hospital and physicians share the difference; physicians may receive a bonus. If the cost of care exceeds that of the bundled payment, the hospital and doctors bear the financial liability.

This will be another driver of hospitals hiring physicians. Hospital administrators hate physicians because they are disruptive to smooth operation. They keep demanding things for their patients. That will stop when they are employees. There may not be enough jobs in some specialties.

Potential benefits. Proponents of the system hope it will give providers a greater incentive to coordinate care, thus improving outcomes and reducing waste and unnecessary care.

Potential problems. Physicians worry that hospitals will get the lion’s share of payments and that those unaffiliated with hospitals or integrated networks will find it difficult to participate. Some worry it could put patients at risk because providers might shun very sick patients as too expensive to treat. Access to specialists could be limited. Defining an “episode of care” can be difficult for certain illnesses and chronic conditions.

These are obvious concerns, or should be.

Physician Payment Reform: What it Could Mean to Doctors – Part 4: Prometheus Payment

Kenneth J. Terry, MA

Introduction

Quick summary. One of the current experiments in payment bundling, Prometheus Payment rewards physicians for practicing efficiently and avoiding complications. Prometheus care teams negotiate all-inclusive case rates according to evidence-based guidelines for episodes of acute and long-term care.

How doctors get paid. Physicians are paid fee for service, which is a debit against the case rate. They can share a withhold if their team prevents avoidable complications.

I don’t know if this is bad or good. Some doctors have high complication rates and there is little that can be done unless they are egregious.

Pros. Physicians stand to receive bonuses for high-quality, efficient care without being at financial risk.

Cons. Physicians need the infrastructure of a large organization to make this model work.

Where it stands. The private organization behind Prometheus is conducting four pilot projects across the country, and more are on the way.

Whether Prometheus will catch on, however, depends on whether its incentives to follow evidence-based guidelines will eliminate enough waste to fund quality-based bonuses for physicians.

Conceived by a health policy experts and healthcare, insurance, and employer leaders, Prometheus Payment received a $6 million, 3-year grant from the Robert Wood Johnson Foundation in 2007. The Healthcare Incentives Improvement Institute, Inc, a Newtown, Connecticut, think tank housed at Bridges to Excellence (a national, employer-sponsored pay for performance program), is working with the pilot organizations to develop a variety of approaches to the Prometheus concept.

There could be some benefit to this concept but the temptations inherent in Obamacare are the source of much moral hazard.

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Posted in economics, health reform, medicine | 3 Comments »

A Nexus Between Medical Journals and Government.

Monday, July 5th, 2010

The Wall Street Journal has one more article on the effect of Obamacare on doctors. A couple of interesting statements bring up some statements on an excellent medical blog I read.

First the WSJ points about Obamacare.

The act will reinforce the worst features of existing third-party payment arrangements in both the private and public sectors — arrangements that already compromise the professional independence and integrity of the medical profession.

Doctors will find themselves subject to more, not less, government regulation and oversight. Moreover, they will become increasingly dependent on unreliable government reimbursement for medical services. Medicare and Medicaid payment, including irrational government payment updates, are preserved (though shaved) and expanded to larger portions of the population.

The Act creates even more bureaucracies with authority over the kinds of health benefits, medical treatments and procedures that Americans get through public and private health insurance. The new law provides no serious relief for tort liability. Not surprisingly, various surveys reveal deep dissatisfaction and demoralization among medical professionals.

I’ve been posting about this for a couple of years and it is no surprise.

Now here is where it gets interesting.

On top of existing payment rules, regulations and guidelines, the new law creates numerous new federal agencies, boards and commissions. There are three that have direct relevance to physicians and the practice of medicine, and the nature and scope of the regulatory regime will be decisive.

Under section 6301, the new law creates a “non-profit” Patient-Centered Outcomes Research Institute. It will be financed through a Patient Centered Outcomes Research Trust Fund, with initial funding starting at $10 million this year, and reaching $150 million annually in Fiscal Year 2013, with additional revenues from insurance fees.

Don’t you think the “Patient Centered” touch is a nice one ?

In effect, the Institute will be examining clinical effectiveness of medical treatments, procedures, drugs and medical devices. Much will depend upon how the findings and recommendations are implemented, and whether the recommendations are accompanied by financial incentives or penalties or regulatory requirements.

Under section 3403, there will be an Independent Payment Advisory Board, with 15 members appointed by the president. The goal of the board is to reduce the per capita growth rate in Medicare spending, and make recommendations for slowing growth in non-federal health programs. It’s hard to imagine any other outcome other than continued payment cuts.

Now, we turn to the blog I mentioned. The author, a cardiologist mostly retired, discusses a recent randomized clinical trial. The way we decide on “clinical effectiveness” in an ideal world is randomized trials. They are the Gold Standard. So how was a recent randomized trial treated in a major medical journal? From the blog.

This week, the Archives of Internal Medicine published four (four!) articles assaulting the legitimacy and the importance of the JUPITER trial, a landmark clinical study published in 2008, which showed that certain apparently healthy patients with normal cholesterol levels had markedly improved cardiovascular outcomes when taking a statin drug.

