A number of years ago, through a connection I made at a Rotary International meeting at the YMCA in Jerusalem, I spent hours interviewing the medical directors of three of Israel's largest health systems. When I finished these meetings, I felt as if I had delivered hours of psychotherapy to these individuals who were beseiged by the need to deliver life-saving health care through an irrational system, bounded and constrained by politics and religion rather than by scientific medicine.
In listening to President Obama's meeting today, I had that feeling again. It was clear that the parties on both side of the aisle understand the desperate straits that our health care system is in, but prefer to give precedence to irrational political (and personal) considerations in the guise of putting their constituents' needs first, rather than deal honestly with the issues. My bottom line is that all sides at the meeting were adequately informed as to our health system's prospects for a disasterous future, but that none is willing to abandon political strategy, and personal interest, to meet our country's and its citizens needs.
A good conference, Mr. President. But perhaps the next one should be led by an experienced psychoanalyst. Call me and I'll give you some names.
Thursday, February 25, 2010
Monday, February 22, 2010
Saturday, February 20, 2010
The Alzheimer's Disease Patient As Childcare Provider
For many years I was the medical director of a federally commended small skilled nursing facility associated with an women's charitable organization's retirement residence. When they moved into the residence, many of the entering retired teachers, librarians and former professionals chose me as their physician and came to my office, often with their daughters (rarely with sons), for care.
I had a long-term view of the lives of these women, as they told me of their early days, education, families, professional careers, death of their spouses, their leaving the towns and homes where they had lived for decades at the urging of their families, and the trauma of their entry into the retirement residence. Because they had lifetimes of independence, I encouraged them to remain independent and to use their new living situations as a springboards to different lives. For some of them that new life included a role in the care of grandchildren and great-grandchildren, such as transporting them to and from school and other activities.
As years passed, I found that some of these women developed dementia. But when I asked about their activities, they told me that they continued their usual childcare responsibilities, including driving children throughout the community. This prompted me to ask them to have their daughters join them for the next visit, and if necessary, we contacted the daughters directly "to come in with Mom" when the other approach failed.
Most of the daughters, highly dependent on their mothers for childcare help such as driving, had not recognized that their mothers had become significantly demented from Alzheimer's disease, passing off mother as "not as sharp as she had been" but otherwise OK and responsible. Only when I performed a brief simple mental status examination (what season is this? what month is this? what year is this?who is the president? what city do you live in?) and mother answered every question wrong did the daughter acknowledge the severity of mother's impairment and agree to relieve mother of responsibility for driving and complex child care which she had undertaken. And then to take action to stop mother from driving a car entirely.
And then, angry with me because of my intervention, a number of these patients found other physicians for their care.
I had a long-term view of the lives of these women, as they told me of their early days, education, families, professional careers, death of their spouses, their leaving the towns and homes where they had lived for decades at the urging of their families, and the trauma of their entry into the retirement residence. Because they had lifetimes of independence, I encouraged them to remain independent and to use their new living situations as a springboards to different lives. For some of them that new life included a role in the care of grandchildren and great-grandchildren, such as transporting them to and from school and other activities.
As years passed, I found that some of these women developed dementia. But when I asked about their activities, they told me that they continued their usual childcare responsibilities, including driving children throughout the community. This prompted me to ask them to have their daughters join them for the next visit, and if necessary, we contacted the daughters directly "to come in with Mom" when the other approach failed.
Most of the daughters, highly dependent on their mothers for childcare help such as driving, had not recognized that their mothers had become significantly demented from Alzheimer's disease, passing off mother as "not as sharp as she had been" but otherwise OK and responsible. Only when I performed a brief simple mental status examination (what season is this? what month is this? what year is this?who is the president? what city do you live in?) and mother answered every question wrong did the daughter acknowledge the severity of mother's impairment and agree to relieve mother of responsibility for driving and complex child care which she had undertaken. And then to take action to stop mother from driving a car entirely.
And then, angry with me because of my intervention, a number of these patients found other physicians for their care.
Tuesday, February 16, 2010
Health Insurers and Olympic Hurdles
At one of our Thursday lunches, a physician related that he prescribed medicine "A" and called the patient's insurer to get preauthorization but was refused when the insurer told him that he had to use another drug of the same class first (medicine "B"). Then, with another patient covered by the same insurer, he applied his experience and prescribed the medicine "B" only to be told by the insurer to try the "A", which they had previously disallowed, first.
This isn't good health care, this is a highly strategic insurance company game aimed at allowing the insurer to delay having to pay for a prescribed drug. But a second motivation is to make doctors gun-shy and reluctant to have to spend their time or their staff's time writing letters or making telephone calls to get an important prescription approved for insurance company payment.
When your doctor, with a waiting room full of sick patients, has to spend 45 minutes on the telephone trying to get approval for an important medicine for you, the experience will drain him of energy just as an Olympics downhill slalom soaks up athlete's energy. The winning skier gets an Olympic gold medal; the successful physician just gets tired and disillusioned. We all pay for the inefficiencies that insurers deliberately inject into the system; but since our insurance regulators and elected officials are often beholden for campaign contributions to the insurers, the insurers and not the public get the blue ribbons.
