In chess, beginners can start the game with a flourish, but they lose. Average players can work into the middle-game with some wins and some losses. But the champion chess player excels in the end game where inventiveness, visualization, skill and guts make the difference between winning and losing.
Health care reform is approaching the end game. The issue is whether Reid, Pelosi and Obama have the inventiveness, ability to visualize, skill and guts to win true health care reform with a federal alternative insurance program. Are the lobbyists for pharmaceuticals, insurers and health professionals going to determine how and whether Americans get the health care they need and the nation can afford? Are there any legislators who think in terms of what is best for America and its citizens rather than their political supporters?
Will Obama, Reid and Pelosi be check-mated?
Tuesday, October 27, 2009
A Reader's Question and My Response
Hurray for the doctor who recognizes that electronic medical records sometimes contain medical incorrect information which later physicians and nurses mistakenly believe and rely on to make important (but incorrect) decisions because everyone believes the myth that what's in a computer must be accurate. Hurray for the doctor who has staff validate the accuracy of the information that your wife gave on previous visits, because sometimes the information that patients provide is wrong. Hurray for the doctor who has protocols which express a high standard of information verification to protect his patient and the child she is carrying. If the doctor is as careful and consistent as your question suggests, your wife has chosen a careful and competent doctor.
HPK
On Tue, Oct 27, 2009 at 10:21 AM, Anonymous
Anonymous has left a new comment on your post "Is Something Rotten In Canada's Health IT Stimulus...":
My wife, JK visited her doctor today, at his office in a NYC hospital. She was interviewed by a sweet young thing who asked her the same questions, that she has been asked on her many visits, questions about her medical history.
Wouldn't it be sensible, time saving and more accurate if her records were available on a protected basis on a computer? It might, dare I say,even be cheaper.
Sunday, October 25, 2009
We're From The Government & We're Here To Help You
This is not a good time for hospital emergency room or intensive care unit director physicians in your communities. If a more severe mutated form of H1N1 ("swine") influenza or a more lethal influenza such as H5N1 (avian) appears, one of these physicians may have to make decisions for which he or she is not likely to be professionally prepared, for which there are no community accepted ethical standards, and which may leave the decider professionally liable for misconduct and exposed to personal financial ruin.
Quietly and without significant current public input or current public ethical discussion , national, state and local public health authorities have assumed the responsibility to order the take-over of public, private and non-profit hospitals, and determining the priorities to be applied when providing life-saving treatments during a national health emergency which swamps the system. As described in The New York Times, 10/25/2009 "Week in Review" section at page 3, the dilemma of "Choosing Who Gets the Breath of Life" and other serious issues of life-saving facility availability will be resolved by government-prescribed triage rules, rather than the rules which govern today's allocation of health care. Who among this blog's readers knows what those triage rules are? Who gave appointed officials the authority to dictate this approach to medical decision-making?
Who among my readers knows which patients will be allowed to continue to receive respirator support and which patients will have that support terminated for the benefit of another person? Who among my readers knows which patients will have dialysis terminated so that another person can have access to the dialysis machine? Who among my readers knows whether, under the triage rules, some older citizens will be removed from life-saving support to benefit those who are younger, what the rules will be on allocation of support among various races, ethnicities, religions, social groups, economic status groups, political members, citizenship groups or occupational groups?
Decisions will have to be made. But having them made by appointed bureaucrats without vigorous current public input and without active current discussion of the ethical issues is inappropriate. The public has the right to participate in this discussion and those with experience and expertise in analyzing and formulating ethical choices and decisions should be heard.
After all, this is America.
Quietly and without significant current public input or current public ethical discussion , national, state and local public health authorities have assumed the responsibility to order the take-over of public, private and non-profit hospitals, and determining the priorities to be applied when providing life-saving treatments during a national health emergency which swamps the system. As described in The New York Times, 10/25/2009 "Week in Review" section at page 3, the dilemma of "Choosing Who Gets the Breath of Life" and other serious issues of life-saving facility availability will be resolved by government-prescribed triage rules, rather than the rules which govern today's allocation of health care. Who among this blog's readers knows what those triage rules are? Who gave appointed officials the authority to dictate this approach to medical decision-making?