Superficially, at least, the JUPITER study appears to have been pretty straightforward. Nearly 18,000 men and women from 26 countries who had “normal” cholesterol levels but elevated C-reactive protein (CRP) levels were randomized to receive either the statin drug Crestor, or a placebo. CRP is a non-specific marker of inflammation, and an increased CRP blood level is thought to represent inflammation within the blood vessels, and is a known risk factor for heart attack and stroke. The study was stopped after a little less than two years, when the study’s independent Data Safety Monitoring Board (DSMB) determined that it would be unethical to continue. For, at that point, individuals taking the statin had a 20% reduction in overall mortality, a dramatic reduction in heart attacks, a 50% reduction in stroke, and a 40% reduction in venous thrombosis and pulmonary embolism. All these findings were highly statistically significant.

This is a dazzling result for a randomized trial. Usually, you are looking at small changes and trying to calculate the “p value” to see if it is significant. Why would a journal publish attacks on such a dramatic study ?

If medicine were practiced the way it ought to be – where the doctor takes the available evidence, as imperfect as it always is, and applies it to each of her individual patients – then the incompleteness of answers from the JUPITER trial would present no special problems. After all, doctors never have all the answers when they help patients make decisions. So, in this case the doctor would discuss the pros and cons of statin therapy – the risks, the potential benefits, and all the quite important unknowns – and place the decision in the perspective of what might be gained if the patient instead took pains to control their weight, exercise, diet, smoking, etc. At the end of the day, some patients would insist on avoiding drug therapy at all costs; others would insist on Crestor and nothing else; yet others would choose to try a much cheaper generic statin; and some would even opt (believe it or not) for a trial of lifestyle changes before deciding on statin therapy.

This is the way we all want to practice. “Best Practice” they call it.

But in recent years, and especially now, as we bravely embark on our new healthcare system, this is not how doctors will practice medicine. Instead, they will practice medicine by guidelines. These guidelines (which, in modern medical parlance, is a euphemism for “directives”) are to be handed down from panels of experts, identified and assembled by members of the executive branch of the federal government.

And this makes the stakes very high when it comes to a clinical trial like JUPITER. For guidelines do not permit a range of actions tailored to fit individual patients (consistent with the uncertainties inherent in the results of any clinical trial). Instead, guidelines will seek to take one of two possible positions. That is, under a paradigm of medicine-by-guidelines, the results of clinical trials generally cannot be permitted to remain imperfect or nuanced or subject to individual application, but must be resolved by a central panel of government-issue experts into a binary system – yes (do it) or no (don’t do it). In the case of JUPITER, the guidelines must decide whether or not to recommend Crestor to patients like the ones enrolled in the study, at a potential cost of several billion dollars a year. It should be obvious that the answer which would be more pleasant to the ends of the central authority, and by a large margin, would be: No, don’t adopt the JUPITER results into clinical practice.

Well, we shouldn’t worry because all doctors, and especially well known academics are ethical. Right ?

Right ?

Now comes the interesting part and I think he is absolutely correct.

This, DrRich submits for your consideration, is likely what instigated the almost violently anti-JUPITER issue of the Archives this week. DrRich theorizes that what we’ve got here is a bunch of wannabe federally-sanctioned experts, auditioning for positions on the expert panels. What better way to get the Fed’s attention than to let them know that you are of the appropriate frame of mind to assiduously seek out scientific-sounding arguments to discount the straightforward and compelling, but fiscally unfortunate, results of a well-known clinical trial?

Of the four papers appearing in this week’s Archives, three are more-or-less legitimate academic articles that make reasonable points, but do no harm to the main result of JUPITER. The fourth is a straightforward polemic, which has no place in a peer-reviewed medical journal, and whose very presence, DrRich believes, very strongly suggests that the editors of the Archives themselves must be auditioning for the Fed’s expert panel.

Most doctors resent guidelines unless they are obviously data driven. Most of that data comes from randomized trials.

What we are seeing her is the erosion of the ethics of those who publish and conduct such studies and who use them to establish guidelines. There is another type of guideline, call “consensus guidelines” in which a committee of “experts” debates the best practice. These are the guidelines most doctors distrust. Now we see the corruption of even the randomized trial as a source of data driven guidelines.

Posted in corruption, economics, health reform, medicine, science | 9 Comments »

How not to reform health care.

Friday, June 11th, 2010

The academic world of health care likes the Obama health “reform” act. They are now figuring out how it will affect healthcare since it is a slapdash combination of pork barrel projects and untested assumptions. For example, it uses all the old command and control theory to deal with utilization and cost.

For years, the debate over health care has rested on the assumption that the uninsured should be brought into the health-care system the rest of us use. But what if something like the opposite is true? What if the best way to help the uninsured is to make the health-care delivery system they already use — the St. Elsewhere model — better, more efficient, and more affordable — in short, more like the VA? And what if, eventually, the rest of us could join that system?

Longman says the first step is covering the uninsured, particularly low income people. We’re on that path now with the passage of health reform. But we don’t have to put all the newly covered people into the current strained fee for service system and Medicaid. He proposes creating the “Vista Health Care Network” (VistA is the name of the VA’s electronic medical record system). Invite the “St. Elsewheres” and individual doctors to join an integrated delivery system to serve the newly insured. Like the VA, it would have a team approach, use health IT and comparative effectiveness protocols. Doctors would be salaried, and rewarded for quality not quantity. In other words, it would be what has now become known as an “accountable care organization.”

