Saturday, October 27, 2012

Medicare, falls, families, and risk: "Qualifying" to be in a safe place

Older people are, like all people, a widely varied group. Some are healthy and independent and can live on their own until very old age, while others have diseases that make them infirm at chronologically much younger ages. Some live with family members or have family members living with them. Most of those are well cared for, but some are exploited or even abused. Some elders live in assisted living facilities or nursing homes. A lot more of them are women than men, a reflection of differences in life expectancy. And most of them will, sooner or later, have an adverse event occur that leads them to be hospitalized. Sometimes it is almost routine, getting admitted for a complication of an existing condition such as chronic lung disease or heart disease; sometimes it a surprise, as when a 90-year old who has lived alone and been healthy falls and breaks her hip. The first time something happens, I find myself often repeating to these people and their families, is always the first time, whether at 20 or 90.

Whenever I am the attending physician on our inpatient service, we have a number of such people admitted, but in the last two weeks the number of people admitted who were what my residents call “little old ladies” seemed especially high. They ranged in age from their late 60s to 104; some lived in nursing homes, some with family, and some lived alone (including the 104 year old!). Some were admitted to the hospital for the first time, while others were “frequent fliers”; some had families hover around and others seemed to be left alone even when their family lived in town. A lot of them had falls, sometimes with broken bones (most commonly hip fractures, but others as well), sometimes, fortunately without. Some had moderate to very severe dementia, from Alzheimer’s or other causes, and may know only who they are (or not even that); others are “sharp as a tack” – at least when we can fix the dehydration or whatever else has brought them in.

One characteristic shared by many of these people is that they are unlikely to be safe returning to their homes. If they have fallen, they are likely to fall again. If they avoided a hip fracture this time, they may not next time. We do tests to see if there is an “explanation” for why they fell that might be treatable. Did they have a stroke? Should they be on blood thinners that make another stroke less likely but make the possibility of a bleed into their brain much higher if they do fall and hit their head? Heart rhythm problems? Maybe a pacemaker. Low blood sugar? Are they taking too much insulin? Maybe they “just” tripped: on the cat, on the rug, on the hem of their pants (which might be because those pants are hanging low from the 40 lbs they have lost since they were last seen a year ago -- really? I have been eating. I never noticed I was losing weight!) But, while anyone can trip, if it happens more than a couple of times, they are at risk of something bad. Sometimes it is possible for a health worker or family member to the home and help get rid of clutter, area rugs, and such, but sometimes that isn’t enough.

No one wants to go to a nursing home, especially compared to some idealized vision of being better and functional at home. Few families want to send their parents or grandparents to a nursing home, feeling that it is abandonment, or undignified, or irresponsible. Occasionally, there are complicating social issues, as nursing homes will take the Social Security check that family members are living on or Medicaid will require the sale of the house that family members are living in. And nursing homes are not a panacea; some are better than others, and folks get sick enough to require admission back to the hospital even from the best. But often they are a safer option, even when the family is committed to care. A person may be hospitalized by the family for a minor change that makes the Alzheimer’s victim even harder to care for; the primary care doctors may have already discussed admission to a nursing home, and, as one put it, “their voices said ‘no’, but their eyes and body language said ‘yes’.”

Medicare will pay for a period of time in a “skilled nursing facility” (SNF), where a person who was hospitalized but no longer needs to be in an acute-care hospital can get time to recover, get physical therapy, get to the point where they in fact, often with home health and a supportive family, go home. It works for someone who just had surgery, or someone who broke a bone and either had it surgically repaired or not. But to get this “benefit” the person needs to spend 3 midnights in the acute care hospital. Whether they need acute care or not. Indeed, if they don’t “meet Medicare criteria” for an inpatient hospitalization, they are not even officially “admitted” but are in a fantasy world of “observation status” where they are in the hospital, but are officially outpatients. And those nights don’t count toward “qualifying” for a SNF. So if you (or your father, or grandmother), “just” tripped and hurt themselves, and didn’t break a hip this time (sometimes they have already had both hips repaired), and is “just” bruised, and may have a “little” disorientation but no new stroke, and a little difficulty caring for themselves, and could really benefit from a month of skilled nursing, you better be able to pay for it, because Medicare won’t because they didn’t have 3 nights of “qualifying”.

