The College Cost Reduction and EMTALA

Linking Title IV of the College Cost Reduction and Access Act to EMTALA.

The benefits of the Public Sector loan forgiveness clause.

Recently, current medical students and residents received a scare after the passage of HR 2669 – The College Cost Reduction and Access Act. As many now know, the language in the bill would have ended the so-called 20/220 debt-to-income rule that allows most residents to receive economic deferment status of federal loan repayment during postgraduate training. It is possible to qualify for the 20/220 pathway if an individual’s debt burden is greater than 20% of income and if their debt to income ratio is less than 220% of the federal poverty level for a two person household. Any resident with $100,000 of federal loans (2/3s of all medical school graduates) would qualify for the deferment during all three or four years of post-graduate training.

Instead, the CCRAA would have implemented an income-sensitive repayment plan. There is an important difference between deferment and forbearance in regards to delaying repayment and many residents would have had to seek forbearance during their training. Deferment means that subsidized student loans will continue to be subsidized during the deferment period. When the CCRAA passed, 20/220 pathway to deferment looked to be out the window. Furthermore, the income-sensitive repayment plan proposed a cap on borrower’s repayments at 15% of their income with a minimum of $4,200 per year. This would result in approximately a payment of $350 per month beginning in 2009 and given residents and unwelcome choice between this large monthly bill or the accumulation of interest.

Here is the problem with that in comparison to the old plan: If you pay $350 per month during 3 years of residency ($12,600 over 36 months) you have essentially just taken a pay cut of about $4,000 per year and you will still owe the same on your loans as you would have under the old deferment model that paid the interest for you. Why? Assuming you have the maximum aggregate subsidized loan, you will only be touching the interest during that 36 month period – the interest that would have been paid by the government in the deferment model. Thus, residency salaries essentially decrease by $4K.

Fortunately, while the CCRAA did pass, the 20/220 rule was NOT eliminated thanks to hard work by the AAMC, AMA and AMSA. You can help ensure that the 20/220 stays intact by supporting S. 2303 and visiting www.ama-assn.org/go/cola for more information.

So, now that the fear of monetary loss has subsided, is there anything good about the CCRAA? Does it have any impact on EM or medicine more broadly? Well, indirectly the answer is “yes”, more directly, the answer is “maybe”. Let’s take a look at the CCRAA and explore some ways I think that the bill’s language might allow improvements in our own discipline by putting this law in the context of other federal legislature such as EMTALA (or at the very least brings in to question some areas of EMTALA that could be improved by further advocacy).

First of all, the CCRAA does some very important things that should be commended: the law increases the amount of a federal Pell grant by almost $1100 by 2012 and establishes a $4,000 a year grant for future teachers. For those of us in or near repayment, the new bill also decreases Stafford loan interest rates to 6.8% if disbursed between 2006 and 2008. Eventually, interest rates will be 3.4% for loans disbursed in 2012. The new law also increases grant funding through College Access Challenge Grants for underserved student populations. In addition, specific funds are disbursed to minority serving institutions.

While all of these aspects of the CCRAA are laudable, I would like to turn our focus to Title IV of the legislation. This part of the CCRA discusses loan forgiveness and outlines a program to increase public service employment among new graduates. More specifically, the portion of the bill allows for full Federal Direct Loan forgiveness after 120 months of income sensitive payments occurring simultaneously with 120 months of public service employment. Borrowers who have FFEL or other federal loans could consolidate/reconsolidate their loans under the Direct Loan program to qualify.

So, what qualifies as a “public service job”? Well, let’s look at the language of HR 2669. The CCRAA defines a public service job as follows:

A full-time job in emergency management, government, military service, public safety, law enforcement, public health, public education (including early childhood education), social work in a public child or family service agency, public interest law services (including prosecution or public defense or legal advocacy in low-income communities at a nonprofit organization), public child care, public service for individuals with disabilities, public service for the elderly, public library sciences, school-based library sciences and other school-based services, or at an organization that is described in section 501(c)(3) of the Internal Revenue Code of 1986 and exempt from taxation under section 501(a) of such Code; or Teaching as a full-time faculty member at a Tribal College or University as defined in section 316(b) and other faculty teaching in high-needs areas, as determined by the Secretary.

Is “EM physician” a public service job? I would argue that the answer to this question is “yes” for two reasons.

1. The language of the bill specifically states that those with a full-time job in emergency management are considered public service employees. Certainly, an EM Physicians manages patient services, an emergency department, as well as broader aspects of emergency care (including EMS and disaster planning). These are all components of the job duties found in emergency medicine physician positions.

2. Federal mandates to treat all comers defined by EMTALA specifically link emergency medicine services to public service. The ED is often the last resort for patient care in our current health care setting. There is a legal and ethical responsibility to treat every patient that enters our doors and this responsibility is taken up by EM physicians when other fields refuse. This treatment, however, does not come with any guarantees for reimbursement nor are we protected from litigation resulting from undesired outcomes. The services we provide to the community and the risks of increasing our legal exposure during difficult cases suggest that we provide a public-service as a full time job. Thus, EM physicians should be eligible to qualify for the loan forgiveness provision.

When the CCRAA was passed this year, no one envisioned the potential burden to current and future medical residents. This was an unintentional consequence and, once it was pointed out, was quickly resolved. Now, we are left we a CCRAA that will likely be modified to make the 20/220 pathway permanent. Therefore, we can turn our attention to positive aspects of the CCRAA. We have invested heavily into higher education in this country. The interest on our student loans will finance education in this country for the next generation. Thus, as heavily invested shareholders, we have a stake and claim to an associated piece of legislature that affects the economic and monetary rewards of that system. The recognition of EM physician as a public service job will lead to some relief from a heavy loan debt for many young members of this field.

The issue of funding in relationship to EMTALA can be taken a step further (and outside the context of the CCRAA). This debate reminds us that, while we are obligated to treat all-comers to the ED, there is no guarantee of monetary reimbursement associated with that responsibility. Whether we work through the language in the CCRAA or not, we must continue to advocate progress in the current structure of EMTALA. More specifically, until funding and exposure issues are resolved, we will continue to fail at resolving the problems laid out in the 2006 IOM report on emergency medicine. The on-call shortage is inherently linked to this issue and, in the current context of medico-legal liability, it is up to us to find creative approaches at raising awareness to the problems that exist within emergency medicine. If that means using a new law as a tool for advocacy, so be it.

gay marriage amendment isn't just about gay marriage

The Florida4Marriage group has 587,000 signatures out of the 600,000 required to force an amendment on the 2008 ballot banning gay marriage. Aside from the irony of the group's name (kind of like the "clean air act"), notice also the timing. Doing this in 2008 - a presidential election year - is simply a good bait and switch tactic.

The Republican presidential candidate will not be strong enough to bring swarms of voters to the polls, but an intense hatred of homosexuals should certainly do the trick. And hey, while there, why not go ahead and vote for Rudy/Romney/Fred

Tampa Tribune Story

Apple 3rd Generation (3G) Nano -- How to get TV Out setup

Bottom Line:

1. If you have a TV/DVR or Cable Box with composite video (3 RCA inputs - red, white, yellow), you need the Apple Composite Video Cable.

