Road To Hellth

Mar
19

Carefully Crafting the Politically Correct Physician

Pop Quiz: You’ve just been in a car accident, or been diagnosed with cancer, or struck by lightning, or you’re coming to your doctor’s office as sick as a dog with something you got last week and you haven’t been able to keep anything down for the past 48 hours. What’s your top priority with respect to what you want your doctors to know? Do you want her to be: (a) culturally sensitive; (b) financially aware; or (c) know how to fix you? If you answered (c), you’re clearly behind the times.

One of the strangest things about efforts to “reform” the U.S. healthcare system is how easily people seem to forget the purpose of the whole endeavor. For example, based upon the key provisions of the Affordable Care Act (aka, “ObamaCare”), one could easily conclude that the purpose of the healthcare system is to provide health insurance coverage, even if that coverage is as inherently defective and unsustainable as Medicaid. At least one self-described “liberal” blog has accused “right-wingers” of thinking that:

“The purpose of a health care system is to support a profitable health care industry. For example, regulations that mandate insurance companies insure people with pre-existing conditions are bad, because they are bad for business.

On the other hand, if your underlying assumption is that the purpose of a health care system is to provide health care to people who need it, you must be a liberal.”

Unspecified in the “liberal” definition are, of course, many details including what one can or should define as “health care”, whether one person should be required to pay for the care of another, or how many healthcare goods and services any individual should be entitled to.

But these are simply a couple of exhibits that demonstrate that our national discussion of healthcare “reform” is increasingly missing the point. The real purpose of any healthcare system can and should be getting patients and physicians and other clinicians together in an effort to impose chemical, structural and biological changes that will result in better, longer lives for the patients affected. The inimitable Dr. Rich produced a good and purposeful definition in the course of writing his first book on the subject:

“The purpose of healthcare services [i.e., the healthcare system] is to maintain or restore the individual’s health when possible or to optimize functional capacity, control symptoms, and compensate for restrictions when a disease or disability cannot be cured or prevented.”

In other words, the single most important purpose of any healthcare system can and should be to minimize the ravages that nature would otherwise impose upon our bodies and lives. Most notably you can’t fight nature with insurance, you can’t fight it with profits, and you can’t even fight it with the utmost in empathy, cultural awareness and good intentions. At its very core one can only fight the infirmities wrought by a completely objective and indifferent Mother Nature, with science.

We’re forced to remind our readers of this reality as a result of recent changes and proposed changes to the medical education, candidate selection and training process. Like many aspects of modern culture, these changes seem to be the result of an effort to replace logic and science with something warmer, fuzzier and more politically correct. For a few weeks ago, the American Association of Medical Colleges (AAMC) announced that it was changing the content of its Medical College Admissions Test (MCAT) to de-emphasize scientific knowledge and skills, and instead concentrate on ensuring that physicians of future are more in touch with their sensitive side than anatomy, biochemistry or statistics. As reported in MedPage Today:

“The change means that the MCAT will stop focusing solely on biology, physics, statistics, and chemistry, and also will begin asking questions on psychology, ethics, cultural studies, and philosophy.

The announcement of the change — made Thursday by the Association of American Medical Colleges (AAMC), which administers the test — represents a major shift in thinking on what makes a good doctor. Instead of training doctors that can spout off disease causes and treatments with encyclopedic knowledge, the new test is meant to begin training doctors to empathize and communicate better with patients, and to improve their bedside manner.

According to AAMC president and CEO Darrell Kirch, MD, a recent survey showed that the public has high confidence in the medical knowledge and ability of doctors, but feels physicians often lack the basic social skills required to really connect with a patient.

‘Bedside manner is a complex mix of understanding people, where they come from, and why they behave the way they do, and we think this shift in emphasis [of the test] will actually help us round out that dimension of a good doctor,’ Kirch said on a Thursday afternoon call with reporters.

The MCAT was created in 1928 and has been used for decades as a crucial component of getting into medical school. The standardized test hasn’t seen a major change since 1991, when a writing sample was added. The current test has two natural science sections (including concepts taught in college biology, organic chemistry, biochemistry, and physics classes), as well as a reasoning and a writing portion.”

The new test will add a section called “Psychological, Social, and Biological Foundations of Behavior,” which includes questions on behavior and behavior change, cultural and social differences that influence well-being, and socioeconomic factors, such as access to resources.”

Far be it from us to be pessimistic party poopers, but let’s think for a second about what the good Dr. Kirch just said. Patients currently feel quite confident about the medical knowledge and ability of physicians selected and trained under the previous system, so the AAMC thinks that it’s a good idea to potentially jeopardize those qualities in order to recruit doctors who may be medically ignorant and inept, but have a great perspective on the cultural differences between Puerto Rican Hispanics, Cuban Hispanics and Mexican Hispanics. Too bad a Clostridium difficile infection doesn’t much care whose gastrointestinal tract it’s infected any more than an auto accident cares whose chest it’s traumatized. They’ve all got to be treated properly or all the sensitivity in the world isn’t going to result in a patient who is any less dead.

