31 January 2012

When politics trump health care

Seriously, this is bullshit:

Susan Komen Foundation halts grants to Planned Parenthood

NEW YORK – The nation's leading breast-cancer charity, Susan G. Komen for the Cure, is halting its financial partnerships with numerous Planned Parenthood affiliates. 
Komen says the key reason is that Planned Parenthood is under investigation in Congress - a probe launched by a conservative Republican who was urged to act by anti-abortion groups.
The result is a bitter rift, linked to the national abortion debate, between two iconic organizations that have assisted millions of women. 
Planned Parenthood says the cutoff, affecting grants for breast exams, results from Komen bowing to pressure from anti-abortion groups. Komen says the key reason is that Planned Parenthood is under investigation in Congress — a probe launched by a conservative Republican who was urged to act by anti-abortion activists. 
The Komen grants, which totaled about $680,000 last year and $580,000 in 2010, went to at least 19 Planned Parenthood affiliates for breast-cancer screening and related services. Planned Parenthood hopes to raise new funds to fill the gap.

Planned Parenthood used these grants to fund 130,000 breast exams and 6,500 mammograms.

As usual, the so-called "Christian" right puts their ideology and politics above actual women's health, whether it's blocking the HPV vaccine or forcing women to undergo unnecessary medical procedures.

For the record, the pretext for this decision is fairly thin; Komen has a policy which prohibits funding of any organizations under congressional investigation. Congress is investigating Planned Parenthood. Ipso facto, case closed, not at all political, right?

However, according to the Washington Post, this is a new policy, adopted after Komen hired conservative Georgia politician and failed gubernatorial candidate Karen Handel as their senior Vice President of Public Policy. Handel, who is pro-life, ran for governor on a pledge to defund Planned Parenthood if elected. No other organizations have been similarly affected at this point. It is also worth noting that the "investigation" which triggered the termination of the partnership is nothing more than a partisan fishing expedition led by pro-life government oversight chairman, Daryl Issa.

There's nothing wrong with any of that: Komen is a private organization and they have the right to follow any ideological agenda they choose. But don't believe any apologists who may claim that this was not driven by politics or a pro-life agenda.

Still, it's disturbing and disgusting to see a formerly reputable organization dedicated to women's health become co-opted by the christian right.

The founder and chairperson of the Komen Foundation is Nancy Brinker, whose email address, I am told, is nbrinker@komen.org, and Elizabeth Thompson is the CEO, reachable at ethompson@komen.org. I have reached out to both of them and politely expressed my concern about this politicization of their organization.

For my part, I will no longer support any Susan Komen Foundation activities or fundraisers so long as this situation persists. Frankly, there are plenty of other organizations doing great work for women's health in general and cancer in particular:

The American Cancer Society
The St Baldrick's Foundation
and, of course, Planned Parenthood itself.

I'll be directing my dollars and charitable efforts there instead.

Boomerang Bill

One perk, or drawback, of working in the ER is that there are no shortages of interesting characters we see. Many of them we see over and over, and get to know very well. There was the old guy with the pacemaker who we saw >500 times for chest pain over a three year period. And the asthmatic who every doc in our group has intubated at least once. And the brittle diabetic who could somehow survive with a bicarb of five. They stick in your minds.

One guy we will never forget around here was the alcoholic we called "Boomerang Bill."  As his name implied, he was in the ER pretty damned regularly. He had money, and was actually rumored to be independently wealthy. (A repellent figure, he once confided to me that he spent all his money on "booze, hookers, and taxis.") He was routinely found passed out under a bar stool somewhere, or puking on someone's lawn in the middle of the night, and the medics would routinely bring him to us to sober up. He was kind of an ass when he was drunk, and the nurses hated him because he would grope them every chance he got. But once he sobered up he was pretty polite and pleasant.

But every once in a while, he would run out of money or get too sick to drink, and then he would go into fearful DTs. I mean, his shakes and seizures and delerium were a thing to behold. We nearly used up all the ativan in the hospital chilling him out on more than one occasion. He would camp out in the ICU forever and the hospitalists hated dealing with him. But he was hard to kill, as so many of these hard-core alcoholics are, and he always rallied and made it back out to the street, where his first order of business was always, of course, to go get a drink.

