By DAVID INTROCASO PhD
In late January the Trump administration proposed a Department of Health and Human Services’ (DHHS) regulation that would legally protect any health care worker who refuses to provide care directly or indirectly to any individual by claiming a religious, moral or conscientious objection. While the federal government has for decades protected freedoms of conscience and religious exercise, the proposed would vastly expand these protections. No longer would these protections be applied to a very limited number of medical procedures. Think: abortion. Now, for example, a pediatrician could to provide care for a lesbian couple’s newborn or an emergency room nurse could refuse to provide a terminally ill patient palliative sedation.
Criticism of the proposed rule was immediate. Opponents contend if finalized the proposed would allow providers to ignore a patient’s medical needs including emergency needs that in some instances cause the patient further harm. It would undermine a healthcare entity’s effectiveness and patient safety responsibilities and would legally allow a provider to violate both their professional code of ethics and the patient’s civil and human rights. Critics argue the rule constitutes, in sum, an insidious form of bigotry. It would weaponize discrimination particularly against LGBTQs. It would, for example, roll back the Obama administration’s interpretation of the Affordable Care Act’s (ACA) anti-sex discrimination provision that protected gender identity. These, not insubstantial, criticisms aside there appears to have been little discussion of the proposed’s underlying rationale. What is the Christian theological basis, if any, for legally protecting religious exercise in denying health care?
“It’s a terrible way to die” The oncology fellow told me bluntly as we walked to the room. “There is nothing okay about this.”
Knocking on the open door, we entered his room. The blinds were raised to reveal a stunning view of the area surrounding the VA hospital, and light poured in.
Our patient reclined in bed, his eyes closed although he was not asleep. He opened his eyes at the sound of our entrance, and the eyes seemed to bulge, too large for his shrunken face with wasted muscles. A plastic tube, taped to the bridge of his nose, entered his nostril and disappeared. The other end of the tubing led to a canister filled with dark green liquid that had been suctioned from his gastrointestinal tract. Despite this invasion, his stomach remained distended, protuberant compared with his otherwise frail frame.
The man had an aggressive colon cancer. The tumor in his colon had grown so large that the hollow of his bowel had closed off, allowing no food to pass through. With nowhere else to go, the contents of his bowel backed up, puffing out his stomach and causing terrible nausea and vomiting. Even worse, the tumor invaded outwards too, anchoring tendrils into the surrounding tissue so that there was no longer any hope of removing the tumor surgically. “Palliative” chemotherapy to try to shrink the tumor would be offered, but it had no chance of curing his disease. The oncologist’s note summarized the situation: “Prognosis is extremely poor.”
It was a good learning case, a late presentation of a disease increasingly diagnosed at early stages by screening colonoscopies. This patient had not undergone screening, which might have diagnosed the cancer while there was still time for a cure. As an African American, this patient was more likely to develop this cancer than Caucasian patients his age.
In 1980, industry healthcare planners imagined a system where the centerpiece was a hospital in every community and a complement of physicians. Demand forecasting was fairly straightforward: based on the population’s growth and age, the need was 4 beds per thousand and 140 docs per 100,000, give or take a few.
In 1996, the Dartmouth Center for the Evaluative Clinical Sciences published the Dartmouth Atlas on Health Care quantifying variability in the intensity of services provided Medicare enrollees in each U.S. zip code. They defined 306 hospital referral regions (HRRs) that remain today as the basis for regulation of our healthcare system.
In the same timeframe (1980-2000), the ratio of doctors per 100,000 doubled as the number of medical schools increased from 75 to 126 leading health planners (Graduate Medical Education National Advisory Council) to predict a surplus of 70,000. Meanwhile, demand for hospital beds edged down slightly to 3.5/1000—the result of managed care efforts in certain parts of the country.
Today, we operate 2.4 beds per thousand and have 265 physicians per 100,000. But the bigger story is the widespread variability in the volume, costs and quality of care across our communities. Across the 306 HRRs, bed supply ranges almost 250%; physician supply even more and costs as much as 400%.
Pharmaceuticals play a major role in today’s population health era – they can prevent and cure disease, improve or maintain wellness and slow progression of existing conditions. Yet, their promise can also be a curse if high prices limit patient access and bankrupt the healthcare providers and insurers bearing significant financial risk for patient care.
The proactive new leadership at the FDA is promoting competitive markets by combatting the abuse of well-intentioned programs and market share monopolies. Commissioner Scott Gottlieb has ramped up the FDA’s efforts to prevent drug manufacturers from “gaming the system” in a number of ways.