This is the standard fantasy of the political left. If we could just get rid of those evil profits and monetary incentives, everyone would adopt the virtues of the Utopia. Marx said “to each according to his need and from each according to his ability.” That may work well in religious communities where everyone is concerned with salvation. It doesn’t work in the real world, as anyone who studied the Soviet Union or Cuba should attest.

Longman predicts many struggling hospitals would see it as a lifeline. “Reimbursement rates would be set much higher than in Medicaid, and when combined with the efficiency in the VA model of care, they’d be high enough to guarantee the solvency of participating providers.”

Does anyone really believe that ?

The hospitals that take Vista’s offer would have to radically change the way they do business. They’d have to join the twenty-first century and integrate health IT into the practice of medicine. They’d have to embrace the VA’s safety culture. They’d also have to shed acute care beds and specialists and invest in more outpatient clinics in which, for example, diabetics could learn how to manage their disease, or people with high blood pressure could join smoking-cessation and exercise programs.

Where would the sick people go, if not to the hospital ? The graveyard ?

As with the VA, there would also be much more emphasis on integrated mental health-care and substance-abuse programs. Also as with the VA, doctors who work for these hospitals would be salaried and earn bonuses for effective performance (keeping their patients well). No longer would doctors have financial incentive to engage in overtreatment.

Yes they would have an incentive to under treatment. Sort of like the Netherlands ER doctors who give emphysema patients a lethal injection of morphine rather than admit them to the hospital. A doctor who admits an emphysema patient with respiratory failure is fired. Period. NO appeal. Everyone knows the rules. Except the families.

There is another opinion, well summarized in another medical blog. His posts are heavily embellished with humor that not all will appreciate. His ideas, however, are right on the money.

Until quite recently, DrRich counted himself among the stalwarts of scientific strict constructionism. He was truly dismayed that the NIH and some of our most well-regarded academic centers (under the guise of wanting to conduct objective “studies” of alternative medicine) have lent an aura of respectability and legitimacy to numerous bizarre ideas and fraudulent claims masquerading as legitimate medical practices. To DrRich, such developments were yet another clear and unmistakable sign of the End Times.

Furthermore, DrRich (a well-known paranoid when it comes to covert rationing) saw a more sinister advantage to the official and well-publicized support that government-funded institutions were giving to the alternative medicine movement. Namely, fostering a widespread impression among the unwashed rabble that alternative medicine is at least somewhat worthwhile (and plenty respectable) advances the cause of covert rationing. That is, the more you can entice people to seek their diagnoses and their cures from the alternative medicine universe, the less money they will soak up from the real healthcare system. With luck, real diagnoses can be delayed and real therapy put off until it’s far too late to achieve a useful outcome by more traditional (and far more expensive) medical means.

I think there is some truth to this. Chiropractors, for example, have made good use of the myth that their services are far cheaper than conventional medicine and therefore a money saver. The legislators who vote for these “money saving” changes in the law have never spent much time looking at the house size of chiropractors compared to MDs. In the Workers Compensation world, I have seen a case in which a disabled worker received 900 chiropractic treatments in one year.

Rather than a term of opprobrium, “alternative medicine” may actually be our most direct road to salvation. Indeed, DrRich thinks that far from damning alternative medicine, we should be blessing it, nurturing it, worrying over it, in the precise manner that a mountaineer trapped in a deadly blizzard would worry over the last embers of his dying campfire.

What turned the tide for DrRich was a recent report, issued by the U.S. Centers for Disease Control and Prevention, estimating that in 2007, Americans spent a whopping $34 billion on alternative medicine. That’s $34 billion, for healthcare (in a manner of speaking), out of their own pockets.

The implications of this report should be highly encouraging to those of us who lament the impending creation of a monolithic government-controlled healthcare system, and who have been struggling to imagine ways of circumventing the legions of stone-witted, soul-eating bureaucrats now being prepared (Sauron-like) to descend upon us all, doctor and patient alike.

This is why DrRich has urged primary care physicians to break the bonds of servitude while they still can, strike out on their own, and set up practices in which they are paid directly by their patients. Such arrangements are the only practical means by which individual doctors and patients can immediately restore the broken doctor-patient relationship, and place themselves within a protective enclosure impervious to the slavering soul-eaters.

This is the lesson to be drawn. We’ll see how many physicians take the hint. The seriousness of the trend is suggested by the efforts of the government, especially in Massachusetts, to make private practice of medicine illegal.

DrRich has speculated on various black market approaches to healthcare which could be attempted by American doctors (and investors) should restrictive, government-controlled healthcare become a reality. But now, thanks to the success of alternative medicine, there is a direct and straightforward path for American primary care physicians to re-establish a form of now-long-gone “traditional” American medicine, replete with a robust doctor-patient relationship, right out in the open – the kind of practice where patients pay their doctors themselves.

Simply declare this kind of practice to be a new variety of alternative medicine. Likely, PCPs will need to come up with a new name for it (such as “Therapeutic Allopathy,” or “Reciprocal Duty Therapeutics”), and perhaps invent some new terminology to describe what they’re doing. But what’s clear is what they will be doing is so fundamentally different from what PCPs will be doing under government-controlled healthcare as to be unrecognizable, and nobody will be able to argue it’s not alternative medicine. In fact, it will seem nearly as wierd as Reiki.