2. If you have TV(HDTV)/DVR or Cable Box with component video (5 RCA inputs red, blue, green + 2 audio inputs), you need the Apple Component Video Cable.

*The Apple Universal Dock is not required for this setup but does allow you to use a remote control.

Okay - here is how I figured this out after much tinkering and a few trips to my local apple store. This was written as I was doing things, so some aspects are resolved with the notes above.

First, let me note that the problem is mostly related to those who have composite, not component video. Meaning, if you only have composite video input (just the yellow RCA input jack with the red and white audio inputs) instead of component video, then things seem a little more difficult. Let me explain.

If you have a more fancy-schmancy receiver such as HDTV or some DVR boxes (but not mine from Brighthouse), then you will likely have the red,blue green inputs. If you have the component video input, along with stereo input (a red and white input jack), then all you need is the new apple component video cable . This can be plugged in directly to your ipod and your receiver and you should be good to go.

Now, if you only have composite video (the red, white, and yellow inputs), you will need another route. Okay, first of all you will need the apple composite video cable and you *might* need the apple universal dock as well. I will explain why I say *might* below.

Alright, here's the problem I ran into though. My local apple store didn't have the apple composite video cable - they only had the third party version made by monster (the itv link cable ). So, I bought that cable and went home, hooked it up to my ipod and to my yellow,red, white inputs on my DVR. Of course, I set the settings on the Ipod to TV out, selected a video and then hit play. What I got was an ugly picture of a 30 pin cable on my Ipod screen and the message that "TV Out is selected Please connect output cable". Grrrrr....

I then went back to the apple store and picked up the universal dock . I went back home, put my ipod on the dock and stuck the monster cable into the back and hit play again. Okay, now some progress. The video showed up on the TV screen and looked pretty good (like a DVD). BUT.....NO SOUND! I double checked the cables, everything was in the right place.

Frustrated, I took the Ipod off the dock, with the video still playing, and plugged the monster cable directly into the ipod -- booo-yah! Sound and video and no error message!!!

So, here's the really weird thing - I have to do this EACH time I play a video. If I try to play a video with the monster plug directly in the back of the ipod, i get the error message. If I play the video with the Ipod in the dock, NO SOUND. Instead, I have to start each video with the monster cable plugged into the dock and the apple on the dock. Then, after it's playing, I have to take the ipod off the dock and plug it in directly to the monster cable. Weird, but it works.

Now, my plan is to order the apple composite cable and see if it works better than the monster cable. Plus, I wonder if you can bypass the dock with the actual apple cable since I really don't know what the actual role of the dock is in the process since my technique is jury-rigged.

Okay, the final thing I will say is that the old way of doing this - with a 1/8" cable plugged into the line out of the ipod or the dock, no longer works at all. In other words, don't buy this apple ipod AV cable - it's useless with the new nano

Well, I hope this rant helps someone who is having the same problem - and if anyone knows a way for me to do this with less rigging, please do let me know. Thanks.

**Update -
My Apple Composite video cable arrived today via FedEx. I plugged it in directly to the Nano and to my input on the DVR. Everything worked great first try - none of the rigging described above with the itv link cable by monster (that's going back to the apple store today). Only small glitch is that the sounds is a bit low and requires the TV/stereo receiver to be turned way up - but everything else is fine.

http://docs.info.apple.com/article.html?artnum=300233

Legislation in Support of Emergency Medicine

There are 3 bills that have lingered in congress without a vote that would greatly increase funding to emergency medicine, address issues outlined in the 2006 Institute of Medicine report on EM, and help deal with shortages in on-call specialists and lack of access to EDs for patients. Here, I will briefly go through the language in those bills and talk a little bit about their potential impact on practice.

1. HR 3875 (S 2750):
Access to Emergency Medical Services Act
This bill is sponsored by Rep. Barton Gordon, a democrat from Tennessee (and people claim dems are friendly towards medicine!). As of 1/1/2007, there were 47 co-sponsors of the bill - 23 democrats, 24 republicans. The bill was referred to the House Energy and Commerce and then to the Subcommittee on Health. Unfortunately, the bill didn't make it out of committee and died two years after it was introduced. Furthermore, the attempt to move past a subcommittee on the Access to Emergency Medical Services Act has been ongoing since 1995 (the 104th congress). It is imperative that this bill receives broader support and is reintroduced in a future session of congress.

Federal legislation (Emergency Medicine Treatment and Liability Act -- EMTALA) dictates which patients must be treated in an ED, regardless of funding status. However, the mandate to treat legislation, while morally right, is not correlated with any increased federal funding or immunity from liability. Thus, it is difficult for hospital EDs to meet the requirements of EMTALA financially. Furthermore, the IOM has discussed the clear crisis in on-call specialists available to EDs. This crisis is partially due to fear of no reimbursement and exposure to liability with unknown patients by specialists. Finally, EDs are overcrowded. This is often due, not to the level of business in the actual ED, but, instead, to the number of beds filled throughout the entire hospital.

The Access to Emergency to Emergency Medical Services Act would solve many of those problems by amending the Public Health Services Act to include EDs as members of the Public Health Service in regards to liability and exposure, providing a separate and limited fund for any such claims.

In addition, the act would amend Medicare (Title 18 of the SS act) to increase funding for ED services for Medicare patients. This is critical. The Medicare sustained growth rate (SGR) formula is noted to be flawed as it does not increase proportionately with other health care costs and inflation. Cuts to SGR have been approved but kept from taking place at the last minute each year. This is an ad-hoc funding method. New legislation would outline protected, increased, funding of ED services to Medicare patients.

The Act also adds incentive payments to hospitals that admit patients to the floor in a timely manner, thus, creating an economic benefit for the hospital to ease ED overcrowding.

This is a bill that makes sense for patient safety and physician employment.


References
1. EM News - EPs, Nurses lobby congress for Overcrowding Relief
2. Govtrack.US HR 3875


2. S. 3606 This bill was originally sponsored by Democrat Jeff Bingaman, New Mexico and two other democrat co-sponsors. The bill echoes a portion of the more inclusive Access to Emergency Services Act discussed above. S. 3606 specifically links EMTALA and funding issues to a proposed amendment to Title 18 of SS act and away from the flawed SGR designed by CMS (Center for Medicare and Medicaid Services). Effectively, this would raise payments for ED services by 10% for medicare and medicaid patients. This bill has been referred to as the SOS Act of 2006 (Save our Safety Net)

References
1. TeamHealth Advocacy Center

3. Health Courts I have posted a number of times in the past about my support for a Federal Health Courts system to decrease physician liability, frivolous lawsuits, and the lack of real access to malpractice benefits for true victims are poor health care. You can read the latest update on this blog by clicking here.

