Category Archives: Children’s Issues

Alabama Legislators Want “Blood on the Floor”: Especially the Blood of Children and Grandparents


Well. I heard from a very credible source yesterday that our state legislators are not playing chicken with the budget this time. You know, it seems like every year they expect us to display panic and beg them to fund essential programs– it is so predictable it is almost like we have a set script. We get tired of it, but at the same time we think jeez, if we don’t play our assigned role, maybe they will do the bad thing.

This year may be different, if my source is correct. Their plan this time is to go ahead and pass a severely cut budget, which the governor will refuse to sign, and then override him. Then when there is “blood on the floor” (and I quote), they expect us to come screaming to them to pass taxes and re-fund the state. They do not feel they have support from their base, otherwise.

I don’t know. From my perspective, we already have blood on the floor. People in this state have been bleeding all over the floor for a long time, and it hasn’t mattered so far as the budget. The only blood I think the legislators care about is corporate blood and their own, so maybe the point is that business will begin fleeing the state once Medicaid is defunct and all the people in nursing homes have to move in with their families or be dumped on the street.

Getting even a level budget for mental health would not be a win, because there is major blood on the floor with our current budget. Getting the expected cut to Medicaid ($320 million, taking the federal match into account) would make the floor downright slippery. The cuts to doctors will be so sharp, around 40% cut to payments already well below private insurance rates, that I have personally heard several pediatricians say their plan would be to immediately drop Medicaid. Most practices have overhead in the range of 60 to 75%, so that 40% is at least the entire salary of the physician. There will not be enough of us left to see those suddenly doctor-less kids, even if we worked 24-7 without sleep. The 2 Children’s hospitals will close, because they depend on Medicaid money to fund their specialists. And good luck trying to get programs like that rebuilt to their current level of excellence, once they are gone. It takes decades.

Who will be affected first? The elderly in nursing homes. Children (guess they should take more personal responsibility). Because people of color are disproportionately affected by poverty, this is also a racist move. Some advocates are making a case by reminding legislators and voters that middle class elderly are in nursing homes using Medicaid funds, and that there are more poor white kids than black ones. Why should that even be said, as if poor elderly and black kids matter less? Only a racist and classist audience would need to be told such things.

I asked it there is anything at all we can do to stop this disaster, and my source told me we need to call our legislators. I’m going to add that you really need to talk to your neighbors, co-workers, etc and explain what is about to happen. Because legislators have told me previously that although phone and email contacts matter, they also use their in-house polling results, which are secret. They call their base on a regular basis to check in, and I am betting they are getting the no new taxes response from those voters.

If our legislators were ethical, they would be calling those voters not to ask their opinion but to persuade them– they would be pulling out the stops to stop the bleeding. They would stop putting forward bills that they know will cause us to waste tons of money defending federal lawsuits. The fact that they aren’t doing so says a lot.

I remember the last time this type of cut was proposed, and the legislators came up with a Hail Mary to borrow money for Medicaid– I had prominent progressive friends telling me that I was just playing the game by begging for votes to save the program– that I should let things play out, let the blood flow, call their bluff. So it isn’t just conservatives who are the problem. I do not believe an ethical person who understands these are not numbers– they are human beings– would promote such an idea. We all have our preferred ideas of where the funds should come from, and y’all, we do not have strength in numbers to bicker over that right now. If we do, we will surely lose the farm. I can say that a lottery would come too late and is not a solution for the current funding gap, which could begin as early as June. Otherwise, I’d support whatever taxes they are willing to pass, even though I’d prefer to stop corporate subsidies first.

My source says the fed will not likely permit our Medicaid program to be cut so much without responding. We could be taken into some kind of Medicaid custody. But… the kicker is that they can’t MAKE us write a check, so this is different from school integration. They can put key decision-makers in jail, they can withhold federal funding as leverage, but they can’t issue money from the state, raise our taxes for us, etc.

