I have a new plan for healthcare reform. Take HMO and pharma executives on mandatory tours of the ER.

How did I come up with this brilliant plan, you ask? Let me talk you through it…

Last night I admitted a 23 year-old woman to the hospital. Let’s call her Marisa. Her only medical problem, diagnosed when she was fourteen, was Crohn’s disease, which is an inflammatory condition of the bowel that causes unpleasantness like chronic diarrhea, vomiting and abdominal pain.

For many years Marisa’s disease was well-controlled with Azathioprine, meaning she had very few of the disagreeable symptoms i just listed. Then a year ago her insurance (which was chosen by the university she attended — none of that mythical free-market “choice”) decided that they weren’t going to cover azathioprine, because for most patients cheaper medicines would do the trick just as well.

There’s a problem with basing overall policy on how most patients react. I’ve never met someone named Most Patients. Every real human being is a little bit different than the composite they create from research. It may be true that in a study of 4000 people, the average Diarrhea Symptom Index score (i just made that up) was not significantly different between Azathioprine and another medicine. But what does that matter to Marisa? For her the “average” patient is meaningless. She needs exactly this medicine to treat her disease.

We have a gargantuan, multi-billion dollar profit-making pharmaceutical industry in this country. The industry is constantly pumping out new drugs, each of which does almost exactly the same thing as its predecessor. Most of the time, it doesn’t matter which of the ten available drugs is chosen. But in the rare cases where it does matter — like now, with Marisa lying on a stretcher in front of me — shouldn’t the patient have access to the drug? Why do we have this massive pharmaceutical industry otherwise?

Marisa couldn’t get her Azathioprine six months ago, so she was forced to try inferior alternatives, none of which have done the trick. She came to the ER last night because things had gotten so bad she’d begun to experience rectal bleeding. Not just blood in her stool, mind you: this is blood dripping from her rectum at random intervals without her control. She’s twenty-three and she has to wear a diaper.

I could almost justify a system of huge profits, shameless marketing, and ridiculous unnecessary drugs, if at least that system gave this one 23 year-old the relief she was crying out to me for.

But it didn’t. I had nothing to offer her.

The dinosaurs who believe in free-market healthcare carry around a certain fantasy — something akin to elementary school civics class. Remember “How a Bill Becomes a Law”? We learned that there are three branches of government, and each branch provides checks and balances to the other two. None of them can get too strong, because the others are watching.

The free-marketeers think the same thing will happen in healthcare. They are deluded into thinking that although the pharmaceutical industry will ply us with expensive new medicines, the HMOs will keep them in line. In turn, consumers will keep the HMOs in line by demanding that they cover the medicines that work. Checks and balances.

But in the case of Marisa, we have an example of how the checks and balances only serve to slam every door and leave the patient out in the cold. The patient has no voice. It’s not a coincidence that they call them for-profit entities, not for-patient entities.

You might think I’m naive to expect a giant HMO or pharmaceutical company not to pursue profit. And it’s true, I would not expect otherwise. But that’s why situations like Marisa’s make me want to cry: corporations may be evil, but the human beings inside them aren’t. If any of the people working for Aetna or Merck met this poor girl, and heard her story, I know they would do everything they could to get her the medications she needs. They would be touched, they would see her as a human being, and they would act compassionately.

But the people who work for Aetna and Merck haven’t met Marisa. They don’t know her story. They are are blissfully removed from her life, and from the lives of millions of other people they affect daily. For them, this 23 year-old Crohn’s patient exists only as an account payable, a number to be spindled and manipulated and shifted into the proper column. If enough of these faceless numbers move in the right direction, the workers get a healthy year-end bonus. Hey, they’re just doing their job. Nothing cruel or heartless about that.

Which is why it’s time for the mandatory ER tours. Sign-up sheets will be posted soon.

(cross-posted to whyitstime.blogspot.com)

I have a patient with hepatitis C. She had some signs of cirrhosis (fibrosis in the liver, which is one of the effects of the virus), and she wanted to get treated, which usually requires a liver biopsy. So I referred to the liver clinic.

They sent her back to me saying that she needed an ultrasound beforehand. The ultrasound showed a possible mass, which could be liver cancer (hepatoma). In my discussions with the liver people we decided that she needed an MRI to rule out the hepatoma before moving forward with her Hep C treatment.

So like a good little monkey, I ordered her an MRI, filling out all the forms and getting all the prior approvals, kissing all the rings on all the HMO fingers.

But since it wasn’t an emergency, they gave her an MRI date five months in the future.

One week before she’s supposed to get scanned, I am contacted by the MRI techs. Why? Her ultrasound (remember that?) is now TOO OLD, so she needs to get a new ultrasound before she can get her MRI.

So okay. That would be a good end to the story: unnecessary bureaucracy causing the need for multiple imaging, the waste, etc etc.

Except that’s not the end of the story. Because of course, it’s impossible to get an ultrasound in one week, so she ends up missing the MRI appointment that it took so long to get. Now it’ll be God knows how long before she gets scheduled for another MRI. (And by the time it rolls around, the repeat ultrasound i’m getting today will be outdated. Repeatedly. Again.)

