The race for Boston mayor

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opinion

The race to become Boston’s next mayor is heating up quickly.  Two dozen candidates have announced bids to run for the position that Mayor Tom Menino will be leaving next year.  The next mayor of Boston will be one of the 24 people below who signed up for nomination papers,  but signing up for signature papers is a far cry from becoming an official candidate. Campaigns must gather 3,000 valid signatures by 5 p.m. May 21. Voters can sign multiple nomination papers, but a signature will only count for the first campaign that submits it to City Hall.

 

 

 

 

 

 

 

 

 

 

 

 

I’m certainly happy to see a healthy amount of minority representation among this crowd, although there is no Asian candidate – odd considering almost 10% of Boston’s population is Asian.  But more striking to to me is the three women out of 24 candidates.  Women account for 52% of the city’s population, and 30% of businesses in Boston are owned by women.  Are we fooling ourselves into thinking that women have made a lot of headway?  This field of candidates might suggest otherwise…

On a positive note, one of the lead stories in today’s Boston Globe is about some powerful supporters rallying behind Charlotte Golar Richie.

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

Tags

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.

Maxim Hot 100

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opinion, ridiculous

I know, this isn’t a topic I normally would post about, but after hearing the top 10 list of Maxim magazine’s 100 hottest female celebrities, I couldn’t help but post.  I mean, who came up with this list exactly?  The fact that both Selena Gomez (#2) and Taylor Swift (#13) beat out someone like Sofia Vergara (#49) is ridiculous.  I’m also a little disturbed by the fact that the oldest woman of the top 10 list (Jennifer Love Hewitt) is only 34.  The youngest btw is 20.

1. Miley Cyrus
2. Selena Gomez
3. Rihanna
4. Mila Kunis
5. Jennifer Lawrence
6. Jennifer Love Hewitt
7. Ashley Tisdale
8. Kate Upton
9. Vanessa Hudgens
10. Elisha Cuthbert

Thoughts?

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…

Tags

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.

what a jerk

Tags

opinion

This guy may win the award for jerk of the week.  Apparently, he thought it would be funny or cute to display a sign reading “Toronto Stronger” at Game 3 of the Bruins-Maple Leafs playoff series.  You can imagine that the reaction from Bostonians, Americans elsewhere in the country, and some Canadians was less than pleasant.

Incidentally, the Bruins beat the Maple Leafs in Game 3.  So who’s stronger now?

12 First Date Deal Breakers

Tags

opinion, ridiculous

This story appeared yesterday on The Huffington Post, and I couldn’t help but share.  Christine Gallagher details the twelve things you should never discuss or reveal on a first date.

I happen to agree with most of these, but I’m curious what people think about #3.  Is it really NOT okay to talk about your dog or cat at all during the date?  Yes, clearly there is a danger zone in going overboard, but mentioning you have a dog or cat?  Really?

Btw, as a pescatarian, #5 could be incredibly important – especially if that first date is at a restaurant.  I don’t mind if my date eats steak or pork or some other meat for dinner – but there are a lot of vegetarians/vegans out there who do.  Might be good to know that in advance.  Just saying…

12 Things to Never Mention on a First Date

1. The ex. It’s best not to vomit up what went wrong in your last relationship. If you do, your date will be sure to pick up any information about how you might behave in a relationship with him or her. So zip it. Never share the details, particularly the gory ones, until you know each other a whole lot better.

2. Your finances. There’s a lot of talk right now about people being financially strapped — there’s even a new sitcom about a divorced woman living with her parents. But it’s not sexy, okay? Again, let’s hope that you are so stunning in other ways that your date doesn’t give a damn and is more than happy to sneak in through your childhood bedroom window if things get that far. But don’t count on it. It’s best to tread softly when you reveal financial woes.

3. Beloved pets. Nothing is more unappealing than listening to a new date express undying love for their pet. Keep the iPhone photos to yourself. Don’t share pictures of Fido at the doggie Easter egg hunt. If you have more than two cats, never share that information until you’re on more solid ground. And don’t say you can’t ever have a sleepover because your cat or dog can’t be left alone. As for deceased pets you had in childhood, let them rest in peace.