All that said, I would still call your legislators. I would tell them that level funding is not enough for mental health and that it is killing people as we speak, because of waiting times. And if you happen to have a job opportunity out of state, you might want to strongly consider it, especially if you have children. I’m going to stay as long as I can, but I do have a disabled adult family member who depends on both Medicaid and me, so there will be a limit. I don’t know how long my employer will be able to keep me, if well over my entire salary is defunded. Feel free to share all or part of this post if you think it will help.

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Filed under Alabama Legislative Session 2015, Alabama Politics, Children's Issues, Medicaid

Decriminalizing CBD Oil: Let’s Do a Good Deed Together


Complaining about current conditions or worse ones in the pipeline gets tiresome sometimes—nobody really wants to be Debbie Downer. So I’m glad to let you know of a bill in the works for Alabama this year with bipartisan support that could not only actually pass but also truly be a good deed. 

HB 207/ SB 174 would decriminalize the possession of CBD oil from marijuana plants for persons needing it to treat their own medical conditions or their children.

CBD oil, cannabidiol oil, is a natural derivative of marijuana with minimal amounts of THC (the part that makes people high). Although there is not enough THC in the oil to be psychoactive, just the tiny amount present makes the product illegal in our state. Google CBD oil and you’ll pull up rave reviews for treatment of just about everything under the sun. I’m generally suspicious of panaceas—cure-alls, good for what ails you miracle drugs, generally turn out to be fads that get dropped when, surprise, they don’t actually cure it all. I wrote that last line before I found this article with a good description of the endocannabinoid system using almost the same words—by a physician in favor of medical marijuana.

Not all the purported benefits of CBD oil have been seriously studied, but some have. It turns out the research is compelling in animal models of epilepsy. CBD oil has shown strong anti-seizure effects for generalized, partial and temporal lobe epilepsy. We don’t have that level of data for human use, just a few small studies in adults. For children, we do have multiple anecdotal reports of patients with intractable seizures, who didn’t respond to any other treatment, using CBD oil with good results. Some of the stories are enough to make me catch my breath— children with Dravet Syndrome, suffering years of daily prolonged seizures and associated developmental regression, becoming not only completely seizure free or close to it but also showing reversal of their brain damage.

There is one published survey, from Stanford, of 19 parents who tried CBD oil for their children with epilepsy, including Dravet Syndrome. Sixteen of them, 84%, reported fewer seizures, most with 80% reduction or more. The three who didn’t respond did not get worse. The only side effects reported were drowsiness (37%) or fatigue (16%). The authors point out that common side effects of prescription seizure medication—rash (sometimes life-threatening), vomiting, irritability, dizziness, confusion and aggressive behavior did not happen with any of the children.

Animal studies have also not uncovered serious adverse reactions. One paper noted a shift in cytokine production by human cell cultures exposed to CBD, which could be helpful for autoimmune and inflammatory illnesses but might be harmful in chronic infections like HIV. We don’t have good quality clinical data on this question—Cochrane Reviews could not come to a conclusion about long term effects of marijuana or derivatives in HIV outcomes, for good or ill.

The way to find out if CBD will live up to these early reports? More well designed trials, and larger ones.  We need to know if there are side effects that didn’t show up in the smaller groups, the best dosing regimens, and who is most likely to benefit. We need access to oil that will have a reliable concentration of CBD. The FDA has approved sites to study a specific, reliable concentration CBD oil in children, and 7 additional sites will be given IND (Investigational New Drug) approval for compassionate use.

Now I’m at the exciting part. Alabama may be getting one of those compassionate use approvals. I spoke to a respected pediatric neurologist who would be heading the program if done here. She has high hopes that the CBD oil may prove its worth.  She told me it was very important for children to be able to get CBD oil with a known percentage of active ingredient and low THC, because parents had reported inconsistent results from one batch of oil to another with non-standardized products. The problem is that it is illegal in Alabama, standard or not. So parents in the FDA approved program would risk arrest – unless we pass a law to protect them.

