October 28th, 2009 by SteveSimmonsMD in Primary Care Wednesdays
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Over 25 years ago I witnessed a crime, committed by my family doctor. I was waiting to pay for my visit when an elderly, dignified, but obviously poor woman pulled out her checkbook, clicked open her pen, and asked, “How much do I owe?”
The receptionist’s answer piqued my interest and admiration, “The doctor said no charge, we’ll just bill your insurance.” I still remember the gratitude conveyed by her body language as she said, “Thank him for me,” returned her checkbook to her purse and left. Naïve to the complexity involved in medical billing, I was unaware that anything wrong had been done and did not resent having to pay for my office visit since our family could afford to pay; however, he eventually served time in jail for what I have always considered crimes of compassion. Perhaps I lack the details of his legal case to properly consider his actions but I’ll never forget the respect shown him by my home town in rural Tennessee after his time had been served; my family among many he continued to care for. Read more »
October 7th, 2009 by SteveSimmonsMD in Primary Care Wednesdays
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“To see what is in front of one’s nose needs a constant struggle…” George Orwell
Do you know what the “P” in HIPAA stands for?
If you said “privacy” you are quite wrong. HIPAA stands for Health Insurance Portability and Accountability Act and was originally intended to guarantee health insurance when someone changed jobs. But the word “portability” is a far cry from “privacy.”
Since April 14, 2003, patients have been required to sign these forms, creating the durable illusion that our medical records are private. We sign HIPAA forms when we see our dentists, doctors, and upon receipt of a host of other health-related services. Yet your personal health information is anything but private — and the more legislation Congress passes the more public this information becomes. Read more »
September 16th, 2009 by SteveSimmonsMD in Primary Care Wednesdays
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The debate on Health Care Reform has devolved into partisan politics with each side denigrating the ideas of those they oppose instead of objectively searching for real and effective reform. In the September 4 issue of the Washington Post, an Alec MacGillis’ article “The Unwitting Birthplace of the ‘Death Panel’ Myth” shows how partisan politics brought about the destruction of a very good idea. The piece details how those on the far Right disingenuously represented a provision in the House Health Care Bill to compensate physicians for time spent counseling their patients about end-of-life decisions.
I’d like to add a physicians’ perspective to both Mr. MacGillis’s story and an important aspect of life … death. I applaud the efforts of those who tried to have this provision added to the HC Reform Bill and believe that it supported the doctor-patient relationship while trying to preserve the dignity of human life. I ask: “Are we really supposed to believe that paying physicians to talk to their patients about death will lead to the creation of ‘Death Panels’?”
If you were to collapse right now and an ambulance sped you to a hospital Emergency Room, physicians and nurses would work to save your life, exhausting all options. If you survived a prolonged effort at resuscitation this would likely be your ticket to a stay in the Intensive Care Unit (ICU) and with luck you would survive to resume your normal life as you had before. It seems simple, right?
Wrong.
A whole host of what-ifs come to mind. What if you have terminal cancer? What if you are chronically ill? What if you have already spent months in an intensive care unit and desired never to experience that again? What if you are left brain dead, to be characterized euphemistically as being in a persistent vegetative state? Would you want your body to be kept alive, cast adrift without your mind to steer it?
I could go on and never run out of possible what-if scenarios. That’s what you have your doctor for and if you haven’t talked to your primary care doctor about scenarios specific to you, then you have surrendered control of how you die to a combination of chance and the decisions of your family. Furthermore, you are transferring all responsibility for these decisions from yourself to your loved ones and that includes the guilt that comes with making hard decisions.
Here are three tools that can express your wishes and absolve your loved ones from the burden of near-impossible decisions while also allowing you to protect the dignity of your own life as you alone can truly define:
1. Living Will: A legal document which goes into effect if you can no longer speak for yourself. It will make your wishes regarding a variety of life prolonging medical treatments known to the physicians treating you. One example would include whether or not to be kept alive in a persistent vegetative state by tube feedings. It is also referred to as an advance directive.
2. DNR Order: This stands for “Do Not Resuscitate.” In the event that your heart stops beating or you stop breathing, Emergency Personnel will be required to try to ‘bring you back.’ This includes electric shocks, chest compressions, and putting a tube into your windpipe to breath for you. These invasive techniques can be life-saving but for some patients only delay death for a short period of time. Since being shocked by electricity, having someone break your ribs doing chest compressions, or having a plastic tube in your throat are all painful, one’s doctor should make clear to their patient if these efforts would be futile and a DNR order fully explained. It does not prevent you from being treated.
3. Durable Power of Attorney for Health Care: Families (usually spouses and adult children) can make health care decisions for you if you are unable to. But families tend to disagree and by assigning a power of attorney you have the chance to pick someone whose views more closely match your own or who you trust to follow your own wishes.
