Archive for July, 2014
Today’s medical futility is tomorrow’s routine care. A very hopeful thought. However, in the present consider a modern intensive care unit. A treatment area in most hospitals where a month of care could easily cost half a million dollars. That’s a big bill for any individual, hospital or insurance company and there is mounting pressure to use technology more wisely.
Cost is the most important factor to consider in a discussion of medical futility. Futility means doing something that will fail. Of course, our modern definition is doing something that will likely fail but might not if we spend enough money. If there is only one treatment for a horrible disease and it only costs a penny — we would spend it instantly, even if the treatment is futile. But, if it costs ten million pennies … we think about futility.
American medicine has been plagued with the problem of implementing treatments before they are affordable or even proven. Nobody asks a medical innovator “could you work on the invention a little more to make it less expensive”. Nobody asks a surgeon if a surgical procedure is proven — coronary bypass surgery is a good example, since the proof of effectiveness came 20 years later — turns out it’s not for every patient, just a select few.
The same question of effectiveness exists for intensive care. It’s clearly not for every patient, just a select few. But, how are doctors identifying those select few?
Critical illness is fraught with uncertainty. We have lots of expensive treatments but where do we draw the line. Deploy the technology or let nature take it’s course? Ethicists and theologians suggest they know the answers.
Yet, patients and families seek a pragmatic solution: grandpa was in great health but now his aneurysm has ruptured — he looks bad, should he have surgery?
Research shows critical care doctors actually predict outcome fairly well in this sea of uncertainty. They tend to favor using their skills to “give it a try” and make money doing so. But, if they say the chance of meaningful survival is less than 10% — absolutely do not go down that road. The road is often a dead end — the end may be after weeks in the ICU, or weeks in rehabilitation, or months in a nursing home.
Critical care is extremely stressful to the body. Research has shown that persons over 65 who survive an illness but who spend a week connected to a mechanical ventilator only have a 50% chance of living 6 months. So, even walking out of the hospital after critical illness is not a guaranteed success.
Back to the question of futility. Severe illness does not provide the luxury of time, time to check the internet, or time to go to the best doctor. This is when going to a hospital with a high quality score is important. There are always media splashes about miracle cures or soap opera dramas — the reality is patients and families do not want futile care. This is one time “ask your doctor” is exactly the right thing to do — listen carefully.
Wishful thinking is not sound public policy. (Bjorn Lomborg) The South, unlike the rest of the US, has rising numbers of the uninsured. The “Health Reform Monitoring Study” from the Urban Institute is disturbing . Why? Because insurance subsidies were supposed to insure more people. The problem seems to be the money is not reaching the people who can’t afford insurance. The original ACA plan was for Medicaid to cover the very lowest income people then at some higher income level the ACA insurance subsides would take over. Many states in the South did not elect to expand Medicaid so there is a gap between Medicaid and the income level at which ACA subsidies are available. According to the study, the most frequent reason given by uninsured people for not having insurance is: “it costs too much” and second “it might affect immigration status”. The following is a graph is a comparison of each region between 2013 and 2014: The South has a huge problem with health literacy — many residents have no idea how to approach health insurance. About 11% of Southern uninsured people say they do not want insurance — it’s like asking someone if they want a kumquat — if you don’t understand what it is or what it costs you might not want one.
The Governors of the Southern States are hurting people, not something expected. Somehow they thought by not expanding Medicaid and ignoring the ACA the health care problems in the South would go away or get better by magic. Wishful thinking is not a strategy for success.
Patients like a choice of healthcare providers but never are willing to pay much for that opportunity. Recently, insurance companies have taken advantage of shrinking the available panel of physicians to select those that are both less expensive and provide higher quality. The higher quality part is obviously secondary.
Electa Draper of the Denver Post reported 7/27/14 “Coloradans could lose medical choices, but save money”. The essence of the article was a report on the United Healthcare (UHC) plan to “narrow the panel” of available physicians. $100 per month is reported as the possible savings for subscribers to the plan.
UHC is the largest insurance carrier in the US. This national strategy to “narrow the panel” will save someone some money; but, the amount of leverage this gives to quality is nebulous. This huge insurance company could raise US healthcare quality to number 25 from number 26 in the world — sadly they don’t have much ambition for international competition.