Once, after dealing with him in withdrawal four times in four months, the hospitalist who was in charge of his care decided to try something new. He located Bill's brother, who was in New Orleans, and convinced him to agree to take Bill into his home and care for him. Bill was himself willing to go and try to start over. The only problem was getting him there. So a collection was taken up among the medical staff — hospitalists and ER docs alike contributed eagerly — and we bought him a plane ticket as well as some new clothes. When he was ready for discharge, the hospitalist drove him to the airport himself and actually put him on the airplane.

And that was the last we saw of "Boomerang Bill." Until (you must have known this was coming) about four months later when he showed up in our ER again, drunk but starting to go into withdrawal. I'm not sure whether we were more astonished or horrified to see him again. When the hospitalist came down to admit him (the same one who had driven him to the airport) he asked, in dismay, what had happened, why wasn't he in New Orleans with his brother? Bill replied in his gravelly voice, "Man, it's too damn hot down there. I couldn't stand it." He added, in an aggrieved tone, "And it took me forever to hitchhike all the way back up here, too."

The hospitalist's shoulders just slumped in defeat. The boomerang had come back once more.

Epilogue: We continued to see Bill on and off for the next couple of years, on his usual irregular schedule. One day he staggered out into traffic and was hit by a car and left for dead. He was brought into the ER in critical condition and died a couple of days later. Some of the nurses noted that he had seemed more despondent in his final ER visits and wondered whether this was a passive (or active) suicide attempt. And so it goes.

30 January 2012

Things that are not at all surprising, part 26

I remember way back in the paleolithic era when the debate was actually going on over what health care reform would look like (before we settled on "greatest threat to liberty ever," that is) and my comment section was deluged with folks who railed against the very concept of universality in healthcare insurance. They, further, denied that such a thing as involuntary uninsurance existed, or that underinsurance was a problem at all. These commenters tended to be the rugged individualists of our great nation, and their testimonies were along the lines of: "I have type 1 diabetes and I've had three limbs amputated and I do just fine with my catastrophic health insurance plan" or "I have chosen not to buy health insurance and I'm just so badass that if I ever get sick I will go off onto an ice floe so as not to be a burden to society, so why should we hand out free healthcare to goddamned moochers?"

Or something like that.

So, it actually turns out that catastrophic/high deductible plans actually kinda suck. I'll take a moment to allow you to recover from the shock of that.

Now we already knew that being uninsured made you (that's the general you, not you in particular) more than four times as likely to skip or delay needed care. That makes sense. Healthcare is expensive, even if you're only paying charity rates, if you can find them. If you have to pay, and you don't have a lot of money, in many cases you just don't get it. And it turns out the same phenomenon is at play with high-deductible "catastrophic" plans. When you have to pay out of pocket (which is the central concept of these plans), you're more than twice as likely to skip or delay needed medical care.

Still, high-deductible plans are great if you never have to make a claim, but there you have it...

Fun factoid: if you have a high-deductible plan, and someone in your family is ill, then the effects on your own health trickle down, as you also tend to skimp on your own health care.

And back to the subject of the truly uninsured, the CDC came out with a report which found that (again, brace yourself for the shock) being unemployed makes you about 3 times as likely to be uninsured.

Aaron Carroll takes on directly the myth of the "uninsured by choice" cohort:

Many people like to think that being uninsured is a “choice”. And they’re correct, in the sense that you can “choose” not to buy insurance. I get that. But many people “choose” not to buy insurance for the sole reason that it’s crazy expensive. The average – not gold plated, but average – employer sponsored insurance plan for an individual plan in the United States last year was $5429. And that was just the premium. It didn’t include deductibles, co-pays, or co-insurance. The average family plan was $15,073. The median salary in the US, on the other hand, was less than $50,000 for households. For individuals, the median paycheck is $26,364. When you’re making that amount, and you lose your job, paying for that insurance plan is no longer possible. Paying for COBRA is even harder, as it’s usually more expensive.
I kind of wonder why I am wading back into this topic. Experience has shown me that it's become such an ideological shibboleth that the true believers are completely impervious to reason and data. I'm like a moth to the flame, I guess. I just can't leave it alone. Someone is wrong on the internet.

