Why Jolie’s announcement matters… and also why it doesn’t

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health policy and management, opinion

Angelina Jolie took the media by storm today when she announced in an Op-Ed piece in the New York Times that she had undergone a prophylactic bilateral mastectomy.  She made the bold decision after she discovered she tested positive for a gene mutation that increases the risk of breast cancer.

So why does this matter?  Well for one, women who carry these mutations have a highly increased risk of developing breast cancer.  The average woman has a 12% lifetime risk of developing breast cancer, while women who carry the same mutation as Jolie have about a 65 percent risk of developing breast cancer.  Women with the gene mutation are also at increased risk for ovarian cancer, and the breast and ovarian cancers they develop tend to be more aggressive than in women with an average risk for breast cancer.  Advocates for testing point out that knowing one’s mutation status can help make future treatment decisions.  Women of child-bearing age may decide not to delay pregnancy when they test positive for the mutations.  Surgical options for reducing cancer risk include the prophylactic bilateral mastectomy that Jolie chose as well as potentially removing the ovaries.  Regardless of any surgical options, women who test positive for the mutations are likely to undergo more frequent screenings for breast cancer including mammogram, ultrasound, or MRI.

Awareness is arguably the most critical piece of detecting and treating any disease; never underestimate the importance of getting the world out.  An announcement by a high profile celebrity does far more to instantly increase awareness than any foundation or charitable organization.  If you don’t believe me, just look to the media – Jolie’s story was instantly splattered across newspaper websites as well as Facebook, and Angelina Jolie is currently the top trend on Twitter.

But Jolie’s announcement requires a word of caution, as not everyone who is at increased risk will develop breast cancer.  Nor is testing appropriate for everyone.  As she points out, Jolie was at increased risk for the mutations since her mother was diagnosed with breast cancer prior to age 50.  However, most women with breast cancer do not have the BRCA mutations, nor do the vast majority of women in the general population.  While the BRCA genes (conveniently named BRCA1 and BRCA2) account for between 5 and 10% of all breast cancers, estimates are that only 0.11% to 0.12% of women carry one of the mutations.  Look at those numbers closely because that means that 99.88 to 99.89% of women do not carry the gene.  Clearly testing every woman in the United States doesn’t make sense, as the US Preventative Services Task Force has already correctly deduced.  The real question then, who should get tested?

According to the American Society of Breast Surgeons, only high risk individuals should be tested for BRCA1 and 2.  High risk is defined as a greater than 10% chance of cancer.  Patients with multiple risk factors or with borderline risk are often referred to genetic counseling for more information and guidance about testing and what the results mean.  More than one of the following risk factors is needed to achieve that 10% threshold:

1. early onset breast cancer (diagnosed before age 50)
2. two primary breast cancers, either bilateral or ipsilateral
3. a family history of early onset breast cancer
4. male breast cancer
5. a personal or family history of ovarian cancer (particularly non-mucinous types)
6. Ashkenazi (Eastern European) Jewish heritage in the setting of a newly diagnosed breast cancer or family history of breast cancer
7. a previously identified BRCA1 or BRCA2 mutation in the family
8. Early onset breast cancer (diagnosed before age 50)
9. “Triple negative” breast cancer diagnosed prior to age 60 (triple negative refers to three specific markers of certain breast cancer cells including ER, PR and Her2).

Part of why Jolie’s announcement doesn’t matter is that she is certainly not the first woman to undergo a prophylactic bilateral mastectomy.  Nor is she the first celebrity to undergo a double mastectomy; countless others have done so after a unilateral diagnosis of breast cancer, including Christina Applegate and Giuliana Rancic.  Nor is Jolie the first to do so for purely prophylactic reasons, although perhaps not as publicly.  Sharon Osbourne underwent prophylactic bilateral mastectomies last year due to a gene known to cause an increased risk of breast cancer, although it’s not clear if Osbourne carries a different genetic mutation from Jolie.