Who among my readers knows which patients will be allowed to continue to receive respirator support and which patients will have that support terminated for the benefit of another person? Who among my readers knows which patients will have dialysis terminated so that another person can have access to the dialysis machine? Who among my readers knows whether, under the triage rules, some older citizens will be removed from life-saving support to benefit those who are younger, what the rules will be on allocation of support among various races, ethnicities, religions, social groups, economic status groups, political members, citizenship groups or occupational groups?
Decisions will have to be made. But having them made by appointed bureaucrats without vigorous current public input and without active current discussion of the ethical issues is inappropriate. The public has the right to participate in this discussion and those with experience and expertise in analyzing and formulating ethical choices and decisions should be heard.
After all, this is America.
Wednesday, October 21, 2009
Don't Blame The American Cancer Society
In the 1990s, health insurers, HMOs, PPOs, actuaries, and their "quality" evaluation certifying agencies, couldn't demonstrate that they were increasing survival (a meaningful endpoint - the "real thing") so they decided to boost their marketing appeal by convincing employers, their insured, unsophisticated government bureaucrats and other "hangers-on," that requiring providers to do lots of mammograms and high numbers of prostate specific antigen tests constituted appropriate proxies for the real thing. Of course, that wasn't true, but by hyping untruths often and loud enough, and casting an aura of doing good, potential clients and some public charities interested in specific disease types spread the word for their own fund raising and economic purposes.
Today, the truth about excessive mammography for breast cancer and over-testing (using the PSA) for prostate cancer was published (New York Times, 10/21/09, page 1). We can now understand that some of the "good" that was done was actually unnecessary evaluation, testing and treatment which had no effect on patient outcome. The "sunshine enema" when the surgeon comes out of the operating room and tells the family that "we got it early" inferring "cure" (when actually the disease that was found was only possibly cancerous) has been exposed. We need to be more skeptical, to question the confidence limits of treating physicians in the correctness of their diagnoses. Public skepticism about proposed treatments and the very real risks inherent in surgical procedures, radiation therapy, weird diets and drug treatment should be reflected in a demand for peer-reviewed scientific evidence that what is being proposed, is appropriate.
Today, the truth about excessive mammography for breast cancer and over-testing (using the PSA) for prostate cancer was published (New York Times, 10/21/09, page 1). We can now understand that some of the "good" that was done was actually unnecessary evaluation, testing and treatment which had no effect on patient outcome. The "sunshine enema" when the surgeon comes out of the operating room and tells the family that "we got it early" inferring "cure" (when actually the disease that was found was only possibly cancerous) has been exposed. We need to be more skeptical, to question the confidence limits of treating physicians in the correctness of their diagnoses. Public skepticism about proposed treatments and the very real risks inherent in surgical procedures, radiation therapy, weird diets and drug treatment should be reflected in a demand for peer-reviewed scientific evidence that what is being proposed, is appropriate.
Sunday, October 18, 2009
Exercise? It's A Matter of Understanding People!
Link to a VW commercial which says more about human nature and exercise than any infomational TV or a respected government health guru. Will health insurers rush out to emulate the exercise equipment shown?
Friday, October 16, 2009
Same Old, Same Old . . . .
Will health insurers proclaim that they cooperate with health reform, while they take aggressive measures to avoid risk? Will they play these games?
1. Devise drug formularies which provide limited access to expensive medications required for lifesaving treatment of serious diseases?
2. Provide a disincentive tier copayment system for drugs which makes them unaffordable for persons with serious diseases (genetic and acquired) requiring expensive new drugs?
3. Provide no or very limited network access (or high copayments) for consultation or follow up with expert physicians and facilities for patients with rare diseases which are expensive to treat?
