There’s no mystery about why the July 23 execution of Joseph Wood in Arizona took so long. From the anesthesiologist’s point of view, it doesn’t seem surprising that the combination of drugs used—midazolam and hydromorphone—might take nearly two hours to cause death.
The convicted murderer didn’t receive one component of the usual mixture of drugs used in lethal injection: a muscle relaxant. The traditional cocktail includes a drug such as pancuronium or vecuronium, which paralyzes muscles and stops breathing. After anyone receives a large dose of one of these powerful muscle relaxants, it’s impossible to breathe at all. Death follows within minutes.
But for whatever reason, the Arizona authorities decided not to use a muscle-relaxant drug in Mr. Wood’s case. They used only drugs that produce sedation and depress breathing. Given enough of these medications, death will come in due time. But in the interim, the urge to breathe is a powerful and primitive reflex.
So-called “agonal” breathing, which precedes death, may go on for minutes to hours. The gasping or snoring that eyewitnesses described would be very typical. People who are unconscious after overdoses of heroin try to breathe in a similarly slow, ineffective way, before they finally stop breathing altogether or are rescued by emergency crews.
More about the drugs
Midazolam is a member of a class of drugs called benzodiazepines. The common “benzos” that many people take include Valium, Xanax, and Ativan. What these drugs have in common is that they produce relaxation and sleep. You might take a Xanax pill, for instance, to help you nap during a long flight.
In anesthesiology, we use benzodiazepines for another important reason: because they produce amnesia. There are stories of people taking a Valium to relax a little before they give an important talk, and the next day panicking because they can’t remember if they actually showed up and gave the talk.
Amnesia can be very helpful in my business. Many of my patients don’t want to remember coming into the operating room and seeing the bright lights and surgical instruments. After I inject one or two milligrams of midazolam into the IV, they’re often smiling and relaxed, and they have no memory later of coming into the operating room at all. The next thing they know, surgery is over and they’re waking up.
Continue reading “No Mystery: Arizona Execution Lengthy Due to Drug Choice”
Filed Under: OP-ED, THCB
Tagged: Agonal breathing, anesthesiology, Benzodiazepines, Clayton Locket, death penalty, Hydromorphine, Joseph Wood, Lethal injection
Jul 26, 2014
This story was co-published with NPR’s “Shots” blog.
In the name of patient privacy, a security guard at a hospital in Springfield, Missouri, threatened a mother with jail for trying to take a photograph of her own son. In the name of patient privacy , a Daytona Beach, Florida, nursing home said it couldn’t cooperate with police investigating allegations of a possible rape against one of its residents.
In the name of patient privacy, the U.S. Department of Veterans Affairs allegedly threatened or retaliated against employees who were trying to blow the whistle on agency wrongdoing.When the federal Health Insurance Portability and Accountability Act passed in 1996, its laudable provisions included preventing patients’ medical information from being shared without their consent and other important privacy assurances.But as the litany of recent examples show, HIPAA, as the law is commonly known, is open to misinterpretation – and sometimes provides cover for health institutions that are protecting their own interests, not patients’.
“Sometimes it’s really hard to tell whether people are just genuinely confused or misinformed, or whether they’re intentionally obfuscating,” said Deven McGraw, partner in the healthcare practice of Manatt, Phelps & Phillips and former director of the Health Privacy Project at the Center for Democracy & Technology.For example, McGraw said, a frequent health privacy complaint to the U.S. Department of Health and Human Services Office of Civil Rights is that health providers have denied patients access to their medical records, citing HIPAA. In fact, this is one of the law’s signature guarantees.”Often they’re told [by hospitals that] HIPAA doesn’t allow you to have your records, when the exact opposite is true,” McGraw said.
I’ve seen firsthand how HIPAA can be incorrectly invoked.
