In order to understand the concept of pain and its relationship to the current opioid crisis, it is prudent to review the neurology of pain an why it exists. Several concepts are important to integrate.
Nociception: Nociception is the capacity to sense a potentially tissue damaging (noxious) stimulus. To illustrate this one should place a forefinger in a glass of ice water and determine how long passes until an unpleasant sensation arises. If one performs this experiment in a large group, one can recognize that, although the stimulus is the same (a glass of ice water), the sensation arises at different rates in different people.
In fact, a bell shaped curve will describe the distribution in any population of people. Within 30 seconds almost all will have perceived an unpleasant sensation that is known at pain. Nociception is a very primitive sensation.
It is present in virtually all animals, even those without a brain, such as Aplysia, the sea slug. Though it lacks a brain, it has nerves and ganglia that allow it to sense and move away from a noxious stimulus. Nociception is absolutely essential to our survival and well-being. Without it, one would suffer tissue damage and ultimately death. The human disease, leprosy, is a salient example of an infection that destroys the nerves that are responsible for nociception. That lack of nociception is what causes all of the disfigurement that is characteristic of leprosy. Anyone who has had a dental anesthetic is aware that one can inadvertently bite one’s own lip until the anesthetic wears off.
Nearly every morning lately, as I make my daily dart to the metro station two blocks away, I pass a familiar face. She is one of about a dozen women who toil in the local nail salon. She does not live in my neighborhood, yet I see her early most mornings hiking up our hill, long before the salon opens.
Most days I wave and smile. But one recent morning I stopped and asked what she was doing. Her English is so-so and my Vietnamese is non-existent. But she managed to proudly convey, “Ten thousand steps!”
She’s not the only one. I myself have caught the walking bug, egged on by my better half and a Fitbit. For me, the rubber wristband has been revelatory. Given how active I am, I just assumed I was getting 10,000 steps every day. Far from it. Knowing your count – and how far you are from the daily goal – is an effective nudge to get off the metro one stop early or choose a lunch spot that’s a few blocks further away.
Diagnostic tests such as CAT scans are not perfect. A test can make two errors. It can call a diseased person healthy – a false negative. This is like acquitting a person guilty of a crime. Or a test can falsely call a healthy person diseased – a false positive. This is like convicting an innocent person of a crime that she did not commit. There is a trade-off between false negatives and false positives. To achieve fewer false negatives we incur more false positives.
Physicians do not want to be wrong. Since error is possible we must choose which side to err towards. That is we must choose between two wrongness. We have chosen to reduce false negatives at the expense of false positives. Why this is so is illustrated by screening mammography for breast cancer.
A woman who has cancer which the mammogram picks up is thankful to her physician for picking up the cancer and, plausibly, saving her life.
A woman who does not have cancer and whose mammogram is normal is also thankful to her physician. The doctor does not deserve to be thanked as she played no hand in the absence of the patient’s cancer. But instead of thanking genes or the cosmic lottery, the patient thanks the doctor.
Josef Stalin famously said: one death is a tragedy; one million is a statistic. Perhaps 250, 000 preventable deaths from medical errors, according to an analysis by Makary and Daniel in the BMJ, maketh a Stalin.
The problem with Makary’s analysis, which also concluded that medical errors are the third leading cause of death, isn’t the method. Yes, the method is shaky. It projects medical errors from a series of thirty five patients to a country of 320 million, which is like deciding national spice tolerance on what my family eats for dinner.
The problem with Makary’s analysis isn’t that it is full of assumptions. Assumptions are inevitable in biomedical research, and abundant in health services research. Researchers of medical errors must determine whether a bad patient outcome, such as death, was avoidable. Bad outcomes lie in a spectrum between inevitability and preventability. If every death is inevitable doctors are rendered impotent, and if every death is avoidable doctors are rendered omnipotent (FWIW, I prefer omnipotence).
An article this week in Politico entitled “Obamacare’s November Surprise” observes that premium announcements for Obamacare’s exchanges should be published around November 1, and that the news will be offputting, to say the least. Double digit increases from beleaguered insurers are likely, reflecting substantial structural and financial flaws within the exchanges as currently designed. The article suggests that this might be problematic for Democrats.
I’m doubtful whether, even if there is November rate shock, that it will substantially derail the then Democratic candidate, which absent some stunning intervening event will be Hillary Clinton. While the ACA is a natural extension of what Ms. Clinton has advocated for decades, she did not design the exchanges, and to hold her responsible for their design flaws seems a tad unfair. Likewise, she always has taken the position that rather than repeal the ACA, its flaws should be rectified. Easily said, a very safe position to take, and fair enough as it goes.
But what IS going on with the exchanges and the many co-ops that have failed? What happened?
It was the Mother of unintended consequences.
By the time of the 2016 elections, health plans, hospitals and health systems had squeezed and consolidated and trimmed and cut costs under the gun of lower Medicare reimbursements and the new rules of Obamacare — but mostly they had adapted. Most of them had survived.
On November 9, the country woke to find itself with a Republican President-elect, a Republican majority in the House, and a Republican majority of 55 in the Senate. The Grand Old Party was dedicated to repealing #EveryWord of the Affordable Care Act, the hated Obamacare which was, after all, “destroying the country,” “the worst thing to happen to the country since the Civil War,” and “equivalent to slavery.”
