What Do Hearing Aids, Diaphragms, Condoms & Diabetes Glucose Meters Have in Common?

Quick answer: none of them work when left, unused, in a bedroom drawer.

My focus today is on diabetes and my point is: get a reliable meter (your insurer may have specific models available for you) and test frequently enough (3-4 times a day every day) so that you become the super expert on your diabetes. How does your body react to your medicine? When does your medicine "kick-in"? What are your high and low periods for glucose?  When your glucose is high - how do you feel?  When your glucose is low, how do you feel? What foods raise your glucose level and how soon after eating them does your glucose rise?  When does it drop again? Modern meters give reads which can be recorded in a logbook, or, using computer software for a suitable meter, downloaded, printed and in deliverable form so that your  doctor can review your daily records each month and you and your doctor can discuss the findings while your doctor also checks your retina for diabetic changes, your feet for diabetic problems, the parts of your body between your head and your feet, and some appropriate laboratory testing, and then gives you advice on management.

With this information you have a much better understanding of your diabetes, its treatment, and how you can control your sugars!

TV commercials, ads in newspapers and magazines and brochures  tout the benefits of new free give-away glucose meters for diabetics from companies which didn't exist a year ago. I chose my meter with my physician and confirmed the wisdom of my purchase by looking - not at my TV set or throwaway ad - but in Consumers' Union (Consumer Reports) which rated a variety of meters in terms of cost and accuracy a year or two ago.  The initial cost of a meter is only a small part of its actual cost: glucose test strips, lancets and other simple materials used in testing all are expensive which makes insurance coverage highly beneficial. Some meters are more accurate and reliable than others. The best lancets (which are not significantly more expensive) have very fine needles which are essentially painless. Some meters use strips which require a large blood drop which can be difficult when your fingers are cold, or your hands are stiff, arthritic and have impaired feeling sensation.

A practical example: if at 11:30 AM your glucose is high, is it because your medicine hasn't acted yet, because you ate late, because you ate too much for breakfast, or because you skipped your morning walk? If you've been testing regularly you might know that instead of taking more medicine, you should take a 30 minute walk and then retest to probably find that your glucose came down because the medicine had more time to work and you burned off glucose with your moderate exercise. Wow - doesn't it feel good to be in control?

How Much Is Your Relationship With Your Doctor Worth?

An over-65 year old friend and I had an interesting conversation. He was being asked to pay almost $2000 a year for himself and the same amount for his wife to remain patients of a physician who was reducing his practice to 600 patients. The only patients who would remain in the practice were to be those paying the access ("access" is my term, not the physician's) fee.

I wondered about this arrangement, which has the name of a major American household product company associated with it.  But the first issue, was the most difficult. In economic terms, how does a patient (who is not an expert on the competence, quantity or quality of care a particular physician generally provides, but may have strong emotional ties to the physician) calculate the value of his or her relationship with a particular physician?

I had lots of questions. How does the physician's proposal match up with licensing obligations and his role as a Medicare provider or a provider under the Affordable Care Act ("Health Reform")?  How does the proposed relationship coordinate with the various HMOs, PPOs and other insurance arrangements of my friend, which describe themselves as paying for a limited group and range of services and have their own set of "access" requirements?  How do the arrangements mesh with the physician's need to take time off from call, sleep, go on vacations, and attend medical education meetings?  Assuming that the physician has "on-call" coverage arrangements with other physicians, will those physicians honor the "special relationship" that the up-front cash access payment to the doctor is said to provide? Will consultants to whom the patient may be referred be limited to physicians who engage in similar financial arrangements?  Will the patient receive money back if he or she develops a condition requiring intensive care from a different physician, such as an oncologist (cancer), hematologist (benign and malignant blood disorders), nephrologist (kidney disease) or other specialist? What will happen if the physician decides to reduce practice size even further?  What will happen if the physician decides to retire? Is the physician moving into "borderline" issues in which the physician is at an unfair advantage, and the patient at a serious disadvantage, in the economic arrangement? Does the "access" fee create a conflict of interest?

In these days of "full disclosure," does the arrangement require special disclosure of information to the patient which might affect the patient's decision: information relating to the quality and quantity of continuing medical education, physician health (including medications taken and substance abuse) or social problems, deficiency notices from medical organizations, hospital medical staffs, governmental bodies, or personal debt which might impact on his practice?  After all, the patient is being asked to pay for access not for actual health care, and perhaps "truth in advertising" concepts should apply.

Is the proposed arrangement beneficial to my friend?  I don't know. But he has a lot to discuss with his wife and their doctor.  After all, we're not just talking about which dishwashing detergent to buy here.

Our Nation's Employment Hot Spot

Before anyone becomes wildly enthusiastic about changing the projected path of America's Health Care in the next session of Congress check the Bureau of Labor Statistics databases which clearly demonstrate that health care is the employment bright spot in our economy. Make health care unaffordable or unachievable, put healthcare workers out of jobs, and we will worsen our depression and economic outlook.

To pique your interest, here is the health care employment summary chart comparing health care employment in 2010 with 2000. If you want to see more (suggested - follow straightforward instructions at the BLS site), click here.

Employment, Hours, and Earnings from the Current Employment Statistics survey (National)

Series Id:     CEU6562000101
Not Seasonally Adjusted
Super Sector:  Education and health services
Industry:      Health care
NAICS Code:    621,2,3
Data Type:     ALL EMPLOYEES, THOUSANDS

Download:  Year    Jan    Feb    Mar    Apr    May    Jun    Jul    Aug    Sep    Oct    Nov    Dec    Annual
2000    10739.7    10751.2    10776.4    10782.0    10804.3    10868.7    10892.0    10902.9    10894.7    10925.9    10962.2    10993.7    10857.8
2010    13618.5    13622.4    13671.5    13694.2    13715.1    13768.7    13809.9    13826.9    13804.2    13859.5(P)    13900.5(P)     
     
P : preliminary

Bottom Line: Further tampering with health care may be damaging to America's healthy economy.

Dear Doctor

Dear Doctor
Am I correct?
That you are less interested in my health problem
Than before?
Is it me or is it you?
Your 10:05 AM Patient.

Dear 10:05 AM Patient
My 9:55 AM patient was much
more medically engaging than you.
My scheduler controls my day
Not me, not you.

Chocolates, Brownies, Fudge and Emotional Depression

The Christmas season is a time when doctors' offices are deluged with chocolates, brownies, fudge and lots of other goodies which staff and professionals enjoy, though with some guilt.

But there is another side to the holiday season which is more troubling then extra calories and saturated fat.  It is the distress of many women we would see with serious holiday depressions because they were exhausting themselves physically, spiritually and financially, trying to make the holidays "perfect" for their families and other loved ones.  To the women who read this blog - I wish you well and hope that you will do what you can reasonably do and recognize that perfection is not a human characteristic. To the men who read this blog and pay attention to what their spouses are going through, I suggest you make it a point to notice what is going on around you, support your loved ones and help set family holidays goals which will leave everyone refreshed, rather than exhausted physically, spiritually and financially.

Truly happy holidays depend on the strength and joy of family relationships.  What ever holiday is yours, I wish you and yours holiday happiness.

Texas Health Insurance Maternity Benefit Unavailability - Response to Comment

I don't know whether the commenter is correct that passage of the Affordable Care Act was responsible for strategic actions taken by Texas health insurers to raise rates or make unavailable maternity benefits (2 sides of the same coin). Was the decision by insurers to raise their rates for individuals seeking maternity benefits as part of their insurance package solely due to health care reform or was it a response to actuarial experience (increases in the range of 10-15% have not been unusual in the health insurance business in many states, even before health reform),  to the extraordinarily high costs of  Texas health care (as documented in 2010 journal articles and federal government discussions),  was it a business strategy to mobilize public opinion against health reform, or was it a non-publicized highly selective business or political strategy?

I don't know.  Do any of my readers have other insights?

Silence - Not A Winning Strategy

Last week I spoke to lawyers, retired judges and others at a local bar association meeting about the "Patient Protection and Affordable Care Act" (the "ACA").  As I spoke about the availability of high risk insurance coverage, the Elder Justice Act, parents' health insurance for children up to age 26,  Long-Term Care insurance, the support for young families (including college students),  and the ultimate effect that supporting and encouraging young families to have children by removing financial and health insurance barriers through  providing health insurance and other benefits, it was clear that my audience was hearing this material for the first time.  WHY?

It wasn't their fault. Congress passed and President Obama signed a comprehensive health care reform act and the only thing the public heard were a few words from the administration about its benefits and a lot of words from the right about its high costs.  The administration spent a lot of time demonizing insurers, provider groups and our existing system but failed to support champions out in the field explaining to groups of citizens why the ACA was specifically in their interests.