The lack of transparency is striking:
- will all the cost savings be passed on to the consumer?
- will CEO Stephen Hemsley’s salary go higher than $106 milllion?
- physicians seem easy to squeeze for money; what about drug companies, device makers and hospitals?
- what quality measures cause physicians to be excluded?
- forcing patients to change doctors as employers change insurance plans is common practice — when will this stop?
- will UHC or any insurance company saying they intend to improve quality also reduce errors? Will they stand shoulder to shoulder with physicians who are named in medical error suits?
- will UHC reduce patient waiting times?
- will UHC drop Medicare patients and stick with younger healthier patients?
Saying “sorry” is the human thing to do. Doctors and nurses should say it when they feel it.
Saying “sorry” seems to have two meanings: 1) something bad happened and I understand your emotions 2) something bad happened and I had some connection with the event for which I feel partly responsible. Bad things do happen in health care but “sorry” is a very uncommon utterance for health care providers.
Dr. Abigail Zuger writing in the New York Times 7/14/14 “Saying Sorry, but for What?” compared how she felt about a plumber who broke a valve in her house with medical personnel who broke other things — neither said “sorry.” Sorry truly does not fix anything; but, the absence of “sorry” is infuriating.
The problem is ego. Ego infuses some health care providers with the notion bad things are an act of God but good things are an act of ME. Absence of “sorry” is a sure sign of defense (a defense of self). Perhaps the health care provider was spanked as a child or yelled at by teachers. Who knows … ego has gone wild.
Quality health care depends on people believing errors are due to system failures. When providers fail to embrace that philosophy they fail to correct problems. No failure, no correction.
A fall in the hospital can be deadly. Recently, a family member fell in a room while no nurse was present and they died. The nurse did not say “sorry.” There was no acknowledgement of responsibility. No acknowledgement the system was at fault, no realization there was a better way, and no reason to prevent future deaths. The simple statement “sorry, I wish I had been there to stop the fall, we will investigate this to help others” would be the right thing to say, and believe.
Lawyers are not the cause of excessive health care ego. However, lawyers with the threat of suit are a convenient excuse. When bad things happen honesty and caring are much more likely to assuage the displeasure of a family than stonewalling.
Doctors could learn a lot from pilots. Flight simulators have revolutionized commercial aviation so pilots can train without endangering passengers. Patient-care simulators do the same for doctors yet doctors fight the idea. See the article in the Wall Street Journal 7/21/14 by Melinda Beck “Doctors Upset Over Skill Reviews.”
There are cognitive skills and procedural skills; both are amenable to testing and training. The current buzz words are “maintenance of certification” or MOC. The specialty societies have raised the bar –and the price –for the MOC tests. Each state empowers a board, or group of people, to oversee medical quality and issue licenses to practice medicine at a much lower educational standard than the MOC. So, many physicians feel the specialty boards have gone too far.
Examples of specialties include: family medicine, internal medicine, general surgery, ophthalmology, and gynecology just to name a few. The MOC process requires many hours of education each year and periodic tests. If the process is not completed the physician is designated “not meeting MOC requirements” which is a black mark for any specialist.
The offended doctors object to being forced to learn about subjects like:
- how to recognize abuse of children and elderly adults
- teamwork during operating room emergencies (a simulator lab)
- how to review a chart to identify areas for improvement
- principles of quality improvement
- new information about cost effective drugs
Of course, all those topics are a waste of time for busy doctors that stay on the cutting edge of medicine by getting information from drug reps and journal ads. The high cost of continuing education, $2000 for a refresher course, is ridiculous since that is the usual salary doctor receives for 3 days of work. Who ever heard of using a simulation laboratory; it’s not proven. Practicing on live patients to see what works and what doesn’t is the way — some live and some die. Besides, what does a pilot really learn when they crash a simulator rather than a real plane!
When Quasimodo answers your call light instead of the the nurse you know something is wrong. It probably has to do with all that paperwork — one third of a nurse’s time is spent doing clerical work either on paper or on the computer.
Laura Landro of the Wall Street Journal reported 7/21/14: “Nurses Shift, Aiming for More Time With Patients”. Ms. Landro highlights one hospital where nurses are getting more help from LPNs and CNAs so they can spend more time at the bedside.