4. Redline areas which traditionally have higher-than average claims costs?
5. Shift patient utilization and serious sickness risks to physicians or physician groups who are not financially equipped to shoulder these risks?
6. Provide low payment to physicians in certain specialties and geographic areas to discourage physicians from attracting high-cost, high-risk patients?
7. Adopt the 85% rule which means that if 85% of the patients do not complain, or on survey say that they are satisfied with the plan, that is sufficient? (Such a plan may discourage sick high-users who are in the 15% of the dissatisfied group.)
8. Deny benefits retroactively (i.e., an out of the area claim for a traveling patient who reasonably considered the condition to be an emergency)?
9. Use marketing measurements of "quality" rather than disease outcome measurements?
10. Discourage utilization by providing telephone roadblocks to patients and physicians obtaining authorization for care?
1. Devise drug formularies which provide limited access to expensive medications required for lifesaving treatment of serious diseases?
2. Provide a disincentive tier copayment system for drugs which makes them unaffordable for persons with serious diseases (genetic and acquired) requiring expensive new drugs?
3. Provide no or very limited network access (or high copayments) for consultation or follow up with expert physicians and facilities for patients with rare diseases which are expensive to treat?
4. Redline areas which traditionally have higher-than average claims costs?
5. Shift patient utilization and serious sickness risks to physicians or physician groups who are not financially equipped to shoulder these risks?
6. Provide low payment to physicians in certain specialties and geographic areas to discourage physicians from attracting high-cost, high-risk patients?
7. Adopt the 85% rule which means that if 85% of the patients do not complain, or on survey say that they are satisfied with the plan, that is sufficient? (Such a plan may discourage sick high-users who are in the 15% of the dissatisfied group.)
8. Deny benefits retroactively (i.e., an out of the area claim for a traveling patient who reasonably considered the condition to be an emergency)?
9. Use marketing measurements of "quality" rather than disease outcome measurements?
10. Discourage utilization by providing telephone roadblocks to patients and physicians obtaining authorization for care?
Thursday, October 15, 2009
Follow The Money: NHLBI Awards $170 Million to Fund Stem Cell Research
If you want to know what the government research priorities are, and where the government views its agenda as most likely to be achieved, see the NIH following release by clicking on the link..
Wednesday, October 14, 2009
Kidney Dialysis: Futile Care For Some Nursing Home Residents
Though most of my readers are unlikely to subscribe to the New England Journal of Medicine, Yahoo has done an excellent job in summarizing important issues described in Tumura and Covinsky's original 10/15/09 NEJM article, "Functional Status of Elderly Adults before and after Initiation of Dialysis" (N Engl J Med 361:16).
I read the original article, and Yahoo's summary, with particular interest because a family member chose to end dialysis, and be allowed to die with comfort-only care, when this person's quality of life had severely deteriorated. In my professional life, the issue of starting or continuing dialysis for elderly nursing home patients has presented several times, and each time I have found the underlying questions troubling.
I will not repeat the summary or further describe Tumura and Consky's article. But I do want to highlight the nature of the decision made to perform dialysis for nursing home patients and the persons who participate in the decision. Kidney failure in the elderly rarely presents precipitously, unless it results from a medication or procedure known to acutely damage kidneys (i.e., certain antibiotics or x-ray procedures). As kidney function gradually deteriorates in the elderly, there are often coexisting and contributing serious diseases, such as diabetes, arteriosclerosis, heart disease, and hypertension. And sometimes there may be age- related dementia or other serious neurologic impairment. The nursing home population, which may be considered for dialysis, is a frail impaired population for which kidney failure is just one of several illnesses which day by day take their increasing toll and in which simply performing the activities of daily living requires trained assistance for the patients.
