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My first wife died almost 4 years ago, in April. She was 55 years old when she died. Her life story was remarkable in and of itself, one in which I was fortunate to play a part. Her story began, it turns out, with a natural experiment.

First, she was taken from her biological mother and placed in foster care for several months. Second, her adoptive parents were carefully selected. They were screened for resemblance (white but not too white), religion (not Catholic), and temperament.  Third, little Delphine had the full 1960’s data wipe. Her birth certificate was changed to reflect her adoptive parents and new name (Danielle). The date and size (I suppose) remained the same but the hospital, mother’s city of birth, father’s name, and any other detail was transferred over then attested to be the truth by the Orleans Parish registrar. She was a tabula rosa, existing to be filled out with the essence of Bev and Hank. She was one of 100,000 “closed adoptions” in 1961.

How did this experiment turn out? By the 1970’s, adoptees (mostly post WWII babies) were clamoring for personal information. Many were unhappy with their wiped identity. By the 1980s registries popped up and birth parents were allowed to register as were adoptees. By the 1990s most adoptions had some degree of openness. With the advent of 23 and Me, there were no secrets. Most adoptions now include some degree of openness.

Well, we really don’t know how the “taking away of babies and wiping them clean” experiment worked out because it wasn’t treated as an experiment. The societal belief  was that being taken out of a house where one is unwanted and being placed in a loving, nurturing environment would always be a good thing. Perhaps we should have looked more closely.

But a research brief published in October by the Institute for Family Studies threw a bit of cold water on this fantasy. The report, written by psychologist Nicholas Zill, was sobering: At the start of kindergarten, about one in four adopted children has a diagnosed disability, twice the rate of children being raised by both biological parents. Adopted children were significantly likelier than birth children to have behavior and learning problems; teachers reported they were worse at paying attention in class, and less able to persevere on difficult tasks.

In Danielle’s case, she found her birth mother (Pat) when we were in our 30s and had just moved back to Mobile. Or, rather, her birth family found her. At the reunion (on Royal Street during Mardi Gras), I knew that the slate was never wiped clean, despite the efforts of the state of Louisiana. Where Bev was shrewd, Pat was open (like Danielle). Where Bev was practical, Pat was creative (like Danielle). Where Bev was closed, Pat was open. Where Bev used soaps whose smells I found irritating, Pat used THE SAME SOAP AS DANIELLE. Oddly enough, Pat was 55 years old when she died.

The tabula rosa thing was not studied as an experiment. Why study something we knew “felt right?”  The closest science came to looking at this was the Minnesota Study of Twins Reared Apart. These investigators look at closed adoptions where twins were taken from families and raised as singletons. They have found that genetic factors appear to influence personality, mental, and activity-level changes as adults become older, to the tune of half. Yup, turns out you can only wipe the slate 50% clean.

One example of the amazing similarity of twins reared apart is the so-called “Jim twins”. These twins were adopted at the age of four weeks. Both of the adopting couples, unknown to each other, named their son James. Upon reunion of the twins when they were 39 years old, Jim and Jim have learned that:

  • Both twins are married to women named Betty and divorced from women named Linda.
  • One has named his first son James Alan while the other named his first son James Allan.
  • Both twins have an adopted brother whose name is Larry.
  • Both named their pet dog “Toy.”
  • Both had some law-enforcement training and had been a part-time deputy sheriff in Ohio.
  • Each did poorly in spelling and well in math.
  • Each did carpentry, mechanical drawing, and block lettering.
  • Each vacation in Florida in the same three-block-long beach area.
  • Both twins began suffering from tension headaches at eighteen, gained ten pounds at the same time, and are six feet tall and 180 pounds.

Closed adoption have not stopped. This is because when people look at a newborn they don’t see a thing half full of mom and dad but believe they are viewing a tabula rosa, despite evidence to the contrary.

Why think about natural studies? Because we are about to embark on one in this country around Covid-19 spread. What we know is that, left unchecked, every person with Covid-19 infects about 3 other folks and they infect 3 other folks, and so on until the whole world is infected and about 2% of the world is dead. That is, unless, the person who is infected stays home AND the person who is not infected doesn’t come into contact with an infected person. This breakage in the chain of infection has occurred because of shelter in place severe social distancing. Currently, this is a nationwide effort. As we reach the end of this phase, we are about to see 50 states going in different directions. The East Coast and West Coast states, for the most part, seem poised to maintain distancing for a bit longer, test a lot of folks, and chase down those that are infected to keep them from restarting the chain of infection. We on the Gulf Coast seem poised to demand an end to social distancing, eschew testing, hit the beaches and the baseball stadiums, and blame Barack Obama for the destruction of the economy.

Many are looking at this Covid-19 crisis through a different lens than I. What I see is a broken the chain of infection. What I see is a virus that is deadly and lurking, waiting for the chain of infection to be re-activated. We are about to embark on a natural experiment. Those of us whose neighbors look around and see conspiracy may bring Covid-19 deaths back into our nursing homes. I only hope we are measuring what happens.