I could launch into the discussion of money and resources at Jolie’s disposal and how expensive the testing, and subsequent treatment, currently is.  But that could go on for days and will ultimately devolve into a discussion of whether one likes or hates Angelina Jolie.  But more importantly, that discussion degrades the understanding that this decision is faced by thousands of women, and it is a deeply personal decision.  The most important part of Jolie’s announcement may be that once testing is recommended, the decision to test or not is a decision that cannot be made for you.  Nor is it one to be made lightly; the results can be life changing and prompt consideration of the limited available options.  One needs to ask whether knowledge really is power and how that knowledge may permanently alter life’s course.

Angry? Yes. Surprised? Not at all

Tags

health policy and management, opinion, ridiculous

Five different people emailed me regarding the New York Times article about the vast differences in hospital billing to Medicare.

The revelation that hospitals charge vastly different prices shouldn’t surprise you.  For one thing, I’ve commented on this before – here, here, and again here.  (seriously, what have you people been reading?)  Part of the problem is the historical underpinnings of the ways hospitals used to be paid, much of this is due to the fee for service payment system that continues to dominate American healthcare.  But the fact is, we’ve allowed the system to operate this way by championing free markets and allowing hospitals to run like businesses.

Quite frankly, hospital charges are not based on a solid foundation of cost nor are they based on quality of care provided.  There is little to no evidence to support that costs or quality are the basis for what hospitals charge.  Furthermore, when hospitals negotiate with insurers for reimbursements, those negotiations are considered trade secrets;  an insurer cannot tell hospital B what it is reimbursing to hospital A for the same service.  Similarly, hospital X is under no obligation to tell insurer Z what insurer Y is reimbursing.  As the article states, it truly is a cat and mouse game between hospitals and insurers.  And the game is only expected to get worse as hospitals merge and combine into large systems in order to form “accountable care organizations” or ACOs under the Affordable Care Act.

You might think that price transparency might be a solution to this dilemma.  Make hospitals report their prices and that should fix the problem, right?  Patients would naturally switch to lower cost providers, and high cost providers would be forced to lower their prices, regressing toward a new lower average price.  Makes sense…that’s how competition works so this should work, right?  Wrong.  In 2007, New Hampshire did just that after health officials noticed huge variations in the hospitals prices within the state.  Not only did the tactic not work, it had the opposite effect.  Patients had little incentive to shop based on price as those with insurance rarely saw the bills.  Many of the hospitals in the state are in isolated geographic areas and therefore experience little to no competition from other hospitals.  Even more concerning, the lowest reimbursed hospitals raised their prices to match their well reimbursed competitors.  The hospitals regressed toward a new mean price, but that new average price was now higher, not lower.

Some in the health policy community use this evidence to advocate for a single payer system with universal insurance as the only solution to this problem.  Others suggest we adopt payment setting similar to the Maryland all-payer system (you’ll notice that none of the data comes from Maryland).  I’ll admit I’m not a huge single payer fan for too many reasons to details here, but Medicare is about the closest thing we have to a single payer in this country.  As the largest single nationwide insurer, Medicare is in the unique position to provide a stabilizing force to the wide variations (you could argue that the Veterans Administration does this as well, but the VA both finances and delivers care, while Medicare merely finances it.)  But with a myriad number of private insurers out there, the “single payer” Medicare effect gets diluted.

The thing is, the Centers for Medicare and Medicaid Services (CMS) looks at the hospital bill, laughs, and then says “here’s what we’re going to pay you”.  The payment is formula based – a base price is set based off of what CMS thinks the average cost of the provided service is and then multiplies that by certain factors such as geographic location, severity of illness, teaching status, etc.  To be fair, there are a lot of factors, but ultimately CMS arrives at a reimbursement which is much less than what the hospitals charge.  So in reality, even though two hospitals across the street from each other taking care of two patients for the exact same condition with the exact same illness severity might charge CMS widely different prices, CMS will reimburse them almost the same amount.

