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Humans will be human.

This week the governor of the great state of Massachusetts, my home state, signed into law a bill that puts strict limits on new opioid prescriptions, specifically a limit of a dosage sufficient for 72 hours, among other things.  This of course, is in response to the opioid addiction problem afflicting the country.  Many other states are taking similar measures.

I am of two minds on this.

Such laws are a good idea

First of all, why are these laws targeting doctors?  Well, we’re the source, at least in part, at least at the beginning.  It has become a habit with surgeons to send patients home with 30 percocet after a hysteroscopy, for instance, or a knee scope.  I can’t speak to the habits of other kinds of doctors, but according the the New York Times, primary care doctors prescribe the bulk of opiates in this country, so there’s habits there too for, say, back pain or a sprained ankle. (http://www.nytimes.com/2016/03/17/health/er-pain-pills-opioids-addiction-doctors.html?hp&action=click&pgtype=Homepage&clickSource=story-heading&module=second-column-region&region=top-news&WT.nav=top-news&_r=0).

Why so many pills?  For the same reason I sometimes (well, a lot of times) put pre-packaged snack bags of Goldfish in my kids lunch instead of cutting up fruit or putting baby carrots in sandwich bags.  It is the habit of human nature to go with what is easier.  Escalators vs. stairs, jarred marinara instead of homemade, roller bags vs. the kind you have to carry.  Dishwashers.  Those things guys put on their heads so they can drink beer out of a straw while watching football.  Quicker and easier.  The patient will not call you on the weekend for a refill.  The patient will not ask for more at their next office visit.  It takes a lot longer to tell a patient why they can’t have a drug than just give it to them.  It’s a hassle to explain to the people who do patient satisfactions surveys why Mr. Jones sent in a bad review because his doctor wouldn’t give him what he wanted.

On the other hand, it is generally taught in medical school that pain that doesn’t go away in a timely manner should prompt an investigation into why it hasn’t gone a way.  This is definitely true for acute pain.  If you’ve had your appendix out, 3-5 days of a mild narcotic should get you through the post-op phase.  If you’re still having pain requiring opiates after a week, the doctor will, or should, look for other causes of pain like infection or perforated bowel.  So in the case of acute pain in which the source is clear, Governor Baker’s (Charlie, of Massachusetts) new law makes sense.

Plus, the doctor can tell Mr. Jones it is not her fault – blame the government.

Such laws solve nothing

Studies suggest that giving patients a short course of opioids for acute pain does not lead to addiction.  Here’s Scott Strassels, a pharmacologist writing in the journal Advanced Studies in Pharmaceuticals in 2008.

…several studies have demonstrated very low rates of addiction among patients receiving opioids for acute pain. One chart review of nearly 12,000 hospitalized patients who received opioid medications identified only 4 patients with evidence of iatrogenic [treatment-caused] addiction.” (http://www.utasip.com/files/articlefiles/pdf/2nd%20article.pdf)

Secondly, anyone who has ever met an addict knows that restricting one source of his or her fix only sends the addict to a different source, i.e, the practitioner of the unregulated open drug market also known as your local heroin dealer. If my kid wants chocolate and my answer is no, they’ll go to their dad, the babysitter, the mailman, anyone else, hoping for a different answer.  This is because it is human nature to want chocolate and kids want what they want NOW.  Addicts are no different.  Doctors are not responsible for what people put in their mouths or how they choose to use the pills they are given.

Lastly, drug prescribing restrictions are, or can be, a trifle condescending.  Here’s Dr. Sarah Wakeman, a Massachusetts General Hospital physician who served on Baker’s Opioid Working Group, according to the Boston Globe:

“We prevent diabetes by limiting exposure to foods and beverages. We prevent lung cancer by limiting exposure to tobacco smoke,” she said at the news conference. So the proposed opioid prescription limit will help to minimize excessive exposure to opioids.”

Well, no actually.  We (meaning doctors I assume) don’t limit exposure to foods, we don’t limit exposure to tobacco.  We can recommend that people do these things, but people do what they want.  Opioid addiction is a problem because of behavior, not just opioids.

 

Let go and let God?