The changes to healthcare did not wait until Inauguration Day, much less until the 115th Congress could assemble to gut the law. They began instantly.
November 9, of course, was just nine days into the annual Open Enrollment period for plans under the Affordable Care Act exchanges. Many of the 12.7 million who had signed up for 2016 could see that the subsidies they were getting through the exchanges would likely disappear in the wake of the election, and decided not to sign up. “Why chance it?” as Betty Cornwall of New Rhodes, Kentucky, put it to Fox News’ Megyn Kelly.
Health plan strategists, masters of not getting blindsided by risk, decided that it was a bad idea to sign up millions of people for plans without knowing what would happen to the law. They did not want to get stuck with serving people who did not pay, and did not want to get blamed for dumping people after they had signed up. So most large health plans withdrew immediately from the exchanges, before many more people could sign up, draining the exchanges in many states of any choices at all.
Lisa Bari, a Master of Public Health candidate at Harvard, attempts to take me to ACO school in her response to a piece I wrote. I welcome the discussion. Game on!
Lisa’s initial point, and the one she ends on, seems to say my argument falls apart because I somehow don’t understand the difference between a commercial ACO and a Medicare ACO. I beg to differ. She states that CMS cannot be held responsible for a commercial non-governmental agreement between a private insurer and a group of health care providers.
I guess you do need to go to Harvard to decipher this stuff. Is the implication that the only ACO model the architect of the ACOs are responsible for is the initial Pioneer model? It makes no sense. To recap: CMS was instructed to create ACO’s. There are 2 programs to do this. The Pioneer model, and Medicare shared savings program (MSSP). As I understand it, the large regional ACO next to me is set up as part of the MSSP. Someone makes a payment to these ACOs when there are cost savings, right? By the end of her first paragraph, one almost has the impression that ACO’s are a renegade program that emerged from thin air between insurers and health care providers. Yes, a commercial insurer decides to make an agreement with an ACO and they set a $4 rate. I guess I am to assume if the govt/CMS did it directly it would be much more. And I do realize that ACO’s are for PCPs, and not designed for specialists. The only reason I think I have any ‘contract’ at all is because I have a PCP I work with. My point with regards to the ACO payment was that I have no clue where that $4 is going – but that compensation for care coordination at that level is inadequate, and would require quite the mix of healthy:sick to make that work. Is there another number you can give me so I can take an opinion on the matter – or should I just continue to trust our fearless leaders?
Hillary Clinton is now the presumptive Democratic nominee and the odds-on favorite to be our next president.
For healthcare, that could be a very good thing, not just compared to a Trump (or Cruz) presidency but for the following reasons:
(1) Hillary knows and cares deeply about healthcare.
Even if you don’t support or like her, she’s been a tireless advocate for reform and coverage expansion for decades. She worked, for example, in the 1980s with the Children’s Defense Fund and other groups to enhance coverage for children.
As first lady, of course, Bill put her in charge, in 1991, of developing a health reform plan. Though the process had its flaws, she was steeped in the subject for over a year and learned it inside and out.
Famously, the legislation failed in 1993-94 due to staunch Republican opposition (and, yes, a bungled legislative strategy by the White House). A widespread impression still exists that Hillary slunk back from the issue after the Clinton reform failed. Not true. Continue reading…
I think I speak for most physicians when I say that we did not choose to go into medicine to shape health care policy. Medicine is a calling, and I treated it as such. I immersed myself with taking care of patients, and keeping up with the ever changing knowledge landscape that is medicine. I left the policy making to the folks I voted for the last 8 years. These were the adults, the intellectuals – they would take care of the task of taking out the bad elements of our healthcare system and leaving the good. I truly believed. I eagerly began the ehr/meaningful use saga believing this would result in better care for patients.
It took me two years to realize the meaninglessness of meaningful use. I still can’t believe how long it took me to realize that creating a workflow in my office to print out and deliver clinical summaries to patients didn’t do anything other than fill the trashbin. I still held out hope. I thought – this was a first draft, improvements would come. What came instead were positively giddy announcements of the success of the meaningful use roll out. The administration was actually doubling down. There was no acknowledgment for the mess that had been created – onward and forward on the same road we must continue to march. Except the road would no longer be paved and we would be walking uphill.
Accountable care organizations (ACO’s) promise to save us. Dreamed up by Dartmouth’s Eliot Fisher in 2006, and signed into law as a part of the Patient Protection and Affordable Care Act (PPACA) in 2010, we have been sold on the idea that this particular incarnation of the HMO/Managed Care will save the government, save physicians and save patients all at the same time. I dare say that Brahma, Vishnu and Shiva together would struggle to accomplish those lofty goals. Regardless of the daunting task in front of them, the brave policy gods who see patients about as often as they see pink unicorns, chose to release the Kraken – I mean the ACO – onto an unsuspecting public based on the assumption that anything was better than letting those big, bad, test ordering, hospital admitting, brand name prescribing physicians from running amuck.
I realize I am being somewhat harsh towards the creators of the ACO morass. But, while they all may be well-meaning, hard-working folks that own a Harvard crimson sweater, their intent is to fundamentally change how health care is provided – this mandates a withering evaluation. As Milton Friedman aptly said, “One of the great mistakes is to judge policies and programs by their intentions rather than their result.” Thus, with little regard to intent, and with an eye on the end result, I say unequivocally : ACO’s do not work.Continue reading…