Let’s be honest, Americans don’t often “look to Kentucky” as an exemplar for a lot of things. But Kentucky is turning out to be a bright and shiny star for President Obama’s health care reform law. And here’s why…
Kentucky governor Steve Beshear is one of the only Southern governors to apply the Affordable Care Act as it was written – persuading the Legislature to expand Medicaid eligibility as well as create a state-based health insurance exchange. The effect? In a state where 15% of the population is uninsured (about 640k people), over 56k have already signed up for new health care coverage. The majority have signed up for Medicaid, but about eleven thousand people have signed up for private health plans.
Creating a state run exchange instead of relying on the federal website has proven to be a godsend for many states, not just Kentucky, as the federal website has continued to flounder. For those who are salivating at all of the chatter about cancelled insurance plans and skyrocketing premiums, this article from the Washington Post describes the Kentucky experience in Breathitt County. These are the very people the law was designed to help – those with low incomes that are too high for traditional Medicaid but too low for insurance. Those with part-time jobs that don’t offer insurance. Those who never knew they were eligible for health insurance and those who could never afford the care they needed.
“But wait… imagine if you’re the survivor of the heart attack death sex!”
In September, Victor Fuchs wrote an opinion article in JAMA titled “Current challenges to Academic Health Centers” discussing the perils facing academic health centers in the future. Fuchs offers some valid points as to why academic medicine is becoming increasingly threatened in the current health care environment.
Academic health centers (AHC) are at the top of the medical pyramid. They are the referral centers for tertiary care when community hospitals do not have the technology or expertise to take care of complex patients. AHCs are often the location of last resort for many patients without insurance or with specialized medical conditions. They are the centers of breakthrough research, the pioneers of new interventions, and by and large the centers of education for the nation’s future crop of physicians.
Their missions of pioneering health care, education, and breakthrough research come at a price, and that price is that care provided at AHCs is often expensive. In the current environment of cost control, Fuchs argues that without change AHCs “may lose their place at the apex of US health care.” He states that AHCs must change how they organize, price and deliver care, changes that ultimately will affect their education and research missions. But like all hospitals, AHCs also face the problem of changes in the US patient population and shifts in location of service. The inpatient hospital population is becoming older and more chronic illness, while the bulk of care is moving from the inpatient to the outpatient and ambulatory settings. AHCs may find it particularly difficult to quickly shift care from inpatient to outpatient as many AHCs are located in urban centers with aging infrastructure, where high property values and construction costs make it difficult to build new structures or convert existing structures.
But Fuchs also argues that the way we pay for medical care is by far the biggest threat. And while his general assumption is correct, I take issue with his argument. Fuchs states that payment has shifted from fee-for-service to bundled payments, which is true, but he argues that the shift has meant no longer ordering every test, drug, or procedure that offers some benefit but instead to the “socially optimal amount of care.” Fuchs states that by controlling costs, public and private payers are implicitly asking physicians to redefine optimum care away from what is medically defined to what is socially preferable. Fuchs goes on to say that eliminating “waste” is a surrogate for prescribing “socially optimal” care.
In doing so, Fuchs ignores the obvious – that not all care of marginal benefit may be worth the costs, especially to the patient who cannot pay. Physicians across the country are constantly confronted with trying to provide what is “medically optimal” yet not financially possible for the patient. Furthermore, physicians often blame patients for being “non-compliant” with the prescribed “medically optimal” therapy when in fact the patient would love to comply – if they only had more money.
Undoubtedly, Fuchs raises the controversial point of what amount of benefit justifies the cost of an intervention. What he ignores is that “benefit” is largely determined by the patient…
Humans will always make mistakes regardless of their training, experience, or determination. In other words, the universal constant is that human infallibility is impossible, and those who build a system that depends on the absence of serious human mistakes will fail utterly.
We must expect literally every medical order to contain a potentially lethal mistake.
~John J Nance, JD
What other enterprise in this nation with such high responsibility and potential liability would tolerate the level of individual practice variation that has become standard in medicine? Try this: Would you fly on an airline that lets their captains decide individually whether to use flaps or checklists, or turn on all the engines for take off? Would you want your neighborhood nuclear power plant to run in freeform, avant-garde style by a manager who thinks he’s smarter than the rules and is intent on experimenting with, say, the cooling valve positions and fuel rod extraction procedures?
~John J Nance, JD
Are they for real?
Stuart Altman speaks for the Boston University School of Public Health’s October Health Policy Forum. Dr Altman is an economist by trade and is currently the Chairman of the Massachusetts Health Policy Commission. He is an active faculty member at the Brandeis University Heller School for Social Policy and Management. He formerly served as Chairman of ProPAC, the congressionally legislated Prospective Payment Assessment Commission, responsible for advising the U.S. Congress and the Administration on the functioning of the Medicare Diagnostic Related Group (DRG) Hospital Payment System and other system reforms.
His official job title should be genius.
I cannot take credit for this list of things that millenials need to know about the ACA, but a big thanks to Kaiser Health News for this list.
- Even superheroes need health care.
