'It was a bungee cord accident and I'm having trouble bouncing back.'

‘It was a bungee cord accident and I’m having trouble bouncing back.’

Recently at morning report:

Resident: The patient is a 66 year old woman who had pneumonia and has pretty bad dementia and congestive heart failure and was just discharged from our service 7 days ago. Her family brought her back in.  They had her meds all messed up.

When I was a medical student at Charity Hospital in New Orleans it was also known as The Big Free. The hospital name was derived from the order of religious sisters initially brought in to nurse those in the hospital back to health, the Daughters of Charity. The nickname was derived from the fact that there were no charges generated for the care delivered (Free) and the fact that Huey Long built a series of smaller hospitals throughout the state (Little Charities) that provide less comprehensive care.

Resident: Somehow they gave her the antibiotics but forgot to give the diuretic.

We were not introduced to the concept that care costs money in the entire of medical school. People were admitted, people were discharged, procedures were learned, people were readmitted and no bills were generated. I left medical school knowing little about cost. Fortunately for my patients, because no bills were generated, only the state of Louisiana was responsible for the costs my mistakes generated.

In almost all training programs up until very recently, when a patient came back, whether it was the care team’s mistake or the fault of the patient, it was “bounced back” to the previous team. This at worst meant you had one extra patient on your service and, if the patient had insurance, turns out the hospital made extra money. In some cases lots of money.

A 2009 study published in the New England Journal of Medicine analyzed almost 12 million Medicare beneficiaries and found that approximately one-fifth were readmitted within 30 days of discharge and an even more alarming 34 percent were admitted in 90 days. Wait, it gets worse. If we look a year out from discharge they reported 67.1 percent who had been discharged for a medical condition had been readmitted or had died. This revolving door is expensive and cost Medicare $17.4 billion dollars in 2004.

Beginning 2 years ago, Medicare began docking the pay of those hospitals that have a lot of “bounce backs.” Hospital administrators  were not happy about this. “There are things we don’t control, and we certainly don’t control patient behavior either,” said Nancy Pratt, chief quality and patient safety officer for Irvine, Calif.-based St. Joseph Health System. “You could do everything right and still end up having a patient readmitted.”

Me: People just don’t forget. That’ll count against us.

Resident: Well it was on the medication reconciliation. The visiting nurse went by the house and went over the meds. I don’t know what else we can do short of putting it in her mouth ourselves.

In the post ACA world, there are no more mulligans. More and more, the care delivery system is taking responsibility for the totality of the care. Hospitals are trying a lot of things in addition to reconciling meds, such as discharge coaching and post-discharge phone contact.

Systems engaged in reducing readmissions are now realizing that the cost of care is not random but is aggregated into a very small number of patients. In this recent article from the New England Journal, investigators in Massachusetts (where there is close to 100% coverage) found that, depending on insurance, the costliest 1% of people accounted for between 14% and 22% of total costs. To reduce readmission in this cohort, care delivery systems would have to provide services such as nurse care managers to work with high-risk Medicare patients, integrating mental health services into broader care-coordination and disease-management models for Medicaid patients, and improved access to low cost specialty pharmaceuticals for young folks with severe illnesses.

Improved care delivery just went from a liability (we make our money off repeat customers) to an asset. As the NEJM authors wrote, As reform activities shift payment away from fee-for-service models, the incentives to improve care for high-cost patients will continue to grow.” Now we have the opportunity to not only teach the importance of keeping folks out of the hospital, but get paid for it as well.

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Donald Trump and Hillary Clinton were walking down the street when they came to a homeless person. Trump gave the homeless person his business card and told him to come to his office for a job. He then took $20 out of his pocket and gave it to the homeless person.

Hillary was very impressed, so when they came to another homeless person, she decided to help. She walked over to the homeless person and gave him directions to the welfare office. She then reached into Trump’s pocket and got out $20. She kept $15 for her administrative fees and gave the homeless person $5.00.

Joke” on the internets

Chronic homelessness is a complex problem. In 2006 Malcom Gladwell told the story of “Million Dollar Murray.” Murray was a gentleman who lived in Reno, Nevada, and had a major substance abuse problem. A veteran who learned to cook while in the service, Murray had two personalities. When drinking, he drank a lot. He was arrested a lot. He ended up in the emergency room a lot and, in fact, someone did the math and it was calculated that during one binge he cost over $1,000,000 in services. When supervised, sober and in housing supplied by an agency, he cooked well. He made money. He would be released on good behavior and go back to drinking. A lot.