There is a novel suggestion.

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Posted in health reform, medicine | 1 Comment »

Cash medical practice

Friday, May 21st, 2010

I am also blogging at Chicago Boyz and have a new post up there about the trend to cash practice. Rather than repost it here, I suggest you look over there for the post. That is a very interesting blog and I was flattered to be invited to be a member.

Posted in geriatrics, health reform, medicine | 1 Comment »

Lies about malpractice reform

Friday, February 26th, 2010

I looked at Washington Monthly today, as I usually do to see what the far left is thinking. They were, as usual, obsessing about the health “reform” legislation and yesterday’s summit. I noticed a link to another article about malpractice reform.

First, from Wash Monthly,

John McCain recommended malpractice reform modeled on California and Texas.

There’s two examples right now of medical malpractice reform that is working. One is called California and the other is called Texas. I won’t talk about California because we Arizonians hate California because they’ve stolen our water.

“But the fact is that Texas has established a $750,000 cap for non-economic damages; caps doctors at $250,000; hospitals at $250,000; and any additional institution, $250,000; and patients harm to a finding of medical malpractice are not subject to any limitations on recoveries for economic losses. And I hope you’ll examine it.”

Wash Monthly comes back with a response that is based on lies.

I hope policymakers will examine it, too, because the results of the experiments in California and Texas offer some important lessons.

McCain preferred to ignore California’s experience, not because of water rights, but because the caps haven’t worked the way conservatives would have liked.

This is a lie. The “source” he links to is Jamie Court who is a really far left anti-insurance zealot and part of the phony Prop 103 auto insurance “rollback” that passed a decade ago and screwed up California’s auto insurance for a while. Here is what Court says:

Data from the National Assn. of Insurance Commissioners show that doctors’ malpractice premiums nearly tripled in the first dozen years after the 1975 California law. Premiums fell sharply and stabilized only after Californians passed insurance reform Proposition 103 in 1988.

Under 103, $135 million was refunded by malpractice insurers. The insurance measure also created an elected insurance commissioner who imposed a rate freeze for his entire first term, implemented stringent regulation and ended price fixing.

This is just a lie. I was practicing surgery in California the entire time he refers to. I began my private practice in 1972. My malpractice premium was $3500 per year. In 1974, following the stock market decline which devastated insurance company investments, my malpractice carrier raised my (and my partner’s) premium to $35,000 per year, but we learned that the company was insolvent. For a while, there was no insurance available except at stratospheric rates we could not afford. Thousands of California doctors practiced without insurance for several years. In 1974, there was a statewide doctor’s strike. Many doctors refused to treat any but emergency cases until the state did something about medical malpractice. Governor Jerry Brown called an emergency special session of the state legislature in January 1975. They passed a very good law called AB1XX, named for the special session. Since that time, it has been called MICRA, The Medical Injury Compensation Reform Act.

It has been attacked many times by the trial lawyers, with whom Court is affiliated. Eventually, the State Supreme Court upheld the reform act, in spite of furious attacks by the medical malpractice bar. It has resisted further attacks every few years for the past 25 years.

Court claims that premiums tripled and that Prop 103 affected the rates. Both are lies. My partner and I practiced without insurance for three years. In 1978, when we added another surgeon to our practice, we decided to start buying insurance again and we joined a company called CAP/MPT. That stands for Cooperative of American Physicians/ Medical Protection Trust. It is a non-profit cooperative of doctors who are self insuring. We each deposited $20,000 into a trust fund. We were than assessed an amount each year according to our specialty. Surgery is higher risk than General Practice, for example. My assessment remained at about $6,000 per year for the next 20 years.

I was sued several times although most were nuisance suits. For example, when we did apply to CAP/MPT, I learned that I had eight wrongful death suits filed against me. When we investigated, we found that these were ER patients, mostly trauma cases, that had died. Some, I had not even been involved with their care. I wrote letters to each law firm asking them to dismiss the suits or be subject to a suit by me for malicious prosecution. All were quickly dismissed. I was threatened with suits a couple of times by disgruntled patients. One woman kept coming back complaining because she had a tiny scar from a varicose vein injection. I couldn’t see it from ten feet away. I finally (a mistake) asked her why she was so obsessed with this scar that no one else could see. She had been warned that these injections can cause scars. I even asked her if she was having personal problems, with her husband, for example. That was a big mistake. She threatened to sue me but she could never find a lawyer to take her case.

Ironically, she had originally come to me because I had saved her mother’s life. Her mother, a smoker, had been in California to help her daughter with a new baby. While here, she had a catastrophic vascular accident that resulted in her entire small intestine dying. I put together her duodenum and colon but did not expect her to live. She had no remaining bowel that could absorb nutrients. Also, the connection of the bowel was tenuous because of the poor blood flow. Amazingly, it healed but she had no way to absorb food. We put her on total parental nutrition and she did well but there was no known way to keep the catheter from getting infected. They had never been used for a chronic IV nutrition situation.

