Blog Page 4

Thanks to the AHCA We Could Now See Cervical Cancer Rates Increase

2

In 2014 I took my first trip to Kenya. After my plane landed in Nairobi I rode for 10 hours with my medical colleagues to Bungoma, a town on the western edge of the country. We set up our clinic in the local hospital and then spent the week training local healthcare providers on a technique called ‘Visual Inspection with Acetic Acid (VIA)’. This is an inexpensive method to screen for cervical cancer and pre-cancer in low resource settings using vinegar. As a part of the training we screened 189 women for cervical cancer in that week.

The Papaniculou (pap) smear was revolutionary in cervical cancer prevention. The incidence of cervical cancer in the United States has decreased from 14.8 cases per 100,000 women in 1975 to only 6.5 cases per 100,000 women in 2012.

However, despite this relative ease of screening for cervical cancer it is still a health crisis in less developed countries. Worldwide, approximately 500,000 new cases of cervical cancer and 274,000 deaths are attributable to cervical cancer yearly, making cervical cancer the second most common cause of death from cancer in women.

A Health Plan CEO Daydreams

5

Jim was at his desk, looking weary.

The last few weeks had been brutal.  Despite working twelve-hour days, he felt that he had little to show for it.  His annual board meeting was to take place the next day, and he expected it to be tense.

With a replacement bill for the ACA about to be voted on, and with Trump in the White House, the situation seemed particularly precarious.  The board members had asked him to present a contingency plan, in case things in DC didn’t go well.

As CEO of a major health insurance company, Jim was well aware that business as usual had become unsustainable in his line of work.  No matter what insurers had tried to do in the last few years—imposing onerous rules, setting high deductibles, pushing for government subsidies—prices had been going up and up.

Premiums, of course, had had to do the same but, evidently, the limit had now been reached.  The horror stories being told at town hall meetings across the country were all too real.  People were fed up, and politicians were feeling the heat.

Something needed to be done to change course, but what?  He did not have any good plan to propose to the board.

Health Reform Must End the Harms of Prior Authorizations

4

As the White House continues to push for a revised Republican proposal to replace the Affordable Care Act (ACA), one thing is for certain, many of the sickest Americans will continue to suffer as they are denied medications and other treatments under current health insurance strategies to save costs.

Both the ACA, and the recently proposed MacArthur Amendment, do not address a well-established practice of health insurers’ use of restrictive prior authorization requirements to deny or delay coverage of medications and treatments to seriously ill patients. In my own practice caring for cancer patients and those with terminal conditions, I have witnessed the additional suffering caused by denying these patients timely access to medications for pain.

A prior authorization is essentially a check run by insurance companies or other third party payers before approving certain medications, treatments, or procedures for an individual patient. Insurance companies justify this practice as a means to save costs to consumers by preventing unnecessary procedures from being covered, or requiring generic drugs to be used instead of brand-name, more expensive alternatives.

How America Dropped the Ball on Sports Concussions

4

As GOP lawmakers grapple with the “replace” aspect of Obamacare and seek to overhaul the subject “nobody knew could be so complicated,” we must remember that one of the best ways to reduce spiraling healthcare costs is to improve health through preventive measures.

For instance, increased participation in youth sports would help control rising obesity and sedentary rates which are responsible for 21% of annual medical spending – a staggering $190.2 billion a year. Inactivity among youth spiked from 20% in 2014 to 37.1% in 2015. But while the NIH identifies preventing weight gain in childhood as critical to warding off lifelong obesity outcomes and playing sports as one of the strongest weapons against teen obesity, participation rates have declined nearly 10% since 2009. A number of factors have been attributed to this trend, but with the biggest losses in contact sports like football and wrestling, it’s impossible to ignore the long-standing elephant in the stadium – concussions.

