Tennessee's experiment in (slightly less than) universal healthcare coverage

The Wall Street Journal had a front page story last week,"Covering the Uninsured, But Only up to $25,000" describing Tennessee's second experiment at expanding coverage of the uninsured by a program called CoverTN. A number of years ago, a program called Tenn-Care was introduced which was similar to Medicaid which greatly expanded the roles of the insured. Sounds great right? Well, the program was dramatically cut back (dropping 175,000 enrollees) in 2005 after it was bankrupting the state as it was consuming more then 1/3 of the budget. There's a good editorial from the 2004 Wall Street Journal "HillaryCare in Tennessee
The disaster that might have been for the entire country." outlining the massive failure of the program.

The new program (a "mini-medical" plan) features up to $25,000 of care (only $10-15,000 of which is for inpatient care) annually for premiums of about $50 a month. What happens when that cieling is reached? Well the patient will have to pay their bills, ask the hospitals for charity care, or (as commonly happens) just not pay anything and ignore the bill. Govenor Phil Bresden (DEMOCRAT-TN), who personally made a fortune strip-mining the health care system as the founder of a managed care company, is the auteur of this plan which is posed as a more pragmatic (read affordable) solution the the more ambitious programs proposed by Govenors Romney & Schwarzenegger in Massachusetts and California.

Alan Sager, a professor of health policy at Boston University, said that CoverTN is "flimsy insurance" that will "provide cover for employers to save money." University of Tennessee College of Medicine professor David Mirvis was slightly more charitable saying, "It may be better than nothing, but it's not real insurance."

Read the fine print of the article for the poison pills in how this program will actually work. A big advantage of the program is the "steep discounts" they theorize they will be able to extract from hospitals and doctors, with Gov Dresden saying "I don't have a problem with hospitals holding the bag. (for deficits in the program)". This attitude is typical of corporate insurance executives dealing with cost containment. BlueCross BlueShield of Tennessee, who would administer this plan, has proposed to pay approximately half of what it costs the hospital to provide care to CoverTN enrollees

Good luck finding widespread participation of physicians or hospitals who will be paid less then cost for their efforts and potentially losing tens (or hundreds) of thousands of dollars on enrolees who exceed their "salary cap" policy limits. Dr. Charles Handorf, president of the Tennessee Medical Association points out a practical problem with the program, "There are (already) virtually no specialists willing to participate in the program, because they know by the time the patient who gets sick is referred to them, all the coverage will be used up.". The whole program is one big shell game about shifting costs. The states seek to shift the costs to the Doctors & Hospitals, while employers seek to shift the costs of coverage to their employees and walk away from providing health insurance.

You can see others assessing this the same in articles like "Money issues stop CRMC's participation in CoverTN" , "Hospitals expect no gain from CoverTN",

I don't make this commentary to just throw jabs at Tennessee's program. There are no easy solutions to problems like funding health care. For the most part no one wants to discuss the tradeoffs. Ironically, presidential candidate, Sen. John Edwards (Dem), (who made tens of millions suing doctors and hospitals) is the only one honestly speaking about the cost involved. Tennessee voters rejected starting a state income tax program to help finance this which only makes the budget issues more painful.

Really funny column about "chickens" (external breast enhancers)

Funny, funny anecdotal piece written by a dancer about her life with her external silicone bra inserts (aka "chickens") over at Backstage.com. Click here to read it. These semi solid silicone (say that 3 times really fast) inserts mold over your breast get their nickname from resembling raw chicken breast when you look at them in the box.





From "Put in Your Chickens and Face the Jazz Hands"

"But this was not enough! I was an actress, dammit, and everybody knew that actresses needed boobs. Plus, I was going to college in the fall, and everybody knew, at least all the people who watched "Girls Gone Wild," that college girls really needed boobs.

And thus, chickens entered my life."

There's some great stories about the occupational "hazards" of flying chickens during professional dance auditions which you'll have to read for yourself.

At right is Baron Bob's "Flying Slingshot Chicken"

Hapy 100th birthday to the bra

The excellent Catwalk Queen blog has a feature on the 100th anniversary of the bra which can be viewed here.


I wrote about bras last summer from a technology point of view in this post, "Bra Science"

Today's plug for free stuff!

I'd like to put in a quick plug for an incredible free streaming Internet radio station, the wonderful RadioParadise. This station is kind of like the old AOR format stations which feature a little something for everyone. I find new and interesting artists every time I listen. At some hospitals with PC's in the O.R., I've even set it up to stream for background music when I've forgotten my beloved Ipod.