It takes time for a physician to adequately answer questions regarding end-of-life decisions and for most primary care doctors today, there is no time for it. I used to be scared to mention a DNR or living will to my patients, aware that doing so could translate into an hour wait for every person scheduled to see me for the rest of the day.
If primary care doctors were reimbursed for time spent discussing end-of-life decisions more people would have living wills and DNRs, and this would pay both financial and ethical dividends to our society. We would not waste so much money on people at the end of their life; and I am quite comfortable stating that to keep someone alive by artificial means when they wouldn’t have wanted it is wasteful. Ethical dividends would include protecting the dignity of human life, easing the emotional burden of loved ones in a time of crisis, and giving some control to individuals in deciding how they die — an unavoidable aspect of life that our society needs to honestly discuss and plan for. We will all die but many of us first suffer needlessly and at great expense because we didn’t plan for it ahead of time.
Until next week, I remain yours in primary care,
Steve Simmons, MD
August 19th, 2009 by SteveSimmonsMD in Health Policy, Primary Care Wednesdays
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On Saturday, Breitbart.com posted an article about President Obama’s most recent town hall meetings and closed with the following paragraph: “Obama is yet to reveal a detailed plan, but promises to expand coverage, control spiraling healthcare costs, rein in insurance companies and prioritize preventative care.”
I’ve been looking for an actual plan since Health Care Reform was seriously proposed. In July, Rahm Emanuel, Obama’s Chief of Staff, was quoted in the Washington Post, stating that the Administration had decided against having an actual plan for Reform since it would expose the administration to criticism. Yet, I remained optimistic about Reform, and relished the chance to debate the facts as our Nation turned its focus upon a topic I have long been passionate about.
Unfortunately, my optimism waned as an honest and forthright debate about how to implement Reform has become ever-elusive. Disappointed in the turns this debate has taken on its journey through our national consciousness, I am leery of the simplistic viewpoint portrayed so often… “You are with Obama or against him” …. “You’re a Republican or a Democrat” … “You are for Reform or against it …”
Determined to find Obama’s plan, I began my search by reading his speech to the AMA, surfing the White House website, watching his ABC infomercial all the way through Nightline, and observing a number of town hall meetings. I went on to plaster the walls of my home office, to the amusement of my wife, with everything the President had said, color-coded on poster boards.
By July, as I looked around my office I realized that I was surrounded, not by a plan, but by a group of wishes, beliefs, hopes and ideals. I love the way it sounds when I say “prioritize preventative care” and I long for a day when the $100 million salaries of insurance company CEOs has been “reined in.” However, I am not naïve enough to expect this to happen without a coherent plan.
I used to believe the White House would propose a bona-fide plan. Instead they are implementing a strategy that combines the president’s rhetoric with the defensive tactic of refuting critics of Congressional plans or the President’s zeal.
Even after the House passed their Reform bill (the first actual HC plan to come out of Washington), I can’t make myself take down all of those poster boards leaving me surrounded by inspiring and hypnotizing ideals. Yet I fail to see how the House bill will transform these beautiful ideals into reality as it creates multiple new government agencies and burdens doctors’ offices with more clerical responsibilities — new for the busy doctors of tomorrow: the physician quality reporting initiative, cultural and linguistic competence training, financial disclosure reports between providers and suppliers, and national priorities for performance improvement.
John Mackey, CEO of the Fortune 500 company Whole Foods, wrote an op-ed piece about HC reform for the August 11 Wall Street Journal. His editorial includes understandable plans, worthy of intelligent debate while being based in large part on the health care benefits Whole Foods currently has in place for 36,000 of its employees, and includes the following recommendations:
1. Promote high-deductible health insurance plans and HSAs by removing legal obstacles.
2. Equalize the tax laws so those buying individual insurance can enjoy the exact same tax break employer related insurance customers receive.
3. Encourage competition by allowing insurance companies to compete across state lines.
4. Enact tort reform since insurance costs, frequently over $100,000 per doctor, are passed back to all of us in the form of higher prices for health care.
5. Make costs transparent so we can all understand what health care treatments cost.
6. Enact Medicare Reform.
7. Whatever reforms are enacted it is essential that they be financially responsible.
Three days later, instead of arguing the merits or demerits of Mackey’s plan, an ABC News story focused on the controversy his editorial had stirred up after briefly touching on some of his ideas. Spcifically, the ABC story focused on the boycott by many of his customers with one expressing the following belief, “I think a CEO should take care that if he speaks about politics, that his beliefs reflect at least the majority of his clients.” Another described Mr. Mackey’s position as a slap in the face to millions of progressive-minded consumers. The author quoted four customers pledging to not buy their food at Whole Foods anymore and added them to the implied masses gathering on Twitter and Facebook.
