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What About Single-Payer?

Nov 1, 2018

By James Burdick, MD

President Barack Obama’s vision for health-care reform could have resulted in a much better law had it not been for congressional decrees at the start that a single-payer system was “off the table.” But guess what has appeared back on the table during the thoughtful pondering of the problem by the Supreme Court?

Justice Anthony Kennedy said on March 27: “Let’s assume that it could use the tax power to raise revenue and to just have a national health service, single payer. How does that factor into our analysis? In one sense, it can be argued that this is what the government is doing. It ought to be honest about the power that it’s using and use the correct power.”

As a doctor viewing the Supreme Court drama unfolding over the Affordable Care Act, I have high hopes that patients will emerge with much more access to the wonders that modern medicine can provide. Being able to treat and perhaps cure patients is essential to the freedoms and entitlements protected by the Constitution and its Bill of Rights. But the constitutional question has been framed as one of interstate commerce — not rights.

Commercial interests dominated during the formulation of the Affordable Care Act. An average of eight lobbyists were at work for each member of Congress, and the insurance companies were delighted when they saw the initial draft.

Patients may get sick and need care without adequate insurance. Doctors have always known this, but the conundrum is now occupying our country’s best legal minds. That and other failures of our insurance-based system of coverage for health care have been highlighted. And the logic is overwhelming: We need to just get on with providing affordable, quality health care coverage for everyone, like every other developed country.

It is easy for the naysayers to prey on fears that a national system must cost too much, must allow people to get too much health care at others’ expense, and must subject patients and doctors to rationing and government interference. But none of this is necessarily so.

If patients understand that their doctors are practicing high-quality medicine when they employ just the right care for a health problem — not less but also not more — we are on the way to solving the problem. Excess care is harmful as well as expensive. The insurance companies profit because they force patients to make unhealthy decisions based on finances, not medical need.

Fear of higher taxes comes from extrapolation of present spending patterns. But the things that would make universal coverage cost too much are bad for patients. In overcoming them, we can save $500 billion by avoiding unnecessary care, more than $150 billion in administrative costs, and billions more in avoidable, excess costs for the uninsured.

Doctors are faced with decreasing incomes and at the same time are beset by a huge proliferation in Medicare billing codes due to fee-for-service payments, and by increasing administrative quality requirements and insurance restrictions. Given the necessary legal responsibility and authority, doctors (not insurers) can define necessary care, which will cut excessive spending and end the fear of unfair, unrestrained use of health care. Doctors tend to resist this proposed responsibility, viewing it as the government again telling them what to do — but many are ready for change. And this would be different: It could work according to rules that would be set by doctors for doctors, doing what federal and insurance company administrators cannot do.

In short: We doctors, along with our patients, need to take over the decision-making and control harmful and unnecessarily expensive practices. Dr. Toby Cosgrove, president of the Cleveland Clinic, recently noted that “health-care overhaul is happening, regardless of what the Supreme Court decides,” with improvements that doctors are already achieving.

The savings from having everyone automatically covered will support better professional incomes. Patients will be safer and healthier, and the deficit will no longer be held hostage to increasing health care costs.

Good sense about what the Constitution means may carry the legal day. But even if the Affordable Care Act is struck down, we must move forward with the intent of the law: to make the purpose of medical coverage to create good health.

Dr. James Burdick, a professor of surgery at the Johns Hopkins University School of Medicine, had a career as a transplant surgeon and served in the Department of Health and Human Services as director of the Division of Transplantation. He is writing a book detailing his doctors’ plan for health reform. His email is jburdic1@jhmi.edu.

Roulette

Nov 1, 2018

By Rob Lamberts, MD

“I want you to get me a new doctor,” she told me, a bit of disgust coming out in the sharp tone in her voice.

“What happened?” I asked.

“He asked me if I was nauseated, and I told him no, I was just vomiting. Then he asked if I was feeling pain in my stomach, and again I told him no, it was just vomiting. He then told his nurse to write down nausea and abdominal pain. When I objected, he just gave me a bad expression and walked out of the room.”

I tried to come up with a plausible explanation for his action, but there was none. ”I’m sorry,” I said. ”There are a lot of people who come back from him feeling really happy and listened-to. It’s obvious that you saw none of that from him.”

“I asked his nurses if he aways acted this way,” she continued, “and they just shrugged and told me that he sometimes did.”

“I’m happy to send you to a different doctor,” I said, shaking my head.

I hate it when this happens.

I send people to specialists for two main reasons:

I am not qualified to offer the treatment or procedures the specialist can give.
The specialist has far more experience with the problem, and so can offer better care.

