Our buddy Trent McBride has stirred up a great controversy. So When Are We Going To Get That Free-Market Health Care Everyone's Complaining About? . If you find that interesting, he has 2 follow-up posts.

His rant explains (and I agree here) that we do not have a free market health care system. We have an almost nationalized health care system. Government payments and regulations prevent any free market influence (in general).

He has created quite a stir in the blogosphere. I believe that this stir shows a general misunderstanding of medical practice.

The biggest influence on medical reimbursement is Medicare (unless you do pediatrics). When they develop reimbursement, the insurers quickly follow. When they develop regulations, physicians pay.

He rightly comments on various governmental regulations which increase overhead without allowing a way to recoup those costs. Government (i.e., Congress) influences physicians and hospitals in ways which negate any free market forces.

Medicine has some exceptions - cash payments for some plastic surgeries, cosmetic dermatology, etc. However, generally, we work in a highly regulated environment. Kudos to the Proximal Tubule for starting the debate. We here at the Countercurrent Mechanism applaud his efforts.

Test Drug Said to Increase Good Cholesterol and Torcetrapib Significantly Increases HDL Cholesterol Levels. Epidemiologic data indicate that low HDL cholesterol levels put patients at a significant risk for atherosclerotic complications - coronary artery disease, stroke, peripheral vascular disease. We assume that raising the HDL would therefore decrease the risk of these conditions.

Until now, the only drug which consistently raised HDL was niacin. A new study shows that (at least under experimental conditions) one can increase HDL with a new drug.

According to the authors, another HDL-raising strategy involves the use of torcetrapib, a novel cholesteryl ester transfer protein (CETP) inhibitor. CETP is a plasma glycoprotein that facilitates the transfer of cholesteryl esters from HDL cholesterol to apolipoprotein B?containing lipoproteins.

Remember that this drug is still experimental. We must wait to learn two major things. First, how safe is this drug when taken over time. Second, does this drug improve patient outcomes.

One must always take these preliminary articles as just that - preliminary. The concept has promise. Now we must wait a few years until the appropriate studies are done.

Malpractice Legislation Remains Stuck in the Senate

Republicans say their measure could help reduce unnecessary lawsuits and higher malpractice premiums that make it harder for doctors to practice. They tried last year and again earlier this year to force votes on similar measures.

"The crisis faced by obstetricians, gynecologists and emergency and trauma care professionals illustrates the urgent need for national medical liability reforms," the White House said in a statement.

Democrats accuse Republicans of playing up to their donors in the medical and insurance lobbies and say that limiting damages is unfair to injured patients and their families.

I have received a few important comments about the match. The wife of an incoming intern wrote:

I wouldn't say most students would ask for the match. They probably keep quiet because they don't want to be branded a troublemaker and jeopardize a career they've worked so hard to make possible.

My husband just went through match 3/02 for a competitive specialty and we cursed every moment of it. Since then, it's become increasingly clear that residents often give a lot more than they get and that residency, as it exists now, works primarily to the hospital's benefit. Just a few of my complaints:

First, please read very carefully Save the Match. Second, imagine the world without a match. Who would suffer?

I proposed this question to some residents while supervising in clinic a couple of days ago. To paraphrase one, "obviously the critics have not participated in a non-match fellowship search". She shared with me her initial concerns about the match as a 4th year student. However, having just finished the interviews and acceptance of a non-match fellowship, she lamented the lack of a match in her fellowship!

The match uses the game theory which John Nash (he of a Beautiful Mind) developed. The current algorithm helps students get the highest choice which has an opening for them. It is student biased rather than hospital biased (go to the web site for links to the studies).

The match does not drive wages, or working conditions. Medicare reimbursement drives wages. ACGME and residency review committees drive working conditions.

Working conditions have improved dramatically since I graduated in 1975. I see excellent progress regularly.

I could develop a thought experiment in which working conditions might worsen at some highly desirable residencies! However, the working conditions depend more on regulatory bodies, and how the students "vote" during their match. Programs which treat their residents better tend to have better matches.

The anarchy of life without a match would (according to the web site) disadvantage couples (over 500 couples matched last year) and minorities. This protest and lawsuit are (in my opinion) poorly considered. Few would benefit from the unintended but predictable consequences of the lawsuit's success.

A Job or More School? Young Doctors Take On 'The Match'

In the suit, filed in 2002 by three former residents, the plaintiffs say graduating medical students should be able to negotiate wages and work hours. The medical associations and hospitals named as defendants in the suit contend that the match system compensates residents fairly.

The Federal District Court in Washington ruled on Feb. 11 that the residents who sued had an adequate basis to argue the existence of "a purported scheme of restraints that has the purpose and effect of fixing, artificially depressing, standardizing and stabilizing resident physician compensation."

Graduates of medical schools now sign binding work agreements with residency programs the minute they file their applications, before most hospitals have announced the wages. A new policy, to take effect next year, will require that residents be shown copies of their contracts before committing to programs.

The concern over salaries is heightened by the fact that medical students often carry enormous debts. In 2003, the average debt of a medical student was nearly $110,000, double the figure in 1993.

So why have a match? Why not have a free market for residencies?