The bill doesn’t recommend CBD oil use—both versions are going through their respective Judiciary Committees, not Health. Sure, they leave other ground untouched, like medical marijuana in general or even recreational marijuana. I think it would be inhumane for legal marijuana advocates to ask these children to wait until more comprehensive legislation has a chance. An exhaustive evidence base is not necessary. All we need to do is say CBD oil has no reason to be illegal. I could walk down any drugstore aisle in Alabama, close my eyes, spin around and point my finger, and I’d put money in advance that whatever I’m pointing at would have more known side effects.

When I first spoke to Mike Ball, the House sponsor, he was concerned he might meet opposition from those who are just going to say no to anything remotely related to marijuana. He said it was probably risky to sponsor the bill during an election year, but that after meeting the parents who are begging for help, he had to take the chance. He told me this hill was worth dying on.

I’m a skeptic about politicians, just like panaceas, and I tend to distrust their motives more often than not. Even though Mike and I don’t see certain critical issues the same way, I believe he is an honest man, and I believe he sincerely had his heart touched by these children and their parents. I’m impressed that he was willing to take a political risk for a good deed.

Since we talked, I’m seeing reports that the bill may not meet the opposition he anticipated—that’s good news, and all the more reason for us to pile on. First, we want to be darn sure it passes. Second, we don’t always have to pick only the iffy bills to champion. Sometimes, it might just be good to show an overwhelming support, across partisan lines, for a worthwhile goal. Sometimes, we can all get to be the home team. If you agree with me, please take this opportunity to contact your legislators. No matter what happens in the 2014 midterms or in 2016, we are going to need to find a way to get things done together in Alabama, and maybe it starts with something this simple and sweet.

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Filed under Children's Issues, evidence based medicine

Poop Happens: New Rules for Alabama Medicaid


In the ongoing effort to squeeze more juice out of the budget turnip, Alabama’s Medicaid office has revised pharmacy benefits.  There are new limits on the number of prescriptions per month for adults, and for all ages, the program will no longer cover any over the counter medications as of October 1.

 

Were you aware our Medicaid program covered some (not all) OTC medications if prescribed?  After all, most private insurances do not, and neither does Medicare.  This is an optional coverage by states—we don’t have to do it, and now we won’t.

 

 Most of the OTCs I prescribe for kids are fairly cheap—for instance, 1% hydrocortisone for mild eczema is under $5 a tube.  Others are a little pricier—polyethylene glycol for constipation is about $12 to $36 for a one month supply depending on the dose.  For most of us, that’s still less than the typical pharmacy co-pay anyway, so what’s the big deal?

 

You’d be surprised how many families tell me, as they are leaving the office, that they can’t even afford to buy ibuprofen to give their children pain relief, or a thermometer, or a bulb syringe to suction a baby’s nose.  Children with Medicaid live at the very lowest income levels, so sometimes there really isn’t $5 or $10 for an OTC medicine.  Sometimes, maybe there is—maybe the household budget is out of line and maybe that $5 was spent on something you might judge wasteful or frivolous.  The problem for the kids is that whether their parents could budget differently or not, many will simply not get their medications unless Medicaid covers them. 

 

I wasn’t the only pediatrician who thought the change sounded like a problem.  Several of us made lists of the most commonly used OTC medications for which there is no good or inexpensive prescription substitute.  The list was submitted by an advocacy organization to our Medicaid agency, along with an explanation of our request to have an exception for these limited items.  A few days ago we got our answer—no.

 

We are told this is because of federal rebates for prescription drugs, not available for prescribed OTCs.  I understand how that would work in general, but not for everything.  1% hydrocortisone, for instance, can be used sparingly on the face for eczema (along with a thick moisturizer).  Stronger prescription steroids are not a great idea on the face for extended use.  So our next step up from the $5 OTC is… pimecrolimus or tacrolimus, priced online at $150 or more.  I don’t know what Medicaid pays and gets back as a rebate, but I’d be surprised if it isn’t a money loser by comparison to the $5 product.

 

One of my friends out of state suggested the decision may also be related to Medicaid’s possible switch to Pharmacy Benefit Managers.  If we go with third party, for-profit PBMs, they make their profit on our prescriptions and would likely object to any coverage of OTC meds.  I’ve asked around and have not been able to find out if PBMs are a factor.

