Hey everyone, I’m back! It has been awhile since I posted here. Aside from the inescapable fact that life goes on while I’m trying to live my life, one of the the reasons I haven’t written is that nothing health-care related has outraged me recently. And I definitely write better when agitated about something. Of course, I have plenty of disgust for much of what is going on in the world. Guns? Outraged. Syrian refugees? Outraged. ISIS. Outraged. Donald Trump? Please. Healthcare? Meh.
Except for one thing. Health is more than doctor visits and pharmaceuticals. One could most definitely say that a person killed by a gun is not healthy. But how about a Syrian refugee? Is she really healthy? Or the ISIS fighter. Is he healthy?
Back in 1948 the World Health Organization defined health in this way: (http://www.cdc.gov/hrqol/pdfs/mhd.pdf)
Health is a state of complete physical, mental, and social well-being – not merely the absence of disease or infirmity
And here’s the CDC in 2000:(http://www.cdc.gov/hrqol/pdfs/mhd.pdf)
Some of the variables generally considered to be the domain of health include premature mortality and life expectancy, various symptoms and physiological states, physical functions, emotional and cognitive functions, and perceptions about present and future health.
Everything that involves humans is health-related. But that’s too big, right? Health as the sum of a person’s well-being in all parts of life. We have trouble dealing with such a broad definition. So we restrict it. We decide that, well, health is the sum of a white person’s well-being, or an American’s well-being, or the well-being of a certain demographic group. And we further restrict ourselves to things we can easily define and treat: high blood pressure, diabetes.
The mass shooters in California, for instance. Those two were employed, legal, presumably tax-paying citizens with, apparently, no chronic health problems. Healthy.
The Syrian refugees. If you believe, as I do, that the refugees are upstanding citizens of what used to be a functioning society, and assuming, for the sake of argument, that they are physically healthy (or were), they would be healthy except for the part about social well-being. Specifically, they are homeless and stateless. But they are foreign, unknown, part of a demographic group with some very violent outliers, so their social ill-health is not our concern.
ISIS fighters. Generally young and healthy, no symptoms of illness, normal physical functioning, no diagnosable mental or emotional problems. (Radicalization is a social process, not a mental disease.) They are not homeless or stateless. Healthy. Except for being surrounded by a society that can’t provide jobs or positively directed meaningful work, being constantly in contact with violence and being fed a steady diet of extremist rhetoric. That part in the CDC definition of health about perceptions of present and future health? Yeah, they definitely have a problem there. They are not so healthy, maybe, but they are also foreign and plus they kill people, so their health is not our concern either.
Until it is.
A quick example of the mindless craziness weighing down the people who are trying to take care of other people. Exhibit: from an article in the ASA Newsletter by Annette Antos and Matthew Popovich:
In just over a year, ASA’s Department of Quality and Regulatory Affairs (QRA) and the Anesthesia Quality Institute (AQI) have engaged physician anesthesiologists and their staffs on Physician Quality Reporting System (PQRS) requirements associated with the Qualified Clinical Data Registry (QCDR) option.
Federal legislation created the QCDR reporting option in late 2012, and the passage of the Medicare Access and CHIP Reauthorization Act (MACRA) earlier this year further strengthens the position of QCDRs in measuring health care quality well into the future. Seeing this as an opportunity to develop a pathway for physician anesthesiologists to satisfactorily participate in PQRS, the AQI National Anesthesia Clinical Outcomes Registry (NACOR) applied for and received approval as a QCDR from the Centers for Medicare and Medicaid Services (CMS) in 2014. The ASA QCDR was the first anesthesia QCDR approved by the agency.
If you have any questions, Ms Antos and Mr. Popovich can be found at the QCDR Virtual Office Hours with QRA staff that has worked closely with the AQI. TXT me with Qs.
PS: CMEO – Crying My Eyes Out.
Attention graduates! If you’re looking for a career with a ton of job prospects, look no further than an International Classification of Diseases Coder. This fun and fulfilling career will take you into new worlds of diagnosis, laterality, specificity, and nitpicky-ness as you dive into thousands of columns of numbers and qualifiers. You’ll even get to call doctors and harass them any time you want. Sign up for your free brochure and get started on the career of your dreams now!