Audio streams from Radioparadise are available at bitrates up to 256k MP3 signals which approach CD quality (if you buy songs from iTunes or other major sources you get songs at about 1/2 the quality). If you're really industrious, you can download software which can "capture" these streams and save them onto your computer for playback.

Can you take cosmetic surgery as a tax deduction?

As we've come up on tax season, I thought I'd try to tie this in somehow. I've found some tax experts who maintain that in sometimes, there may be circumstances where some one's cosmetic surgery is actually eligible to be taken as a tax deduction. If you're to do this, be ready for extra scrutiny by the IRS.



If Michael Jackson's for example underwent yet another rhinoplasty (nose job) procedure, it might be considered a professional tax deduction if the singer claimed he needed the surgery to reach a certain musical pitch.

A more interesting and pragmatic case involved exotic dancer, Cynthia Hess — better known as "Chesty Love" — made tax law history in 1994 when she successfully sued the IRS to take a $2,088 deduction on a boob job that left her with a size-56FF chest.




From ABC News

U.S. Tax Court Judge Joan Seitz Pate noted that Hess increased her income as a result of the surgery and that her cumbersome breasts, weighing 10 pounds each, were so large that she could not derive personal benefit from them. Hess had undergone the surgery "all for the purpose of making money" at an Indiana strip club, and the tax court allowed her to deduct the expense as a "stage prop."

For the record, a surgeon who puts implants in that size for breast augmentation is a disgrace - Rob

Check out the "Top Ten Strangest Tax Write-Offs" from legalzoom.com

Does it make sense for an E.R. doctor to do your breast surgery?

An Orlando,Florida radio station's contest offering a free breast implant is drawing controversy over both the contest and the "surgeon" who will be performing the operation. Real Radio 104.1 is offering the breast augmentation to the woman who parties during a so-called slumber party. The rules: Spend 30 hours with radio personality Tiffany (click for NSFW gallery) in front of a camera broadcast live on the Internet. The station website says "the girl that parties the hardest" wins.

An article from the news outlet Florida Today is available titled "Breast implant contest doc on probation"

The man chosen to perform the surgery, an osteopathic doctor with a licence under probation.



Now what specialty do you think the doctor is??

He's a Plastic Surgeon of course, right? No

Well, ok... at least he's a Surgeon then? No

Is he at least a MD? ....Well apparently he underwent an osteopathic residency in emergency medicine in Ohio twenty years ago. Does that sound kosher enough for you?

What you have here is another example of a non Plastic Surgeon (who I repeat is not even a trained surgeon)who promotes his expertise in way that makes it hard for patients to figure out exactly what he is. Like many of the fringe group of specialties trying to reinvent themselves as cosmetic surgeons, he performs office surgery while (according to the Florida Medical board website) holding no hospital privileges to perform surgery.

This "loophole" is something that has been discussed, where in the future you may actually be required to have similar credentials in a hospital to do surgical procedures in your office. This makes too much sense not to be widely embraced, that I'm sure it never happen. Rules re. how you can advertise your credentials in print or in advertising are also starting to pop up which would hopefully kill off the cottage industry of "board certifications" by organizations of dubious quality. See this blog entry I did last year "Who's a Plastic Surgeon (and who is not)"

Now this ER doctor may in fact be both a nice guy and a capable doctor, but it is inconceivable from available information in the Florida Department of Health practitioner database that he should be performing procedures this far out of the scope of practice of his accredited medical training in emergency medicine.

The radio station seems somewhat unapologetic about the controversy saying

"We got a contest going on in two days that I thought would get more attention, we are doing 'Fatties at the Fair' (tasteful!) where we send big women to the Central Florida Fair where they ride rides and eat food all day. I thought that would get more attention than this. Obviously, when you are in radio, you do whatever you can to get attention but you don't want anybody to actually get hurt or anything to happen. Nothing bad is going to happen to our listeners. We love the Monster fans."

Pitbull versus Porcupine - Ouch!

(a brief respite from medical issues of the human kind today. This is an oldie but a goodie. )


Ever wonder what happens when a pit-bull squares off with a porcupine?

Now we know the answer as nearly 1500 quills were removed from this dog. I'm sure he's thinking "But you should see the other guy!"

Thru the looking glass - how a 15 year old editorial on silicone breast implants could have been written today

On this day April 16,1992 the FDA started the groundwork for what would ultimately be the reintroduction of silicone gel breast implants (SBI) when they relaxed the outright prohibition that had been hastily introduced shortly before and started some of the early clinical trials that would provide data for further review.