 

Now I’m going to talk about poop, so if you are eating or squeamish, skip to the end.  Pediatricians are bad about poop talk in front of nonmedical people, even at parties.

 

Constipation is a common problem in babies and children—hard stools that not only hurt but can even tear the anus.  I’m talking blood.  Children are scared to poop afterwards—they expect pain and they hold back, resulting in more stool buildup and more pain the next time.  Eventually, this pain/holding cycle can lead to encopresis—large amounts of hard stool in the now dilated rectum with thinner, liquid stool leaking around it and out into the underwear.

 

Parents may think their children are not wiping or are having accidents.  The kids are embarrassed.  It smells bad.  They get called names.  Whenever I see “train tracks” in a child’s underwear, I know I need to do a rectal exam and see what’s up in there.  After diagnosing and explaining the problem, I outline a course of treatment in which we need to get the poop cleaned out and then keep it very soft, like pudding, for several months to avoid new tears and recurrent buildup.

 

Treatment is almost always successful.  OTC polyethylene glycol, PEG, (aka, Miralax is the best thing going for encopresis—both for the initial cleanout and for maintenance.  It isn’t absorbed into the body—it pulls water into the stool to soften it.  When I was in training, we had mineral oil—a chore to coax children to drink even with heavy flavoring, and there were cases of aspiration pneumonia when the oil got into their lungs.  Then we had lactulose—better accepted than mineral oil but not quite as effective as PEG and rarely with significant side effects, including obstruction of the bowel.  We had various fiber supplements, which helped inconsistently.  For cleanouts, we often had to resort to milk and molasses enemas.  Finally we started using PEG.  Kids will drink it, it works most of the time, and there are minimal side effects.  Life for constipated kids got much better. 

 

Now, depending on the dose needed, families may have to spend as much as $36 a month to keep treatment going.  Some will manage to do it, and others will not.  Say whatever you want about what the parents “should” do—if it doesn’t happen, it doesn’t happen, and the kid will be the one with a bleeding bottom.  Or in the ER for abdominal pain.  The number one cause of abdominal pain in children who visit the ER is constipation.  Untreated constipation can lead to urinary tract infections.  It can lead to CT scans and repeated radiation exposures in the ER.  Sometimes we have to admit children for cleanouts, with PEG dripped through a nasogastric tube.  I have had kids who got so constipated they vomited fecal material, but not since we’ve been using PEG.

 

I know some of you by now are asking why we are using medication for constipation at all.  Isn’t it a crutch?  Why not fix the diet, try juice, prunes, coconut oil, stop all the dairy products, or whatever your favorite home remedy is.  We do!  If you have been in my office with your child and we haven’t talked about diet, one of us has had memory loss.  The problem is sometimes the same as with the cost of the PEG—reality.  The children are not buying their own food.  And to be fair, some parents really do provide healthy food and the constipation remains.

 

Whatever your thoughts about how children ought to be eating, when they get painful constipation or encopresis, OTC PEG gets them out of misery.  And coverage for it is going away for many of our patients on October 1.

 

I don’t know if our Medicaid will track ER visits for constipation or complications like UTI to see if costs go up. Will we save money on medications only to spend extra elsewhere?  I doubt it will take very long for us to see problems in our practices.   I plan to let the state know if I do.

 

 I want the Medicaid money to stretch as far as it can, so that no one goes without needed care.  I appreciate the state’s creative efforts to work the budget.  This particular change is probably not going to be as bad as the limit on prescriptions for adults, which will land some in the hospital (what do we skip this month—the diabetes medicine, the blood pressure medicine, the heart rhythm medicine?), but it will cause some definite problems.  No matter what insurance system we have, even if we had single payer, we would have to think about this type of decision.  