More low-level helpers — where does that lead? Probably not to more Florence Nightingales at the bedside but rather fewer RNs who will mainly serve as supervisors. Nurses are getting expensive so the trend will save money for hospitals.
Nurses are hit from many directions. Shift-work is hard on family life and the educational requirements have increased. Highly motivated nurses often escape the shift work by training to become outpatient nurse practitioners — why try to climb the corporate ladder? Nurses aspire to be more like doctors at a time when doctors as hospitalists become more like nursing supervisors. And, hospitals don’t see much value to experience — they fire a 50 year old nurse so they can hire 2 twenty something nurses to save money.
Nurses are criticized for quality issues as well:
- Poor shift to shift communication — who knows what the guy at the end of the hall has?
- Collection of information that has no value 24 hours later — a huge waste of time. Unfortunately, the nursing model is focused on filling out forms or online queries. Always made worse by legal concerns.
- Training that inhibits drawing a conclusion. For example, if a nurse finds a patient is on the floor bleeding from a cut on the head … the conclusion is “deficit of patient comfort” rather than “scalp laceration and possible brain injury”. That’s the doctor’s job — too bad the doctor is not always there.
It’s almost a perfect storm. A general shortage of nurses, a background of quality problems, hospitals anxious to find lower cost employees, and nurses obtaining more training to command higher salaries. Nursing is not going away but the RN job will be different in the future.
Asthmatic abuse: (definition) The systematic and intentional market manipulation of asthma medication prices resulting in large corporate profits and financial ruin for people with asthma (see also: racketeering, theft, extortion, corruption, complicity and congress).
Price gouging of people with asthma by U.S. pharmaceutical companies is legendary (New York Times). Now some of those same companies want to move their corporate offices to other countries to avoid U.S. taxes. RIPOFF is the technical term.
An inhaler is a pressurized gadget to make a mist of a medication so a person can inhale the mist (see the picture at the right). It should have never been patented: it is useful, but it is trivial and certainly not novel. Now, through patent manipulations and suits there are NO GENERIC INHALERS FOR ASTHMATICS; there are only high priced brand name products — despite the fact this type of sprayer and medication has been available for 40 years.
Albuterol is the most common anti-asthma inhaler. The drug is easy to manufacture (costs a few cents) and the inhaler is trivial (costs less than a dollar). The US price listed below is from Costco (considered the lowest price source in the US). The Indian price quoted below is from allmedsdeal.com (this is not an endorsement, just an example).
- The US price: PROAIR HFA 90 MCG INHALER (TEV) $55.46
- The Indian price: Ventorlin CFC Free Inhaler / Salbutamol 100mcg (GSK) $4.40
These are the same drugs: US price $55, Indian price $4. GSK is a reputable UK company that manufactures albuterol, sells it worldwide, but not in the US. Without the unreasonable market restrictions and nearly insane FDA rules asthmatics would be able to purchase albuterol for about $4 per inhaler.
Patents should be allowed to exist, but consumer prices must be limited. Countries other than the US exercise this control. Citizens fight price-gouging companies — why not fight price-gouging drug companies? Medicare insists doctors accept payment at the lowest rate offered, so why should Medicare fail to insist on the lowest price drug companies offer elsewhere in the world?
The current laws for pharmaceuticals are so complicated it defies understanding. If you like complexity, like laws and like legal suits then continue the current system. Instead, consider the following:
What part of this simple rule would be difficult to understand:
THE RETAIL PRICE OF ALBUTEROL INHALER SHALL BE $4.
That’s the kind of pharmaceutical control the US needs.
Severe dementia comes to an end. And, as the end approaches the POA (the person designated as the health care “power of attorney”) must face some difficult questions. Be assured, such questions are not new. Ethicists and philosophers provide some guidance:
- Understand death is near.
- Be conservative — try not to interfere with a natural death
- Comfort should be the goal.
- Avoid tests, treatments or procedures unrelated to comfort.
- Approaching death creates emotion. But, strive for logical decisions.
- Discuss the above 5 principles with health care providers and family.
- Keep in close contact with family members.
When is dementia severe? First, it is not something that happens suddenly. There is a progression from mild, to moderate to severe that develops over months to years. Finally, the person looses connection to reality and does not remember who they are, where they are or what time it is. Physically, they they loose coordination, slow down, get weak, don’t talk clearly, frighten easily, anger easily, choke easily, fall easily, and often loose control of bladder and bowels. Eventually, they need help even with the simple activities of daily living: like dressing, going to the bathroom, bathing, feeding themselves and even sleeping at the right time.
