Shall we be callous or shall we be people? There is hope.

This is a repost from yesterday from my other, non-medical, blog "Life the Universe, and a Few Things". I have gotten some positive feedback on it, so have decided to post it to MSJ as well.


Charles Blow, who appears every Saturday in the New York Times, is one of my favorite columnists. He is terse and articulate. His column always features a fascinating graphic with data that presents additional insight into his topic. Sometimes his topic is overtly political, as when he recently wrote about the disappointment many, including African-Americans, feel in President Obama. Frequently it is about people, especially poor people, especially children, and the incredible challenges that they face in this land of “everything for the rich and squeeze the most needy”. His colleague, Nicholas Kristof, often writes about the plight of children in the rest of the world. Between them, we learn a great deal of about the desperate situation of so many, as in Kristof's On Top of Famine, Unspeakable Violence, September 25, 2011.

So, on September 24, 2011, it was uplifting to have a column presenting something good happening for these children, It Takes a Village. Blow describes his visit to the Dorothy Day Apartments on Riverside Drive in West Harlem, a “former drug den” converted in 2003 to housing for destitute and homeless families. Most of the adults were drug addicts or are HIV victims or mentally ill or all these. He writes about the cheerfulness of the design of the entire building (including the art gallery on the top floor with views of the Hudson River), of the yoga done by “wee little legs that barely have kneecaps” on mats placed in a courtyard that was previously 6 feet deep in garbage.  It has been successful by any measure – no teenage pregnancies, successful graduations from high school and entry into college, and done at a cost far less than “housing” people in prison, shelters, or mental hospitals.

Blow quotes Lady Bird Johnson saying “Where flowers bloom, so does hope”. I am reminded of the song (taken from a poem by James Oppenheim written in 1911) “Bread and Roses”, “Yes, it is bread we fight for, but we fight for roses too!” The poem is associated with the women who struck the textile mills in Lawrence, MA in 1912, and since the name of many projects and organizations, including an “integrated arts” high school in Harlem.  If I am disappointed in anything in Blow’s column, it is that he fails to mention who Dorothy Day was. Day, who died in 1980, co-founded the Catholic Worker movement in 1933, “a nonviolent, pacifist movement that continues to combine direct aid for the poor and homeless with nonviolent direct action on their behalf”. If anyone wonders if Catholics are focused only on anti-abortion, anti-contraception, and child abuse, or whether there are those practicing the precepts contained in the New Testament rather than greed, prejudice, and selfishness, the Catholic Worker Movement is a good place to start. We are very fortunate to have such a center, Shalom House, in my town of Kansas City, KS.

On the same page as Blow’s op-ed is one by Theodore R. Marmor and Jerry L. Mashaw, who are academics rather than columnists. “How do you say ‘Economic Security”?” discusses the situation in the Depression in 1934, and how the government was seen as the vehicle for helping those in need to achieve a dignified life. They talk about how the discussion has changed in the last 50 years. “In 1934, the focus was on people, family security and the risks to family economic well-being that we all share. Today, the people have disappeared. The conversation is now about the federal budget, not about the real economy in which real people live.“  They go on to say that “In 1934, the government was us. We had shared circumstances, shared risks and shared obligations. Today the government is the other — not an institution for the achievement of our common goals, but an alien presence that stands between us and the realization of individual ambitions. Programs of social insurance have become “entitlements,” a word apparently meant to signify not a collectively provided and cherished basis for family-income security, but a sinister threat to our national well-being.”

There were selfish bad guys with lots of money in 1934. But they were unable to control the debate, hard as they tried, with their control of the media (Hearst newspapers, anyone?). Somehow today they do. Occasionally, there is a burst of hope, the mass rallying of regular people to contribute to and work for Barack Obama in 2008, and the dashing of hope as this figure too seems to serve those with the most power. Marmor and Mashaw conclude  “Over the last 50 years we seem to have lost the words — and with them the ideas — to frame our situation appropriately. Can we talk about this? Maybe not.”