4. Physical ailments. This is especially important for hypochondriacs. Trust me — only your doctor is interested in a history of your ailments and injuries. And if you have any suspicious rashes, particularly on hidden parts of your body, don’t tell your date, okay?

5. Special diets. If you subscribe to a restricted eating lifestyle, don’t discuss it at length. You may come across as boring, dogmatic or worse. Vegans should go easy, particularly if their date is happily cutting into a big juicy steak. Eccentric eating preferences should also be handled carefully. I once had a date with someone who revealed they only ate white food. I still can’t articulate why, but this was an immediate total turnoff.

6. Your brilliant children. All of us are crazy about our kids.  We think they’re incredibly talented and adore their quirky behavior, but a total stranger has absolutely no need to know the details. Of course, do reveal you have kids. Mention their ages. Then move on.

7. Sexual practices. A first date is never the time to discuss what you like or don’t like in bed. If you have a bag of sex toys in your closet, don’t share. Don’t, under any circumstance, talk about past lovers and their talents and preferences.

8. You don’t like sex. You may get lucky and be dating someone who feels exactly the way you do. But it’s not likely, okay? So save this tidbit for later.

9. Unusual habits. This is a very broad category.  It could be something benign but potentially off putting — like your kids still sleep in a family bed with you, or you have a side business providing custom pet funerals. If you have a hard time gauging if your habits might be “unusual”, ask a candid friend for feedback.

10. Your porn addiction. Okay, so you’ve been single for a while and spending evenings in fantasy porn land. But now you’re out in the real world with a real person. You don’t have to share.

11. Arrest records. Any arrest, even if you were deemed innocent, should not be revealed upfront. It will raise big-time red flags and scare away a lot of people. Same goes for IRS problems, foreclosures, disciplinary hearings etc.

12. How miserable and lonely you are. Chances are your date is equally miserable and lonely, but it’s still a big turnoff and should be kept for your therapist. For your date, put on your best face and keep it in the light zone. And who knows? Maybe a sliver of magic will pass between you.

yet another #fail from the NRA

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opinion, ridiculous

For the record, using the Boston Marathon bombing as a political weapon to argue for or against gun control is completely inappropriate.  When Arkansas Representative Nate Bell asked how many Bostonians were cowering in their homes wishing they had an AR-15 the night before the lockdown, social media responded quickly… and Nate Bell found himself apologizing for the “timing” of his unfortunate comments.

Apparently Wayne LaPierre, the Executive Vice President of the NRA, didn’t get the same memo, when he asked today “How many Bostonians wish they had a gun two weeks ago?”

The Boston Marathon bombings are not about gun control or gun ownership or gun freedom.  What Bostonians wished for two weeks ago was a swift resolution to a horrifying and terrible event.  What Bostonians wished for was peace and safety.

If you want to turn the Newtown tragedy into a gun discussion, that’s fine – although I would argue it’s inappopriate to not include a discussion about mental health in there.  But the Marathon bombings were not and are not about guns.  They are about terrorism and cowardice.  Turning them into a pro or anti-gun weapon is just as cowardly.

Starting the conversation

Tags

gay, opinion

I didn’t set out to be the first openly gay athlete playing in a major American team sport. But since I am, I’m happy to start the conversation. I wish I wasn’t the kid in the classroom raising his hand and saying, “I’m different.” If I had my way, someone else would have already done this. Nobody has, which is why I’m raising my hand.

Today marks a rather important day in sports history in the United States.  For the first time, an active player in one of the four major sports leagues came out to the country as a gay man.  Jason Collins’s story is heartfelt and personal, including references to Representative Joe Kennedy and the recent Boston Marathon bombings.  To put it in his own words, Jason’s story is both “authentic and true”.