What naturally happens? In a modern care setting the most common final events are pneumonia (from poor swallowing), urine infections, strokes, infected bed sores, blood clots, and falls with head injury or broken bones (like a hip fracture). Often, a demented patient will have one hospitalization after another. The person never seems to fully recover. Any changes in environment, like a new room or new caregivers can drastically worsen the mental situation. Mental stability is aggravated by restraints or sedatives. In the end, the person may become unresponsive (a coma) and bodily functions stop.
Who can help the POA? Decisions by every POA will vary according to the situation and patient wishes. Hopefully, the POA had a discussion with the patient about end-of-life issues before severe dementia intervened. Most POAs will still ask themselves if they are doing the right thing. A discussion of medical facts with the primary care provider helps to put priorities in order. Social workers can be a world of help. Clergy often has a big-picture view that is very comforting. Palliative care programs (if available) can be a relief with a team of doctors, nurses and social workers to give support over long periods of time. When the patient only has a few weeks to live (according to the attending physician) then a hospice program can help in the final weeks at home or in a nursing home.
Even the best prepared POA runs into difficult questions:
- At the care center the patient’s hearing aid is lost — should it be replaced? Answer: probably not. It will likely just be lost again.
- The gastroenterologist office calls to set up a routine colonoscopy, when should it be done? Answer: skip the procedure. It will not make the demented patient live longer and the required sedation may be so disturbing it could cause hospitalization.
- The patient has no dental pain but the dentist suggests a new crown for a tooth. When to schedule? Answer: no pain, no procedure. Any procedure can result in hospitalization for minor complications. If dental pain becomes a problem sometimes a quick dental extraction is the easy answer.
- The patient becomes unresponsive (in a coma) at the care center. Should an ambulance be called? Answer: probably not. If a do-not-resuscitate order is in the chart and the patient is in no distress good nursing care is all that is needed.
Ask not what healthcare can do for you .. ask what you can do for healthcare. The US healthcare system is in trouble — doctors don’t listen to patients and charge too much, there is an increasing shortage of healthcare providers, waiting lists are longer, hospitals often give patients infections rather than prevent them, insurance companies extract high profit and they pay CEOs millions of dollars without much patient benefit.
Yet in this environment patients ask for more engagement with providers (meaning more face time), ask for more informed choices (meaning more education), ask for lower price insurance (meaning congressional action), and ask for shorter waiting times (meaning expanding the healthcare workforce). ASK…ASK…ASK.
There is no question the US system needs change and there is no question people are not getting the attention they need.
So what can people do? Perhaps you have some answers to the question. Here are a few suggestions:
- volunteer to help others figure out medical bills
- volunteer to help in doctors’ offices pass out educational materials
- be outspoken if healthcare workers fail to use alcohol hand gel before visits
- volunteer to be on quality assurance committees in doctors offices and in hospitals
- volunteer to do Internet searches to find health information for friends and relatives
- volunteer to take people who don’t drive to health care appointments
- don’t go to doctor appointments unprepared — have your records and test results in hand.
- send messages to your congressmen any time you experience long waiting times, high drug costs, complexity of health insurance, or high prices of medical devices. If you don’t get results don’t vote for them again.
When you question people given a placebo (containing no medication) 25% will feel better (placebo effect) and 45% will think they have a side-effect (nocebo effect). The remaining 30% notice nothing. What a delema for doctors! Some people feel better without medication, some feel worse with medication and some don’t think the medication is working either way!
The answer is not to over-think the problem. Patient’s should become informed about the medications they take — know the top 3 side effects. And, if something definitely unusual (and bothersome) happens shortly after taking a new medication run down the side-effect list and check with your health care provider. If a side effect you have is really on the list a response from the health care provider: “I’ve never seen that” is just not helpful.
Many medications have side effects that people just must live with. Like strong blood pressure medications that cause a slight dizziness on standing. Or an anti-allergy medication that causes a dry mouth. Some people expect to feel better with blood pressure medication — not so — a lower blood pressure is the desired effect, not any “feeling”.