The most important section of the NYTimes article is in fact this one:

Medicare does not actually pay the amount a hospital charges but instead uses a system of standardized payments to reimburse hospitals for treating specific conditions. Private insurers do not pay the full charge either, but negotiate payments with hospitals for specific treatments. Since many patients are covered by Medicare or have private insurance, they are not directly affected by what hospitals charge.

Experts say it is likely that the people who can afford it least — those with little or no insurance — are getting hit with extremely high hospitals bills that may bear little connection to the cost of treatment.

Steven Brill made this exact point in the TIME magazine commentary “Bitter Pill – Why Medical Bills are Killing Us”.  The fact of the matter is, very few people pay those ridiculously high prices, because almost everyone negotiates a lower rate.  But if you are one of those people paying out of pocket, uninsured or with little insurance (what we call underinsured), you should be angry.  Because the price of your care (and therefore the cost to you) may have been dramatically different if you had simply crossed the street.  And don’t for a minute think that the higher price means better quality.  In fact, crossing the street might mean that the quality of that care may have been better too.

Only two types of people use pagers…

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health policy and management, opinion

… doctors and drug dealers.  And I’m guessing even drug dealers have replaced the pager with the pre-paid cell phone.

A new study reveals that not only is pager technology use in health care archaic, it is actually costing the industry billions of dollars.  Physicians and nurses working in hospitals waste an average of 46 minutes a day when they use beepers to exchange information about patients, rather than modern alternatives like texting on smartphones.  That 46 minutes a day adds up… to the tune of more than $8 billion annually for hospitals.

Pagers are still the most commonly used form of communication in hospitals because they are considered more secure than mobile phones, ensuring that doctors and nurses are in compliance with HIPAA.  But replacing pagers with secure text messaging would be an easy solution – allowing doctors and nurses to communicate with technology they already have on them, their personal phones.  The time reduction?  Evidence suggests that patient discharge times could degree by 50 minutes.

Given the rise of mobile phones and healthcare apps, it’s only a matter of time before these communication dinosaurs go extinct – the question is how long will it take and why hasn’t it happened sooner?  I suspect that the next generation of physicians will be the ones to permanently make the switch.

Happy Nurses Week!

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ridiculous, someecards

From one doc to all of the nurses out there, a collection of someecards for Nurses Week!

Boston AIDS 5k Run and Walk 2013

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workout

so it’s that time of year again…

For those who don’t know, I will be running the Boston AIDS 5K Run on June 2nd in order to raise money and awareness of HIV/AIDS.  Some of you may be asking why and thinking that HIV/AIDS is a thing of the past.  Fact: every 11 minutes, someone is newly diagnosed with HIV in the United States, and nearly a quarter of those new infections are among people between the ages of 13 and 24.

Since 1999, new diagnoses of HIV in Massachusetts have gone down by an astounding 53%, translating into less than 650 new HIV diagnoses in Massachusetts per year.  As a result, 5,700 people have remained HIV negative, and $2 billion in HIV related health care costs have been saved.  But with all the success achieved throughout the past several decades, funding cuts threaten to undermine the very programs that keep countless men, women, and children alive.

I’m running because I care, because this is an issue that is important to me.  Because people’s lives are at stake. Because with all the success, there is still much more work to be done.

To donate, visit my page.  Many companies also match gifts!  Remember, every little bit counts.

routine HIV testing

Tags

health policy and management

So it’s been a very busy week in health policy.  The US Preventative Services Task Force (USPSTF) – the federally funded panel charged with making recommendations to primary care providers on which clinical preventative services to offer to patients – this week made it’s final recommendation on HIV screening in adults.

The new recommendations fall into line with the recommendations from the Centers for Disease Control, stating that all adults age 15 through 65 should undergo routine HIV screening regardless of risk factors.