Yes, friends, after two years of delays, ICD-10 is coming to a doctor near you on October 1st. Mark your calendars. To review:
- ICD-10 stands for the International Classification of Diseases, version 10. The ICD is, according to the World Health Organization, (www.who.int) which publishes and maintains it, “the standard diagnostic tool for epidemiology, health management and clinical purposes. It is used to monitor the incidence and prevalence of diseases, providing a picture of the general health situation of countries.” In the US, the ICD has been adapted for billing.
- Work on ICD-10 started in 1983, but in the US the US Department of Health and Human Services still used ICD-9 (with modifications called ICD-9-CM) until 2013, after which it was delayed twice by Congress.
- The ICD coding system attaches a number for every disease or trauma known to mankind. For example, if you have a broken forearm you have an ICD-9 base code of 813. If it is a closed fracture (the skin was not broken) you’re an 813.0. If it is the lower end of the arm you’re an 813.40. If your skin was also broken and the bone poked through, you’re at an 813.50. If you only broke your radius, but the skin was broken, you’re an 813.52. And so on.
- There are other codes you need too. Your broken arm will need to be splinted, which requires a Current Procedural Terminology (CPT) code or an ICD-10-PCS code, depending on if you are going home from the ER or have been admitted to the hospital. The Healthcare Common Procedure Coding System (HCPCS), which wrote the CPT codes, also has level II CPT codes for ambulance services, crutches, etc. There are also “E codes” to record external causes of injury (vs. breaking your own arm, I guess). And there are V codes for supplementary classification of other problems you might have that relate. So if you broke your arm while pregnant you might be an 813.0V22. I think.
- A whole industry has been created around these codes. Hospitals hire professional coders whose job it is to read through patient records and determine the correct ICD codes to submit to Medicare. Hospitals also hire computer programmers or computer software companies to link hospital data systems to these codes.
So, why do we need new codes? What’s wrong with the old ones? About 100,000 things. That’s the number of new ICD codes that have been created. These new codes require much more specific information. Now your broken arm is classified according the type (open or closed), pattern (spiral or oblique etc.), etiology (how it happened), healing status (in subsequent visits), localization (head, neck, distal, proximal) displacement, classification (Colle’s vs Salter-Harris etc.) and laterality (right or left). Because breaking your left arm is pretty cheap but breaking the right will cost you, I guess.
In ICD-10 your broken arm makes you an S52. Which is, of course, way cooler. If you broke the distal (far) end of your radius you are an 813.4 in ICD-9 but in ICD-10 you could an S52.51 or S52.52 depending on which arm. You could also be an S52.516 or S52.519 or S53.517, depending on alignment and classification. If this is the first time you are being seen for your broken arm you might be an S52.511A.
The purpose of all this, say the experts, is more specific data collection. Here’s the New York Times: http://nyti.ms/1UQ5p6t
The new codes will…make it easier for insurers and federal officials to measure the results of treatment and the quality of care — factors increasingly used in deciding how much to pay doctors and hospitals. Public health officials say the new codes will help them identify outbreaks of disease, causes of death and community health needs. Researchers say the data will help them evaluate new treatments and procedures.
I would also add that coding companies and healthcare data companies will also benefit greatly.
OK, you say, but the actual dollar reimbursement amounts won’t change, so who cares? Let the coders take care of it. Doctors care. Alot. Who do you think is recording all this extra data? Doctors. The amount of information about the patient that the doctor knows doesn’t always change, but how much of it has to be documented does. It is all about documentation. If that coder doesn’t see it written down somewhere, that coder will call the doctor, or code wrong. If they code wrong, the doctor doesn’t get paid and the bill goes to you, the patient. There is no short-term benefit for the doctor, but the documentation required goes up significantly. ICD-10 gathers more data. Doctors do the gathering and the typing. Which is what we went to medical school for. Time magazine has an article this month on doctor burnout. No wonder.
OK, I can’t possibly let this one go.