Malcolm Gladwell points out that most people who are ever homeless are homeless for 1 day. The second most popular number for “days homeless” is 2 days. Murray’s case, though not typical for homelessness, was typical for expensive homelessness.

It’s a matter of a few hard cases, and that’s good news, because when a problem is that concentrated you can wrap your arms around it and think about solving it. The bad news is that those few hard cases are hard. They are falling-down drunks with liver disease and complex infections and mental illness. They need time and attention and lots of money. But enormous sums of money are already being spent on the chronically homeless, and Culhane saw that the kind of money it would take to solve the homeless problem could well be less than the kind of money it took to ignore it. Murray Barr used more health-care dollars, after all, than almost anyone in the state of Nevada. It would probably have been cheaper to give him a full-time nurse and his own apartment.

As told in this article, the George W. Bush administration looked into the chronic housing problem with the lens described by Malcom Gladwell. They found that $10,000 targeted towards these hard cases through housing subsidies could save the government several hundred thousand dollars. This money did not go to making them less dependent on substances. It did not go to giving them employment skills. It went to housing…and it worked:

In terms of impact, the number of chronically homeless people living in the nation’s streets and shelters had dropped by about 30% – to 123,833 from 175,914 – between 2005 and 2007, which policy makers attributed in part to the effectiveness of Housing First

Today that number is a little more than 100,000 with the number of homeless vets (not necessarily chronically homeless) being 40,000.

Why are we not celebrating this success?

From the right side of the aisle, it was seen as a “give away.” It reflected a paradigm shift in housing, the movement away from emphasizing “housing readiness” to offering low demand permanent housing solutions. Though it fixed the problem, it fixed it by giving housing to those who could not control themselves, thus exacerbating the feelings of unfairness amongst those who “play by the rules.”  From the left, Housing First has been criticized on its failure to address broader service outcomes, particularly substance abuse issues. It was seen as a market based solution (these folks cost us less money now) which didn’t address broader issues of equity and values.
John Maynard Keynes said “there is nothing a politician likes so little as to be well informed; it makes decision-making so complex and difficult.” The appeal of many of the current politicians is their willingness to ignore evidence as they pursue policies which have broad, superficial appeal. Homelessness rises to the level of public awareness when the tourists feel bullied or otherwise threatened (see comments following this article). One can only hope that our core values will come through as we work through this election cycle.
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“Of the many painters I have known, almost all I found unhealthy … If we search for the cause of the cachectic and colorless appearance of the painters, as well as the melancholy feelings that they are so often victims of, we should look no further than the harmful nature of the pigments…”

Italian physician Bernardinus Ramazzini in De Morbis Artificum Diatriba

Humans have had  love-hate relationship with lead. Easy to find and convert from an ore to a malleable metal, lead was in cosmetics, eating utensils, and used to create the pipes that move water from the Alps to Rome. The Romans were not universally impressed. Per Vitruvius:

“Water conducted through earthen pipes is more wholesome than that through lead; indeed that conveyed in lead must be injurious, because from it white lead [ceruse or lead carbonate, PbCO3] is obtained, and this is said to be injurious to the human system. Hence, if what is generated from it is pernicious, there can be no doubt that itself cannot be a wholesome body. “

We now know that lead poisoning, or plumbism, is a very real problem (image from Wikipedia).

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For those of us who live in older houses, lead is a constant concern. Our pipes are made of lead, there is lead in our paint, there is lead on the dirt from leaded gasoline. My children were at continuous risk from lead growing up. From the CDC:

Lead-based paint and lead contaminated dust are the most hazardous sources of lead for U.S. children. Lead-based paints were banned for use in housing in 1978. All houses built before 1978 are likely to contain some lead-based paint. However, it is the deterioration of this paint that causes a problem. Approximately 24 million housing units have deteriorated leaded paint and elevated levels of lead-contaminated house dust. More than 4 million of these dwellings are homes to one or more young children.

What those of us who live in old houses and old cities know is that lead much less of a problem if you leave it alone. As long as  the paint is not peeling, the kids won’t eat it. As long as the dirt is not disturbed, the kids (who always eat dirt) will only eat lead free dirt. As long as the pipes are not disturbed, the water will be lead free. Those of us that live in older cities rely on the water board to do the right thing and not create a problem where none exists. And it turns out there is a lot they need to take into consideration.