In fact given the exponential increase in the rate of scientific knowledge and clinical data, one could argue that even the nerdiest dual biology and chemistry major is still going to be struggling to catch and keep up throughout the course of their medical career. As just one example, a recent article in the Annals of Internal Medicine took doctors to task for their frequent inability to interpret cancer screening statistics with a high degree of accuracy. An editorial on the topic in the same issue bemoaned a lack of statistical expertise in medical students and physicians that has now gone unaddressed for decades:

“Medical students do not understand statistical concepts well, and Wegwarth and colleagues’ study in this issue suggests that fully trained physicians do not either. A decade ago Sheridan and Pignone reported that despite a relatively high level of numeracy among medical students, (77% correctly answered 3 numeracy questions), only about half correctly interpreted risk-reduction data for the treatment of a hypothetical disease… Physicians clearly do not understand how to interpret cancer screening statistics themselves – expecting them to communicate this information to patients is a stretch.”

The editor might well have added that it is a stretch regardless of how culturally sensitive a given physician might happen to be. (Incidentally, Dr. Elaine Schattner has written a nice commentary on this recent article on her Medical Lessons blog.)

But perhaps we’re being too harsh and concrete in our thinking about whether people of Slovak ancestry would like to get an appropriate diagnosis and treatment as much as those who are Native American. Clearly there is merit in the idea that individuals vary tremendously with respect to their cultural attitudes, education, intelligence, religion and a host of other factors. In our clinical experience, for example, many Native Americans seek and receive services from both conventional medical doctors and native medicine men. Devout Muslim men are reluctant to have their wives and daughters examined by male physicians. Why shouldn’t all professionals in every walk of life benefit from a culturally sensitive and socially aware educational background, and have the nation modify all school curricula to require these courses for plumbers, hair stylists, attorneys and politicians as well as physicians? Our legislators have the power. After all, the State of California is now requiring that gay, lesbian and transgender history be included in all social studies courses. Requiring all Americans to receive a similar cultural education (but modified to include the particular foibles of every race, creed, color, country, size, shape, disability and a host of other factors) is just a simple law away. Why not make this change for all Americans with the very best of intentions?

But why stop there? The healthcare system doesn’t simply operate in a medical and social environment, but also an economic one. Shouldn’t our medical professionals also be required to be proficient in the sciences of economics and business management?

It should come as no surprise that this has already been proposed by Dr. Frederic W. Hafferty, PhD., professor of medical education and associate director, Program in Professionalism and Ethics, Mayo Clinic, Rochester, Minnesota, and colleagues in a recent paper in the journal Academic Medicine. Assuming that these authors are serious (and we believe that they might be, although we ourselves could easily have offered up the same paper as an instructive piece of sarcasm), we must allow them to speak for themselves:

“The nation teeters on the precipice of financial insolvency. Health care costs darken the economic horizon. Public trust in medicine is at an all-time low…

Key to this alienation is that physicians lack insight into the economic and social burden of the services they orchestrate. As a consequence, the most pernicious threat to health care and medical education in the United States today is not patient safety, nor the lack of an evidence-based practice, but rather the alienation of trainees and physicians from the financial cost to patients of their work.

We propose, therefore, a training process organized not around disciplines, organ systems, diseases, or clinical problems, but around cost. Beginning with the admission process, all medical school applicants will be required to demonstrate proficiencies in micro-, macro-, behavioral, and health care economics, and to document community service and related shadowing experiences in clinic business offices or sites related to the recording and payment of medical charges. A new MCAT exam, Kaplan course work, and premed advising will all mirror this shift…

…The first two months of medical school (with preexisting courses taxed to create this curricular space) will be devoted to the economics of care. This block will involve multiple pedagogical approaches from traditional didactics and problem-based learning to simulation and social networking. Instructors will range from topic experts to patients and members of the public whose lives are being bludgeoned by health costs. Preceptorships will be community based and will focus on student experiences in educating the public on the cost of both schooling and health care. Once this competency is mastered, students will begin to meet with patients upon discharge (clinic or hospital) to explain all charges. There will be no traditional “patient care” contact until students are fully able to decode and explain the highly cryptic billing statements that encumber patients. As students enter the biomedical side of their training, patient meetings will begin to add explanations of diagnoses and treatment options to those of cost. No student will be admitted to the care side of the educational continuum until he or she is fully able to explain to patients what has been done to them and why.”

And there you have it. If we put all of these requirements together the physician of the future will be culturally sensitive, empathetic, well-rounded and financially eloquent. They may also have received some actual medical training along the way, although perhaps not enough to actually diagnose and manage your particular problem.