 

My, how time flies when you are having fun. As president of our national organization of Family Medicine Department chairs, I had the opportunity to lead our group in a discussion regarding the response to Covid-19. As a work product (a great meeting BINGO word) we created a to do list for America (found here). We are now 3 weeks, 500,000 cases, and 20,000 additional deaths from the publication of this work product. How did we do?

  1. 4 week shelter in place order for all jurisdictions – as of April 7th, at least 316 million people in at least 42 statesthree countiesnine citiesthe District of Columbia and Puerto Rico are being urged to stay home. This is up from 9 states on March 23. While correlation does not prove causality, at least we were on the leading edge of recommendations. It is believed that this action saved (or will save) over a million lives in this country.
  2. Training and deploying a cadre of individuals capable of contact tracing and dramatically increasing access to testing – This will be vital to the SUCCESSFUL reopening of the country. As of today we have tested 3,000,000 Americans over the course of the outbreak. While a big number, in a country of 325 million people, not so many. We need to test close to 2,000,000 folks PER WEEK. We need to test people who have fevers. We need to test people who have been with someone with a fever. We need to test people who work in nursing homes. We also need to, once we find a positive, go and make sure that they are quarantined AND THEN TEST THEIR CONTACTS. This is a skill set that many in public health have allowed to atrophy since infectious disease became unsexy. If we were good at this, syphilis would not be a problem. For Covid control if we were to open the country, everybody would need to be tested approximately every 2 weeks with adequate investigators for the positives.
  3. Adequate personal protective equipment. – As someone who trains medical learners, this is near and dear to my heart. It is unclear how many health care workers, first responders, even grocery workers have been infected in their line of work. This is due to a broken supply chain, inadequate planning, and an inability to plan for the “unthinkable.” The CDC, on April 3rd, issued guidance on reusing “single use” equipment, One can only hope that we are working to adequately protect our health care workers. While there are many feel good stories about folks repurposing their plants to make eye protectors, there are many more about the lack of PPE and the fear that care delivery workers carry home with them.

So, now what? Hopefully we will continue to shelter in place, obtain testing and case finding to allow us to open the country, and obtain adequate PPE to protect vital workers. Fact is, Covid-19 is a disease that has no effective treatment and when fully manifested does not respond well to supportive care. It kills very few people in their 30s, more in their 40s, and so on until the population gets to be around 80, where 20% of those who develop an infection will die. For most of these older folks, besides protecting them from the virus we cannot alter the course of the disease

What can we do? To quote one of America’s great physicians, Sir William quote Osler, “Ask not what disease the person has, but rather what person the disease has”. The reality is we as caregivers are back in the era of “The Doctor.” I took some time today to read the bio’s of the Covid victims and I recommend you all do the same. Honor the victims. Let’s take some time to remember the people we care for, despite the isolation.

This is not about an invisible enemy except in that if you remain isolated you will not encounter it. This is about an insidious disease that is brought to our patients because of the efficient way we care for them (nursing homes, group homes), the way we ask them to work (low wages, no health insurance, limited childcare, no sick leave), and the limited information we give them (let’s reopen the economy). We need to fight THOSE enemies.

 

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The group of academic family physicians that I have the honor of leading this year have found themselves in the midst of a Covid 19 outbreak. Representing all 50 states, these academic leaders are working in some of the largest, most modern academic health centers in the world. Academic health centers that, unfortunately, are not prepared for the challenge that is just now hitting the coasts but will soon spread across the country.

The preamble to this crisis goes back 30 years. As hospitals have tried to maximize their profits, they began using “just-in-time” inventory. Toyota, it turns out, does not have a warehouse for parts. Instead it gets the carburetor (or whatever parts cars have in them now) delivered at the exact moment the car rolls to that point on the assembly line. Hospitals began using the same, getting only the masks or other equipment they need for the next week from the plant (in China) rather that maintain a warehouse. Well, also only having enough hospital beds for people who need them. Toyota never needed to plan on all of America needing a car within the same 2 month period. Hospitals, turns out, also never planned for Americans to get sick all at once. Guess now we know.

We might have overcome the lack of protective gear except for one problem. If you are treating all of America for a virus that acts like 5 other viruses except it kills you, the only way to “not going to die” people from “just might die” people is by testing for the bad virus. If you know the patient has the bad virus, you can isolate him or her and protect the health care workers more accurately. America, with the best funded health systems in the world, botched the test.

If the country could have accurately tracked the spread of the virus, hospitals could have executed their pandemic plans, girding themselves by allocating treatment rooms, ordering extra supplies, tagging in personnel, or assigning specific facilities to deal with COVID-19 cases.

We have less protective equipment, fewer hospital beds, and more chronically ill people than Italy (7503 deaths to date, 743 last night) and Spain (3434 deaths to date, 514 last night). We did not spend the last year preparing for this surge and, by screwing up the testing, we probably have 200,000 infected people going around infecting others. If you look at the cities where things are bad, they are also cities where either lots of people live (New York, Los Angeles) or cities that had a lot of recent visitors from all over (Mardi Gras in New Orleans). It takes about 4 days to know if you are infected (with something….is it the flu? I just feel a little achy) and if you are going to get really sick it happens on about day 8. So now what?

