Ethics, Equity, and Influenza Pandemic

We are in the middle of an H1N1 influenza pandemic. Fortunately, though H1N1 influenza is spreading rapidly in the United States, it has been a moderately severe infection (more like seasonal influenza) rather than deadly like its grim cousin, epidemic avian influenza. If you are wondering about ethical considerations, public health decision making and decisions, issues concerning limited resources, professional responsibilities and who may be treated and who may not be treated, please see the World Health Organization publication "Ethical considerations in developing a public health response to pandemic influenza."   It's worth reading. And after you have read it, contact your county public health department and learn how it has dealt with these issues which will be vitally important to you and your family when the next lethal pandemic, or public health emergency,  strikes.

DEFENSIVE MEDICINE - MALPRACTICE SUITS NOT THE ONLY ISSUE

Republicans, and now Democrats, proclaim that defensive medicine is a major factor in health care inflation. Defensive medicine is the practice by which physicians (and hospitals and other providers) order all of the tests and procedures required to meet the highest standards of professional (or institutional) practice in order to thwart malpractice accusations based on failure to consider, and test for,  all of a patient's conditions which might give rise to a professional negligence lawsuit. Defensive medicine does not necessarily constitute high-quality care, but does reflect a rational fear of loss of a malpractice lawsuit and attendant consequences. Unfortunately, more tests and procedures may expose patients to increased false positive and false negative results and lead to inappropriate and unnecessary medical risk.

But fears of malpractice actions aren't the only cause of defensive medicine.  Physicians are held to a local, and sometimes a national, standard of practice through a process called "Peer Review."  If the practice in the community is to perform tests and evaluations and a physician chooses to do fewer tests, he may find himself in front of a medical group, hospital, county or other institutional review board (perhaps with some competitors as peer reviewers), defending himself against charges of failure to practice in accordance with applicable professional standards. Unlike some malpractice lawsuit results, a finding against the physician being reviewed (improper "competence or conduct") has an increased likelihood of resulting in her receiving a negative report to professional organizations and to the state and federal government, jeopardizing her family relationships, personal reputation, professional license, malpractice insurance,  hospital privileges and medical staff membership,  and  provoking exclusion from state and federal health programs (Medicaid and Medicare). Defense of each such case at a hospital or local level may cost $100,000 or more in attorneys' fees for each side, and if the case escalates to an investigation and charges brought by a state or federal agency,  the cost may substantially increase.

While defensive medicine related to malpractice is well-known and understood, defensive medicine related to peer review may be more subliminal and less appreciated.  In either case, many physicians play it "safe."  Faced with the dire consequences of a failure to comply with professional standards, they may notch-up their ordering of  additional tests and procedures to test for unlikely, but not impossible diagnoses. You, or the insurer, get a bigger bill but the physician continues in practice, sleeps at night, and doesn't waste thousands of dollars on attorneys' fees.

If you were a physician, what would you do?

Our Diminishing Resources

In the closing statement of his last lecture to my graduating class, the late Ludwig Eichna, M.D., then chair of the Department of Medicine at Downstate Medical School, told us  that 50% of what we had learned in the preceding 4 years would be proved wrong in 10 years.  He was too conservative:  more than 50% proved to be wrong and the timeframe was half of what he predicted.

Medical school graduates move through their internships, residencies and fellowships and,  like fish wrenched from the ocean,  lose their freshness and even begin to smell. They practice with the skills they acquired in their training. They apply the principles they learned early in their careers. They receive their continuing medical education ("CME") from programs sponsored by hospitals (often directly or indirectly funded by pharmaceutical companies), not-for-profit or for-profit educational companies (which may be funded directly or indirectly by pharmaceutical companies or similar vendors), and become focused on common medical problems which present no great intellectual challenge. Like those ocean fish, their eyes glaze over and they lose their enthusiasm and skills for anything other than simple non-taxing straightforward cases for which they have had hours of lectures telling them which pharmaceutical product to prescribe that day (without recognizing that the courses they have had were really intended to push a commercial "cure" or "maintenance medication" for the problem they were dealing with in their 10 minute patient visits). I should be clear: there are legitimate continuing medical education courses, but they are often not as convenient in terms of location, access and time requirements, as the commercially-sponsored programs, though some publications (i.e., the New England Journal of Medicine and The Medical Letter) do provide CME through internet or other available access.