What Makes Health Care Different

Nov 1, 2018

By Donna Dubinsky

As best as I can tell, the arguments at the Supreme Court did not touch on a critical part of the discussion about government’s role in health care: the broken market for private insurance. And I think I know why.

A key assumption underlying the arguments, questions and answers was that all uninsured people are uninsured by choice. Sure, some very ill people with preexisting conditions do not qualify. But the implication was clear: Most uninsured people either do not want to pay for insurance or cannot afford it. Justice Samuel Alito said, “You can get health insurance.” Justice Ruth Bader Ginsburg made the point that people who don’t participate are making it more expensive for others, that their “free choice” affects others. The “free rider” problem is thoroughly examined.

It was as if the court forgot that the private insurance market does not function as a normal market. If you are not employed and you want to purchase insurance in the private market, you cannot unilaterally decide to do so. An insurer has to accept you as a customer. And quite often, they don’t. Insurers prefer group plans, with lots of people enrolled to spread the risk. Can you blame them? The individual consumer is a lot of work, is a higher risk and produces relatively little revenue.

States’ Revenue Rising, Spending Not So Much

Nov 1, 2018

By Merrill Goozner

Call it the Scott Walkering of America.

Even though tax revenues are finally rising faster than expenses, governors across the nation are recommending more austerity in the budgets they’re presenting to state legislatures this year, the latest survey from the National Governors Association shows.

For the fiscal year beginning July 1, governors are recommending a 2.2 percent increase to $683 billion in general revenue fund spending. That’s down from the 3.3 percent increase in state spending in 2012. Revenue, meanwhile, is projected to rise four percent during the coming fiscal year.

“The public sector has even more uncertainty at this time than the private sector,” said Dan Crippen, executive director of the NGA and former head of the Congressional Budget Office. Citing the looming Supreme Court decision on health care reform, the uncertain levels of federal aid from the “fiscal cliff” negotiations, and talk of tax reform that could cut tax expenditures that benefit state and local governments, “it’s pretty hard for states to plan,” he said.

The Nursing Workforce of 2020: Well Trained, Well Paid, and — Actually, Who the Hell Knows

Nov 1, 2018

By David Glenn

This morning’s wretched jobs report tells a now-familiar tale: Employment has risen nicely in health care (a net gain of more than 340,000 jobs between May 2011 and May 2012). But almost every other sector has been flat or worse.

You might think that would mean that new-graduate nurses are having an easy time finding work. That’s still true in rural areas — but elsewhere, no.

In many U.S. cities, especially on the west coast, there’s real evidence of a nursing glut. The most recent survey conducted by the National Student Nurses’ Association found that more than 30 percent of recent graduates had failed to find jobs.

How is that possible?

While demand for nurses has been rising, it actually hasn’t risen as fast as most scholars had projected. Meanwhile, the supply of nurses has spiked unexpectedly, at both ends of the age scale: Older nurses have delayed retirement, often because the recession has thrown their spouses out of work. And people in their early twenties are earning nursing degrees at a rate not seen in decades. We’re now in the sixth year in which health-care employment has far outshone every other sector, and college students have read those tea leaves.

So what will happen next? Here are crude sketches of two possible futures:

I. THE NURSING SHORTAGE OF 2020

(This scenario draws from a talk that Vanderbilt University’s Peter Buerhaus gave two weeks ago at the U. of Maryland School of Nursing. Buerhaus still sees a shortage coming, though a less severe one than the shortage that he and two colleagues had predicted in a widely-cited 2000 paper.)

In June 2012, the Supreme Court upholds the Affordable Care Act, and Republicans never manage to do much to weaken the law. Tens of millions of Americans gain access to insurance, and the demand for nurses rises in tandem.
Some time around 2014, the general labor market finally recovers. There’s less desperation in the air. Sixty-year-old nurses are more likely to retire, and twenty-year-old college students who aren’t actually that interested in nursing go back to majoring in anthropology or accounting or whatever, because they’re reasonably sure they’ll find jobs.
The millions of soon-to-retire Baby Boomers utilize Medicare at rates similar to previous cohorts of 70-year-olds.
Changes in health care delivery mean that nurses and nurse practitioners are heavily deployed to provide primary care and to coordinate patients’ services.

