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The Canadian Health Care System I Disparaged

May 6, 2014• 50

By Wendell Potter

When I recently returned home after a two-week speaking tour of Canada and began catching up on news about Obamacare, I was angry and upset, and not just at politicians and special interests that benefit from deception-based PR tactics.

I was — and still am — mostly angry and upset with myself. And I know I always will be.

Over the course of a two-decade career as a health insurance executive, I spent hours and hours implementing my industry’s ongoing propaganda campaign to mislead people about the Canadian health care system.

We spread horror stories about “rationed care” and long waiting times for medically necessary care. Our anecdotes were not at all representative of most Canadians’ experiences, but we spent millions of dollars to persuade Americans that they were.

At every stop between Halifax and Vancouver last month, I explained how the United States had achieved the dubious distinction of having both the most expensive health care system on the planet and also one of the most inequitable.

While Canadian lawmakers in the 1960s were implementing a partnership between the federal and provincial governments to create the country’s publicly funded universal health insurance system — known as Medicare — our lawmakers in Washington were establishing America’s own single-payer Medicare program, but only for folks 65 and older and some younger disabled people.

Congress also created the federal and state-administered Medicaid program for the nation’s poor.

Ever since, most of the rest of us have had to deal with private insurance companies and pay whatever they felt like charging us for coverage.

Dad, You Have to Inhale

May 6, 2014• 2

By James Salwitz, MD

My wife calls them “hand-me-ups”… things we inherit from our kids. My ex-fashionable shirt that my son wore in college.Our semi-vegetarian diet my daughter adopted in high school. The dog at my feet that came visiting for the weekend, three years ago.

Our lives are enhanced and modified by the most unexpected of teachers, our children. The mentoring of our progeny keeps those of graying years at least partially youthful. Still, I was astonished to hear this week, the words, “Dad, you need to starting doing drugs.”

The “dad” being addressed is 93 years old and has advancing cancer. He is tired, nauseas, anxious and sleeps poorly. Though he likely has a number of months to live, he has become withdrawn. Despite my usual medical brew, his incapacitating symptoms are without palliation.

Dad is miserable. Enter his daughter with the solution. The “drug” she is talking about is the treatment de jour, marijuana.

How did this happen? We raise our kids to be good, honest, mature citizens; we drive them to soccer, suffer through years of homework (do you remember dioramas?), and do the whole college obsessive-compulsive tour thing. In addition, above all, we beg our offspring to stay away from pot, pills and addictive mind-altering potions.

Now they turn on us, pushing ganja in our time of need. How did we go wrong? Actually, it is we that missed a great opportunity.

50% of Americans have inhaled marijuana at some point in their lives. More than 25 million of our neighbors have used it within the last year. Those that imbibe are of a decidedly younger demographic. The oldest citizens, especially those of the Greatest Generation, are much less likely to have experience with cannabis.

Fortunately, once again, youth presents the solution.

Adventures in Caring and Acting Affordable

May 6, 2014• 3

By Rob Lamberts, MD

I’m back. I’m recovering right now from trauma related to the Affordable Care Act. I’m OK, but probably a few months until fully recovered.

Some would think that since I no longer accept money from insurance companies, the Affordable Care Act would have less of an effect on me. Those folks may be right in how it directly impacts my practice (since I don’t know the actual impact on other doctors, it’s not easy to compare), but there has been a significant impact. I’ve got plenty of ACA stories.

But that’s not what I am going to discuss in this post.

My personal adventures with this law are far more interesting from the other side of the insurance card: the health care consumer (AKA patient). It has been quite a ride — one that has not yet reached its destination.

CHAPTER 1: December 9, 2013

Being the adventurous guy I am, I thought I’d give the Healthcare.gov website a whirl. Expecting the worst, I set aside a lot of time for the experience. It was actually quite a bit easier than advertised. My family is as follows:

Me – Age 51, healthy
Wife – Around my age, but actual age disclosed only for legal reasons.
Child 1: Son, 21 years. College grad but living at home for now.
Child 2: Daughter, 20 years. In college
Child 3: Son, 18 years at time of application. In college. Birthday later in December.
Child 4: Daughter, 14 years.

I submitted the information about whether any of us smoke (no), any of us are pregnant (no), and how much money we earn (not much, as I am starting a new business). I immediately got the following eligibility notice.

The End of Antibiotics. Can We Come Back from the Brink?

May 5, 2014• 38

By Tom Frieden, MD

Antibiotic resistance — bacteria outsmarting the drugs designed to kill them — is already here, threatening to return us to the time when simple infections were often fatal. How long before we have no effective antibiotics left?

It’s painfully easy for me to imagine life in a post-antibiotic era. I trained as an internist and infectious disease physician before there was effective treatment for HIV, and I later cared for patients with tuberculosis resistant to virtually all antibiotics.