  1. Sheltering in place. What we know is that if people who are infected limit themselves to limited contact with a small group people, the virus “dies out.” It takes enough time for the virus to finish with patient 0 (the first sick person) and the 2 other people who will likely get sick from that person as well. This virus is spread through coughing, sneezing, and otherwise having fluid spewed. 15 days is not nearly enough time to reduce the number of infected people. Even of only 5% of Americans get this virus (17,000,000) and 10% need intensive care we would need almost 1,000,000 ventilators. This is about 700,000 less than we have now. Without these ventilators people die, with them they live.
  2. Testing and contact tracing. Once we stop sheltering in place, the virus will still be with us. The countries that have successfully reopened have continued to test their populations and, once a positive is found, identified all of the folks they have come in contact with and placed them in “shelter in place” for 2 weeks as well. We not only have not invested in protective gear, we have not invested in this very basic public health workforce.
  3. Adequate personal protective equipment. 40% of those who became ill in China were associated with health care delivery, either as care providers or the families of care providers. Protecting health care workers is vital. Sending health care workers out to potentially die is unconscionable.

So, here we are. One choice is to shelter in place for the next month or three, put up with occasional outbreak which gets tamped down, and delay until a vaccine is developed. Another choice is to throw our hands in the air, declare this too hard, and sit back while 4,000,000 die a potentially preventable death. My colleagues and I believe the first choice is the only choice. Please discuss with the policymakers in your states.

“Nobody knew that health care could be so complicated”  @realDonaldJTrump

We are 341 days and some change away from the presidential election which will determine the fate of healthcare in this country. The current president, Donald J Trump, campaigned in 2016 on the “repeal and replace Obamacare” platform. Although there was a flurry of activity which threatened to bring back the fear of preexisting conditions and the creation of an Obamacarelite product (perfect for those not planning on being sick) for the most part Obamacare remains intact. In fact one of the key components, Medicaid expansion, actually seems stronger than it did under president Obama.

As we gear up for the next election it seems that healthcare is once again getting the politician’s attention. The Republicans are still of the mind that “Obamacare doesn’t work” although they are unable to come up with anything better. The Democrats have pushed out seemingly hundreds of ideas. Though somewhat of a moving target, it seems that the ideas can be coalesced into “Medicare for All” (Sanders and Warren), “Medicare for some more” (most folks), and “Better Obamacare for some” (Harris and Buttigeig). What piqued my interest today was what I thought was an arcane mental health discussion. Senator Harris called to:

Repeal the Institutions of Mental Disease (IMD) exclusionThe IMD exclusion precludes Medicaid funding for adults receiving care in psychiatric facilities with more than 16 beds, and has also exacerbated a severe shortage of acute psychiatric care beds nationwide. Repealing the IMD exclusion will reduce the number of Medicaid patients who end up in already strained general hospital emergency rooms when they need acute psychiatric care.

I thought “This makes sense” until I saw this Vox article:

But on Monday, when Harris’s campaign rolled out its mental health policy plan, it had not been nearly so thoughtful. Harris seems to have gone all-in on attacking the freedom, dignity, and privacy of people with mental health conditions. People like me.

I have to admit, although I know little about the Senator, she does not strike me as THAT evil.

As it turns out, back in 1965 when Medicare and Medicaid were being designed, there were a lot of people in mental institutions that were being imprisoned for their mental illness. Congress, fearful of states using the new Medicaid money to build bigger insane asylums, created a mental illness exception for inpatient treatment. Any facility with more than 16 beds that exclusively treated mental illness was ineligible for Medicaid funding. Although there have been some attempts to repeal it, this exception has stuck over the years. In part because of fears of mental health advocates such as those expressed in Vox. In part because of fears of increased cost. From a demonstration project which included Alabama where the exception was waived:

“Overall, we found little to no evidence of MEPD effects on inpatient admissions to IMDs or general hospital scatter beds; IMD or scatter bed lengths of stays; ER visits and ED boarding; discharge planning by participating IMDs; or the Medicaid share of IMD admissions of adults with psychiatric EMCs.

Available data suggest, however, that increased access of adult Medicaid beneficiaries to IMD inpatient care would likely come at a cost to the federal government.

In short, we are likely to find ourselves where we have always been. Folks suffering from serious mental illness (including substance abuse) only able to use their Medicaid for treatment if they are not too sick. This is in part due to a fear that those who are functional have that they will be locked away rather than treated in the least restrictive environment. This is also reflects the reality that the feds fund “healthcare,” not the prisons and underpass encampments where folks with intractable mental illness are now found.

