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
September 2nd, 2009 by AlanDappenMD in Primary Care Wednesdays
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My early childhood memories hit and miss like a receding dream until four years of age when I boarded my first airplane flight. Our family landed in Mexico City to live. The experience was the first of many jolts which awakened my dreamy complaisant memory.
Within weeks I started kindergarten. That first day was filled by my ceaseless crying. Much to my relief, I had mastered the art of playing hooky by the next morning. A week later I matriculated into the American school. Scary but at least fifty percent of the day was in English. It wasn’t long before a Mexican classmate invited me to his birthday party, complete with a piñata. I was too young then to understand that a piñata holds as much in life metaphors as candy and little did I realize then that this metaphor would resurface again in my life decades later as the efforts to reform the embattled U.S. healthcare system.
Like so many things that first year in Mexico, the piñata held excitement mystery and possibility. At that first party I was an eyewitness to a mob. The instant the piñata broke open the school of piranha-like children devoured the innards so fast that I was left dejected, clutching only a little scrap given to “the gringo” by some benevolent adult.
At the next party, when it was piñata, time, I was in the mix; I dove in before the final coup de grace and caught a piece of the bat. My strategy turned upon being first one in but missing the bat, only to learn that this transferred the piñata to the one embracing almost all the candy. I was jumped, kicked, whacked, gouged, and crushed to smithereens while all those greedy hands and bodies piled on me and plied the precious treasure for my hands. Once again I emerged with tears and a few scraps.
Finally by the fourth party I’d gotten adept with the bat and with a super satisfying whack disintegrated “the Toro” to shreds. Pay dirt at last. By the time, my blindfold was off, the scrum was well underway. The school of hard knocks was one more time teaching me a lesson.
Few activities can compete with a piñata party in a child’s imagination. It offers the opportunity of unimaginable candy treasures. After years of practice and experience the master can be picked from the crowd. This child can be seen as cool, calm, and collected. They bat early, never trying to break the treasure open but enough to soften it up. Once back in the pack they make subtle repositioning moves as the batter swings in different directions blindly thrashing at the swaying and bobbing papier-mâché animal idol. At the right moment they dive into the scrum usually coming up with a lot of candy. Winners keepers losers weepers. That’s the rules.
There are many strategies at the piñata party, the imagination of greed can get the best of you when all those marbles (or candy or money) sit inside that single collective pot.
Fifty years later I cannot help but reflect that the rules and spiritual lessons gained within the piñata experience are very applicable to the US healthcare system. With thirty years of healthcare experience I remain awe struck at observing the same sets of behaviors demonstrated at children’s piñata parties.
Be you the patient, doctor, hospital, pharmaceutical company, lawyer, supplier, coder, consultant, or insurance company, each party fully play out their perfect, “what’s in it for me” expression, “Don’t worry what this is costing, we’re just attacking the piñata. Everything in the party has been fully covered. Cracking a few of heads to reach the object of my desire is just good party fun, no offense.” We have become piñatas inside of piñatas, with of course the patient metaphorically becoming the ultimate piñata, after all the party is thrown for each and every one of us willing to pay entrance to the ever increasingly expensive party.
Next week I will start with my personal experience and then move to the global great American health care healthcare piñata gala bash. Let me get the party invitations sent out and also invite you to attend the grand gala 2009 healthcare piñata party.
I’ll let you bring the pinata to my party if I can bring mine to yours.
Until next week I remain sincerely yours in primary care,
Alan Dappen, MD
September 1st, 2009 by RamonaBatesMD in Better Health Network, Opinion
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I’m going to wade right in here. I am not a fan of abortions, but neither am I of amputations. Both are sometimes necessary. To me, too often abortion opponents forget the mother. She is a life present before us. Her care should not be forgotten.
I have been listening and reading the discussions over how the abortion coverage may sink health care reform. I think it would be a shame if this one issue does sink reform.
If my understanding of the Hyde Amendment (and it’s amendments over the years) is correct the Federal Government covers the cost of abortions in cases of rape or incest or when the life of the mother is at risk. It does not cover the cost when the health of the mother is at risk:
With these bans, the federal government turns its back on women who need abortions for their health. Women with cancer, diabetes, or heart conditions, or whose pregnancies otherwise threaten their health, are denied coverage for abortions. Only if a woman would otherwise die, or if her pregnancy results from rape or incest, is an abortion covered. The bans thus put many women’s health in jeopardy.