II. THE NURSING GLUT OF 2020

In June, the Supreme Court strikes down the ACA’s insurance mandate. Mitt Romney wins the 2012 election and pushes his health proposals through Congress. In this scenario, at least 45 million fewer people have health insurance than would have been the case with an intact ACA.
The EU zone goes to hell, and the ensuing financial crisis means that the U.S. labor market stays miserable for years. College students continue to pour into health care fields, because that’s the one sector with better-than-zero growth.
The millions of soon-to-retire Baby Boomers utilize Medicare at significantly lower rates than previous cohorts of 70-year-olds. (Unlike the other items on this list, this one is good news.)
Changes in health care delivery don’t lead to a relative increase in the deployment of nurses and nurse practitioners. Accountable Care Organizations use social workers and other non-nurses to coordinate patients’ care across providers.

What will actually happen? Probably something in between, of course. (Or maybe the Yellowstone volcano will erupt and this will all be moot.)

We had better hope that it is something close to halfway in between. Both shortages and gluts are bad for patients and bad for the nursing profession. Nursing shortages, because patients are even more likely than usual to face understaffed units and overstretched nurses. Nursing gluts, because nurses are so afraid of unemployment that they don’t speak up about problems on their units.

David Glenn is a student at the University of Maryland School of Nursing and author of the blog, Notes on Nursing, where this post originally appeared.

Separating Professional and Hospital Records

Nov 1, 2018

By John Halamka, MD

As Patient Centered Medical Homes and Accountable Care Organizations form, the lines between professional and hospital practice become increasingly murky.

CMS has long required that hospital and professional records be separable, so that in the case of audits or subpoenas, it is clear who recorded what.

Today, the BIDMC ACO continues to expand into the community, adding owned hospitals, affiliated hospitals, owned practices, and affiliated practices.

Our strategy to date has been to use our home-built inpatient and ambulatory systems at the academic medical center, Meditech in the community hospitals, and eClinicalWorks in private ambulatory practices which are part of our ACO.

We share data among these applications via private and public HIE transactions – viewing, pushing, and pulling.

The challenge with emerging ACOs is that professionals are likely to work in a variety of locations, each of which may have different IT systems and each of which serves as a separate steward of the medical record from a CMS point of view.

Our clinicians are asking the interesting question – can I use a single EHR for all patients I see regardless of the location I see them?

Our legal experts are studying this question.

An Open Letter To Governor Mary Fallin

Nov 1, 2018

By John Schumann, MD

On November 19, the Governor of Oklahoma announced her intention NOT to participate in either a state electronic health insurance exchange or to accept Federal Medicaid dollars to provide coverage to 150,000 Oklahomans out of the 600,000 that currently have no health insurance.

You can read about the decision in brief, with cogent analysis, here.

Below is the text of a letter I faxed to her office:

Dear Governor Fallin:

I am extremely disappointed with the decision declining Oklahoma’s participation in the expansion of Medicaid under ObamaCare.

As a practicing physician and medical educator, I see the impact of ‘uninsurance’ on low income, chronically ill Oklahomans every day. Options for these folks are few. Since they aren’t moneyed, and struggle to get by in every sense, they aren’t well-represented at the ballot box.

The decision not to participate in a broadening of the safety net is morally, financially, and medically wrong.

How to Practice Medicine in a World We Can Never Truly Understand

Nov 1, 2018

By Kent Bottles, MD

Central to the problem of how best to live in a world that we cannot understand is how to regard:

“The Extended Disorder Family (or Cluster): (i) uncertainty, (ii) variability, (iii) imperfect, incomplete knowledge, (iv) chance, (v) chaos, (vi) volatility, (vii) disorder, (viii) entropy, (ix) time, (x) the unknown, (xi) randomness, (xii) turmoil, (xiii) stressor, (xiv) error, (xv) dispersion of outcomes, (xvi) unknowledge.” (Nassim Nicholas Taleb, Antifragile, London: Allen Lane, 2012)

To this impressive list, I would add seventeenth and eighteenth items: failure and death. All of these characteristics scare and frighten most of us, and so we do our best to avoid them.

Despite the popularity of self-help books emphasizing the pursuit of happiness, a vocal minority has advocated embracing all of the above negative items in order to live fully and successfully.

Eric G. Wilson perhaps provides the best overview of this minority report when he observes that

“To desire only happiness in a world undoubtedly tragic is to become inauthentic, to settle for unrealistic abstractions that ignore concrete situations.”

And

“Our passion for felicity hints at an ominous hatred for all that grows and thrives and then dies.” (Eric G. Wilson, Against Happiness, New York: Sarah Crichton Books, 2008)

To be alive and to realize that you are going to die means being insecure and vulnerable. According to Martha Nussbaum one should embrace this uncertainty.

Modeling readmissions

Oct 1, 2018

By PAUL LEVY

The current intent to judge hospital performance and modify hospital payments based on relative rates of readmissions is not wise. Contrary to President Obama’s characterization that readmitting a patient to the hospital is equivalent to bringing a car back to the mechanic after a repair, rates of readmissions are based on a number of factors, of which a significant portion are services not provided by the hospitals and environmental conditions not controlled by the hospitals.