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Filed under Children's Issues, Medicaid

Stop the Forced Drugging of Babies: Say No to SB 3


Last spring, in the midst of all the hullabaloo surrounding Alabama’s 2012 legislative session, a particularly dreadful health related bill was quietly set aside without much public knowledge.  I wanted to write about it but was asked not to—I had already made some folks angry in our statehouse over Medicaid funding, and I was told my involvement might interfere with others being able to help this bad bill go away. With some difficulty and uneasiness, I kept my mouth shut.  I would have felt awful if it had passed because of my big mouth!  Now I see the bill we thought was dead has risen again for 2013.   I’m going to tell you the whole tale before I get cold feet.

On the evening of April 17, 2012, I got an email from a reporter in Montgomery saying he was doing a story on “the Governor discontinuing to allow doctors to prescribe palivizumap [sic, palivizumab] for premature babies or any babies.” The reporter said there was a bill, SB 196, that would “keep [palivizumab] in the Medicaid formulary.”  He wanted to know my thoughts.

I was startled—palivizumab, brand name Synagis, is an injected antibody for high-risk babies to cut down risk of severe RSV (respiratory syncytial virus) infection.  RSV is the bane of winter for pediatricians and parents of young infants.  As this article explains, the virus is “ubiquitous”, so unless you live in a bubble you are going to catch it more than a few times in your life.  In very premature or certain other high risk babies, RSV can create havoc—wheezing, inability to breathe well enough to feed, and sometimes bad enough illness to require the ICU and a ventilator.  Sometimes it kills babies.  Palivizumab doesn’t totally prevent RSV and does NOT reduce the overall death rate, but it does cut down on the number of hospitalizations needed for these high-risk infants.  Notice the risk groups described in the article I linked to?  Not every premature infant will benefit.

I couldn’t imagine why Governor Bentley would try to ban palivizumab and thought I would have heard of something so drastic .  So I read the bill.  It was full of meaningless stuff about streamlining the Medicaid prior authorization for premature infants, implying that this was somehow especially difficult (it isn’t).  Big whoop-de-do.  Finally towards the end there was this line: Alabama Medicaid must “[e]nsure that all medicines that are prescribed to premature infants shall be given, at a minimum, in the dosage and duration as directed by the product’s Prescribing Information provided by the Food and Drug Administration.” The bill didn’t mention palivizumab, but as soon as I read that line, I knew.  This had to be a drug company bill.  I got goose-bumps.  To me, that’s even scarier than ALEC.  When drug companies start writing our state legislation, we are in big, big trouble.

I called some friends in Montgomery and had my suspicions confirmed that SB 196 was being called the “MedImmune bill”—MedImmune is the company that makes palivizumab.  If used according to the FDA guidelines applied to ALL infants born at less than 37 weeks gestation, this bill would have cost our state about $9 million extra a year with no clear additional benefit.  The FDA specifies it is to be used for prevention in high risk groups of pediatric patients (but gives no age limit or definition of high risk), for the duration of RSV season, usually 5 months in the Northern hemisphere.  Pediatricians and insurers, including Alabama Medicaid, use published research and guidelines to decide when to prescribe palivizumab and the number of doses to give for each group (5 for some, 3 for others), and SB 196 would have prevented us from practicing according to good evidence.

Here is what the bill really says, in effect:  “Medicaid must ensure that palivizumab is given to babies who shouldn’t get it at all, according to the best research, and that babies who should only get 3 doses are given 5 instead.”  Intentionally giving unneeded medication or more doses than are needed to babies is at best fraud and at worst malpractice.

You can read the palivizumab guidelines for Alabama Medicaid and from BCBS Alabama.  The same, and the same as in the AAP guidelines I already cited.  Notice the language of the bill tells Medicaid it must “ensure” medications are given at certain doses and durations when prescribed, not just that it must approve them if asked (which would be bad enough).  That implies it must require participating physicians to toe the MedImmune line.  I told the reporter this, although I requested he keep me anonymous, and explained to him that the Governor and Medicaid were not trying to stop doctors from using palivizumab appropriately.  They were doing the right thing, at political risk—we owe them gratitude for this particular stewardship of valuable resources and child health.