I’d like to say “maybe yes”. Maybe we can look at the Dorothy Day Apartments and the Catholic Worker movement and Shalom House and the dozens of groups called “Bread and Roses” and the thousands of organizations and millions of people who really want to make this country and this world a better place for actual people, and have hope. And, if we want to look back for inspiration, let me offer a few passages from FDR’s “Four Freedoms” speech of January 6, 1941:

“The basic things expected by our people of their political and economic systems are simple. They are:

Equality of opportunity for youth and for others.
Jobs for those who can work.
Security for those who need it.
The ending of special privilege for the few.
The preservation of civil liberties for all.
The enjoyment -- The enjoyment of the fruits of scientific progress in a wider and constantly rising standard of living….

Many subjects connected with our social economy call for immediate improvement. As examples:
We should bring more citizens under the coverage of old-age pensions and unemployment insurance.
We should widen the opportunities for adequate medical care.
We should plan a better system by which persons deserving or needing gainful employment may obtain it….

In the future days, which we seek to make secure, we look forward to a world founded upon four essential human freedoms.
The first is freedom of speech and expression -- everywhere in the world.
The second is freedom of every person to worship God in his own way -- everywhere in the world.
The third is freedom from want, which, translated into world terms, means economic understandings which will secure to every nation a healthy peacetime life for its inhabitants -- everywhere in the world.
The fourth is freedom from fear, which, translated into world terms, means a world-wide reduction of armaments to such a point and in such a thorough fashion that no nation will be in a position to commit an act of physical aggression against any neighbor -- anywhere in the world.”

Are we now such a different people that such aspirations are no longer possible? I hope not.

Legislating Public Health and Medical Care

It is pretty tempting, if you are a legislator and don’t like something, to try to pass a law against it. You can always find a constituency to support you, because there are people who will support almost anything. If you are lucky enough you can find a well-off and powerful constituency, or set of advocacy organizations, and then you are more likely to be successful (ref: see almost all laws passed by the Congress). Health and medical care are no exceptions; bills and laws that impact on public health and even how providers interact with their patients are increasingly common.

Some laws are very good for the public health: banning smoking in public places; requiring cars to have seat belts, airbags, and other safety features; requiring vaccination against infectious disease for entry into school. But the plethora of regulations governing the funding of health care providers from Medicare and Medicaid, the kind of documentation that needs to be submitted, and the rules that need to be followed (generally termed, collectively “compliance”) is bewildering. Complying with all the rules put forth put forth by federal agencies (including different division of Health and Human Services, as well as the Department of Justice and the Department of Treasury) requires large providers to have full-time “compliance officers” and small ones to operate at their peril. Then add in state and local regulations. These regulations are often contradictory, so complying with one violates another. The blame is usually placed on the bureaucrats that write these regulations, but in fact many of these bureaucrats are quite aware of these contradictions, but have no option, because the laws that they have to write regulations to implement are often very prescriptive. Beware the Law of Unintended Consequences!

This law, never to my knowledge passed by any legislative body, has a major impact on those that are passed, and this impact is just as true in laws regulating public health and medical practice. These effects are most serious when the law in question is passed to address a political agenda rather than to improve health. A famous example is the “gag rule” implemented in the early GW Bush years that prevented providers receiving federal funds from discussing the option of abortion with their patients. (Overturning this rule was a major, and under-recognized, accomplishment of the early Obama administration.)  A more recent example is the law passed in Florida (and now, thankfully, blocked from implementation by a federal judge) that would prohibit physicians and other medical providers from discussing gun safety with their patients. Let me be clear: the limitation was not on gun possession or use, but on doctors and nurses and public health officials talking to people about the risks that guns in the home posed to their children and themselves and how to keep the guns that they had more safe to limit accidental discharge, injury and death.  Guess what organization pushed this law? If you said “the NRA”, you’re right, but it was a “gimme”. And of course it was signed by the governor, former “health care” magnate Rick Scott, who as CEO of Columbia/HCA led the company in paying huge fines for Medicare fraud.