There may be little or limited conversation between a patient and his primary physicians other than a statement that the doctor has found severe kidney disease and believes it "is time" to refer the patient to a nephrologist (kidney doctor) and perhaps a vascular dialysis shunt surgeon for consideration of dialysis as a "life-saving" option. In due course the patient is seen by the consultants whose major professional interests and income may revolve around dialysis and the patient, and the patient's family, become convinced to pursue dialysis. Sometimes the patient and family are given full disclosure about the difficulties of performing and maintaining the vascular shunt for dialysis, and sometimes they are not. Sometimes patients and their families are educated about transportation difficulties, complications and discomforts associated with dialysis, and sometimes they are not. Sometimes patients and their families mistakenly believe that dialysis may allow the kidneys to regain function. As the process, initiated in hope, proceeds, patients grow older and more impaired from their complicated medical conditions.
Perhaps a neutral ethicist or "ombudsperson" should be involved early in the decision-making process for all patients to whom chronic dialysis is being offered to evaluate patients' and their families' knowledge and understanding of what is being considered and offered: to perform a reality check with patients, their families, health care surrogates, caregivers, primary care physicians and consultants. If with medical advice, adequate information and understanding, the decision to proceed with dialysis is made, I suggest interval rechecks to verify that the decision remains unchanged rather than proceed unthinkingly simply because dialysis has been initiated.
I read the original article, and Yahoo's summary, with particular interest because a family member chose to end dialysis, and be allowed to die with comfort-only care, when this person's quality of life had severely deteriorated. In my professional life, the issue of starting or continuing dialysis for elderly nursing home patients has presented several times, and each time I have found the underlying questions troubling.
I will not repeat the summary or further describe Tumura and Consky's article. But I do want to highlight the nature of the decision made to perform dialysis for nursing home patients and the persons who participate in the decision. Kidney failure in the elderly rarely presents precipitously, unless it results from a medication or procedure known to acutely damage kidneys (i.e., certain antibiotics or x-ray procedures). As kidney function gradually deteriorates in the elderly, there are often coexisting and contributing serious diseases, such as diabetes, arteriosclerosis, heart disease, and hypertension. And sometimes there may be age- related dementia or other serious neurologic impairment. The nursing home population, which may be considered for dialysis, is a frail impaired population for which kidney failure is just one of several illnesses which day by day take their increasing toll and in which simply performing the activities of daily living requires trained assistance for the patients.
There may be little or limited conversation between a patient and his primary physicians other than a statement that the doctor has found severe kidney disease and believes it "is time" to refer the patient to a nephrologist (kidney doctor) and perhaps a vascular dialysis shunt surgeon for consideration of dialysis as a "life-saving" option. In due course the patient is seen by the consultants whose major professional interests and income may revolve around dialysis and the patient, and the patient's family, become convinced to pursue dialysis. Sometimes the patient and family are given full disclosure about the difficulties of performing and maintaining the vascular shunt for dialysis, and sometimes they are not. Sometimes patients and their families are educated about transportation difficulties, complications and discomforts associated with dialysis, and sometimes they are not. Sometimes patients and their families mistakenly believe that dialysis may allow the kidneys to regain function. As the process, initiated in hope, proceeds, patients grow older and more impaired from their complicated medical conditions.
Perhaps a neutral ethicist or "ombudsperson" should be involved early in the decision-making process for all patients to whom chronic dialysis is being offered to evaluate patients' and their families' knowledge and understanding of what is being considered and offered: to perform a reality check with patients, their families, health care surrogates, caregivers, primary care physicians and consultants. If with medical advice, adequate information and understanding, the decision to proceed with dialysis is made, I suggest interval rechecks to verify that the decision remains unchanged rather than proceed unthinkingly simply because dialysis has been initiated.
Monday, October 12, 2009
My Worst Day "At The Office"
It was my last year at Stanford as a Senior Resident. Marie asked me if I wanted to make an extra $25, moonlighting as the doctor at a Redwood City, California, High School football game. In those days, particularly to a medical resident with a checking account balance hovering at about $10.00 on a good day, the chance to make $25 was irresistable. Since sports medicine was not my field, I asked a fellow resident (an orthopedist) how to be a doctor at a high school football game: "Whatever you do, don't touch an injured player" was his advice. "All of the players have their own doctors, and if someone is really injured, call for an ambulance."