Nobody knew mental health care was THIS complicated…

“I’m hearing more about getting more people covered,” he said. “I think they should do what they need to do to get elected, [but] . . . getting the costs down is the most important thing.” (Voters have big health worries…. Washington Post)

The concept of “the commons” is not an easy one for Americans to grasp. The concept of the commons originated in England. Sheep were (and are) owned by people but the grazing area was (and is) owned by the community. It was pointed out by William Lloyd that while there was an advantage to the individual to have a bigger herd (more money from wool), collectively the community would suffer as the land was overgrazed. Garret Hardin pointed out the problem of individuals acting in rational self-interest by claiming that if all members in a group used common resources for their own gain and with no regard for others, all resources would still eventually be depleted. Writing in the journal Science, he felt that relying on conscience as a means of policing commons was problematic as it favors selfish individuals – often known as free riders – over those who are more altruistic.

The median American spends under $300 on health related expenses in a given year. However, the average American spends $10,000.  How is this? It is because  5% of the population account for half of all health spending. The 5% of people who spend the most on health care spend an average of around $50,000 annually; people in the top 1% have average spending of over $109,750.  Getting into the top 1% is kind of a random thing. You get bad cancer…you are there. You have a baby, you are not there but you move from $300 to $11,000 for that year. If you have the unfortunate luck of having your baby early…boom, your baby just hit $1,000,000.

So, in the The Affordable Care Act was designed, in part, to address the “free rider” problem in health care. Turns out almost everyone is willing to pay $300 for their healthcare every year. Almost nobody can pay over $100,000 when they randomly get cancer. What people are inclined to do is take advantage of the fact that other folks are paying into a system to support cancer care and then, when they get cancer, show up and  assume “it’ll get paid for.” The problem of the commons. The mandate was put in place to make us all pay for it to be there. Also, to make us all aware that the way we have it set up is very expensive and inefficient.

What we have made explicit through the Obamacare mandate is that the admission to the healthcare commons costs working families about $17,000 a year. On top of that about a third of our tax dollars are going into paying for the healthcare commons. Given the small amount Americans see themselves taking in a given year, it is no wonder they resented the mandate. On top of that, the value we receive is much less than what citizens of other countries get. On average they live longer, are healthier, and report fewer problems than Americans. They pay about half (or less) of what we do as well.

In the analogy of healthcare as a commons, who is getting rich?  Unlike sheep, sick Americans are not left to graze alone. Although there are now “free riders” because the mandate has been removed, this is only a small part of the problem. Turns out that our “grazing” is directed by doctors and hospitals motivated by the profit motive (with no price transparency), pharmaceutical companies advertising high cost medications directly to the consumer (with no price transparency) and people with limited health literacy who are making decisions based on fear, misinformation, and who are given guidance by folks who profit from the consumers ignorance. Other aspects of Obamacare, designed to fix these problem, are either not being implemented or being held in check by powerful interests (doctors, hospitals, pharmaceutical companies).

Which brings us to the the tragedy of the healthcare commons. We as a country are about to enter into a time where we spend more on healthcare than the average person makes. In England, to this day, there are all sorts of rules about who can use the common land and how many ducks, sheep, and the like he or she may put on the land. In America, we declare where our cows are to be a “sovereign state” and shoot at those who try to enforce the rules of the commons. One Republican Senator said of the  folks engaged in rule-breaking, “These people are patriots.”

We thought the individual mandate addressed free-riders. The reality is that the person with no health insurance who gets in a car crash or gets bad cancer is only part of the problem. The real “free riders” are those who profit but have no responsibility for the upkeep of the commons. The controls needed are not to keep people from consuming healthcare. The real need is for controls on those who would profit from folks who are scared, hurt, and confused about how to use a broken system. There are many ways for these controls to be put into place. The question is do we have the strength as a country to enforce such controls or do we declare those folks who profit at the expense of all of us patriots?

Business executive at party: “What do you and your friends do?”

Me: “We work at the medical school”

Business executive: “No, I know that. I mean what is it that you guys DO”

Me: “We all work in different areas. For example I train doctors in Family Medicine”

Business executive: “Well, tell me, why do we need Obamacare”

Me: Very long, detailed soliloquy about pre-existing conditions, the contributors to the cost of health care, etc, fueled by lots of wine and ending in the need for Medicare for All if we don’t let Obamacare do what it was designed to do.

Business executive: “So why does it need to be so complicated? Why can’t folks just pay for insurance?”

Me: Sigh. “Excuse me, I’m going inside for a bit. Can I bring you anything?”

It is difficult to discuss health system reform with people not closely engaged in care delivery. Most people have interfaced with the care delivery system and so believe they know how best to fix it. Most people consume under $300 worth of healthcare annually but don’t question the opportunity cost of having access (over $17,000 annually for a private insurance plan). Most people are thrilled when told of a negative test (“Congratulations, it’s not cancer”) but don’t question whether the test should have been done in the first place. Airplane crashes put the focus on the safety of the aviation industry because 300 people dying at a time is newsworthy. Losing 4000 people annually in Alabama to premature heart disease because of a poorly performing health system is a yawner.

