Tuesday, January 19, 2021

Emergency services, COVID, and the health system: Your life could well be at risk

I recently had a very unpleasant health event, involving severe abdominal pain for most of a day and night, and many days of recovery. The details of my specific condition are not particularly important, other than to say it is a chronic, recurrent problem, resulting from an event decades ago; it could well need emergency surgery and can have serious results. The point is that I had to decide whether to go to the emergency room that night, and to discuss the issues, both personal and structural, that impacted that decision, and what it demonstrates about our healthcare system, made even worse by the stress of COVID.

Considerations on the side of “go to the ER” were 1) I was in a lot of pain that was lasting longer than it generally has (say twice a year), and wanted to not be, 2) I knew pretty well what was causing it and that, while it had happened before and usually resolved, it could also NOT get better and maybe require emergency surgery, or worse. Considerations on the side of “don’t go to the ER” were 1) it has usually in the past resolved, eventually, on its own, and 2) the idea of getting in the car to go to the ER, and then waiting to be triaged and seen, and maybe imaged, which was likely to take many hours, all while in such pain, was a very negative incentive. If I was going to be writhing in untreated severe pain, I would prefer it to be in my own bed than in the waiting room of an ER. Plus, COVID. Both because it has made the crowding and wait times in ERs and hospitals much worse than “normal”, and because being there increases the risk of exposure and infection. I happen to live in what is currently a “high COVID” state, but nowhere is a really “low COVID risk” area. As it turns out, I didn’t go, and by morning, after about 18 hours, the worst was past. This time. But it will happen again and I will again have to decide what to do.

As do many, many thousands of others, every day, in the US. For many people, a major concern is cost – because visits to the ER are costly for those with no or poor insurance (really a lot of people). Fortunately for me, I’m not in that group. For others, it is because of fear of finding out what the problem is, and that it will be something really bad that they don’t want to know about. That also wasn’t really my issue; as a physician who has dealt with this, I knew what the problem was. Unfortunately, that can make it worse, since my fears and realization of the possible outcomes are based in evidence and not just fear. For yet others, it is the expectation that because of who they are (not White, poor, poorly insured, not well-dressed, have a history of alcohol or drug use or mental illness, or something else that doctors tend to associate with making one of less value) that they will be pushed back in the line, not believed, have their stories discounted, and generally be treated badly. Not really me either, although my physician privilege is decreased now that I am retired in another city, and do not get to go to the ER in the hospital where I work every day and people know me. For a lot of people, it is a combination of these, synergistically making their experience, and expectation of that experience, worse.

In case there may be anyone who is skeptical about my saying it is likely to be hours of waiting even when one presents with an emergency condition and is obviously educated and “respectable” (as a physician or nurse), it happens, and is happening much more continuously in the Age of COVID, when facilities are completely stretched to their limit and resources and people who work there are stressed to the max. Just recently, the last few months, two people who are close to me and are healthcare professionals have been through this experience. One had acute appendicitis, and needed emergency surgery, and after waiting many hours at home before venturing to the ER, waited there for 7 more hours before being seen. Luckily, they are now OK. It was not a positive experience! The other had a similar serious need, a ruptured diverticulitis causing peritonitis. She also waited in excruciating pain for hours, despite the fact that she was accompanied by her husband, a physician from the community who has practiced here for decades who was reduced to screaming at staff before she got her necessary emergency surgery. (For the record, these two people and I are all “seniors”, but these scenarios can and do affect everyone; my initial crisis was when I was 40 years old.)

The best advice anyone can give me is “get an ambulance”; they’ll see you sooner than if you arrive by car. This may well be true, and it may be good advice for me or for any other individual who is not worried about an additional $2000 bill, but in no way addresses the systemic problems that obviously exist.