27 January 2012

Selling the ACA, 2 years too late

This is a cute and informative video about the health care reform act:

My favorite drawing is this, of economist Jon Gruber about to be crushed by the ogre of uncontrolled health care spending:

Gruber ogre

In fact, I think this will be my new twitter avatar.

Still, it would have been nice to have seen more of this sort of education and messaging two years ago when public opinion regarding the ACA was more malleable. Now people's ideas are pretty well set, hardened in part by their partisan stances. I was shocked to see that 55% of Americans now think that the individual mandate is unconstitutional. This is evidence, I think, of how effective the impassioned rhetoric from the opponents of the ACA has been in shifting the way the law is viewed. I don't think that many people have done a deep dive into Wickard v Filburn and come to this conclusion on their own; I suspect that more have been influenced by the persistent and angry denunciations of the mandate by its many opponents, with flaccid or nonexistent defenses of the law from its supporters. Consider, by the way, that when the court challenges were filed against the ACA's mandate, it was considered hopeless by legal observers; now we are truly a coin flip away from its invalidation. That's how far the frame has shifted, and it's entirely due to the effective case that has been made by conservatives and the failure of defenders of the law to respond.

Hopefully, this will be moot. If SCOTUS doesn't decide to overturn decades of precedent, and if Obama does manage to win re-election, the law will be completely implemented. In that case, I suspect it will becomes less of a partisan football, and we can maybe move beyond repeal to more productive arguments.  I can dream, can't I?

26 January 2012

Doctor Cat

A friend alerted me to the existence of this:

Unfortunately, the Doctor Cat cartoon seems to be on a bit of a hiatus for health reasons (here's hoping the author gets better soon).  It works for me on a number of levels:

1. Cats are cute (no explanation needed)
2. Cats are like doctors in that they are variably narcissistic, imperious and inscrutable.
3. Did I mention the cute factor?

Reminds me of this brilliant series from Medium Large:

25 January 2012

The Myth of the Cost Sensitive Patient

It simply will not go away, and the fact that anyone who has ever interacted with the health care system thinks this will ever be more than a pipe dream is simply delusional.  The offender (this week) is former CBO and OMB director Peter Orszag. (Disclosure: I once had a man-crush on him as the uber-wonk of health care reform, until he left government and cashed in at Citigroup.)

Orszag writes in Bloomberg: To Shop Smart, Patients Need to Know Price of Care, in which he argues for greater price transparency "with the goal of helping people become smarter shoppers."

Sweet baby zombie Jeebus help me.

To his credit, Orszag notes that the extant experiments towards this goal "have not been overwhelmingly successful," in perhaps the same way that the captain of the Costa Concordia was "not entirely prudent" in his navigation. He also acknowledges that cost-conscious medical bargain hunters are "unlikely to play a dominant role in reducing health expenses." So he at least relatively connected to reality, unlike the free-market fanatics who continue to insist that if only patients were obligated to bear the costs of their medical care, they would magically demand only the most cost-effective care and our health care cost inflation crisis would be solved.

But it's just not so. I've made this point before over and over. But again, it bears repeating:
The patients who are the drivers of health care costs (you know, the sick ones) are neither equipped nor situated nor interested in pursuing the cheapest health care.

Bear in mind that we are talking about a relatively small slice of patients: half of all health care costs are concentrated in the sickest 5% of patients in the US, and 80% of costs are accounted for in the top quintile!

cost distribution

These folks are sick, which means in many cases they are not feeling good, what with being sick and all, and when you are not feeling good it's hard to be really rigorous in making sure that your procedure of the week is being performed by the cheapest possible surgeon. What's more, when you are sick, you often have a doctor, and that doctor has associates and affiliations which you may find yourself being steered towards. And you may even trust your doctor, and when he tells you that a certain consultant or hospital is a good one, then you might just take him at his word and go there without first creating a spreadsheet of all the local options and their variation in costs.