The USPSTF gave a grade “A” recommendation for routine testing.  Why is that important?  Because under the Affordable Care Act, insurers are required to cover preventive services that receive an A or B recommendation by the USPSTF.  These preventative services have to be provided without out of pocket costs to the patient, meaning the service isn’t subject to a co-pay, co-insurance, or deductible.

This is a critical next step to reducing the stigma around HIV and to improving rates of HIV screening in the country.  It should also eliminate confusion on the part of physicians as to which patients should be screened.  And routine screening should aid in reducing the spread of HIV by identifying new cases and starting therapy when appropriate.

oh, the FDA…

Tags

health policy and management

Yesterday, the Food and Drug Administration announced that the Plan B One-Step contraceptive pill would be available to women ages 15 and older without a prescription.  This was a major step for the FDA, as Plan B One-Step is currently only available behind the pharmacy counter to women ages 17 and up.

Although the FDA advisory panel initially approved Plan B as an over the counter medication for women of all ages, many in the medical community were taken by surprise when Health and Human Services Secretary Kathleen Sebelius overruled the FDA’s scientists in 2011 and implemented the over 17 age rule.  That decisions recently came under fire from U.S. District Judge Edward Korman of New York, who blamed the Obama administration for imposing the age-17 limit as election-year politics instead of science.

The FDA claims the current 15 and up recommendation was already pending prior to Korman’s ruling, as the pharmaceutical company Teva had amended it’s initial application to the FDA.  But is the FDA’s current position any better?

Let’s consider the fact that FDA’s decision requires identification to verify age in order to purchase Plan B One-Step.  Anyone who can’t provide such proof as a driver’s license, birth certificate or passport wouldn’t be allowed to complete the purchase.  I wonder how many girls between the ages of 15 and 17 lack a driver’s license (certainly all of the 15 year olds) or a passport (probably a decent number).  And how many of them have easy access to their birth certificate without having to ask a parent for it first?

In the words of Nancy Northrup, president of the Center for Reproductive Rights, lowering the age limit ‘‘may reduce delays for some young women but it does nothing to address the significant barriers that far too many women of all ages will still find if they arrive at the drugstore without identification.”

For the whole gambit of reactions, click here.

The METI Project

Tags

travel, twitter

I am extremely excited to announce the launch of the METI Project.  If you’re wondering what I was doing in Haiti back in January, this is it.

METI stands for Medical, Education, Training, and Infrastructure.  The first METI team just arrived in Port-au-Prince today.  A long week of work is ahead of them.

The METI Project is a non-profit organization whose mission is to promote sustainability in healthcare through medical education, training, and improved infrastructure in under-served areas of the world.  Launched in 2013 by Professional Ambulance (Pro EMS) and Pro EMS Center for MEDICS, The METI Project’s first initiative addresses critical medical needs in Haiti, one of the world’s poorest countries.

In conjunction with the St. Luke Foundation for Haiti, The METI Project will send a team of medics, paramedic students, and emergency department staff to Haiti to provide medical training and needed clinical services.

You can follow the METI Project on Twitter (@METIProject) and “Like” them on Facebook.

I look forward to future work with The METI Project in late June and again in October!

10 Ways to Improve Patient Safety … Now

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health policy and management

A little over a month ago, the Agency for Healthcare Research and Quality (AHRQ) released a report recommending several interventions for health care organizations to implement in order to improve patient safety.

1. Improve hand hygiene compliance
2. Use barrier precautions to stop the spread of infection
3. Implement care bundles to prevent central-line associated bloodstream infections
4. Use real-time ultrasonography (ultrasound) when placing central lines
5. Use protocols to reduce catheter-associated urinary tract infections (UTI)
6. Employ preoperative checklists to reduce surgical complications
7. Improve venous thromboembolism prophylaxis
8. Use preventative intervention care bundles to cut rates of ventilator-associated pneumonia
9. Avoid hazardous drug abbreviations
10. Use multicomponent interventions to prevent pressure ulcers.

