Friday, February 5, 2010

Exactly. Health Care Choice Reduces Cost.

From at Dr. Elaine Shattner at Huffington Post, a little honesty:

Some might say, even assume that our already unchecked health care costs would escalate; our demanding, aging population would drive the system to even more exorbitant levels.


But maybe, if doctors would provide only the kinds of care people choose for themselves, the price of medicine would go down.


Many patients, a.k.a. medical consumers, would choose less, at least in the way of technology, than their doctors prescribe. And more care.

Not all of us care to die in ICUs, plugged into monitors with breathing tubes in our throats and feeding holes in our stomachs. Rather, the comfort of a hands-on physician, someone who's honest and realistic, who treats what's treatable, who's kind and considerate, is more than many hope for.

I know this based on my experience as a physician who has practiced for nearly 20 years, and as a patient who's had breast cancer and other chronic medical conditions since childhood.

"Please, don't ever let that happen to me" was one of the first things I told my husband after my breast cancer diagnosis some years ago. As a physician, I'd witnessed too many people end their lives in a cloud of treatments, intended to help, but really just prolonging agony.

The U.S. spends over 2.4 trillion dollars each year on health care. Medical outlays skyrocket as patients near death; typical life-extending measures include costly procedures, medications, intensive nursing and care by multiple physicians. Medicare, the largest provider to those 65 and older, exhausts roughly a third of its $400 billion budget on end-of-life care.

Last month the journal Cancer published a troubling report revealing that a majority of U.S. doctors would only raise the subject of DNR orders, palliative or end-of-life care with patients who have metastatic cancer and a poor prognosis. The article generated considerable attention in the press for good reason - it bears on health care costs, patients' rights, doctors' communication and time constraints.

The study findings mesh with my own experiences as a practicing oncologist, when I observed that many good physicians are reluctant to stop prescribing chemotherapy and other treatments even as their patients near death. The reasons vary:

Some doctors sincerely think it's better for their patients if they stay upbeat, and this may indeed be true.

Some recognize that if you tell someone there are no curative options left, they'll go elsewhere. Most people, if they're sensible, do want to get well. And many are desperate enough to try anything if a doctor tells them it might work.

Another, unfortunate factor is financial pressure for physicians; giving treatment is far more lucrative than billing for simple office visits.

Doctors have egos, too. If you can "fix" someone thought hopeless, that's great. It's not just the patient, but your reputation at stake.

And feelings -- I've seen physicians become so invested in a case that they don't realize when therapy is useless.

Yet, maybe some dying patients would appreciate a doctor's honesty.

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What Happened to the Conscience Clause?

Amy Sullivan asks today at Time's Swampland what the status is of the conscience clause, that nasty rule that the second Bush rammed through in his final month as president. A year ago, the Obama administration asked around for some opinions on the law that allows practically anyone in the medical field to discriminate against a woman's access to emergency birth control, contraception, or other services that they don't agree with.

The most commonly used scenarios when discussing the clause are these:

A woman walks into her neighborhood pharmacy with a prescription for birth control. The pharmacist looks at the prescription and says: a) we don't fill that, period, b) let me get my colleague to fill that for you, c) there's a pharmacy on the next corner that will fill that for you


A rape victim finds her way to an emergency room where she is treated with a standard rape kit and: a) is not informed of emergency contraception that would prevent her from being impregnated by her attacker, b) is told what emergency contraception is and, after another test, is given the medication (Catholic hospitals will often only give EC if the victim has no chance of getting pregnant) c) is told that another facility will provide her with EC if she wants it but not the one she is in

In the first scenario, the woman may be shamed by the pharmacist, or she may be inconvenienced. Unless there is another person on hand to fill out the prescription, she will be at the mercy of the person behind the counter who has decided what her rights to prescriptions should be.

In the second scenario, the victim, most likely in an emotional and vulnerable state, will have a care-giver decide how able she is to protect herself from an unwanted pregnancy or how inconvenienced she will be to prevent that pregnancy.