This is crazy. I am a huge fan of “Medicare for All” rather than the nonsense patchwork of often-inadequate private insurance plans (and people who are uninsured) that we currently have. But that Medicare for all – and right now, for those who are on it – needs to have a rational payment and benefit structure. I understand the financial challenges facing Medicare (and the whole health insurance system – it is not a “Medicare” problem, it is a medical care problem) and believe that we need to save money by spending it rationally. This means, perhaps, not paying for every drug that the FDA approves even when it is not better than an existing, cheaper drug. This means not doing fantastically expensive interventions on people whose quality and duration of life will be marginally affected. It does mean placing people in the settings in which they can get the most appropriate, cost-effective care, whether at home with or without home health, in a skilled nursing facility, in a long-term care facility or in an acute care hospital. It does not mean requiring that someone who would benefit from a stay in an SNF first have to “qualify” by being in an acute care hospital overnight.

My local paper recently had a big front-page article about the fantastic new technology being employed at our hospital using GPS to map the location on the heart where an abnormal rhythm is being generated, so that it might be able to be fixed. Congratulations to the cardiologists and engineers who have developed this, and to the PR department that got it in the paper. It might be a big help for a few people, and will almost certainly be very costly (and profitable for the hospital). But as we develop all these expensive new technologies that might help a few people a lot and might help a few more a little, it is insane if we save money by not providing what we already know is the right thing in prevention and intervention for the conditions that affect the many. Right now, Medicare is trying to save money by identifying “fraud”; they do this (this is absolutely true!) by contracting with bounty-hunter companies called “RAC”s to discover when a patient has been “admitted” when their condition didn’t technically qualify and they should have been on “observation” status. They should be saving money by not paying for expensive high-tech procedures which offer little benefit.

A rational health care system, as we have discussed before, means that people are getting the right care in the right setting; this is the ostensible promise of health-care integrated systems. But, just as we will never have enough primary care doctors doing prevention and early treatment as long as we pay them a fraction of what we pay those doing heroic (and often ineffective) intervention for far-advanced disease, we will not have a rational health care system if we pay for huge high-ticket items but not for people to be in the right setting for them to receive the care that they need.

Medicare can, and should take the lead. For seniors, it is our national health program. Others will follow. 

Saturday, October 20, 2012

Simple treatments: bad doctors or a bad health system?

The New York Times editorial on September 9, 2012, “Simple treatments ignored”, is a commentary on a report in the September 7 issue of the Centers for Disease Control and Prevention (CDC) publication Morbidity and Mortality Weekly Report (MMWR)  that many Americans with hypertension (high blood pressure) were not being adequately treated. The Times notes that the study “found that 67 million Americans had high blood pressure and that 31 million of them were being treated with medicines that reduced their blood pressure to a safe level. The remaining 36 million fell into three groups: people who were not aware of their hypertension, people who were aware but were not taking medication, and those who were aware and were treated with medication but still had hypertension.”

This is definitely not a good thing; hypertension is a serious disease that can have devastating results – most obviously in stroke, but also in increasing the risk of heart attack and kidney failure. Also, as the article states, treatment is relatively easy – that is to say, there are drugs that are available for effectively keeping hypertension under control. In fact, so many people are receiving effective treatment that the incidence of bad outcomes, such as stroke, has greatly decreased. The Times editorial, however, creates the impression that much or most of the fault of for lack of treatment is the result of ignorant, incompetent, uncareful (or uncaring) physicians; the reason, they write, is “…mostly because overburdened doctors did not give hypertension high priority.” This is a highly dubious assumption.

The editorial goes on to praise, specifically, the Kaiser Health System for doing a good job of controlling its patients’ blood pressure, and thus reducing the rate of strokes and heart attacks:  “The organization created a hypertension registry to track patients and the care they were getting; eased the burden on doctors by using pharmacists to initiate drug therapy and medical assistants to monitor patients’ progress; made it easy for patients to get free blood pressure checks; and showed doctors how their record on controlling blood pressure compared with others in the system.” This is great.

People should get treated effectively for treatable diseases, and hypertension is certainly one. There are, however, many reasons why they are not always treated, and this problem includes patient as well as provider issues. Hypertension is, on the whole, asymptomatic; it does not cause pain or weakness or even, usually, headaches; thus the sobriquet “silent killer”. The treatments, in addition to drugs, include things like “…weight loss, increased physical activity, lower sodium and alcohol consumption, and stress management,” which require significant effort and commitment on the part of the patient, and are not easy to do.

But, more important, the lessons of Kaiser are not easily translated into the rest of the health system. Kaiser is a very atypical in that it is a vertically-integrated, closed-panel health system. For starters, and it is a very important start, every patient in their panel is insured (though Kaiser) and every patient sees a Kaiser provider. Thus, they control both the coverage and direct care of this population, and they have a large enough scale to do outreach programs to encourage and support people in adopting and maintaining the behaviors listed above. This is, however, not the case for most of the community. Many people are not insured, and many others have insurance that does not cover drugs and other treatments. A variety of factors, some provider related (such as not being able to get an appointment) and others originating from patients’ own decisions (choosing to go to ERs and urgent care centers, and indeed “doctor shopping”), they see different providers. That the US has an uncoordinated health non-system is the key problem, not that "their doctors are asleep at the switch."