Sound familar?  They should – that’s because many of these strategies are common sense (like washing your hands to reduce the spread of infection) or are already in place in many hospitals.  However, AHRQ notes that the implementation of these interventions varies significantly and is far from universal – both within any one hospital as well as across hospitals.  The report, published in March, strongly encourages that these interventions be implemented within the next 3 years.

But what isnt highlighted is the failure of a uniform policy to direct attention to these interventions from every health care institution.  Once again, the fragmented nature of our nation’s medical system impedes the universal implementation of these guidelines.

Sugar!

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health policy and management

This short cartoon shows the effects that high sugar beverages are having on our nation.  And it uses polar bears… because who doesn’t love polar bears!?

The Real Bears

Humanity in medicine, part 2

As a follow up to yesterday’s post on humanity in medicine, I’ll refer you to this article in the New York Times WellBlog section written by medical student Dhruv Khullar.  The quote below is fairly powerful – and I believe it would strike a chord with anyone who works in healthcare.

Like many of my classmates, I entered medical school with an idealized notion of medicine. But I will leave with the knowledge that the reality is far more complex. There are patients who don’t listen, who can’t listen; who try, who don’t try; who smile, thank and love; who steal, curse and hate. Each of these patients deserves the full extent of our respect and abilities. But too often those most in need of our compassion are least likely to receive it.

The balancing of complex emotions, time constraints and limited resources will only become more difficult with the influx of millions of previously uninsured people into our medical system. As we continue to carry out the Affordable Care Act and enter an era of tremendous change, we must confront our natural tendencies to favor patients we find pleasant — especially when it comes at the expense of those we find less so. We must recognize that sometimes the patients who behave the worst are those who are hurting the most.

Transparency

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health policy and management

The Boston Globe recently reported that medical mecca Brigham and Women’s Hospital (BWH) started publicly reporting its medical errors beginning in January 2011.  BWH joins its across the street rival Beth Israel in opening the door to transparency in medicine.  BWH publishes the errors in a monthly online newsletter accessible to its employees.

As the article points out, hospitals are not usually so open and honest when it comes to errors.  While they may publicly report information on infection rates to their employees, serious medical errors are often kept under wraps.  While acute care hospitals in Massachusetts are required to report events to the Department of Public Health, ultimately only the frequency of events is reported to the public.  The details often remain unknown.  Hospital leaders often fear that the public will find out exactly how bad things really are, either scaring patients away or opening the door for litigation.

According to the Globe, leaders at BWH started the publication to encourage staff members to talk about mistakes and to also propose solutions in order to prevent errors.  The focus on transparency at BWH supports the notion that keeping errors secret may actually hamper efforts to reduce the errors from occurring in the first place.  Learning from errors in an open forum may be the only means to find out what happened and prevent them from happening again.

“Transparency until it hurts” is a phrase we often throw around at the Bureau of Healthcare Safety and Quality within the Department of Public Health.  The idea that patients and consumer deserve to know what they are getting into is paramount in our organization.  Apparently, Brigham and Women’s took a page out of the transparency book as well.  Hopefully other hospitals will follow suit.

Humanism in medicine

Tags

opinion

A few weeks ago, The Atlantic published an article that was essentially a guide for pre-med students to find a medical school that would provide a good fit.  The article also focuses on how medical education needs to change in this country to add a more student centered and humanistic approach.  I’ll let you read the article for yourself.  I will say that the suggestion that interviewees should ask “What difference are you making in the lives of your students?” is rather bold and perhaps borders on naive; however, the follow up question “What difference are you making in the lives of your patients?” is more than appropriate.