Current polls show 94% of U.S. adults believe sport concussions constitute a public health concern and a full 100% of parents are affected by them. But do the risks of playing contact sports really outweigh their myriad physical, mental, and social benefits? After decades of research, why do we still not know what to do about concussions?

Eric Lindros, who retired from the NHL after suffering 6 concussions and donated millions to the cause, hit the nail on the head in lamenting the lack of tangible results and guidance from concussion research: “It seems like there are so many groups trying to do the right thing, but our voice would be stronger through consolidation. Are we sharing all the information? Let’s get people working together.”

Lindros’ frustrations are best illustrated by disagreement about what a concussion even is. Google defines it as “temporary unconsciousness caused by a blow to the head.” But only a small minority of medical “consensus statements” (of which there are more than 42) even require a loss of consciousness and most sources say indirect impacts are also sufficient to cause concussion. These differences aren’t just academic – accounting for sport concussions that did not involve loss of consciousness made the prevailing incidence rate jump from 300,000 to 1.8 – 3.6 million annually. Failure to agree on how to define the problem has created a snowball effect, contributing to inconsistent diagnostic standards and unreliable incidence and prevalence data that cannot be aggregated or compared.

Building Boats and EHRS

4

Imagine that you want a boat. You tell someone to build or buy you a boat, and tell them to send you a bill. What would you get? A kayak? A windsurfer? A boat for waterskiing? A sailboat. A party boat? A cruise ship? A submarine? A battleship or destroyer? You probably would not get what you want. Very likely you would end up with something expensive – that you cannot use.

The Ketamine Papers: Science, Therapy & Transformation

6


The Ketamine Papers serves as an essential window into the rapidly accelerating application of the anesthetic cum party drug ketamine to individuals with disorders such as treatment-resistant depression and post-traumatic stress disorder (PTSD). In addition, the book’s release coincides with other psychedelics, MDMA (aka ‘Ecstasy’) and psilocybin, being cleared for late-phase clinical trials as therapeutic adjuncts for the treatment and – dare we say – cure of those and related disorders, a process that will still take some years. Given what seems to be an increasing explosion of interest in the use of psychedelics for everything from therapy to micro-dosing of LSD to fuel creativity, The Ketamine Papers offers a range of views into how the psychiatric and psychotherapeutic communities are putting to use what amounts, for now, as the only legal psychedelic drug left standing, and for a group of people who very much struggle and suffer, at a significant cost to themselves, their relationships, and society.

The recurrent leitmotif of The Ketamine Papers is that of stubbornly lingering psychological illness – with feelings and behaviors ranging from sadness and stuckness to suicidality – that doesn’t just happen. It is often the function of trauma, childhood and otherwise, and lack of attachment not offset by a resilience that some develop and many do not. Those statements won’t be surprising to anyone who has read the works of psychiatrists and psychologists who have rooted depression – by far the most common form of mental illness – in unresolved childhood conflicts.

The Doctor Will Connect With You Now

4

One of my advisors has a great perspective on healthcare delivery from the large system perspective.  He served as the chief of staff to our last CEO.  Recently, he posed an incisive question to me.:

“Joe, when are we going to take all of these digital health concepts from the 30,000 foot level and get them into that 10 minute window that the doctor has with the patient?”  It is not hyperbole to say that this put the last 20+ years of my career in a whole different perspective.

I remember in the early 1990s, when it seemed we were just getting used to a new tool called voicemail.  Fax machines had become popular in the late 1980s, and we’d all had answering machines that tape recorded messages, but voicemail seemed like a brand new concept with the potential to be a very robust messaging channel.  It seemed like we were just getting used to voicemail when we got another new channel for communication–email.  All the talk in the executive suite was about how we were being inundated with multiple communications channels which, for a while, were overwhelming.

I can’t recall exactly when things changed, but I have to ask: when was the last time you got a meaningful fax?  How about voicemail?  My children chide me, saying nobody uses voicemail any more.  With caller ID, you can quickly decide if you wish to return the call.  Our communications channels have narrowed considerably in the past 20 years, to voice and asynchronous text-based messaging.