In 2005, when I was a reporter at the Los Angeles Times, I was asked to help cover a train derailment in Glendale, California, by trying to talk to injured patients at local hospitals. Some hospitals refused to help arrange any interviews, citing federal patient privacy laws. Other hospitals were far more accommodating, offering to contact patients and ask if they were willing to talk to a reporter. Some did. It seemed to me that the hospitals that cited HIPAA simply didn’t want to ask patients for permission.
Continue reading “Are Patient Privacy Laws Being Abused to Protect Medical Centers?”
Filed Under: OP-ED, THCB
Tagged: Charles Ornstein, Deven McGraw, HIPAA, Hospitals, LA Times, patient information, Privacy, VA
Jul 24, 2014
Today’s 2-1 decision by the DC Court of Appeals striking down federal premium subsidies, in at least the 27 states that opted for the feds to run their Obamacare insurance exchanges, has the potential to strike a devastating blow to the new health law.The law says that individuals can get subsidies to buy health insurance in the states that set up insurance exchanges. That appears to exclude the states that do not set up exchanges––at least the 27 states that completely opted out of Obamacare. Another nine states set up partnership exchanges with the feds and the impact on those states is not clear.The response by supporters of the law, and the IRS regulation that has enabled subsidies to be paid in the states not setting up exchanges, hinges on the argument that the language is at worst ambiguous and the Congress never intended to withhold the subsidies in the federal exchange states.
But in the DC Court ruling one of the majority judges said, “The fact is that the legislative record provides little indication one way or the other of the Congressional intent, but the statutory text does. Section 36B plainly makes subsidies only available only on Exchanges established by states.”
My own observation, having closely watched the original Obamacare Congressional debate, is that this issue never came up because about everybody believed about all of the states would establish their own exchange. I think it is fair to say about everyone also believed a few states would not establish their own exchanges. Smaller states, for example, might opt out because they just didn’t have the scale needed to make the program work. I don’t recall a single member of Congress, Republican or Democrat, who believed that if this happened those states would lose their subsidies.
Continue reading “Halbig Decision Puts Obamacare Back on the Front Burner and Will Give GOP a Massive Political Headache”
Filed Under: OP-ED, THCB
Tagged: Exchanges, Halbig, IRS, Laszewski, Premium, Subsidies, Washington
Jul 22, 2014
The answer to the doctor shortage isn’t more doctors
Yesterday, the New York Time’s Editorial Board published a piece on the shortage of physicians in the United States and what’s needed for healthcare workforce redesign.
It’s a good, concise piece about the common thinking around the gap between the needs of our growing patient population and the number of doctors available to deliver the care they need. As as an example, the article refers to a recent statement by the Association of American Medical Colleges whose models predict a shortage of 90,000 doctors in the U.S. by 2020. In Canada, the story is sometimes different where physician unemployment is growing due to inadequate infrastructure and poor workforce planning.
While I do agree that ensuring access to care is important, to think that the solution is simply more doctors comes from framing the question incorrectly.
The question shouldn’t be “how many doctors do we need for a growing population?”. Rather, the question should be “how do we care for a growing population in a cost-effective way?”
When you reframe the problem in this manner, it’s easy to see that simply churning out more doctors isn’t the answer. In fact, with the direction healthcare is heading, those numbers are likely overestimates.
The major problem with workforce planning models is that they assume healthcare delivery of the future looks very much like healthcare delivery of the present. That the future will continue to be, in many ways, very doctor-centric.
Continue reading “The Answer To the Doctor Shortage Isn’t More Doctors”
Filed Under: OP-ED, Tech, THCB
Tagged: doctor shortage
Jul 21, 2014
European health care systems are already awash in “big data.” The United States is rushing to catch up, although clumsily thanks to the need to corral a century’s worth of heterogeneity. To avoid confounding the chaos further, the United States is postponing the adoption of the ICD-10 classification system. Hence, it will be some time before American “big data” can be put to the task of defining accuracy, costs and effectiveness of individual tests and treatments with the exquisite analytics that are already being employed in Europe. From my perspective as a clinician and clinical educator, of all the many failings of the American “health care” system, the ability to massage “big data” in this fashion is least pressing. I am no Luddite – but I am cautious if not skeptical when “big data” intrudes into the patient-doctor relationship.
