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Patient: I know I already had the Covid. Remember when I was so sick in January? Couldn’t breathe without coughing, so weak? THAT was the Covid, I’m sure. 

Me: No, it wasn’t. Covid didn’t move from the bats to people until late 2019 and it really wasn’t here in Mobile. I think that was probably the flu

Patient: But the test said it wasn’t. Did you test me for the Covid? I’m sure I had it.

Me: No, we didn’t have tests yet in this country. But the flu test could have been wrong

Patient: Wait, you ordered the wrong test on me???

Testing in healthcare is rather more complex than one might think. Folks come to me as a physician and want a diagnosis. I order a test and then say “Have you had it before?” When they say yes I say “Well ya got it again.” Not really. Actually, before I order the test I need to know a lot of stuff, otherwise the results will not be useful.

The first thing I need to know is how the test “performs.” Take a pregnancy test, for example. What the over-the-counter pregnancy tests measure is a chemical produced by the body in early pregnancy. In order to be more accurate, it only detects a level that is consistent with a 3 1/2 week pregnancy. So if a woman gets up, has sex, and uses a pregnancy test to see if she is pregnant, the answer will be “Not Pregnant” even though she is “maybe” pregnant. Also, late in the pregnancy, the chemical goes away in some woman, So if a woman has gained 30 pounds and feels something inside her kicking and moving, and has an ultrasound showing a baby she is “pregnant” despite the negative test. The number of times the test accurately detects the condition (in this case pregnancy between 3 1/2 and 15 weeks) is known as the positive predictive value (98%) and the number of times it accurately tells woman “not pregnant” is known as the negative predictive value (95%).

The other thing is that if there is a lot of disease, a positive test is more likely to be a “true positive.” If there is little disease, a negative test is more likely to be a “true negative.” So, if you do a pregnancy test on a woman who has had a hysterectomy, a positive is almost certainly not a pregnancy and is a “false positive.” Conversely, if the young woman pours water on the strip because she doesn’t want her mom to know she is having sex, the negative is almost certainly a “false negative.” Here is a really good video explanation.

What, you say, does this have to do with Covid-19? Currently, there is  controversy over testing. Initially, in this country, there were no tests. In the absence of tests, all the doctors and patients had was their clinical intuition. This works really well in flu season EVERYONE in the house has the flu and then MOM gets sick (OH MY GOD, WHAT DO WE DO). Mom has the flu ,and no one needs a doctor to tell her or the other people in the family, who have to resort to eating Kleenex. This works just OK in strep throat season when, even under the best of circumstances, the child with the sore throat might have a 50:50 shot at having strep even if his best friend had strep. The possibility that the person has the disease prior to the test being run is known as “pre-test probability.” If that number is very low, then the a positive test will almost certainly be a “false positive.” So, before the plane loads of Italians and Wuhanians debarked, we needed 0 tests. All of the coughing and shortness of breath was not Covid.

Once the first plane loads of feverish (and pre-feverish) folks from Wuhan and Milan were in America, lots of tests would have really been nice for multiple reasons. First, one of the ways to stop an infection for which there is no treatment is to catch the potentially infected people and quarantine them until the risk of spread is diminished. Had we kept these folks separated from the rest of America until we had a “true-negative” test, the virus would have never come here. Secondly, there is no way to distinguish this virus from the influenza virus, the parainfluenza virus, or any of the other viruses that cause fever, chills, shaking chills, and the rest of the symptoms associated with Covid-19. The difference is that Covid-19 kills people over 65 and is spread by people who don’t know they have it. A positive test (whether true or false) in combination with paid sick leave could have kept meat plant workers away from their colleagues, infected visitors away from their family member in the nursing home, and allowed patients with infection to be treated by an appropriately dressed care team.

The timeline for the test for the virus is as follows: The gene sequence was known on January 12. Once this is known a test can be created. The first known infected person got off an airplane on January 15. We only had 200 test kits made by February 4th but they had a really high (almost 100%) false positive rate. It was another month before the CDC would let commercial labs create their own test. By March 14th we were collecting specimens in Mobile and sending them to a commercial lab in Birmingham that had just gotten permission to run the swabs. Problem was that the results took 5 days to come back. It was several weeks before we could get a result back in the same day.