- The time has come – a lot of big ACA changes already happened… on October 1st.
- Obamacare marketplaces are like shopping online – something millenials are good at.
- Your coverage options are affected by a lot of factors, especially where you live.
- What’s covered under your plan also depends on where you live.
- Employers with greater than 50 workers will have to give employees coverage, but the options vary.
- Navigators, available both online and in person, are like the GPS of health care.
- Insurers can no longer charge you more or drop coverage because of certain health conditions.
- One of the most important things you can do is understand your plan!
The government shutdown has left several federal agencies running with skeleton crews. The problem? Many of those agencies are directly responsible for monitoring the nation’s health. If there was ever a time to highlight the important role that public health plays in keeping America healthy, it is now. Here’s a few specific examples:
-the Centers for Disease Control and Prevention is one of the agencies affected by the shutdown. The CDC monitors for disease outbreaks, in particular for foodborne in particular for foodborne illnesses. If you hadn’t heard, there’s currently a salmonella outbreak that has sickened over 270 people. This is only one of some 30 other outbreaks that the CDC is monitoring, but with reduced staff, investigating outbreaks has slowed significantly.
-The CDC has also stopped its surveillance for influenza, although thankfully it’s early in the flu season.
-OSHA or the Occupational Safety and Health Administration has stopped workplace checks for safety and health violations
-probably the scariest public health related casualty of the government shutdown is the Food and Drug Administration (FDA), which has stopped routine inspections of food facilities. The FDA is responsible for inspecting approximately 80% of the nation’s food supply (the other 20% falls mostly under the authoridy of the USDA – which is still mostly staffed).
I knew returning to surgery residency would be difficult and challenging. It’s not like I forgot the long hours, the (often) annoying consults, the personalities of different physicians and nurses, and the typical hospital drama. I knew that my free time would significantly shrink from the days when I was pursuing a Masters in Public Health. I knew things would be different.
But no matter how much you think an experience will turn out, the reality is significantly different from what you envision. Sometimes for the worse and sometimes for the better. It’s been three months so far, and over all the experience has left me with mixed feelings.
When I left residency, I was a third year resident – just starting to run a service as the “chief” and yet still dealing with surgical consults on overnight call. On my return, I’ve been propelled into the world of a fourth year resident, the “chief” on each service (ours happen to be trauma surgery and pediatric surgery at our main hospital, and general/vascular surgery at a community hospital). As a third year resident, I often found myself running the service and delegating tasks to an intern during the day and fielding phone calls and calling the chief resident and attending on call during the evenings. It was a career split between ultimate responsibility during days and coverage during nights.
But that’s all changed now. Ultimate responsibility prevails both during the day and at night, although there is always an attending for backup. But for a type A control freak, I sometimes (read: almost always) find it difficult to delegate away all tasks and hope/pray/believe that those tasks will be accomplished on my patients. Overseeing others is incredibly difficult, further compounded by the fact that their mistakes are ultimately my mistakes. I haven’t bothered to ask, but I can only imagine that the interns on service with me get annoyed with my mostly hands-on but occasionally hands-off approach. In addition to clinical responsibilities, surgery, and patient care, teaching occupies a portion of the day as well. In my mind, intern year is about learning how to actually be a physician as opposed to acting like one – and teaching interns how to “be” a physician is significantly harder than teaching medical students how to act like one. Furthermore, teaching second and third year residents how to manage surgical consults can be incredibly challenging when you’ve been “out of the game” for two years.
That said, it hasn’t all been unnerving. Returning to the operating room has been wonderful, although these days I’m not operating much on my current service. I’m no longer the first call for consults; to not be the first person woken up in the middle of the night because a patient in the ER has abdominal pain is basically a gift from baby Jesus. Rejoining the surgery residency “family” on a full time basis has been great too – one’s co-residents do become very good friends considering how much time we all spend together. And I’ve been blown away by how many people have said things like “glad to have you back” or “we missed you” – certainly a good feeling.
I’d be lying if I said I didn’t miss my MPH days – the freedom and the free time. The time to sit and read, to write, to blog, and to work out. Friends and family ask how I can give that all up for a grueling work life/schedule. And try as I might to explain it, there’s really nothing out there that is equivalent to performing a tracheoesophageal fistula repair on a one day old infant or doing a latissimus dorsi flap to reconstruct a woman’s breast after breast cancer surgery. To everyone else, these are just words…
“I feel like I can’t even swallow what’s in my mouth right now.”
um… wow… that um… not sure I know what to tell you about that…
“oh, I bet you put in the crease!”
Everyone in the medical community is a little superstitious. For example, most of us don’t want to hear someone say “hope you have a quiet night” because for some reason those always end up being the busiest nights. Here’s another example of that hospital paranoia…
“The hospital just listens to you and then says ‘I’m going to f*ck him so hard and totally screw him over’”
If people really knew what went on in the minds of doctors, they might be horrified…
“You might want to arrange direct transfer to a funeral home… via hearse…”
“You may want to grab a shovel and start digging his six foot hole now.”