I have it on good authority that Christians are nice people.  They are super nice, and super generous.  If you are in certain kinds of trouble, a Christian will do anything to help you.  Prayer chains will stretch miles.  Casseroles will multiply.  Christians know that they are super nice.  In fact, they trust each other with their very lives, or at least the part of the body that rust doth corrupt.  They are, however, a tad judgmental,  particularly with regard to “moral” principles and certain branches of government.  It seems to some Christians that health insurance has become one of these issues.  Health insurance is Business, Government, and Coercion, plus some plans cover abortion and contraceptives. So Christians have come up with their own solution: The Health Care Sharing Ministry.
Here’s how the Ministry works, at least at Samaritan Ministries International:
Each member commits to sending a set “Share” amount each month. These “Shares” are sent directly through the mail from one household to another, to the members with “Needs”. Samaritan Ministries uses a database that randomly matches Shares to Needs, so that the Sharing is coordinated and Shares go to the appropriate members with Needs.
OK, so it is just health insurance but the language is different.  Shares are premiums and Needs are beneficiaries.  At Samaritan Ministries that “Share” is about $400/month.  Some organizations have members sent the money directly to the Needs folks, some have members sent the money to a central location from which it is distributed.  So far, so good.
Here’s the problem: there is no regulation on these groups, and no guarantees.  Here is a quote from the Health Care Sharing Alliance, an advocacy group promoting Health Care Ministries:
There is usually no pool of funds, but even when there is, there is no contract for future benefits and no assessment of risk. In fact, every member of a Health Care Sharing Ministry is responsible for paying his or her own medical bills. The purpose of the Ministry is simply to organize other people who voluntarily choose to help fellow members pay their medical bills in keeping with Biblical commands to “share one another’s burdens.”
(The “share one another’s burdens” comes from Galatians 6:2: “Bear one another’s burdens and so fulfill the law of Christ.”)
Ok, so the health ministries are just putting a human face on beneficiaries.  It feels better to pay into a system in which you know who is getting the benefit.  Especially is you agree with their world view.  Again the Health Care Sharing Alliance:
Insurance executives would think this is crazy — how can you rely on the goodwill of other people for paying bills? Exactly. It makes no sense at all in the world of business. It only makes sense in the Kingdom of God and the world of faithful believers. All others should stick with the insurance model.
Oh.  So relying on goodwill is really only for believers.  Which is just as well, because the Health Care Ministries benefits come with certain caveats.
1. No coverage for preventive services
2. No coverage for mental illness
3. No coverage for pre-existing conditions (sometimes)
4. You can’t sue the organization
5. No coverage for injuries caused by morally questionable behavior, such behavior I assume to be determined by whoever is administering these plans.  So STDs, HIV, out-of-wedlock pregnancies, drunk driving accidents, depression, schizophrenia… you’re out of luck.
So Paul’s letter to the Galatians really says that people who are true believers should share the burdens of other true believers unless the true believer’s behavior is not in keeping with the behavior deemed appropriate by said true believers.
Well that’s kind of unfortunate for Christian teens, who have a pregnancy problem related to lack of contraceptives and abstinence only sex education.  U.S. states whose residents have more conservative religious beliefs tend to have higher rates of teen pregnancy according to a new study in the journal Reproductive Health.  Joseph Strayhorn of Drexel University College of Medicine found “…a strong correlation between statewide conservative religiousness and statewide teen birth rates, even when they accounted for income and abortion rates.” (Bryner, 2009, http://www.wtamu.edu/webres/File/Academics/College%20of%20Education%20and%20Social%20Sciences/Department%20of%20Political%20Science%20and%20Criminal%20Justice/PBJ/2013/3n2/3n2_02MJM.pdf).
It would also be unfortunate for anybody with an unexpected premature infant or surgical complication – Samaritan only covers costs up to $250,000.
Ok, but maybe there are other reasons why Christians are opting out of regular health insurance.  Maybe health insurance is too expensive and these Health Care Ministries are cheaper. Many Christians are in lower income brackets.  The Pew Research center says that 35% of Christian families make less than $30,000 per year, and number that increases to 53% in African-american families.  Abby Goodnough of the New York Times (http://nyti.ms/1LTcSTJ) spoke to one family who had decided on a Ministry option.  The husband is a machinist and the mother is a stay-at-home mom.  They say that their premiums and deductibles are too high.  They would probably be eligible for subsidies under the Affordable Care Act.  They might also get medicare, except they live in Texas, which has chosen not to expand Medicare because it was Obama’s idea and they’re Republicans and most Christians are Republicans and Oh isn’t that interesting.
Sorry.  I digress.
Here’s Ms. Goodnough on the Ministry response to this objection:

Acknowledging that many families can qualify for subsidized insurance policies with free preventive care through the Affordable Care Act, Mr. Lansberry [James Lansberry, executive vice president of Samaritan Ministries International said that most new members were not “joining primarily on price; they are joining primarily on principle.”

On principle.  The same principle that Christian Healthcare Ministries of Ohio invoked when the guys in charge spent $15 million on homes, vehicles and excessive salaries out of the central fund where members had sent payments.

I hate health insurance as much as anybody.  But trusting your money and your life on a principle is dangerous.

We’re all unqualified.

In this election year, with so many choices to be made between so many totally insane and completely unqualified applicants, I think it would be helpful to remember how totally insane and completely unqualified any of us are when it comes to making decisions, political, occupational, medical, or otherwise.

Most people don’t know what they want.

We have to see things in context and comparison.  What we see tends to change depending on what things are next to each other and how we judge each.  My car looks great next to that old jalopy but it looks like a bucket of bolts compared to the Jaguar on the other side.  Nursing looks great next to my high school friend working at Starbucks, but maybe doesn’t look so great next to your other friend who is transplanting hearts.
What other people think also has a great impact on what we think we want.  When somebody says “You’re so smart.  You should go to med school”, they are imposing their judgements, values, and stereotypes on the decision.  But you’ll care about what they think, and as I said above, it will influence how you decide.