In any given year, only 5% or fewer of the US population use the healthcare system for something serious like cancer Most folks who interface the care delivery system (make a doctors appointment) do so for a self-limited illness. They come in either because a) they want assurances they are not going to die and want to feel better or b) they need a note for work. From a survey done in 2014, when a person seeks care here is what they want:

  1. Be seen without an appointment within 30 minutes any time of the day or night for $0 to include labs and x-rays done on site.
  2. Have the same person see them every time and have them spend unlimited time explaining symptoms
  3. Have this magic 24/365 office close to home (next door is preferable).

Business executives, I suspect, pretty much get this type of care. Michael Jackson, for example, had his own cardiologist. Access costs money. In corporations the CEO tends to have the same insurance as the lowest wage earner. What happens when a large corporation pays for care that includes this type of access? The executive may not be worried by the high premium (average is over $12,000 annually for a family plan) and additional company cost ($5000). The low wage worker, on the other hand, might be willing to trade immediate access for better food or housing choices but isn’t often given the choice. Obamacare was designed, in part, to put the brakes on healthcare inflation.

In states where the Affordable Care Act has been fully implemented more employers are paying for health care and more people are covered by other types of coverage. As more people have ended up on public plans (Medicare and Medicaid) health care inflation has reduced. The number of bankruptcies due to medical conditions have fallen precipitously.

Despite all of the rhetoric, it appears that the system reforms put in place by the Obama administration are working. In an essay in Vox, Mae Rice points out that spending some money on a small luxury like Starbucks every day can lead to enhanced responsibility. We, as a society, have a responsibility to people like her. Not to ask her for her Starbucks money. Not to blame her for failing to save for a catastrophic illness that is unanticipatable. Not to ask her to be a prisoner at a minimum wage job so her CEO can get 24/7/365 access to any specialist she wants. We have a responsibility to provide access to quality healthcare at a reasonable cost. Although not perfect, Obamacare is moving us in that direction. As a society, this is a responsibility all of us, including business executives, should take very seriously.

 

JW is a 33 year old black female with sickle cell anemia (SS) who presents with an acute pain crisis. This is her third admission in the last 6 months and she is a “bounce-back” having just been discharged 7 days ago. Her past medical history is pertinent for multiple admission included 2 ICU admissions for acute chest in the past couple of years. She is here today for pain control and is on Dilaudid 1 mg every 2 hours

Intern presentation at morning report

 

Sickle cell “disease” is an example of a chronic illness. It is actually a family of genetic disorders with the most well known being sickle cell anemia.  People who have the disease inherit a substitution on chromosome 11 from both parents. Folks who are unfortunate enough to inherit this disorder are destined to suffer:

The lack of tissue oxygen can cause attacks of sudden, severe pain, called pain crises. These pain attacks can occur without warning, and a person often needs to go to the hospital for effective treatment.

The red cell sickling and poor oxygen delivery can also cause organ damage. Over a lifetime, SCD can harm a person’s spleen, brain, eyes, lungs, liver, heart, kidneys, penis, joints, bones, or skin.

 

This is the medical condition. As a doctor, we give pain medicine to make the pain go away, we give antibiotics to treat the infection, we treat the low blood count with transfusions…in other words, we do what we can. What we can, for some patients, isn’t enough. This is one example of a chronic illnesses that is not curable but instead is characterized by folks getting better and getting worse. What we in medicine call “exacerbations and remission.” There are many other such illnesses.

Sickle cell disease is also characterized by what we call “variable penetrance.” Although the science of sickle cell is easy (Sickle hemoglobin differs from normal hemoglobin by a single amino acid: valine replaces glutamate at position 6 on the surface of the beta chain. This creates a new hydrophobic spot. In a sickled red blood cell, valine 6 (beta chain) binds to a different hydrophobic patch) the body’s response to these sickled cells is dependent on a lot of other things. Some people with this will have a problem with pain only once a year. Others (about 20%) will struggle on a daily basis with pain, fatigue, and the consequences of damage to other organs as a consequence of the randomness of genetic inheritance. This is also true for a number of chronic illnesses. Some folks, for example, have diabetes for years and have no problems. Other folks develop kidney and heart disease almost immediately. How someone reacts to their disease is also, in a major way, genetically determined.

The real consequences of chronic illnesses, for those who are affected the most, are an inability to work and dependence on a healthcare system. Inability to work because, well, people who are tired, in pain, or short of breath all the time make terrible employees. Dependence on the healthcare system because without a job many have no food and can’t pay rent. If there is no food at home or even no home to go to, people with a poorly controlled chronic illness can almost always get admitted to the hospital. Poorly controlled chronic illnesses are the reason 1% of Americans account for 20% of healthcare costs and 5% account for 50% of all costs. Much of that cost is generated by recurrent, preventable hospital admissions that are as much a consequence of an untenable living situation as they are to medical conditions. A sickle cell patient without money for pain medication, for example, will use the emergency room and likely get admitted. The same for a diabetic without money for insulin.