I had been to the American College of Surgeons meeting a couple of months before and had seen a new catheter that was intended for long term IV use. It was still experimental. I called Belding Scribner, who had invented the first shunt that allowed chronic dialysis for renal failure. He was the one at the meeting who was showing the new catheter. He told me the name of the small company that was making them and they agreed to send me one. They are now commonly used for chemotherapy but this was probably the first use for a patient who lost her entire small bowel. It worked and she went home to Bethesda, Maryland after we taught her husband how to care for it. I called the National Institutes of Health to find someone who could help the husband with the care and she did well for several years, finally dying of a heart attack. Ten years later, her daughter sued me for a 2 mm scar.

I had a couple of other suits, one of which went to trial and I was exonerated, including being awarded the court costs. In 1994, after a major back operation for an old injury, I retired. A couple of years later, my $20,000 trust fund contribution was refunded. Court is lying about the malpractice situation in California and trying to puff up the role of his anti-insurance Prop 103. There was no refund until I retired and that had nothing to do with Court and his Naderite pals.

The fact that the left has to lie to support their position is excellent evidence that they have nothing else on their side.

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Hmmmmmm

Tuesday, February 9th, 2010

CNN today has a bit of information about the death of John Murtha.

The Democratic congressman recently underwent scheduled laparoscopic surgery at National Naval Medical Center in Bethesda, Maryland, to remove his gallbladder. The procedure was “routine minimally invasive surgery,” but doctors “hit his intestines,” a source close to the late congressman told CNN.

That happened in December.

Then;

The National Naval Medical Center issued a statement saying Murtha was admitted January 28 for surgery, but declined to reveal additional details, citing his family’s request for privacy and federal privacy laws.

I’ve done around a thousand lap choles. When I took students to Children’s Hospital in Los Angeles to see surgery, we usually saw pediatric procedures, many of them quite unusual. One day, we were watching a lap chole on a teenager who had developed gall stones, unusual in the pediatric population. I finally had to leave the room as I watched surgeons, quite skilled in other procedures, struggling with the gall bladder.

Laparoscopic surgery involves certain skills that take a lot of practice. You look at a TV monitor and manipulate long instruments inside the abdomen. The instrument goes through the abdominal wall and that creates a fulcrum. When you move your hand to the right, the tip of the instrument goes left. When you move your hand toward the patient’s head, the tip of the instrument goes toward the feet.

Then I thought of this.

I wonder how many lap chole’s the Navy Medical Center does a year and what their complication rate is ? We’re not likely to find out. Remember this story?

Maybe they did everything right but there should not be bowel injuries from that procedure.

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Worthwhile In The Science Literature

Sunday, January 3rd, 2010

By Bradley J. Fikes

(Crossposted at my newspaper’s sci-tech blog).

A cheaper way to make antisense oligonucleotides From the abstract in PLoS ONE:

“Antisense oligonucleotides targeting microRNAs or their mRNA targets prove to be powerful tools for molecular biology research and may eventually emerge as new therapeutic agents. Synthetic oligonucleotides are often contaminated with highly homologous failure sequences. Synthesis of a certain oligonucleotide is difficult to scale up because it requires expensive equipment, hazardous chemicals and a tedious purification process. Here we report a novel thermocyclic reaction, polymerase-endonuclease amplification reaction (PEAR), for the amplification of oligonucleotides.”

My take: This should be of interest to companies working with RNA-based therapeutics, like Carlsbad’s Isis Pharmaceuticals or Regulus Therapeutics.

Evolution of Primary Hemostasis in Early Vertebrates From the PLoS One abstract:

Hemostasis is a defense mechanism which protects the organism in the event of injury to stop bleeding. Recently, we established that all the known major mammalian hemostatic factors are conserved in early vertebrates. However, since their highly vascularized gills experience high blood pressure and are exposed to the environment, even very small injuries could be fatal to fish. Since trypsins are forerunners for coagulation proteases and are expressed by many extrapancreatic cells such as endothelial cells and epithelial cells, we hypothesized that trypsin or trypsin-like proteases from gill epithelial cells may protect these animals from gill bleeding following injuries. In this paper we identified the release of three different trypsins from fish gills into water under stress or injury, which have tenfold greater serine protease activity compared to bovine trypsin. We found that these trypsins activate the thrombocytes and protect the fish from gill bleeding. . . In conclusion, we believe that the gills are evolutionarily selected to produce trypsin to activate PAR2 on thrombocyte surface and protect the gills from bleeding. We also speculate that trypsin may also protect the fish from bleeding from other body injuries due to quick contact with the thrombocytes. Thus, this finding provides evidence for the role of trypsins in primary hemostasis in early vertebrates.

My take: Evolution is a highly conservative process: Once it finds something that works, it uses it over and over. So here the researchers have found a mechanism that protects fish, using enzymes commonly found in vertebrates. Trypsins are used in digestion among mammals and other vertebrates. The implication is that the last common ancestor of modern fish and mammals — a water-dwelling animal that looked like a present-day fish — had these trypsins, and that they were important in preventing blood loss. On the surface, you wouldn’t expect to see an enzyme used for digestion to have a role in stopping blood loss, but evolution doesn’t care about what humans would expect.