The driver for all this is the notion that “health care” can be brought to heel with a “systems approach.”
This was first advocated by Lucien Leape in the context of patient safety and reiterated in “To Err is Human,” the influential document published by the National Academies Press in 2000. This is an approach that borrows heavily from the work of W. Edwards Deming and later Bill Smith. Deming (1900-1993) was an engineer who earned a PhD in physics at Yale. The aftermath of World War II found him on General Douglas MacArthur’s staff offering lessons in statistical process control to Japanese business leaders. He continued to do so as a consultant for much of his later life and is considered the genius behind the Japanese industrial resurgence. The principal underlying Deming’s approach is that focusing on quality increases productivity and thereby reduces cost; focusing on cost does the opposite. Bill Smith was also an engineer who honed this approach for Motorola Corporation with a methodology he introduced in 1987. The principal of Smith’s “six sigma” approach is that all aspects of production, even output, could be reduced to quantifiable data allowing the manufacturer to have complete control of the process. Such control allows for collective effort and teamwork to achieve the quality goals. These landmark achievements in industrial engineering have been widely adopted in industry having been championed by giants such as Jack Welch of GE. No doubt they can result in improvement in the quality and profitability of myriad products from jet engines to cell phones. Every product is the same, every product well designed and built, and every product profitable.
Continue reading “Missing the Forest For the Granularity”
Filed Under: OP-ED, THCB
Tagged: Big Data, Epic, ICD-10, Lucian Leape, Quality, Six Sigma, Systems Approach
Jul 11, 2014
I recently called my primary care physician (PCP) for the first time in years to get my immunization records, and encountered a strange message saying he was not currently seeing patients. My mom had apparently encountered the same message weeks ago. “Maybe he retired,” she suggested.
I did a quick google search of my PCP’s name to find an alternate contact number, and instead found a shocking article from the local newspaper. Apparently my PCP has been indicted for falsifying tax returns and participating in an online pharmacy organization that provided prescription drugs without an in-person physician examination.
Remote Prescribing: Lucrative, Pervasive, and Very Illegal
I did a quick search online and confirmed that the practice of offering prescription drugs through a “cyber doctor” prescription, relying only on a questionnaire is indeed very illegal.
It is also very pervasive. The National Association of Boards of Pharmacy (NABP) reviewed 10,700 websites selling prescription drugs and found that 97% of them were “Not Recommended”. Of these, 88% do not require a valid prescription and 60% issue prescriptions per online consultation or questionnaire only.
What struck me was how this appeared to be a case where the market came together to produce a “triple win” for profit-seeking internet pharmacies, shady physicians (such as my own), and a subset of patients willing to pay a premium to access drugs (most commonly weight loss drugs, erectile dysfunction drugs, and commonly-abused antidepressants and painkillers).
According to one analysis, one such website offering prescriptions from its own doctors listed prices for fluoxetine (brand name Prozac) and alprazolam (brand name Xanax) that were roughly 400% to 1800% higher than prices from a more traditional Internet pharmacy not offering prescriptions. The fact that such “remote prescription” websites remain in business despite the huge price differential suggests that they are attracting patients willing to pay that premium to avoid seeing their regular doctor. And as for where that money is going—well, my doctor was alleged to have received roughly $2.5 million over six years.
Continue reading “How Telehealth May Be Promoting Fraud and Abuse”
Filed Under: OP-ED, THCB
Tagged: NABP, PCP, Prozac, Telehealth, Xanax
Jul 7, 2014
Last month the American Medical Association wrapped up its annual meeting in Chicago, where it has reached the final stages of modernizing its 167-year-old Code of Medical Ethics, last updated more than 50 years ago. The central role of ethics in medicine is reflected in the fact that, at the AMA’s first meeting in 1847, it treated the establishment of a code of ethics as one of its two principal orders of business. Much in medicine has changed since 1847, but this founding document, which most physicians and patients have never seen, still offers important insights that deserve to be reaffirmed.