Obviously this can’t go on forever, so where do we draw the line?

What we have here is completely classic problem in economics. Resources are finite. In this case the relevant resources are the time and tuition that any prospective physician must spend in order to stuff information into his or her head. On the other hand people’s wants are infinite. In this case people want every medical doctor to be a renaissance person – medically perfect, culturally sensitive, financially aware, gentle, understanding, self-sacrificing and (incidentally) typing 120 words per minute and completely skilled in the use of computerized medical records. Every time we expand the non-medical training requirements or place other political, social and bureaucratic demands on clinicians, it comes at a cost. The most obvious trade-off is that we will have culturally sensitive doctors who have an increasingly difficult time acquiring and keeping the skills they need to deal with actual medical conditions. Few if any of these conditions really care about the social graces, yet all of them answer to science.

This leads to the obvious question: Exactly how many additional days of illness, lost productivity and death are we willing to trade in exchange for the cultural and financial sensitivity gained by diverting physician training in this direction? We know that there must be a tradeoff – the only question is how much. Did the AAMC estimate what this potential impact might be? Did those calling for these changes even consider that it might be their friends and loved ones who might be adversely affected when the time came? We can only hope so. Unlike people, Mother Nature doesn’t mess around.

Categories : Clinical Care, Economics, Ethics, Healthcare Policy, Politics, The Practice of Medicine

Mar
8

Medical Specialty Certification Exams: The Real Scandal

by Dr. Doug Perednia

Note to our readers:

This article was recently published on The American Thinker website, where it can be found here. We’ve added some additional comments at the end of the article based upon reaction to the original, and some additional thoughts and news we’ve had since publication.

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Earlier this year, CNN broke the story that generations of dermatologists have been “cheating” on their specialty board certification exams. Like their colleagues in radiology and most other medical specialties, large numbers of dermatology trainees have been studying for the boards by using massive collections of historical exam questions that were memorized and shared immediately after each year’s test. Having access to these questions is useful because many specialty boards re-use questions from previous tests. Until this year about 20% of the questions used by the American Board of Dermatology (ABD) were recycled from previous years, compared with about 50% for the written exam in radiology.

The widespread use of these so-called “airplane notes” or “recalls” has been common knowledge in the medical world for decades, but the flurry of recent press reports has caused consternation in the powerful board certification industry. Stung by the publicity, the American Board of Medical Specialties issued a press release condemning the practice and calling it an unethical violation of copyright laws. Apparently caught by surprise, the executive director of the ABD admitted that she’d “never seen airplane notes, but I’ve heard about it”, and subsequently cancelled a scheduled on-camera interview on the topic. Meanwhile, the American Board of Radiology hurriedly announced that its 2012 certification examination will be composed of entirely new questions for the first time in ten years. But while the lay press often frames the issue as one of “public safety”, the real scandal surrounding specialty board certification is quite different.

Modern specialty boards are holdovers from a time when there was little standardization or regulation of medical training. The American Board of Dermatology was founded in 1932, a time when various programs to train dermatologists ran for either one, two or three years. This era ended for good in 1981 when the Accreditation Council for Graduate Medical Education was established to regulate and accredit residency training programs for all medical specialties. Every physician in America is now superbly trained over a period ranging from three to seven years depending upon their specialty. As quality and standardization improved, medical boards began making test questions increasingly esoteric in order to preserve a normal statistical distribution of scores. Most boards also began grading “on the curve”; failing a percentage of examinees with the lowest test scores regardless of whether the content they missed was critical to the practice of safe, high-quality medicine. “Recall” and “airplane notes” developed in direct response to these “fail somebody” policies. As one radiologist said to CNN: “”If they had a test where you could study relevant radiology knowledge and they tested on it, that would be fine. Part of the problem is the test and the questions that they ask. Because some of the questions are so obscure, that unless you know that they like to ask questions about that topic, you’re not going to study it because some of them are completely irrelevant to the modern practice of radiology.”

None of this would matter except that medical boards have managed to turn their monopoly on physician certification into a multi-million dollar gauntlet of tests and more tests that must be passed in order for physicians to stay on insurance plans and hospitals’ staffs. Taking the initial dermatology board certification exam comes with a $2,500 fee, while regularly required “maintenance of certification” tests cost nearly $1,000 each. And therein lies the true scandal in the saga of board certification and “recall” questions: it’s not that the tests are allowing incompetent physicians to care for patients, but that they are keeping many highly qualified doctors from entering practice and earning a living.

The math behind this injustice is relatively simple. The nearby figure shows the score distributions of two hypothetical board certification exams like the one given by the ABD, each composed of 300 questions. The left-hand curve shows a normal distribution of scores if none of the examinees have access to questions from previous tests that are re-used on this one. The right-hand curve shows the change in scores that will result if 90% of the test takers already know the answers to 60 out of the 300 questions as a result of studying “airplane notes. Let us further assume that the specialty board in question decides that it will flunk out the bottom 10^th percentile of test takers as a matter of “ensuring the quality” of its certification procedures.