The first of these is the incredible stress put on the system and the individuals working in it, doctors, nurses, and other healthcare workers, by the COVID pandemic. The burden on hospitals and healthcare workers has been phenomenal. In this sense, doctors and nurses and others on the front line are our heroes, as they are often portrayed. Yes, sometimes they can exhibit inappropriate behaviors. These can even be exhibited by folks in whom they rarely manifested before as a result of the continuous stress of working in the situation that they, and we as patients and as a society, find ourselves in. The governmental response to the pandemic, led by a federal administration who acted as if their intention was to do everything completely wrong, was shockingly inadequate. Yes, building new hospital capacity is possible and usually slow, but some localities did it, and yes, training and equipping more healthcare workers takes time. But there is no conceivable justifiable excuse for not having sufficient PPE, for example, months into the pandemic. This could only happen because of the worst possible management. Remember that this is the country that put a person on the moon 8 years after the first suborbital flight, that built the interstate highway system, that could assemble battleships in weeks during WW II, that has enough money to give trillions of $$ in tax cuts to billionaires and corporations. It only did not happen because of more than ineptitude; it happened because of an intent to do evil. We can hope that at least much of this can be reversed by a Biden administration.

The other big structural issue is our terribly designed and implemented healthcare nonsystem that discriminates against people based upon wealth and insurance status, race and ethnicity, age and pre-exisiting conditions, geographical location, and in appropriate allocation of resources that in the best of (non-COVID) circumstances sends a hugely disproportionate number of true emergencies (medical, surgical, trauma) to some hospitals while others have relatively low, and more mild, usage of their emergency facilities. It is also the fact that many people cannot get into see their primary care physicians promptly, or do not even have primary care physicians (or other providers, such as NPs) so end up waiting until they are severely ill and going to the ER. These are people who, if they get hospitalized, can be considered “primary care preventable” hospitalizations. That is, if they had been able to easily and promptly see a primary care doctor for their illness, and at least as important, had their chronic diseases effectively managed and controlled, would have not needed hospitalization – or emergency care. This needs another set of structural solutions. It needs, first off, a universal national health insurance system. Every single person in the country needs to be completely covered for every medical necessity, without copays, deductibles, etc., and we all need to be in the same program.  The pandemic has clearly demonstrated the vulnerability of employer-based coverage. It is long past time, if it ever was, for ideas of gradual piecemeal expansion of Medicare, ACA, Medicaid, etc. If everyone is not in the same system, it is not a possibility but rahter a certainty that some will get better care than others. Separate, the Supreme Court ruled in 1954, is not equal in education, and separate insurance systems cannot create equality in healthcare.

A universal health insurance system, such as Medicare for All, is not going to fix all of the things that I discussed above. We need to ensure that there are hospitals and ERs available to all people. We need to ensure that all hospitals are welcoming to all patients, and that there is a rational system of referral from smaller to larger hospitals.  We must ensure that there is adequate primary care capacity so that everyone can have a provider that they can see regularly, and promptly when needed, and do not need to access ERs for either primary care or for urgent conditions that could have been prevented by good primary care. And we need to make sure that there is adequate emergency capacity for all emergencies to be cared for emergently, and that ERs, and hospitals, and health systems, are designed and funded and run based solely on what best needs the health needs of the entire community, and not on what makes the most profit for the owners. A universal health insurance system is necessary but not sufficient.

We need all that, and need it yesterday.

Tuesday, December 22, 2020

Protecting the community: Essential workers, nursing homes, and the incarcerated

The COVID-19 pandemic continues, resurging across the US and in many other places. Different strategies have been adopted in different places, with varying degrees of success in slowing the spread of infection and death. This should provide us with information on what works well, and what strategies we should be adopting. For one example, family medicine colleagues in São Paulo, Brazil, report on their experience in nursing homes in the Royal Australian Journal of General Practice. They used public health management techniques including no visitors, rigid use of testing, recommended PPE and isolation, and others, as well as medical management and psychosocial management working with families and patients to help them through this process. They have had only 4 cases in the last 90 days (as of the November publication date), no people in isolation, and a low death rate.