Spanning 15 pages, the 1847 Code of Ethics addressed just three fundamental concerns: the duties physicians and patients owe each other, physicians’ duties to each other and the profession at large, and the reciprocal duties of the profession and the public. This structure, focused on moral duties, evinces an important feature of the authors’ view of medicine. Namely, medicine is essentially a moral enterprise, grounded in mutual responsibilities, in which patients, physicians, and the public unite to serve the interests of the suffering.
In fact, the preamble to the 1847 Code of Ethics states explicitly that medical ethics “must rest on the basis of religion and morality.” Ethics is not merely a matter of consensus, and the boundaries of professional ethics are not outlined by what a particular patient or physician might happen to agree to. The fact that an employment contract or informed consent form has been signed is insufficient. Professional ethics requires loyalty to ideals that transcend any particular person or group of people. Like taking an oath, it rests on the presumption that professionals serve something higher than themselves.
The preamble to the 1847 Code also acknowledges that, in framing their code of ethics, the authors have “the inestimable advantage of deducing its rules from the conduct of many eminent physicians who have adorned the profession by their learning and piety.” It explicitly holds up the example of the “Father of Medicine,” Hippocrates, by whose conduct and writing the duties of a physician “have never been more beautifully exemplified.” The Code’s authors emphasize that these ideals are not only aspirational but achievable, having been exemplified by “many.”
The first chapter stresses the physician’s duty to answer the call of the sick, which is all the more deep and enduring “because there is no tribunal other than the physician’s own conscience to adjudge penalties for neglect.” In other words, the Code entrusts the ethics of medical practice not to lawmakers, the courts, or hospital executives, but to the conscience of each physician. We can detect and punish violators, the Code’s authors are saying, but it is impossible to legislate goodness, whose flame must ultimately burn nowhere else but in the hearts of professionals themselves.
The first chapter also states explicitly that physicians should never abandon a patient because a case is deemed incurable. In an era obsessed with improving measurable outcomes such as length of stay and cost of care, many of today’s healthcare leaders need a reminder that a physician’s contribution cannot be fully assayed in terms of cures. Incurable does not mean hopeless, and it is always possible to care well even for those who are dying. The authors state that physicians should strive to be “ministers of hope and comfort to the sick.”
Continue reading “Should Medical Ethics Be Modernized?”
Filed Under: OP-ED, THCB
Tagged: 1847 Code of Ethics, American Medical Association
Jul 7, 2014
The debate over the price of specialty drugs is intensifying and could well be the next major healthcare issue to dominate the national, even international, agenda. In a nutshell, how will society pay for breakthrough scientific innovation?
Specialty drugs, complex therapies used to treat severe illnesses such as cancer, multiple sclerosis and Hepatitis C, are coming in with price tags that have purchasers sounding alarm bells. At $1,000 per pill, the newest Hep C medication runs about $86,000 for a course of treatment. Two major insurers have publicly cited the price of this single new drug as contributing to next year’s rise in premiums.
In fact, analysis by our team at PwC’s Health Research Institute shows that this one new therapy will impact overall U.S. health costs by .5% this year and .2% next year. Considering the nation’s total healthcare budget is $2.8 trillion, that is a remarkable budgetary impact for one product.
But the story doesn’t end there. Drug costs represent just 15% of total health spending, compared to nearly one-third spent on inpatient care. Short-term budget spikes could become long-term savers from both a cost and health standpoint. For the most severe patients, the price of Hep C medication – that is nearly 90% effective – is three to six times less than treating a lifetime of cirrhosis ($270,000) or providing a liver transplant ($580,000.) Patients essentially “cured” of Hepatitis C can go on to have productive, long lives.