Those are the easy ones to find fault with. But, just as with the “compliance” issues described above, efforts to impose “good” medical practice can be flawed. Vaccine safety and benefit is a big topic I will probably post a separate piece on (short answer: get them), but there are many others. One example is the bill introduced by Sen. Jay Rockefeller (D-WV), along with Sen. Chuck Schumer (D-NY), that would require practitioners who prescribe opiates to have 16 hours of continuing medical education (CME) in their use every 3 years. This is motivated by a serious concern for the abuse of opiates, including re-sale by those receiving prescriptions, which leads to many deaths each year (and in which West Virginia leads the nation). There is no question that this is a huge problem.

We have seen two movements, often in conflict with each other, in recent times. One is the increase in the advocacy for patients with chronic pain to receive adequate treatment; the other is concerned with addiction and prescription drug abuse. Unfortunately, as in West Virginia, the same populations are often afflicted by both. Chronic pain often occurs in those who do physical labor, but people from these same populations are the ones often dying of overdose. The problem is that the same drugs that reduce pain also (initially) get people “high”, and in time create physical addiction where the “positive” effect of the “high” is replaced by pain and misery just from not having the drug. Ideally, there would be a pain reliever that was effective, did not cause any pleasurable symptoms (other than relief from pain), and was non-addictive. We don’t have one.

Will requiring this CME of physicians reduce the problem? I think that it will decrease the number of prescriptions written for opiates, and thus maybe the amount of potentially-abusable narcotics circulating in the community, but perhaps not through the intended mechanism. There is no question that there is a lot that many providers could learn about proper use of opiate pain relievers by taking such courses. One example is the use of long-acting pain relievers (methadone, sustained release patches, long-acting morphine) whose slow release controls pain while decreasing the “high” that results from a sudden infusion of narcotic. (An exception is the most widely-prescribed – and advertised, which might be related – long acting pain reliever, Oxy-Contin®, 30% of which is release immediately, making it more popular among drug abusers than other long-acting opiates.) Another is the use of the “pain contract” that limits a patient to receiving opiates from one physician, at determined intervals, refuses to ever refill if a person is found to be receiving prescriptions from multiple sources, and may require urine tests to be sure that s/he is not using other unprescribed substance.

However, for this plan to work it would require that physicians and other providers want to prescribe narcotics. Obviously some do. Many of these do so because they are concerned about the chronic pain so many patients are in; there are pain medicine specialists who come from a variety of medical backgrounds: anesthesiology, psychiatry, family medicine, internal medicine. There are certainly others (relatively few) who are “Dr. Feelgoods” who make their living prescribing narcotics and other controlled drugs in large amounts, knowing that they will be abused. But the reality is that most doctors find chronic pain patients, well, a chronic pain. They find it difficult to feel certain who is a “legitimate” pain patient and who is “abusing”, or selling, their pain medications. Or who is a “legitimate” chronic pain patient whose family members are using, or selling, that person’s pain medication, leading to both the spread of narcotics in the community and having the patient continue with unrelieved pain. These are the patients who, whether “legitimate” or “abusers”, call the office all the time for refills, call in the middle of the night, yell at the staff because they are in pain (or withdrawing from narcotics, or find their livelihood that comes from selling them is threatened). Most providers would be willing to not take the CME, and have a good excuse to not prescribe opiates, and be free from all these problems. This is, according to testimony at the recent convention of the American Academy of Family Physicians, already happening in some places. Of course, that will also mean reduced access for people who do have chronic pain.