The Affordable Care Act, as written, forced all of us to care about people with chronic illness. Insurance companies would have to give them insurance. Not-sick people would  have to pay for the care provided to those with chronic illnesses though their insurance premiums. Our society would start to feel pressure to move some of the money we spend on healthcare (expensive doctors, expensive drugs, too many needless procedures) into value for patients with uncontrollable chronic illness (food security, supportive housing, transportation assistance, self management support, legal assistance). The challenge in designing the ACA was in figuring out how to cut costs, wisely and fairly, for the disastrously ill and preventing diseases before they become chronic.

We as a practice elected about a two years  ago to work to provide value-based care to our patients with chronic, expensive illnesses. We wanted to reduce avoidable hospitalizations. Mostly because it was the right thing to do but we were encouraged to do so by our healthcare enterprise. They want us to figure out how to make money from “not hospitalizing” a patient.

We changed the way we practice. We employ a care manager to help our patients obtain needed transportation and housing when they are unable to afford such. We employ behavioral health specialists to help patients to learn self-management techniques which will reduce their dependance on the health care system. We use pharmacist to make sure medications are appropriately managed. Physician work on facilitating good care and making sure therapeutic goals are met. It is entirely possible that the patient who suffers from this severe form of sickle cell anemia would be presented to me in this manner:

JW is a 33 year old unemployed woman with hemoglobin SS who suffers from chronic pain and is unable to work full time. She is unable to afford a car and has to rely on public transportation. She lives in supportive housing. Her pain is a 4/10 with her chronic pain medication today. The behavioral health specialists are in the room now, working with her on non-pharmacologic adjuncts to pain. The Care Coordinator is working to get her transportation to her specialty appointments as well as make sure she qualifies for food assistance. She believes that with an increase in her oral pain meds she can overcome this so I will give her a small increase to last for the next several weeks. My nurse will give her a call in 3 days to see how she is feeling.

Despite the current administrations decision not to enforce the health care law (explained here) our intent is to continue to practice medicine and teach others to practice medicine in this manner until we are directed to stop. It is our belief that keeping people out of the hospital is better, always. I hope America feels the same.

The website 538.com has posted an essay (found here) about the great state of Alabama. Unlike most click bait-y articles that Alabamians seem to be attracted to on Al.com (i.e. What are the 11 greatest barbecue places within 30 miles of Bryant-Denny stadium?) but instead an in-depth look at healthcare in Greene County, Alabama. Greene county is currently the least populated Alabama county (9,045 people, 81.5% black or African American). In 1860, the county had about 30,000 people. Well, kinda depends on your definition. 23,598 of those “people” were actually enslaved human beings. Although the math works out to approximately 4 enslaved humans for every 1 “person,” in fact it was almost 7000 enslaved humans were owned by about 50 folks. As described in the Encyclopedia of Alabama, this was not a bad thing

In the decades leading up to the Civil War, Eutaw experienced a golden era as the mercantile and legal center of the Black Belt. The first courthouse, built in 1838, burned in 1868. The current courthouse was built in 1993.

The county is in a region of the state known as the “black belt”, named not for the color of the population but for the color of the soil. The slow slide to economic despair over the last 150 years has taken a toll on the region. Immediately after the civil war, the region was home to 40% of the “citizens” of Alabama. The systematic oppression of former slaves and the descendants of former slaves has lead to the growth and development of many civil rights leaders, blues musicians, and story tellers. It has also lead to a bunch of people moving away. The region, once the economic engine for the region, is now home to 12% of Alabama’s population. In the words of one Percy County resident

“The only reason people come to town now is for funerals, and they leave as soon as they’re over ’cause there’s nothing to do and nowhere to stay,” said Walker, 64, the son of sharecroppers

For those who have stayed, economic prosperity has been an uneven proposition. The racial makeup of the Black Belt region was 52.2% African American, 45.8% White, 0.2% Native American.

The poverty rate among [Wilcox] county’s white population is just 8.8 percent, which is lower than all but five counties. The poverty rate among the county’s much larger black population is 50.2 percent. The 41.4 percentage point gap is the largest in the state.

Other Black Belt counties have a similar dynamic. Lowndes County has a 4.1 percent white poverty rate – the lowest in the state – but a 34.5 percent black poverty rate. In Perry County, the white poverty rate is 8.1 percent, while the black poverty rate is 32.7 percent. In Marengo County, it is 5.6 percent and 40.8 percent respectively.

So why worry about these folks? Can’t they continue to vote with their feet?

“The Black Belt is a road map,” said Patrick Sullivan, a professor at the Rollins School of Public Health at Emory University who previously worked on HIV surveillance at the Centers for Disease Control and Prevention. “That’s what’s so tragic and so compelling. It’s an endgame depiction of what happens when you have social and structural inequalities. It’s the vestiges of slavery and inequality, and in the long run those things do play out as health inequalities.” Sullivan and colleagues have studied why HIV rates are so much higher among African-Americans and Latinos than other racial groups3 and found that health insurance is the most important mediating factor. People in both racial/ethnic groups are more likely to be poor and have less education, which are related barriers, but insurance coverage is where the local and federal government could improve access to treatment, Sullivan said.