Although the curves look similar, the use of recall notes produces a big difference in the specific score that will be used to fail test takers. In turn, this translates into a major change in who will be allowed to pass the test. Over half of doctors who did not use “airplane notes” and who would normally have been safely above the 10^th percentile threshold will now flunk as a direct result of their inability to answer all of the re-used questions correctly. These well-trained and competent physicians will be wrongfully kept from medical practice while they prepare for next year’s $2,500 test. If they’re smart they’ll find a set of “airplane notes” to study from rather than risk failure yet again. It’s no wonder that training program directors have been known to encourage their young doctors to seek out every review course, old test question and study tool they can find.

In the modern world of American healthcare, none of this multi-million dollar hoop-jumping is necessary or even appropriate. Every accredited specialty training program director already knows exactly what their residents know because they work with them each and every day. By the time physicians completes their specialty training they’ll have been asked tens of thousands of questions by a host of attending physicians in almost every conceivable setting, from the surgery suite to the lecture hall. Training programs have the ability to hold back or terminate questionable residents at any time.

Gilding the medical lily with endless layers of deliberately esoteric tests and certifications does nothing to improve patient safety or well-being; it simply prevents significant numbers of competent physicians from providing much-needed healthcare services. It’s time for the medical establishment and the general public to decide that high levels of excellent training are far more important than all the testing in the world.

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In an effort to be perfectly constructive, we would like to suggest two alternatives to the current mess. The first is that one might have a board certification test that encompasses the truly important and mainstream information and examples of work-ups and treatment decisions that everyone in a given specialty ought to know. A pass rate of 100% should be the goal. What’s the point of flunking out ANY clinicians who know this basic and critical information? Make the old exams public for everyone to study. The entire point of the exercise needs to be ensuring basic awareness and good decision-making, not putting million of dollars into the coffers of self-selected specialty boards. A second alternative is asking residency training programs to do their own self-assessments of knowledge, decision-making and basic skills, and hold back or fail anyone who fails to meet their standards. This can again be based upon a national consensus of training program directors that documents those elements of training that are needed to produce good clinicians. Again, the goal should be a pass rate of 100%.

One has to wonder if there is not a class-action that should be taken against the medical specialty boards who recycle questions, that should be filed on behalf of all those who may have taken these exams and failed – quite possibly through no fault of their own – over the past 15 years.

One comment about the American Thinker article that struck us as being particularly interesting in light of the impending shortage of physicians is this one by someone using the pen name “Sud”:

I am boarded in 3 subspecialties and on my initial exams scored in the 90th percentile in my primary specialty with no special access to old questions. As of last year I am employed by a hospital that requires only 1. I will not recertify in the others. There is no economic advantage, and patients apparently perceive no quality advantage when they are perfectly willing to see a nurse practioner and refer to them as their doctor.

I believe “keeping many highly qualified doctors from entering practice and earning a living” is the whole point Dr. Perednia. Qualified physicians still cost more than government payers wish to spend. They have initiated price controls on physician services, inducing workforce shortages in primary care specialties so that when the baby boomers all start dying, and physician access is nil the sheeple will embrace single payer, and Big Brother can install less thoroughly trained alternatives as the answer to a failed system, whose failure big government has ensured. They may be PAs, NPs or eventually a newly minted CNA with a clipboard and clinical decision flowsheet at the end of a 1-800 number. If they don’t want physicians in general seeing patients, why on earth would they want board certified subspecialists.

Sud’s observations may sound a bit like a conspiracy theory, but the fact is that it makes absolutely no sense whatsoever to be making it harder and harder to be “qualified” to practice medicine as a physician, while at the same time expanding the ranks of lesser trained and lesser qualified physician assistants and nurse practitioners who are expected to make up for a shortage of doctors.

After this article was posted on The American Thinker, we were contacted by the folks at the organization Change Board Recertification. This organization has done some extraordinary work documenting the tens or hundreds of millions of dollars of “non-profit” profits that are flowing into specialty board coffers each year. RTH readers may well find this organization, and the specialty board tax returns that it has made available on-line, worth a second and third look.

Categories : Abuse of Power, Business and Law, Clinical Care, Economics, Ethics, Healthcare Policy, Politics, The Practice of Medicine

Mar
5

Two Interesting Posts That Mosey Down the Road to Hellth

by Dr. Doug Perednia

Megan McArdle over at The Atlantic is one of our favorite bloggers, as she routinely discusses various practical aspects of combining economics with human behavior. Megan has apparently committed herself to another project for the next few weeks or months, and has left her blog in the hands of several guest bloggers – a couple of whom often write about healthcare. Today two of them posted pieces that we found quite interesting, and we wanted you, our readers, to know about them.