The article concludes: “The benefits of reducing high blood pressure — not to mention the cost savings — are obvious. The wonder is that the health care system has done such a bad job of delivering those benefits.” To me the wonder is that we have tolerated not actually having a health system for as long as we have, and that health policy continues to try to address issues of quality of care while ignoring the elephants in the room: that so many people have no coverage or poor coverage, and that reimbursement overwhelmingly rewards intervening once problems have arisen rather than preventing them. That a physician hired by a hospital to inject clot-busters into the brain’s arteries to try to reverse a stroke that has already occurred earns, literally, several times as much as (and works much less than) a primary care physician who treats hypertension (and many other diseases). The reimbursement system is completely inequitable and inappropriate, and the health system is a sick hodge-podge of half measures.

First, we need a health insurance system that covers everyone: Medicare for all. Then we need to reward systems-based and outcomes-based care. Then maybe all of us can see results like Kaiser's.

Saturday, October 13, 2012

Physician advocacy: for patients and for social change

A recurring question for physicians and others in the health profession is what degree of health advocacy is expected or appropriate. For those of us in medical education, the question becomes how much of the training (and evaluation) of medical students and residents should be based on advocacy for their patients or populations. Sarah Dobson and colleagues provide a useful formulation of this question in a “Perspective” in the recent Academic Medicine, “Agency and activism: rethinking health advocacy in the medical profession”.[1] They note that “Health advocacy appears in various forms in professional charters and standards”; however, as Canadians they focus on the CanMEDS document. This is “…a competency-based framework developed by the Royal College of Physicians and Surgeons of Canada that describes the core knowledge, skills, and abilities of specialist physicians,” that has 7 core roles including “health advocate”.

In the United States, the clearest expression of the role of advocate is in the American Medical Association’s (AMA) Declaration of Professional Responsibility: Medicine’s Contract with Humanity, which contains, as item #8, “Advocate for social, economic, educational, and political changes that ameliorate suffering and contribute to human well-being.” Overall, the Declaration is quite an impressive document, the contents of which would surprise many in both the medical and lay communities who think of the AMA as professional advocacy group with no social conscience; sadly, there might be as many unpleasantly as pleasantly surprised by the discovery. Advocacy for patients is generally considered an appropriate role for physicians by physicians, but advocacy for social, economic, educational and political change is far less widely accepted.

Dobson and colleagues propose a parsing of the concept of advocacy into two components. They call these “agency”, working on behalf of the interests of a specific patient, and “activism”, which is more directed toward changing social conditions that impact health, and whose effect is seen on populations more than individuals. This is helpful in clarifying different perspectives on the term “advocacy”. While the CanMEDS framework, for example, calls for physicians to “…responsibly use their expertise and influence to advance the health and well-being of individual  patients, communities, and populations,” the authors observe that trainees “…have variously described it as charity or as going above and beyond regular duties.” They note that “...several studies have concluded that although physicians generally endorse the idea of advocacy, they rarely engage in it.” They summarize the difference between agency and activism by saying “…whereas agency is about working the system, engaging in activism is about changing the system.”

The article concludes that there is a distinction to be made between the role and responsibilities of the individual physician and that of the medical profession as a whole. “Physicians and other health professionals witness the effects of the socioeconomic determinants of health every day, made
visible to various degrees in every patient encounter, “ but they question “whether this authority translates into an obligation.”

There are, however, many physicians who do act as social activists, and we need more of them. The source will be medical students who then become residents. Luckily, there seem to be no shortage of entering medical students with this commitment. They demonstrate it by community volunteer work, creating and working in free clinics, volunteering their time to work in schools, and pursuing training in public health, public policy, and community involvement. Sadly, however, along with empathy, which has been shown to dramatically drop as medical students enter their clinical training (Hojat, et al.[2], and this blog, “Are we training physicians to be empathic? Apparently not., September 12, 2009), so does volunteerism and commitment to social change.