Alabama is not a Medicaid expansion state. Our Doctor-Felon-Former-Governor decided it was a political chance he did not want to take, even after his re-election into a term limited position. Remember, adults who are employed but make less that 138% of poverty uninsured are not eligible for Obamacare. In counties like Greene, where 40% of the population is below the poverty level, that is a lot of folks, almost all of them black. When the median household income is $20,000, people are going to choose food when having to decide regarding food vs insurance, every time. So what is the right thing to do? In the words of my friend and colleague John Waits, quoted in the article:

“Nothing happens without Medicaid,” Waits said. “It is the No. 1, the No. 2, it is the top 10 solutions.”

I’m beginning to think this is about something other than partisan politics.

Frandal Wright, who went 27 years without health insurance before getting HIP 2.0 coverage last year, makes his $1 monthly payment at the Wal-Mart in Anderson.

Because the store is on the other side of Anderson from where he lives, Wright tries to pay as much as he can at each visit to minimize the number of times he has to make the trip. Right now, he says, he’s trying to find someone to give him a ride to make his payment and determine if he has enough money to make a lump sum payment.

“I’m a little behind now because I almost forget about it,” said Wright, 46. “I want to pay for the whole year. I’m trying to do that this time. I’ll probably give them $20 if the Lord blesses me.”

Do Indiana’s poor Medicaid recipients really have skin in the game?

As I viewed my electricity bill today I was told by Alabama Power “You pay on average $5 a day for your electricity.” This means I have “skin in the game.” I have the power to determine if I pay nothing per day or $20 per day. Well, only a little as it turns out.  It seems that Alabama Power won’t let me come off the grid easily, so I will end up paying something no matter what. Also, my major non-air conditioner power usage corresponds to my use of the clothes dryer. I can minimize the use of the dryer by hanging a clothesline, I suppose, but elect not to.  What I have decided is that I cannot do  without electricity. So, although I have skin in the game, I can’t say “no, thank you, I’m using a cheap alternative to electricity so go away Alabama Power.” I rely on the Public Service Commission to negotiate fair rates and rely on the government to force my appliances to become energy efficient. Oddly, as appliances become more energy efficient, rates per kilowatt hour tend to go up. I now have less skin in the game (using efficient appliances less frequently still costs the same because I pay more per kilowatt hour) but still reflexively try to use less electricity. Modern life is confusing at times.

Many folks have asked me what I think is going to happen with health care. Conventional wisdom is that the people appointed dictate policy. Seema Verma, who helped design the Medicaid expansion in Indiana, is the new director of CMS (the agency responsible for Medicaid and Medicare). The buzzwords for poor people and perhaps all sick people will likely be “personal responsibility.”

Ms Varma has written on the philosophy she has used to design the system in Indiana (article found here). It seems that this is not just about making sure poor, sick folks have needed care but importantly involves  bootstrap repair as well:

[M]any of Medicaid’s enrollment and eligibility policies, which might make perfect sense for certain vulnerable populations, are not always appropriate for able-bodied adults possessing different capabilities and earning potential. Able-bodied adults need coverage, but not the same set of policy protections.

One of the precepts of President Lyndon Johnson’s War on Poverty, from which Medicaid arose, is that government assistance should exist to provide a temporary pathway for people to lift themselves out of poverty toward a state of self-sufficiency.

The recipients are given a Health Savings Account and are required to make their personal contribution to teach them responsibility (as was the client in the anecdote above). Finding frequent rides to the insurance payment window and personally making a payment which provides continued access to lifesaving insulin and health failure medications, apparently, is freeing:

HIP respects the dignity of each member by setting a fair expectation of personal investment and engagement in his or her own well-being. Contributions are a way for members to demonstrate personal responsibility, but they also encourage members to stay engaged with their health plan, providers, and overall personal health. Because HIP Plus members’ own dollars are at stake, they have “skin in the game” and therefore an incentive to make cost-conscious health care decisions.

Well, maybe not…Turns out that for “frequent flyers” hospitals are seeing to it that the $1 premium is being paid. Because, if you miss a payment, you are kicked out. So it does seem that someone has skin in the game, just maybe not the patient.

As a pragmatist, I believe that the motive is unimportant if the desired result is achieved. Results to date are mixed. Ms Varma points out that those who have paid their premium continuously (folks with “skin in the game”) are more likely to have a primary care doctor, less likely to go to the ED, and more satisfied with their care. Critics point out that enrollment is not by any means what it should be as many folks can’t get a monthly ride to pay their dollar. Also, less that half of folks who were enrolled knew that they even HAD a health savings account much less how to use it. As they say, further study is needed.

In my professional experience, people believe they are healthy until they are sick. A monthly trip to Walmart to pay a dollar is likely not to change that. I hope that we choose to look at real measures of health and not try to do social engineering with our healthcare dollars.

