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Moral Injury: A Physician’s Premature Retirement

Calder Wedding

BY HAYWARD ZWERLING

Synopsis:

  • After a 3 decade career in a solo private practice the healthcare environment shifted
  • As an employed physician, my institution’s policies hindered my ability to care for my patients
  • The consequent moral injury left me unwilling to re-engage with the healthcare industry

I retired early from the profession that I loved because the devolution of the healthcare system had made it impossible for me to provide care to my patients in a manner which met my own standards. The resultant “moral injury” left me leary of again becoming involved with our healthcare system in the near future.

My Early Career

Although I had originally planned a career as a physician-scientist, it became apparent toward the end of my training that this was not the best career path for me and I choose to pursue a career in private practice. 

My first post-training job was as a physician working in a clinic owned by Blue Cross and Blue Shield (1989-1991.) After two years in this relatively low stress environment it became clear that taking care of young, healthy patients was not much fun nor interesting.

I then joined Dr. LP’s private medical practice where I learned how to run a private practice.  It was in this setting that I began to create an electronic medical record program for my practice, ComChart EMR. ComChart evolved into a minor commercial endeavor, it was a hobby that earned me some money, and it connected me to many interesting physicians around the US, some of whom I continue to hear from to this day.

After a couple of years practicing alongside Dr. LP I decided it was time to strike out on my own. I built out a new office and soon thereafter added a nurse practitioner.

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Not The Last of Them

By KIM BELLARD

I’m seeing two conflicting yet connected visions about the future. One is when journalist David Wallace-Wells says we might be in for “golden age for medicine,” with CRISPR and mRNA revolutionizing drug development. The second is the dystopian HBO hit “The Last of Us,” in which a fungal infection has turned much of the world’s population into zombie-like creatures.

The conflict is clear but the connection not so much. Mr. Wallace-Wells never mentions fungi in his article, but if we’re going to have a golden age of medicine, or if we want to avoid a global fungal outbreak, we better be paying more attention to mycology – that is, the study of fungi.

We don’t need “The Last of Us” to be worried about fungal outbreaks.  The Wall Street Journal reports:

Severe fungal disease used to be a freak occurrence. Now it is a threat to millions of vulnerable Americans, and treatments have been losing efficacy as fungal pathogens develop resistance to standard drugs. 

“It’s going to get worse,” Dr. Tom Chiller, head of the fungal-disease branch of the Centers for Disease Control and Prevention, warns WSJ.

A new study found that a common yet extremely drug resistant type of fungus — Aspergillus fumigatus – has been found even in a very remote, sparsely populated part of China.  Professor Jianping Xu, one of the authors, points out: “This fungus is highly ubiquitous — it’s around us all the time. We all inhale hundreds of spores of this species every day.”

We shouldn’t be surprised, because fungi tend to spread by spores  In fact, according to Merlin Sheldrake’s fascinating Entangled Life: How Fungi Make Our Worlds, Change Our Minds, and Shape Our Futures, fungi spores are the largest source of living particles in the air. They’re also in the ground, in the water, and in us. They’re everywhere.

That sounds scary, but without fungi, we not only wouldn’t be alive, we never would have evolved.

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Matthew’s health care tidbits: Time to get Cynical

Each time I send out the THCB Reader, our newsletter that summarizes the best of THCB (Sign up here!) I include a brief tidbits section. Then I had the brainwave to add them to the blog. They’re short and usually not too sweet! –Matthew Holt

Plenty of reason to worry about the future of American health care this week. The biggest for-profit hospital chain–HCA–was accused of aggressively pushing patients into hospice care, sometimes in the same room, in order to make their hospitality mortality numbers look better. Most of the leading benefits consulting companies were exposed as taking payments from PBMs–yup, the same organizations their employer clients thought they were negotiating with on their behalf. And one of the biggest names in digital health, Babylon Health, tumbled into destitution, taking billions of dollars with it and leaving uncertain the fate of the medical groups in California it bought less than two years ago. Even the most successful capitalists in health care — United HealthGroup and its fellow insurers — saw their stock fall because apparently outpatient surgery volume is ticking up

On the policy front the malaise is spreading too. The end of the public health emergency (remember Covid?) is being used as an excuse by the old  confederate states to kick people off Medicaid. Georgia and Arkansas appear to be bringing back work requirements, even though I thought CMS has banned them and every study has acknowledged that they are cruel and ineffective. About 20 million people got on to Medicaid during the public health emergency and KFF estimates up to 17 million may be kicked off, while over 1.7 million already have.