The first of these two articles, entitled Need a Reason to Question Obamacare? Just Look to Louisiana is by Avik Roy, who usually does a great job blogging at The Apothecary blog over at Forbes. In this post, Mr. Roy talks about “The Louisiana Purchase” – the deal made with Sen. Mary Landrieu’s (D., La.) that was supposed to give her state $200 million in extra federal Medicaid Funds in exchange for her support for the Patient Protection and Affordable Care Act (“ObamaCare”). In one of those unaccountable mistakes that can only happen in the halls and back rooms of our nation’s capital, it seems that in the course of torturing the language of the bill so that only Louisiana would get this special deal, they accidentally awarded Ms. Landrieu’s constituents $4.3 billion due to “a drafting error”. From Mr. Roy’s post:

On March 20, 2010, hours before the final vote on the health care bill in the House of Representatives, the Congressional Budget Office and the Joint Committee on Taxation issued their fiscal scoring of the bill. According to their analysis, the “Louisiana Purchase” would cost $0.1 billion in 2011 and $0.1 billion in 2012, with no additional spending thereafter for a total of $0.2 billion, or approximately $200 million.

Republicans were angry, as were many voters. But while President Obama voiced some opposition to the special deals cut in Congress in support of his signature legislation, he made an exception for the Louisiana Medicaid adjustment, incorrectly asserting that the language also applied to Hawaii:

“Something that was called a special deal was for Louisiana. It was said that there were billions–millions of dollars going to Louisiana, this was a special deal. Well, in fact, that provision, which I think should remain in, said that if a state has been affected by a natural catastrophe, that has created a special health care emergency in that state, they should get help. Louisiana, obviously, went through Katrina, and they’re still trying to deal with the enormous challenges that were faced because of that…That also–I’m giving you an example of one that I consider important. It also affects Hawaii, which went through an earthquake. So that’s not just a Louisiana provision. That is a provision that affects every state that is going through a natural catastrophe.”However, in November 2011, when the Centers for Medicare and Medicaid Services (CMS) tried to make sense of the legislation, they came up with a much larger number: $4.3 billion. This was, in part, because the text of the law didn’t phase out the adjustment in two years, as originally intended, but rather increased the federal subsidy in out-years.

The language in Section 2006, wrote CMS, “results in increased, rather than phased down, financial assistance to [Louisiana] each year, and allows [the state] to continue to qualify for assistance after their underlying FMAP has stabilized. The resulting assistance will be higher than initially projected.”

You can say that again. In fiscal year 2012 alone, the federal government sent about $700 million in supplemental funds to Louisiana’s Medicaid program, with another $3.6 billion to be spent in fiscal years 2013-2015. In FY13, the law changed the feds’ share of Louisiana Medicaid spending from 61 percent to 72 percent: a billion-dollar adjustment for the Bayou State.

Take a few minutes to read the article. It reads like a how-to manual on destroying the U.S. healthcare system by drafting laws that are either wickedly clever in their deceit of the public, or sublimely incompetent in the drafting.

The second Megan’s-guest-blogger article we’d like to highlight is “You’re Fat and You Know It: Why Government Anti-Obesity Efforts Fail” by Katherine Mangu-Ward. It’s hard to swing a cat anymore without having some part of it’s anatomy strike a state or federally-funded study or public education program designed to tell members of the heftier segment of the public that, contrary to what they might have heard elsewhere, being obese is actually not that good for you!

One interesting question is what the purpose of these messages is other than to spend everyone’s tax dollars? Is there anyone who does not know that being obese is not so great for your health? As it turns out, no:

Fat people have a surprisingly accurate sense of the health costs of being fat, for example:

“Finkelstein et al. conducted a survey of 1,130 adults in the United States to test whether overweight and obese individuals believe they are at greater risk of obesity-related diseases and premature mortality. They found that obese and overweight adults forecast life expectancies that are 3.9 and 2.4 years, respectively, shorter than those of normal-weight adults….The authors concluded that mortality predictions generated from the survey were “reasonably close” to those generated from actual life tables for adults in the United States.”

Numerous studies have found that lack of information about a healthy diet or opportunities to eat well aren’t the problem either. Cramming calorie counts and other nutrition information down customer’s throats doesn’t do much to change food choices. A second Marlow paper, forthcoming in what I’m told is the respectable journal Applied Economics Letters, finds that living near fast food doesn’t cause weight gain. That finding is supported by another recent study in the Archives of Internal Medicine, which found that living near supermarkets doesn’t improve diets, and (with the possible exception of young, low-income men) living near fast food doesn’t make for a less healthy diet.

So if telling people about the problem over and over and over does nothing to solve it, why does the government keep spending money on this? Why do we do the same unsuccessful thing over and over again in healthcare? Are we stupid or something?