But let’s put my objections aside and determine how we would model an “appropriate” rate of readmissions. Well, a new article in JAMA* explores existing models, noting that robust models are needed “to identify which patients would benefit most from care transition interventions, as well as to risk-adjust readmission rates for the purposes of hospital comparison.” The article concludes that the capability for doing these things does not yet exist.

In “Risk Prediction Models for Hospital Readmission,” the authors state as their objective: “To summarize validated readmission risk prediction models, describe their performance, and assess suitability for clinical or administrative use.” Their conclusion, after reviewing two dozen such models, was that “Most current readmission risk prediction models that were designed for either comparative or clinical purposes perform poorly.”

The Journey We Take Together

Oct 1, 2018

By Susan Prisant

Yesterday it became real. I was choking just listening to an hour of horrifying instructions over the phone. You want to scream out: “Stop. No. I’ve changed my mind.”

But how can I? My husband will die.

The heart transplant coordinator is telling us every unpleasant detail to come, now that he has been formally added to the National Register for a double transplant. Things that you really did not want to know about.

There will be a comatose donor, nearly brain dead, and a family in agony. No goody-byes. No more life to share with them.

How will we face stealing a life that is no more, so my husband may live? Maybe.

While our minds can’t help but wander to these ethical, life-and-death issues for a split second, the heart coordinator continues on through her list. The phone will likely ring in the middle of the night, she says, waking us from a deep sleep and beginning the final phase of this latest medical odyssey. Frightened for our lives together, there’s not time to think. We absolutely must get to the hospital within four hours.

We’ve never been big believers in telephones. We’re notorious for just letting calls go to voicemail. Our argument was unassailable―we never ever missed an offer of a million dollars, an authentic call from Elvis or a Presidential appointment because we didn’t pick up the phone.

But not anymore. If you miss one call for a donor that matches, that could be the ballgame. So we’ve now got to be packed and ready. And jump to answer every call.

Now she’s saying “so the first surgery will last ten to fourteen hours.” (10 to 14 hours??) And I’m immediately thinking: Oh my God…what will I do, waiting to hear?

But she’s still talking. When the surgery’s over, she says, Mrs. Prisant you will see your husband connected to ventilators, monitors and more.

I’ve seen all this before with Sandy―twice now, but this time I will have to wait all alone. There are no more lifelong doctor friends around and no family. So there’ll be no one putting their arms around me; no one offering kisses and hugs.

And then, within 36 hours, the next agony will begin―the second surgery. The kidney transplant. That should take about nine hours more.

The coordinator is still reading all the rules and instructions. Not cold, but very business-like. Is she slightly detached? After all there are dozens of candidates who get this far and need to know these rules even though some will never get that transplant.

And every few minutes I can’t listen anymore. We’ve lived with this illness for over four decades, but none of it felt as daunting as this―after eight months of evaluation, we’re now facing hospital testing and blood draws almost every other day for weeks or maybe months after surgery.

This phone call is now becoming suffocating. Our throats are dry as we listen and grunt acknowledgment of each instruction. And then, “Mrs. Prisant you have to get your own accommodations for the two weeks or more Mr. Prisant will be in hospital. And then three days a week he will have to come back for checkups. You will be responsible for room, board, meals parking, etc. (She forgot about the cost of kenneling the dogs and other incidentals.) You stop listening to her for a second as your internal calculator starts throwing up big numbers. Very big numbers.

Having been through these near-death experiences before, you might think I wouldn’t find this overwhelming. But it’s almost a year now since Sandy has been so sick. And all those months since we started the grueling transplant evaluation.

It tells you all you need to know about saga to learn that on the very night, December 28, we got good news: my husband formally went on the National Transplant Register. And bad news: he was ordered back into hospital for kidney failure problems. Hope and heartache. Hand in hand.

And that left me in a hotel room nearby. The next morning this very charming lady in the hotel café asked if she could share my table. Her husband was also in the hospital. It’s easier to talk with a stranger when they’re sharing similar pain. But Karen’s situation was different. Her husband had already been on life support and just died. Our pain was one. We held each other, no longer strangers. Two women sharing a moment of peace.

And then Karen stopped her story in mid-stream and made an astonishing offer. She learned slightly forward and said to me: “Can I offer you my husband’s kidney?”

Susan Prisant’s husband is awaiting a kidney and heart transplant after a lifelong struggle with a congenital kidney ailment. The both blog about their experiences at My Story Lives.