I think I speak for much of the LGBT community when I say that I hope for the day when people, including athletes and celebrities, don’t need to fear coming out of the closet.  I think I speak for the LGBT community when I say that I long for the day when an athlete or a celebrity holding a press conference about being gay is no longer a headline but rather another boring piece of everyday news.  Scratch that – I hope for the day when those press conferences never have to occur in the first place.

The conversation in professional sports has been a long time coming.  Thank you to Jason Collins for raising your hand and starting that conversation.

Boston Strong Yankee Candle

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opinion, ridiculous

I’m probably going to catch some flak for this but… am I the only person who thinks this is going a bit too far with the Boston Strong theme?

I understand that Yankee Candle is a local company and that proceeds go to the One Fund Boston.

But what exactly is this Boston Strong candle supposed to smell like?  Beer?  A bathroom at Fenway Park? The Green Line?  Dunkin Donuts?  The exhaust from the Duck Boats?  I mean… seriously…

[steps off soapbox]

Tweet #truth

Tags

opinion, twitter

This girl is amazing.  Definitely my Tweet of the week.  Arkansas Representative Nate Bell should take some notes.

#epicfail

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opinion, ridiculous

While I’ve been fairly absorbed in the events unfolding in Boston for the last three days, there was one major headline on the Huffington Post that was hard to miss.  Yesterday, the US Senate voted on amendments to a gun control bill.  One such amendment was the bipartisan Manchin-Toomey amendment to expand background checks for guns sold over the internet and at guns shows.  The amendment did not gain the 60 votes necessary to pass, falling short at 54 in favor to 46 against.

Immediately after the vote count, at least two members of the Senate gallery shouted “Shame on you!”.  Family members of those killed in the Sandy Hook and Virgina Tech shootings were in attendance.

I’m not sure you can call an amendment “bipartisan” when only 4 members of the minority party vote for the bill.  But the fact that the amendment was supported by 90% of Americans according to a Washington Post/ABC News poll and yet failed to pass in the Senate says something striking about our political system.

In case you’re wondering who voted for and against the measure…

*Note: Senate Majority Leader Harry Reid (D-Nev.) supported the legislation, but he voted against it for procedural reasons, in order to preserve the right to bring the measure back up.

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.

late night MBTA service?

Tags

opinion, ridiculous

Not too long ago, the Massachusetts Bay Transportation Authority (MBTA) Rider Oversite Committee issued a survey asking commuters if they would be in favor of extended hours on public transportation services in the city of Boston.  For readers from New York or Chicago, I know it may be hard for you to imagine a subway or bus system not running 24 hours a day… but such is the reality of life here in Boston (and I suspect many other cities in the country).

MBTA thought that roughly 500 people would answer the survey.  They were blown away when nearly 26,000 people responded with a resounding “YES”.  Over half of respondents said they would be willing to pay at least double the regular fare to take a “night owl” bus of subway ride.

I, for one, am all in favor of extended hours on public transportation for multiple reasons.  For one, it cuts down on accidents, injuries, and deaths associated with drunk driving, as residents are more likely to take public transportation into the city knowing that it runs later.  Public transportation is especially important to young professionals, who coincidentally are most likely to use the late night service.  Extended hours would also cut down on automobile traffic, as individuals who work late or overnight shifts might be more willing to take the “T” instead of driving to work.  Finally, I truly believe that to succeed as a vibrant, modern city in the United States (and one that wishes to reduce automobile traffic in your city center) you need to offer residents a means other than a cab for accessing the nightlife and cultural attractions that keep a city humming.

To be clear, I’m all for extended hours.  And I also commend the MBTA for “feeling the pulse” of the people.  Residents continually clamor about the desire for extended hours; without actual evidence like this survey, these stories only amount to anecdotal evidence.