This is all assuming that you have a choice in the matter. The ambulance may take you to the closest ER, or the surgeon who offers the best price on your cardiac bypass might happen to practice at a hospital with the most expensive ICU (which you weren't expecting to need so you didn't put that line item in your spreadsheet).

This is assuming that you live in an area with more than one network of providers; many regions have evolved a near-monopolistic health care ecosystem.

Finally, it's all academic because the typical patient who is a real super-user of medical care is spending so much money that even an insurance policy which is designed to have a high level of cost sharing and encourage patients to be highly cost-conscious cannot have a hope of paying a reasonable fraction of the actual costs of their care.

For example (a not-entirely random example): when I got the bill for my wife's radiation therapy last year, it was the largest invoice I have ever seen that did not have a mortgage attached to it. If I recall correctly, it was about $80,000. Worth every penny, I might add. So what threshold would be effective in getting me to choose one provider over another when the treatment is so insanely beyond my means to pay? None. At least none that exist in the real world. If I were on the hook for 25% of that $80K, it would be a horrible burden (even for a rich doctor, yes). I would have been able to scrounge the money I am sure. But then, I'm in the 1%. Well, maybe the 2%. What about a median-income patient? Someone earning $60,000 a year (well above median, I might add) would find medical co-pays of $5, 10, 20,000 crippling and completely beyond their means. Which means that healthcare insurance either insulates the typical patient from the cost or forces them to defer needed care.

There's very little middle ground. Yes, it's theoretically possible to find the magic level that would motivate a patient to become a "smart shopper" without resorting to self-rationing, but that sweet spot is so small and so variable from person to person that I am skeptical it could ever be implemented on a large scale, and certainly will never ever "bend the curve" on health care costs.

None of this should be interpreted as an argument against transparency in health care costs. The system is so distorted that the typical gross charge is triple the actual cost, and just like airline fares, no two people pay the same price for the same service. It's an outrage, or it should be. Transparency might be a good thing in and of itself. There might even be merit in linking costs to quality, if it can be done rationally (of which I am not entirely convinced). But I wish to god that people would stop pretending that patients who are seriously ill and marginally informed about the economics of health care can ever be utilized as a tool for reducing the national cost of said care.

Because it's a fricking delusion.

17 January 2012

Surgeons behaving badly: a rant

I recently saw a patient who had had a major surgery at a downtown medical center. He had done fine initially, but at about 2 weeks out, the patient started having fevers and chills. He saw his surgeon in follow-up and was diagnosed, reasonably, with a UTI and started on antibiotics. Unfortunately, he got worse and presented by EMS to my ER quite ill indeed. It was clear that he needed to be admitted and possibly to have another surgery.

In this case, I was pleased that the patient and his family thought the world of their original surgeon. "Dr Smith was great, so thoughtful and kind and he knows all about my problem, you will call him, won't you?" "Oh, I have to be admitted and maybe another surgery? Can you send me to Dr Smith? He's the one I really trust."

No problem, I thought. So, on this holiday weekend, I call The Big Medical Center and get hold of Dr Jones, who is the partner of Dr Smith. I explained the situation and laid out the facts. Dr Jones surprised me by ignoring the fairly obvious clinical conclusion and asking, "Well, what do you think should be done?"

"I'm not a goddamn surgeon, which is why I'm asking you, you passive aggressive jerkwad," I didn't say. I did suggest that the patient needed to be admitted and perhaps explored versus observed. I waited for him to sigh and say "OK, why don't you send him down here. I'll arrange a bed."

"What do you want me to do about it?" he replied. It was becoming clear that he viewed the fact that the patient had landed in my ER, and not his, to be a stroke of luck, as the patient was my problem and not his. Oh well, I had given him the opportunity to be graceful and accept the responsibility.

"I think we should send him to The Big Medical Center and you should take a look at him. I honestly don't know whether you need to operate or not: that's going to have to be your decision."

"Why would you want to do that? You have [my specialty] at your little hospital. Have your surgeon look at him and I am sure they are competent enough to manage the issue." His voice was dripping scorn at this point.