4. HR 676 -- United States National Health Insurance Act/Expanded and Improved Medicare for All Act
-Sponsored by John Conyers, MI -- 85 cosponsers (1/3 of the Democrats in Congress
-Introduced in 2005
-in the Subcommittee on Health
Thomas Summary on HR 676

Alternatives/Paths to Single-Payer Healthcare

I support a complete overhaul of health care spending that includes shifting administrative costs associated with the dissolution of multiple payers, the money from costly premiums, and the generated revenue from allowing the Bush tax cuts to expire in 2010, into a single-payer health care system that keeps corporations from dictating the type of care my patients receive (care synonymous for "medical losses" in the lingo of the HMO).

There is a broad recognition that our health care funding system has failed, mostly brought upon by the realization that even middle-class workers with "good" health insurance are being bankrupted by high costs and denied coverage. This epidemic of underfunding (even with high costs to employers and workers for premiums) is likely to go further than the epidemic of unfunded (close to 60 billion) people in this country.

In addition, my vision of a real single-payer system is integrated into a number of other economic reforms and increases in social insurance. Since it is unlikely for all those necessary reforms to occur in this conservative/corporate climate, it is necessary to find other ways to put America on a path to universal health coverage.

On the even of the 2008 elections, we can already see that health coverage and health care spending will play an important role. Republicans such as Mitt Romney have designed semi-progressive models in their platform and past experiences (as governor of Massachusetts) that do serve as some improvement. In addition, all of the Democratic candidates for President have offered some form of health care reform (although only Denis Kucinich has proposed a true version of universal health care).

The major problem with the Obama, Edwards, and Clinton plans is that insurance is still tied to employers. This allows - forces - employers to seek the cheapest, not the best coverage. In addition, tax subsidies to employers for offering health care, combined with the tax-free status of a health care benefit to an employee, do not allow us to collect appropriate revenues that could lead to a more broad restructuring of health care. And, of course, this does nothing to correct the flaw in a model of health care that puts patients and physicians against HMOs since those groups have two very different groups (improving patient health vs. increasing profits by denying coverage). One of the worst aspects of the Democratic health care proposals is that, by setting a mandate that everyone must have insurance, the candidates have essentially said "You must have health care. Now, go out and buy it! Good Luck!"

Having acknowledged these flaws in the potential reforms, there are also some positive aspects of these plans that move us much closer to 100% health care coverage (and 100% reimbursement for the physician). A mixed-model approach can put the pieces in order to -- eventually -- get us to true single-payer universal health care while maintaining - or even decreasing - current per capita spending.

This path is best presented by Paul Krugman who outlines 4 components of the current proposals that may reduce costs and might lead to increased and adequate funding.
These 4 components are community rating, subsidies for low-income families, mandated coverage, and public-private competition.

The idea of community rating allows us to move past the "Go out and buy some health care - Good luck trying to afford it!" aspect of current policy. How? Currently, insurance companies try to minimize loss by first screening out any person with risk factors for health problems, or charing them exorbitant premiums (they also minimize loss by denying coverage once a person is accepted for underwriting). Anyway, the community rating (which is already in place in New York) prohibits health insurance companies from charging different premiums to different people. Some models of community rating also prohibit denial of coverage if there is any penetration of that company within a given community.

Next, subsidies exist in the form of medicare and medicaid. These programs can be slowly expanded (lowering the age for medicare eligibility and increasing the % of poverty to quality for medicaid).

Community rating and subsidies create a lower burden for low and middle income workers in the context of mandated coverage. However, public-private competition (laid out best in John Edwards health care reform proposals) might go furthest to eventually creating a true single payer health care system.

To understand why public-private competition may lead to a lower spending burden per capita on health care, it is first necessary to understand the differences in administrative costs between govt programs and corporate health care. More specifically, Medicare/Medicaid provides health care to a large number of Americans and operates with a 2-3% administrative cost. On the other hand, health care spending associated private insurance companies, as a whole, operate around 15% administrative costs. In Canada, the percent of administrative costs as a total of all health care spending is under 5%. Thus, the elimination of multiple private insurance companies and the consolidation of spending into a single agency could, effectively, reduce administrative fees from 15% of health care spending to 2-3% of health care spending.

Furthermore, if govt programs can operate with lower overhead/admin costs they can also operate with lower premiums and costs to patients. Therefore, if patients are allowed to chose between the govt plan and the private plan, they will likely chose the cheaper plan (assuming it offers the same level of coverage). The govt plan is likely to be cheaper and this will, in effect, out compete the private plan. In addition, some have proposed caps on % of health care spending per capita that can be made up by premiums. Thus, if premiums were capped, this might also limit a profit making company's ability to bring in an adequate margin.

The ideas for health care reform are out there and many of them, while not perfect, are quite good. If the house and senate Democrat majority is retained and one of the leading Democrat candidates are elected in 2008, there is a real chance that some type of broad change will take place in health care spending.

As Krugman points out, there was also a good chance for this to occur in 1993 with Clinton health care reform proposal. However, the failure of the Hillary Clinton health care plan and the beginning of the dot.com era in the context of increased economic growth, allowed the urgency of universal health care to fall further and further away from public concern. Plus, total health care spending did stop rising for a brief period in the early-mid 90s. Now, however, we are again seeing drastic rises in health care spending as %GDP (now over %16), an increase in unfunded/underfunded individuals, and no clear economic boom insight. Even though unemployment rates are indeed low, the existence of employer based health care has decreased drastically. Thus, the next 10 years are critical for the direction of health care spending in this country and for the possibility of escaping a true health care crisis that has already begun.

If you haven't read Krugman's work yet, you should. Even though the writing is a little sloppy and the writing is double spaced, the basic argument is sound (that we need a new new deal with universal health care at the center combined with increased taxes on high income earners in order to redistribute wealth and decrease inequality by growing a middle class). I just wish he would have had a better editor - there are missing commas after transition words and plenty of independent clauses simply smashed together with dependent clauses during long run-on sentences (like the ones you see in this blog!). Anyway, Krugman is not the most camera friendly person or best orator. His writing is reflective of those two things. However, his logic is strong and his vision should be commended.

Paul Krugman. The Conscience of a Liberal. 2007.

Shifting Demographics: A quantitative assesment of ED patient visits in a hypothetical setting of universal health coverage

ABSTRACT

INTRO: How would universal health coverage change the volume of patient visits, the acuity of encounters, and the structure of residency training in a typical academic ED? To put this question another way, if the current structure of health care funding in the United States is partially responsible for the growth of academic emergency medicine and residency training, how will changes to that funding system impact medical education within the field? In order to enter the national debate regarding access to health services, emergency medicine must understand the current relationship between visit acuity and funding and the potential changes to that relationship given various specific funding policy initiatives. If patient volume and acuity is partially responsible for the increase in the number of EM residency training positions over time, what would the impact on medical education be if that volume and acuity shifts? Is there any reason to expect any shifts in the context of universal health coverage?