New York Times, today, the Opinion Pages: When Bad Doctors Happen to Good Patients (http://nyti.ms/1JvPsyX). These two guys, Thomas Moore and Steve Cohen… well, maybe they were dropped at birth or beaten by the nuns at catholic school or didn’t get vaccinated, I don’t know, but they are not purveyors of peace and love between all beings. Here is a sampling of the things they say:
“Doctors and hospitals are doing a poor job of policing themselves, yet they have been successful at keeping anyone else from doing it.”
“When juries do award large pain-and-suffering amounts, it is because that is the only way our system allows people who have been grievously harmed to recoup some measure of what they have lost.”
“Don’t limit what injured people may collect, and don’t make it more difficult for victims to get their cases heard.”
“As long as hospitals and doctors block legislation and fight regulation, patients will remain in peril.”
“The greater shame is that hospitals don’t put more emphasis on patient safety.”
You get the gist. The comments section pretty much says everything I would say about all this, except for one thing, one sentence of reason in a sea of nonsense:
“Even better for all concerned, keep the negligent act from ever happening in the first place.”
Let’s forget for a moment the most salient part of this statement from Moore and Cohen’s viewpoint, which is that it would most definitely not be better for THEM. The truth is that it would, in fact, be better if we could prevent medical errors from happening. Very rarely is an error the result of one “negligent act”. Virtually nothing that happens in hospitals is the result of the unilateral action of one person. Let the comments on the OP-Ed piece tell that story.
But let’s imagine, just for now, that patients are harmed by the individual negligent acts of doctors, so-called Bad Doctors. There are Bad Doctors out there. They’re generally not evil, just incompetent. They exist. Everyone who works with them knows who they are. And the medical profession hasn’t been great at preventing incompetent doctors from practicing. I’ll give the lawyers that one.
The thing is, doctors are not created in a vacuum. Doctors are created from medical students and residents. Medical students and residents are, or are supposed to be, closely watched by senior doctors, whose job is not only to teach them but to evaluate their skills. It is a well-known trope among young students that medical school is hard to get into but once you’re in it’s virtually impossible to get kicked out. The same goes for residency. Residency directors will go to great lengths to get poorly-performing residents through their program of training. It is, of course, very hard to tell a young person who has invested so many years of their lives that they have to go find some other line of work. In sports the natural process of sorting out incompetence happens all the time: If you win you’re in, if you lose you find another job. It’s true in business as well. In medicine, once you’re in you’re pretty much in.
Once that under-performing resident is released into the world, they can’t be taken back. They’re launched. They’re doctors.
Suing more doctors for more money will not prevent incompetence. It hasn’t yet and people have been suing doctors for a couple hundred years. If there needs to be a weeding-out process, or a “policing” process, perhaps we need to focus our efforts earlier on in the educational process.
What do an amniocentesis and a public school have in common? Funny you should ask…
Facebook is a mixed blessing. If you dig through all the pictures of people’s kids, selfies in front of Cinderella’s castle, and what everyone ate for dinner, people put some really great stuff. For instance, this article in The Atlantic from a couple of years ago: Thinking About Pregnancy Like an Economist, by Emily Oster. (http://www.theatlantic.com/health/archive/2013/08/thinking-about-pregnancy-like-an-economist/278874/)
The story is that Ms. Oster and her husband decided, like many a couple throughout history, to have a baby. Both people being economists, they made this decision like economists. Here’s Ms. Oster:
Ultimately, microeconomics is the science of making decisions–a way to structure your thinking so you make good choices. Making good decisions–in business, and in life–requires two things: the right data, and the right way to weigh the pluses and minuses of a decision personally. The key is that even with the same data, this second part–this weighing of the pluses and minuses–may result in different decisions for different people. Individuals may value the same thing differently. Making this decision correctly requires thinking hard about the alternative, and that’s not going to be the same for everyone.
Ms. Oster naturally assumed that any decisions she had to make during the pregnancy could be handled in the manner outlined above. She assumed wrong.
Anyone who has been pregnant knows the mountain of dos and do nots that shower pregnant women wherever they go. Don’t drink. Don’t eat deli meat. Don’t drink caffeine. Do get your triple screen. Do eat organic. Don’t run. Do run if you’re a runner. Don’t sleep on your back. Do make a birth plan. Birth plans are for sissies. You know how it goes. Ms. Oster ran into all of these, but she ran into something else: Medical Protocol. In other words,” There are rules, Ms. Oster, and here in pregnancy land we follow the rules.”