If everything works right (the person has the right swab stuck up his or her nose and put into the right liquid and sent to the right lab) the virus test allows us to tell people if they are currently shedding virus with excellent certainty (it is a “true positive”). If they have fever, it tells us that they have the Covid. If they have no fever it tells us they have a 50:50 shot at developing the Covid fever. Either way, it also tells us that they can give it to folks they live with, work with, or cough on in a nightclub. It allows us to tell them to wear a mask and stay away from folks for 14 days or until they test negative. Even if it turns out they had a “false-negative,” their being quarantined would save lives and allow live to go on for others.

What we lost by not having good virus testing is control of the disease. We had people coming to the hospital who were potentially (but not certainly) sick with the Covid. We had their family members and the hospital staff who helped them exposed to the Covid, who they then went home to their families. We had people who were dying anyway catch the Covid and give it to their caregivers and we had no clue that they had the Covid. We had people come to the Mardi Gras because they had a scheduled hotel room and cough on people at the parade who then, with a little headache and muscle aches, went to their job at the nursing home. It came to funerals in rural Georgia, Easter service in rural Alabama, and Veterans Nursing Home where it killed 22 of our greatest generation. It is now in every county in Alabama.

Where are we now with testing? We, as a country, have tested over 10 million people since March 8th and found 1.4 million folks with the Covid. Although it sounds like a lot, since Covid is in every nook and cranny of the country experts say we need to test up to 35 million folks A DAY to find everyone infected. We also need to test more than people with fever or headaches. We need to test people who have contact with those who are sick to find virus shedders who are not going to run a fever. We need to identify those people who are infected and have them sit out the next 14 days so the chain of infection can be broken.

But wait, you say, if I already had it, can’t I be free to move about the country without fear? The answer is yes, but I’m 99% sure that you haven’t. That, my friend, is the story for next time.

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.

 

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.

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When last we left the village (about 2 weeks ago) whose entire existence was to support pulling babies form the stream, a search party had gone upstream to find out where the babies were coming from. Meanwhile there were still babies coming down the stream. As you may remember, a very sophisticated infrastructure had arisen to pull the babies from the stream. The folks who took the lead, the “baby savers,” took their job very seriously and were valued. They often had to jump in and save babies who were coming down or might have to manipulate the equipment to pluck one from the waterfall. As befits their importance, they were paid very well and had an honored place in the village.

The baby savers executive committee, already threatened by the fear that the search party might find where the babies are coming from and put a stop to it, began looking somewhat critically at the entire operation:

Baby saver president: As you know, we have been looking into the “babies in the stream” issue. We have a lot of folks who care a whole lot about babies and have been giving  there time to make sure the babies are pulled safely from the water. However, it seems there is room for improvement.

Village baby saver: What do you mean improvement, we work our butts off.

Village baby saver 2: Yeah, we are up all night. Often I have to jump in. The water is cold.

Baby saver president: Well, we have started to keep track of your work and, to be honest, we are not doing some of the things we should. As you know, we pay you by the baby.

Village baby saver 3: Your point?

Baby saver president: Not to name names, but I think we should have thought through this more carefully. I’m not going to name names, but one of you pulls out a lot of babies. Many of these babies are blue when they come out and the baby resuscitators are complaining. They say you (not to name names) are too rough and push others out of the way so that you can get the most babies.

Village baby saver 2: They are just jealous.

Baby saver president: And one of you, again I’m not naming names, is just too old to do this. Your eyesight is poor and you don’t swim well. The resuscitators have to jump in and grab your babies but then you take credit.

Village baby saver 3: They need to step back and let me do my job.

Baby saver president: I suspect the search party will be successful and there will be many fewer babies going forward. So we are going to start posting how well you do on the wall over there and it may well be that some of you won’t be able to be baby savers any more. From now on, everyone will know how many babies you catch, what percent are blue, and how many went over the waterfall that you should have saved.

Village baby savers (talking at once): wait, that isn’t fair. How is it my problem if they come down too fast? What if more than 2 people are on a shift? I have a wife and kids to feed. Those resuscitators can kiss my…

If you want to see how hospitals do in regards to preventable mortality and certain procedures and use that to pick your hospital, the government’s hospital compare website is for you (go to this site). If you want to see if your hospital or surgeon has an unusual number of complications or just doesn’t do a lot of the procedures that you need, Propublica has a tool that compares individual surgeons (go to this site). If you want to float along and let a random person pull you out of the water and hope they do a good job, enjoy the ride and I hope you avoid the waterfall.

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