I once lived in a moderately large condominium. I had kids, as did a couple of others, but the majority of residents were older, with no children in their homes. The association would sometimes pass rules that restricted what children could do, especially when the working parents couldn’t make the meetings. These rules affected my children and penalized me. My position was that the association’s rules should be limited to things that affected the safety of the building and maintained its property values, not just anything that 51% of the owners could agree upon. Legislatures, whether federal or state or local, can pass any law that they can get a majority to agree on (with the obvious exception of the US Senate, where apparently, at least with the current President, it requires 60% votes – 59% wouldn’t do it). It doesn’t matter how dumb the laws are, or how much they conflict with existing law, or how much trouble they cause the bureaucrats who have to write the regulations, or how confusing or sometimes impossible it becomes for folks to comply with them all. Unless the courts strike them down, they are law (thank goodness for separation of powers!).

But because you can pass a law or rule about something doesn’t always make it a good idea to do so, whether you are a legislature or a condominium association. Because the Law of Unintended Consequences is always present.

Unintended pregnancy and health disparities

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In "Health in All" policies to eliminate health disparities are a real answer, August 18, 2011, I discussed the work of Steven Woolf, MD, as it relates to health disparities. The major point of that piece is that the health and mortality differences between groups, particularly racial groups, in the United States accounts for an enormous number of excess deaths. If that gap were closed, and everyone in the US had the same age-adjusted death rate as whites, the number of lives saved would far exceed those saved by all medical care. Indeed, it would far exceed the number of lives saved even by public health interventions, at least as narrowly construed. Many of the social interventions that Woolf and colleagues indicate would be necessary to decrease disparities could be thought of as “public health” in a broader sense, because they would improve the public’s health, but in general eliminating poverty and raising educational levels are not part of the narrower public health construct.

In “Unintended pregnancy in the United States: incidence and disparities, 2006”, published on-line-before-print in Contraception, Lawrence B. Finer and Mia R. Zolna of the Guttmacher Institute report on the disparities in a particular group, women of reproductive age, in relation to unintended pregnancy. They combined data from several sources, “…on women's pregnancy intentions from the 2006–2008 and 2002 National Survey of Family Growth… a 2008 national survey of abortion patients and data on births from the National Center for Health Statistics, induced abortions from a national abortion provider census, miscarriages estimated from the National Survey of Family Growth and population data from the US  Census Bureau,” to assess rates of unintended pregnancy and disparities between groups, and compared  this data to rates in 2001.

 They found that the percent of unintended pregnancies remained high, with a slight increase (from 48% to 49% of all pregnancies) from 2001 to 2006. The actual rate increased from 50 to 52 unintended pregnancies for every 1000 women aged 15-44. There was a significant decrease in the rate of unintended pregnancies in women 15-17 years old, but this group still had the highest rates (79%, down from 89%). While the fact that an increased percentage of pregnancies in such young women were intended is not necessarily a good thing, the overall pregnancy rate per 1000 decreased from 47 to 42 in this group. The rates of unintended pregnancy went down with age, but all other age groups had an increase in their rates from 2001-2006, the largest in women 18-24. To say this again: the rates of unintended pregnancy went up in each age group except 15-17, but that group still had the highest rate, with rates decreased in each older age group.

The most important finding was the disparity in the rate of unintended pregnancy by characteristics other than age: by race/ethnicity, by income, and by educational level. The unintended pregnancy rate for women with less than a HS diploma (80 per 1000) was more than 2.5 times that of college graduates (30); the rates for women who were HS grads and those with “some college” were in between. The rate for Black women (91) and Hispanic women (82) was also 2-3 times that of white non-Hispanic women (36). Income, perhaps, had the greatest disparity: the rate for women at <100% of poverty (132) was more than 5 times the rate for women >200% of poverty (24).

OK. This is a lot of data, and maybe it is hard to follow. But the main point is simple: these are staggering differences, and they are difference based upon the same social factors that Woolf and his colleagues address. The magnitude of these differences overwhelms all the other factors that affect this rate. The women whose resources make them least able to economically provide for unplanned children are most at risk of having them.

The percent of unintended pregnancies ending in abortion also decreased, from 47% to 43%, with the greatest decrease (from 47% to 41%) in women 20-24, but rather than being a positive, this decrease is much more likely to reflect the decreased availability of abortion services than a shift in attitudes toward abortion. That is, a larger number of children are being born as a result of unintended pregnancy to families that will have difficulty caring for them. In addition, these families are getting less and less aid from public sources because the same folks who are against abortion and the protection of the “unborn” are also against social services that will help the families of the born.