What struck me about the article was actually the comments from some of the medical providers.  While I admit that the article is a little “touchy-feely”, I think some of the comments about what “modern medicine” is like are a bit off base.  The fact of the matter is, patients DO want physicians who are not just doctors but actual human beings.  Gone are the days when the “doctor knows best”, patients want to feel engaged and understood instead of talked over and talked at.  There is ample evidence to suggest that patients are more likely to adhere to treatment regimens when they have a good relationship with their physician.  And there is plenty of evidence that admitting faults and mistakes, and saying “I’m sorry” when a physician commits an error leads to lower chance of a malpractice lawsuit.  More importantly, the patients that like their physicians and feel that their physicians understand and empathize with them are not only less likely to sue, but are more likely to continue their care with that same physician.

So far as the rigorous training is concerned, graduating medical students are well aware of which residency programs are considered “malignant”.  It’s no surprise that many of these same programs are generally considered “top notch” institutions.  But it’s important to note that these high profile programs are either riding on legacy or name recognition or are ranked as such by publications such as US News & World Report, publications that value metrics such as research dollars or number of specialists rather than actual quality of care or clinical outcomes.

A doctor once told me that there are three vital skills in medicine, but that to be successful, you only need to possess two out of the three.  He told me that patients prefer doctors that have two of the three “A’s”: availability, ability, and affability.  So while it is possible to be a physician with great technical skills who is always available to his/her patients while being a complete jerk, two out of those three combinations require a human touch.

Now, in defense of grumpy 60+ year old physicians – yes, medical training is rough and challenging.  As it should be; we are training the (supposedly) best and brightest to become the next generation of physicians, the next generation of individuals charged with keeping America healthy and alive.  But that doesn’t mean there isn’t room for a touch of humanism in there.

Curbing early elective inductions

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health policy and management

For nearly 30 years, the American College of Obstetrics & Gynecology has recommended that doctors and hospitals wait until at least 39 weeks to perform elective inductions or Cesarean sections, except for justifiable medical causes.  Despite this guideline, 10-15% of babies born in the US every year are delivered early.  The reasons are plentiful – doctors (and hospitals) receive higher reimbursements for elective inductions, women do not know about the risks of early inductions and C-sections, and both doctors and mothers see early induction or C-section as a convenience to themselves.

However, early inductions and C-sections are not without risks.  Babies born before 39 weeks gestation are more likely to have respiratory problems, difficulties with feeding, and developmental problems that can be long term.  So the question is, how can we get elective induction rates to decline?

There have generally been two approaches to this problem.  The first is to systematically review every single pregnant woman admitted to the hospital to see if she meets medical criteria for a necessary early induction.  Intermountain Healthcare in Utah has been practicing this type of utilization review for years, requiring the head of the Department of Obstetrics and Gynecology to sign off on any elective inductions.  Prior to instituting the review process, 27% of deliveries were by elective induction at less than 39 weeks.  That figured dropped to 6% within 18 months.  The end result?  Healthier moms and babies… and the hospital lost a lot of money.  But hospitals are increasingly jumping on the bandwagon to reduce elective induction rates, as reported by Kaiser Health News, including some of the most high-profile maternity hospitals here in Massachusetts.

It’s comforting to know that hospitals are at least beginning to realize that what may be good for their bottom line isn’t necessarily good for their patients.  However, money in medicine does a lot of talking, and one of the most effective ways to reduce unwanted behavior in the medical community is simply to stop paying for it.

And that’s just what has happened.  UnitedHealthcare, the nation’s largest private insurer, began rewarding hospitals for taking steps to limit early deliveries if they could demonstrate a drop in their rates.  BlueCross/BlueShield of South Carolina stopped reimbursing providers altogether for performing early deliveries without a medical cause.  The South Carolina Medicaid program followed suit; together, the two insurers pay for 85% of births in South Carolina.  The Texas Medicaid program has a similar rule on the books, and New York and New Mexico are considering adopting this policy as well.

Time will only tell which strategy will be more effective, but I wouldn’t be surprised to see early elective induction rates fall faster in the states that stop paying for them.

words to live by

Tags

overread

In his landmark satire of medical residency, The House of God, Samuel Shem (a pseudonym for psychiatrist Stephen Bergman) outlines the 13 Laws of The House of God.  Shem wrote and article for The Atlantic in late 2012 as a follow up to his novel.  In the article, Shem adds four new laws to his prior list of thirteen.  Below is one of those new laws, #15.

