Uncategorized – Page 13 – The Doctor Jones Dialogue

February 12, 2015February 12, 2015

Healthy Utah: Medicaid Expansion or GOP Shell Game?

Healthy Utah is Gov Gary Herbert’s (Republican) idea of a unique “Utah solution” to Medicaid expansion. While I support the plan in general (mainly using Medicaid funds to subsidize purchase of private insurance), the idea that this is a “uniquely Utah” (read: anything different than what the dark overlord Obama wants us to do) way to do it is hogwash, as multiple other states have tried very similar iterations. Gov Herbert is walking the fine line of utilizing federal dollars to follow the public polls supporting coverage of everyone (yes, even in Utah) while trying to make it seem that he does not support, and will not participate in, the great evil that is Obamacare.

Straight Medicaid expansion was never a serious consideration in Utah, so Healthy Utah was negotiated with the Centers for Medicaid and Medicare Services (CMS) for Utah to get as far away from traditional Medicaid as the feds will allow. Healthy Utah now is a legitimate option for Utah, passing the Senate Health and Human Services Committee yesterday 4-1. It now goes to the Senate where there should be enough votes to get it through easily, though the House represents the biggest challenge to the law.

As in all politics, the joke comes when certain politicians oppose something for ideological reasons and yet try to pass a bogus argument off as the real reason for their disapproval. Senator Christensen, a dyed in the wool, Obama-hating, gun toting tea partier (along with many other conservative legislators) claim to be against Healthy Utah for fiscal purposes, even though it is simply because they hate Obama and the federal government and don’t want to be associated with this administration in any way. The plan will cost Utah $237 million over 6 years, bringing in $3.2 billion dollars in federal funds, expanding the state economy by $650 million per year over that time, and decreasing social services spending in other programs by $60 million. This all to cover well over 100,000 citizens who currently do not have health care. Sen Christensen’s legislative response to Healthy Utah (SB 164), nicknamed Frail Utah, is the “medically frail” Utah bill (SB 153). While covering only 10% of the most “medically frail” (which is a very nebulous definition to be sure) Utahns, this bill would cost $200 million over 6 years, bringing back just over $600 million in federal funds. The tea partying Utah House members claim that this represents a significant savings as compared to Healthy Utah, and that it won’t hamstring the state’s budget as much. “I’ve got $100 million worth of requests sitting in my committee and there are not any of them that will get funded if we take it all for Healthy Utah,” said Christensen, (R) Ogden. I don’t see how the medically frail option saves any more money, considering the dramatically increased amount of federal money coming to Utah and the savings to other programs, not to mention the overall economic increase that will bring in more tax revenue. I call a big fat BS. Just call a spade a spade—the GOP hates Obamacare. We can all respect honesty, as opposed to this hiding behind false arguments.

Much of the fiscal conversation also revolves what will happen after 6 years, as the federal match gradually decreases; how on earth will we pay for it then?!? Why do so few people realize that step 1 to decreasing medical costs is providing coverage? It could seem a little backwards to cover people in order to decrease costs, but the ability to get care when and where it’s needed is one of the biggest problems in our system today. I’m sure there are diminishing returns with the number of uninsured being covered and decreasing costs, but I can accurately guess that we are nowhere near that threshold where the decrease in costs may not justify the investment (strictly from a fiscal point of view). We will be much better off and easier to handle our elevated costs years from now if everyone has health coverage.

I initially testified before the Utah Legislative Health Reform Task Force in support of the Healthy Utah plan in September. My testimony is what evoked poor Rep Michael Kennedy’s (Republican) now infamous comment. The task force voted against any sort of federal dollars back to Utah for coverage expansion.

I spent all of yesterday morning at the Utah State Capitol testifying in support of Healthy Utah. I testified first to the Social Services Appropriations Committee, and then at a press conference for the new PUSH Coalition, which includes a number local and national patient advocacy groups. 3 years ago even the most optimistic Utahn would not have guessed we would be as far as we are today. I don’t think any health coverage plan is ideal, but I fully support Healthy Utah as something that will cover all remaining Utahns with a reasonable plan.