"I don't think the family would be happy with that. They liked Dr Smith a lot and they really want to go back to The Big Medical Center, and for continuity of care it probably is in his benefit to do so."

He wasn't being put off so easily though. "Well, it's the holiday and Dr Smith is not going to be in the hospital and I don't know anything more about this patient than your surgeons do so he might as well stay there. Besides, his insurance probably won't pay for the ambulance transport -- does the family really want to be stuck with that sort of bill?"

Now I'm fuming. I'm pissed because this guy is doing everything he can to block this late-night admission, and moreso because his points are more or less correct. Still wrong on the global level, but accurate on the details.

I had no choice but to force the issue: "Look, I can keep him here, but if I do that, everybody is going to be unhappy. My surgeon is going to be unhappy that he's had somebody else's complication dropped in his lap. I'm going to be unhappy that I have to force him to take this case. The patient is going to be unhappy that they were not cared for at the institution and the medical team of their choice. And Dr Smith is not going to be happy that his patient was refused admission by his partner." I did not add that I was already unhappy that I was having to bully and threaten him into doing his bloody job.

He relented, getting in one last passive aggressive jab, "Fine. I'll accept him, since you're clearly incapable of caring for him up there."

I took a deep breath, swallowed some bile, and thanked him and set the phone down. I got what I wanted, the patient was getting the care he needed, and so I had won, at the expense of twenty-five points of elevated blood pressure and the need to work on the heavy bag for a while.

My experience is that there is nothing a surgeon hates more than having somebody else's trainwreck dropped in their lap. Many times I have had that conversation, where I call our specialty surgeon and he snarls at me, "Why is this patient here? Why didn't they go back to wherever the original case was done? Can't you send them back? I'm not fixing that guy's complication!" And frankly, I understand that perspective. The second surgeon is often offended that the primary surgeon is shirking - the ethos among surgeons is generally one of responsibility, though, and even mild territoriality. They usually want to be called about their patients and they usually want to have their patients sent to them when there is an issue down the road. I like that.

Which is why it was so maddening that this guy, who was partners with the original surgeon, was blocking the referral. It was his responsibility. He agreed in advance to cover his partner's cases, as they do for him. And here I am having to bully, badger and hector him into doing his bloody job. Gah.

I should point out here very clearly that this was an unusual event, which made it rant-worthy. My general experience with surgeons, en masse, is that they are very good about taking responsibility for their complications. The few who shirk this responsibility, though, give the rest of them a bad name.

16 January 2012

13 January 2012

Spirals and Fibonacci Series and Pine Cones

This is so freaking cool:

And part two:

How is it that the world works like this? How awesome is it that the world works like this?

I remember once being criticized by a more touchy-feely friend who specialized in the humanities, for being a reductionist, too scientific. By wanting to break everything down into its component elements and understand how they work, he contended, we rob them of their mystery and their beauty. This video, I think, is a wonderful refutation of that contention. I get so much more satisfaction and joy out of understanding on a deeper level how the world works, and how deeply simple mathematics are embedded in the design of life. This is where the wonder and mystery reside, and this is why I will always love science and math, even when I'm not actively engaged in research myself any more.

Washington Medicaid vs Prudent Layperson

Consider this scenario: You are driving down the road and your car is hit from behind. You car, being older, doesn't have the greatest safety features, and the seat back breaks, and your head is wrenched backwards by the force of impact. You feel a sudden sharp pain in your neck, and you are afraid to try to move because you don't know how bad the injury is. The next half hour is a blur. Bystanders and the police keep you in the car, the paramedics come and slap on a collar and strap you to all sorts of devices and next thing you know you are cold and naked under the bright lights of a trauma bay. You are examined, medicated, poked, prodded, scanned and rescanned. Finally, you are told that there doesn't seem to be any serious injury. Eventually, the collar is removed and you are taken off the backboard. You are allowed to go home and over time you recover. You were diagnosed with an acute cervical strain.

According to the State of Washington's Medicaid administrator, the Health Care Authority (HCA), the above scenario represents a non-emergent, inappropriate use of the ER. According to new guidelines they are putting in place, such care will no longer be compensated. Under Federal Law, providers may not attempt to recover monies from Medicaid beneficiaries (not that they have the ability to pay, typically, because they're on Medicaid). So the hospitals and other health care providers are mandated to perform this service for free.

