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Category: OP-ED

On Teaching Hospitals and Conflict of Interest and Other Politically Charged Topics

How much does it matter which hospital you go to? Of course, it matters a lot – hospitals vary enormously on quality of care, and choosing the right hospital can mean the difference between life and death. The problem is that it’s hard for most people to know how to choose. Useful data on patient outcomes remain hard to find, and even though Medicare provides data on patient mortality for select conditions on their Hospital Compare website, those mortality rates are calculated and reported in ways that make nearly every hospital look average.

Some people select to receive their care at teaching hospitals. Studies in the 1990s and early 2000s found that teaching hospitals performed better, but there was also evidence that they were more expensive. As “quality” metrics exploded, teaching hospitals often found themselves on the wrong end of the performance stick with more hospital-acquired conditions and more readmissions. In nearly every national pay-for-performance scheme, they seemed to be doing worse than average, not better. In an era focused on high-value care, the narrative has increasingly become that teaching hospitals are not any better – just more expensive.

But is this true? On the one measure that matters most to patients when it comes to hospital care – whether you live or die – are teaching hospitals truly no better or possibly worse? About a year ago, that was the conversation I had with a brilliant junior colleague, Laura Burke. When we scoured the literature, we found that there had been no recent, broad-based examination of patient outcomes at teaching versus non-teaching hospitals. So we decided to take this on.

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Only Alternative Facts Can Support the Protecting Access to Care Act

In late March of this year, JAMAInternal Medicine published a study finding that the “the overall rate of [malpractice] claims paid on behalf of physicians decreased by 55.7% from 1992 to 2014.”  The finding wasn’t new.  In 2013, the Journal of Empirical Legal Studies published a study co-authored by one of us (Hyman) which found that “the per-physician rate of paid med mal claims has been dropping for 20 years and in 2012 was less than half the 1992 level.”  In fact, peer-reviewed journals in law and medicine have published lots of studies with similar results.  It is (or should be) common knowledge that claims of an ongoing liability crisis are phony.

But inconvenient facts have never stopped interest groups or politicians from making false claims about med mal litigation.  Since 1991, when Dan Quayle struck gold by asserting that the U.S. had too many lawyers, Americans have heard non-stop about “jackpot justice” in which patients who weren’t even injured win millions; about the flood of frivolous lawsuits in which doctors are sued even though they didn’t make any mistakes; about jury verdicts skyrocketing out of control; and about doctors working all their lives only to have their savings wiped out by a single malpractice suit.  All of these charges are false—you can find the evidence here, here, here, and here.  But in politics, it’s staying on message that counts; it doesn’t seem to matter whether the message is true.Continue reading…

Would the World End if We Eliminated the Deductible?

While Congress ponders a true fix for the Affordable Care Act (ACA), consider this about health coverage.

Problem #1, Can’t Use It: Healthy people, or people who don’t make a lot of money, sign up for the cheapest health insurance policy available. It gives them catastrophic coverage, protecting their family and home in the event of a big-time medical condition. But it also makes them mad. They pay a monthly fee for health insurance they can’t use until a large deductible is satisfied. For example, a person might pay $300 a month but have a $7,000 deductible. Do the math. That’s well over $10,000 before that person gets to use what they are paying for every month.

Problem #2, January Comes Too soon: Health is not an annual event. Maybe you go all year and suddenly need a bunch of medical help in December. The deductible hasn’t been reached so you pay the bill “out of pocket.” Nasty, because in January you still need medical care for the same thing, yet the deductible goes back to square one. Not nice. This makes more people mad. Solution for Problem #1 and Problem #2: eliminate all annual deductibles and replace with co-pays.

Problem #3, We Need To Build a Wall: Even by eliminating deductibles there are people who are required to pay more than they can afford. Fixing or replacing the ACA needs to build a wall of protection that limits the total amount—a percentage of income—paid by individuals or families in a calendar year—a guarantee that includes the cost of prescription drugs.

How America Dropped the Ball on Sports Concussions

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.

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The Ketamine Papers: Science, Therapy & Transformation


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.

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Would Repealing the ACA Violate International Law?

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.

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Why Science is Mistrusted

Recently, the Harvard Chan School of Public Health, in their press release, reported about the effect of surgical checklists in South Carolina. The release was titled, “South Carolina hospitals see major drop in post-surgical deaths with nation’s first proven statewide Surgical Safety Checklist Program.”

The Health News Review, for which I review, grades coverage of research in the media. Based on their objective criteria, the Harvard press release would not score highly.

The title exudes certainty – “nation’s first proven.” The study, not being a randomized controlled trial (RCT), though suggests that checklists are effective, far from proves it. At least one study failed to show that surgical checklists improve outcomes.

The press release’s opening line is “South Carolina saw a 22 percent reduction in deaths.” It reports relative risk reduction (RRR). Reporting RRR is now considered a cardinal sin in healthcare journalism, because RRR inflates therapeutic optimism by making the intervention sound more efficacious than it is.

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The 401W: A Wellness Program Even Al Lewis Could Love

I’ve been quite vocal about supporting only wellness done for employees and not to them…but what if there could be a “conventional” wellness program – even including screening, HRAs etc. – that both you and I could love?

People manage what’s measured and what’s paid for. If employers want people to stay healthy in the long run, why not measure and pay for health in the long run?

Why not give people the incentive to stay healthy during their working years, instead of giving them the incentive to pretend to participate in programs of no interest, just to make a few bucks? Or, worse, give employees the incentive to learn how to cheat on biometrics, and how to lie on health risk assessments. Attempts to create a culture of health often create a culture of resentment and deceit.

Short-term incentives haven’t changed weight, as noted behavioral economist Kevin Volpp has shown. Nor have they changed true health outcomes – it is easily provable that wellness has almost literally never avoided a single risk-sensitive medical event. So-called outcomes-based programs, ironically, are more about distorting short-term outcomes than achieving long-term outcomes. They have more in common with training circus animals to do tricks in exchange for treats than they do with helping employees improve long-term health.

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Who’s to Blame For the Shortage of Doctors? Doctors and Politicians

After missing an appointment with a physician recently, one of us was tongue-lashed by a medical assistant who explained that the practice has a months-long waiting list for new patients.  The dressing-down included a threat.  Another no-show and the miscreant would be discharged from the doctor’s practice and have all medications cut off.

Wondering if patients really wait months to see this doctor, the delinquent called back, pretended to be a new patient, and asked how quickly he could get in.  The first available appointment at the closest location was, in fact, 2 months out.  (The wait could have been cut in half by driving to an office that was farther away.)

Two months is a long time to wait to see a doctor.   If your auto mechanic or air conditioner repairman told you that it would take a week to fit you in, you’d find someone else to take care of the problem and you’d never go back to the person who told you to wait.  Given the transcendent importance of health, why do patients who need medical assistance routinely wait far longer?  And if patients with good insurance wait for two months, how long is the queue for those who rely on Medicaid or who have no insurance at all?Continue reading…

Evidence-Based Diagnosis and Faith-Based Solutions

It’s official: the Medicare Payment Advisory Commission (MedPAC) has at long last decided that MACRA’s MIPS (Merit-based Incentive Payment System) can’t work.
MedPAC reached this decision at its January 12 and March 2, 2017 meetings.

Its principle rationale was that measuring “merit” (quality and cost) at the individual physician level, which is what MIPS requires CMS to do, is not possible. As one MedPAC staff person put it at the January meeting, “A redesign of the MIPS program should build off a clear-eyed assessment of the limit of the national Medicare program’s ability to assess clinician performance” (pp. 235-236 of the transcript  of the morning session of the January 12, 2017 meeting).

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