 In Arizona, as in the US, case rates and mortality continue to rise.  We have more cases than ever, and fewer hospital and ICU beds. The state has chosen to address this issue by lifting restrictions on businesses, opening restaurants, bars, salons and gyms. Based on all evidence from everywhere, this is likely to further increase infections and deaths (“Health chief changes benchmarks so no Arizona business will be shuttered in pandemic”.)

Thie new policy is clearly in response to business owners concerned about their livelihoods and the probability that they will even survive. This is a real problem for them, and for us, in the horrific economic downturn that has accompanied the pandemic for most people (for major investors, however, the stock market has done well). Pima County, where Tucson is, has taken a more aggressive and restrictive approach; after more than 320 cases reported among county employees, including the chief health officer, it has furloughed 20% of the work force for 3 weeks. Of course, this will be an economic hardship for those people’s families.

Thus we have the situation where we know what to do to prevent increased infections and deaths, but have to also address the serious financial impact on regular people who lose their jobs and businesses and incomes. Sadly, efforts to reopen have been almost linearly associated with increased infection rates and deaths. The efforts taken by our Brazilian colleagues were effective in an important and high-risk, but ultimately limited, venue, that of nursing homes. The fact that the increased infection and death rate in our communities will take its greatest toll on the elderly and those with chronic disease, not those whose exposure to others in workplaces, schools, and meetings (although they are also at risk, and not immune) makes it even more complicated. The leadership at the federal level, sometimes inaccurately described as “lack of leadership” when in fact it is actively leading us in entirely the wrong direction, is making things much worse, and creating and exacerbating an incorrect understanding of the disease among many people.

Those who work in high-risk occupations, who cannot “phone (or Zoom) it in” but rather have to be present, most often among the lowest paid, those who live in multi-generational and multi-family households, are paying the highest price. These people are not only members of racial and ethnic minority groups, but those groups are far over-represented in their numbers. A recent article in the New York Times again makes the point that Black and Latinx people are hardest hit, not because of any genetic or biologic reason but because of their social and economic situation resulting from centuries of structural racism. Race, it is clear but requires repeating, is a social, not a biological construct. The negative impacts on health, income, longevity, education, and everything else is not from “race” but from “racism”; indeed, the only significance of “race” is that it is the basis for racism.

Now there is a vaccine (actually, two, maybe soon three, vaccines) and administration of them is rolling out, especially in the wealthy countries that have acquired most of the doses (of course, in the US the Trump administration jeopardized this by passing on an opportunity to acquire more doses of the Pfizer vaccine, and this was certainly not to help out the poor parts of the world!) The debate now moves to who should get it first and in what order. In most places in the US, priority is going to health care workers and nursing home patients, which makes sense. They are, respectively, the most likely to contract and transmit the infection and the most likely to die from it. And then? Who? Those with the highest risk or those with the best connections? In many hospitals we hear reports of the C-suite executives (the “front office”) being at the front of the line for vaccine, despite the fact that they do no health care. Nice of them to want to “model” behavior, but the vaccine should go first to those who see patients. The priority should be those who not only interact with the public, but who cannot do their jobs if they don’t actually show up for work, and among those, people who would be the worst off if they lost their jobs (and those who have already been laid off but might be able to come back and begin working again). The last would be those who can continue to work from home, or are retired without major health risks, and can continue to isolate themselves.

Another major group that is finally getting some media attention, even if it is unlikely to get much vaccine, is the incarcerated population. The AP reports that “1 in 5 prisoners in the US has had COVID-19, 1,700 have died”. This could be predicted; it is a group crowded together, unable to isolate, often with pre-existing conditions, and essentially without agency – they have to do what they are told. There are, broadly, two reasons for immunizing them. The first is human – they are human, and they are at very high risk, and they are already being punished; they should not be further punished by getting this disease. The second is practical; prisoners are not, actually, entirely separate from the rest of the population. In addition to guards and others who move between the inside and the outside, many prisoners are released; this is most especially true for jails, where the length of stay is short (usually awaiting a court appearance for those who cannot post bond), and thus is really part of the community from which inmates come – and go back to. Nathaniel Lash makes this case convincingly in the New York Times Sunday Review, “The coronavirus has found a safe harbor”. For example,

Cook County Jail was the site of the largest detected outbreak in the country early in the pandemic. In recent weeks, it has exceeded that — there were 340 active cases among inmates on Dec. 16. The population, meanwhile, has returned to levels typical before the pandemic, about 5,500 people.