Law 15 : Learn empathy. Put yourself in the other person’s shoes, feelingly. When you find someone who shows empathy, follow, watch, and learn.

Happy National Public Health Week!

Tags

health policy and management

unusual activists

Tags

adorable

I couldn’t help it… too funny!

confused over health reform?

Tags

health policy and management, opinion

Apparently you aren’t alone…

The Patient Protection and Affordable Care Act was signed into law three years ago, but a new poll indicates that the public knows less about the law today than they did three years ago.

The poll by the Kaiser Family Foundation found that nearly two-thirds of uninsured adults – the very people the law is supposed to help – don’t know what the law means or how they will be impacted.

It’s been three years since President Barack Obama signed the Affordable Care Act into law, yet two-thirds of uninsured adults — the very people the law sets out to help — say they still don’t know what it means for them.  Furthermore, the general public doesn’t seem to know what steps their respective states are taking.

According to the federal government, enrollment for new coverage in the exchanges and Medicaid expansion is set to begin on October 1st of this year. Yet nearly half of those polled said they didn’t know if their state would be running its own health insurance exchange.  Nearly 80% had no idea if their state was planning to expand Medicaid or not – regardless of whether that state’s governor had announced Medicaid expansion plans.

The public appears to know less about the positive aspects of the law than they did three years ago, including tax credits to small business to buy insurance, subsidy assistance for individuals and guaranteed issue of health insurance.  And false impressions still run rampant.  57% incorrectly believe that the ACA includes a public option. Almost half think the law provides health insurance or financial assistance to illegal immigrants, and 40%, including 35% of seniors, still believe the law will create so called “death panels”.

I’m not one to normally criticize our sitting President, but the evidence from polls like this suggest that the Obama Administration has failed miserably and continues to do a poor job at communicating key provisions of the Affordable Care Act to the people who matter most – the general public.  This might explain the continued resistance to the law on the part of conservatives; if the public were better informed, perhaps our politicians would put plans to overturn the ACA to rest…

Bitter Pill: Part 10

Tags

health policy and management

Moving on to Section 3 of the TIME magazine article “Bitter Pill: Why Medical Bills Are Killing Us“.

3. Catastrophic Illness — And the Bills to Match

People, especially relatively wealthy people, always think they have good insurance until they see they don’t.

This quote from billing advocate Patricia Palmer says so much in so few words.  Millions of Americans still obtain insurance from their employers, with little understanding of what deductibles, copays, and coinsurance actually mean.  If you were to ask the average American about their insurance plan – most of them couldn’t tell you their monthly premium or what is covered by their plan.  The fact of the matter is that in the quest to obtain health insurance, people are either unaware of what their insurance actually covers because it comes from their employer, or knowing full well the limits of their plan, they have no other options and are desperately willing to take risks to secure coverage.   If this sounds strange or wrong to you – it should.  In the world’s wealthiest nation, we shouldn’t have to risk our health and our livelihood simply for the ability to obtain medical care.

And yet we do.  People like Sean and Stephanie Recchi and Rebecca and Steve S knew that their insurance coverage was inadequate or contained coverage limits in the fine print.  But the Recchis and the “S” family bought what they could afford; they chose between having health insurance and not having health insurance, even if the choice to obtain coverage left them vulnerable.  Anyone else in their situation would probably have done the same.  Because in the United States, having health insurance is the first gateway to health care access.