Uwe Rheinhart, a noted health economist, was asked to predict what would become of healthcare under Trump leadership. He said “My hunch is that the “replace” in what is coming will reflect that conservative vision. It is bound to spell more hardship for the poor, the old, and the sick.” I am afraid that that is what “skin in the game” means.

Jean, an Arizona teacher whose employer provided group health benefits but did not contribute to the cost for family members, gave birth to her daughter, Alex, in 2004 and soon after applied for an individual policy to cover the baby.  Due to time involved in the medical underwriting process, the baby was uninsured for about 2 weeks. A few months later, Jean noticed swelling around the baby’s face and eyes.  A specialist diagnosed Alex with a rare congenital disorder that prematurely fused the bones of her skull.  Surgery was needed immediately to avoid permanent brain damage.   When Jean sought prior-authorization for the $90,000 procedure, the insurer said it would not be covered.  Under Arizona law, any condition, including congenital conditions, that existed prior to the coverage effective date, could be considered a pre-existing condition under individual market policies.  Alex’s policy excluded coverage for pre-existing conditions for one year.  Jean appealed to the state insurance regulator who upheld the insurer’s exclusion as consistent with state law.

From a 2005 Wall Street Journal article

People hate Obamacare. People in “real” America really hate Obamacare. Kaiser Family Foundation convened a series of focus groups in counties that voted for Trump to find out what EXACTLY Trump voters hated about Obamacare (article found here).  They hated that those that were really poor and on Medicaid didn’t have the same barriers to care (high co-pays and deductibles) as did those who were working hard. This was even when the groups included voters on Medicaid. They hated how expensive their premiums were, how high their co-pays were, and how much was not covered. They hated how complex the system is and how when you think you have it figured out someone throws another thing at you. They hated the mandate to purchase insurance.

There is currently a bill  being formulated to “repeal” significant parts of the ACA and replace it either with a “To Be Named Later” or with a mismash of proposals which would be labeled “replacement.” How pre-existing conditions fit into this bill remains unclear but is worth understanding (Kaiser article here). Prior to the passage of the ACA, insurance companies were state regulated, and in all states were able to do medical underwriting, This meant that they could effectively eliminate people with preexisting conditions. Although it would be possible to repeal the ACA and keep in the current underwriting rules, it is not likely this will happen. In the case of our pre-Obamacare insurance at our work, the “lookback” was “270 days, known or unknown, manifest or unmanifest.” This meant that, the human gestation being 270 days from conception, if you had your first day of work and went home and celebrated with your significant other (and one thing lead to another) you had best hope the baby was a week late. If not, you were paying cash. Much worse was the patient we had whose cancer was manifest 4 months after his employment commenced and we got to tell him that he had to pay $100,000 up front or die of his cancer. Kaiser estimates that 52 million people will be denied coverage if the old rules are put back into place. Perhaps not denied outright but effectively denied by bringing back these old favorites:

  • Rate-up – The applicant might be offered a policy with a surcharged premium (e.g. 150 percent of the standard rate premium that would be offered to someone in perfect health)
  • Exclusion rider – Coverage for treatment of the specified condition might be excluded under the policy; alternatively, the body part or system affected by the specified condition could be excluded under the policy. Exclusion riders might be temporary (for a period of years) or permanent
  • Increased deductible – The applicant might be offered a policy with a higher deductible than the one originally sought; the higher deductible might apply to all covered benefits or a condition-specific deductible might be applied
  • Modified benefits – The applicant might be offered a policy with certain benefits limited or excluded, for example, a policy that does not include prescription drug coverage.

Some have suggested that a “high risk pool” would allow these folks to obtain coverage and keep the cost down for the 50% of the population who have no need to access the healthcare system in a given year. We actually tried that before, turns out. As the Kaiser article points out, these didn’t work for a number of reasons. First is the nature of health care expenses. Some folks have a lot of expense in a single year (car crash) and the next year are perfectly fine. Others have a lot of expense in an ongoing fashion for a very long time (think Magic Johnson and HIV).

Planning for these disparate situations was tough and no one got it right. The reasons for failure included:

  • Premiums above standard non-group market rates – All cost a lot, the states with the most success provided a substantial subsidy.
  • Pre-existing condition exclusions – Once again, how do you deal with folks who wait until they get sick to pick up a policy
  • Lifetime and annual limits – Most ranged from $1 million to $2 million and others imposed annual dollar limits on specific benefits such as prescription drugs, mental health treatment, or rehabilitation.
  • High deductibles – The plan options with the highest enrollment had deductibles of $1,000 or higher.

The conclusion was that they could work but it’ll cost a lot to get it right.

Back to the focus groups. What Trump voters said they wanted was low premiums and little out-of-pocket expense for drugs, visits, and procedures. They wanted no mandate and no increase in taxes but felt that not covering pre-existing conditions was “un-American.”

They expressed confidence that as a businessman President-elect Trump could pull this off. Hope they are correct.

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