Enthusiasm from investors and IT personnel aside, computer diagnosis programs are not much help to physicians who never had or have lost,  or don't have the time,  to exercise the skills in history-taking they may have once learned.  Computer diagnosis programs don't provide help to physicians who have lost, or never had, adequate skills in physical diagnosis.  Lab tests may mislead physicians through false positives and false negatives, causing unnecessary additional testing and procedures which add not only cost to our system, but expose patients to inappropriate and unnecessary risks. X-rays and CT scans expose patients to potentially high doses of ionizing radiation

Many states have mandatory continuing medical education requirements, meaning that some physicians get at least 25 hours of dozing a year as the lights in auditoriums are turned-down for PowerPoint programs of the day, provided to the speaker by a pharmaceutical company or device manufacturer with the expectation that their investments will generate increased sales of their products.

Health Care Reform will require an up-to-date, well-trained, physician force whose competency is continuously upgraded.  Is there anything that you have heard from the President or Congress which will deal with these issues? Is there a line-item in the health care reform budget for updating and upgrading physicians' knowledge bases? Is anyone thinking about training 20th century doctors to take care of 21st century patients?

Max Baucus' Health Reform Proposal

I received this Chairman's health reform mark up courtesy of the American Society of Hematology. As you will note, it is scheduled for mark-up by the Senate Committee on Finance on September 22, 2009, though it is without Republican support and there is a question as to whether the Democratic Senate leadership has the votes needed to bring it to the floor. 

Where Do I Get Prescribing Information?

You may have heard about the uproar concerning "Comparative Effectiveness" proposals which would require head-to-head comparisons of various treatments or drugs in studies which have the power (i.e., which usually means a large number of subjects tested) to determine which treatments or drugs provide the "best" results.

We haven't seen many head-to-head drug tests because they are economically risky for participating manufacturers. Several years ago in a head-to-head test a well-known cholesterol-lowering "statin" didn't fare well against another manufacturer's product, teaching the industry a lesson about losing market share, losing sales, requiring your company to spend a lot more money on promotion to convince doctors to prescribe your drug, making discount deals with HMOs and other entities,  hurting your stock price . . .  Well, you get the picture.  So pharmaceutical manufacturers and holders of patents and rights on other forms of therapies are understandably reluctant to expose their products to the truth about their effectiveness, as compared to other products.

The issue really isn't rationing.  It is access to statistically valid information about the effectiveness of various therapies.  It will be difficult for a pharmaceutical company to convince the doctors at a pharmaceutical company lunch, or in its advertising, to prescribe its product when the objective evidence clearly favors another manufacturer's product (or maybe even no treatment). Your doctor often selects a drug for your treatment for entirely irrational reasons, not because your doctor is irrational, but because the system keeps accurate verifiable information from her. I met with a group of doctors and a drug company representative a few days ago and listened to information which omitted an important "black box" requirement which had just been implemented by the FDA

I get prescribing information from The Medical Letter On Drugs and Therapeutics to which I have subscribed for more than 30 years. Articles begin with the rationale for the FDA's approval of the subject drug, a review of its pharmacology, a review of clinical studies and adverse effects, an analysis of drug interactions and medically significant issues, and a conclusion, which often suggests that practitioners should delay prescribing the drug in question until more data becomes available. The Medical Letter is non-profit, has no advertisements, is neutral in tone, and provides reliable information.

By the way, until we have Comparative Effectiveness evaluations, why don't you ask your own doctor where he gets his information.  Is it impartial?  Is it truthful?  Is it complete? Does it come with a free lunch?

#37 - The Production

For a satirical put-up on the U.S. ranking of #37 in health care, go to:

http://www.youtube.com/watch?v=yVgOl3cETb4

"Insurance Insecurity"

HealthReform.gov has published "Insurance Insecurity" which is a fast read intended to bolster public perception that the health insurance industry has failed to serve the public interest. Sources are also provided, which will be helpful to professionals and academics.

A Sort-Of Historical Speech

It was a textbook, "let's make a deal" speech, aimed at obtaining concensus on the principles which President Obama laid out, so  that later, the principles could be expanded to provide the real muscle and meaning behind the vague wording. For its purpose, it was well done. I found myself asking for more specifics, but having watched/listened to several of Obama's internet-based presentations, knew that I and other Americans stood no chance of getting specifics  tonight. It was not what I had hoped for in my blog of September 6, 2009.

Having spent a long afternoon today at a biomedical ethics meeting dealing with serious issues of life and death, I resented the failure of Obama to discuss anything other than the business of health reform.   I also found myself resentful of the Republicans, massed and unsmiling in their dark blue suits, unwilling to let their politics yield to human and national needs, and almost expecting someone among them to stand up to demand that Social Security be repealed.