It was nearly 15 years later this past October when they finally (officially) concluded that they were likely mistaken and reintroduced SBI's. We're now part of the international consensus of over 60 countries where this has been the decision by the respective health regulatory agencies overseeing this in other countries.

I found this January 1992 editorial from Reason Magazine (click to read) which is an interesting window into the mindset and arguments flying around at that time. Many of the philosophical issues are the same now as then. It's interesting that the author of this was spot on in warning that (at that time) pending epidemiological studies might not corroberate the claims being asserted in lawsuits. Since then an avalanche of literature has done just that.

In its letter to the Food and Drug Administration requesting a ban on the implants, the advocacy group Public Citizen repeatedly emphasized the frivolous nature of cosmetic surgery: "Because approximately 80 percent of these devices have been used for breast augmentation, as opposed to reconstructive purposes, the overwhelming 'public need,' not the public health need, for these devices is the psychological benefit of having more perfect or larger breasts . . . . We do not accept that the psychological needs of women, who seek breast augmentation, are legitimate public health needs within the meaning of the {Food, Drug and Cosmetic} Act."

The notion that breast augmentation is simply wrong undergirds much of the hostility to the procedure. In her widely discussed book, "The Beauty Myth," Naomi Wolf characterizes breast augmentation as "sexual mutilation." And Public Citizen declares in a press release, "The widespread use of silicone gel implants for surgery that is purely cosmetic is a particularly egregious aspect of the issue."

Take the claim that silicone breast implants cause scleroderma, a connective-tissue disorder that leads to a painful tightening of the skin. To lead in to its program on the implant controversy, "Nightline" featured a woman who had had a breast implant and who had later developed scleroderma. Reporter Judy Muller told viewers that the woman's doctor "believes the disease was caused by silicone leaking from the breast implants."

Muller did not inform viewers that there is no epidemiological evidence to back up that diagnosis. To tell whether there is indeed a connection between implants and scleroderma-like disorders would require a large sample of women who had received implants, whose medical histories were well-documented and whose symptoms were unambiguous. Such evidence may be forthcoming, although a May 1991 literature search under the auspices of the American Medical Association turned up only 28 women who had developed connective-tissue disorders after receiving silicone gel implants. For now, it is scientifically incorrect to say that implants cause such auto-immune diseases.

To such arguments, implant opponents reply by pointing to scleroderma victims. See, they say, it happened to this woman. She had an implant and now she has a disease. Post hoc, ergo propter hoc. The statistical standards of proof on which epidemiologists rely do not make for powerful journalism. And they run counter to the case-oriented culture of clinical practice.

In evaluating the safety of breast implants, the FDA and the courts should view the evidence rationally, with an eye toward real epidemiological proof rather than emotional claims. Regulators should seek to inform women of risks, not deprive them of choices. And those women who do want the freedom to make informed choices must take responsibility for the consequences, rather than going to court later to demand compensation for bad outcomes. Above all, the FDA should avoid taking refuge in extremist, paternalistic views of what women should be and what women should want.

A couple of other Reason Magazine articles about breast implants can be read here, here, and here

Buy your own European Plastic Surgery clinic on Ebay

Got $500,000 USD laying around? You too could enter the plastic surgery business as the proud owner of a fully stocked clinic in Prague, Czech Republic.

This is actually listed on Ebay of all places here and comes advertised as a turn-key business.

Finding More Breast Cancer Isn't the Answer

Last week I talked about the recent literature re. the new recommendations by the American Cancer Society on breast MRI's for cancer screening. I touched on both the financial considerations as well as the potential for increased screening to cause more problems then it solved.

There's an excellent overview of this in the Washington Post which crystallizes many of these concepts more eloquently then I. Click here to read.

From the article:

...if you really want to find as much cancer as possible, we would suggest whole-body CT, MRI and PET scans every month. But that would be absurd. Why? Because the goal is not to find more cancer. The goal is to save lives. The two goals are not the same...Over-diagnosis is the reason that the number of people with cancer diagnoses is increasing much more quickly than the numbers dying from those cancers.

For breast cancer, MRI may (or may not) be the best test. We just don't know. The only way to know is to do a true experiment -- a randomized trial -- in which half the participants have MRI while half have mammograms, and determine how many die from breast cancer in each group. These experiments are a lot of work and they take a lot of time. But they are the only way out of what is beginning to appear to be a vicious cycle: more and more testing finding more and more cancer, with the assumption of benefit...Early detection is a strategy that turns many more people into patients. Its effect on how many people die is relatively small, at best. People will die from cancer, whether or not they are tested.