Nature vs Nurture

4

My wife chooses sides in the nature-versus-nurture war expeditiously. When our children are polite, she credits her nurture. When they’re rowdy, she blames my genes. But the nature-nurture war won’t be resolved anytime soon.

The gene played a significant role in the great Indian epic, the Mahabharata. Karna, abandoned by his mother, Kunti, and raised by a charioteer, was taught warfare by Parashurama, a gifted teacher with a fiery temperament, who despised warriors and only taught Brahmins.

One day, Parashurama was asleep with his head on Karna’s lap. Karna was bitten by a scorpion but did not move, because he did not want to disturb his guru’s nap. Parashurama, who believed that Karna was a Brahmin, seeing Karna’s blood on the ground realized that he had withstood pain which only a warrior could abide. Parashurama cursed Karna that he would forget his knowledge of warfare when he most needed it. Karna later fought for the Kauravas in the Battle of Kurukshetra. Parashurama’s malediction helped Arjuna beat Karna, which sealed the victory for the Pandavas. Neither Karna nor Parashurama knew about the double helix. The gene is an abstraction which has stood the test of time.

Would Repealing the ACA Violate International Law?

2

Barely one month after a stinging and stunning legislative defeat, President Donald Trump has committed to revising the AHCA and potentially resubmitting it for Congressional approval.

In addition to Democrats and widespread popular opinion against ACA repeal, the AHCA may face another obstacle – international law.

This week the Washington Post’s Dana Milbank reported that the United Nations Office of the High Commission on Human Rights forwarded a four-page letter to the Acting Secretary of State, Thomas A. Shannon, to express the Commission’s “serious concern” that the US was in danger of violating its obligations under international law if the U.S. ratified legislation repealing the ACA.

The letter authored by Dainius Puras, a Lithuanian with the somewhat remarkable title of UN Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health, argues that repealing core elements of the ACA would negatively impact almost 30 million Americans’ right to the “highest attainable standards of physical and mental health”, particularly those in moderate and low income brackets and those suffering from poverty or social exclusion.

Can Interactive Group Therapy Boost Productivity in Medicine?

0

Imagine attending private lectures and taking all your college exams in your professors’ offices individually, one-on-one. Your instructors lecture you, then pepper you with questions, grading your answers and recording your scores. This is not unlike traditional physician visits. Contrast this to attending classroom lectures and taking online multiple choice exams where a computer algorithm or Scantron tallies your answers and calculates your grade. Classroom instruction with standardized testing is much more efficient that private tutoring. Hundreds of students can learn and take their online exams simultaneously. What if medical productivity could be similarly improved?

Inefficient Physician Communication. When you visit your doctor you are engaging in what’s known as synchronous communication. You queue up in a waiting room and later both you and your doctor meet one-on-one in an exam room (at the same time). You may spend five minutes talking to a nurse and then 10 minutes talking to a doctor. A survey found with waiting and travel time, the whole process takes patients about three hours, on average. Furthermore, many doctors see only about 20 to 25 patients a day. The amount of information conveyed during an office visit is limited — as is the amount of information patients retain. Doctors also must take notes and update medical records during the exam. Fiddling with electronic health records further reduces the amount of useful information exchanged during a 10-minute encounter while your doctor hunts for pull-down menus. The way medicine is practiced is inherently labor intensive, not to mention inconvenient for patients.

Synchronous telemedicine is where you call your doctor or he/she calls back and you talk one-on-one. That may be a little more convenient for patients, but it’s still labor intensive. Asynchronous telemedicine is like email (or snail mail for that matter). You email your doctor or call your doctor and leave a message. Your doctor replies via email or by leaving voicemail. Asynchronous communication doesn’t require both parties to be present at the same time to communicate, but the information flow back and forth can be slow and inhibited compared to talking.