In visiting with my Texas family this past week, I heard that a member who has a vital interest in maternity coverage, could not find an insurer who would provide it at a reasonable affordable cost.  Thus, her entire concept of health reform is that it has resulted in escalating costs and insurance unavailability. She was right in her observation that her interest in health insurance with maternity benefits is important for her and her family and for our country.  So it's time for the Administration to address her issue and at the same time champion provisions of the ACA which are good for American businesses and individuals.

Health care is not a game of golf- 18 holes and a visit to the clubhouse for lunch and drinks.  American lives and security  are at stake. Mr. Obama, treat health care as a continuing important subject. Commit the resources to champion the benefits that each American will - at some point in his or her life -  experience in the ACA.

Otherwise, Americans will face the bleak prospect of unaffordable health care while the lobbyists celebrate victory at their clubhouses.

Kids, You Won't Have to Worry About Mom and Me ...unless

. . . . "They" (insert suitable descriptive political party,  faction or candidate name) repeal The Affordable Care Act and -

*We are old, sick and unable to take care of ourselves (eating, toileting, grooming, dressing, bathing and transferring) and the State decides to send us (or one of us) to a miserable nursing home  bed in another county instead of providing us (or one of us)  with inexpensive home and community based attendant services and support to rehabilitate us and get us (or one of us) going again.

* The State says that I have no right to be independent.

* One of us gets very sick and "They" have done away with our protection, as recipients of home and community services, of protection against spousal impoverishment.

*"They decide that, in spite of the Olmstead Supreme Court Caser ruling, neither Mom nor I have a right to choose long term services in the community, rather than in an institutional setting.

*"They" wipe out the "Elder Justice Act" which protects Mom and me against physical or psychological harm,elder abuse, neglect and exploitation, improves Long Term Care facilities and gives you the information to know - as our kids - whether those taking care of us are trained, doing their jobs competently and honestly, or are crooks stealing our property and your meager inheritances.

So don't worry - unless . . . .

You, Your Family, the US Preventive Task Force Recommendations and Health Reform (ACA)

If you have time on your hands and have chosen to study the Patient Protection and Affordable Care Act,  you have seen many references to the US Preventive Task Force Recommendations.  The ACA references Grade A and B recommendations and tells you that you will qualify, often without charge at all, to receive care specified in those A and B recommendations and implies that that your physicians and insurers had better be familiar with those recommendations because they are binding on them.

I have been around long enough to know that some patients are more knowledgeable about health issues on the internet than their physicians and other providers, so here is the link to the task force preventive services recommendations with my personal recommendation (I am your blogger, not your doctor) that you read through them and - when you have questions about how the recommendations apply to you, your spouse or partner, your kids or parents or grandchildren,  you ask your doc (or other provider or even insurer) those questions.  You may get some blank stares. You may even face some obvious discomfort or annoyance.  But do it anyway, if for no other reason, than your doctor (or other provider) needs to know about them and needs to know that you and other patients and their families know about them. That's how we change behavior and impose new and BETTER societal standards of medical care.  So let's do it.

Response To Comments About Health Care Costs

The Congressional Budget Office projected a $196 billion dollar savings over 10 years. Almost $13 billion from hospitals, about $14 billion from SNFs, about $22 billion from  Medicare Part B cuts (durable medical equipment, labs, ASC, Dialysis and other services),  and almost $40 billion from home health. Medicare Part D premiums will rise as much as 9% over 10 years, primarily as a result of donut hole closure steps.

Here are some links to interesting reading about the economics of US health care costs. I don't pretend that I have personally read every one:
http://www.gao.gov/htext/d04793sp.htmlhttp://www.gao.gov/docsearch/featured/healthcare_spending.html
http://www.gao.gov/docsearch/app_processform.php

If the Republicans Repeal Health Reform -- Then What?

As I have reported, and one of my sons mentioned to me in this morning's phone call, I have plowed my way through  906 single-spaced pages of the Patient Protection and Affordable Care Act ("ACA") which President Obama signed last March. I have read numerous blogs (including those of the Director of the Congressional Budget Office which, being written for Congress people and their staffs, are written clearly) some of which demonstrate complete unfamiliarity with the actual text and meaning of the ACA. I am convinced that many public statements about the ACA reflect uninformed for personal-profit political positions more than hard time-consuming actual work to understand and think about the act.

A disclaimer - I have my biases.  As a physician specialist, I took care of very sick people, never turned anyone away because of  insurance status or lack of it, and have no respect for those that do. I have a large family which has seen more than "its share" of sickness and disease and death and my family has been significantly impacted by our severe recession. I have been the Chief of Staff of a large mid-city hospital, now closed and abandoned, and have seen what economists call "dislocation" and the rest of us call bankruptcy in health care. I have seen excellence and incompetency in health care and the systems which deliver it. I was a member of Stanford University's clinical faculty, providing one morning a week of unpaid time for thirteen years, taking care of veterans with blood diseases at the Palo Alto VA hospital and teaching medical students, residents and hematology fellows. As a member of a powerful well-financed state hospital industry board, I have seen political and economic jousting within and outside the hospital industry. When I practiced health law, among others, I represented a large medical group and was heavily involved in the analysis and negotiating of managed care contracts as well as contracts among physicians and their practice entities.

Bottom line - if health reform is repealed we will be worse off.  The good outweighs the rest.

The ACA will provide access to insurance for Americans who have lost employment and their families' health insurance and don't have enough money to buy Cobra extended coverage.  The ACA outlaws insurance company abuses and will provide health insurance and care to our kids and grandchildren. The ACA will provide incentives to employers to sign their workers up for insurance, insurance which cannot be rescinded or be subjected to unreasonable annual coverage limits or lifetime limits. The ACA will expand Medicare coverage for Part D beneficiaries although there will be a modest increase in premiums over the next ten years and it will even help seniors to stay out of nursing homes, or if in nursing homes, have better quality of care (Also see the Elder Justice Act within the ACA at pages 664 and following) The ACA will improve access to care in rural and underserved areas and the care of the poor. It will train doctors, nurses and others in the health professions without burying them and their families in debt. It incorporates an "Elder Justice Act" which may safeguard seniors against some of the terrible things that I saw happen to my older patients. It has strengthened protections against fraud and abuse. And, it encourages advances in medical inventions, products and care which moves us into a new generation of health services.

The projections are that it will save about $14 billion dollars each year for the next 10 years and thus control the rise of premiums and out-of-pocket expenses that each of us experiences each year. And interestingly, it will make it possible - through support of America's families and children - to grow our workforce so that in coming  there will be young working people able to fill the jobs that America offers and  help America's businesses.

My study indicates that health reform is good for families, good for working-people and those who would work if they could find work, good for America's supply of doctors, nurses and health care workers, good long term for large and small business and less costly than the alternative - no health care reform.

Doctors Groups Fail Because They Don't Understand Risk

The October 7, 2010 New England Journal of Medicine has two interesting articles, one by Harold S. Luft, Ph.D.  titled "Becoming Accountable - Opportunities and Obstacles for ACOs" and the other "The Effects of the Affordable Care Act on Workers' Heath Insurance Coverage" by Christine Eibner, Ph.D. and others. Like the Affordable Care Act, neither of the articles discusses an issue which my experience tells me has played a major role in the failure of a number of physicians' practices to survive managed care and other forms of contracted health care relationships.

Insurance companies understand risk: they hire skilled actuaries to analyze underwriting risk and to tell them about it and how to shuffle it off to others.  The Federal Government understands risk, and as one plows through the 900+ pages of the Affordable Care Act, there are many references to the requirement that highly sophisticated actuarial studies be done to guide future policies and actions  But individual doctors don't have the financial means to hire actuaries (or attorneys)  to tell them about the risks that they blithely assume, and even if they did, their fracturing into relatively small business entities makes the per-doctor cost of securing actuarial advice prohibitive.  And then there are antitrust issues when groups of physicians combine resources to strengthen their ability to negotiate with employers, government and insurers.  So insurers, government and business shift risk to physicians who bite off more than they can chew - and choke.

The current proposals for health reform is not going to solve that problem. As physicians learn that the emphasis on "efficiency" and driving down the cost of services leaves their bank accounts empty, I expect them to resort to their experience-tested means of generating income: see more patients, do more procedures, order more tests and ramp up the billing. In this era of "evidence-based care," ironically it is the physicians who lack evidence about the business risks they are asked to undertake by insurers, government and businesses.

Acountable care organizations will not survive in that environment.

