Science is nothing, but trained and organized common sense.
                                                                                          –Thomas Huxley

First a quick note.  Our postings are fewer and farther between this summer due to a particularly busy schedule, but will become more frequent and regular again as we get closer to the November elections.

In the meantime, the dog days of summer seem to be producing relatively few new or interesting journeys on the Road to Hellth.  Buoyed by the Supreme Court’s decision, The Affordable Care Act is continuing to allocate money in ways that appear to be directed more toward influencing the results of the election than contributing to the long-term viability of the nation’s healthcare system.  A prime example is the ongoing use of “research” money to preserve Medicare Advantage benefits for millions of seniors until just after conclusion of the Congressional and Presidential elections.

Indeed, most everything in healthcare seems to be in a state of suspended animation until after the election.  This only makes sense.  Why should millions of companies and individuals voluntarily make elaborate and expensive plans based upon a law that may be actively overturned (or at least undermined) if Mitt Romney should be elected in just a few months.  No one really knows if ACOs are going to be real or imaginary, whether all of the taxes involved will kick in, or if the dozens of promised carrots and sticks will come into play.  So money continues to be spent and decisions continue to be made based upon the existing law, but they are half-hearted.

Unfortunately, this doesn’t mean that reason and common sense are spreading throughout the world of healthcare either.  In case you missed it, we would like to illustrate with a seasonal example from the world of schools and camps for children.

By now, virtually everyone knows – or certainly ought to know – that too much exposure to ultraviolet light is a bad thing for skin and human health.  The ACA even includes a well-intentioned but ineffective 10% tax to raise money and discourage the use of tanning salons; unfortunately tanning rates have stayed about the same, while the measure has raised far less revenue than previously expected.  For many years the American Academy of Dermatology has paid for advertising campaigns that encourage the use of sunscreens and natural shade, discourage tanning and educate laypeople on the high risk of developing skin cancer as a result of unprotected exposure to the sun.  One might think that schools and summer camps would have picked up on these themes long ago.  But every American institution lives in world where bureaucratic requirements and legal liability concerns eventually trump every other consideration.  Jesse Michener, a mother in Tacoma, Washington found this out the hard way when she sent her two daughters school field trip, only to have them return with severe sunburns.  The reason?  In an effort to ensure that no “drug abuse” takes place, their school has a policy that bans sunscreen use (an over-the-counter item to be sure) without a doctor’s prescription.  We’ll let USA Today tell the story as Ms. Michener:

…was horrified to see two of her daughters, ages 11 and 9, return from a school field day with severe sunburns.

The girls have extremely fair skin, and none of the adults at the event offered them sunscreen — or shade, for that matter — as a rainy day turned sunny, Michener, 37, wrote in a post in her blog, Life.Photographed, that got nationwide attention. More than a week later, their skin still is peeling and red, Michener told USA TODAY Wednesday: “It’s appalling.”

Violet Michener, age 11, after her field trip.

…But sunscreen rules are common. They typically stem from state and local policies that stop kids from bringing any drug — including non-prescription drugs — to school, says Jeff Ashley, a California dermatologist who leads an advocacy group called Sun Safety for Kids.

Sunscreens are regulated as over-the-counter drugs, so many districts treat them like aspirin, just to be safe, he says.

Ashley helped get California to pass laws that say kids have a right to bring sunscreen, hats and other sun gear to school. That was nearly a decade ago, but as far as he knows, no other state has done the same.

So there’s a mish-mash of policies. Often, “sunscreen application at school seems to be an issue that each individual school district rules on,” says Jennifer Allyn of the American Academy of Dermatology. “Some treat sunscreen as they would any other fragrance-type product, and forbid their use to avoid allergic reactions. Others require a doctor’s note, and others treat sunscreen like something as basic as Chapstick.” The academy endorses sunscreen use but has no policy on how schools should handle it, she says.

But Ashley says allergy concerns are overblown: “Sunscreen allergies are no more common than allergies to soap. Are schools going to take soap out of their bathrooms?”

Another common concern: Adults will get in trouble for inappropriately touching kids if they help apply sunscreen. That was the question in Maryland last summer when the state enforced, then repealed, a rule forbidding camp staffers or even other kids from slathering lotion on campers. Now it’s OK, as long as parents say it is.

Michener says her daughters also were forbidden to bring hats to school. That’s another common policy, Ashley says. “Schools will tell you hats can be signs of gang affiliation.” Some schools dodge that danger, he says, by selling or supplying identical sun-safety hats…

Why is common sense so uncommon among the people whom we have trusted with positions of public responsibility?  Is this really the same country that managed to win World War II (although to be honest, with the help of other countries – the Soviet Union and Britain in particular) and put a man on the moon?

There is no question that, in the hands of children or abusers, some over-the-counter (OTC) medications can be positively harmful.  Robitussin® (dextromethorphan) in common OTC cough syrup is often taken and abused by adolescents and drug abusers for the “out of body” feeling and hallucinations that it can produce.  One study showed that 2.4 million teens — about 1 in 10 — got high on cough medicines in 2005.  That makes it just about as common as cocaine abuse.  Excessive ingestion of acetaminophen can cause liver damage.  Laxatives and diet pills often consist of nervous system stimulants.  Should parents, teachers and counselors be worried about these things?  Yes, of course they should.

But as we’ve seen so many times, the problem occurs when someone in a position of power decides to draft a standard “guideline” of care without really knowing what they’re doing.  The guideline rapidly becomes set in stone, and the means by which those dealing with the population in question are judged, rewarded and punished.  In this case the guideline was thoughtlessly crafted to be overly broad; it doesn’t take a genius to determine that some OTC items are more subject to abuse than others, or that some of these items were themselves created and distributed to address a potentially serious healthcare problem.  Sunscreen is one example, but there are others.  Mosquitos and ticks can be carriers of serious illnesses such as Lyme disease and West Nile Virus.  Properly formulated and administered, insect repellents are safe for use in children.  Presumably the same ban on OTC products prevents their use in many schools and camps nationwide.  How difficult would it be to draft a list of “allowed” OTC items rather than banning the entire class of products willy-nilly?  Apparently too difficult for the people whom we are paying to look after such things.

Lest we be too critical, we should note that the provision allowing the use of standard hats as a means countering gang-related activity is a logical and thoughtful response to a pervasive social problem.  At least someone somewhere is using their head.

This particular episode brings up a question that has, as far as we know, been completely ignored in healthcare reform.  Why are physicians and hospitals held responsible for the quality and appropriateness of their actions and decisions, but not the bureaucrats regulating them?  One could certainly argue that a policy-maker in Washington or even at a state school system has far more power over our nation’s lives and treasure than any individual physician could possibly muster.  Why aren’t regulators scored, awarded and punished based upon the health and economic effects of their performance?  Indeed, in some respects laws directed toward enhancing the performance of regulators and policy-makers stand a much better chance of improving public welfare than anything aimed at providers themselves.

Want to mandate the implementation of an electronic medical record system?  No problem.  In that case your own salary will be increased or decreased based upon the resulting change in medical productivity that results from the policy.  Planning on deploying a system of pay-for-performance incentives for healthcare providers?  Excellent.  However be aware that if it does not result in a significant improvement in performance as measured by health-adjusted cost savings, the cost of implementing and administering the plan – including the cost of compliance – will be deducted from your department’s annual budget.  Want to ban the use of sunscreen by schoolchildren rather than encourage it?  Okay, just be aware that we intend to monetize the cost of any excess sunburns that may result, and apply them against the compensation of those formulating the policy.

The quality of healthcare policy and regulation would improve overnight.  So would the use of common sense.