In the US, despite the AMA Declaration, there are no requirements for teaching advocacy included for teaching medical students by the Liaison Committee for Medical Education (LCME), which accredits medical schools, or in training residents by the Accreditation Council for Graduate Medical Education (ACGME), which accredits residency programs. In the absence of such requirements, it is less likely that advocacy programs will be developed for students and residents, and more likely that, when they are, it will be the students who are already interested in doing such activities who participate. That is great, and programs which allow students to be involved and helps “inoculate” them against from losing their interest and commitment will continue to exist (such as several that we have here at the University of Kansas School of Medicine, including our free clinic and longitudinal elective Community Leadership track). However, if these are not expectations of all students, of all physicians, then only a minority will be involved.

Indeed, when we look at the American political landscape, we see a fair number of physicians involved in politics. It could be argued that, in these roles, they are advocating for social, economic, educational, and political changes. What is disconcerting is that the majority of these physician politicians seem to ignore the second half of that sentence, “…that ameliorate suffering and contribute to human well-being”. They are often found among, and sometimes as leaders, in advocating policies that slash the social safety net, decrease funding for public education, and oppose universal health insurance. Too frequently, they act as agents of their own social class than as advocates for those most in need.

That doctors will most often adopt the “agency” role when it comes to issues that most directly affect the health of their patients, that can be arguably seen as “medical”, is very reassuring. I was once at a physician meeting in which a “conservative” state legislator was speaking against a statewide smoking ban. Reassuringly, the vibe in the room was very hostile to the content of her remarks. Sensing that, she turned to a physician from her district who was also very conservative and a political supporter of hers and said “You? Do you agree with this?” To which he shrugged his shoulders and replied, “I’m a doctor!”

The advocacy role is more complex. Not only are many physicians socially conservative and not, perhaps, in support of policies “…that ameliorate suffering and contribute to human well-being,” physicians are busy people who mostly see themselves in the role of providing direct patient care, not advocating for systemic societal change. Even physicians with public health roles may see their advocacy in a much more limited way (for immunizations, smoking cessation, cancer screening, seat belt use, etc.) rather than structural societal change.

I would like to think that all physicians manifest advocacy in the “agency” sense for their patients. It may be wishful thinking to hope that all physicians will manifest advocacy in the “activist” sense, that they will fulfill the AMA’s Declaration by actually advocating “…for social, economic, educational, and political changes that ameliorate suffering and contribute to human well-being.” But if we do not make this a core value for physicians that is ubiquitously taught in medical school and residency, if we do not select students because of their commitment to advocacy, we will have much less of it.

And we need it badly.

[1 Dobson S, Voyer S, Regehr G, “Agency and activism: rethinking health advocacy in the medical profession”. Acad Med. 2012;87:1161–1164.First published online July 25, 2012. doi:10.1097/ACM.0b013e3182621c25
[2] Hojat M, Vergare MJ, Maxwell K, et al, “The Devil is in the Third Year: A Longitudinal Study of Erosion of Empathy in Medical School”, Academic Medicine, Sept 2009;84(2):1182-91

Saturday, October 6, 2012

Abortion and women's health: who truly has a conscience?

“Conscience clauses” have become increasingly common in laws about health care as state legislatures seek to limit people’s access to services that they don’t approve of but have not, as yet, been able to make illegal. Of course, it started with abortion care, with doctors being allowed to “opt out” of training requirements for abortion (not that anyone was ever required to “opt in”), and gained momentum with the development of mifepristone (formerly RU-486), the abortion pill, ensuring that pharmacists would not have to fill prescriptions for it if they opposed abortion.

Of course, mifepristone is only sold directly to providers, so pharmacists are not called upon to fill these prescriptions, so the laws moved on to whether pharmacists could refuse to fill prescriptions for emergency contraceptives (the “morning after pill”). A lot of jurisdictions passed laws under the guise of the “conscience clause”, some even permitting pharmacists to not even dispense regular contraceptive pills. Which, of course, can be used for emergency contraception. And which, of course, is not abortion. But so much for the facts.

It is not coincidental that these restrictions have focused on women’s reproductive health. It appears that legislators’ concern is not about “right to life” (which many make a joke of with their opposition to anything that might help people after they are born), and fall into the arena of “women’s reproduction and the things associated with it, like sex, make us uncomfortable and so we don’t want to be involved with it”. In addition, there is persistent undertone of “…after all, these are women, people who do not understand how to take care of themselves and make their own decisions, so we have to do it for them.” This is pretty clearly part of the agenda of the religious right – limiting the ability of women to make their own decisions about their bodies.