The Prism of Ethics: Quiet Plans to Change MEDIGAP Insurance

I remember Dan Rostenkowski's expressions of disbelief, when he joined our meeting of the executive committee of the National Health Lawyers Association in Chicago about 20 years ago.  A couple of days earlier, he had been physically attacked with canes and umbrellas by little old men and women whom had represented in Congress for years.  Their concern that legislation he supported would raise their costs of prescription drugs made them furious. Twenty+ years later, other Chicago based political figures have chosen not to learn from Rostenkowski's experiences

The following vaguely-written section of the Affordable Care Act buried at page 342,  seems to predict significant MediGap change (you will have to refer to your own MediGap insurance brochures to determine how it might affect you). I have underlined the words which I consider most problematic.The approach appears to be double-barreled: (1) reduce Medicare beneficiaries access by raising the cost of plans which might give their purchasers more extensive (or appropriate for their needs?) physician Part B services and (2)  directly or indirectly create barriers to physicians' services to reduce high users (i.e., the sick elderly) access. Since my experience is that older Americans choose their MediGap insurance very carefully and pay the increasing premiums out of hard-earned dwindling financial reserves, I am concerned about the implications of this section for seniors.

SEC. 3210. DEVELOPMENT OF NEW STANDARDS FOR CERTAIN MEDIGAP PLANS.
(a) IN GENERAL.—Section 1882 of the Social Security Act (42 U.S.C. 1395ss) is amended by adding at the end the following new subsection:
‘‘(y) DEVELOPMENT OF NEW STANDARDS FOR CERTAIN MEDICARE SUPPLEMENTAL POLICIES.—
‘‘(1) IN GENERAL.—The Secretary shall request the National Association of Insurance Commissioners to review and revise the standards for benefit packages described in paragraph (2) under subsection (p)(1), to otherwise update standards to include requirements for nominal cost sharing to encourage the use of appropriate physicians’ services under part B. Such revisions shall be based on evidence published in peer-reviewed journals or current examples used by integrated delivery systems and made consistent with the rules applicable under subsection (p)(1)(E) with the reference to the ‘1991 NAIC Model Regulation’ deemed a reference to the NAIC Model Regulation as published in the Federal Register on December 4, 1998,
and as subsequently updated by the National Association of Insurance Commissioners to reflect previous changes in law and the reference to ‘date of enactment of this subsection’ deemed a reference to the date of enactment of the Patient Protection and Affordable Care Act. To the extent practicable, such revision shall provide for the implementation of revised standards for benefit packages as of January 1, 2015.
‘‘(2) BENEFIT PACKAGES DESCRIBED.—The benefit packages described in this paragraph are benefit packages classified as ‘C’ and ‘F’.’’.
(b) CONFORMING AMENDMENT.—Section 1882(o)(1) of the Social Security Act (42 U.S.C. 1395ss(o)(1)) is amended by striking ‘‘, and (w)’’ and inserting ‘‘(w), and (y)’’.

The Prism of Ethics: Was This Change to Medicare Part of the Plan?

In preparation for a talk about Health Care Reform that I am scheduled to give to the West Valley Bar
Association, later this month, I have been going through the Patient Protection and Affordable CareAct [the "ACA"] page by page, line by line and word by word.

At page 271 of the AFA, PART III is entitled "Encouraging Development of New Patient Care Models" which seems benign enough. But as I moved along to page 277, I came upon Section 3022 "MEDICARE SHARED SAVINGS PROGRAM" which describes "Accountable Care Organizations" (ACOs), groups of providersd who may "work together to manage and coordinate care for Medicare fee-for-service beneficiaries through an accountable care organization." Sounds benign enough.  But then I read on.

At page 279 there was this language:  "(c) ASSIGNMENT OF MEDICARE FEE-FOR-SERVICE BENEFICIARIES TO ACOs.-The Secretary shall determine an appropriate method to assign Medicare fee-for-service beneficiaries to an ACO based on their utilization of primary care services provided under this title by an ACO professional described in subsection (h)(1)(A). (Underlining supplied)  Just a moment - I thought that under fee-for-service Medicare, patients chose their own doctors, but this section appears to take away that choice in the interest of a Medicare Savings Program study.  And then, I found this section at page 280:

"(g") LIMITATIONS ON REVIEW.-There shall be no administrative or judicial review under section 1869, section 1878 or otherwise of -
"(1) the specification of criteria under subsection (a)(1)(B);
"(2) the assessment of the quality of care furnished by an ACO and the establishment of performance standards under subsection (b)(3);
"(3) the assignment of Medicare fee-for-service beneficiaries to an ACO under subsection (c) (underlined supplied) . . . . .

So, some Medicare fee-for-service beneficiaries may be plucked out of their chosen physicians' offices and reassigned to an "ACO" with no right of appeal?  Is my reading correct?

Gee, did President Obama, or the people pushing this "reform" bill through Congress mention that to the people potentially affected?

Interesting New HIV/AIDS Potential Treatment Report

In the early 1980s, as a physician and volunteer professional chair of a local Red Cross Blood Services advisory committee, and later as the Chair of  Northern California Red Cross Blood Service's Board (and subsequently, for the Western United States), I had the chance to experience the impact of  HIV on patients, my community and on national blood transfusion programs. As a practicing clinical hematologist, I sat through many meetings about HIV and AIDS, most of which highlighted highly pessimistic views about preventive measures such as  education, pharmacologic measures and vaccines. As a healthcare attorney, and author of a chapter concerning HIV-infected health care workers in the Health Law Guide, I was able to sound a more optomistic note as effective treatments evolved, allowing HIV infected people to experience dramatically improved qualities of life and survivals. But no approach suggested cure.

In an AIDS RESEARCH AND THERAPY abstract from a recently published report from Israel, Aviad Levin and others, at The Hebrew University of Jerusalem, state:

"A correlation between increase in the integration of Human Immunodeficiency virus-1 (HIV-1) cDNA and cell death was previously established. Here we show that combination of peptides that stimulate integration together with the protease inhibitor Ro 31-8959 caused apoptotic cell death of HIV infected cells with total extermination of the virus. This combination did not have any effect on non-infected cells. Thus it appears that cell death is promoted only in the infected cells. It is our view that the results described in this work suggest a novel approach to specifically promote death of HIV-1 infected cells and thus may eventually be developed into a new and general anti-viral therapy."

The report does not promise cure, but does describe a serious advance in the potential for treatment of HIV infection. It is worth reading.

"Shifting the Health Cost Burden"

On 9/3/2010 The New York Times editorial page discussed shifting the health cost burden.  The editorial noted that 2010 health care premiums went up a "modest" 3% for family plans but that workers' shares soared by 14% and expressed what I interpret as "unhappiness"about the cost shift from employers to workers in the form of increased workers' contributions, reduced benefits, increasing deductibles and increasing copayments.

Employers don't take these actions in a vacuum. Insurers structure their plans and premiums to encourage employers to remain with them by manipulating benefits, deductibles and copayments to remain competitive.  Struggling employers, including those who "shop," have few real choices, as health insurance underwriting restricts insurance company willingness to accept high risk business, particularly business which involves demonstrably sick or older employees.  Paradoxically, the longer an employer stays with an insurer, the greater the risk that long-term employees and employees loyal to the employer because of personal or family illness insurability issues, drive up health insurance risk and the premiums. Perhaps health reform will change this picture, but perhaps not.

The Times said nothing about reducible costs of health care, such as (1) eliminating large duplicative professional, business and government bureaucracies which officiously pass paper (and digital data) back and forth and spend endless hours in defining policies and procedures intended to trace, identify, categorize and restrict reduce health services utilization while increasing administrative overhead (2) reducing technology barriers, such as requiring physicians to be data entry clerks for office visits rather than use their time and skills evaluating, diagnosing and treating their patients, (3) finding ways to increase and maintain the skills  and efficiency of all categories of health care professionals free of contributions from pharmaceutical companies and other vendors, (4) providing appropriate subsidies, expertise and legal authority to government and professional entities (including the FDA, Department of Agriculture among others) active in the public health arena, (4) eliminating subsidies which make our citizens fat, physically  inactive and ignorant of how to recognize and deal with their own health needs, and (5) admitting that health care reform focuses on access to and financing of  health care and not the extent and quality of appropriate and necessary health services.

It's easy to complain about the cost shift burden. But focusing on the reasons for excessive health care costs will step on many vested interest toes. Will true reform even drive down some of the high-flying health invested mutual funds?

What About My Child Who Was Cured of Cancer?

For several days, radio and televisions broadcasts have said it: beginning September 23, 2010, under the Affordable Care Act applying to grandfathered group health plans, health insurance enrollees who are younger than 19 years of age cannot be excluded from benefits or denied coverage because a condition was present before the date coverage became effective (or denied).