We believe (the great majority of attendings and residents) that the match protects both applicants and programs. It allows us to go through a careful process of evaluating the many applicants to our programs and choose interns/residents in a standard way. What would happen if we had no match? (my speculation follows)

• Popular residencies could (and therefore probably would) decrease their financial stipends. To get a dermatology slot you might work for much less than today.
• Less popular residencies (either specialty or location) might increase their stipends to try to attract residents. This could lead to bidding wars - financially helping some residents in the short run.
• It follows that considerations other than the quality of training would have a greater influence on residency training
• Timing would become a greater issue. Students would start seeking positions in their 3rd year rather than their 4th year. Programs would encourage this trend to insure that they "fill" their positions. However, 3rd year students often change their minds about specialties. Thus, students might reneg on their committments, leaving programs scrambling to find replacements.
• The above comment seems absurd - until one examines subspecialty fellowships in internal medicine, which have exactly that problem.
• The stresses on applicants would increase without the current standarization

If the courts rule against the current situation, we will have increased chaos. I would suspect that most students would then ask for a match. I am certain that most programs would.

This suit might sound good to some who are not part of residency training. The destructiveness of this suit's possible success scares me greatly.

Most outpatient physicians hate insurance companies (including Medicare). Their pay scales are insulting, and the necessary overhead makes seeing patients minimally profitable. Some physicians have decided to go "old school" and eliminate the insurance companies. Some Doctors Choosing Cash Over Insurance

When Chuck O'Brien visits his doctor, they talk about his aches and pains, his heart problems and his diet, but never about his health insurance. That's because Dr. Vern Cherewatenko is one of a small but growing number of physicians across the country who are dumping complicated insurance contracts in favor of cash.

Is this the health care wave of the future? Probably not, experts say. Most people are content with monthly premiums and $10 copays; nine out of 10 doctors contract with managed-care companies. But cash-only medicine is becoming an increasingly attractive option for doctors frustrated by red tape and for the 43 million Americans who lack health insurance.

``It's a terrible indictment of the collapsing health care system,'' said Arthur Caplan, chairman of the medical ethics department at the University of Pennsylvania Medical School. ``Insurance and managed care were supposed to streamline -- instead what they've done is add so much paperwork and bureaucracy they're driving some doctors out.''

When O'Brien leaves the exam room, he writes a check for $50 and he's done -- no forms, no ID numbers, no copayments.

``This is traditional medicine. This is what America was like 30 years ago,'' said O'Brien, 55 and self-employed, who believes he has saved thousands of dollars by dropping his expensive insurance policy and paying cash. ``It's a whole world of difference.''

Health insurers downplay the trend, while emphasizing recent efforts to mend tattered relationships between doctors and managed care companies.

Cash visits make great sense for patients and physicians.

Cherewatenko, a broad-shouldered 45-year-old who wears black jackets and red stethoscopes at work, switched to cash out of desperation six years ago. His suburban Seattle practice was hemorrhaging money, and he and his partners realized they were spending hundreds of thousands of dollars just to process insurance paperwork.

``We said, 'Let's cut out this administrative waste,''' Cherewatenko said. Before, he charged $79 for an office visit and got $43 from an insurance company months later, minus the $20 in staff time it took to collect the payment. Now he charges $50 -- and he never worries about collection costs, because patients pay in full after every visit.

Cherewatenko sees fewer patients now. His whole office would probably fit inside his old waiting room. But he says the freedom is worth it.

``Accounts receivable is zero. It's a great feeling,'' Cherewatenko said. ``I feel like I'm a real doctor again.''

He started a group called SimpleCare to spread the gospel of cash-only medicine. The organization steers patients to doctors who offer cash discounts, and gives technical and moral support to doctors who want to start cutting their ties to insurance. Membership has grown to 22,000 patient members and 1,500 doctors. Some reject all insurance and take only cash, while others continue to accept insurance while offering discounts of 15 percent to 50 percent for cash-paying patients.

Independent of SimpleCare, doctors in California, Colorado, Minnesota, Texas, Mississippi and other states have also quit the insurance game. Some tired of the paperwork and administrative expenses. Some wanted to spend more time with patients without managed care bean-counters peering over their shoulders. The patients who pay cash range from poor to wealthy, with most in the blue-collar middle.

I love ideas that make sense. Read more about this movement - SimpleCare. This movement runs parallel to the retainer medicine movement. Both movements are suceeding due to patient and physician dissatisfaction with insurance and outpatient medicine. I would still advocate for "big ticket item" insurance. But perhaps this simple concept should become the norm.

Double surgery for obese 'safer'

Doctors first removed part of the stomach and then, in a separate operation, inserted a bypass in the intestines.

The first stage allowed significant weight loss so the second stage could go ahead.

A study of 75 patients was presented to the Society of American Gastrointestinal Endoscopic Surgeons.

The morbidly obese patients, aged from 23 to 72, first had a laparoscopic sleeve gastrectomy. This removes a large part of the stomach.

By performing this less drastic surgery first, mortality was greatly reduced

They were later given a gastric bypass, which involves constructing a pouch and bypassing a small segment of the intestines.

University of Pittsburgh researchers found this reduced the average body mass index (BMI) of patients by 19 points to 49 points after six months.

Interesting, but one must wonder about the side effects of the intestinal bypass. But then drastic situations sometimes require drastic solutions.