Flint Michigan is an old city full of old houses. The older houses were mostly lived in by poor people, who unfortunately were living in a town with an infrastructure built for many, many more people than are currently living there, making the infrastructure very expensive. The people, unable to pay for existing services, were taken over by the state. The state, in a story worth reading, elected to go with cheaper drinking water from the Flint River. The cheaper drinking water, in a predictable chemical reaction, leached the lead out of the pipes and put it into people’s drinking water.

What are the lessons to learn? First, our public infrastructure is aging and that will affect people’s health. Clean water and sanitary sewer systems were a game changer in the 1880s but that was 100 years ago. We need to pay attention. Second, poor people are disproportionately affected by our failing infrastructure. They are more likely to live in poor cities and more likely to live in older neighborhoods. Third, listen to the patient/constituent. The state of Michigan looks especially bad because they tried to substitute toxic waste  for water and when people caught on they tried to cover it up.

Hopefully, Flint will overcome this though it may not be financially feasible to rebuild the water delivery system. I only hope leaders in other towns with aging infrastructures (such as Mobile) heed the warning.

 

 

 

 

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Snake oil” was brought over by the Chinese in the 1800s as a traditional cure. As it turns out, the oil was found to be very effective for the aches and pains associated with doing labor such as, well, building a railroad across America. As this is what the Chinese were doing, they found it very valuable. They also shared it with their non-Chinese counterparts, who found it to be a useful salve as well. Unfortunately for snake oil users, extracting oil from Chinese snakes (or pretty much any snake) in America was tough. Selling snake oil was not. Witness the story of Clark Stanley, aka The Rattlesnake King:

“[Stanley] reached into a sack, plucked out a snake, slit it open and plunged it into boiling water. When the fat rose to the top, he skimmed it off and used it on the spot to create ‘Stanley’s Snake Oil,’ a liniment that was immediately snapped up by the throng that had gathered to watch the spectacle.”

Rattlesnakes, as it turns out, are missing the anti-inflammatory properties of Chinese water snakes. Since Stanley didn’t put any snake in his snake oil, the oil was remarkable ineffective but very lucrative for Stanley.

The evidence based medicine movement, now 20 years old,  helped us to focus our efforts on “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research.” Our attention is now focused on things like “is the patient’s diabetes under control” as opposed to “should I use the latest new drug that the nice rep lady came and told me about.” A blow against snakeless snake oil.

The extension of this movement is focusing us on quality. We are now looking at the quality implications of analyzing large numbers to determine small differences in outcomes. For example, a certain surgeon might have an infection rate of 10% and another of 5%. If this difference is not due to dirtier patients (the surgeon only operates on people who fall in sewers), a patient will likely choose to go to the one with the better outcomes. This data is now becoming available from the federal government from Medicare. For example, hospital outcomes for Medicare patients can be found here.  The score care for orthopedic surgeons replacing hips and knees can be found here. These, data, though useful, only paint a partial picture. The hospitals and the surgeons take care of folks other than Medicare so the truth, although likely present in the data, may be difficult to pull out.

For certain types of procedures a more complete picture can be obtained. If only a few places do a procedure, for example, and they keep track of their outcomes, then folks can see how the program performs over time. Such was the case with pediatric heart operation in Florida. Children’s Medical Services, a state agency that pays for the bulk of the services provided to children with congenital defects, had been quietly tracking information and collecting data of years on heart surgeries done to small children as part of a quality initiative. In information obtained by CNN, about 2300 such procedures were done in eight Florida hospitals from 2011 to 2014, with 4 of the hospitals accounting for over 90% of the cases. These procedures can be very lucrative, bringing in over $500,000 for each operation. The reason CNN began looking into this is because St Mary’s hospital in Palm Beach, one of the low volume programs that was trying to build business, had an extraordinarily high death rate. The rate was even higher than it appeared because several dying patients were transferred to other hospitals immediately prior to death, unusual in a center that performs such complex procedures. Also unusual was when a quality panel was called in and made recommendations on how to fix the problem including not operating on some of the more complex cases, the recommendations appeared not to be followed.  Lastly, unusual because the hospital’s parent company gave money to the governor and, coincidentally, the quality panel which tried to keep the hospital from doing operations they were bad at (and which the governor had created) was disbanded because it had no statutory authority. The hospital eventually did closed their pediatric cardiac surgery program, the CEO resigned, and the physician is giving depositions while being protected by armed security guards in case you were concerned. Florida’s side of the mess can be found here.