An Ultrasound Assisted Anchoring Technique (BoneWelding Technology) for Fixation of Implants to Bone – A Histological Pilot Study in Sheep From the Open Orthopaedics Journal abstract:

The BoneWelding® Technology offers new opportunities to anchor implants within bone. The technology melted the surface of biodegradable polymer pins by means of ultrasound energy to mould material into the structures of the predrilled bone. Temperature changes were measured at the sites of implantation in an in vitro experiment. In the in vivo part of the study two types of implants were implanted in the limb of sheep to investigate the biocompatibility of the method … Results demonstrated mild and short temperature increase during insertion. New bone formed at the implant without evidence of inflammatory reaction. The amount of adjacent bone was increased compared to normal cancellous bone. It was concluded that the BoneWelding® Technology proved to be a biocompatible technology to anchor biodegradable as well as titanium-PLA implants in bone.

My take: The bone-implant interface is tricky because bone is a living tissue, changing, growing and breaking down, with microscopic pores. Fusing an implant tightly to the bone helps it take hold. BoneWelding was recognized as one of the best spine technologies for 2009 by Orthopedics This Week, a trade publication.

BoneWelding is the product of a Swiss firm, SpineWelding AG. Other Best Spine Technologies winners include San Diego-based NuVasive, for its XLIF (eXtreme Lateral Interbody Fusion) technology. Carlsbad’s Alphatec Spine also won for its GLIF – Guided Lateral Interbody Fusion technology.

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PETA’s Poodles

Thursday, July 23rd, 2009

By Bradley J. Fikes

The animal rights group PETA has a well-earned reputation for extremism carried to such an extreme it’s farcical. PETA recently chided President Obama for killing a pesky fly. According to PETA, Obama should have caught the fly in a humane trap and released it outdoors.

With such deranged views, PETA has a hard time getting taken seriously. So PETA zealots have created front groups that advance its agenda, while proclaiming other motives. One of these front groups, The Cancer Project, recently pulled a classic PETA-style publicity stunt, filing a lawsuit in New Jersey asking for a cancer warning label to be put on hot dogs.

Encouragingly, some journalists are skeptical of The Cancer Project’s claim to be purely concerned with human health. A Los Angeles Times story described it as a “vegan advocacy group.” The article even noted that the project is run by the Physicians Committee for Responsible Medicine, itself created by PETA members.

However, the Associated Press inaccurately called The Cancer Project as “an offshoot of a pro-vegetarian organization“. The perfunctory article didn’t even name the organization. Readers weren’t told it was a PETA front group.

(more…)

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How we got here in health care.

Thursday, June 11th, 2009

For those who have not read Paul Starr’s book , The Social Transformation of American Medicine, or my own chapter on medical economics, here is a brief introduction to American medical economic history. Along the way, I will mention some European history.

The first government health plan was in Germany, established by Bismark, who introduced a disability and old age insurance program in 1883. Initially, retirement age was set at 70 and later lowered to 65. His reason was to preempt the Socialists in the German political world. The German health care system evolved over the next 100 years but it is not a government single payer system.

In Germany, statutory health insurance, which covers 90 percent of the population, is financed by a payroll tax. The individual’s premium is not a per-capita levy, as it is in the United States. It is purely income-based. Ostensibly, about 45 percent of the premium is contributed by employers, although economists are persuaded that ultimately all of it comes out of the employee’s take-home pay (See this and this).

An employee’s non-working spouse is automatically covered by the employee’s premium.

The Clinton Plan was allegedly based on the German model.

The health insurance premiums paid by Germans are collected in a national, government-run central fund that effectively performs the risk-pooling function for the entire system. This fund redistributes the collected premiums to some 200 independent, nongovernmental, competing, nonprofit “sickness funds” among which Germans can choose.

The sickness funds are based on employment or the town in which the subscriber lives. The Germans have different priorities than we do. For example, our fixation on hospital length of stay (LOS) is absent. I presented a paper on hemorrhoid surgery to the European laser medicine society in 1988. Most of the questions after my presentation concerned my policy of doing hemorrhoid surgery as an outpatient procedure. The Germans think that is cruel and recommend hospital stays of several days. They also have (most Germans have, anyway) a benefit for two weeks of spa treatment per year. I once had a patient in Orange County who was eligible for German health care, as well. He had his surgery here but he returned to Germany each year for his two weeks of government paid spa care.

I have already done a lengthy analysis of the French system which I think the best model for US reform.

Now, some US history. American medicine was purely private and fee-for-service until the Depression. There were public hospitals, like Charity Hospital in New Orleans, or Bellevue Hospital in New York, or Cook County Hospital in Chicago, or the Massachusetts General Hospital in Boston, or the Los Angeles County General Hospital in Los Angeles. In 1928, the new LA “Big County” hospital opened and during the Depression it offered the finest care in California. I have been told by older physicians that doctors denigrated “the County” to patients, not out of concern for their welfare but because of concern that private patients would choose to go there leaving private doctors in dire straits. Those great public hospitals could have formed a nucleus for care of the poor even today but they were destroyed or badly damaged by Medicaid after 1965 which refused to pay the county hospitals as it emphasized (often inferior) private care over the public hospitals. The budget shortfalls occurred just before the illegal aliens began to flood the public hospitals. The result has been a distinct decline in quality of care.

The Depression brought the first health plans for the middle class. In Dallas, in 1929, the Baylor University hospitals established a plan for school teachers. For six dollars per year in dues, the subscriber was entitled to 21 days of hospitalization. Similar plans began in California and New Jersey and finally, a plan called “Blue Cross” won a suit in New York that exempted it from insurance company reserve requirements. The hospitals were not selling insurance but promising services, hospital care, and did not need to maintain cash reserves.