Enforcing two medical ethics laws could right these discriminations: the right to informed consent where a patient is told of all legal, medically sound treatments; and the right to meaningful referral which would allow a pharmacist or doctor to deny administering objected services but would also protect the patient from discrimination by giving them an option.

But as it has always gone with abortion, so it goes under the Bush conscience clause with birth control. Medical professionals - and denominational hospitals - have refused to comply with demands for informed consent or referrals, saying that telling someone where to get an abortion is the same as performing the abortion. Telling someone where to get birth control or EC is the same as giving it to them.

Sullivan writes:

I suspect that as with Obama's campaign pledge to repeal the Bush executive order allowing faith-based groups that receive federal funds to discriminate in hiring, the White House quickly learned that some of its allies in the religious community liked the conscience rule and didn't want to see it taken away. So they apparently decided to lay low and hold off on making any changes. What's surprising is that they've gotten away with it so far without vocal protests from the choice community.

She's right. The entire fiasco over abortion in health care came about because the administration has strongly courted religious leaders with anti-choice objectives. And she's right that choice activists have not pushed hard to rescind the conscience clause; they're still recovering from being out-maneuvered by the anti-choice gang this past year.

But Amy Sullivan is wrong about the conscience clause disappearing from the radar since last February. Those working to exclude abortion access from the new health care bill have made the insertion of a Bush-like conscience clause part of their demands. I suspect the Obama administration chose to lay off the subject until the health care bill was passed, allowing for the particular conscience fight to be a separate one.

With health care reform on the lam and choice activists regrouping, I don't expect to hear much about the conscience clause for a while. And that means women will continue to experience discrimination, denial of their health care rights and increasing inconvenience in planning their reproductive futures for some time to come.

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Politics and the Persistent Vegetative State.

The big news in medicine this week is the anticipated release of a study, published in the New England Journal of Medicine, that looks at brain activity in persistent vegetative state patients, showing that in - let's admit - very qualified cases a patient shows adequate brain activity to respond to questions via brain scan.

This communication works accordingly: A patient who shows normal or close to normal brain activity is told to visualize two separate activities, playing tennis or walking around at home, as correlating to yes or no answers to questions. The patient's brain was then monitored for the proper response (activity representative of tennis or home) to six yes or no questions. One example cited that a patient "answered" 5 of the 6 questions properly. In other words, their brain, a majority of the time, acted out the activity associated with a yes or no answer in response to a question.

It's a very encouraging study, one that shows opportunity to "reach" patients who have heretofore been thought inaccessible, locked-in, in a coma or "brain dead."

A glimpse of the study and how it would be received was had in January when the media ran away with the story of Rom Houben, a Belgian man who was said to be "discovered" after 23 years in a coma. Steven Laureys, one of the primary writers of the study, has displayed some bashfulness regarding the initial overblown reaction to Houben's media attention. TV and newspapers overplayed the drama - no one could resist the feel-good "discovery" of a man thought to be brain dead, of a mother remaining hopeful for 23 years, of disabilities overcome to where Houben could type on a keyboard. Houben's means of communicating, however, have since been seriously questioned. Yet, Houben's story, however questionable, is one of hope and when it comes to caring for a loved one - for 23 years! - the hope that they are still "in there," is what keeps one going.

What the study is not is an indictment of current policy regarding the decision-making process for patients in persistent vegetative states. But politics are at play and the findings are being used to promote a particular agenda, with various politicized groups and noise-makers working to play it for their own purposes.

GeriPal has already commented on what the media interpreted the study to mean, citing the following headlines as examples of the exaggerated spin:

Take a guess though what the media headlines focus on:
*Scientists read the minds of the living dead (New Zealand Herald)
*Patients in 'vegetative' state can think and communicate (The Telegraph)
*Brain scan shows awareness in vegetative patients (BBC News)
*Brains of vegetative patients show life (LA Times)
*Study Finds Cognition in Vegetative Patients (Wall Street Journal)

These headlines are just wrong. They give the impression that all patients with PVS are aware and can communicate. In truth, this study showed that a minority of patients with PVS showed some signs of awareness, and those happened to only be in those who suffered from a traumatic brain injury (not from other causes such as anoxic brain injury).