The hype sounds good, but what if your 19-26 year old child was treated for heart disease, lung disease, cancer, leukemia, Hodgkin Disease, Wilson's Disease or any other serious condition and the insurance company says "no" to someone age 19-26 with a pre-existing condition under the grandfathered plan?  (A grandfathered plan was one existing on March 23, 2010 and a new plan is one established after that date.) While minors must be covered, not until 2014 will the  pre-existing prohibition for adult children be eliminated.

Sophisticated advisers stress the importance of keeping a close eye on employers' grandfathered plans.  When new insurance is written or major revisions to existing plans take place,  "grandfathered" plans may become new plans and work under a whole new set of more consumer- protective rules.  Pay attention.

Health Reform: Upset WIth Democrats, Afraid of Republicans

My take, based on conversations with professionals and just plain people, is public apprehension about the impact of the 2010 health reform package. On the one hand, people complain about the threat of federalization of health care and on the other, they demand that their Medicare program not be affected by health reform.  While there is recognition of the need to clean up the the old inefficient expensive system which provided economic rationing of care, there is a sense that the political parties are at odds, and that any gains made since passage of health reform in March, 2010 will be undone by Republicans should they gain control of Congress. The uncertainty created by Democratic passage of reform is threatened by the fear that - if the Republicans can control health care - it will be the bad old days again and people will sit in movie theaters (or in front of their big home TVscreens) booing insurance companies, HMOs and any theatrical reference to institutions that control of health care.

The Democrats haven't exactly made it easy for the public to understand what is happening and what will happen under health reform. A recent posting of a letter from Kathleen Sebelius  calling on Health Insurers to Stop Misinformation and Unjustified Rate Increases, said

"Any premium increases will be moderated by out-of-pocket savings resulting from the law.  These savings include a reduction in the "hidden tax" on insured Americans that subsidizes care for the uninsured.  By making sure insurance covers people who are most at risk, there will be less uncompensated care, and, as a result, the amount of cost shifting to those who have coverage today will be reduced by up to $1 billion in 2013.  By making sure that high-risk individuals have insurance and emphasizing health care that prevents illnesses from becoming serious, long-term health problems, the law will also reduce the cost of avoidable hospitalizations.  Prioritizing prevention without cost sharing could also result in significant savings: from lowering people's out-of-pocket spending to lowering costs due to conditions like obesity, and to increasing worker productivity - today, increased sickness and lack of coverage security reduce economic output by $260 billion per year."

Walk into any hospital Emergency Department and you may observe terribly sick and injured people who, because they are not insured American citizens, may still run up substantial costs which will be shifted to the insured population making the Secretary's claim of dubious validity. We need the facts to substantiate claims of savings as an offset to the doubts proclaimed by the political and corporate opponents of health reform.

Otherwise we will have more upset which will outweigh fear.

Who Will Judge Your Health Care Coverage?

Two articles in today'[s New York Times referenced health care costs on the reform bill. Stating that the reform bill  focused on health care access, rather than cost-control. Jonathan Bush opined that health reform will be cost-expansionary. But Andrea Sisko, the main author of a government report predicted modest effects on the  growth of health care cost to accompany a marked increase in access as more than 30 million people gain insurance coverage, although the article citing her report notes that growth in health care spending will increase from its 17.3 percent of the gross domestic product to 19.6 percent in 9 years.

Will our government be forced - by economic realities - to make new changes to health care coverage, limiting benefits for conditions now covered, imposing age barriers to obtaining palliative or even curative therapies, or barring individuals from health care coverage for conditions which they developed  as a result of damage which they self-imposed, such as the use of drugs, high risk sexual behavior, abuse of alcohol, and perhaps even consuming types and quantities of foods known to increase the risk of diabetes, heart disease, hypertension, obesity related joint disease and other conditions? Will government move towards pragmatic limits which will reduce scientific research, impose restrictions which favor the young and healthy, and make individuals primarily responsible for the consequences of lifestyle decisions which end-up costing society money?

Who will judge and who will be judged?  Who will live and  who will die?

Who by Fire?

Highly Sensitive Information

When I practiced internal medicine, asking a patient to go through psychological testing usually meant that the patient would never return to my office.  The issue was too sensitive for many reasons, including the possibility that someone related to the patient socially or through a business connection  (i.e., a spouse, employer or insurance company) would gain access to that information with serious consequences for the patient.

The sensitivity of psychological records remains an issue under federal privacy laws.  Following, is a notice I received today (9/7/2010) which may be of interest to my readers:

Before You Drink That 6-Pack . . . .

As I walked into my local supermarket to buy some flowers for the weekend, I saw the 6-packs of beer leaving the store, tightly clutched in customers' hands.  It made me wonder:
1. Do you believe that drinking the Labor Day weekend 6-pack will make your "crowd" like you?
2. Do you believe that drinking the Labor Day weekend 6-pack will make you more sexually attractive?
3. Do you believe that drinking the Labor Day weekend 6-pack and driving does not increase your risk of an  auto accident, a DUI citation, large hospital bills resulting from that auto accident, loss of auto insurance, lawyers' bills, and grief?
4. Do you believe that drinking the Labor Day weekend 6-pack will bring you joy?
5. Do you believe that drinking the Labor Day weekend 6-pack will absolve you of responsibility for an unwanted pregnancy?
6. Do you think that drinking the Labor Day weekend 6-pack and others, doesn't increase your risk of alcoholic liver disease, esophageal cancer, mouth and throat cancer (especially if you smoke) and gastrointestinal bleeding?
7. Do you think that the only friends worth having are the ones that will consume their own Labor Day weekend 6-packs followed by lots more?
8. Do you think that drinking 6-packs has an effect on your weight?
9. Do you think that drinking 6-packs has an effect on your school or job performance?
10. Do you really believe what the brewery ads imply, that the only way to have fame, fortune, friends, sex and happiness is to find it in the bottles they sell?


Ask any doctor or nurse who works in an emergency room what he or she thinks based on real life experience.

Don't Rush To The Newest Drug

In its September/October 2010 edition of  the American Society of Hematology's The Hematologist, Pete Lollar, M.D. reviews a report by Dutton, Wayman and Wei describing previously unknown actions by the anticoagulant warfarin (proprietary name - Coumadin)  used to combat abnormal venous and in-heart clotting which can produce strokes and pulmonary emboli with catastrophic results. Warfarin is also used as rat poison.

The report notably reports that vitamin K-dependent proteins involved in clotting involve vitamin K epoxide reductase ("VKOR") which is inhibited by warfarin. Humans are not the only life form which uses takes advantage of VKOR, since some bacteria including the one causing tuberculosis partially share VKOR activity.

There is a great deal of interest in new drugs which are being proposed to replace warfarin, a product which has been available since 1948 and, in addition to preventing strokes and pulmonary emboli, may be responsible for serious bleeding, particularly in women above age 80.  We are only beginning to understand the subtleties of the biologic action of warfarin.  When presented with the newcomer anticoagulants, how long will it take for us to understand how they work, and how many patients will experience serious unanticipated consequences of their adoption which we do not fully understand? Serious unanticipated consequences which rival the monitoring, cost savings and bleeding episodes now experienced with warfarin.

REPUBLICATION

We have a serious epidemic of a very serious disease, pertussis (whooping cough) and a substantial number of parents who have chosen not to provide their children with pertussis vaccination, I am republishing this post first written in January 2010.

If your child has friends who have not been vaccinated, consider finding other friends for your kid. If your child has not been vaccinated, be prepared to lose friends.

REPUBLICATION


In a recent study reported to physicians by Medscape (the original article appeared in  the January issue of the Archives of Pediatrics & Adolescent Medicine), approximately 5% of the children who were studied did not have varicella vaccination because of parental refusal. The study found that  the children whose parents refused to have their children immunized were at  "high risk" of varicella infection compared to children who were vaccinated.

Today, a parent's refusal to vaccinate with a medically proved effective and safe vaccine has no societal consequences for the parent other than the guilt which he or she may shoulder from severe complications of varicella infection in his or her child. Other parents, and their children who become infected as a consequence of each refuser's decision (such as children with immune disorders or leukemia who cannot be vaccinated) unfairly bear all of the financial and personal liability flowing from the original refuser's decision, a decision in which they did not participate.

A straightforward marketplace approach to the parents' vaccination decision making could be relatively simple. After being provided with relevant information, a parent who denies his or her child the protection of vaccination (or does not present the child for vaccination) becomes liable for all economic and "pain and suffering" consequences of all downstream infections which can be traced back to that child by public health authorities.  Guaranteed freedom of choice, the refuser could insure against such liability, or could post a bond which he or she purchases. 

Adoption of this approach would reduce the cost of health care because it would prevent the refusing parent from shifting the cost of the decision to payers and other parents.  The refusing parent could reduce his or her exposure to liability through insurance, bringing the opportunity for new business to insurers. Attorneys actuaries, public health officials could be engaged in the "fight against preventable disease".  It's a "win-win".