Indeed, a victory for women was achieved when emergency contraception was made available without a prescription – and then a step backward was taken when HHS Secretary Kathleen Sebelius overruled recommendations from the FDA and prevented its availability without a prescription to women under 17. Now that makes no sense at all if one is concerned about their health – women under 17 are the most likely to have sex without contraception, to be pressured into sex by men, to not be able to plan whether they are going to have sex and thus possibly become pregnant, to have the self-efficacy to walk into a pharmacy and ask for emergency contraception. So we are going to make it particularly difficult for them? Well, it does make sense for an agenda that says “limit rights where we can limit them” and we can move on from there. Yes, these girls are the most vulnerable. So let us victimize them.

What is particularly upsetting is the usurpation of the language of conscience by those who would restrict women’s reproductive options. We do not hear of conscience clauses about not dispensing Viagra, Cialis, and the like because the loss of ability to have an erection with age is natural. Or for that matter, against cosmetics, or drugs that will treat God-given genetic chronic diseases. A joke, but not so funny, supposes a Christian Scientist pharmacist who refuses to supply any medication. This usurpation of language is parallel to the current ownership of the language of “life” by the anti-abortion movement. The implication is that pro-choice people do not value life, but our argument is that we value the life of the born – the woman, children who are alive, and those who might be born.

Into this discussion comes the voice of Lisa H. Harris, in a New England Journal of Medicine “Perspective”, September 13, 2012, “Recognizing conscience in abortion provision”.[1] Dr. Harris argues that the provision of abortion is also driven by conscience, and that this right to conscience has not been protected. So firmly has “conscience” been associated in public discourse with the right to refuse to do abortion, the idea that conscience can be, and is, central to the decision of the abortion provider is almost jarring. And yet it is certainly true.

Harris refers to the work of the physicians who practiced abortion at great risk to themselves, their reputations and their ability to continue to practice medicine in the years before Roe v. Wade:

The conclusion that abortion provision is indeed “conscientious” by this standard is best supported by sociologist Carole Joffe [2], who showed in Doctors of Conscience that skilled “mainstream” doctors offered safe, compassionate abortion care before Roe. They did so with little to gain and much to lose, facing fines, imprisonment, and loss of medical license. They did so because the beliefs that mattered most to them compelled them to. They saw women die from self-induced abortions and abortions performed by unskilled providers. They understood safe abortion to be lifesaving. They believed their abortion provision honored ‘the dignity of humanity’ and was the right — even righteous — thing to do. They performed abortions ‘for reasons of conscience.’”

There are no doctors who showed more courage, more conscience, than these pre-Roe abortion providers. But the power of this commitment, of this conscience-driven provision of abortion, has not lessened in the post-Roe years. The ever-more restrictive laws passed by state legislatures, seasoned with the constant picketing and harassment of patients, leavened with bombings and fires, and finally consummated by the murder of abortion providers, should leave no doubt about the moral strength of these people. The testimonies on “Why I Provide Abortions”, on the website of Physicians for Reproductive Choice and Health (PRCH), or those its video “Voices of Choice” (including the voice of George Tiller, MD, murdered in 2009; see my post In Memoriam George Tiller, May 31, 2009) are clear and moving; they come from physicians who know that, if they do not provide safe abortions, women will obtain them unsafely at the risk of their lives:

"My experience goes back to my residency training at Boston City Hospital. I was appalled by the intermittent but steady stream of otherwise healthy young women dying in front of my eyes from septic shock due to unsterile, botched procedures.”

"When a woman acts in a responsible way, doing what she believes is in her best interests and the best interests of her family, she's being moral.”

“I believe women shouldn't have to explain to governments, religious groups, those of another opinion or the patriarchy at large that they've made a decision to deal with the condition of their own bodies.”

Dr. Harris indicates, correctly, that the same standards of conscience should be applied equally: “Certainly, if abortion providers’ conscience-based claims require scrutiny, so do conscience-based refusals, to ensure that refusals are indeed motivated by conscience and not by political beliefs, stigma, habit, erroneous understanding of medical evidence, or other factors.”

There are many people opposed to abortion who are sincere in their opposition and motivated by conscience. Beyond that, e.g., refusing to fill contraceptives, is getting to the point that maybe it is time to seek a new field of work. But to imply that concern for women and conscience only apply to abortion and contraception opponents and deny the conscience and morality of those who provide such care is unethical and dishonest. George Tiller’s motto was “Trust Women”, but many people don’t.

Another voice from “Why I Provide” says it simply and profoundly:

"I provide abortions because I value the life and health of my patients, and because when abortion is not legal, safe and accessible, women suffer and die.”

That is a conscience clause.

[1] Harris, L. “Recognizing conscience in abortion provision”, NEJM 13Sept2012;367(11):891-3.
[2] Joffe CE. Doctors of conscience: the struggle to provide abortion before and after Roe v. Wade. Boston: Beacon Press, 1995.

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