To quote Forest Gump’s mom, “stupid is as stupid does.”

Categories : Business and Law, Clinical Care, Economics, Ethics, Healthcare Policy, Political Hellth, Politics, The Practice of Medicine

Mar
1

Year After Year, Medicare Keeps Flushing Perfectly Good Kidneys (and Dollars) Down the Drain

by Dr. Doug Perednia

As most of our readers know, Medicare is the government-sponsored health insurance program for the elderly and disabled. What many Americans may not realize, however, is that Medicare has, by law, for many years been unusually and selectively dedicated to the care and feeding of kidney function. This leads us to the question for today: when our elected leaders pass laws about the coverage of specific healthcare services, what logic (if any) dictates the services that will be provided? Is common sense involved? And most importantly, is healthcare policy formulated mostly in the brain, or mostly in the kidneys?

For those of you who may not be overly familiar with them, we should note that kidneys are certainly among the most amazing organs ever created. Their functions include regulating the amount of water and salt in the body, balancing the amounts and proportions of sodium and potassium in the bloodstream, maintaining an appropriate blood pressure, helping to manage the production of red blood cells and various other tasks of great utility, such as detoxifying and/or eliminating potential poisons. There is no question that anything we can do to mitigate the loss of kidney function is a useful social and medical endeavor.

Perhaps as a consequence of the kidney’s great importance in our lives, in 1972 Congress passed an amendment to the Medicare law that essentially made the federal government responsible for the cost of all care associated with end-stage renal disease (ESRD). Since that time this has included both kidney dialysis (a process whereby the blood is filtered by a machine that amounts to an “artificial kidney” when it comes to eliminating excess salt, water and toxins in the bloodstream), and covering the cost of transplanting real kidneys from human donors into ESRD patients. Medicare’s coverage is based upon Congress declaring that any American with ESRD would be declared to be “disabled” for Medicare purposes.

Of course all of this comes with a price. As a recent review article in the New England Journal of Medicine recently documented, this has been considerable:

“In 2008, there were more than 112,000 new patients with ESRD in all eligibility categories (elderly, disabled, and ESRD-only). There were approximately 548,000 U.S. patients with ESRD (about 382,000 of whom were undergoing dialysis) at the end of 2008, but many of them were not covered by Medicare, either because they had not yet fulfilled the initial waiting period or because they had received transplants and their coverage had ceased after 3 years. Medicare expenditures for ESRD in 2008 were $26.8 billion for Parts A and B. Non-Medicare expenditures for ESRD (covered by employer-sponsored group health plans or paid directly by patients) added another $12.7 billion, for total national expenditures of $39.5 billion. According to an analysis by the U.S. Renal Data System, ESRD beneficiaries represented 1.3% of all Medicare beneficiaries and used 7.9% of Medicare expenditures.”

So it was with great pleasure that we met a patient just this week who had directly benefited from this program. She is a middle-aged diabetic woman who had been on dialysis for several years before being able to find a compatible kidney donor. The good news was that she was doing very well with her new kidney and was both pleased and relieved to have been able to discontinue the ritual and inconvenience of dialysis. She felt better, looked better and felt that she could really enjoy life for the first time in years. The bad news was that she was worried. Very worried. In spite of her new kidney she has not yet been able to find work – or at least find work with health insurance. She was most worried about being able to keep using the drugs that were preventing rejection of her kidney. But wasn’t she still covered by Medicare we asked?

“I am for a few more months,” she replied, “but Medicare benefits automatically terminate three years after a successful transplant.” But won’t Medicare continue paying for her transplantation drugs and insulin even after that if she’s unable to find other insurance? After all, if her diabetes rages out of control and she’s unable to take her transplantation medications, she’ll lose her kidney.

“I know. That’s what I’m worried about.” She gave a grim, twisted little smile. “But at least if that happens I’ll qualify for Medicare again and we can start all over.”

In fact, she’s right about that. It’s written in black and white, right here in this document that describes Medicare benefits for those with ESRD:

“If you have Medicare only because of ESRD, your Medicare coverage will end:

• 12 months after you stop dialysis; or

• 36 months after you have a kidney transplant and no longer need dialysis.

Your Medicare coverage will continue if:

• You start dialysis or you get a kidney transplant within 12 months after the month

you stopped getting dialysis; or

• You start or resume dialysis or get another kidney transplant within 36 months after the month you have a kidney transplant.

Your Medicare coverage will resume if:

• Your ESRD Medicare ends and you resume dialysis or get another transplant for kidney failure. Your Medicare can start right away without any waiting period.”

Now here is something strange.