Who Speaks For The Others?

Large and small hospitals may not advertise the fact that they have biomedical ethics committees, but they do. If  a patient's family asks "can Dad's case be reviewed by a biomedical ethics committee?" the answer may be "yes, but, we don't think that's necessary" or it may affirm the availability, willingness to meet and consider Dad's case, and the experience and expertise of the committee in formulating recommendations. Or sometimes, review of Dad's case is suggested by a hospital staff person or physician, familiar with Dad's case who also understands the issues Dad's medical and social condition present and seeks help.

This blog isn't about Dad, the subject of  biomedical ethics committee attention.  This blog is about the focus of the committee on Dad which excludes consideration of the impact of its decision and recommendations on  other individuals and communities which the institution serves.(biomedical ethics committee opinions are commonly in the form of recommendations to the doctors, staff and family, and those recommendations reflect consideration of Dad's medical and social issues, discussion with the family, review of hospital and medical staff policies and procedures, consideration of standards of care and sometimes consideration of applicable law). The review is targeted on Dad and his immediate survivors.

A simple example:  the committee recommends that Dad, who is terminal, receive full resuscitation efforts because that is what Dad's family says they want and their customs demand. Dad dies. One minute after the team begins Dad's resuscitation, a young patient suddenly and unexpectedly experiences cardiac arrest which would respond to competent resuscitation if the resuscitation team weren't occupied with Dad's fruitless resuscitation.  Dad is declared dead, the young patient receives less than optimal resuscitation and survives in a vegetative state. The decision about Dad directly impaired the care another patient received, but the biomedical ethics committee focused only on Dad. No one represented the interests of the potential "others" at the biomedical ethics conference table. When a family aggressively demands services which cannot alter the outcome of care, they may not appreciate or care about the effect of the satisfaction of that demand on the hospital's ability to provide appropriate care to other patients. But this sensitive issue is not often raised in committee deliberations and discussions.

When antibiotics are provided with knowledge that they will not affect the patient's outcome, the appearance of antibiotic resistant bacteria become a threat to all of the patients and communities that the hospital serves. The national cumulative effect of antibiotic resistant bacteria means widespread unnecessary suffering from infections which will not respond to "standard" antibiotics, a huge expenditure for tests and treatments, and preventable mortality. When, with biomedical ethics committee recommendation, an intensive care unit breathing tube is inserted with no expectation that the comatose patient will awaken or ever be weaned, that bed, those staff people, that equipment and the opportunity to care for someone who is highly likely to recover, may be irretrievable.

My suggestion is straightforward. In each biomedical ethics committee case review, one person be appointed to speak for the interests of the "others" - the patients whose lives and care may be impacted by the recommendations for a decision to be made about "Dad." Committee recommendations may not change, but the process will be more honest and inclusive..

Health Care Costs Requires A Long View, Not A Two Minute Sunday Morning "Talking Point" Presentation Invoking the National Deficit As An Excuse

You probably know the answer to the questions which follow, but Representatives and Senators, who claim to operate for the good of the nation and its people go on television on Sunday mornings and ignore the obvious answers because they are not beholden to you, they are beholden to their funding corporate interests.
1. In the long run, does our country save money by providing access to all children for vaccination for serious childhood diseases? If yes, why don't we do it?
2. In the long run, does access to health care, yield healthier adults whose life time health care expenses are lower? If yes, why don't we provide that access now?
3. In the long run, does providing competent,  accessible and affordable obstetrical care for all women reduce the likelihood of injury during obstetrical delivery? If yes, why don't we provide that care now?
4. Does pollution-free clean air reduce the frequency of death and expensive emergency hospitalizations for children and adults? If yes, why are we battling about environmental protection and clean air?
5. Does providing supervised physical activity for kids, instead of sitting them on sofas at home watching TV, help children to be more physically fit and to reduce the long-term costs of their care? If so, why are our kids parked in front of television sets?
6. Does enforcing employment safety rules reduce the frequency and cost of injury born ultimately by the public? If yes, why don't we enforce them?
7. Does the provision of appropriate prescribed medications which the elderly can afford make it more likely that they will take the medicines prescribed by their physicians? If yes, why don't we provide them?
8. Does the provision of appropriately inspected and approved food reduce the number of annual deaths from food poisoning? If yes, why are we experiencing food-borne outbreaks of disease and death?
9. If we have a test for Alzheimers disease, does that mean we can cure the disease? If we have no genuinely effective drugs for Alzheimers Disease, why don't the news reports say so?
10. Is it OK to have "a little diabetes"? If it isn't, what is our national policy to prevent diabetes?
11. Is it better to have a patient with cancer seen earlier or later by competent health care providers? Ask any doctor or nurse.
12.Is there any sensible reason why the federal government negotiates pharmaceutical prices for the Veterans' Administration beneficiaries but not for those who pay for Medicare Part D? So why doesn't it?
13. And finally, other than fancy words, what is our Administration, Congress, our Legislatures and Governors doing today to make Americans healthier?

Failure to provide competent accessible ethically appropriate care at all life stages inflates our long-term health care costs, seriously increases our budget deficit and harms our quality of life.  Why are our President, Senators, Congresspeople, state Governors and legislators not talking about the real issues now?

Now Do This - and More- For All Physicians & Nurses In Training

NIH Announces Availability of Educational Loan Repayment Programs

The National Institutes of Health (NIH) recently announced the continued availability of educational loan repayment through its extramural Loan Repayment Programs (LRPs). The NIH LRPs provide researchers the opportunity to pursue research careers by repaying up to $35,000 of their qualified student loan debt each year. The application period for new and renewal extramural applicants is September 1 to December 1, 2010. Applicants accepted into the programs will engage in NIH mission-relevant research for at least two years, during which time a minimum of 50 percent of their work hours (not less than 20 hours based on a 40-hour work week) must be applied toward their NIH research activities. Details of the NIH LRPs may be accessed through the LRP website.

(Courtesy of the American Society of Hematology)

First, Do No Wrong - Continued

In my blog of July 31, 2010 dealing with an experiment in which physicians' clinical notes are posted on the internet so that patients can read them (or possibly anyone whom the patient permits to see the notes can read them).  I mentioned patient and physician self-censorship with the comment that I would come back to the subject.

In my clinical experience, the most common situation in which patients withheld important information because of fear that it would be released to a third party, was spousal physical abuse about which California  physicians were (are) required to contact appropriate government agencies and patients did not want that report to be made. In spousal  physical abuse, there were telltale signs on examination which told the story even when patients' words did not. And I and other physicians would tell our doubly injured patients (physically and emotionally damaged) that we were required by law to report and that we would comply with the law. Should that information also  be recorded in a medical note to which the offending spouse might gain internet access even before the authorities intervened?

Less common patient censored information included sexual practices, sexually transmitted diseases, patient or familial mental disorders, childhood abuse,  alcohol and other substance abuse, and even the eating of food representing different ethnic practices which patients felt would lead to shame if disclosed to the physician or others. Physician inquiries about familial diseases were often responded-to with "I don't know" rather than the facts which (as time revealed) were well-known to these patients.

Physicians may censor information, which they know may lead to patient difficulties (i.e., advise patients to pay cash for certain tests because insurers might use the insurance-billing information, or information provided which might get back to an employer, in a way which might cause patients to lose insurance or their jobs) and make no mention of their advice or the conditions they were concerned about in their notes.

What do my readers think? For or against posting physician clinical notes on the internet? And why?

First, Do No Wrong

An NPR program on Friday 7/29/2010, which excited listener call-in interest, dealt with patients' rights to their own medical records.  Neither the moderator nor the program's physician consultants mentioned highly relevant federal law on this subject and this blog won't deal with that issue today. The program was short on significant statistics and long on testimonials of questionable value.

The program focused on an experimental New England medical teaching institution-based project to post patients' medical records on a secure internet site for them to review.  The proposed benefits included better patient information about what the doctor was thinking, the availability of records for patients to download and then provide to other doctors, and increased patient trust in physicians because of knowledge of what was in the record. No downside to this process was discussed.

For years, my practice habit was to always dictate my "progress notes"while the patient was sitting two feet away from me. The process took no more than 3 minutes and informed patients about my understanding of their relevant medical histories,  physical findings, interpretation of laboratory data and the diagnosis I had formulated, and my treatment plan and other issues which pertained to that visit.  Unlike the process of later posting the clinician's notes on the internet, my system allowed (the patient was invited to) patient correction of any errors and for me to make the correction or explain why I chose not to.  I had made it my habit to encourage patients (and often accompanying family members) to ask for clarification and for more information about the subjects I had discussed immediately after I signaled that my dictation had ended. When patients left my office, they were secure in their knowledge of what was (and was not)  in their  charts and additional requests by patients for copies of their records was unusual unless they needed records for medical care elsewhere.