We improvised, hoped, and, all too often, were only able to help patients die more comfortably.

To quote Dr. Margaret Chan, Director General of the World Health Organization: “A post-antibiotic era means, in effect, an end to modern medicine as we know it.”

We’d have to rethink our approach to many advances in medical treatment such as joint replacements, organ transplants and cancer therapy, as well as improvements in treating chronic diseases such as diabetes, asthma, rheumatoid arthritis and other immunological disorders.

Treatments for these can increase the risk of infections, and we may no longer be able to assume that we will have effective antibiotics for these infections.

Last September, CDC published our first report on the current antibiotic resistance threat to the United States.

The report conservatively estimates that each year, at least 2 million Americans become infected with bacteria resistant to antibiotics, and at least 23,000 die. Another 14,000 Americans die each year with the complications of C. difficile, a bacterial infection most often made possible by use of antibiotics. WHO has just issued their report on the global impact of this health threat.

It’s a big problem, and one that’s getting worse. But it’s not too late. We can delay, and even in some cases reverse the spread of antibiotic resistance.

So What Do the Expanded Enrollment Numbers Mean?

May 5, 2014• 4

By Paul Keckley

Last Thursday, HHS released the final enrollment stats for health exchange enrollment for 2014. Here’s what we learned:

8.1 million enrolled in a plan in the Health Insurance Marketplace. 3.8 million (47% of total) since the end of February including 1.2 million in the much-watched 18-34 age cohort.
54% are female; 28% are between the ages of 18-34; 63% are White, 17% Black, 11% Hispanic, 8% Asian/other.
20% chose a bronze plan, 65% chose silver, 9% gold, 5% platinum and 2% catastrophic. Note: At the silver level, individuals who earn less than 250% of the federal poverty level — ($29,175 for an individual, or $59,625 for a family of four) — are eligible for assistance for out-of-pocket costs. 85% who picked an exchange plan qualified for a subsidy: 82% in the 14 state-run exchanges and 86% in the federally-run exchange.
Young adults 18-34 were 83% of those applying for the catastrophic coverage.

How Much Will It Cost to Let Me Die?

May 5, 2014• 1

By JaBaris Swain, MD

It was probably the most awkward question I had been asked before, and I did not have an answer…

He was a middle-aged gentleman, neatly dressed—very simple and unassuming. He blended like a lifeless statue in the waiting area. What sparked my notice of him was his accompanying robust file, crammed with familiar pink discharge slips from the ED.

He was clearly what we call a “frequent flyer”, but this would be his first visit in our surgical clinic.

I escorted him into the assessment room, exchanging the usual salutations as he edged unto the exam table, wincing with discomfort. His chief complaint read, “acute abdominal pain and constipation x 1 week.”

Vying to understand more about his issue, I asked, “Sir, how long have you had this problem?” Embarrassed, he lowered his head.

Silence.

I retreated and instead remarked, “Ok. Let’s start from today. Where do you have the most pain?”

Tenderly, his frail digits unbuttoned his shirt, exposing a wasted torso, which hoisted an extraordinarily distended abdomen. It appeared rigid and tense. I reached out to gently palpate it to confirm the realism of my observations. He flinched. His stoic affect instantly collapsed into an aching frown.

Tears welled in his eyes. Something terrible was going on inside. Cancer.

He needed to be admitted and surgery would be very likely, if not too late. I was aplomb in my explanation of his condition, feeling proud of my thoroughness and precision. Yet, seemingly unengaged, he politely interrupted and asked, “How much will it cost to let me die?”

I paused. It was probably the most awkward question I had been asked before, and I did not have an answer. During my training, I was taught to order tests wisely, to avoid superfluous exams and to minimize inefficiency of resources; in spite of this, I had not ever stopped to think about cost in this context.

In my mind, it was my duty to provide the best, quality care to extend life, foremost. Yet, his concern was different. How much would it cost to die?

Nothing.

Doximity Raises $54 Million. But What Value Will They Add?

May 4, 2014• 2

By JOSH HERIGON

Last week’s news that Doximity has raised another $54 million got me thinking ..

On one hand, I’m glad to see these guys continue to raise money and continue their development.

On the other hand, I’m disappointed that we don’t have a better physician-centric social network. While they have been successful at signing up doctors, it seems (at least anecdotally) few are engaging with the network. I have connected with many of my classmates and some physicians I know on the network. I have never interacted with any of them through Doximity.

The article quotes LinkedIn co-founder and Doximity board member , Konstantin Guericke:

I think a lot of doctors will have a LinkedIn profile and Doximity profile. But the key is which part is really going to get ingrained in their lives.

The key question is—what value does Doximity provide over other, non-physician centric social networks? More plainly, what is going to make me open up Doximity on my iPhone instead of my favorite Twitter client?