The CNN story begins with a mother whose child has just been paralyzed and, in the elevator, she has the following exchange:

“Do you know a child with a heart problem here?” asked the stranger.

“Yes. My daughter,” McCarthy answered, and explained what had happened to Layla.

“You need to get her out of here,” the stranger warned.

The hospital had not revealed their their pediatric cardiothoracic surgery team’s low volume,  complication rate, or inexperience to prospective patients. If patients had looked, they would have found outcomes for the 4 high volume Florida programs posted on the internet (here is the one from Nicklaus Children’s). St Mary’s, rather than posting quality data, posted releases heralding the arrival of “nationally renowned pediatric heart surgeon Dr. Michael Black” with glowing claims such as “smaller incisions — improved self-esteem.”

In this era of complex care, the great doctor has been supplanted by the great team. Great teams keep score. Hiding poor quality as an institution is  akin to selling snakeless snake oil. Consumers for elective procedures should demand to know outcomes. Those who insist on keeping their data to themselves should not have the privilege of your business. Et qui vendit pellucidum. Insist on knowing how much snake is in your snake oil.

 

 

 

From a very good article regarding Obama’s legacy in Politico found here:

  1. First, through the use of the stimulus money, his administration  created the infrastructure necessary for change:

A $25 billion incentive program in the stimulus for health information technology has helped drag a pen-and-paper medical system into the digital age, with adoption soaring from about 10 percent of hospitals and 20 percent of doctors in 2008 to about 80 percent of hospitals and 80 percent of doctors today. E-prescriptions are ubiquitous, and digitization is already reducing fatal errors and unnecessary tests caused by sloppy handwriting and inaccessible files. There have been problems getting electronic systems to talk to each other, sparking a backlash of sorts from irritated doctors, but Farzad Mostashari, Obama’s former health IT czar, is confident online medicine will inevitably produce the efficiencies common in online banking and dating.

2. Then, with the ACA,  a plan to improve access was implemented to address the game of uninsured “hot potato”:

It has already extended medical coverage to some 18 million uninsured Americans. It also closed loopholes that insurers used to deny coverage to insured Americans when they got sick. And it eliminated co-payments for quit-smoking programs, birth control pills, certain cancer screenings and other preventive care. As Obama has suggested, it’s what he was talking about when he talked about change.

3. Despite the reality that the right had no stomach for system change and the left had no stomach for cost controls, the majority of the ACA was about those two things. Improving the care delivery system was attempted by putting every idea, good or bad, tried or not, into the law and incenting folks to “don’t just stand there, do something.” Amazingly, it is working. First, the cost side:

Less than one-fourth of the bill was devoted to access. The rest was stuffed with almost every cost-control idea in circulation, from new competitive bidding rules for wheelchairs to a government Innovation Center to test new payment models to a “Cadillac tax” on pricey employer-sponsored plans. “We did a smorgasbord of just about everything people thought could conceivably help,” says Peter Orszag, Obama’s former budget director.

And so far, the cost curve is bending even faster than White House officials had dreamed. Health care is still getting more expensive, but since 2010, the growth rate has slowed so drastically that the Congressional Budget Office has slashed its projection for government health spending in 2020 by $175 billion. That’s enough to fund the Navy for a year, or the EPA for two decades. “We wanted to throw a whole bunch of stuff against the wall to see if any of it would stick, which probably sounded bogus,” Orszag says. “But if these results continue, they’ll fundamentally change the fiscal trajectory of the country.”

And on the quality side:

One recent report found that infections and other “hospital-acquired conditions” have declined 17 percent since 2010, when Obamacare created financial incentives for hospitals to avoid them. That reduction saved an estimated 87,000 lives and $20 billion. A similar effort to incentivize better management of discharged patients has coincided with a decline in hospital readmission rates that’s keeping 150,000 more Medicare patients at home every day, according to Meena Seshamani, director of the administration’s Office of Health Reform.

When put together, it is leading to a much more rational system. Maryland, for example, is experimenting with an “all payers” system:

A recent New England Journal of Medicine article found the state’s hospital costs increased at less than half the expected rate in the program’s first year, saving Medicare $116 million.