This study was also the basis for the excellernt column “Failing Forward” by Charles Blow in the NY Times on August 27, 2011.  He makes these points very strongly, commenting on the policies that restrict access to abortion while effectively punishing the children:

“This is what we’re saying: actions have consequences. If you didn’t want a child, you shouldn’t have had sex. You must be punished by becoming a parent even if you know that you are not willing or able to be one. This is insane.”

As in all of Blow’s columns, he includes a telling graphic, here showing the “States of Child Hunger”, the rate and raw number of children in food-insecure households. There are over 17 million hungry children in the US, or 23.2% of all children. The highest rate is in DC, the lowest in North Dakota. After DC (32.3%), perhaps surprisingly, is Oregon (29.2%). However, after that, unsurprisingly, come the usual suspects , many of the states most commonly associated with poor social supports and frequently conservative Republican leadership: Arizona, Arkansas, Texas, Georgia, Mississippi, Nevada, South Carolina, Florida. Most of the New England states are clustered near the bottom (good) end of the list.

The whole thing is not good. Too many poor and hungry children, too little education, too little opportunity for too many women and their families. Too many people and families caught in the multiple challenges of poverty, poor education, and racial/ethnic minority status, all of which are independently associated with health disparities, and which are synergistic in their effect when found together. This is not a society to be proud of. This is a society that needs great change, and it is the change perhaps we’d hoped for with the election of President Obama.

Frequently, the comic strips (not even the overtly “political cartoons”) capture it best. Here is a link to a “Non Sequitur”, by Wiley Miller. Check out September 4, 2001, with the adventures of super “hero” “CongressMan”. Laugh. And then cry.

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"The Doctor's Dilemma": Balancing needs of individual patients and responsible stewardship of health resources

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On August 25, 2011, in What is the ethical role for physicians in the "business" of health care?, I cited the commentary of Reuben and Cassel in JAMA “Physician stewardship of health care in an era of finite resources”. They identify the various levels at which physicians, physician groups, payers, and government can act to influence the cost/benefit of health care decisions. A similar issue is addressed recently by Victor Fuchs in the New England Journal of Medicine “The doctor’s dilemma – what is appropriate care?”[1] He notes that:

“…organizations representing more than half of all U.S. physicians have endorsed a ‘Physician Charter’ that commits doctors to ‘medical professionalism in the new millennium.’ The charter states three fundamental principles, the first of which is the “primacy of patient welfare.” It also sets out 10 ‘commitments,’ one of which states that ‘while meeting the needs of individual patients, physicians are required to provide health care that is based on the wise and cost-effective management of limited clinical resources.’ How can a commitment to cost-effective care be reconciled with a fundamental principle of primacy of patient welfare?”

He goes on to point out that some very expensive technologies benefit people while some do not or even cause harm, and many can benefit some people but are used too widely. He notes that, for example, “U.S. patients, on average, get almost three times as many magnetic resonance imaging  [MRI] scans as Canadian patients; there is no evidence that this large differential can be explained by national differences in the medical condition of patients or that it results in significant national differences in health outcomes.” This doesn’t mean that your MRI was not indicated, nor that there may be Canadians who did not get MRIs that were indicated, but it does mean that on balance we in the US are doing too many for the degree of benefit received.

Fuchs also addresses health insurance. He notes that, as many policy critics have observed, it is often not the patient but a third-party insurer who pays the bills (with the obvious, and glaring, and unconscionable, exception of the uninsured). Therefore, there is much less incentive on the part of the physician to not order expensive tests than if the patient were paying. I know this to be true. With underinsured or uninsured patients, especially in the free clinic I volunteer in, we minimize the use of unnecessary laboratory tests and maximize the use of generic medications on the “$4 list”. These practices are – or should be --  standard care in all patients. Working in the free clinic setting helps teach our volunteer physicians, as well as our volunteer learners, how to practice more cost-effective medicine. But it is not in itself enough. The free clinic still has major problems getting patients the care they need when they do need an MRI or CT, or a medication that is not available generically, or a specialist evaluation, or an expensive test (and for uninsured people virtually all procedures are expensive!), or a hospitalization.