The current answer to that question is: nothing.

In their smartphone app, the news feed features medical journal articles from the likes of NEJM, JAMA, Lancet, etc. It is unclear exactly how these are selected, but quite clear they are not tailored to my interests. Twitter, on the other hand, provides a constant stream of thoughts and articles related to my interests because of the people I’ve chosen to follow.

Medical Devices and Patient Safety: A Promising Path Forward

May 4, 2014• 3

By Daniel, Gardina & Strait

In an era of sophisticated information technology and rapid communication, the medical device community lags far behind other fields in its ability to alert patients about safety concerns.

For example, auto manufacturers and government regulators are able to quickly identify potential safety concerns by linking reports of crashes, malfunctions and defects with individual vehicle identification numbers (VINs).

They can then communicate recalls to affected customers by using their VIN. Manufacturers will issue notifications via mail or e-mail, or offer customers the ability to search the manufacturer’s website using their VIN.

In health care, drugs are tracked using a system established in the 1970s called National Drug Codes (NDCs). The 10-digit NDCs are assigned to all manufactured medications. The code tracks the vendor, product, and package code, which can then be captured in electronic health records and the FDA’s national database.

Unfortunately, we do not yet have a similar national system that can identify and communicate potential concerns for the tens of millions of patients with implantable devices such as pacemakers, glucose meters, artificial joints, and defibrillators.

Patients are bombarded by news stories about device recalls, but unless they have access to information about the exact make and model of their device, they have no way of knowing if they should be concerned. Since most medical device procedures take place in a hospital, a patient’s health care providers may also lack this critical, sometimes life-saving information.

The patient is then burdened with the task of tracking down their specialist or surgeon, in hopes that they documented the specific device information.

Clearly, the current health care information infrastructure does not yet support a robust surveillance system.

A Swedish Country Doctor’s Proposal for Health Insurance Reform

May 4, 2014• 7

By HANS DUVEFELT, MD

In the forty years since I started medical school, I have worked in socialized medicine, student health, a cash-only practice and a traditional fee for service small group practice. The bulk of my experience has been in a government-sponsored rural health clinic, working for an underserved, underinsured rural population.

Today, I will pull together the threads from my previous posts in the series “How Should Doctors Get Paid?” I will make a couple of concrete suggestions, borrowing from all the places I have worked and from the latest trends among the doctors who are revolting against the insurance companies by starting Concierge Medicine and Direct Primary Care practices.

Because I am a primary care physician, I will mostly speak of how I think primary care physicians should be paid.

I will expand on these concepts below, but here are the main points:

1) Have the insurance company provide a flat rate in the $500/year range to patients’ freely chosen Primary Care Provider, similar to membership fees in Direct Care Medical Practices.

2) Provide a prepaid card for basic healthcare, free from billing expenses and administration.

3) Unused balances can be rolled over to the following years, letting patients “save” money to cover copays for future elective procedures.

4) Keep prior authorizations for big-ticket items, both testing and procedures, if necessary for the health of the system.

5) Keep specialty care fee-for-service.

6) Have a national debate about where health care ends and life enhancement begins and who should pay for what.

Health insurance needs to be simple to understand and administer. It needs to promote wellness, and it needs to remove barriers from seeking advice or care early in the course of disease. It needs to empower patients to use health care services wisely by aligning patients’ and providers’ incentives.

Health insurance should not be deceptive. It should not promise to pay for screenings (colonoscopies and mammograms) and stop paying if the screening reveals a problem (colon polyps or breast cancer). It should offer patients the right to set their own priorities for their health while demanding concern for our fellow citizens’ right to also receive care.

A Holistic View of Evidence-Based Medicine

May 2, 2014• 23

By DAVID KATZ, MD

On Tuesday of this week (4/29/14), I was on the Katie Couric Show to discuss Integrative Medicine.

Somewhat ironically, I returned from Manhattan that same day to a waiting email from a colleague, forwarding me a rather excoriating critique of integrative medicine on The Health Care Blog, and asking me for my opinion.

The juxtaposition, it turns out, was something other than happenstance. The Cleveland Clinic has recently introduced the use of herbal medicines as an option for its patients, generating considerable media attention.

Some of it, as in the case of the Katie Couric Show, is of the kinder, gentler variety. Some, like The Health Care Blog — is rather less so. Which is the right response?

One might argue, from the perspective of evidence based medicine, that harsh treatment is warranted for everything operating under the banner of “alternative” medicine, or any of the nomenclature alternative to “alternative” — such as complementary, holistic, traditional, or integrative.

One might argue, conversely, for a warm embrace from the perspective of patient-centered care, in which patient preference is a primary driver.

I tend to argue both ways, and land in the middle. I’ll elaborate.