And everywhere there are changes to change the payment from one of paying for volume to paying for value:

There are signs that Obama’s convoluted jumble of changes may be starting to rationalize an irrational system. Patrick Conway, the director of the new innovation center, told me about a new Independence at Home experiment that coordinates nurse and doctor visits for frail and disabled patients—and saved Medicare $3,000 per beneficiary in its first year. One elderly diabetic who had 19 hospitalizations the previous year had only one after enrolling in the program.

When Medicare was signed into law, I guess they could have called it LBJCare. Today, no matter what it is called, no one is calling for us to put Grandma back in the attic and let her die. Medicare is here to stay. I suspect that 20 years from now, no one will even think about going back to volume based care delivery with rationing based on income and willingness to pay. Wonder what we will call our care delivery sustem?

edu93Charity Hospital in New Orleans was an incredible place for learning clinical medicine in the 1980s, a veritable clinical playground.  As a third year medical student I was required to do difficult blood draws, put in central lines, and other tasks after seeing someone else do one (the phrase is  “see one, do one, teach one”). In addition, I was called upon to write orders for antibiotics and do other “doctor” things which taught me responsibility, with my role increasing as I become more experienced. It was, however, a playground that was largely unsupervised.To say that supervision was limited was, well, charitable. We saw the attendings maybe once a week in the clinical wards. The residents were overwhelmed, leaving much of the work and the decision making to the medical students. As a student I grew up fast but often acted with little clinical seasoning and limited information.

Mostly what I remember is being scared that I would miss something. We had lectures in every clinical specialty but I remember them as being esoteric. at best. The Starling curve, while unquestionably amazing and unfailingly covered once a week, had little to do with what the Lasix dose should be in heart failure (for this particular drug the “Fat Man’s law” was much more useful). When I discovered the lectures were less useful than a work of fiction, I really panicked.

What did I use? For Internal Medicine, there were two great books. Harrison’s was written by a gentleman named Tinsley Harrison who had by that time made his way to UAB. Cecil’s was written by another guy (named Cecil, I believe). They covered the same material and were each over 1000 pages in length. I had classmates that read them both, in case there were discrepancies. The Washington Manual  was written by some residents at Washington University (St Louis). My attendings looked down on it because it was lacking the academic rigor of Harrison’s or Cecil’s. I found it very useful at 0:darkthirty with a sick patient and not much time. If we had time, we went to the library. There was a multi-volume set,  the Index Medicus, where one could look up a factoid using key words and track it to the source.

In addition, we used each other. We would ask each other  “Hey, what do you think about…” and reassure ourselves that whatever course we decided on was the best one. We would then get the opportunity to defend ourselves in the cold light of day, always being asked for our source of information. We never claimed our colleagues as the source.

Which brings us to yesterday. I was the attending (Attendings now round every day) and their was a question about optimum antibiotic selection for a neonate with a fever. No textbooks. No manuals. Cellphones and tablets came out, databases were consulted (along with Up To Date) and within 3 minutes an evidence based answer was obtained (in fact, I won the mad google prize by getting to it in 3 clicks). Patient received optimum treatment less than 3 minutes after the treatment course was decided.

From the literature, it was clear that the Cecil’s/Harrison’s/Index Medicus skills used in residency did not move with the physician to private practice but asking a colleagues (or drug reps) opinion did. I am hopeful that mad googling skills will.

 

 

 

'Ms. Smith, I have a meeting in ten minutes and I can't find my hidden agenda.'

Discussion in medical school admissions committee:

Colleague: So I asked him “just why do you think you want to be a doctor” and he said, “Oh, you know, I like science, want to help people , like to problem solve.”

Me: I just learned about a new term called “the consent agenda.” In a meeting, if there is stuff everyone agrees on, you put it on the agenda as “consent items.” Then, with no discussion it can pass and you can move on to discussing something germane. I propose we notify all students that love of science, helping people, and problem solving are consent items. Then, we need to find out, how does this person know they REALLY want to be a doctor?

I just learned about this web site called DOC. DOC stands for “Drop Out Club” and it exists to help people transition from clinical medicine into a non-clinical arena such as management or sales. On their web site they say that the “name reflects the sentiment at our original gathering that no clear support systems existed for the paths we were pursuing.”