The more I thought about the situation, the more concerned I got.  I avoid talking to drug reps, because I don’t want to accidentally remember misinformation, but I decided to look up the contact info for our area MedImmune rep.  Michael Petrucelli responded to my email on April 18 very quickly that the best person to talk to was MedImmune’s Government Affairs Manager, Joel Batten, and gave me the phone number.

Feeling a bit like Mata Hari, I called Mr. Batten, who said he was expecting my call.  I confess I pretended to be confused over the legislation and did not let on that I was trying to dig up dirt.  I should probably do some sort of penance.  We had a long conversation.  He said he was keeping track of the bill “on a daily basis.”  I asked him if he knew where our legislators got the idea for it, and he said it had been a two year process.  He said one legislator had noticed infant mortality was 20 to 30% in some of his districts (???—some rural counties are indeed over 20 or 30 per 1000 in recent years, but nowhere in Alabama is it 20 to 30%) and “that’s where we came in.”  He said the senator he talked to was “surprised to learn that any medication wasn’t being given according to FDA guidelines”, but he wouldn’t tell me how the senator came by this information.  I’m not going to give that senator’s name, because I got it second-hand from Mr. Batten and can’t confirm the accuracy.  He said MedImmune was mainly concerned about the 34 week babies only getting 3 doses instead of 5.  Mr. Batten then said that “someone in the Governor’s office contacted someone in the House to say Governor Bentley is opposed to the bill” (that would have forced Medicaid to require inappropriate prescriptions of palivizumab).  He said “politically it could be a bad idea for the Governor to oppose it since it would benefit children.”  So you can see the depth of this drug company manager’s involvement with our legislative process!

By some unknown route, certain of our legislators have gotten the wrong idea that Alabama babies are dying because they aren’t getting enough doses of palivizumab.   I have my ideas about how this misinformation got to them, don’t you?  I sent the quotes from my conversation with Mr. Batten to the reporter.  I imagine he was unable to use them because of my request for anonymity—all I saw changed in his piece was the corrected spelling of palivizumab.  I certainly appreciate that he did protect his source when asked.  Not too long after this, I was told our legislators had been made aware of the true nature of this bill and that it was going to be quietly abandoned.   Now, here is SB 3, already pre-filed for the 2013 session.  Same bill, so far as I can tell.

Infant mortality in Alabama is certainly a travesty.  Death rates of over 20 per 1000 births in some counties put us in third world country territory.  But these sad numbers have nothing to do with palivizumab, which has never been proven to decrease the death rate anyway.  The deaths are primarily related to prematurity and lack of prenatal care.  Universal insurance, expansion of our rural labor and delivery capacity, and rural prenatal clinics in the state are critically needed.  Diverting millions of dollars and legislative effort on the wrong solution will not help matters.

Tying use of a medication legislatively to the FDA guidelines is extraordinarily worrisome.  The initial approval of new drugs is based on data submitted by the drug companies, with paid applications.  They are not required to have research done by an outside agency or to publish their data in peer-reviewed journals for these applications.  Many of the uses, doses and regimens of medications come about well after a drug has been originally approved.  It is usually not cost-effective for a company to pay for a new use or dosage of a drug to be approved, so with every year that passes, the FDA information becomes more and more outdated.

If I stuck with the FDA guidelines and could not prescribe “off label”, I would be unable to prescribe a good many necessary medicines for children, because the drug companies never even bothered to get approval for that age group.  Like other pediatricians, I rely on published studies and professional guidelines instead.  Very often, I need to use a far different dose for a medication than the FDA lists, either because of new evidence or because children metabolize some medications differently than adults and may need higher or lower doses for weight.  If I stuck with the FDA doses for penicillin or amoxicillin, I would be using the wrong doses for strep throat!  I would be going against the advice of the CDC and other infectious disease organizations.