I agree with opponents who do not wish to cover abortions for simply any reason (i.e. the timing for a pregnancy is not good, etc). Abortion should never be used for birth control. That should be done using birth control pills, condoms, abstinence, etc.
Currently, the only abortions available under Medicaid are the ones mentioned above. I think it’s a shame that distinctions can not be made to provide coverage for a woman who’s HEALTH would be negatively affected by her pregnancy. All insurance policies should do so in my opinion.
Opponents of abortion want language that would prohibit any private insurance company that accepts federal funds from offering to policyholders abortions other than those already eligible under Medicaid.
Sources
How Abortion Could Imperil Health-Care Reform by Michael Scherer; Monday, Aug. 24, 2009; Times.com
What is the Hyde Amendment? (July 21, 2004); ACLU
*This blog post was originally published at Suture for a Living*
August 30th, 2009 by DrRob in Better Health Network, Opinion
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My newest podcast is up on iTunes (go here for the web-based version). It’s the first of a two (maybe more) part series on influenza – covering flu in general. We have been seeing a significant number of cases of the flu over the past week, which is extremely unusual for this time of year. Epidemic flu goes around between November and Late April, with sporadic cases appearing at other times. What we have seen so far is not sporadic, so it probably represents pandemic flu (H1N1).
I did a poll on Facebook, asking what people thought of the H1N1 situation. The overwhelming majority responded that they felt the press and the government were hyping it way too much. This really surprised me – not that people would think that, but that a majority of people felt this was the case. It may have related to how the question was phrased or what the other choices were, but still this number betrays a lack of worry about the H1N1 virus.
This worries me.
I don’t think the fear of the H1N1 is misplaced. The normal flu kills over 30,000 people per year, and the H1N1 is expected to infect 3 times more people than the usual flu (for reasons I will go into in the next podcast). The implication of this is that even if this flu is “nothing special” it will kill over 90,000. Put in perspective, prostate cancer killed 27,000 men and breast cancer killed 41,000 women in 2008. A “normal” potency H1N1 virus could then kill more than both of these combined.
Thankfully, the cases we’ve seen so far have not been severe, but still there have been 522 deaths already from the H1N1 in the US. But in 1918, the virus mutated around this time of year and became significantly more deadly. I think those who get it now are actually probably fortunate.
The warnings about pandemic influenza are not hype. But the cynicism about the government and the press are widespread. Some of the more “unconventional” thought (read into that word generously) espouse conspiracies by the government. Here’s one example of this:
It’s man-made. It can be used as a biological weapon. It was developed as an AIDS vaccine-related organism. It was extracted from AIDS patients. It is responsible for virtually all of the symptoms which AIDS patients suffer from. The AIDS virus is at best a co-factor, and not even such a strong co-factor as to bring on all of the symptoms of AIDS. This particular organism, the micoplasma, is associated with this upper respiratory flu-like illness. And it’s also associated in its pathogenic process with a whole variety of other symptoms that mimic AIDS.
This guy is totally nuts extreme, but the theories on the Internet of this flavor abound.
Unfortunately, the religious right Obama-haters have seized on this as anything from a means to push universal health to a weapon to sterilize the US populace. I can assure you that this has nothing to do with Biblical thought and everything to do with the vulnerability of some people to fear-mongering. I even had one patient ask me what I thought about the sterilization theory. I reassured her that I had just gotten mine – although sterilization is no longer an issue for me as it has already been done with my consent. She laughed and went ahead with the vaccine.
But less extreme people still feel this is far too much hype for the severity of the disease. This scrutiny puts the CDC in a bad situation. The only thing that would vindicate their dire warnings is the exact thing they are trying to prevent: a deadly pandemic. Conversely, the more they succeed in preventing this problem, the more people will cast aspersions on them.
Take it seriously, folks. It’s like a massive storm forming in the tropics – it could be deadly and it could be a dud. Either way, we need to do whatever it takes to minimize the damage.
*This blog post was originally published at Musings of a Distractible Mind*
August 26th, 2009 by DrRob in Better Health Network, Opinion
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Something touched a nerve yesterday. I kind of lost my composure when someone tried to defend the insurance industry and responded out of emotion – perhaps putting aside some reason in the process.
I used to get mad at myself or embarrassed when this happened, but now I stand back and try to analyze my reaction. What is it that touched a nerve in me? Why did I feel so strongly? We don’t feel things without reason, and my reaction doesn’t necessarily betray weakness on my part, it shows the depths of my emotion. That passion usually comes from something – most of the time it is personal experience; and my personal experience says that insurance companies are causing my patients harm. That makes me angry.