All this time, there might be a liver cancer growing in her belly.

Could a thing like this happen under another system of healthcare? Absolutely. Might a single-payer system require non-emergency MRIs to wait a few months? Of course.

So really, this story is for those who live in fear that single-payer healthcare will give us long waiting periods. Let’s be clear about it: we’ve already been given long waiting periods. The HMOs gave them to us.

But what the HMOs giveth, we can taketh away. We just have to decideth to.

Over the winter holiday, without any prompting from me, my cousin* started talking about the problems with our healthcare system. Does that sound likely? No, of course not. She started talking about healthcare because I asked her about it over and over. But until she punched me in the arm and insisted we change the subject, I learned some interesting facts.

My cousin recently started a new job, and with it came a new health insurance plan. She has a minor neurological condition, but she thought that, since she moved directly from one job to the next, she would not be excluded from her new health plan. This, after all, is what the fabled COBRA coverage was designed to provide.

But it seems that some of the HMOs have evolved certain mutations that make them resistant to COBRA. When she tried to go see her neurologist, she was informed that she wasn’t allowed because her insurance was severely restricted. Why, she asked? The reason was that four years earlier, she’d had a three-month gap in coverage while between jobs. Due to her lack of “continuous coverage”, she only was given limited access to services.

What does this mean for my cousin? It means that for the next 18 months she is only allowed to see her primary care doctor. She gets one annual visit, and after that she has to pay out of pocket. No neurologist, no ob/gyn, no other specialists. They will cover life-threatening emergency room visits, but not common-sense preventive care for her neurologic condition.

Let’s say her condition acutely worsens and she is forced to see specialists. She could be bankrupted by the repeated visits to the doctor that she will have to pay for. But if her condition had worsened a year earlier, it would have been covered by the insurance. Does this make any kind of sense?

Another point: is it really ethical to restrict a young woman from seeing an Ob/Gyn for 18 months? Yearly Pap smears are pretty much accepted as standard of care. Even the doctors employed by Aetna wouldn’t try to argue that point. So how can they have a policy that prevents an “insured” 32 year-old from seeing an Ob/Gyn?  (Perhaps this is an added argument (if a perverse one) for why all internal medicine docs should be well-trained in pap smears).

The insurance company’s argument in response would be something like this: “During that three-month gap in her coverage, she may have developed some condition which we cannot bear the financial responsibility for.” Yes, who knows what crazy hijinks she got up to while she was Off The Grid? Everything will change after 18 months, of course. They’ll have her all fixed up and spit-shined, and then she will be offered the full spectrum of first-tier HMO services.

The system is illogical and, as always, no single person is responsible. It’s the impersonal nature of the cruelty that makes reform so urgent.

*not her real relationship to me

Cheers to the U.S. House of Representatives!!

On last evening, the House took a great step toward ending discrimination toward a group of patients with the passage of the “Paul Wellstone Mental Health and Addiction Equity Act of 2007,” named after the late Senator from Minnesota who was a passionate advocate for mental health parity. I salute Reps. Patrick Kennedy, D-R.I. and Jim Radstad, R-Minn. for their bipartisan effort to end stigma and right this severe wrong with regards to healthcare in the United States.

The Senate sponsors, Sen. Edward Kennedy, D-Mass., Sen. Pete Domenici, R-New Mexico and Sen. Mike Enzi, R-Wyoming, will work to help send it to the president for signature. This bill is so important. It pains me to have to tell patients who receive all of their care for primary care and specialty services at our hospital that I can not see them or that they have very high co-pays.

It is embarrassing and shameful that a physician in the house, Rep. Phil Gingrey, R-Ga, would not vote for this bi-partisan bill. When will the medical community remember that the brain is still an organ and is vulnerable to illness and should not be separated from the body when we think about the practice of medicine.

Write your Senators! This bill needs to be passed!

I think we have gone done the road of separate but equal once before. It did not work then and does not work now.

“We are one. If we don’t know it, we will learn it the hard way.”
– Bayard Rustin, Civil Rights Activist, Organizer of the 1963 March on Washington

Now is the time to join the National Physicians Alliance at its meeting in Houston, TX. If you have never been to an NPA event, you are truly missing out. Missing out on energy. You may arrive tired and disheartened, but you leave energized and full of momentum to make a difference. Whether you would like to join in NPA’s efforts to ensure the availability of quality health care to all in the US or to explore how big business looks to compromise your practice as a physician and the health of your patients, you can find it with this group.

Certainly, one of the best things about a National Physicians Alliance meeting is finding like minded physicians who are in the struggle to maintain the integrity of our profession, and who strive daily to put their patients first. That is what excites me. It is an exciting time in our country and everyone is talking about change. Now is the time for physicians like us to make a stand and be heard.

When I leave an NPA meeting I truly get what Bayard Rustin was saying. We are truly one!

(link to register for the NPA meeting)

This week in the New York Times Week in Review, there is a column stipulating that we should pay doctors less.

I wholeheartedly agree.