But probably the most important lesson of Steven Brill’s article is this: while having health insurance dramatically improves one’s access to health care, health insurance does not serve as a guarantee to affordable care.  I’ve avoided trying to make the “Bitter Pill” article into an all-out political issue, but this is where money, medicine, and politics collide head on.  When we talk about the uninsured in this country, conservatives (read: Republicans) see a group of lazy people who choose to not buy health insurance and then freeload on the rest of us taxpayers, while ignoring substantial evidence to the contrary.  Liberals (read: Democrats) see a group of people who are desperately in need of assistance in obtaining insurance, while ignoring the fact that coverage does not actually equal access.  Using these terms, the Affordable Care Act (ACA) essentially forces these “freeloaders” to buy insurance or pay a penalty/tax and to help the desperate obtain coverage through subsidies, Medicaid expansions, and state insurance exchanges.

As much of a champion as I am of the ACA, it does little to solve the problem that the Recchi’s or the “S” family encountered.  After all, they already had insurance – and yet their insurance wasn’t adequate.  They fall into the category of people who are underinsured – they have insurance but still can’t afford necessary medical care.  True, the ACA does eliminate coverage limits, high deductible plans, and pre-existing conditions, but in doing so, it only makes health insurance more affordable.  In truth, even though it is called the Affordable Care Act, the health reform law does little to make care truly affordable.

Three Years Later

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health policy and management, opinion

This is likely to be my last post about Haiti for a while.  I’m certainly no expert, nor does my week there in January qualify me as such.  But I had the opportunity several weeks ago to attend a lecture at Harvard – Haiti three years after the earthquake.  The lecture was hosted by the Harvard Haitian Alliance, the Harvard Undergraduate Global Health Forum, and the Tufts Pan-African Alliance.  The panel of distinguished guests included Jonathan Katz – journalist for the Associated Press and author, Dr Rishi Rattan – Advocacy Chair for Physicians for Haiti, Patrick Sylvain – writer and photographer, and Nancy Dorsinville – Policy Advisor in the Office of the UN Special Envoy to Haiti.  In the course of the lecture, the panelists brought up some remarkable points about Haitian healthcare and governance.  Here is my take.

Paul Farmer once characterized the problems plaguing a post-earthquake Haiti as “acute on chronic” – bad on top of already terrible.  The world’s response (read: US, UK, France, Canada) has been to support the Haitian government to the tune of providing over 60% of the country’s budget.  Those have proven to be some powerful purse-strings, likely to influence even the most resolute of politicians to succumb to powerful donors’ wishes and agenda.

However, American politics of late has clearly demonstrated its blatant inability to compromise and solve our nation’s acute problems of budget negotiations, debt ceilings, and the economy, let alone the chronic issues around spending, taxes, debt, education, human rights, violence, and homelessness.  The American medical and health care system, in particular, has been trying to conquer chronic disease in the United States for years while barely managing to contain acute illness among our own citizens.  This approach therefore proves entirely problematic when trying to introduce an “American” system in Haiti to “eradicate” poverty, illiteracy, crime, and disease.  This approach only begs the question, what hope is there for eliminating cholera in Haiti under such a system?

Policy makers devising a “solution” for Haiti will never succeed if that solution continues to be made by international “experts” without consultation of the Haitian majority.  For example, the “expert” opinion on how to eradicate cholera in Haiti, largely supported by the UN, is to employ vaccinations and antibiotics to treat cholera.  However, eradicating cholera is much easier than vaccines and antibiotics.  Removing the source by providing clean water and sanitary facilities is a far simpler and sustainable solution, and one that every day Haitians would much rather have.  Yet with the UN holding the purse strings, Haiti’s response has been to comply.

Point blank, the Haitian State must operate for Haitians – and more importantly be allowed to operate for Haitians – despite the possibility that it may do so poorly or inadequately.  There will undoubtedly be mistakes and failures, but just as a child must be allowed to get back on the bike and try again, so too must the Haitian government be allowed to learn from its own errors without foreign intervention preventing those errors from occurring in the first place.  At the very least, those mistakes for once would be entirely Haitian.  In the United States, we purport to believe in a government of the people, by the people, and for the people.  The lingering question then remains… why is this not okay for Haiti?