The New England experimental program involving electronic health records has several downsides. Patients may self-censor the information provided to physicians and physicians may self-censor what they include in medical records.  Patients' reviews of the their records is deferred which may leave them with significant delay and unnecessary anxiety about what doctors thought. There is no timely patient-physician give and take with a chance for others (i.e., family members brought in by patients) involved in patients' care to participate in the discussion process. And, it takes strong physician training and discipline to provide a complete internet-posted electronic health record which even touches on serious issues such as interpersonal family relationships, the consideration of the possibility or presence of serious social diseases (such as HIV, syphilis, gonorrhea),  or situations, conditions or diseases which may result in deleterious insurer action, employer action, government action or adverse legal consequences.

Maybe we should slow down the use of technology, and bring smart social scientists into the process, so that we do no wrong.

US Government Action Against Rite Aid's Patient Privacy Breaches

I received this notice from HHS today, July 27, 2010 and present it unedited:

 "Rite Aid Agrees to Pay $1 Million to Settle HIPAA Privacy Case

Company agrees to substantial corrective action to safeguard consumer information

July 27, 2010

"Rite Aid Corporation and its 40 affiliated entities have agreed to pay $1 million to settle potential violations of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule, the U.S. Department of Health and Human Services (HHS) announced today. In a coordinated action, Rite Aid also signed a consent order with the Federal Trade Commission (FTC) to settle potential violations of the FTC Act.

 "Rite Aid, one of the nation’s largest drug store chains, has also agreed to take corrective action to improve policies and procedures to safeguard the privacy of its customers when disposing of identifying information on pill bottle labels and other health information. The settlements apply to all of Rite Aid’s nearly 4,800 retail pharmacies and follow an extensive joint investigation by the HHS Office for Civil Rights (OCR) and the FTC.

"OCR, which enforces the HIPAA Privacy and Security Rules, opened its investigation of Rite Aid after television media videotaped incidents in which pharmacies were shown to have disposed of prescriptions and labeled pill bottles containing individuals’ identifiable information in industrial trash containers that were accessible to the public. These incidents were reported as occurring in a variety of cities across the United States.  Rite Aid pharmacy stores in several of the cities were highlighted in media reports.

"Disposing of individuals’ health information in an industrial trash container accessible to unauthorized persons is not compliant with several requirements of the HIPAA Privacy Rule and exposes the individuals’ information to the risk of identity theft and other crimes.  This is the second joint investigation and settlement conducted by OCR and FTC. OCR and FTC settled a similar case involving another national drug store chain in February 2009.

"The HIPAA Privacy Rule requires health plans, health care clearinghouses and most health care providers (covered entities), including most pharmacies, to safeguard the privacy of patient information, including such information during its disposal.

"Among other issues, the reviews by OCR and the FTC indicated that:

·        Rite Aid failed to implement adequate policies and procedures to appropriately safeguard patient information during the disposal process;

·        Rite Aid failed to adequately train employees on how to dispose of such information properly; and

·        Rite Aid did not maintain a sanctions policy for members of its workforce who failed to properly dispose of patient information.

"Under the HHS resolution agreement, Rite Aid agreed to pay a $1 million resolution amount to HHS and must implement a strong corrective action program that includes:

·        Revising and distributing its policies and procedures regarding disposal of protected health information and sanctioning workers who do not follow them;

·        Training workforce members on these new requirements;

·        Conducting internal monitoring; and

·        Engaging a qualified, independent third-party assessor to conduct compliance reviews and render reports to HHS.

"Rite Aid has also agreed to external independent assessments of its pharmacy stores’ compliance with the FTC consent order. The HHS corrective action plan will be in place for three years; the FTC order will be in place for 20 years.

"For additional information and to read the Resolution Agreement, visit www.hhs.gov/ocr/privacy.

______________________________

__________________________________________________________________________ This email "is being sent to you from the OCR-Privacy-List listserv, operated by the Office for Civil Rights (OCR) in the US Department of Health and Human Services. This is an announce-only list, a resource to distribute information about the HIPAA Privacy and Security Rules. For additional information on a wide range of topics about the Privacy and Security Rules, please visit the OCR Privacy website at http://www.hhs.gov/ocr/privacy/index.html. You can also call the OCR Privacy toll-free phone line at (866) 627-7748. Information about OCR's civil rights authorities and responsibilities can be found on the OCR home page at http://www.hhs.gov/ocr/office/index.html. If you believe that a person or organization covered by the Privacy and Security Rules (a "covered entity") violated your health information privacy rights or otherwise violated the Privacy or Security Rules, you may file a complaint with OCR. For additional information about how to file a complaint, visit OCR's web page on filing complaints at http://www.hhs.gov/ocr/privacy/hipaa/complaints/index.html. To subscribe to or unsubscribe from the list serv, go to https://list.nih.gov/cgi-bin/wa.exe?SUBED1=OCR-PRIVACY-LIST&A

Gee, The NY Times Finally Noticed: The Fox Is Guarding the Hen House

Our U.S.government is not expert in the "insurance risk" business, but health insurers and HMOs, which may not have corporate competence in health care but do understand their respective financial bottom lines, understand the concept of risk very well. And corporate health insurers and HMOs lobby for laws which explicitly limit their risk or allow them to limit their risk by defining that risk away and influencing their friends at the states' level to help them.

As Reed Abelson of the Times describes in his 7/24/10  "For Insurers Fight Is Now Over Details" article, insurers are trying to define away their risk under the health reform provision which requires that 80 cents of each premium dollar be spent on the welfare of patients. Instead of the 80 cents purchasing actual health goods and services, the health care industry is attempting is use that 80 cents to pay for the paperwork and clerical functions involved in credentialing doctors in its networks, for commissions to those who sell insurance, for taxes on investment income and other items which will improve its bottom line (such as policing health care billing fraud), but not the health care bottom line of those insured under the health reform package.

Insurers are already showing their willingness to dump sick kids who are under individual (not group) health insurance policies as they manipulate their exposures to risk. Our health care premiums will buy less health care, more bureaucratic services, and we will not have the true reform promised by the Obama administration.  The health insurance and HMO industry, guarding the hen house like foxes, will take care of their needs first and provide only left-overs for Americans who will dig deep into their pockets for health insurane coverage.

Random Vacation Thought

It's not really a vacation, but a conference which runs from 7AM to midnight for 5-1/2 days, providing lots of stimuli for random thoughts.

My thought was: 0 for 3 is fine when (1) was a health reform featuring a single payer system; (2) was a proposal for growing our health professional force by providing sweat-equity subsidies for  college and professional science education and training and (3) was abolishing Medicaid and providing health care to all Americans on a financially and ethically sound basis. 

Disagreement on Benefits of Computerized Health Records

Robert Pear, writing in the 6/7/2010 New York Times ("Doctors and Hospitals Say Goals on Computerized Records Are Unrealistic") quotes several sources to support his thesis that the Federal Government has promulgated inappropriate expectations and time-lines for implementation of billions of dollars ($34 billion) in subsidies for the purchase of health care computer systems by doctors and hospitals.

Although medical literature is divided on whether computerization benefits medical care outcome quality, it seems that medical and hospital administrators, who have no direct patient care ongoing experience and may be interested in the financial benefits of the subsidy, tend to praise the concept of computerization, though not the Obama administration's expectation and timelines.  For my part, I have never seen a computer that can quickly and inexpensively find a breast or testicular lump, or detect a swollen lymph node in the neck, or read a drug-seeking patient's body language. On the other hand, physicians who spend their time entering data into computer keypads probably won't have the time or incentive to carefully check for those breast, testicular and lymph node lumps and will probably find their patient flow statistics enhanced by giving the narcotic-seeking patients the drugs they want rather than deal with the complexities of care that these patient require.

The real benefits of the subsidy may be China, whose industries churn out huge numbers of (?virus infected?) computers which will be bought by American health care providers and brought into doctors' offices and health care facilities where they will store highly sensitive personal data. As someone whose personal medical data was stolen from a health care facility, I wonder if we really know what we are getting into?

Definition Of An Expert

We've seen lots of definitions of  "expert" but they offer no help. Here's one, I've drawn on experience to create, for you to use as you declare your independence this weekend:  an expert is a person who can live with increasing levels of uncertainty.

Health Care: Rights And Obligations

Dean Kagan was not my Harvard Law School professor of constitutional law, but Professor Arthur Sutherland, a gentle scholar with a penetrating mind (and wit) was. He taught us that rights are closely tied to obligations. Although health care issues may seem too mundane to be linked to Harvard legal principles, Sutherland's message remains relevant: health care rights and obligations are inextricably linked.