Finally an article by Bob Kocher and Bob Wachter in Health Affairs Scholar remins us that big academic medical centers are nowhere near ready for value-based care (VBC). Jeff Goldsmith has been vocal on THCBGang and elsewhere about how VBC is becoming a religion more than a reality. And I remind you that Humana’s MA program is still basically a Fee-For-service program in drag (even though that’s now illegal in their home state). 

I grew up in American health care expecting that eventually a combination of universal insurance mixed with value-based purchasing would lead to a series of tech-enabled companies doing the right thing by patients and making money to boot. With the managed care revolution, the ACA and the boom in digital health all firmly in the rear view mirror, the summer of 2023 is a lesson that you can never be too cynical about health care in America.

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THCB Gang Episode 127, Thursday June 22

Joining Matthew Holt (@boltyboy) on #THCBGang on Thursday June 22 at 1PM PT 4PM ET are delivery & platform expert Vince Kuraitis (@VinceKuraitis); privacy expert and entrepreneur Deven McGraw (@HealthPrivacy); and back after way too long of an absence, health economist Jane Sarasohn-Kahn (@healthythinker).

The video is below. If you’d rather listen to the episode, the audio is preserved from Friday as a weekly podcast available on our iTunes & Spotify channels

The Truth About Medicare Advantage Saving Medicare

BY GEORGE HALVORSON

We know from the current annual report from the Medicare trustees that Medicare Advantage is saving Medicare, and that Medicare will be a much stronger program as Medicare Advantage continues to grow.

When we look at actual numbers from that report, we see that Medicare Advantage cost Medicare $403.3bn last year.

The report shows that Medicare is growing 6.7% each year in total revenue. We see that Medicare Parts A and B have expense growth that slightly exceeds 8%, and that Medicare Advantage is projected to have expense growth of 4.2% for the year.

That means we’re losing money from the fee-for-service part of the Medicaid program — and that is eating into the Medicare trust fund. We also can see that Medicare Advantage is making a surplus for Medicare, and is increasing the size of the fund.

We know that Medicare Advantage bids against the average cost of Medicare in every county to create the capitation levels for each year. Those bids are typically discounted by 15% (or more) from the average Medicare cost.

Those discounted bids cost Medicare less in actual dollars each month. The Medicare Advantage critics speculate about coding levels for the plans, but the Medicare trust fund doesn’t care about codes.

They only care about actual dollars. When you look at actual dollars, we see that Medicare spent $403.3bn to pay for the coverage with Medicare Advantage plans.

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Revisualizing and Recoding Healthcare

BY KIM BELLARD

Two new books have me thinking about healthcare, although neither is about healthcare and, I must admit, neither of which I’ve yet read. But both appear to be full of ideas that strike me as directly relevant to the mess we call our healthcare system.  

The books are Atlas of the Senseable City, by Antoine Picon and Carlo Ratti, and Recoding America: Why Government Is Failing in the Digital Age and How We Can Do Better, by Jennifer Pahlka.  

Dr. Picon is a professor at The Harvard Graduate School of Design, and Professor Ratti is head of MIT’s Senseable Lab. Drawing on the Lab’s work, they write: “We hope to reveal here an urban landscape of not just spaces and objects, but also motion, connection, circulation, and experience.” I.e. dynamic maps. Traffic, weather, people’s moment-by-moment decisions all change how a city moves and works in real time.

Dr. Picon says

These maps are a new way to apprehend the city, They’re no longer static. Maps provide a way to visualize information. They’re crucial to diagnosing problems. I think they provide a new depth…It’s a little bit like the discovery of the X-ray. You can see things within cities that were not previously accessible. You don’t see everything, but you see things you were not able to see before.

So I wondered: what would a dynamic map of our healthcare system look like?  

I’m telling you, just a map of what happens between drug companies, PBMs, health plans, pharmacies, and patients would open people’s eyes to that particular insanity in our healthcare system.  Now repeat for the millions of other ecosystems in our healthcare system.  If that kind of dynamic mapping — showing all the complexities, bottlenecks, circuitous routes, and redundancies within the system — wouldn’t lead to health care reform, I don’t know what would.