We should have fewer people in jail.  It is outrageous that people are incarcerated because they cannot pay bond, overt discrimination against the poor, and cannot afford to support the very politically powerful bail-bond industry. This was true before COVID, and is more true now. ‘“There’s no question with a new peak in infections that we have to be decarcerating now,” said Dr. Emily Wang, the director of Yale School of Medicine’s Health Justice Lab. “If we don’t have larger-scale decarceration efforts, we won’t control Covid.”’ The answer is bail reform that corrects these inequities – vicious inequities with frequently fatal outcomes. But the opposition continues to cloak itself in the mantle of morality rather than greed, public safety rather than racism. ‘“We’re seeing the extent of the opposition to bail reform: They so strongly oppose it they will do it in the face of a pandemic,” said Andre Segura, legal director for the American Civil Liberties Union in Texas.’

The US incarcerates more people than anywhere in the world, a lot for relatively minor drug offenses. This does not prevent crime, especially violent crime, and it continues to rise even as crime rates decrease. In 2020 it is out of control, it is inhumane, and it is a significant cause of the spread of COVID. 

We need to get the vaccine out there soon, especially to those at highest risk of both dying and transmitting it to others. Clearly, the incarcerated population must be included.




Saturday, November 28, 2020

No way to run a business: the US healthcare system is not about caring for you!

The most distinctive and defining characteristic of the US healthcare delivery system is how poorly it serves people, and the number of hoops, obstacles, and downright obfuscation people need to work their way through to get care. The most important problem is that we have worse health outcomes and more premature death than any other industrialized country, and the excessive cost of achieving those worse outcomes (the only place where we’re #1!). But the sheer difficulty, pain, and low yield of going through the information needed to make the wisest decisions (actually wise, we will see, is virtually impossible in our system) takes a – completely unnecessary – toll on all of us.

The reason for this situation, very simply, is that the healthcare system in the US is not structured to deliver maximum health benefit, but to deliver maximum profit to the major players – and that is very few of us. It is absolutely critical to remember this core fact, because every other characteristic of our healthcare system derives from it. Worried about surprise medical bills when some of the doctors at your in-plan hospital are out of plan? Worried about paying for the wonderful new medicines advertised on TV that promise you cure for thousands of dollars a month? Worried about whether you can afford the premiums for the plans your employer offers, especially if you need to cover your family? Or the premiums for the better ACA-plans? Whether you can bet on your current health status, if it is ok, continuing into the future? Whether you can survive until you are old enough to get Medicare? And then, when you are, whether Medicare will cover enough of your bills, or if you need – and can afford – a Medicare supplement plan? How about choosing a “Part D” drug plan? Why are the websites and information so opaque and difficult? Is there any plan that is truly of value? And even if “of value”, can YOU afford it?

These questions just touch the surface. Then, you actually need to access healthcare services. Then it gets worse. Primary care doctor? Can you get an appointment? Use urgent care? Is your problem on the list of things that they can competently manage? Emergency room? Wait until you are so sick they have to take care of you? And what about those drugs…?

The specific problems that this system creates for individual people are often overwhelming, and become the focus of people’s lives when they do have chronic diseases or ongoing health needs. Politicians and their policy advisors who keep talking about addressing them one at a time are at least intellectually corrupt (setting aside the question of whether they are also financially corrupt) in believing that a patchwork of – patches – can make people, at least temporarily, think that they are doing something to help while maintaining a predatory structure. Let’s just look at a few recent examples and stories.