Accelerating generic approvals and creating transparency to stimulate competition
For the first time, the FDA made publicly available a list of off-patent, off-exclusivity branded drugs without generic competition. Using the list, Premier immediately identified a number of critical drugs for patient care and has been working with manufacturers to participate in the FDA’s new expedited review process. Additionally, Congress recently enacted legislation creating an expedited review process for generic drug applications when there are fewer than three manufacturers in the market for a given drug product. We strongly support and helped to champion these efforts, and are hopeful that the FDA will use this new authority to foster competition and curb price spikes and shortages in generic drugs where only a few players dominate.
Health Savings Accounts (HSAs) allow individuals to use pre-tax dollars to pay for high deductibles and other uncovered medical expenses. Currently, individuals are ineligible for tax-advantaged HSA contributions if they have “other” coverage in addition to a High Deductible Health Plan (HDHP.) Expanding HSAs to fund out-of-pocket expenses for routine healthcare places control directly in the hands of patients, a move that could bring down health expenditures. Large corporations are wrestling for control to direct where patients spend their hard-earned money.
A group of lawmakers recently introduced the “bipartisan” Health Savings Account Improvement Act of 2018 (H.R. 5138). This bill allegedly “expands” HSA coverage to allow use at “retail-based” (think CVS/Target) or “employer-owned” clinics (think Amazon) without losing eligibility to make tax-advantaged contributions to their HSAs. Increasing the flexibility of HSAs is a laudable goal yet, this legislation herds Americans like sheep into Minute Clinics for the benefit of corporate shareholders.
This bill should not become law. If HR 5138 passes, retail and employer-based clinics will become profit centers. Alternative legislation, known as the Primary Care Enhancement Act (H.R. 365), amends the definition of “qualified medical expenses” to include fees paid to physicians as part of a “primary care service arrangement.” This common-sense legislation flounders in Congress every year.
It starts with the CEO. Studies confirm that the single most important determinant of successful workplace wellbeing programs is the active, passionate, and persistent involvement of the CEO.
The CEO is taken very seriously. When the CEO wants something, people notice. When the CEO is passionate about something, it gets elevated to extreme importance. The sort of paradigm and cultural change needed to create a culture of employee wellbeing simply cannot occur without the full, passionate, focused, and persistent involvement of the CEO. I was a CEO, and one has to have been one to understand the full implications of CEOship. It IS different. This is not elitism. It’s fact.
While I was CEO of Blue Cross & Blue Shield of RI, I made my singular focus ethics and integrity. Why? Because my predecessor became top-of-the-fold news, and our organization quickly gained a reputation for unethical behavior. We had to change that, and I made ethics and integrity part of every speech, virtually every piece of written material I sent to employees, a part of fully half of my weekly newsletters to employees, etc. And over time, it worked. No cutting corners; full compliance; a strong reporting system, etc. And we became recognized, rather quickly, for having ethics “in our DNA.”
I wish I had brought the same passion to the wellbeing of my employees. I didn’t, and now part of my mission in life is correct that by inspiring CEOs, Boards, and C-Suites to do just that.
A somewhat cynical CEO might ask: “Why is this my responsibility?” Or, “Why can’t employees just do what they should be doing?” Or, “Am I also supposed to cure world hunger and take on the responsibility for employees’ happiness?” “Where does it end?”
These are understandable questions. The short answers are, yes, this is your responsibility for many reasons, the chief of which is that it is a strategic imperative for operational success. It’s also the right thing ethically and morally. And no, employees often need help, and the workplace is the best venue to give and receive such help.
Artificial Intelligence is at peak buzzword: it elicits either the euphoria of a technological paradise with anthropomorphic robots to tidy up after us, or fears of hostile machines breaking the human spirit in a world without hope. Both are fiction.
The Artificial Intelligences of our reality are those of Machine Learning and Deep Learning. Let’s make it simple: both are AI – but not the AI of fiction. Instead, these are limited intelligences capable of only the task they are created for: “weak” or “narrow” AI. Machine Learning is essentially applied Statistics, excellently explained in Hastie and Tibshirani’s Introduction to Statistical Learning. Machine Learning is a more mature field, with more practitioners, and a deeper body of evidence and experience.