The site has about 10,000 members, although some may be lurkers like me. The forum at the site is full of folks who feel like they have made a terrible mistake with their lives and are looking for a way out. Many are in residency with statements like “I look around and can’t see myself doing this for the rest of my life” predominating.

Physician career dissatisfaction is a real problem. About 400 physicians commit suicide each year. Suicide is the number 2 cause of death in medical students (following accidents, some of which are also likely suicide). This is thought to be a consequence of underdiagnosed depression, almost certainly made worse by a rapid and monumental debt accumulation. In addition, I will concede that a love of science, a desire to help people, and a joy of problem solving are all good attributes. Unfortunately, they are not sufficient to combat an inchoate  fear that you are 5 years and $300,000 into a terrible, terrible mistake.  And it starts early, also:

A study of all medical students in the United States found that about 49.6% of medical students met the criteria for burn out and 51.3% for depression. Trust me—it’s not all from studying, but from being treated like crap, feeling like we can never make a mistake or ask for help and wondering if anything we do will help to change the status quo or are we just cogs in a wheel trying to crush us.

Approximately 15 years ago, Don Berwick outlined the triple aim for improving healthcare in this country – enhancing patient experience, improving population health, and reducing costs. Tom Bodenheimer recently outlined a fourth aim – improving the work life of health care providers, including clinicians and staff. He identifies the following as some of six things we can do in primary care to keep our colleagues engaged and off the DOC website:

  • Reduce the burden on the physician through team documentation: An encouraging trend I have seen among pre-med students is their being engaged as scribes. This way they get to learn what it is really like to be a physician by being a part of the team and the physician gets to go home without having to do two hours worth of charting after dinner.

  • Expand roles allowing nurses and medical assistants to assume responsibility for preventive care and chronic care health coaching under physician-written standing orders. Things that are automated should happen automatically with the physician not being a barrier to good preventive care. We need to model this for students

  • Co-locate teams so that physicians work in the same space as their team members; this has been shown to increase efficiency and save 30 minutes of physician time per day. We have gotten rid of the office in our practice. The physician work space is a shared space where interaction can occur. It is really important to level the field.

  • To avoid shifting burnout from physicians to practice staff, ensure that staff who assume new responsibilities are well-trained and understand that they are contributing to the health of their patients and that unnecessary work is reengineered out of the practice. This holds true for student members of the team as well. They need to understand their role in care delivery as part of the stress of being a student is constantly being thrown into a new environment.

In short, what we as educators need to do is make sure students understand what they are getting themselves into and make sure they have the tools necessary to do the tasks they are assigned. What students need to do is look away from the books and understand that this is not about science or helping people but is about acquiring the skills to enter into a very difficult profession. While interviewing a residency candidate  for our residency it came out that she had been to cosmetology school and had cut hair at Walmart for 2 years. I asked her what the best thing she had learned from that experience was, and she said “When people sit down in that chair and say ‘do whatever you want,’ they don’t mean it.” I suspect she won’t burn out.

 

Person at a cocktail party to me: Do you think the Governor will expand Medicaid

Me to the person: If the past is prelude I think he will consider it for another two years then let the next governor decide, thus allowing many more people to be killed by lack of access to health care in Alabama then will ever be killed by terrorists in Alabama.

The Governor couldn’t decide what to do about Obamacare and poor people so he appointed a task force. His call made it pretty clear that, although Obamacare wasn’t the answer, there were indeed questions that needed to be answered. In the “Whereas” section, for example:

  • Shortages of healthcare professionals in 65 of 67 counties
  • 40th out of 50 states in primary care physicians
  • 594.000 working people between the ages of 50 and 64 wihtout health insurance
  • 10 hospitals closed in the past 3 years
  • etc, etc, etc

The task force met off and on for about 6 months and had one recommendation:

  • Find a way to close coverage gap that makes health insurance inaccessible to hundreds of thousands of Alabamians.

They didn’t specifically say “the medicaid expansion as written into the Affordable Care Act (Obamacare) will solve 90% of the “Whereas”s” but they, by recommending this one thing, got awfully close.

The Alabama TEA Party response was posted on-line last week. Consistent with the national talking points, it goes something like:

We Alabamians pay enough taxes and would rather keep people with mental illness in jails, have hospitals go under, and allow people to avoid health care and die of treatable illnesses because of fear of bankruptcy rather than pay an extra $10 a year per person in taxes because we are TAXED ENOUGH ALREADY.