MATERIALS/METHODS: This is a retrospective case control study using a computer software database program to conduct a chart review of a large urban hospital ED associated with a university. First, the distribution of visit acuity is described for funded and unfunded patients over a 1 year period. Next, the null hypothesis that there is no difference in those distributions is tested. Finally, multiple regression analysis is used to test the hypothesis that funding status explains the variation in visit acuity and examines how much of the variation in the acuity distributions can be explained by funding status or other variables such as age and race. Finally, these results are discussed in the context of potential new healthcare spending initiatives to address questions of possible changes in patient volume and acuity within an academic ED.

RESULTS:

DISCUSSION: EM has a legal and ethical mandate to treat underfunded and uninsured patients. Therefore, we have unique insight into how health policies affect patients. Thus, we have an obligation to enter the national health care debate.

INTRODUCTION
The goal of this paper is to address the following question: How would universal health coverage change the volume of patient visits, the acuity of encounters, and the structure of residency training in a typical academic ED? To put this question another way, if the current structure of health care funding in the United States is partially responsible for the growth of academic emergency medicine and residency training, how will changes to that funding system impact medical education within the field?

Emergency departments are designed to provide life saving care at all hours of the day and night. However, in reality, many patient encounters are for non-emergent health problems. Numerous hypotheses have been posited to account for this phenomenon and some have suggested that these non-emergent visits likely result from a lack of ambulatory care and underfunding of health coverage in some patient populations (Haywood et al., 1991; Rask et al., 1998; O’Brien et al., 1997). This paper examines the link between the increase in non-emergent ED patient encounters and the number of EM residency training programs. Furthermore, changes to sociopolitical policies and health care affect the demographics of patient visits to the ED. Here, the potential changes that might be expected within some variant of universal health coverage are quantitatively considered.

Past research has focused on differences in the epidemiology and demographic characteristics of frequent versus infrequent users of the ED and a number of researchers have tested hypotheses relating to funding as a causative agent in such differences. In a 2001 study conducted in Sweden by Hansagi et al., the authors found that frequent users of ED services were also frequent users of ambulatory services. The conclusion was that universal coverage does not reduce ED visits. Other studies in Europe have shown similar results regarding the epidemiology of frequent ED users in universal coverage systems (Byrne et al., 2003). However, this conclusion cannot be extrapolated to the United States because many of our patients have no other access to services and we do not know what the ED would like in Sweden sans universal care.

A similar type of study was carried out by Byrne and colleagues in 2003 within a mixed-funding environment (an ED in Massachusetts) and similar results were found regarding the correlation between high frequency ED visits and high frequency outpatient visits. However, these studies have not addressed the types of ED visits that took place or the possible effects of funding changes on those ED visits. In other words, past studies have examined some of the variables within a health services model, but have not examined how those variables co-vary when another variable in that model is changed. Thus, it is critical to explore issues of patient funding, potential changes in coverage, and their estimated effects, on our current system of emergency medicine. In order to enter the national debate regarding access to health services, emergency medicine must understand the current relationship between visit acuity and funding and the potential changes to that relationship given various specific funding policy initiatives. The assumption of this paper is that majority opinion regards the current funding model to be in crisis and that a solution is necessary. Some type of change will arrive and that change might impact the structure of ED visits.

BACKGROUND
Emergency medicine is a growing field. This year, three new allopathic residency training programs have begun accepting new applicants (Florida Emergency Medicine Physicians, Oklahoma State, and UTMB-Galveston) and a number of other programs have increased the allotment of new residents for the subsequent year.

The field of EM was born approximately 40 years ago with the founding of ACEP in 1968 and the subsequent movement toward board specialty status. Herbert Flessa started the first EM residency training program at the University of Cincinnati with Bruce Janiak as the first resident in 1970. By 1975, there were 31 residency programs (http://www.emra.org). In 2001, there were 124 allopathic sites (Lathrop et al., 2001) and AMA-FREIDA lists 141 allopathic EM residency training programs as of October 2007. Furthermore, there were 4,957 approved training spots according to the ACGME in the 2003-2004 season. However, EM, like all fields of medicine, is affected by sociopolitical policies and changes. In the ED, the demographics of our patient encounters may be most reflective of shifting lifestyle choices or social-epidemiological risk factors more so than anywhere else in medicine.

On the eve of the 2008 elections, a number of candidates have outlined some form of mandatory universal health coverage. Furthermore, the recent presidential veto to expand S-CHIP has renewed the debate regarding a broader universal health care system in the United States for both children and adults. While health care expenditures continue to rise as a percent of our GDP, health outcomes have not improved substantially. Many health care professionals now accept the fact that change is necessary to insure solvency and better care for our patients.

In order to remain ahead of potential shifts in health policy, it is important to consider how such changes to coverage and patient funding might affect the volume and types of patient encounters in the ED. Our field is still relatively young and has not yet witnessed multiple shifts in policy and political cycles. It is critical to examine potential scenarios and affects of those scenarios on the field of residency training and medical education in emergency medicine.

The 2006 IOM report on EM notes that, over the past decade, the number of emergency rooms has decreased while the number of ED visits has increased. During this same period, the overall number of training positions has also increased. The volume of patient visits is not the only variable that accounts for the growth of our field. Certainly the spread of the requirement that hospitals staff EDs with ABEM certified physicians has also created a shortage of well-trained doctors that is likely to persist for some time, even if residency training continues to expand. However, it is important to consider all variables that lead to growth of a particular industry and, surely, patient volume must be one of those factors that provides a basis for increasing the total number of EM residency positions. The question is, to what extent does volume matter and, more importantly, is there even any reason to expect a volume decline in the context of improved patient funding and better access to primary care? The goals of this paper are to elucidate the relationships between funding, volume, and acuity of patients visiting a typical academic ED in order to provide more insight into how the field might change a future scenario with 100% access to ambulatory physicians and preventive services.

MATERIALS AND METHODS
In order to answer questions regarding changes to the distribution of visit types and volume, it is necessary to first examine descriptive data for a typical academic ED in an urban setting under the current model of coverage. What is the distribution of acuity in ED visits among insured patients? What is the distribution of acuity in ED visits among unfunded patients?

Next, I will test the null hypothesis that there is no difference in these distributions. If the null hypothesis if false, a prediction is that, if unfunded patients seek ED care for primary health concerns, the distribution should be right skewed (towards lower acuity visits with Level 4 and Level 5 triage designations)*. However, it is also possible that unfunded patients will have a left-skewed distribution toward lower acuity visits if (1) they rely on the ED for ambulatory care at roughly the same volume as the normal population visits primary care physicians and (2) if the occurrence of high acuity visits is infrequent, or at least equal to that of the funded group so as to not inflate the mean due to ordinal numbers of higher magnitude. If there is a right-shift distribution in the unfunded patients, how does this represent the overall distribution of ED visits in a given year?

If there is a statistically significant difference between funded and unfunded low-acuity visits, that difference may represent a pool of patients that would seek care with a primary care physician if funding were equal between the two groups. If this pool of patients is lost, what would the impact be on the ED in terms of lost patient encounters, teaching experiences, residency training and medical education? In other words, how much primary care/ambulatory care do we really see in the ED and how much of that would likely be lost if all patients could visit a primary care physician?