So I also know that Fuch’s next point, criticizing those “policy experts [who]  think that if patients had “more skin in the game” — that is, had less insurance — the problem would be solved. It would not,” is correct as well.  He points out that even those who advocate this position agree there must be a cap on how much a patient should be liable for out-of-pocket (what? $5000?), but that “the extreme skew in annual health care expenditures, with 5% of individuals accounting for 50% of spending in any given year, means that many health care decisions, and especially those involving big-ticket interventions, will be made by and for patients whose costs have exceeded the cap.” The greatest expenditures are for people who need the greatest expenditures, and will be above any acceptable cap. Most people will not be, but most health dollars are not spent on the care of most people; they are spent on this small minority (which, as I have pointed out in Red, Blue, and Purple: The Math of Health Care Spending, October 20, 2009, any of us could join at any time!).

In a similar vein, policy pundits, many of the same ones who talk of “skin in the game”, talk about “freedom of choice” and allowing people to choose the kind of insurance that best meets their needs. Right. In Social Determinants, Personal Responsibility, and Health System Outcomes (September 12, 2010), I observe that all of those making such suggestions (the “Four Ps”: pundits, policymakers, politicians, and professionals) are not likely to be ever in the uninsured group. However, even they, even the doctors, have a difficult time figuring out insurance options. So imagine how it is for others, for most people? As highlighted by Lauri Martin and Ruth Parker in JAMA (“Insurance expansion and health literacy”)[2], for those who are less educated, for the 90 million Americans who have limited health literacy, choosing the “right” plan will be virtually impossible, a total crap-shoot.

What this means is that while large-scale comparisons, like MRIs between the US and Canada, can tell us there is something wrong, they cannot solve the problem. Nor can average expenditures of insurance companies, though again they can tell us a lot. But we must realize that we cannot solve the problem by limiting the individual access of individual people rather than attending to medically-appropriate guidelines that apply to all people. We need more fences, and fewer reins[3].

Ultimately, the contradiction between the commitment to the “primacy of patient welfare” and limiting the use of expensive technology is real, and the ability of physician organizations to put them into the same document without helping to explain how to resolve this “dilemma” is sloppy policy, and unfortunately often characteristic of them. Not just of physician organizations; indeed, given the scope of fine-words-with-no-action (or negative action) prevalent in the political sector, these physician groups are to be commended for calling for action. In “Dr. King weeps from his grave”, NY Times, August 26, 2011, Cornel West observes the same distinction between the actions called for and undertaken by the Rev. Martin Luther King, Jr., and the words spoken by those who have built his memorial. “King weeps from his grave. He never confused substance with symbolism. He never conflated a flesh and blood sacrifice with a stone and mortar edifice.”

The conclusions of Dr. Fuchs, and of Drs. Reuben and Cassel, are not very different. We do not need words, or proclamations, we need system change. In Fuchs’ words: “…when physicians are collectively caring for a defined population within a fixed annual budget, it is easier for the individual physician to resolve the dilemma in favor of cost-effective medicine. That becomes ‘appropriate’ care. And it is an ethical choice… because if all physicians act the same way, all patients benefit.”

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[1] Fuchs V, “The doctor’s dilemma – what is appropriate care”, N Engl J Med 18Aug2011;365(7):585-7.

[2] Martin LT, Parker RM, “Insurance expansion and health literacy”, JAMA 24/31Aug2011;306(8):874-5.

[3] Grumbach K, Bodenheimer T, “Reins or fences: a physician’s view of cost containment”. Health Aff (Millwood). 1990 Winter;9(4):120-6