Dr. Tony Youn on Mesotherapy and Britany Spears

My co-conspirator in Plastic Surgery blogging, Tony Youn, makes note of a report in the UK's tabloid, The Sun that Britany Spears under went Mesotherapy injections in Las Vegas recently. Mesotherapy is the injection of off-label drugs which is toxic to cells (including fat cells) and has been used in a loosely-regulated fashion in Europe for decades to "spot reduce" fatty areas.

It's been banned in some countries (Brazil) for rashes of horrible complications, although in the US we've been more likely to merely see unsatisfied patients rather then people showing up in the E.R. The American Society of Plastic Surgery has taken the lead on evaluating this treatment and has organized clinical studies under internal review board over site to assess the safety and efficacy. Meanwhile, many doctors who have no business performing "human experimentation" (as it's been called) have plunged ahead with this technique and marketed it aggressively.

Irrespective of whether mesotherapy even works (which is still debatable), if this is true, it is a stunning lack of judgement to perform this on someone who is 1) recently post partum & 2) recently discharged from a psychiatric treatment facility.

Complications arising in a scenario like this could leave a Doctor vulnerable to the legal question of whether or not Ms. Spears could reliably give informed consent.

Dr. Rob Oliver
Oliver Plastic Surgery

Two cases where increased imaging of the breast does not improve outcomes

There's another paper today challenging conventional wisdom on how effective screening studies are in the prevention of breast disease. In this instance it's computer-aided detection (CAD) mammograms, which were billed as a way to increase the effectiveness of interpreting mammograms. It uses advanced image recognition software to screen for abnormalities. Despite little data, this technolopgy was quickly adopted. Many mammography centers adopted this technology and were incentivized by medicare with additional payments ( ~ $20 per study) to use CAD. Note: When you do thousands of mamograms a year, this $20 per study can be serious money in someone's budget

CAD is apparently more sensitive then humans to abnormalities, but less able to distinguish malignant from benign. It also tends to identify a number of ductal carcinmona in situ (DCIS) lesions, which if left undiscovered may never turn into invasive breast cancer (aka. "real" breast cancer). Much like small prostate cancers in males, where many would die with it rather then from it, we as yet have no predictable way of tell patients that nothing will come of it and are forced to offer more aggressive surgical and medical treatments and their associated morbidity.




This report is the mirror image of the other large counter-intuitive finding we saw recently with screening CT scans for lung cancer. (ie. we find more disease but don't improve outcomes about death from cancer, while actually increasing morbidity and anxiety for patients.

While I'm off on this I'd like to dovetail on imaging studies for breast implants. With the 2006 FDA approval for silicone gel breast implants came a recommendation for routine screening by MRI of all implant patients starting 3 years post-op then every 2 years. This illogical and unenforceable (and unfunded) suggestion is surely going to widely ignored by patients and I'm not sure I'd blame them. For the period which would encompass the first 2 MRI's (five years out) the rupture rate of an implant in augmentation patients of "regular" silicone implants is likely under 1-2% while after 4 MRI's (10 years out)it's likely only 6 or 8%.

What drove this recommendation by the FDA? Most point to the highly charged political environment that still exists in America over this. One month prior to the FDA approval, Canada released the last of it's token restrictions on the devices and commented that while MRI screening was discussed, routine use was not evidence-based medicine. What do other countries do? They image implants selectively and usually start with ultrasound and reserve MRI for equivocal findings. As consequences of rupture tend to be confined to the breast and we know many woman may go years or decades with asymptomatic rupture, this is the position that makes the most sense to me. If you were to start MRI screen in asymptomatic women it would make sense to do this at 10-12 years when you sit and crunch the numbers.


The form-stable cohesive gel implants from Inamed
(picture below), Mentor, & other companies will make this topic be revisited when they are likely (you never know with the politics of the FDA)approved for general use later this year. When you have a device like Inamed's 410 implant with rupture rates so low as there are no data points to even do projections on rupture rates will the unsound MRI recommendation be attached to it as well? Keep in mind there has also been an issue of a number of false positive MRI's read out with the Inamed 410 and some of the dual-lumen devices (part saline-part silicone)in some of their clinical trials as they look somewhat different on MRI

Stay tuned!

Rob Oliver Jr. MD
www.oliverplasticsurgery.com