Finally, it is important to examine the state of EM and the demographics of patient encounters within academic EDs in other countries that have different types of funding models. For example, the demographics of an academic ED in Canada or other industrialized democracies may provide some insight into expected changes within our own departments.

This is a retrospective case control study using a computer software database program to conduct a chart review of a large urban hospital ED associated with a university. X number of patients will be identified that had no existing funding on presentation. Next, X number of control patients will be identified who have some source of funding (private insurance, Medicare, Medicaid, other state or local agency coverage – such as the Hillsborough County Health Care Plan). [Or should I look at all cases over a given time period – e.g. 6 months, 1 year, etc – depends on how easy it is to pull out info from the database??]. The cases and controls will be assigned a unique identifier. Given the retrospective and anonymous nature of this study, a request for informed consent was [will be] approved by the USF IRB and other aspects of the study were done with appropriate review. [will this likely receive exemption from the IRB people?]

The cases and controls will be compared to ensure that any observed differences in acuity level are explained by variation in funding status, as opposed to age, race, or sex. Thus, a chi-square analysis is conducted between the two groups for each of those three variables. Any significant differences in the groups will be addressed and controlled for in further statistical analyses (i.e. age and/or race may predict funding status and -- especially age -- may also predict level of acuity of a given ED visit).

For the cases and the controls, the level of acuity will be assigned a number from 1-5 based on the initial triage assessment [or should I base this on the discharge ICD-9 code and correlate that to acuity???]. Statistical analysis is used to test the hypothesis that there is no difference in the distribution of acuity level between groups. If there is a difference in acuity level, the hypothesis that the difference is explained by funding status will be further explored.

To test the hypothesis that there is no difference in the distributions of acuity level in the funded and unfunded group, a two-tailed T-test is employed. If statistically significant at p < style=""> Finally, an odds ratio can be calculated for the likelihood of a high acuity visit [Level 4 and 5?] between the unfunded and funded groups. A 95% CI is calculated for the odds ratio. An odds ratio is useful because the results of the ratio calculation can go in either direction and still provide relevant data. In other words, is it more likely that an unfunded patient relies on the ED for all primary care, thus, comes in for a wider range of ED visits with a likely lower mean-acuity score? Or, is it possible that the unfunded patient only uses the ED in a catastrophic event, simply living without medical care for most health concerns?

RESULTS

DISCUSSION
Leadership is seeing problems before they exist and knowing possible answers to questions that have not been asked. EM is a unique position to see the impact of our country’s healthcare policies first hand. Through federal legislation (EMTALA) and the words of our current president (“they can just go to the ER [if they don’t have health insurance]”) we are also the safety net for the underfunded and uninsured. Thus, we have an ethical mandate to play some role in the national health care spending debate.

Currently, we are nowhere near universal health coverage in this country. However, as our patients continue to suffer, vulnerable to the vetoes and philosophical debates of legislation, we must be willing to discuss realistic approaches to improving patient care. If our overall goal is to improve the health of our patients and keep them out of the ED, it is critical to understand the projected impacts of a wide range of potential solutions and improvements to our current healthcare crisis. While the idea of keeping customers away may seem to be a paradoxically positive outcome in the business of EM, this is balanced by the prospect of 100% reimbursement rates in the context of future health care spending policies.

References

1. http://www.emra.org
2. http://www.acgme.org/acWebsite/CMS/resPopData_specialty03-04.pdf
3. http://www.cjaonline.net/Communities/FL_Hillsborough.htm
4. Hayward RA, Bernard AM, Freeman HE, et al. Regular source of ambulatory care and access to health services. Am J Public Health. 1991;81:434-438.
5. O’Brien GM, Stein MD, Zierler S, et al. Use of the ED as a regular source of care: associate factors beyond lack of health insurance. Ann Emerg Med. 1997;30:286-291.
6. Rask KJ, Williams MV, McNagny SE, et al. Ambulatory health care use by patients in a public hospital emergency department. J Gen Intern Med. 1998;13:614-620.
7. IOM. Hospital based emergency care – at the breaking point. 2006.

Notes
* However, this is complicated by the possibility that unfunded patients waiting to seek care may present with more high acuity complaints due to delay in care.

**In Hillsborough County, there is an award-winning and nationally recognized comprehensive health care plan for indigent members of the community. Up to 28,000 residents are eligible for this plan at up to 100% poverty level. The plan emphasizes preventative services, early intervention, health education, and the coordination of health and social service. Thus, enrollment previous to recorded ED visit will be considered “funded” for this paper. However, enrollment during ED visit will be considered “unfunded” even if retroactive funding covers the particular visit since that patient would not have benefited from the primary care inherent to the plan previous to the ED visit.

***If there are more than funded vs. unfunded (e.g. underfunded) – conduct a trend analysis to examine the relationship between acuity and level of funding

The "Green New Deal" - a call to lead in renewable energy

I don't agree with Thomas Freidman about everything, but I do think he is getting smarter and further away from his support of the Iraq War. Friedman basically gets his argument right in "The World Is Flat" that there is a growing global middle class causing a crush on resources (I also think it's unfair to label him a neoliberal since he doesn't support unregulated capitalism).

I also think that our nation and our generation is waiting for a broad vision regarding renewable energy. Anyway, here is a video with Friedman explaining his idea and call for such leadership.

Thomas Friedman Video "The Power of Green"

If anyone has any idea how to embed NY Times videos on the blog, please let me know.

blogging you blogging us - ACEP in Seattle

I'm currently up in Seattle for the big Emergency Medicine conference. On Monday, I was sitting in the lobby next to Sanjay Gupta as he banged away on his PDA/smart phone. A little bit later, I checked his blog and a post had appeared regarding an article that is presented at this meetings regarding the safe use of tasers by police (which is a whole other issue for a whole other blog post). The post is attributed to one of his staffers, but who knows.

We are staying at the Ramada Inn (thank you USF College of Medicine) in the middle of the financial district -- the same area that was hosted the WTO in 1999 and, of course, was home to the massive street demonstrations that same year.


The Ramada is on the corner of 5th avenue and Blanchard Street. The video above is a webcam from 4th avenue and Pike - just a few blocks away. The ACEP convention that I am attending is at 6th avenue and Pike. Things look clean and sterile (but admittedly very nice - nice city) today in front of the Washington State Convention Center.

William Easterly vs. Jeff Sachs - A question of treatment threshold and dose response

Professor Sachs is well known for his advocacy to increase federal aid to poor countries, while also canceling debt in many areas. Furthermore, Sachs advocates meeting the funding goals outlined in the Monterrey Consensus that calls for rich countries to give 0.7% of GNP. If the countries involved were to meet this funding level, Sachs argues that the Millennium Development Goals to end poverty by 2015 would be met. Unfortunately, only a small number of countries have reached the 0.7% level and the U.S. and UK are not among those.