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As Health Professionals Go, So Goes Our Democracy

By MIKE MAGEE

Last weekend’s New York Times headline, The Moral Crisis of America’s Doctors, spotlights that there is growing concern that the monetarization and corporatization of nursing and medical professions by hospital and insurance power houses, have seriously undermined the mental health and ethical effectiveness of health care professionals. The pandemic has only heightened the crisis.

Since focusing on the social science of Medicine in the 1990’s in Philadelphia, it has been an uphill battle to convince leaders in and out of Medicine that doctors and nurses are critical to individual and societal success. Recently, I’ve come to the conclusion that this may have more to do with a general lack of knowledge of our form of governing, democracy, than a misunderstanding of the stabilizing effect of professional doctors and nurses.

What is democracy? For an answer I turned to John J. Patrick PhD, professor emeritus in history, civics and government at the Indiana University. In his “Understanding Democracy,” he explains that democracy as we know it is a “startling new development.” The practice of rule (krater) by the people (demos), or “demokratia,” dates back 2500 years to Athens, Greece. Citizens did rule by majority vote, but only free males of Greek descent could rise to the status of “citizen.” In those days, individual freedoms took a back seat to unconditional support of the city-community.

Establishing a modern democracy in America has been a bit of a struggle.

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THCB Gang Episode 126, Thursday June 15

Joining Matthew Holt (@boltyboy) on #THCBGang on Thursday June 15 were double trouble futurists Jeff Goldsmith and Ian Morrison (@seccurve); patient safety expert and all around wit Michael Millenson (@mlmillenson); Suntra Modern Recovery CEO JL Neptune (@JeanLucNeptune); and policy expert consultant/author Rosemarie Day (@Rosemarie_Day1). Lots of discussion about United and their hold on the US health care system, the continued hype around AI, and where the rubber is meeting the road or not on health equity.

You can see the video below & if you’d rather listen than watch, the audio is preserved as a weekly podcast available on our iTunes & Spotify channels.

Air, Air, Everywhere, and Not a Breath Safe to Take

BY KIM BELLARD

If you live, as I do, anywhere in the Eastern half of the country, for the past week you’ve probably been thinking about something you’re not used to: wildfires.  Sure, we’ve all been aware of how wildfires routinely plague the West Coast, particularly Oregon and Washington, but it’s novel for the East. So when the smoke from Canadian wildfires deluged cities through the East and Midwest, it came as kind of a shock.

For a day last week, New York City supposedly had the worst air quality in the world.  The next day Philadelphia had that dubious distinction.  The air quality index in those cities, and many others, got into the “Maroon” level, which means it was hazardous for everyone.  Not just for the elderly and other “sensitive” groups, and not just some risk for some people, but hazardous for everyone.   

If you didn’t know about AirNow.gov before, you should now.

New Yorkers are used to smog and air quality that is less than idyllic, but smoke from wildfires, containing fine particulates that easily get into the lungs, weren’t something anyone was prepared for.  “Wildfires were not really a scenario, in all honesty, that I recall us specifically contemplating,” Daniel Kass, New York City’s deputy commissioner for environmental health from 2009 to 2016, admitted to NBC News.   

“People on the East Coast aren’t used to seeing these types of situations. There was a much slower response,” Peter DeCarlo, an associate professor of environmental health and engineering at Johns Hopkins University, also told NBC News. “We can probably learn a thing or two from our West Coast friends.”

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Trump Earns a Failing Grade in Civics (K-12) in North Carolina.

BY Mike Magee MD

Events over the past year clearly have confirmed that we are a “work in progress” even as we stubbornly affirm our good intentions to create a society committed to “life, liberty, and the pursuit of happiness.”

With the Dobbs’ decision, our Supreme Court has unleashed long-abandoned regressive state laws designed to reinforce selective patriarchy and undermine the stability and confidence of America’s women and families. As a result, our nation’s health professionals, and the patients they care for, potentially find themselves “on the wrong side of the law.”

It calls to mind the well-worn phrase of mothers everywhere to their bossy children, “Who died and left you boss?”

Since our former President, on the eve of his latest indictment, decided to deliver a message to North Carolina Republican supporters this past weekend, claiming that he was engaged in the “final battle” with “corrupt” forces, most especially the “Deep State” that was “out to get him,” I decided to fact check his claims with the kids of North Carolina.

North Carolina’s K-12 lesson plan, titled “The Rule of Law,” begins with the Teddy Roosevelt quote, “No man is above the law, and no man is below it” from his 1903 State of the Union address.

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