In 2008, when I started this blog, I discussed the franchise that health care professionals obtain when they receive their licenses, granting them their rights to practice, and noted that their rights were accompanied by serious professional obligations to provide services in the public interest which those licenses were granted to serve. For physicians, it means the obligation to provide care for desperately ill patients who may not be able to afford the health care provider's "usual and customary fee." For licensed (franchised) hospitals, whether for-profit or not-for-profit, it means taking care of the needs of those who would become seriously impaired, suffer unnecessary pain, or die without the hospital services the institution is licensed to provide. For licensed (franchised) insurance companies, it means considering issues above and beyond profit when underwriting and providing insurance benefits. For patients who proclaim their rights to health care, it means taking those personal measures which promote health rather than (i.e., alcohol, tobacco and dangerous drugs as well-as high-risk behaviors) demand that society take the responsibility to correct the damage they have done to themselves. It may mean understanding that the demands which an individual makes on the health care system may be unrealistic, unnecessary and economically impossible and, if met, may result in the system being unable to provide basic care to others.

Each of us will require health care. When we (or our surrogates) make demands upon the our health system, we should understand the system's capacity, it's obligations and our own. Health care does not represent a bottomless trough at which we can all line up to get our fill. Nor is it an ever-growing source of revenue to its franchisees.

What are your health care rights? And what are your obligations?

About Alzheimer's Disease

In my medical practice, and particularly in my roles as Medical Director of a women's retirement home and its nursing unit, I frequently dealt with patients who had Alzheimer's Disease  and their families. The beautifully written article, by Arthur Kleinman in Harvard Magazine, "On Caregiving" is worth reading..

They Used To Use Tar for Psoriasis Treatment

The TV report was very low key. There was an assistant head of a shrimper's group who said he was really concerned about the his health, his wife's health, his kids' health, his brothers' health and the health of the people working, not in the normal trades, but in the massive oil spill cleanup breathing that air that smelled so bad. In his direct honest way, he plaintively asked why there was so little information from the government or anyone else about the health effects on people of the oil and its fumes. He said that the people in the area had poor insurance, if any, little access to health care facilities, and felt adrift.

Then another TV scene, this of a lot of doctors at a Louisiana meeting, not of a government agency but of an important-sounding institute group. Lots of uniforms, very somber people. Their words were as guarded as a lawyer's  before the U.S. Supreme Court. Nothing to cause panic or to even raise alarm.  The big issue was skin rashes from irritation from the petroleum floating in the water and filming the marshes.  If you listened carefully, there was only the slightest hint of concern expressed about long-term effects.  What was most significant was the silence about serious health issues. What was most significant was that there was no responsible response to the shrimper's pleas for information about the health effects of the oil and its benzene-containing fumes and what they could expect in the short term and out eight to ten years.

When I was in medical school, various tars (often from coal derivatives) were used to treat conditions such as psoriasis. I was surprised that no one, recorded by the TV cameras,  said "consider the "up" side: smear some tar on your psoriasis and your skin might improve.

Link to CDC site for professionals added 7/1/2010:

BP's Oil Spill: The Next Propaganda Wave From Petrochemical Forces?

Most mutations are not particularly beneficial and result in non-sustainable life forms. Over billions of years, humans have evolved because of mutations which, in the Darwinian sense, have augmented human survival,  There is some religious, but no scientific uncertainty about these observations.  However, critics have developed sophisticated techniques for creating doubt, even about proved scientific conclusions such as evolution.

If you have followed the global warming debate, you may understand that a technique used by opponents of scientific acceptance of human activity's contribution to global warming is to inject "uncertainty" into the argument. Even when there is overwhelming evidence for human influence on global warming, the opponents argue that "we really don't know and so we shouldn't do anything," framing any sensible responsible activity aimed at stemming global warming as irresponsible.

Take a skeptical look at the inferences injecting uncertainty about the dangers of oil sludge  in today's New York Times article which discusses bio-organisms flourishing in areas of oil/gas presence on the ocean floors. My impression is that the article subtly suggests that the oil sludge in the Gulf of Mexico waters might really have an upside, resulting in the growth of beneficial marine organisms. Should the Times have demarcated the inferences by question marks?

Perhaps the next article will  suggest uncertainty as to the effects of BP's oil spill on the dead fish, birds and other life forms in the Gulf and along the Louisiana coast and a potential "upside" as life forms are recycled and today's oil-covered dead fish becomes food for new generations of gulf life.  Perhaps an article will claim that if we wait long enough, BP pollution of our water and shores will be an evolutionary godsend and perhaps worthy of a process patent. 

Is exposing our gulf coast population to the risk of mutation, leukemia and brain tumors, really something that can be sweet-talked?  Next, will we be showered with pictures of cute  (mutated) Ninja Turtles singing the praises of BP in local hospitals where kids with acute leukemia and brain tumors are to be treated?

The Great Vaccine That Your Parents Don't Get

Simple questions: if your parents were in an age group (over 60) where they were at risk of developing a common disfiguring painful debilitating, sometimes blinding or fatal, disease and you learned that they could get an effective vaccine which had about a 1-1/2% risk of a serious adverse effect, would you tell them to get the vaccine? And would the doctor have it to give to them?

The disease the vaccine has a 51% chance of preventing is shingles (herpes zoster), a viral inflammation of the nerves caused by the chickenpox virus, which is contracted in childhood. The painful complication the vaccine has a 67% chance of preventing is postherpetic neuralgia, a miserable disabling complication of shingles which requires expensive medicine for partial relief and may last for years.

According to The Medical Letter Letter On Drugs and Therapeutics (5/31/2010), citing various studies, only 2% of the over 60 years old patients in a 2007 study had received the vaccine. Cost ($194 wholesale),the requirement for freezer preservation, and Medicare Part D reimbursement, were factors affecting vaccine use.

The vaccine (Zostavax) is better than having shingles. Tell that to your parents and have them discuss it with their doctors. And if a doctor isn't familiar with the vaccine and won't take the time to learn about it, maybe it's time to seek out another doctor.

Judge For Yourself: Health Risk Information About BP's Crude Oil Disaster

 From the CDC, published today: "Occupational health and safety experts have questioned the Offshore Air Monitoring Plan for Source Control, BP’s plan to protect the health of the more than 24,400 workers cleaning up the oil spill in the Gulf of Mexico, because they say it exposes workers to higher levels of toxic chemicals than is generally acceptable. The clean-up effort exposes workers to volatile organic compounds (VOCs), which are subject to federal regulations that do not specify safety thresholds. Because of this, BP is not currently required to supply respirators, evacuate workers, or take other precautions. Critics say the plan allows workers to remain in an area where vapors are four times higher than accepted practice. “This protocol seems to be written in a way that allows them to continue to work when conditions are such that, in any other setting, you’d pull your workers or you’d put them in better protection,” said Mark Catlin, a worker safety advocate and expert who worked on the 1989 Exxon Valdez tanker spill. BP spokesman Ray Viator, however, said that the plan is aggressively monitoring toxins and protecting workers. “It’s being managed by professionals who have reviewed the plan and who are making sure it’s been implemented correctly. It involves graduated responses and we’re prepared to accelerate it if the situation arises,” he said. The Coast Guard approved the plan on May 25, and although the Occupational Safety and Health Administration (OSHA) reviewed the plan, the agency’s jurisdiction only extends three miles off-shore."

To form your own judgment on whether Americans in the affected area are receiving appropriate information from the federal government read and analyze the  CDC's evaluation of the BP Gulf  oil spill and consider applicable federal law pertinent to emergencies.

See Taylor's Miami Herald expert's analysis of the protection offered to works and residents of the affect area (referenced above).

And finally, if you can stomach it, take a look at Louisiana's May 5, 2010 information to its coastal citizens.

Did I Miss Something

And  in his June 15th, 2010 TV talk, President Obama said what about the potential adverse health effects of benzene exposure on the men, women and children downwind from BP's crude oil disaster?  And who is to assume financial responsibility for dealing with those effects as they become real? And how will the victims and their families be made whole? And who is monitoring the environmental health risks and results?  How have Americans been notified of their exposures and the adverse consequences of those exposures?

Sorry, but a "I've got the situation in hand"  political talk just doesn't deal with the reality of a toxic exposure which may have consequences far worse than any terrorist attack our nation has yet experienced.

BP's Gift That Keeps On Giving

At 6:15 AM today, on National Public Radio, I heard the word. A scientist was describing the conditions she encountered at the BP oil environmental catasrophe site and she said that she experienced a strong smell of benzene in the air.