I don’t think the people in the insurance industry are bad people. I think vilifying people is the easy way out. The people there feel like they are doing the right thing, and are no less moral than me. But I do not think the way to fix our system is through letting them do their business as usual in the name of “free market.” Defending the current system of insurance ignores some obvious problems in our system:
1. They are financially motivated to withhold services
If you hire a contractor to work on your house, how wise is it to pay them 100% in advance? You have just given them financial incentive to do as little work as possible, as it will maximize their profits to do so. The insurance industry is in such a situation; despite any good intention, they are put in a position to decide between profits and level of service. It is much better to pay more for better service, not worse; but that is what we have done with health insurance companies.
2. They have been given the ability to withhold services
If all United Health Care (for example) did was to provide insurance, they would not be vilified as they are. But since the only data available for medical care was the claims data they hold, they were put in a position to control cost. This was sensible initially, as they had both the data and the means (denying unnecessary care) of cutting cost. It’s OK that women aren’t kept in the hospital for a week after having a baby. It’s OK that I can’t prescribe expensive brand-name drugs when there is a reasonable generic alternative. There was a whole lot of fat to cut, and they did a good job cutting that fat.
The problem came when all the fat was gone and they were used to big profit-margins. Once there was not any more unnecessary care to cut, they had two ways to keep their profit-margins: increasing premiums or cutting services. They did both. Both of these have hurt my patients.
- Patients have had premiums increased or have been dropped because they were diagnosed with medical problems. I have had patients beg me “don’t put that in my record,” as they know a diagnosis of diabetes or heart disease will be disastrous. I am then caught between the pleas of my patients and the demands of honestly practicing and documenting my care.
- I do what I can to follow evidence-based standards, but there are times when people fall out of the norms. Medicine is not science, it is applied science. This means that I am trying to take an individual and somehow match them with the scientific data. Sometimes it works, but everyone is different. If something is true 90% of the time, 10% of the people will be exceptions to the rule. I have repeatedly been told by “gnomes” (people with minimal medical education who sit in front of a computer screen with a protocol for care) what “good medicine” looks like. They see things as black and white when it is just not that way. This has caused people to be unnecessarily hospitalized, it has required them to get unnecessary tests to follow their rules. There is no arguing with people in front of computers.
3. They covertly ration
Dr. Rich Fogoros (whom I recently met) has coined this phrase to explain what happens in our system. Because it doesn’t look good to deny necessary care, insurance companies (including government-run ones) resort to making things exceedingly complex. This makes it look like care is being offered, but not taken advantage of. What does this mean?
- The burden of proof is put on the provider to show the tests ordered are necessary. The assumption is that a test will be denied unless the doc can prove otherwise.
- Tests are sometimes inappropriately denied. They then can be appealed, but the appeal process is even more difficult than the initial approval process, and so some people give up. Every time someone gives up, less is paid out by the insurance company and their profits go up.
- The rules for coding and billing are so complex, that it is very easy to make mistakes. This means that an appropriate test ordered by a doctor that is not perfectly coded doesn’t get paid for. The patient gets the bill and must get the doctor to appeal the denial. This appeal process, again, is difficult.
Because of this, I have to hire staff whose sole task is to learn all of the rules of the different insurance carriers (including public ones) and then play the game properly with them so that we get as few denials as possible. I probably spend $70-80 thousand per year to deal with the frustratingly complex system we have.
————
I have health insurance. I do understand why it needs to exist, but I also see how harmful the current state can be to my patients. I get frustrated with Medicare and Medicaid as well, but that is not my point. Just because government run insurance has problems doesn’t do anything to change the problems with private insurance. The fact that you can be killed by firing squad doesn’t make the gallows any better.
The cost of care has gone up dramatically over the past 10 years while my reimbursement has dropped. Where is that extra money?
But the system is very broken right now. It needs to be fixed. Things need to be changed in both the private and public sector. When I was in DC I made the point that our ship is sinking and we are arguing about who will be the captain. The problems in our system are not simply who is writing the checks.
Honestly, I don’t really care who writes the checks. All I want is for the system to reward good care and to stop hurting my patients. Those who deny the reality of either of these problems will invariably draw my ire.
*This blog post was originally published at Musings of a Distractible Mind*