But issuing such a survey at the current time seems almost irresponsible.  The MBTA is notoriously cash-strapped and indebted – although to be fair, much of that debt was forced on the agency due to the Big Dig.  However, at a time when the MBTA is pleading with state legislators for new funding streams to close budget deficits and is floating the idea of either cutting service or raising fares, even considering the idea of extending public transit hours seems ludicrous.  Residents of Boston and the surrounding areas that rely on the MBTA to commute in and out of the city every day constantly complain about the poor and unreliable service of the many buses, subways, and trains.  How many times did the commuter rail shut down this winter?  And how many days has it been since the Green Line or Red Line last suffered a breakdown?  Do we really think that extended service will be any better?  Perhaps we should focus on fixing what we have before we consider extending ourselves farther…

No folks, the MBTA shouldn’t even be entertaining the idea of extended hours until the agency can offer frequent, efficient, reliable, and sustainable service to the areas it currently serves – and without a negative operating margin.  Without those fixes in place, public transportation service during extended hours will be subject to the same delays, inconsistencies and breakdowns, and will be yet another source of discontent with the MBTA for Bostonians.

Marriage Equality

Tags

gay, opinion

This symbol and several variants of it began appearing on social media sites on Monday night, in anticipation of the arguments before the Supreme Court over California’s Proposition 8 and the federal Defense of Marriage Act.

Opponents and naysayers are quick to point out that posting this image to one’s Facebook profile is pointless, for despite the thousands (if not millions) of people who changed their photo, the symbol itself is unlikely to overturn any law or change the opinion of any lawmaker or Supreme Court justice.  They are quick to ridicule this form of “Facebook activism”, noting that expressing symbols such as these on a social media website does not compare to championing civil rights “on the streets” and does not adequately put one’s “skin in the game”.  But by deriding those who choose this form of self-expression, opponents and naysayers entirely miss the point.

Let me be clear – we all know that this symbol will not change America overnight.  We all know that this image will not overturn laws, rewrite constitutions, alter history instantly, or sway the minds of politicians or judges.  We are very well aware of what this symbol cannot and will not do.

But this is a powerful symbol.  For thousands of LGBT men and women out there, it is a symbol that they are not alone.  It’s a sign of love and solidarity from fellow LGBT individuals.  It’s a symbol of love from those in the straight community that support the rights of their LGBT family, friends, coworkers, neighbors, and fellow Americans.  It is a sign of hope that the future of marriage equality is bright even if the recognition of this right does not come today, tomorrow, or even three months from now.  It is an acknowledgment that we are here.  It is a representation of changing attitudes, changing tides, and changing times.  This image is a beacon of hope to all the young gay, lesbian, bisexual, and transgender individuals living in fear, who feel they are alone, that out there in the world are people who at the very least support them, and at the most are championing their fundamental rights as citizens.  No… rather their fundamental rights as human beings instead of second class citizens.

For those in the LGBT community, this symbol is a recognition of what has been a long time coming.  For those in the straight community who support their LGBT brothers and sisters, it is a way of freely and unabashedly demonstrating their support without coercion or pretense.  No my friends, this is not an empty gesture; this is a recognition of just how far we have come… and how much farther we have to go to ensuring that all Americans have the opportunity to marry the one they love.

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…

Meet the Gaybros?

Tags

gay, opinion

I’m not going to win any popularity points with this one, but I don’t care.

Brian Lowder wrote an article for Slate that posted yesterday titled “Meet the Gaybros.” The subtitle was “They like sports, hunting, and beer. They make the gay community mad.”

I’ll tell you what makes me mad… articles like this one.

The article starts off with Lowder walking around Boston with a group of men who have dubbed themselves “Gaybros”, gay guys with traditionally manly interests like sports, hunting, and beer.  They travel to the city’s “premiere gay sports bar” Fritz, where Lowder comments on the diversity of the crowd.  To call Fritz a “premiere” anything is a joke; the fact of the matter is that Fritz serves a clientele who, unlike so many other places in Boston, don’t give a f*ck who you THINK you are.  People go to Fritz not because it’s a great place to watch sports but because it’s low key and unpretentious.  The “Gaybros” later head off to Club Cafe, a locale I would ironically dub the exact opposite of Fritz… but also not “premiere”.  Lowder, on the other hand, makes an exit and heads to a house party at a “handsome” townhouse where he is surrounded by the “Crate and Barrel brand of gayness.”