I showed up precisely at the designated time, but found that the game was in already in progress. One of the grumpy high school coaches showed me where I was supposed to sit and immediately left to go yell at his players on the field. When a player was injured, I left the bench to make sure the student was OK. If he looked bruised, I sent him to the bench for a 5 minute respite and went back to my seat. By the time I sat down and looked at the field, his coach had been him back in the game, again and again and again.
It took about 2 minutes to figure out my role: I was there because California law required the presence of a doctor. It did not require that the coach (or the student) take the doctor's advice. And he didn't.
A few days ago, an article about dementia among former football players appeared. Professional football teams and their managements were pictured as villains. But my experience taught that the problem of player abuse began earlier, when high school football coaches sent injured students, for whom they were responsible, back into the game.
I showed up precisely at the designated time, but found that the game was in already in progress. One of the grumpy high school coaches showed me where I was supposed to sit and immediately left to go yell at his players on the field. When a player was injured, I left the bench to make sure the student was OK. If he looked bruised, I sent him to the bench for a 5 minute respite and went back to my seat. By the time I sat down and looked at the field, his coach had been him back in the game, again and again and again.
It took about 2 minutes to figure out my role: I was there because California law required the presence of a doctor. It did not require that the coach (or the student) take the doctor's advice. And he didn't.
A few days ago, an article about dementia among former football players appeared. Professional football teams and their managements were pictured as villains. But my experience taught that the problem of player abuse began earlier, when high school football coaches sent injured students, for whom they were responsible, back into the game.
Friday, October 9, 2009
Is Something Rotten In Canada's Health IT Stimulus Program
See Dana Blankenhorn's report which begins:"The scandal involves charges of influence peddling regarding the 2007 award of a health IT contract to Pixalere Healthcare, now called Web Med Technology, for wireless diagnostic software." Pouring billions into our health system's electronic records and allied systems will open another door to health care fraud in America which may make predictions of cost-savings ludicrous..
Thursday, October 8, 2009
Texting While Treating
Imagine yourself in a cab in Boston when the cab driver asks "is it OK with you if I text and drive?" My guess is that you would say "no" (perhaps with some added expletives) because you understand the relationship between texting while driving, inattention to the road, and the increased possibility that you will be injured or killed in a crash.
Today, at my occasional Thursday noon lunch, some of the physicians were discussing the introduction of computerized medical records to their practices. One doctor, whose practice is months into the process of medical computerization, complained that he couldn't concentrate simultaneously on the patient's statement of her history and the need to record the encounter into his computer. The doctor was texting while practicing - no less a dangerous activity than proposed by the cabby.
But what if the cabby had said - "Look, the government says I must text when I drive?" Or what if the doctor says "The government is telling me to text during our office visit?" In either case, the risk is that inattention to the task at hand may result in injury to you.
So the next time you are in the doctor's office and the doctor's eyes are focused not on you, but on the keyboard and computer monitor in front of her, fasten your seatbelt and hold on: you may be the victim of a lifethreatening error caused by operator inattention.
The message to doctors: you can't deal with your patient's serious medical issues when your mind is focused on your computer.
Today, at my occasional Thursday noon lunch, some of the physicians were discussing the introduction of computerized medical records to their practices. One doctor, whose practice is months into the process of medical computerization, complained that he couldn't concentrate simultaneously on the patient's statement of her history and the need to record the encounter into his computer. The doctor was texting while practicing - no less a dangerous activity than proposed by the cabby.
But what if the cabby had said - "Look, the government says I must text when I drive?" Or what if the doctor says "The government is telling me to text during our office visit?" In either case, the risk is that inattention to the task at hand may result in injury to you.