Benzene causes bone marrow damage and cancer. Exposure of children, pregnant women, adults and the elderly to toxic benzene will have serious long term effects, including leukemia and other diseases caused by benzene's capacity to cause mutations. The problems BP has created will not be gone by Christmas; BP's gift will  create catastrophes for our people for many years.

Read for yourself and then start writing the White House and your Congress people, since both should shoulder the blame for allowing BP to cause this mess. Ask them to tell the truth about the environmental catastrophe BP has caused for people's health, not just the health of fish and birds and shrimp. Demand that the United States Public Health Service be responsible for tracking and publicly reporting the downstream health effects of BP's polution. Demand that BP pay all of the health care costs resulting from their pollution of the ocean and air, and not dump the costs on the government and its taxpayers. Demand that Congress adequately fund the agencies responsible for regulating oil drilling and that the White House staff the agencies, not with political cronies who will rubber stamp "APPROVED" on every harebrained idea proposed by oil companies which buy unregulated freedom through political contributions.

This was not just BP's failure. It was a failure of our government (the political and administrative actors are attempting to distance themselves from responsibility). Our children, men and women, workforce and industry are suffering from BP's destruction of our environment and continuing American government willful  incompetence.  Demand accountability.

Another Example of Severe Disease From Toxic Exposures

Not only did the 9/11/2001 terrorist attack on New York have an immediate destructive effect on lives and structures, as  Aldrich and others' New England Journal of Medicine 4/8/2010 article concluded, carefull follow-up studies have shown a substantial number of rescue workers to have serious permanent abnormalities in lung function from their massive acute exposure to dust at the World Trade Center site both at the time of the attack and afterwards. The workers' health will never be the same.

Unlike today's  BP downwind exposure victims, politicians rushed to New York and the Pentagon to laud firefighters and Emergency Service Workers for their heroism and self sacrifice as they worked to save lives and property. The news media featured pictures of the rescue workers and highlighted their service above self-interest in the face of an horrific American tragedy. America recognized the sacrifices those people had made.

But the toxic exposure of children and adults in Louisiana downwind from BP's mess seems to merit no such interest although Obama has made cursory trips to the area and today's New York Times shows a sympathetic  picture of an oiled bird and an antiseptic picture of oil decontamination in Alabama. What about toxic exposure of the the adults and children  (who could not afford to run self-serving costly full-page newspaper ads, as BP did) to the fumes from  BP's flood of oil and the possible health consequences of that exposure. What is the extent of their exposure, what consequences can be predicted and why is our government and news media not talking about this issue?

Is there a conspiracy of silence?  Or is it just an election year? Or is BP advertising revenue a factor?

A Common Denominator: Questions For Obama's Administration

As a hematologist, I had many patients with severe, life-threatening blood malignancies, such as acute myeloid leukemia. I also consulted on patients with less advanced blood and bone marrow disorders of the type which predicted "there is a high likelihood that this person's bone marrow has been severely injured and will eventually develop leukemic changes".  There was a startlingly common denominator: even with extensive and repeated history-taking, most of the patients could not provide a history of toxic exposure which might have damaged their bone marrow.  Sometimes their occupations shed light on a petrochemical cause: commercial painters, workers (often undocumented immigrants working for construction contractors) who crawled under houses to spray for insects, farmers who worked land that had been contaminated by the dumping of insecticides years earlier), shoe-makers,  and artists using oil-based patients and solvents. But even homemakers with no commercial exposure to high levels of petrochemical based products came to my examining room with the story that they had "sprayed"  in a closed area (their homes' crawl-spaces) to rid their homes of destructive or annoying insect pests. Sometimes children who lived in residential communities not far from what we later learned was toxic industrial contamination of local water supplies presented with fatal acute leukemias. In each and every case, the person affected lacked information which would have aided him, her or parents to accept or avoid a life-threatening toxic exposure.

As I listen to the story of BP and the oceanic flood of raw oil contaminating the ocean, shore and coastal environment, I find it disturbing that there is no reliable information coming from the federal government about the level of highly toxic oil-based environmental contaminants to which adults and children are being exposed every day on the streets, at work,  in their homes and in their schools.  Why is this information not being obtained and distributed to the media for public knowledge?  How are people in the areas affected to know whether they and their families are being exposed to a high risk of bone marrow damage from raw oil and its airborne fumes?

This is serious business.  The Obama administration needs to treat its citizens as sensible adults and not dummies. The Obama administration should give the people facts about the very real and serious exposure to toxic materials spewing  from BP's disastrous oil well and let the people decide what is in their - and their families' - best interests. Should there be evacuation of entire shoreline communities? Should hospitals be gearing-up for an eventual flood of patients with petroleum-based bone marrow toxic effects, such as acute myeloid leukemia? Or is BP's calamity truly benign?

Have our public health authorities been gagged or do they just not know? And is finding out and disseminating information about toxic exposure a high priority or have the massive political contributions of the petroleum industry set the priorities to favor industry concerns over citizens' welfare?

The Answers Weren't In Any Computer

Some examples may help you to understand why I, and many experienced physicians, am dubious about reliance on computerized medical records.

Case 1: A 16 year-old food service worker in a nursing home who underwent a periodic employment exam. During the 5 minute examination, she was found to have a tiny lump in her thyroid.  A medical record indicating that the thyroid was previously normal would have been irrelevant. She was referred back to her physician, was sent to a surgeon and had her thyroid cancer cured.

Case 2: A 21 year-old male presented for a brief pre-employment physical examination. He had a lump in one testicle. A medical record indicating that his testicle was previously normal would have been irrelevant. He was referred to a urologist and had his cancerous testicle removed. He died of metasatic testicular cancer about ten years later.

Case 3:  A patient in her late 40s sought medical advice for her upper respiratory infection. She previously had a mastectomy for breast cancer. She was examined that morning by her very competent Ob/Gyn doctor and no breast lump was found and the chart entry was of benign breast findings. On examination that afternoon a small breast lump was found. Several days later, her second breast was removed for cancer.

Case 4: A 25 year old male presented with an upper respiratory infection. On examining his lungs, the physician noted a grayish black mole on his back, which the patient denied ever being told of before. The following week his malignant melanoma was removed.

Case 5: A 30 year old man with Hodgkin Disease was followed with frequent visits at a university clinic. Regular reports were mailed to his primary physician. No one at the university clinic had asked the patient to remove his shoes and socks and no one observed the large malignant melanoma under his toenail. The medical record led  readers to believe that the patient had been successfully treated for his malignant lymphoma, but no one looked past the chart to actually examine the patient's cancerous foot. He died of malignant melanoma, not of his well-charted Hodgkin Disease.

A physician's time spent in data entry clerical duties would be better spent in talking with and examining the patient.

The Seventh Doctor

In 1965, when I began my internal medicine training at Stanford University's Hospital,  life expectancy after treatment for a patient with acute leukemia was 69 days.  Times have changed and now I receive notes from patients whom  I treated for their leukemias and malignant lymphomas more than twenty years ago.  Millions of dollars invested in research and therapy has allowed fathers to survive and be there to parent their famiies and help their children grow to responsible adulthood. Millions invested in research and treatment has allowed women with malignant blood disorders to become active grandmothers, rather than just distant unfamiliar names in the family tree.

When I served on the national board of directors of the Wilson's Disease Association, I learned that many of our members with adolescent liver disease, severe depression, speech difficulties and neurologic disability were seen by six doctors before the seventh doctor recognized the symptoms, obtained appropriate tests, established the diagnosis and began treatment.  Early diagnosis and treatment of Wilson's Disease leads to prevention or minimization of copper accumulation in these genetically affected patients at minimal expense. Early diagnosis and treatment saves lives, preserves function and allows them to have fully productive lives at a cost of a few cents a day for safe and effective medicine.

Your interest and  investment will help to prevent a a child with Wilson Disease from dying in adolescence of liver disease, or becoming disabled by severe depression, or becoming unable to speak intelligibly, or developing  severe depression, or becoming unable to walk.   Your appropriate investment will prevent the untreated disease from proceeding to destruction of health, normal life and of economic loss.

What if, through the Wilson Disease Association public service and investment in training and education of physicians and other providers of health services (geneticists, physical therapists, psychologists,occupational therapists, nurses dieticians, eye doctors)  it was the first doctor, not the seventh who recognized the disease and prescribed proper treatment?

The Wilson Disease Association works with medical training programs and physicians throughout the United States (and internationally) to make that happen. They need your support. And the results of their work are  spectacular.

UPDATED CONTACT INFORMATION

Wilson DiseaseAssociation
5572 North Diversey Blvd.Milwaukee, WI 53217
Fax: 414-962-3886
email: membership@wilsonsdisease.org