Here’s why I hate this article.  The “us versus them” mentality and the compartmentalization of gay culture in this article (and in real life) is ridiculous and does us a disservice.  At a time when the community should be rallying behind each other in support of legal rights for ourselves and the rest of the LGBTQIA community, instead we continue to separate and ridicule one another.  We do to each other exactly what the straight (male) community continually does to us.  Gay men are, in fact, our own worst enemies.

The whole notion of “masc” versus “fem” is utter ridiculousness.  The idea that gay men can only fall into one category or another is ludicrous.  These labels, if you will, are not mutually exclusive. What this article highlights is a nasty division within the gay community, one that employs labels taken directly from the very people who oppress the gay community in the first place.  The fact of the matter is, there is plenty of room within the gay community for everyone – Gaybros included.

In the words of the person who sent the article my way, “I can love watching the Emmy’s and watching the Pats on the same day.  I totally go to Red Sox games because I’m a fan, but I also love to watch my design shows on HGTV.  Cut the crap – ALL OF US.”

Gays – it’s time to grow up.

in defense of marriage

Tags

gay, opinion, overread

Among social conservatives, the argument against marriage equality that reigns supreme is the notion that same-sex marriage undermines the very institution of marriage.  Since Massachusetts began to recognize same-sex marriages in 2004, voters in many states have approved amendments to their state constitutions barring same-sex marriage.  A number of states have also granted marriages to same-sex couples, and certainly the 2012 election ushered in a historic moment for marriage equality in the United States.  The compromise position for the remainder of the states has been the recognition of civil unions and domestic partnerships, as most recently demonstrated in Colorado.

In 1995, David Boaz wrote an essay for the New York Times on the subject of civil unions and domestic partnerships called “Domestic Justice”.  In that article, he noted that politicians “overlook that there are two kinds of domestic partnerships – heterosexual and same-sex.  Although the most vocal opposition to domestic partnerships is aimed at gay couples, giving them [legal] benefits does not undermine marriage.  Rather, it remedies the injustice that homosexuals can’t marry the people with whom they share their lives, and it creates financial incentives for stable relationships.”  Boaz wonders that for social conservatives who are so opposed to affirming marriage equality, are these not the same goals that we seek in encouraging heterosexual couples to marry?

Giving domestic partnership benefits to unmarried heterosexual couples, on the other hand, does undermine marriage.  They give people who can marry all the financial benefits of a legal union without demanding commitment.

If social conservatives really want to stand on a platform of family values, shouldn’t they be encouraging the creation of long lasting committed partnerships and families?  By offering domestic partnership benefits to heterosexual couples who do not marry, social conservatives undermine the very institution they hold so dear and continually wave in the face of same-sex relationships.  Instead, domestic partnerships and civil unions are seen as a peace offering to the gay community, relegating them to second class citizens and simultaneously undermining the institution of marriage by offering a similar set of rights to unmarried heterosexual couples.

Perhaps because domestic partnerships and civil unions are a step toward correcting a wrong, perhaps they have more bipartisan support than marriage equality, perhaps they are viewed as a compromise, or perhaps people believe the gay community will tolerate domestic partnerships and civil unions and therefore cease the push for marriage equality.  But we know from history that separate but equal is all too clearly separate but never in fact equal.

On the recently passed civil union bill in Colorado, state senator Pat Steadman (D) had this to say. “Civil unions are not marriage. They are something that are separate, and distinct, and lesser, and unequal.  And that really is not good enough. We passed this bill because this is the best we can do.”

Three Years Later

Tags

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?

Bitter Pill: Part 5

Tags

health policy and management, opinion

TIME magazine recently released an article called “Bitter Pill: Why Medical Bills Are Killing Us“.  Here begins my commentary on Section 2.

2. Medical Technology’s Perverse Economics

Brill opens section 2 by wading into the rise of medical technology and the effects of medical malpractice.  I’ll handle each of these in turn.