Continue reading “The Coming Debate Over Specialty Drugs”
Filed Under: OP-ED, THCB
Tagged: Hepatitis C, Liver transplants, PwC Health Research Institute, specialty drugs
Jul 2, 2014
In July, CDC will roll out a new way every hospital in the country can track and control drug resistant bacteria.CDC already operates the National Healthcare Safety Network (NHSN), with more than 12,000 health care facilities participating. Now we are implementing a breakthrough program that will take control of drug resistance to the next level – the Antibiotic Use and Resistance (AUR) reporting module. The module is fully automated, capturing antibiotic prescriptions and drug susceptibility test results electronically.
With this module, we’ll be able to create the first antibiotic prescribing index. This index will help benchmark antibiotic use across health care facilities for the first time, allowing facilities to compare their data with similar facilities. It will help facilities and local and state health departments as well as CDC to identify hot spots within a city or a region.
We’ll be able to answer the questions: Which facilities are prescribing more antibiotics? How many types of resistant bacteria and fungi are they seeing? Do prescribing practices predict the number of resistant infections and outbreaks a facility will face? Ultimately with this information, we’ll be able to both improve prescribing practices and identify and stop outbreaks in a way we have never done before.
This will help deploy supportive and evidence-based interventions at each facility as well as at regional levels to help stop spread among various facilities.
The need for a comprehensive system to collect local, regional, and national data on antibiotic resistance is more critical than ever. The system now exists, and we need quick and widespread uptake.
Rapid and full implementation of this system is supported through the proposed increase of $14 million contained in CDC’s 2015 budget request to Congress.
With the requested funding increase in future years, CDC would look to develop web-based tools and provider apps so physicians will gain access to facility- and community-specific data via NHSN on the most effective empiric antibiotic for the patient in front of them. For example, a physician in a burn unit treating a patient with a possible staph infection will know what antibiotics that particular microbe is likely susceptible TO and which ones are likely to be most effective.
Instead of broad-spectrum antibiotics being the default choice, as is often the case now, doctors will see recommendations for targeted narrow-spectrum antibiotics that are more likely to be effective and less likely to lead to potentially deadly infections such as C. difficile.
Continue reading “Where Are The Hot Spots For Antibiotic Resistance?”
Filed Under: OP-ED, Tech, THCB
Tagged: Antibiotic resistance, Antibiotic Use and Resistance Module, antibiotics, CDC, National Healthcare Safety Network
Jun 24, 2014
Throughout history, physicians have treated patients for conditions that generations of their professional successors later deemed figments of their (the physicians’) imaginations. The list is long, but in just the last 100 years, it has included such disorders as female hysteria, homosexuality, moral insanity, neurasthenia, and vapors, among many others. The consequences of such diagnoses were not trivial, and in some cases, patients were stigmatized, ostracized, subjected involuntarily to a variety of noxious treatments, and even incarcerated because of them. Yet we now believe that each of these conditions was a fiction, and they are absent from today’s textbooks.
Something similar may be afoot in the profession of medicine today. The affliction is known as conflict of interest, and medicine is thought to be suffering a pandemic of it. In fact, its proponents argue that no physician is safe. Its symptoms among researchers are a tendency to conduct investigations and publish results that are biased, and among clinicians, to prescribe tests and therapies that their patients do not really need. The underlying cause of the condition is thought to be financial inducements from industry, which lead these gullible physicians and scientists to betray their personal and professional integrity without even knowing it.
For example, industry funding of research might lead physician-scientists to bias their results in ways that line the pockets of pharmaceutical companies and medical device manufacturers. Likewise, the presence of industry representatives in offices and hospitals might lead physicians to write inappropriate prescriptions for industry-promoted drugs. If physicians are presented with a gift such as a pen, a notepad, a book, or a free meal from an industry representative, they might be more inclined to use that company’s products in their practice. The implication? Physicians are insufficiently self-aware and trustworthy to put patients’ interests above their own.
Continue reading “How Conflict of Interest Became a Health Care Urban Legend”
Filed Under: OP-ED, Physicians, THCB
Tagged: Conflict of interest, Physicians, professionalism, Urban Legends
Jun 19, 2014