Blue Shield plans began in California where the California Medical Association devised a plan in which low income subscribers would be guaranteed physicians services. The AMA, in those days still very powerful, opposed the plan but it persisted and a fee schedule was established in spite of Federal Trade Commission opposition. At one point, when I was first in practice, the FTC required the CMA to surrender all copies of the fee schedule, called Relative Value Schedule (RVS) but Medicare required that doctors use the RVS for billing ! We all had xerox copies of the RVS for a while. Such was the stupidity we encountered.

Until the Second World War, medicine was relatively inexpensive and of limited effectiveness. Surgery was effective in curing most surgical conditions after 1900. Critical care came as a result of the war and antibiotics arrived just in time for the war casualties. Blood banks began about 1937 at Cook County Hospital. Few medical conditions other than infection were treatable until the 1950s. Hypertension was the cause of death for President Roosevelt but there were no effective drugs until the 1950s. Winston Churchill’s life was saved in 1943 by sulfa drugs in an episode little known to historians. The “golden age” of medicine began about 1950.

Health insurance in America began with unions and the Stone Cutters Union had the first health plan that would pay for delivering a baby in 1887. In 1945, the United Rubber Workers Union established a health plan that paid $50 for delivery of a normal pregnancy. For years, the doctors in Butler, PA had collected a fee of $50 for this service. That was the established fee. When the insurance began to pay this $50 fee, the doctors increased their fees to $75. Here was the beginning of the destruction of the profession although it seemed to be progress at the time. The union health plan increased its payment to $75 and the doctors then raised their fees to $125. They were now back to the original arrangement with patients. The patient paid $50 cash and the insurance paid the rest. Here was the fatal bargain. A third party was paying the bill and both the doctor and the patient had little responsibility. The cost issue began here. In 1969, my second son was born in Pasadena at a cost (hospital bill) of about $260. It was not covered by insurance. A few years later, with insurance paying the bill, the price was more than ten times that amount.

The French had similar cost issues in the 1950s after the French system was established in the aftermath of the war. Our own system was also a consequence of the war as wage and price controls allowed a loophole for “benefits.” The employer offered health benefits as an inducement for scarce labor when 12 million men were in uniform. In France, President De Gaulle settled the issue by scolding the medical associations and asserting “I saved France on a colonel’s salary !” A national fee schedule was established but it is not mandatory. It does, however, provide the fee schedule that is paid by the health plans. Doctors and hospitals may charge more but the balance is up to the patient to pay. Canada made a terrible mistake by banning private practice. The result has been emigration plus a disincentive for young physicians to train in long programs since they will not be rewarded financially for the specialty and the hours and years invested. We are already seeing a similar effect in this country as medical students choose “lifestyle” specialties, which allow shift work, like Emergency Medicine, and which avoid long hours and weekend call.

The factors that have brought the crisis include technology, the incentive for both patient and doctor to overuse benefits, plus the aging population. The Obama program, if passed, does not seem to bar private practice. I am seeing doctors dropping out of Medicare and practicing on a cash basis. Whether that will become an issue if there is a large exodus from the government option is a question.

One major issue is the fact that medical bills do not reflect real costs. A hospital bill for $100,000 may in fact represent only $25,000 in insurance payments. The cash patient is at a huge disadvantage. This becomes a factor if you have a 20% co-pay, as many high deductible policies do. The “20%” you pay may be more than the amount paid by the insurance company for the “80%” share they have. The 20% co-pay is based on the inflated retail price of the care. It also makes medical IRAs far less useful since the cash market is using inflated retail prices that may by four times the negotiated price the insurance plan, or Medicare, may pay.

Doctors may be willing to practice on a cash basis with realistic bills approximating the actual Medicare payment. I have heard of orthopedic surgeons doing total hips for $1200.00, far less than the usual billed fee but approximately what Medicare actually pays. If such a surgeon bills that fee, Medicare (if he is still a member) will reset his fee “profile” at that rate, then pay him 25% of that lower fee. Thus, the surgeon must drop out of Medicare completely to switch to a market price practice. Will hospitals be willing to do this ? I doubt it. Will Obama’s new plan reset the prices so they represent actual costs ? I doubt it.

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Autism

Thursday, March 19th, 2009

Autism is a childhood developmental condition that has had a suspected increase in incidence in recent years. It causes a major mental developmental arrest at an early age. Some children begin to develop speech and then regress, a factor that has led to unfortunate theories of causation, such as the hysteria about childhood immunization. Now, a cluster of cases among Somali immigrants in Minnesota might offer some new leads to the cause.

Autism and schizophrenia share some similarities in that both conditions result in problems with social interaction and functional behavior. The autistic child fails to develop speech and other social behavior such as emotional attachment to others. Schizophrenia has similar effects on interpersonal behavior. The autistic child often seems to live in a world cut off from others, responding to inner stimulation but unable to relate to parents or other children. Similarly, the schizophrenic is unable to interpret visual cues and social interaction is difficult. The schizophrenic typically has auditory hallucinations, hearing voices. The autistic child may have similar inner stimuli but is unable to express what is happening because of speech failure.

There are theories about schizophrenia as a consequence of brain development, especially the phenomenon of cerebral dominance which gives us speech and handedness. Now, new theories implicate hormone changes that might be common to both conditions. Animal studies have suggested this association.