One common theme in the great commotion about healthcare in America today is the concept of “waste, fraud and abuse”. A second one – most common among intellectuals such as President Obama and former head of Medicare Dr. Donald Berwick – has to do with the need to institute and disseminate “best practices” in medicine. And a third has to do with not delivering more care, but “smarter care”. In light of all of these let’s consider the facts of this particular patient’s case.

A kidney transplant costs between $100,000 and $125,000.

A year of hemodialysis costs between $6,000 and $10,000 per month, or about $71,000 to $120,000 per year.

Put them together and you have the same amount of money that would place a taxpayer in the top 2% of annual income. This is so much money that the President routinely lumps households like this into the general category of “millionaires” for tax purposes.

A month of immunosuppressant medications to prevent rejection of a transplanted kidney costs between $1,000 to $3,000 per month, less than one-third the cost of hemodialysis.

But even now, several years after the passage of the Affordable Care (“Obamacare”) Act, the federal government’s own health insurance program will pay for the entire cost of years of dialysis and a kidney transplant to get patients like this one off of dialysis, and then completely squander those investments by discontinuing coverage of the immunosuppressant drugs after 36 months, regardless of whether this will cause the patient to lose the kidney and go back on dialysis.

Lord knows we hate to be critical, but this is just plain stupid – even for a government agency whose healthcare policies routinely seem to be, er, ill-considered. And clearly the patient we met this week is hardly an isolated case. The briefest of Web searches on the topic uncovered this 2009 New York Times article about a patient on her second Medicare-funded transplanted kidney. She lost the first one when she started stretching out her doses of immunosuppressant drugs due to cost considerations.

Perhaps what baffles us most about all of this is that so many people continue to place so much faith a single-payer healthcare system run by the federal government. On what basis can they possibly believe that it will be efficient and/or well-run? These are people who will appropriate and spend $17 billion to force physicians and hospitals to deploy expensive, inefficient and frequently despised and quite possibly even dangerous electronic medical record systems, but they can’t find the money to preserve organs they already paid to transplant once already? Can’t this whole kidney program be considered a rather pure and special form of wasting and abusing taxpayers’ dollars?

Under these circumstances it’s hard to say which is in shorter supply: kidneys or common sense.

Categories : Business and Law, Clinical Care, Economics, Ethics, Healthcare Policy, Politics, The Practice of Medicine, Waste Fraud and Abuse

Feb
24

Will the Ignorant Be Around Even Longer Than the Poor?

by Dr. Doug Perednia

For ye have the poor with you always, and whensoever ye will ye may do them good…

– Mark 14:7

We’ll be the first to admit that there are many, many people who are more observant, eloquent and articulate than we are. Many of those people are physicians. So when one of them speaks up on an important subject that does not normally receive a great deal of attention in the conventional media, it is only right that we try to draw some attention to what they have to say.

This is certainly the case with a comment written by Dr. Edward A. Cutler that we recently read on a physician networking website. It was written in response to a post that expressed the utter frustration felt by a doctor who was taking care of a Medicaid patient who was clearly abusing this publicly funded healthcare system for the poor. Here’s how Dr. Cutler, a pediatrician, responded:

“There are two kinds of Medicaid patients. There are those who need Medicaid and other benefits to get minimal health care, and there are those who simply game the system to get others to pay for their needs while they pay for their wants.

This afternoon I saw Robert, a 19 year-old boy, to re-evaluate his ADHD and to refill his medications. He is home schooled in ECOT, “the electronic classroom of tomorrow,” but he is nowhere near graduating from high school. His parents can barely read or write.

Robert was playing a video game, and I asked him to show it to me. It was so complicated I could not figure it out.

He asked me if I had a Play Station 3, and I replied, “No.” He had one.

He asked me if I had cable TV with hundreds of stations and HBO. I said I did not; he said he did.

He wore better clothes than I have.

He has lived in the same house in The Bottoms for most of his life. His family has section 8 housing and pays about $100 per month to rent it, and gets subsidized utilities, and food stamps. The family of four receives more than $30,000 per year from SSI.

I have lived in the same house in The Bottoms for 30 years. The Bank of America has foreclosed and will not let m pay it off and will probably sell it on Friday. I pay hundreds of dollars per month for property taxes, water, sewer, electricity, and gas.

Robert eats steak, burgers, and a lot of fast food. Often I eat porridge, potatoes, and eggs because they are inexpensive and nutritious.

I asked Robert why his brother, Michael, did not show up for his appointment.

“He had to work,” Robert told me.

“What kind of work does he do?” I asked.

“He is getting $400 tonight for removing some trash from a basement.”

The members of this family let us pay for their needs; they pay for their wants, and they pay plenty.

My next patient was different. Sadie, an eight year-old girl arrived with her father one hour early. Father said they had to walk 4 miles to get here (and it was a cold day) and didn’t know how long it would take and didn’t want to be late.

Their clothes were obviously from the thrift shop, adequate but not stylish.