Fortunately, one customer, Frank Federer, was quoted as saying, “At a time when most folks are more inclined toward rancor than discussion of facts, I applaud John Mackey.”
So do I.
A realistic map showing us how to get from point A to point B is missing in the Health Care Reform debate. Facts are one thing in short supply to plot a course on this map. While the main ingredient in the fertilizer used to grow Whole Foods produce is in abundance, there’s just not enough for some of Mr. Mackey’s customers.
July 1st, 2009 by SteveSimmonsMD in Better Health Network, Primary Care Wednesdays
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When my six-year-old daughter heard that I was going to write about President Obama’s speech to the American Medical Association in Chicago, she offered me this insight: “He’s not a doctor! He isn’t supposed to tell people what to do when they’re sick; he’s supposed to rule the world.” Yet, regrettably, doctors do need his help and it was with great interest that on June 15, the medical community listened.
I suspect that my colleagues in Chicago are the only crowd to boo the President during a speech since his election, and I think that much can be learned by examining why this occurred. Just moments before being booed, Obama received raucous applause when he acknowledged, “that some doctors may feel the need to order more tests and treatments to avoid being legally vulnerable. That’s a real issue.” Physicians in the audience then booed the next line, “I’m not advocating caps on malpractice awards which I believe can be unfair to people who’ve been wrongfully harmed.” The President went on to offer a plan to help physicians avoid practicing expensive defensive medicine. “We need to explore a range of ideas about how to put patient safety first, let doctor’s focus on practicing medicine, and encourage broader use of evidence based guidelines.”
I do not object to President Obama’s sincere and well delivered remarks to the AMA, but found some of them to contain trite platitudes. Encouraging physicians to “put patient safety first, focus on practicing medicine and follow evidence-based guidelines” is like asking airline pilots to pay attention to safety gauges, fly their planes, and respect passengers. I found the admonition to follow evidence-based guidelines as a means to avoid medical malpractice claims a particularly naïve statement. I’m not arguing against using guidelines, I just don’t see how guidelines will protect me from a lawsuit any more than the currently used standard-of-care.
I share the President’s opinion that any individual should have the option of remediation through the court system when wronged but large, punitive settlements change the way hospitals and physicians practice medicine and have resulted in an untold number of unnecessary surgeries as well as causing the actual death of many who never had their day in court. Unreasonably large medical malpractice settlements often have consequences that reach far beyond the parties involved in the original suit. Follow the relationship between cerebral palsy and C-sections and you will understand my assertion. In 1985, then trial lawyer John Edwards won a settlement of 6.5 million dollars against a hospital and 1.5 million dollars from an OB/GYN doctor arguing that if a C-section had only been done for an unfortunate child she would have been born without cerebral palsy. This case set off a chain reaction of suits throughout the country, leading obstetricians to practice defensive c-sections. The United States currently has the highest rate of C-sections in the world, the most expensive obstetrical costs per birth, and when measuring infant mortality ranks 42nd out of 43 industrialized nations.
In 1970, six percent of births in the U.S. were done by C-section; today that number has risen to over 30% while the WHO recommended, in 2006, that the actual rate should be no higher than 15%. Yet, the last four decades have seen the cerebral palsy birth rates remain close to 2 per 1000 live births in the U.S. without change. Considering that women are 4 times more likely to die during a C section than during a vaginal birth it becomes a simple and tragic mathematical exercise. Consider that in Scandinavia the maternal death rate is 3 per 100,000 births while 13 mothers die per 100,000 births in the United States; unless you’re African American–then you count an appalling 34 dead for every 100,000 births. Furthermore, once you have had a C-section there is a very good chance that all future births will be done the same way with an increased rate of hysterectomies, post-operative infections, blood clots, drug reactions, etc.
On the other hand, tort reform has resulted in major shifts in the physician workforce. In 2003 Texas put a cap of a quarter million dollars on malpractice settlements for pain and suffering but did not place a limit on the actual economic loss suffered by a plaintiff. The limit for a wrongful death case was set at 1.6 million dollars. Since 2003 Texas has seen 18% more doctors filing for new medical licenses per year (30% in 2007) and by the end of 2007 there was a 6 month backlog for the medical board to begin processing new license requests. The increased number of physicians has helped to improve access to care. Medical malpractice reform is necessary to avoid the kind of collective defensive behaviors that, ironically, may not be in the best interests of patients.
In my next few posts, I plan to discuss various aspects of our broken healthcare system. It is imperative that we understand all of these problems to avoid making things worse. This will require a probing and honest evaluation of what is wrong today. I also intend to discuss the President’s plans for reform and while I don’t agree with all of his plans, he has put forth many ideas that I do agree with. The time for reform is here, action appears inevitable, and the moment to speak out is now.
Until next week, I remain yours in primary care,
Steve Simmons, MD