If medicine truly is the profession that I believe it is, you should hear a chorus of doctors saying, “Fix this system, even if it means paying me less.”

(Read more…)

It is not quite true to Wallace’s words -

For the hand that rocks the cradle
Is the hand that rules the world.

- but drug companies have targeted medical students (in some sense “infant doctors” – no offense implied)  with their marketing and “freebies” for years. As the Baltimore Sun reports,this is the case at the University of Maryland, but it is hardly an isolated case. The rationale is simple: the earlier and more often doctors a ‘primed’ and associate pleasure with a particular drug, the more likely they are to later prescribe that drug when they can make the choice. This holds true for any stage of training. When I was a fellow at the University of Washington, almost every lunch meeting of the residents in Medicine seemed sponsored by a drug rep. This was justified by the Medical Department by stating that they could not afford to pay for these meals and that residents would not show up for conferences if  they were not catered. The latter part may be true (would you skip lunch if you worked 60 to 80 hours a week?). However can we allow the pharamceutical industry and complicit major academic institutions to contaminate the learning enviroment in such a way? The answer is No! The American Medical Student Association (AMSA) and the National Physicans Alliance strongly oppose this practice and I can only urge all medical student, residents and “grown up” physicans to support us in this cause.

We are adaptable creatures, and while that is generally good, sometimes it’s a problem. We have no difficulty taking prompt action when faced with a sudden calamity, like a bleeding head wound, say, or a terrorist attack. But we are not good at moving against the creeping, more insidious threats — whether a slow-growing tumor, waistline or debt.

It’s as true of societies as of individuals. We did not muster the will to reform our long-broken banking system, for example, until it actually collapsed in the Great Depression.

This is, in a nutshell, the trouble with our health care crisis. Our health care system has eroded badly, but it has not collapsed. So we do nothing.

For at least two decades, polls have shown that most consider our health system seriously flawed. With family insurance premiums now averaging $12,000 a year, the insured fear it will become unaffordable, and businesses regard health benefit costs as their single greatest obstacle to competing globally.

People without insurance are proven to be more likely to die, and 28 percent of working-age Americans are now uninsured for at least part of a year. Emergency rooms, required to care for the uninsured, have become so full they turned away 500,000 ambulances last year. As a result, large majorities support the idea of fundamental change…

from Atul Gawande’s commentary “Can this Patient be Saved?” NYTimes May 5,2007. (thanks to Donkey O.D. for sharing the full piece, which is otherwise on the pay-only section of the Times website).

The bolded section above (emphasis mine) is a pet peeve of mine — we’ve put billions and billions into disaster preparedness and bioterrorism work in the past few years, and we’ve taken billions OUT of more insiduous killers like chronic disease programs, integral public health mechanisms, and such basics as housing, food, transportation, etc.

I’m a doctor at a county hospital and clinic in Los Angeles, where we mostly treat the uninsured, underinsured, or undocumented. We’re the safety net hospital in the area. However, we’ve been packed to the brim and have had to say no to ambulances (channel them to other county or non-county emergency rooms) over and over and over again. Now that’s what I call scary. Spillover from a safety net hospital.

Also — the cost that Gawande mentions for health insurance for a family isn’t overstated. In my state of California, individual health plans are more than $4500 a year, and family plans are definitely more than $12,000 a year. And what’s minimum wage, in California or in the U.S.? You do the math. (Obviously this cost is too high even for middle-class folks!) That’s seriously problematic.

Last week, I took care of a patient that most physicians have seen — and many have cursed: a woman admitted for “pain control”. She had a history of substance abuse (clean for over a decade now), was morbidly obese, and now had pinched her sciatic nerve, which caused her to be less active, which worsened her chronic back pain. So, she was admitted. It was clear from reading the notes that her primary care physician was working with her to reduce her reliance on pain medications, and she had been making progress until now.

(Read more…)

Today in my continuity clinic, one of the staff physicians was talking about his experiences on Capitol Hill where he has lobbying on behalf of primary care physicians. He said that every meeting that he has ever had has ended with the member of Congress saying (in effect): “While this is an important issue, it just isn’t one that has an constituency.”

How can that be? Why is there not a “constituency” for the issues that doctors talk about? After all, everyone will at some point need a doctor. Why are doctors ineffective on the Hill?

Perhaps it’s because we talk about the wrong things. A colleague conducted a study where he asked Congressional staffers about the issues that physicians lobbied for on the Hill. He discovered that doctors came to Congress mostly to talk about their own reimbursement rates. If that is the only thing that members of Congress are hearing from physicians, no wonder they respond with “there is no constituency for that issue.”
More revealing, the Congressional offices thought physicians were effective advocates, and would be particularly effective on issues that affected our patients directly. Our patients are, after all, their constituents.

And that’s what attracted me to the NPA – it brings together physicians from all specialties who want to be advocates for our patients. By working for what is best for our patients, we can achieve the goals of why we went into medicine in the first place.

Physicians can – and are – effective advocates. And we achieve the most success on Capitol Hill when we address issues that directly affect our patients.