As I noted earlier this week, using the example of Terri Schiavo, the media reports were rather over the top but consistent (despite their titles and spin) in their description of what ramifications the study had for patients like Terri Schiavo: None. Hers was an anoxic brain injury caused by lack of oxygen, not a traumatic injury as those who showed brain activity and response to the study's tests.

The media's objective is clearly to convey an attention-getting, emotional, sensational story of hope. Use the cultural ignorance of scientific studies to inflame the cultural divide. It gets ratings. Other's have another purpose.

Bobby Schindler, brother of Terri Schiavo, full time "pro-life" speaker, and co-founder of the Terri Schindler Schiavo Foundation, has long called for a reexamination of the persistent vegetative state diagnosis because he wishes to prevent removal from artificial nutrition and hydration of any PVS patient, despite their living will (advance directive) or the wishes of their medical proxy. At the foundation website today is a story that claims more tests should have been done on Schiavo before the court upheld her husband's wishes to remove her from ANH. It's a disingenuous position, a case of hope perpetuated too long, used only to prevent other patients from having a say in their medical decisions.

Then there's the conservative Discovery Institute Fellow Wesley J. Smith, amusingly called a "top bioethicist" by Catholic blogs, who was wrong about Rom Houben's media attention, too blinded by the report's ability to support his "pro-life" case to see the junk science parlayed by the media. Smith, a close friend of the Schiavo family, specializes in demonizing those who desire a science- and patients' rights based approach to end of life decisions as the "culture of death." Want to remove your loved one from ANH? You must be a killer. The judge in the Schiavo case? He wasn't using judicial precedent to determine who should choose Schiavo's medical options, he was, as Smith says, eager to let the bad people "kill" her:

"Indeed, when it was clear that Terri would be lying in bed for a year pending appeals, the family begged Judge Greer to permit sophisticated brain scanning that had never been used on her before," he recalled. "It couldn't have hurt her, and it might have shown something. But stubbornly, he refused. I will go to my grave believing the judge knew what he didn't want to know."

And then you have the Catholic Church, powerful, organized, rich in resources, motivated as the aid in dying movement brings end of life decisions to the forefront around the globe, to increase its efforts to oppose patient's rights.

In November the Church changed its Ethical and Religious Directives - which govern treatment of 1/5 of patients in the US - to prevent patients or their families from requesting removal from artificial nutrition and hydration. In fact, those who do not want the insertion of feeding or hydration tubes would now only be abided by when the Church decided.

The media may be looking for good ratings, but other constituents like the Schindlers, Smith and the Catholic Church are working for something much more nefarious: to take away your rights.

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Called to Help Haiti's Children.

Anthea Butler writes today at Religion Dispatches about the motivations of the Baptist group that tried to remove Haitian children from the country. You can read the entire post here. And here's a clip:

The Real crux of the issue is this: these ten do-gooders walked into the trap many well meaning white evangelical Christians fall into: those poor brown/black/yellow/red people need My help. Jesus wants Meto help them. To much of White American Evangelical Christianity the We often means Me. It’s what God Called Me to do. It’s what God would want Me to do. The problem with the Me mentality of much of conservative Evangelical Christianity is that they often can’t see the We—the people of Haiti—who love their kids so much they’re willing to let some white people who claim to be “Christians” take them away to what they promise will be “a better life.”

The focus on Me takes away from the real ways that people in disasters can be helped without the insertion of well meaning, helpless interlopers into their story. The New Life group is now finding out what living in an impoverished and earthquake-ravaged country is like. Perhaps now they will begin to understand what it means to live alongside the poor, as opposed to swooping into a disaster for a quick “feel good Christian moment” designed to make them feel better about themselves. Hopefully, other groups will rally to do the real work that is still so urgently needed, and make a long-term commitment to bring life and stability to Haiti and its children who are in desperate need of it.