So the next time you are in the doctor's office and the doctor's eyes are focused not on you, but on the keyboard and computer monitor in front of her, fasten your seatbelt and hold on: you may be the victim of a lifethreatening error caused by operator inattention.
The message to doctors: you can't deal with your patient's serious medical issues when your mind is focused on your computer.
Monday, October 5, 2009
Critical Political Effectiveness
A few days ago, my wife and I visited the Lyndon B. Johnson museum and Library at Austin'sUniversity of Texas campus. We saw a detailed history of Johnson's life and political activities from childhood to death. What struck us was the thoroughness of his apprenticeship and life's training as a political figure and campaigner, his long-hours of work (often from 4 A.M. to midnight), his extraordinary Congressional career which earned him respect, and political chips, from Representatives and Senators on both sides of the aisles, and his principles concerning civil rights which dated to his early career as a teacher in a Texas Mexican-American primary school.
When Lee Harvey Oswald murdered President Kennedy, Vice President Johnson had the energy, talent, politcal experience, credibility, focus, commitment and contacts to become an extraordinary President, actively involved in passage of revolutionary civil rights and health care reforms, including the establishment of Medicare. However, his commitment to continuing the Vietnamese war eroded public support and led to his decision not to seek reelection.
In my opinion, President Obama lacks a number of the presidential qualities of President Johnson. Obama's decision to flee Washington to pursue the illusion of a Chicago Olympics, rather than to provide needed leadership to ineffective Harry Reid in the Senate battle over health care reform, demonstrates a lack of focus and a failure of staff to work with him to set an appropriate agenda. Obama abandoned the appearance of serious comitment to health care reform to chase after international games. Like the Olympics, his actions suggest amateurism.
When Lee Harvey Oswald murdered President Kennedy, Vice President Johnson had the energy, talent, politcal experience, credibility, focus, commitment and contacts to become an extraordinary President, actively involved in passage of revolutionary civil rights and health care reforms, including the establishment of Medicare. However, his commitment to continuing the Vietnamese war eroded public support and led to his decision not to seek reelection.
In my opinion, President Obama lacks a number of the presidential qualities of President Johnson. Obama's decision to flee Washington to pursue the illusion of a Chicago Olympics, rather than to provide needed leadership to ineffective Harry Reid in the Senate battle over health care reform, demonstrates a lack of focus and a failure of staff to work with him to set an appropriate agenda. Obama abandoned the appearance of serious comitment to health care reform to chase after international games. Like the Olympics, his actions suggest amateurism.
Friday, October 2, 2009
HHS-OCR GINA Proposed Rule
HHS OCR Issues GINA Notice of Proposed Rulemaking
October 1, 2009
The U.S. Department of Health and Human Services (HHS) Office for Civil Rights (OCR) has issued a notice of proposed rulemaking to strengthen privacy protections for genetic information under the HIPAA Privacy Rule, as required by the Genetic Information Nondiscrimination Act of 2008 (GINA). GINA gives individuals new privacy and nondiscrimination rights with respect to the use of genetic information in health insurance decisions and employment. The proposed rule would modify the HIPAA Privacy Rule to clarify that genetic information is health information and to prohibit the use and disclosure of genetic information by health plans for underwriting purposes. The proposal includes a 60-day public comment period.
October 1, 2009
The U.S. Department of Health and Human Services (HHS) Office for Civil Rights (OCR) has issued a notice of proposed rulemaking to strengthen privacy protections for genetic information under the HIPAA Privacy Rule, as required by the Genetic Information Nondiscrimination Act of 2008 (GINA). GINA gives individuals new privacy and nondiscrimination rights with respect to the use of genetic information in health insurance decisions and employment. The proposed rule would modify the HIPAA Privacy Rule to clarify that genetic information is health information and to prohibit the use and disclosure of genetic information by health plans for underwriting purposes. The proposal includes a 60-day public comment period.
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