Brill is right about medical technology making procedures and treatments both easier and safer.  Take gallbladder surgery for example.  Traditional gallbladder surgery involves a large incision, painful abdominal surgery, and a multi-day hospitalization.  This open surgery was usually only performed for specific conditions like acute inflammation of the gallbladder (acute cholecystitis) or a few other gallbladder complications.  When laparoscopic surgery for the gallbladder came out, skeptics said it would never work and wasn’t as safe as traditional open surgery.  But the technology improved, and the operation became easier and safer – no large incision and decreased post-operative pain moved the procedure from major inpatient surgery to minor outpatient surgery.  Now, traditional open cholecystectomy has largely been replaced by laparoscopic surgery. But by virtue of making the technology making the operation easier and safer, surgeons opened up an entirely new market.  Patients who previously had merely had gallstones or pesky gallbladder symptoms (biliary colic) could now easily have their gallbladder removed instead of altering their diets for the rest of their lives.

The number of laparoscopic cholecystectomies has skyrocketed, far surpassing the number of open gallbladder operations ever performed, thereby increasing the total cost to the medical system just by sheer volume.  Add in the additional costs of the expensive technology needed to perform laparoscopic surgery, and you have a double whammy.  And finally, there is little push back from patients who desire the quick fix – because ultimately they will not pay for it directly or do not know the price until after the fact.

That’s not to say that we shouldn’t be, to quote a friend, “excited by emerging life-saving technologies.” Brill’s arguments negate the tremendous improvements that medical technology has brought to both our longevity and quality of life.  But in a system with finite resources, we need to take a step back and really ask ourselves if we are overusing the technology that has become all too easily available.  Does “if you build it, they will come” really have to apply?

Beyond the hospitals’ and doctors’ obvious economic incentives to use the equipment and the manufacturers’ equally obvious incentives to sell it, there’s a legal incentive at work.

There certainly is a legal incentive at work, but it’s not as simple as Brill states.  To give you some numbers, the United States spent approximately $2.7 trillion on health care in 2011.  The cost of the medical malpractice system (malpractice insurance premiums, trials, legal fees, and payouts) accounts for roughly 2.4% of health care expenditures, somewhere in the range of $64.8 billion.  That may sound like a big number, and as it turns out, a fairly easy number for economists to figure out.  The difficulty, however, is figuring out how much defensive medicine costs our nation each year.

When Brill interviews executives for his article, one of them is quoted as saying, “We use the CT scan because it’s a great defense [...] For example, if anyone has fallen or done anything around their head — hell, if they even say the word head — we do it to be safe.”  Brill tries to make the argument that it’s not the insurance premiums, verdicts or settlements that matter but rather the “cover your ass” behavior of physicians – the notion that one must practice medicine on the defensive in order to avoid being sued for potential wrong-doing.

There is no doubt that defensive medicine plays a role in our health care expenditures.  The problem is, no one really knows how much of a role it plays.  I, for one, think it plays a much larger role than most like to think.  Physicians commonly cite malpractice concerns as a reason for ordering more tests, but studies show the money isn’t always where their mouth is.  Studies looking at defensive medicine on the state level saw a 5-9% decrease in hospital expenditures after states instituted reforms to the malpractice tort system.  States with caps on non-economic damages (e.g. physical or emotional distress) have 3-4% lower overall health spending than states without these same caps.  Further studies have shown that a 10% increase in malpractice payments was associated with a 1.3% increase in Medicare expenditures and a 2.9% increase in expenditures on imaging studies like CT scans and MRIs.  Clearly there is some effect of defensive medicine.  But even if one takes a liberal estimate and assumes that 10% of total health expenditures are a direct result of defensive medicine, that only accounts for roughly $270 billion in 2011.  Now I’m not one to poo-poo any figure that amounts to billions of dollars, but that hardly begins to explain the $2.7 trillion in national health care expenditures.

That said, there is no doubt in my mind that we should be encouraging providers to order what is appropriate, not what will keep them safe from litigation.  Because even though that same hospital executive said, “we can’t be sued for doing too much”, the fact of the matter is you CAN be sued for doing too much when the patient has a bad outcome.  And the American public needs to know that more in health care is not necessarily better.