In reality, pregnancy medical care seemed to be one long list of rules. In fact, being pregnant was a lot like being a child again. There was always someone telling you what to do. It started right away. “You can have only two cups of coffee a day.” I wondered why–what were the minuses? What did the numbers say about how risky this was? This wasn’t discussed anywhere. Then we got to prenatal testing. “The guidelines say you should have an amniocentesis only if you are over thirty-five.” Why is that? Well, those are the rules. Surely that differs for different people? Nope, apparently not (at least according to my doctor). Pregnancy seemed to be treated as a one-size-fits-all affair. The way I was used to making decisions–thinking about my personal preferences, combined with the data–was barely used at all.
Well, Ms. Oster, wait until your child goes to public school kindergarten. You are in for a whole world of hurt, my friend. Take, for instance, the requirement that all children have an updated physical exam from a physician every year. Sounds like a good idea, and probably a good idea from a parenting perspective. But as a blanket rule, is it really necessary? Does the school nurse read every one of these reports? Is there any data to support greater safety or superior learning in kids who have a physical exam on file in the office? Then there’s the lab work. Every child must have a documented lead level at some point in their lives before entering kindergarten. Why? Is every kid in town vulnerable to lead poisoning? If I have a completely healthy and normal kid what is lead screening going to tell me? If my kid lives in a house built in the last ten years, has never eaten paint, and to my knowledge has never eaten any toy made in China, why do I need to subject my kid to a needle?
Sorry, I was ranting there for a minute. The point is that people who enter the health care system (or the public school system) are subjected to a lot of arbitrary rules imposed by well-meaning people who have no data, or who once had data but that data no longer applies, or who just think “it’s a good idea”. For some patients following the rules works for them. For patients like Ms. Oster who, what with that PhD in economics and all, needs more data, doctors had better be able to come up with some.
Now, if you’ll excuse me, I have to go follow some rules.
A very personal piece, for your reading pleasure and maybe food for thought:
Here in Massachusetts the ad campaign for the state Lottery (and maybe it’s a national thing, I don’t know) goes like this:
YOU CAN’T WIN IF YOU DON’T PLAY.
This statement is true, so far as it goes. If I don’t pay my dollar, I have no chance of winning a million dollars. But there are a couple of corollary ideas naturally following the above statement. Of course, given the statistical chance of winning the lottery, one such statement could be IF YOU PLAY, YOU’LL PROBABLY NOT WIN. But there’s another idea that I believe has a much stronger visceral message:
YOU CAN’T LOSE IF YOU DON’T PLAY.
Humans naturally give more weight to the experience of loss than to the experience of gain. Once we have something we are much more afraid to lose it than we were happy to get it. Similarly, the pain of losing a competition often lingers far longer than the joy of winning, though I suspect this isn’t true for winning the lottery. Why not? Because the personal investment a person makes in a lottery ticket, a dollar or so, is relatively insignificant. We don’t mind losing in the lottery because we haven’t put much out there at risk.
But what if what’s at risk is bigger? What if it is a larger amount of money, or a job, or a life savings? What if what’s at risk feels like life itself?
If you have a life that is comfortable, what you really have is a life that is familiar, a life in which you can control the variables and have a pretty good idea of the outcome of a given situation and, most importantly, a life in which your senses of self and identity are safe. A comfortable life isn’t necessarily a happy one, or a fulfilling one, or the one you dreamed of, but if you stay in it you are unlikely to feel threatened by much. You have your stuff and you want to keep it. The comfort comes in not taking any risk. The threat of losing, or failing, often feels much bigger than the prospect of fulfillment.
Say I’m a tennis player. (I am most assuredly not, but let’s assume.) I’m a good tennis player, and I’ve worked hard at it for many years. Imagine that I get an un-seeded spot at Wimbledon. I have spent years learning the skills necessary to compete in this tournament and I know I’ve worked just as hard as everybody else. In fact, my entire identity thus far in life has been becoming a good tennis player. I’ve been told by teachers that I’m a good tennis player. I went to the best coaches and schools.