Fittingly, on the TEA party editorial page was an advertisement for Farxiga. which made the list of Huff Po’s worst drugs of 2014:

But the more frightening news is that patients taking Farxiga in studies done for the FDA were more than five times more likely to contract bladder cancer than the patients who took an older diabetes drug.

Priced at only $10 a day and advertised as first line treatment, I am sure it’ll end up in many physician’s sample closets. Uninsured patients with diabetes, then, who are unable to afford insulin (which is surprisingly expensive) will get lots of Farxiga samples. With any luck, they will contract bladder cancer. Because they are lucky enough to get cancer, assuming the blood in their urine scares them enough to seek care AND assuming they can find a urologist who will scope them on credit, become Medicaid eligible in Alabama. Then they can get insulin for their diabetes and get their bladder cancer treated. Don’t know why the task force didn’t recommend this, instead.

From the Montgomery Advertiser:

MONTGOMERY — Gov. Robert Bentley said Thursday after a speech at a legal conference that his administration is considering expansion of Alabama’s Medicaid program, but has not made a final decision.

Bentley said he was concerned about the health care access for the state’s working poor and rural health care infrastructure.

However, Bentley said a stumbling block is figuring out a way to fund the state’s share of costs.

Thirty states have expanded Medicaid under President Obama’s health care law.

The governor has previously said he might support a state-designed program with work and premium requirements on recipients.

Remind the governor that the state needs this and that states that have expanded have seen increased tax revenue and lower costs of care for their citizens.

From Kaiser Family Foundation

If all states accepted the expansion:

  • The number of nonelderly people enrolled in Medicaid would increase by nearly 7 million, or 40 percent.
  • 4.3 million fewer people would be uninsured.
  • There would be $472 billion more federal Medicaid spending from 2015 to 2024.
  • States would spend $38 billion more on Medicaid from 2015 to 2024.
  • Savings on reduced uncompensated care would offset between 13 and 25 percent of that additional state spending.
  • States would be able to realize other types of budgetary savings if they expanded Medicaid that are not included in this report.

Remind the governor that a major cause of bankruptcy is unpaid medical bills from catastrophic illnesses and Medicaid protects people from this and in general people with Medicaid get better quicker.

From Urban Institute

Why insurance is important for folks:

Uninsured people receive less medical care and less timely care, they have worse health outcomes, and lack of insurance is a fiscal burden for them and their families. Moreover, the benefits of expanding coverage outweigh the costs for added services. Safety-net care from hospitals and clinics improves access to care but does not fully substitute for health insurance.

And let the governor know that despite the beliefs of our delegation, “repeal and replace” is not an option in Congress so let’s work with what we can get:

From The Hill

Repealing the Medicaid expansion is a dicey proposition for endangered Senate incumbents running in four states: Illinois, Ohio, New Hampshire and Pennsylvania, all of which broadened Medicaid.

Another Senate Republican, speaking on condition of anonymity, expressed concern that states that expanded Medicaid would be penalized by billions of dollars if Congress repealed the federal assistance.

“Repealing the Medicaid expansion is not going to be in there because it’s too problematic for many Republicans,” said the lawmaker, adding, “I don’t want to stick the state with the bill.”

Here is the governor’s contact information. Let him know what you think.

What should be huge medical news is that the mortality rate (the rate at which people die) for white men and women aged 45 to 54 with less than a college education is rising in this country. This despite all the money that is spent on health care. This just does not happen. Why is this? Per the Washington Post:

“Drugs and alcohol, and suicide . . . are clearly the proximate cause,” said Angus Deaton, the 2015 Nobel laureate in economics, who co-authored the paper with his wife, Anne Case. Both are economics professors at Princeton University.

Whitedeath2

And we are talking about a lot of excess deaths

Based on the findings, Deaton and Case calculated that 488,500 Americans had died during that period who would have been alive if the trend hadn’t reversed.

There is a lot of speculation about the exact why and more studies are certain to follow, It is clear that the economic recovery has left these people behind and it is also clear that the safety net, including mental health but also including meaningful retraining, has not been effective for this group of people. For now, as a physician I need to do a better job of screening for pathological substance use and mental illness, As citizens we all need to advocate for more, not less, support services for this at risk population. As people, we can all say out neighbor “Is there anything I can do to help?”

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