This isn't good health care, this is a highly strategic insurance company game aimed at allowing the insurer to delay having to pay for a prescribed drug. But a second motivation is to make doctors gun-shy and reluctant to have to spend their time or their staff's time writing letters or making telephone calls to get an important prescription approved for insurance company payment.
When your doctor, with a waiting room full of sick patients, has to spend 45 minutes on the telephone trying to get approval for an important medicine for you, the experience will drain him of energy just as an Olympics downhill slalom soaks up athlete's energy. The winning skier gets an Olympic gold medal; the successful physician just gets tired and disillusioned. We all pay for the inefficiencies that insurers deliberately inject into the system; but since our insurance regulators and elected officials are often beholden for campaign contributions to the insurers, the insurers and not the public get the blue ribbons.
Monday, February 8, 2010
Medicare Drops The Ax On Consultations For The Elderly Ill
I spent many years as a consultant hematologist practicing in the office and hospital, in addition to my role as an internist. Understanding both roles, I have difficulty with Medicare'[s recent pronouncement barring the use of "consultation" codes for billing and its requirement that consultant physicians bill the consultation as "new patient." The function, intellectual requirements, educational requirements, costs of operation and stresses of a consultation practice are quite different from an internal medicine or primary medicine practice and it would be much easier to simply practice as a primary care physician on autopilot than to have to, as a consultant, diagnose and treat very sick consultation patients with leukemia, lymphomas, fulminant blood disorders and bizarre rare conditions. A new "internal medicine" patient could be seen in 20-30 minutes; a complex consultation patient would often take more than an hour for the first visit.
So I was not surprised when the Thursday afternoon physician lunch group, which is composed of physicians with consultative practices in different specialties, focused its attention on Medicare's billing decision and its financial and professional impact on the specialist consultants. Some of these excellent physicians are already having financial problems operating their practices and are being forced to consider whether they should abandon taking care of really sick prople as consultants and take the less taxing and more financially rewarding path of practicing primary medicine. The inevitable consequence would be to reduce the ability of the elderly ill to obtain consultation from highly skilled experts. Gosh - isn't that what the Medicare population is already worried about?
So I was not surprised when the Thursday afternoon physician lunch group, which is composed of physicians with consultative practices in different specialties, focused its attention on Medicare's billing decision and its financial and professional impact on the specialist consultants. Some of these excellent physicians are already having financial problems operating their practices and are being forced to consider whether they should abandon taking care of really sick prople as consultants and take the less taxing and more financially rewarding path of practicing primary medicine. The inevitable consequence would be to reduce the ability of the elderly ill to obtain consultation from highly skilled experts. Gosh - isn't that what the Medicare population is already worried about?
Tuesday, February 2, 2010
What's Not There May Mean More Than What Is
Thinking about President Obama's State of the Union speech, I flashed back to Harvard Law School Professor Ben Kaplan's cogent statement on the first day of our freshman class in civil procedure. He told us that what gets lawyers in trouble is not what they put on their lists of important things, but what they leave off.
At a time when struggling American families, who have played by the rules, are furious about the self-serving greed of the banking and financial industry not one word was said by the President about new ethical standards for these industries and their people. At a time when the pharmaceutical industry has flooded Representatives,Senators and their political parties with political donations, not one word was said about ethical standards. People who have lost their insurance, people who have insurance but cannot obtain the health services they need, and health care providers are aware of the use of industry money to assure that the insurance industry's desires are fulfilled while their families' and patients' health needs remain unmet, have lost their trust in government and corporate institutions and received no solace from President Obama's words which simply left out any reference to meaningful ethical standards with respect to health reform. Ethical reform for health care hasn't made the list.
The other item which was left off the list during the President's speech was respect from the Republican minority sitting arrogantly in the hall behaving in accordance with its own agenda. Evident disrespect is a disturbing negative.
Ben Kaplan was right. There was a lot to learn that night from what wasn't there.
At a time when struggling American families, who have played by the rules, are furious about the self-serving greed of the banking and financial industry not one word was said by the President about new ethical standards for these industries and their people. At a time when the pharmaceutical industry has flooded Representatives,Senators and their political parties with political donations, not one word was said about ethical standards. People who have lost their insurance, people who have insurance but cannot obtain the health services they need, and health care providers are aware of the use of industry money to assure that the insurance industry's desires are fulfilled while their families' and patients' health needs remain unmet, have lost their trust in government and corporate institutions and received no solace from President Obama's words which simply left out any reference to meaningful ethical standards with respect to health reform. Ethical reform for health care hasn't made the list.
The other item which was left off the list during the President's speech was respect from the Republican minority sitting arrogantly in the hall behaving in accordance with its own agenda. Evident disrespect is a disturbing negative.
Ben Kaplan was right. There was a lot to learn that night from what wasn't there.
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