I asked what they were going to eat for dinner, and they said beans and cornbread.

“Could you schedule next month’s appointment on a Tuesday instead of Monday?” father asked after I gave them a Monday appointment. That way I’ll be able to sell my blood on Monday, and we’ll have the money to take the bus.”

Our challenge is to eliminate freeloaders like the first family without hurting those like the second.”

In terms of Dr. Cutler’s message itself, we really have nothing to add. He is as right as the Earth is round, water is wet and the Sun is bright. However we would like to comment about why his thoughts are so unusual in public discussion, so powerful and so important.

Just about every clinician can tell you stories about patients who might as well be stand-ins for Robert and Sadie. One of the blessings and curses of life as a physician or nurse is that one gets an unadulterated view of people as they really are, warts and all (no pun intended). Quite frankly, this sort of personal, real-life contact is one of the most important things that differentiates those who would be wise from the vast majority of administrators, politicians, academics and the sort of people who would wage class warfare by invoking the sanctity of the “poor” over the greed of the “rich”. If you deal with enough of them, one inevitably comes to realize that the innate behavior of homo sapiens is perfectly immune to petty distinctions such as race, gender, income level or social status. The rich have no monopoly on greed and selfishness, just as the poor have no corner on the market for either hard work or laziness.

These are the sorts of details that never seem to make it into position papers, scholarly books and political discourse, mostly because the people writing them have never actually had to work with whole segments of the population such as the poor, the sick, the addicted, those in private industry. It’s why one can make calculated, meaningless statements like “the rich need to pay their fair share”, while “the poor are just trying to make a living”. “The rich” – especially if you define them as households making over $200,000 per year are no more a homogenous group than “the poor” if you define them as those having an apparent income of $22,350 for a family of four. These things say nothing about the behavior or character or deservedness of the individuals involved any more than the color of their skin.

The heterogeneity that exists within arbitrary groups of people – and conversely the consistency of human behavior across social divides – is typically what dooms most of the well-intended social policies that are broadly intended to benefit those who are perceived to be in need of assistance. This is because the vast majority of these policies assume that the occupants of this group or that are equally needy, and that individual attitudes and behaviors are somehow irrelevant to the desired outcomes. Nowhere is this truer than in healthcare, where individual attitudes and behaviors are often the single most important deciding determinant of who gets sick and who stays well – of which patients incur large costs, and which one utilize care cost-effectively.

One result is that many of society’s efforts are completely unappreciated, and therefore wasted. If individuals do not appreciate or value the resources that they are given, those resources will be squandered. This is especially the case if those resources belong(ed) to other people and frittering them away carries no personal penalty.

A simple example can be seen at a large medical clinic of our acquaintance. As a result of long experience, all of their Medicaid patients are always scheduled at the end of each day? Why? Because 70% of them fail to show up for their appointments; appointments that others would have taken gladly. Management would like to charge a no-show fee in order to motivate patients to keep their appointments, but Medicaid forbids this because the patients are “poor”. But since the no-shows have wasted appointments others could have used, new patients (Medicaid patients included) must wait 2-3 months before they can be seen.

So month after month, some poor people are depriving other poor, sick, and even desperate people of healthcare. Technically this is not a crime, but shouldn’t it be? If the patients who are waiting to be seen suffer a heart attack, or die of their uncontrolled asthma, or wait too long before their cancer is diagnosed, who really killed them? Was it the unthinking, uncaring people who used up all of the appointments without keeping them, or the people in state government and Medicaid who decreed that there should be no consequences for depriving others of the care they needed?

This is problem with governing from an ivory tower, or even running a political campaign from one. All of those nice, stereotyping generalizations one makes to establish policy from the far right or the far left simply don’t survive their first encounter the messy reality of human nature. Not in medicine. Not in anything. People who try to make policy that way may or may not be well-intentioned, but they are certainly ignorant. Even worse, we let them keep trying it over and over and over again.

Dr. Cutler’s challenge to all of us is to resist the urge to think of how to fix groups, and concentrate on fixing individuals. This means holding people accountable for their actions as individuals. Oh sure, it’s not as easy as blithely throwing other people’s time and money at a problem. But in the long run, it’s the only thing that’s ever going to work.

[Ed. note: Many thanks to Dr. Cutler for allowing us to reprint his comments here.]

Categories : Clinical Care, Economics, Ethics, Healthcare Policy, Personal Responsibility, Political Hellth, Politics, The Practice of Medicine

Author Archive for Dr. Doug Perednia – Page 2

Carefully Crafting the Politically Correct Physician

Medical Specialty Certification Exams: The Real Scandal

Two Interesting Posts That Mosey Down the Road to Hellth

Year After Year, Medicare Keeps Flushing Perfectly Good Kidneys (and Dollars) Down the Drain

Will the Ignorant Be Around Even Longer Than the Poor?

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