In all,  it was  not a memorable night.  Perhaps there will be substance soon to come.

And don't forget  ethics.

The One Bright Spot in Our Severe Unemployment Landscape

Current American employment and unemployment statistics are dismal, except for health care which is helping to carry our economy.  Government reports show increasing non-health industry numbers for the unemployed and  underemployed. Congress, in its infinite wisdom, may  pass health reform legislation which profits its political contributors and philosophical allies, but cripples our health care system and puts health care workers out on the street for "efficiency's sake" while protecting those in the financial industry who are responsible for our economy's collapse. 
 

This is a dangerous time for health care and for our economy.

In summary of the report:

1. In August, the number of unemployed persons increased by 466,000 to 14.9 million, and the unemployment 

rate rose by 0.3 percentage point to 9.7 percent. The rate had been little changed in June and July, after increasing 0.4 or 0.5 percentage point in each month from December 2008
through May. Since the recession began in December 2007, the number of unemployed persons has risen by 7.4 

million, and the unemployment rate has grown by 4.8 percentage points. 

2. Total non-farm payroll employment declined by 216,000 in August. Since December 2007, employment has

fallen by 6.9 million. In recent months, job losses have moderated in many major industry sectors. In August, 

construction employment declined by 65,000, in line with  the trend since May. Monthly losses had averaged

117,000 over the 6 months ending in April. Employment in the construction industry has contracted by 1.4 million

since the onset of the recession. Starting in early 2009, the larger share of monthly job losses shifted from 

the residential to the nonresidential and heavy construction components. In mining, employment 

declined by 9,000 over the month.

In August, manufacturing employment continued to trend downward, with a decline of 63,000. The pace of job loss 

has slowed throughout manufacturing in recent months. Motor vehicles and parts lost 15,000 jobs
in August, partly offsetting a 31,000 employment increase in July.

Financial activities shed 28,000 jobs in August, with declines spread throughout the industry. Job loss in 

financial activities has slowed since the beginning of the year. Employment in the industry has declined by 

537,000 since the start of the recession.

Wholesale trade employment fell by 17,000 in August. Employment in information continued to trend down 

over the month.

Employment in the retail trade industry was little changed in August. Employment also was little changed 

in professional and business services over the month. From May through August, monthly employment
declines in the sector averaged 46,000, compared with 138,000 per month from November through April. 

Job loss in its temporary help services component has slowed markedly over the last 4 months.

Employment was little changed in August both in transportation and warehousing, and in leisure and hospitality.

3. Employment in health care continued to rise in August (28,000), with gains in ambulatory care and in nursing and residential care. Employment in hospitals was little changed in August; job growth in the industry slowed in early 2009 and employment has been flat since May.  Health care has added 544,000 jobs since the start of the recession.

A Season Of Discontent?

For Jews, the month of Elul is a time of stocktaking, introspection, reconciliation and spirituality, activities which America's  leadership might emulate with respect to our health care system. It is not a time for  a Quicken-type printout of  life's balance sheet and a perfunctory paper plan for change, nor is it a time to measure health care only in economic terms.  It is a time to ask how our health system reflects out national values, where have we achieved our goals and where have we fallen short, to genuinely express regret over our national failure to provide appropriate health care to all Americans, to recognize that our unwillingness to take societal responsibility for health care represents a serious deficiency in the American spiritual system, to acknowledge that there is a greater good which must be achieved,  to describe, adopt and implement an appropriate Health Plan and then move-on.

This is not a season of discontent.  It is a time for hard work and political commitment  which will bring appropriate health care to all Americans, the poor, the rich, the weak, the old, and all of our children. It is a time when our mirrors' reflections should allow us to observe ourselves with pride, knowing that as a nation we have done the right thing.

Kathleen Sebelius Secretary, HHS: Reform To Help Older & Senior Women

Strengthening the Health Insurance System: How Health Insurance Reform Will Help America’s Older and Senior Women

Executive Summary

While all Americans shoulder the burden of rising health care costs and increasingly inadequate health insurance, the 17 million older women (ages 55-64) and 21 million senior women (ages 65 and older) in America have unique situations and health care needs that make them particularly susceptible to rising costs – at a time in their lives when access to affordable health care is increasingly important. Health insurance reform will remove these hurdles to ensure that older and senior women, along with all other Americans, get the quality, affordable health care they deserve.


Link To Report: http://www.healthreform.gov/reports/seniorwomen/index.html