Imagine that I get the draw, and I find out I’m playing Roger Federer in the first round. At this point I can consider my options: I can’t beat Federer if I never play him, but even if I play Federer the likelihood of beating him is very small, i.e, I’m likely to lose.
Now I have to ask: How big a blow is losing? How big of a risk am I taking? What am I putting out there for the world to see? At this point my decision to play in Wimbledon or not will depend on how I think about myself in relation to tennis.
- Is there anything to gain from playing Federer? Might I learn something? If so, maybe I should just get out there and see what happens, even if I am temporarily humiliated. I win experience, if not the match. With this view, I feel like I’m not really risking much, but I can potentially gain greatly for the future.
- If I feel like I am risking my very life, that my entire sense of self will be destroyed if I lose, if I can’t stand what people might think of me, might it not be better to withdraw from the competition? After all, I can’t lose if I don’t play.
The outcome of most of human’s lives rests on which perspective is taken.
Ladies, the moment you have all been waiting for is here! No, not affordable childcare. Not equal pay for equal work. Not gun control. Not abortion rights or paid maternity leave or a female majority in Congress or a constitutional ban on the word “chicklit”. Girls, it is so much better than all that. We got pink Viagra!
Flibanserin. Catchy name. Addyi for short. Approved by the FDA for that horrible disease called Hypoactive Sexual Desire or, for clarification, Inhibited Sexual Desire, Sexual Aversion, or Sexual Apathy. The New York Times Health Guide defines this “disorder” in the following way: (www.nytimes.com/health/guides/disease/inhibited-sexual-desire/overview.html)b
Inhibited sexual desire refers to a low level of sexual interest. A person with ISD will not start, or respond to their partner’s desire for, sexual activity. It often occurs when one partner does not feel intimate or close to the other. Communication problems, lack of affection, power struggles and conflicts, and not having enough time alone together are common factors. ISD can also occur in people who’ve had a very strict upbringing concerning sex, negative attitudes toward sex, or traumatic sexual experiences.
No way. You can take a pill for the disorder called Brought Up Baptist? Here’s more:
Illnesses and some medications can also contribute to ISD, especially when they cause fatigue, pain, or general feelings of malaise. Commonly overlooked factors include insomnia or lack of sleep, which can lead to fatigue.
Wait. Is the problem that I have Inhibited Sexual Desire or that I just want to go the f%^$# to sleep?
The FDA actually rejected Addyi twice, in 2010 and 2013. The reasons cited included the fact that it doesn’t really work. Women who took it didn’t experience an increase in desire on a daily basis, but did have one more “satisfying” sexual experience per month than the placebo group. Plus, it has side effects, like low blood pressure, fainting, nausea, dizziness, and, hilariously, sleepiness. And, it has a boxed warning that the drug should not be used by people who drink. Which is problematic, to say the least. But, no worries. The pink Viagra can only be prescribed or dispensed by practitioners who have watched an online slide presentation and passed a test of their comprehension. So, thank God for that thorough education at least.
So why did the FDA decide to approve Addyi this time? The same reason children are still getting gunned down in elementary schools: lobbying money. Plus the deployment the biggest money word there is: Sexism. Some women’s groups have accused the FDA of sexism for not approving a women’s libido pill while sanctioning a men’s version. Or rather, a few vocal women have. Prominent Washington feminists, together with the (female) co-founder and CEO of Sprout Pharmaceuticals (the company that makes the pill), the president of the National Organization for Women, and the help of a public relations company, managed to convince some people in Washington that the FDA was being discriminatory. A very effective social lobbying campaign sealed the deal.
What all these feminists have missed is the very sexist labeling of yet another normal human female function as a “disease”. Men can get Inhibited Sexual Desire, too, but no one is talking about that “problem”. (Viagra, by the way, is not a libido enhancer. It is an erection enhancer.) All of this looks very much like a mirror image of the Victorian-era belief that women should, in the immortal, and paraphrased, words of Queen Victoria, “lie back and think of England.”
Low sexual desire in women is, if it is a problem at all, a symptom, not a disease. Some women don’t desire sex and are fine with it. For everybody else it is a normal response to normal life problems. But, hey. Maybe there’s a pill for that too.