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Malpractice Lawsuit Limits Overturned in Illinois.

The New York Times is reporting on overturn of the five-year-old law limiting medical malpractice lawsuit awards. To my mind, limiting awards is wrong - an overreach of the legislature into the judicial branch's territory.

Such limits, however popular among the Right (unnatural and rhetorical opponents of individual rights) do little to bring down the costs of health care in the US. It's a cheap ruse to distract from the real causes of our over-priced, ineffective system. Limiting awards is like putting a band aid on your sore, blistered heal because you refuse to give up the cheap shoes that are causing the damage. All it does is inhibit patients' rights in favor of the medical industry.

If lawsuits are a problem, perhaps we'd be best to understand why they occur (examine the cheap shoe) and stop penalizing the patient victims?

From the story:

The ruling came down as federal proposals to cap malpractice awards are receiving fresh attention on Capitol Hill. Republicans enthusiastically support the limits, and they are seen as a potential vehicle for restarting the stalled health care negotiations in Congress with bipartisan impetus. Neither the House bill that Democrats passed late last year nor its Senate counterpart included significant changes to medical malpractice regulations.

In a 4-to-2 ruling, the Illinois court wrote that the legislature, in enacting the 2005 law, violated the state Constitution’s separation of powers clause by imposing decisions that should be reserved for judges and juries. The law established caps of $500,000 for non-economic damages in verdicts against doctors and $1 million in cases against hospitals.

The decision armed opponents of such provisions with fresh ammunition, and held a particular sting for the American Medical Association, which has its headquarters in Chicago.

A statement from the American Association for Justice, formerly the Association of Trial Lawyers of America, said the decision illustrated “why federal efforts to place arbitrary limits on the amount injured patients receive won’t pass muster or fix America’s broken health care system.” Nearly 30 states have laws that limit non-economic damages, although the caps and circumstances for imposing them vary widely. According to theAmerican Medical Association, courts in 16 states have upheld the laws, while those in 11 states have overturned them.

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Rick Scott Claims a Victory.

There's no doubt that the health care bill, in either House or Senate form as it sits in limbo at the moment, is a stinker. It does little to cover all citizens, complicates and degrades women's reproductive rights, grants legitimacy to the profit-driven insurance industry, and patently avoids all the system overhauls that are necessary to make health care in this country non-discriminatory, affordable and accessible.

But whatever happens to the bill now - and the status of the Democratic party so desperately tied to its passing - one thing is sure: Rick Scott and his nasty, ironically named Citizens for Patients' Rights are not responsible to killing it. Yet they've taken an ad in the conservative Washington Post touting such a success.

From Crooks and Liars:

Remember Conservatives for Patients’ Rights (CPR)? It's run by the icky Rick Scott and represented by the public relations firm behind the Swift Boat Veterans For Truth. And boy, are they happy over the president's lack of leadership and the refusal by Congress to offer them an alternative to the insurance monopoly:

Today, CPR has a large, nearly full-page ad in the Washington Post cheering the public option’s death. The top of the ad has a tombstone reading, “PUBLIC OPTION PLAN R.I.P. January 27, 2010.” More text from the ad:

In his State of the Union Address, the President didn’t doom his Public Option health care plan with faint praise, he simply BURIED it with deafening silence. [...]

Finally, those of us who opposed your government-run Public Option plan can close this chapter.

By educating on the perils of your government-run Public Option plan, we achieved our goals to protect patients’ rights and stop a government takeover of our health care choices. Today, we join with our fellow Americans concerned with protecting patients’ rights to celebrate that our months of hard work finally paid off.

ThinkProgress spoke to CPR spokesman Brian Burgess of CRC Public Relations, who said that the ad was running only in the Washington Post.

CPR was not reflecting the views of most “fellow Americans” in its campaign. Over the summer, there was actually strong public support for the public option. Through an aggressive campaign, the health care industry spread misinformation to create opposition.

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