Another problem with knowing What You Want is the relationships we have with past present, and future.  Knowing What You Want means that you have to be able to anticipate how you will feel if you choose different options, which in the case of health care is very difficult to do.  And the ability to accurately predict how you will feel is even more important when the thing being chosen, as in medicine, is years away from actually happening.
Here is how Kent Greenfield, in his book The Myth of Choice, puts this:

“Our ability to make anything close to a good decision in the present depends not only on our judgements about what we want, think, and feel right now but on our memories of what we wanted, thought, and felt in the past and our predictions about what we will want, think, and feel in the future.”

A classic example of this is in food shopping.  When we go to the store we are buying in the present things we think we will eat in the future, because we liked them in the past.  If we buy something that is new, we are predicting that we will like it in the future and that when the future becomes the present we will eat it, because we liked similar things in the past. When it comes time to actually choose something to eat, we might or might not like the things we bought.

Most people know what they want.

This is why a simple list of pros and cons doesn’t work when it comes to these kinds of decisions.  Gut feeling is a powerful indicator of what we really want.  Most of the time our gut is drowned out by social structures and expectations, but it is a very important piece to pay attention to.  For example, if you are making a decision about whether or not to buy a new car you might make a list of all the good things and bad things about buying a new car vs. keeping the old one.  What you might not factor in is the gut feeling that says “I want a new car.  Now.”  So you end up buying one even if your list concluded it wasn’t a good idea.  We are not completely rational creatures.

You have to get this step right.  No amount of information will help if you don’t know yourself and what you want.  Not just what you think you want, or what you think you should want, or what someone else tells you is the right thing to want.

The condescension will continue until morale improves.

The latest in the “Of Course All Women Are Irresponsible Idiots” category of health care.

Women all over Massachusetts, where clearly new mothers are all selfish, drunk, and lazy, are now being informed, through the haze of hormonal blizzards, the fog of sleep deprivation, and the blinding realization “Oh, S#$@*, what have I done to my life!” that putting their newborn infants in the nursery for a few hours is, well, not allowed. Here’s the Boston Globe: (http://www.bostonglobe.com/lifestyle/health-wellness/2016/02/06/nurseries/Ur4Xi846SPStbUx5PhxQtJ/story.html)

Women seeking a few hours of rest after hours of labor or a caesarean section often are surprised to learn that Massachusetts hospitals are increasingly restricting nursery access or, in some states, have closed the nurseries altogether. In Boston, Boston Medical Center began widespread “rooming-in’’ years ago, Mass. General followed suit more recently, and Beth Israel Deaconess Medical Center is taking similar steps. They collectively deliver more than 11,000 babies a year. Brigham and Women’s Hospital also expects to move in this direction.

And why is this new trend being imposed upon consenting adults? Budget cuts? Lack of infant nurses? Bankruptcy of the company that makes those little plastic bassinets on rollers? Too many episodes of “Switched at Birth”? Did we run out of pink and blue stocking caps?

No, ladies.  We need to be taught, schooled if you will.  Left to our own devices we would all be terrible mothers, our children would all have attachment disorder, and they’d all be on the Short Bus because of the alleged evils of formula.  Oh, and all the kids have Fetal Alcohol Syndrome because the world hasn’t, as the CDC recommends, banned half the world population from drinking alcohol between the ages of 21 and 50 (but that’s another story).  Apparently,

The shift is part of a national movement designed to promote breastfeeding, bonding, and parenting skills by having mothers and healthy newborns room together around-the-clock, attended by nurses who look after their needs. Many postpartum specialists now believe that nurseries, long a life raft for recovering mothers, is not the best, or most natural, way to provide care.

Ok, yes, let’s do this.  Since we’ve already decided that women shouldn’t make choices about breast vs. bottle, abortion or childbirth, drinking or not drinking, let’s also take away their choice to not drown in the wonderful, horrible, crazy sea of new motherhood. Because we really can’t be trusted to choose the best way for ourselves and our children.

You know what’s “natural”?  Having a baby squatting in a field, wrapping the baby in your headscarf, and going back to the harvest.  You know what’s “natural”? Women being pregnant non-stop for 40 years.  You know what’s “natural”?  Sending the first twelve kids to work the farm while you “bond” with the thirteenth.

The world, mercifully, at least in the US, is different now.  Women now have the choice to earn money while squatting in the fields and nursing and being pregnant.  Except for the vast majority of women, it’s not a choice.  You know what promotes breastfeeding?  Paid maternity leave.  You know what promotes bonding? Paid maternity leave.  You know what promotes good parenting skills? Paid maternity leave.

But, sure, take away the nursery.  I’m sure the Postpartum Specialists know best.

Health Is For Us, Not You.

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.

ROFL and LMAO. Or CMEO?

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.

No Wonder.

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:

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.

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