February 7, 2015

HHS Sees the Light

It’s only taken multiple years of pointing out the successes of patient-centered medical homes and primary care, but finally the US Dept of Health and Human Services (HHS) has discovered that these are good ideas to improve quality, decrease cost, and improve patient experience! Shocking. Below is the video of HHS Sec Burwell discussing this on 1/26/15. It is accompanied by an increase in value-based payment models by Medicare, which is a good idea in general, but the devil is always in the details. We’ll all stay tuned to see how this progresses, and rest assured that the American Academy of Family Physicians is working to make to optimize this for patients and primary care physicians!

https://www.youtube.com/watch?v=UY088YyQ6uA

February 7, 2015

How We Do Harm

I recently finished a book by Otis Brawley entitled How We Do Harm (referring to health care) published in 2012. Dr Brawley, an Oncologist in Georgia, has done a very interesting job highlighting the effects of the evolution of medicine to the point where we harm patients as often as we benefit them. He is unsparing and blunt in his criticisms, the book dripping with his self-righteousness, but the sad thing is he’s right on. It is obviously easier to tolerate and accept such piety when you agree with it to begin with, but hopefully those who read it will be open-minded enough to accept his personal anecdotes and representative statistics of health care’s true ills.

He condemns the business of medicine, the ignorance (apathy?) by physicians and systems regarding evidence-based medicine, and the selfishness that pervades the medical profession today. Part of this is the attitude of an aging physician lamenting the good ol’ days, though much of his vehemence is directed at physicians of his own generation. The “eat what you kill” philosophy of private practices has morphed to the point where killing often becomes all too literal. And many young physicians come into the profession not knowing anything else.

One main problem in the book is that the author focuses mostly on the field of Oncology (not surprisingly as he is an Oncologist), but myriad examples exist outside of that field as well. Every specialty and hospital department has its whispered stories of excess and over or under treatment, but it has gotten to the point where those experiences seem to outweigh the good.

In many ways a changing cultural and economic landscape and expectation has driven these less-than-ideal behaviors among physicians and health systems, though Dr Brawley does not spare the personal responsibility inherent in the medical system’s conduct. Is it too scathing, too much blame placed on individual physicians acting in their own self-interest? Possibly. But the points and examples he brings up of physicians ignoring medical evidence, either willfully or through intentional ignorance, to pad their own pockets cannot and should not be ignored. He is right on when he says that the health care “system” gets the exact results that it is structured to get.

I offer an excerpt that seems illustrative of much of the book:

“I tell Ralph [a patient who was a victim of the system] about a conversation I had with a marketing guy at a major American cancer center. He explained that they ran free screenings at a local mall every September as part of Prostate Cancer Awareness Month. As I struggled to control my anger, this gentleman explained the business formula:

“’First, free screening provides free good publicity for the health system. People really feel good about us, because this is a community service. It will cause women to come to our women’s center and men to come to our chest-pain center. It increases almost all our product lines. It’s cheap, effective advertising.

“’For every thousand men over age fifty who volunteer for free screenings, one hundred and forty-five will have an abnormal screen. Given the demography of the mall, ten of the one hundred and forty-five will have insurance that our health system doesn’t take. So, one hundred and thirty-five will come to us to see why they have an abnormal screen. We make up the cost of offering free screening by charging for evaluation of the abnormal screens. About forty to forty-five will have cancer. We hit bingo with them. We know the number who will get radical prostatectomy, the number who will get radiation therapy, the number who will get hormones.

“’We know the number who will have incontinence so bad that they will want an artificial urethral sphincter implanted. We even know the number who will not be able to get erections and will want Viagra. We know for how many Viagra won’t work. We know how many penile prostheses we will sell.’

“Realizing that I have been granted an audience with Lucifer, I asked the fundamental question: ‘How many lives will you save if you screen a thousand men?’

“The marketer took his glasses off and looked at me as if I were a fool. ‘Don’t you know, no one knows if this stuff saves lives? I can’t give you a number on that.’”

This example is part of a larger portion of the book on how prostate screening has not been proven to save lives, and likely even causes more harm than good. But the hospital marketer is only acting in a way that would be expected by an organization looking to maximize its profit. It has no incentive to provide proper care, but is actually incentivized to offer poor care so as to then make more money in “fixing” the outcomes of that poor care.

These are not arguments against capitalism and the idol of the “free hand” as some may interpret it in general by Dr Brawley, but merely a description of an industry run amok which has negative consequences for every single one of us. Health care may have gone to the wolves.

I would highly recommend you read this book to get a better understanding of the current health care environment.

4.5/5 stars