While the U.S. did pledge to meet the 0.7% bar, the country is currently no where near this level of giving. However, the U.S. has expanded - nearly tripled - it's international aid donation during the Bush administration compared to the 1990s. However, at 0.23%, that still puts the U.S. well below the 0.7% benchmark. Jeff Sachs points out that this is only $0.23 of every $100 of income and only $0.70 is needed.

Easterly, an economist at NYU, is a long-time intellectual opponent of Prof. Sachs. In numerous articles and books, Easterly has criticized Sachs for his support of foreign aid, the Millennium Development Goals and the current state of international aid organizations. One of Easterly's comment critiques is that international aid has not been effective -- over the past 50 years, aid has increased exponentially but rates of poverty have also gone up throughout the world - specifically in those areas that receive the most aid. He makes many good observations for why this might be and also outlines important ways to improve the delivery and efficacy of foreign aid. However, his call to stop increasing foreign aid because it doesn't work is completely misguided.

In medicine, drugs have a window of efficient action called the Therapeutic Index. This window is the range of doses that - at minimum - allow the drug to affect the given pathology and -- at the top of the range -- the maximum dose that will not produce increased morbidity/mortality due to adverse reactions or drug side effects.

In terms of international aid, we are under the therapeutic index. Thus, Easterly is perfectly correct in his claims that increases in aid have not let to reduction in poverty. However, it is a fallacy to assume that further increases in aid will not lead to a dose-response once we surpass some threshold (namely 0.7% of collective GNP from donor countries). Until that benchmark is met, Easterly's argument is moot.

Finally, Easterly does have two ideas that should be integrated into the arena of development economics. Namely, incentives and accountability. People work harder and produce more when they have incentives - usually monetary gain. The distributors of international aid need incentives to optimize the results of every donated dollar. Finally, we do need accountability as well. Both Easterly and Sachs note that the majority of aid, in the past, has not reached the appropriate people due to corruption by top-level officials in aid countries. This has to stop if we are going to get a return on our aid dollars. But the approaches of Easterly and Sachs do not need to remain mutually exclusive.

Easterly seems nervous that Sachs is calling for a top-down, centralized approach to government when the truth is that Sachs is actually in support of a market economy within the framework of appropriate wealth distribution in the vein of - as he calls them - Nordic economies (namely Finland, Denmark, and Sweden).

An update on Health Courts

An alternative to jury based malpractice decisions and a potential solution to the malpractice crisis

The Health Care Blog has posted an interesting audio file updating us on Health Courts via a discussion with Professor Mello from the Harvard School of Public Health. Definitely worth a listen.

If you have been reading my blog for a while, you may remember a discussion of a bipartisan bill which proposed a Federal Health Court System. I couched that discussion in terms of, at that time, recent 2004 elections which added to health-related amendments to the Florida state constitution. If you are interested in those amendments or the context of the original discussion, read the post here.

Otherwise, here is an excerpt of my original discussion that is limited to a summary of the Health Courts Proposal:

"....only 2% of patients injured by negligent care ever file a malpractice claim and the current malpractice system only compensates 1 in 14 people. These low odds and the lack of precedent cause attorneys to adopt a strategy of swamping the courts with malpractice claims, 4 out of 5 of which are found to be invalid. A system of standards for awards and for care would greatly reduce frivolous suits and would allow attorneys, patients, and physicians to modify their practices and behavior accordingly.

There is a solution to these problems that would be in complete alignment with Amendment 3 and Amendment 8. The Progressive Policy Institute, among others, proposes a system of health courts for liability claims and written standards of liability settlement that would function similar to the workers compensation claims process operated by the Board of Labor.

The most striking and revolutionary changes that would follow the health court system would be a shift from designating blame to a particular physician into assigning a process of blame to a team, group, or institution. Furthermore, and maybe most controversial, the system would end jury awards for malpractice and would rely on written standards to dispense benefits.

The basic tenants of the Progressive Policy Institute proposed Health Court system include (1) replacing civil courts with health courts to hear liability claims (similar to specialized tax courts), (2)creating a written standard of accelerated compensation events (ACEs) of common medical mistakes and errors (e.g. bleeding after colon surgery requiring an additional surgery) that would detail a benefit schedule that could be included with lost wages and direct economic damages, (3) ability for patients to directly file liability claims with the health care provider or hospital, (4) a local board that would review injury claims and determine if they meet ACE designation or if they require further judafication, (5) a system of state and federal health care boards with mixed funding at each level, (6) the establishment of additional ACEs and benefit standards determined by written case law (7) experts will be paid and obtained by the court and board, not by the attorneys from either side, (8)the ability to monitor truly negligent hospitals and institutions over time and (9) use of evidence based medicine to establish a standards board for practicing physicians.

The benefits of this system are that physicians will have a clear idea of what constitutes malpractice and liable behavior because their will be a written set of standards developed from court rulings. This will decrease overall health care expenses by decreasing the practice of “defensive medicine” which is common among physicians (an over abundance of tests are ordered to cover liability). Furthermore, all patients will have access and ability to pursue injury claims in a similar manner in which they already pursue worker’s compensation claims. In addition, the hiring of experts by the court will reduce attorney fees significantly making it easier for low-income individuals to obtain representation. Also, juries should not be in the business of deciding law, they should be focused on deciding fact. However, the unclear precedents in current malpractice suits make it so that the jury focuses their efforts on deciding law since there are no clear standards of care. It is quite possible that two people suffering identical injuries will receive very different awards simply based on the jury they receive. A physician faces the same fate at the mercy of an assembled jury. Health Courts remove juries from these decisions and allow clear expectations and standards to develop over time.

The Progressive Policy Institute has also outlined a number of potential objections to this system. The objections will likely come from attorneys for two reasons – (1) citizens have the right to a jury trial and (2) malpractice attorneys could suffer decreased compensation and less demand for services. However, the workers compensation model is ideal for demonstrating that it is possible to settle liability claims without a jury. Furthermore, if only 2% of malpractice injury claims are pursued at present, and only 1 in 14 of those receive an award, attorneys may be able to find compensation simply by the increased frequency of malpractice cases they will be able to take on.

One other potential problem is that large jury awards have been significant for increasing reform in other industries. For example, tobacco lawsuits resulted in billions of dollars in jury awards that threatened tobacco companies and resulted in significant modifications within their industry and an increase in positive health outcomes among the community. However, the large jury awards are not useful in altering physician behavior or hospital practices. Since there are no clear standards in place, it is not possible that a systematic practice of negligent and liable behavior is occurring. In other words, there is no behavior to deter by these awards. As a matter of fact, the large awards are linked to increased health care costs due to the practice of defensive medicine and high insurance rates.