Deep Learning is a different animal – a hybrid of Computer Science and Statistics, using networks defined in computer code. Deep Learning isn’t entirely new – Yann LeCun’s 1998 LeNet network was used for optically recognizing 10% of US checks. But the compute power necessary for other image recognition tasks would require an additional decade. Sensationalism by overly optimistic press releases co-exists with establishment inertia and claims of “black box” opacity. For the non-practitioner, it is very difficult to know what to believe, with confusion the rule.
Access to basic healthcare services is a cardinal human right, enshrined in the World Health Organization’s Constitution, which envisions the “highest attainable standard of health as a fundamental right of every human being”. Comprehensive, quality healthcare services are critical not only for treatment, but also prevention and management of illnesses which culminates in reducing unnecessary death and injuries and increasing overall life expectancy.
Globally, millions of people face challenges accessing adequate healthcare services, with those living in rural settings the most affected. One of the key components of healthcare is timeliness in availing these services, including access to a location with adequate healthcare provisions. More recently, the Sustainable Development Goals have also emphasised the importance of expedient access in Goal 3.8 which seeks to provide “access to quality essential healthcare services”.
In general, there are three types of delays in a healthcare system which can negatively affect the patient’s life. These include a delay in decision to seek care; delay in reaching a health facility; and delay in receiving appropriate treatment. These blockages in the system are almost always prevalent in countries with poor socioeconomic conditions, such as Bangladesh.
Many states have been looking for alternatives to reimbursing Medicaid providers piecemeal on a fee-for-service (FFS) basis. Increasingly they have been moving beneficiaries into Medicaid managed care plans. Today 39 states contract with managed care organizations to care for at least some Medicaid beneficiaries. States have been slower to integrate drug benefits with managed care, however. The Medicaid Drug Rebate Program requires drug manufacturers to rebate a portion of the drug costs to states and the federal government. Prior to the Affordable Care Act states did not qualify for drug maker rebates unless states managed their own Medicaid drug program on a FFS basis. States can now receive rebates for drugs purchased by Medicaid managed-care plans as well.
Medicaid is a partnership between the federal government and the states. Regardless of whether states manage Medicaid drug benefits, enrollees fill their prescriptions at local pharmacies. Pharmacies are reimbursed for the cost of each prescription, plus a dispensing fee. If the state manages Medicaid drug benefits, the state agency sets fees and reimburses pharmacies.
Today 26 states have transitioned at least some Medicaid beneficiaries away from FFS drug programs into drug plans integrated with managed care. Yet, recent legislative initiatives are bucking this trend for political reasons. Senate Bill 5 in the Kentucky legislature (and similar proposals in Ohio and Arkansas) would require the state to manage Medicaid drug benefits on a FSS basis. Indeed, nearly half of states still hang on to outdated FFS drug programs for political reasons.
The study that changed everything was published last week. An alien visiting the national cardiology meeting in Orlando may have thought that the trial of note was the one that featured the culmination of one hundred years of lipid research to develop an inhibitor of the enzyme PCSK9 (Proprotein convertase subtilisin/kexin type 9) that lowers lipids and reduces the risk of future heart attacks.
The Martian would be wrong.
The trial that has cardiologists across the land choking back tears is a hypertension study done in black barbershops. The idea is fairly simple. Black men have the highest rates of disability related to uncontrolled hypertension, in large part related to a difficulty in engaging black men with the health care system. The end result of poorly controlled hypertension in this community was on full display where I did much of my medical training as a student and resident in the heart of North Philadelphia. Ensconced in the walls of Temple we learned to manage the end organs ravaged by hypertension. I have to say I never stopped to think what we could have done to interrupt this process even though we were located in the heart of an underserved black community.
Luckily, Ronald Victor has been thinking about this problem for some time. A Cedars Sinai physician, his research focuses on community interventions to rectify health care disparities. His first study in 2007 sought to examine the feasibility of blood pressure screenings in black barbershops because this was where black men congregated and may be susceptible to influence by important peer influencers: barbers.
The 2007 study by Victor proved that it was feasible to enlist barbers to measure blood pressures, correctly stage hypertension, and make a referral to a clinician for treatment. This opened up funding for the next step in the process- actually affect blood pressure control in barbershops. The trial was wildly positive. In stark contrast to the multibillion dollars of research that lead to a $1000/month PCSK9 inhibitor that gives us a 15% relative risk reduction of a composite outcome of stroke/death/heart attack, the Victor barbershop protocol resulted in a staggering average 27mmHg blood pressure drop in 6 months. The potential ramifications are large for a 20mmHg drop – a 30% reduction in risk of a heart attack or a 40% reduction in risk of a stroke.