The background here is that last session, the Washington state legislature tried to close the gaping budget deficit with all the subtlety and grace of a machete. They simply directed the HCA to reduce expense in "unnecessary" ER utilization by $72 million. Initially, the HCA tried to make a list of non-emergent diagnoses and issued a rule that if a certain client visited the ER more than three times for non-emergent diagnoses, subsequent visits would not be paid for. The WA healthcare community responded with a lawsuit that was successful in having the rule thrown out on procedural grounds — the HCA had not gone through the required public steps in issuing the rule.

We hoped that this had ended the matter, but the HCA has doubled down. They now intend to simply stop paying for any care in the ER which they determine, after the fact, to have been non-emergent or which could have been delivered in an office setting. This will be determined by a retrospective review of the coded diagnosis. Unlike the previous attempt, there will be no exceptions for children, wards of the state, those presenting via EMS or those referred to the ER by their PCP. The new policy will be effective on the first visit, not the third non-emergent visit. The HCA has decided not to go through the public rule-making process, nor will they apply for a State Plan Amendment with the Federal Center for Medicaid & Medicare Services. They simply decided they had the authority to not pay for things that are not, in their view, emergencies.

Why is this problematic? We all agree that Medicaid patients do overuse & abuse the ER, and for less acute complaints. Isn't it a good thing that the state is finally doing something about it?

The biggest problem is that this policy doesn't actually do anything to keep these patients out of the ER. They pay nothing now, they will pay nothing under the new policy. And it's not like there is a huge network of private docs waiting and eager to accept Medicaid patients in their offices. So they will continue to come, and emergency providers will simply be obligated to care for them without reimbursement. It's a forced cramdown on hospital and physician reimbursement, and other, more urgent, patients will still suffer longer waits because of the ER crowding driven (in some part) by overuse.

The next problem is that the health care community did come to the table with a variety of suggestions to reduce unnecessary ER use, including community care coordination, case management for ultra-high ER users, and better oversight and management of narcotic pain medications prescribed through the ER. Unfortunately, the HCA was not interested in any sort of meaningful collaboration and declined to pursue these suggestions, despite evidence that they would actually have reduced ER use and saved money.

Finally, the concept of retrospective denials is so patently unjust that I'm shocked that they have the gall to propose it. It was a common practice in the '90s for managed care auditors to deny payment for an ER visit for chest pain if the final diagnosis was heartburn. This sort of abusive behavior became so widespread that all 50 states and the federal government now have "Prudent Layperson" laws on the books which dictate that it is the presenting symptom, not the final diagnosis which determines whether it was appropriate for a patient to visit an Emergency Department. These apply to state- and federally-sponsored commercial health plans, but apparently not to Medicaid. The HCA flaunts that exemption in returning to the old days of abusive practices.

This is not over, by any stretch. The healthcare community in WA is fairly galvanized by this threat. It will surely return to the court system. Given the patent unfairness of the proposed policy, and the way in which the HCA simply arrogated themselves the right to make the non-payment decision, I think there's a good chance that it will also be struck down. There is, however, no guarantee.

Strikingly, the person behind this initiative is himself a physician. Jeff Thompson MD, MPH is the medical director and by all accounts has been the driving force behind this policy change. We have expressed our disagreement and concerns about the policy to him personally and in great detail, to no avail. His email address is published on the HCA web site. Perhaps you could contact him directly and let him know what you think of this policy. As always, I would encourage a polite and respectful tone, and bonus points if you live or work in Washington state.

05 January 2012

Awesome CPR PSA Video

Yeah, this is pretty great:

One thing that always bugs me about these videos is that the chest compressions look fake, well, because they are. If you've ever really seen CPR done right, pushing in 2 inches is a huge thing, in the videos, they're barely denting the skin. The consequence is that when someone does real CPR for the first time they NEVER push in deep enough.

I wish they would swap in a dummy or use some effects to make the compression depth more dramatic and obvious. Yes, it's a nitpick, but it matters.