........By enacting a short-term 1% increase in malpractice premiums, a much larger decrease could be expected in the following years. The 1% increase can be used to set up a state Health court, as well as local boards that create ACEs and review claims. Once the system is launched, necessary attorney fees will drastically decrease as neutral experts are hired by the state, not the legal team. In this scenario, injured claimants would certainly recover 30%, or more, of their first $250,000 in non-economic damages. Furthermore, a state board would be created with the ability to monitor negligence and malpractice among individual physicians and hospitals...... It is possible that even with the significant reduction in attorney’s fees and the elimination of unfair jury awards, malpractice premiums may not decrease. At that point, the state should explore insurance reform, similar to the MIRCA in California to ensure that we maintain a population of specialist physicians in the state. In the immediate future, a state Health Court would allow us to address numerous problems now posed to us by the liability crisis. Furthermore, we would create the necessary infrastructure that goes beyond putting a band-aid on a gushing wound, allowing us to plan for adequate delivery of health care services now and in the future."

Links
1. My original post about health courts and new Florida law
2. Professor Michelle Mello, Harvard School of Public Health, Audio File
3. Progressive Policy Institute Article on Health Courts
4. Common Good Explanation of Health Courts

everything in moderation

I think it's funny that Naomi Klein's new book calls for a "mixed-economy" - which I agree with in principle (a mix of free markets with strong support for govt social programs and regulation). But there is also a reactionary feel to her work - such as her criticism of people like Prof. Jeffrey Sachs.

I like what Klein is saying in her book but I like the policy and goals of people like Sachs even more. If I wasn't moderate about my intake of information and opinion/perspective formation, these two things would NOT be able to co-exist. Why? Klein calls Sachs "The New Shock Doctor" in response to his radical economic policies in Bolivia and in Poland in the 1980s.

More importantly though, Sachs has an outlined goal to END poverty - he has steps to take and is working on the Millennium Project with the UN, and with his own Earth Institute at Columbia University, to carry out those steps.

The point is not whether this will work or not, the point is that Sachs has a vision for change , the education to formulate real steps and ideas, and the influence/power/experience to actually carry out many of those propositions.

Why spend so much time criticizing someone who wants to find ways for local economies to meet financial independence through the creation of their own infrastructures? In the Sachs model, populations become less dependent on the U.S. - something you would think Klein would be in favor of? But, in the uni-lens view of "shock"/in the reactionary vein, it is difficult for the author to see this - even though it sounds like she is advocating moderate approaches that would support other ideas about economic progress in her push for "mixed economies". The NYU economist William Easterly has a much more serious rebuke to Sachs' ideas. However, his training and his acceptance of many basic tenants laid out by Sachs make his review more serious than that of Klein.

Blinded by ideology -- something that scared me about the left when I was younger and something that keeps me much more independent now (whether I align 90% of the time or not). More on all of this later, when I give more detailed discussion of Sachs and Klein - or moreover (and more fair, since Klein isn't an economist) - to Sachs and Easterly.

Bridge Clinic - USF Free Clinic

Congrats to Sam, Omar, Shelby and Waldo. More importantly, congratulations to the USF area population. They now have some refuge during our country's continuing health care crisis.

My colleagues' hard work to open the Bridge Clinic in the USF area has paid off. The clinic has the full support of Dean Klasko and is up and running as a student-run continuity clinic (supervised by attendings) with the ability to make specialty referrals, provide lab testing and other services - such as physical therapy.

Channel 10 did a recent story that you can view by following the link below:

http://www.tampabays10.com/video/player.aspx?aid=48866&sid=64484

The Bridge Clinic

The Inkwood Penalty: Are locally owned businesses worth the tax?

Tampa doesn't have a very large market of independently-owned businesses that carry things I consume. One of the few that does have stuff I want is Inkwood Books on the corner of Armenia Avenue and Platt Street in South Tampa.

The small bookstore became popular when I was a high school student at Plant in the mid-90s during an era predating amazon.com - the store was the place to go for english lit books throughout the school.

As I got older, and the non-fiction market grew, I turned to Inkwood more because it simply was the best place to go in hopes of actually locating a new book that I wanted to read. While Amazon was prevalent by the late 90s, always carried what you wanted, and almost always cheaper - instant gratification could not be found online. Thus, local bookstores did - and still do - win out when I wanted/needed a new tome.

However, Borders began to expand their selection in the late 90s -- stocking their shelves with more "independent" and "small" publishers. Thus, the choice between the mega seller and Inkwood became less clear cut.

In addition, the social attraction to Borders over Inkwood also became clear as a college student and grad student looking for a place to take up space. Coffee, couches, music are all good ways to pack customers into a store and keep them there until they buy a book.

Furthermore, new books at Borders sell for about 25% off the list price. A select handful of new books each month sell for 20% off the list price at Inkwood. Therefore, in many cases, shopping at Inkwood results in paying a penalty and receiving less goods (no coffee, couches, music) for a higher dollar figure.

In addition, if you sign up online for Borders Membership Rewards club, you receive a coupon every Friday for for 20-30% off any item in the store. You can print out as many coupons as you want - there is no limit on hitting the print button and no link to your exact account (to be more clear, I'm sure Borders would prefer you to come in and buy infinite products at 20-30% off then no product or 1 only product).
Furthermore, every time you buy something at Borders, you get another coupon for 20-30% off anything in the store, allowing you to keep the purchasing cycle alive ad nauseam.

Essentially, you can find everything at Borders that you can at Inkwood (plus a whole lot more stuff you don't really want to find). You can also get it cheaper with more hours in the day to get there(Borders is open until 11pm everyday, Inkwood is open as late as 9pm only 1 time in the week).

If price and convenience were the sole factors, certainly Inkwood would be out of business (at least out of the direct retail business - maybe they would subsist instead only with contracts/deals with local schools). So why are they still in business? More importantly, why did I go there this weekend and pay $13 more (30%) for a book I could have also purchased at Borders, less than 1.5 miles away? What makes a consumer willing to spend such an exorbitant penalty?

Branding. Inkwood has a prius in the parking lot. Inkwood carries a wide range of books but certainly has all the liberal non-fiction and the small-press fictional literature that is hot in the Democracy Now!, NPR, McSweeney's circles. Inkwood is an independently-owned local business with a connection to other independent news sources, radio stations, and stores within the community.

The bottom line for me is that I almost feel as "duped" by buying within my brand - feeling some intangible need to support local business. Moral economics?

I buy a lot of books and I'm not convinced that conscious consumerism is really worth such a high economic penalty. I suppose one way to look at it would be - Who can do more with the extra dollars? The local business you are supporting or you --the individual? Well, if that's how you look at it, then I would say that the answer is dependent on what percentage of income we are talking about. Until I'm an attending physician, $13 - potentially over $100 per month - is still a decent chunk of change on a med student or resident's salary with a teacher for a wife who doesn't exactly rake in the millions.

At this point (and maybe at any point) I could probably "do more" with the excess dollars by purchasing more books at a cheaper price. Wouldn't this scenario lead to larger support of the publishing industry as a whole by supporting a larger group of people then just one store? Not too mention, increased knowledge acquisition by me and a better return on my money at every purchasing event (comfort of borders, etc).