The Upshot in the NY Times recently had a piece on how the pandemic has increased the use of telemedicine, and how this might lead to better access to emergency care, citing a very positive study done by the Veterans Administration. The study shows, among other things, that same-day access to primary care can obviate the need for emergency care. Beyond that, having a regular source of primary care, and being able to get in when you need to, decreases hospitalizations and mortality. Of course, it is important to remember that the VA is (like the military) a single-payer health system and works better than the rest of US health care within the constraints of continually decreasing funding, part of a general Congressional and executive effort starve it for funding, specifically to ensure it doesn’t work as well as it could. Those same legislators then blame the VA rather than themselves for veterans not getting the best possible care, a tried-and-true tactic for evil politicians. Except the VA, and military health care, do work better than the private sector. (For more on the VA, see the excellent article “Shaping the Future of Veterans’ Health Care” by McCauley and Ramos in the New England Journal of Medicine, Nov 5, 2020, which requires a subscription.) The comments by the brilliant and incisive Dr. Don McCanne, found at the above link to the Upshot article, clearly makes these important points. And why can’t you get same day visits, or even prompt visits, with your primary care provider? Remember the key factor in all US  healthcare; it is usually not that your doctor is unwilling; it is that they also work for a corporation whose policies are about maximizing income and profit, not about improving your health.

In a recent conversation with a friend – also a senior citizen knowledgeable about health care policy, who was long on a medical school faculty and now lives in a relatively rural area – we discussed the best choice for a Medicare Part D plan. I noted that in 2020 I had assumed that my insurer would, absent my making a change, continue me in the lowest-cost plan as it had the two years previously. It didn’t; it automatically bumped me up to the highest-cost plan. With no added benefit, because of Catch-22 – I could never make my deductible, and thus have the plan kick in, because all of my drugs were “tier 1” and didn’t count (the calculators offered are only of use if you use high-tier high-copay drugs like those advertised on  TV). This year I made sure to change back to the cheap one, so I can pay $17.50 instead of $55 a month for no benefit. My friend agreed and will choose the same plan. But did note that if a family doctor and a health economist had trouble figuring this out, it might be hard for a lot of people! It is this characteristic of our health insurance system that makes the claims of those who advocate for private health insurance because it gives you, the consumer, “choice” are completely bunk. Almost no one can read, digest, understand, and utilize the information that is (sometimes) provided, in all different places, to get to a decision on what will work best for them. And, for the few who can, it usually turns out not to be very good! Remember: this is not some quirk, it is how our healthcare, and health insurance, system are purposely set up: To be confusing, opaque, and beneficial only for the sellers, not the consumers.

My friend and I also talked about several interactions he recently had with the health system his primary care doctor is part of. One involved his receiving (as an ex-smoker) a scanning CT scan and suggesting that they obtain an older one, from the medical school where he used to work, to compare the new one to. “We don’t do that,” he was told by the person at the other end of the phone. Another was about finding out how he could get documentation to be in an early group to get COVID-19 vaccination when it becomes available, given that he is high-risk not only by age but by having chronic diseases. They don’t do that either. These are unacceptable answers, as he told the office of the vice president he complained to, and who agreed to make things happen. This is not a flaw in the system; it is how it is structured, for everyone. Most people, you see, will not complain, and thus will, well, get screwed. But it saves the company money. This is a core way health insurers function. The higher the bill from a doctor, the more routine it is to just deny it, making the doctors work to prove they should get paid. Clearly, this is a particular issue for surgeons, who usually have staff who routinely fight with the staff of the insurance companies to appeal these denials.

There is an old saying that “this is no way to run a business” But, for most companies involved in health care – insurance companies, pharmaceutical manufacturers, long-term care companies, hospital systems, and increasingly large physician groups owned by corporations, it is the way they run their business. And it is a very profitable way to do it.

It is just no way to provide healthcare.

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