Understanding the neurobiological substrates regulating normal social behaviours may provide valuable insights in human behaviour, including developmental disorders such as autism that are characterized by pervasive deficits in social behaviour. Here, we review the literature which suggests that the neuropeptides oxytocin and vasopressin play critical roles in modulating social behaviours, with a focus on their role in the regulation of social bonding in monogamous rodents. Oxytocin and vasopressin contribute to a wide variety of social behaviours, including social recognition, communication, parental care, territorial aggression and social bonding. The effects of these two neuropeptides are species-specific and depend on species-specific receptor distributions in the brain. Comparative studies in voles with divergent social structures have revealed some of the neural and genetic mechanisms of social-bonding behaviour. Prairie voles are socially monogamous; males and females form long-term pair bonds, establish a nest site and rear their offspring together. In contrast, montane and meadow voles do not form a bond with a mate and only the females take
part in rearing the young. Species differences in the density of receptors for oxytocin and vasopressin in ventral forebrain reward circuitry differentially reinforce social-bonding behaviour in the two species.

This is from Philosophical transactions of the Royal Society of London. Series B, Biological sciences. 2006 Dec 29;361(1476):2187-98., “Oxytocin, vasopressin and pair bonding: implications for autism.”, by Hammock EA, Young LJ.

This may seem a rather far fetched association with human autism but there is more.

CNS neuroscience & therapeutics. 2008 Fall;14(3):165-70., “Oxytocin levels in social anxiety disorder.”, by Hoge EA, Pollack MH, Kaufman RE, Zak PJ, Simon NM.

Department of Economics, Claremont University, Claremont, CA, USA.
ehoge@partners.org

Oxytocin is a neuropeptide recently associated with social behavior in animals and humans, but the study of its function in populations with social deficits such as autism, schizophrenia, and social anxiety disorder has only recently begun. We measured plasma oxytocin in 24 patients with Generalized Social Anxiety Disorder (GSAD) and 22 healthy controls using an enzyme-linked immunosorbent assay. There were no significant differences in oxytocin level (pg/mL) between patients (M=163.0, SD=109.4) and controls (M=145.0, SD=52.9, z=0.21, P=0.8). Within the GSAD sample, however, higher social anxiety symptom severity adjusted for age and gender was associated with higher oxytocin level (R2=0.21, beta=0.014, SE=0.006, t=2.18, P=0.04). In addition, dissatisfaction with social relationships was associated with higher oxytocin levels (R2=0.18, beta=-0.20, SE=0.10, t=-2.01, P=0.05). Our data provide preliminary support for a link between social anxiety severity and plasma oxytocin. These findings may suggest a possible role for oxytocin as a facilitator of social behavior, an effect which may not be fully utilized in individuals with severe social anxiety.

This is very preliminary but the existence of the Somali cluster of autism cases might allow further work in this association. Oxytocin has been known as the hormone that begins labor and brings the mother’s milk “down” but it is increasingly seen as having other roles in human behavior. It is not unusual to see the hormones, originally thought to have a single function, assume new roles as physiology is investigated. It would be very interesting if these hormones turn out to play a major role in mental illness. Freud is finally gone from the treatment of major mental illness.

“This is one of the first looks into the biological basis for human attachment and bonding,” said Rebecca Turner, PhD, UCSF adjunct assistant professor of psychiatry and lead author of the study. “Our study indicates that oxytocin may be mediating emotional experiences in close relationships.”

The study builds upon previous knowledge of the important role oxytocin plays in the reproductive life of mammals. The hormone facilitates nest building and pup retrieval in rats, acceptance of offspring in sheep, and the formation of adult pair-bonds in prairie voles. In humans, oxytocin stimulates milk ejection during lactation, uterine contraction during birth, and is released during sexual orgasm in both men and women.

Vasopressin is also involved, especially in males. Vasopressin is a hormone secreted by the pituitary gland and associated with water retention by the kidney. It now appears that it has other functions, as well.

Progress in brain research. 2008;170:337-50.

Neuropeptides and social behaviour: effects of oxytocin and vasopressin in
humans.

Heinrichs M, Domes G.

Department of Psychology, Clinical Psychology and Psychobiology, University of
Zurich, Zurich, Switzerland.

The fundamental ability to form attachment is indispensable for human social relationships. Impairments in social behaviour are associated with decreased quality of life and psychopathological states. In non-human mammals, the neuropeptides oxytocin (OXT) and arginine vasopressin (AVP) are key mediators of complex social behaviours, including attachment, social recognition and
aggression. In particular, OXT reduces behavioural and neuroendocrine responses to social stress and seems both to enable animals to overcome their natural avoidance of proximity and to inhibit defensive behaviour, thereby facilitating approach behaviour.

Doesn’t this sound like autism ?

AVP has primarily been implicated in male-typical social behaviours, including aggression and pair-bond formation, and mediates anxiogenic effects. Initial studies in humans suggest behavioural, neural, and endocrine effects of both neuropeptides, similar to those found in animal studies.

Schizophrenia is more common in males and is hereditary. Anxiety is a major factor. There may also be a hereditary association in autism. This is enormously exciting research and might even be the first sign of a cure for these disorders of brain function.

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