Inkwood does do a service that should afford some extra price of their products - they bring in many authors for book discussions. I would be open to the argument that this service offsets the services provided by Borders of comfy confines. Only problem is, Inkwood rarely brings in the folks I want them too. Thus, this happens to be a matter of personal taste and I can't feel guilty about neglecting the store on that point. For example, this weekend I bought a book by Naomi Klein (The Shock Doctrine). The author is currently on tour but not coming anywhere near Inkwood. Perhaps if the author was going to speak at the store I would have no problem paying the extra $13 for my copy of her work?

I think my conclusion, for now anyway, is that " The Inkwood Penalty" is one that I just can't pay - especially when you know you are getting less material return for your dollar.

Now, if Inkwood wants to start honoring those competitor coupons I get each week, maybe, just maybe, we could talk.

T-mobile or T-rex?

The dinosaur of wireless companies and the ridiculous expense/luxury-tax on true wireless internet (not yet obtainable to even a tech-savvy consumer).

For some time, I have been curious about using upgrading my existing T-mobile service into the world of full wireless internet. hahaha - this was a thought in futility as I, instead, learned all about the outdated infrastructure of T-mobile and the high price of all wireless companies in the realm of broadband access.


1. Currently, T-mobile has only an EDGE network which runs at about 90 -135 kbps. Almost every other major carrier sports a 3G network, allowing speeds around 300 kbps.

2. There are rumors that a 3G T-mobile network is now ready for launch sometime in the near future. However, it is apparently on a different frequency then current phones (1900 mhz instead of the more common 1700 and 2100 mhz [european]) so new phones/PDAs will need to be created before it can work with mobile devices. Plus, there is no exact launch date yet. The slow down may be due to some government related entanglement involved in freeing up the 1900 mhz frequency according to this article.

3. The new T-mobile combo phone/PDA (the T-mobile Wing - see video review here) is really not a great improvement over the 2005 T-mobile MDA ( video review here) that I currently have. The new Wing does have Windows Mobile 6 (which is itself apparently not a great improvement either) but no real upgrade in processor speed (201 mhz vs. 195 mhz), SDRAM (both 64 mb) or onboard flash memory (128mb in both). Most of the improvements seem to be in things I don't really care much about - nicer design, better color, square keys on keyboard, and a bigger menu button. Plus, the camera went up to 2.0 megapixels with an 8X zoom - whoope-dee-f*in-do....it's still a crappy plastic lens and a crappy camera that should only be used in odd situations (spy photos while looking busy at work!) or emergencies (you get in a car accident with no camera handy, etc).

4. I would like to make the transition to full wireless company networking - e.g. get rid of the cable modem if possible to obtain non-801 dependent wireless access.

5. My options are to stay with T-mobile and move around the network like a dinosaur with arthritis or to eventually make a switch to another company when our current T-mobile contract expires at the beginning of may.

6. I will first consider the options to stay with T-mobile in hopes that 3G shows up by May but will also examine networking possibilities with AT&T/Verizon/Sprint since they seem to be far far ahead in that arena. Especially AT&T which has produced the exceptional 8525 phone/PDA combo that definitely outperforms the T-mobile Wing and will be adding Windows Mobile 6 later this year.

7. I only consider Windows Mobile OS-based in this review. I have a personal preference for this type of phone, which are also usually designed with the slide-out QWERTY keyboards. No Palm Treo models are considered.

8. What am I looking at here? The ability to convert our house to non-cable modem internet access on the 2 laptops and having a fast and efficient PDA/phone for work.

9. T-MOBILE
a. T-Mobile Wing: Price w/contract renewal = $300
b. 2 Sony Ericcson Laptop Network Card s = $150/card = $300 (listed as $199 on web, but phone rep verified $150 price)
c. Internet Access Price per month = $50/laptop X 2 ($100/month for, essentially, dial-up speed!)
d. 2 Year Total Cost = $3000

10. AT&T
a. 8525 Smartphone: Price with contract = $350
b. 2 AT&T Laptop Connect Cards: Free with 2 year contract (AT&T also offers ability to use your smartphone as a modem to get to the 3G network)
c. Laptop Connect/Data Connect Internet Access Price Per Month = $60/laptop with 1 $5/month discount for a voice plan ($115/month)
d. 2 year total cost = $3110

11. SPRINT
a. Spring Mogul by HTC Smartphone: Price with contract = $300
b. 2 Sprint PX-500 Network Cards: $10/card with 2 year contract = $20
c. Unlimited Broadband Mobile Connection Plan = $60/laptop X 2 = $120/month
d. 2 year total cost = $3200

12. VERIZON
a. Verizon XV6700 Smartphone: Price with contract = $300 (slightly outdated, Mobile 5.0, plans for new one?)
b. Verizon PC5750 PC Card: Price with Contract = Free
c. Unlimited Data Plan = $60/laptop X 2 = $120/month
d. 2 Year Total Cost = $3180

10. Additional Costs OVER Existing Roadrunner Cable Modem Service
a. Do not need to include cost of T-mobile Wing -- if no changes were being made to internet service, I would still buy a wing (excluded = $300) - so this is not really an extra cost.
i. The adjusted cost over 2 years with that considered-credit then is as follows
T-mobile = $3000 - $300 = $2700
AT&T = $3110 - $300 = $2810
Spring = $3200 - $300 = $2900
VERIZON = $3180 - $300 = $2880
b. Roadrunner Cost Per Month
i. Currently have Digital Combo Package = Cable + Roadrunner = $79/month
ii. Digital Cable Alone is $60/month
iii. Thus, the Roadrunner incurred cost = $19/month
iv. We would keep basic cable if we canceled the internet, thus, our bill would only derease by approximately $22/month (when taxes are included)
v. The savings of 2 years of this service decrease = $22 X 24 = $528
c. The additional cost after 2 years of cellular-company based wireless is
i. T-Mobile = $2700 - $528 = $2172
ii. AT&T = $2810 - $528 = $2282
iii. SPRINT = $2900 - $528 = $2372
iv. VERIZON = $2880 - $528 = $2352

11. 2 Year Costs PER Laptop
a. T-mobile: Network Card $150 + Internet Access $50/month ($1200) = $1350 - $528 = $830
b. AT&T = Internet Access $55/month ($1320) - $528 = $792
c. SPRINT = Network Card $10 + Internet Access $60/month ($1320) = $1330 - $528 = $802
d. VERIZON = Internet Access $60/month ($1440) - $528 = $912

11. CONCLUSION
In May, I will likely just "upgrade" (not much of an upgrade) from my current T-mobile MDA to the T-mobile Wing - mostly for mechanical reasons (my MDA takes a daily beating and it is starting to show). With two computers, you just pay way too much for the internet access - essentially paying more than double what it's probably worth. Anyway, with one computer, things are a little more attractive (as low as a $792 luxury fee to have this service if you go with AT&T).

With more than one computer and still high prices, another 2 years as a T-mobile customer is likely (will go to 10th year of T-mobile at that point I believe). I'm not happy that this company hasn't made infrastructure upgrades and I'm even more unhappy that the cost of true wireless seems ridiculous compared to the traditional cable modem/wireless router/hit up paneras approach I currently employ. My guess is that this may be cheaper and easier in a few other countries out there.