For newborns, the dose of gentamicin (an antibiotic) is now significantly lower than the FDA approved pediatric dose per weight and is correctly given at 24 hr intervals instead of every 8 hours.  SB 3, because it applies to ALL drugs given to premature infants, would require Medicaid to be sure I overdosed a premature newborn with gentamicin and risked permanent kidney damage.  Don’t worry, I wouldn’t do it.  I’d have to commit civil disobedience.

Other than the cost, is there any drawback to prescribing palivizumab to babies who wouldn’t benefit?  Possibly, even though it appears to be generally a very safe medication.  The published rate of anaphylaxis (life-threatening allergic reaction) is extremely low, but when I have ordered palivizumab for preemies in my practice, it has come with its own epinephrine syringe, pre-loaded with the correct dose for that patient.  I find that puzzling—any doctor’s office should have epinephrine at the ready, and I don’t get a pre-dosed syringe with other medications.  Why is the pharmacy who supplies it so nervous?  For a new drug, there is a substantial period after approval when unexpected side effects may show up.  Even with acetaminophen (Tylenol), reports of possible links to asthma development took decades to emerge.  If we were to start using palivizumab for all preemies, would we start seeing more side effects?  I do not know, but as a parent and a doctor, I would not want to give a child ANY medication that was not necessary.

Alabama Medicaid funding is always on the edge these days.  If we are forced to waste millions of dollars on unnecessary medication, we may have to cut other important services.     As closely involved as MedImmune is in our legislative processes now, I would be surprised if they didn’t know our budget woes.  That MedImmune would jeopardize children’s health services and force babies to be given unneeded drugs in order to line their pockets astonishes me.  It should not, but it does.

I will admit I had some anxiety about my personal risk in writing about this.  I still do– MedImmune is a large, powerful company.  This is big money for them, and we may be a sort of test state for the legislation.  I have to imagine other drug companies are dreaming up how they can cash in on similar bills for other products.  I don’t know if there will be retaliation for what I’m telling you.  But the cost of knowing what they are up to and NOT speaking up is too high.  You need to know these things.  I have a duty to protect my patients.

If you are reading this from out of state, please take a few minutes to find out if similar bills are in the pipeline where you live.  If you are in Alabama, please write or call the Senate health committee members today, and let them know you are opposed to drug companies writing legislation for our state.  Tell them SB 3 could force doctors to commit malpractice on babies.  Tell them the pace of medical research and scientific advance is far too rapid to be set in stone, and explain to them why the FDA guidelines are not an appropriate standard.  They may truly not understand this, since it is a bit esoteric—you may not have known before either!  Now you do.  Tell them Medicaid and physicians need to be allowed to use the most up to date research, for the safety of children in our state, without the interference of drug company lobbyists.  Tell them to squash SB 3.

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Filed under Children's Issues, drug companies, Medicaid

I’m Voting Yes on September 18—and Yes in 2014


I hope you’ve read my posts earlier this week, explaining why even a short term cut or delay in Medicaid payments would cause years of damage to our healthcare system in Alabama.  If that hasn’t convinced you to vote Yes next Tuesday, here are a few more things to consider.

 

First of all, most people in the loop don’t believe our legislature will totally axe Medicaid or cut it so badly they might as well have—but even those folks aren’t quite certain. There are some Legislators who have actually said things like “Medicaid is going to be unaffordable soon anyway, so we might as well go ahead and end it.”  That’s right, they think we can get along with various free clinics already overloaded and understaffed, and I guess they are going to hastily build some free nursing homes, free hospitals, and free mental health centers.   Don’t know what they are smoking, but we’ll all probably want some if they get their way.

 

I have a lobbyist friend who has worked the hallways in Montgomery for years.  He told me he had never seen anything like it—he would go in a room and think he knew what the intentions were, then come back a half hour later and everything would have changed.  Every time I saw him last spring, he would shrug his shoulders and throw his hands up, because he had no idea what this group would end up with.

 

After three and a half months of time to make a realistic budget last spring, they couldn’t come to an agreement.  They waited until the last few hours to put a poorly thought-out plan together.  Now they have thrown this mess in our laps.  The same people who did that last spring are still with us, and I don’t think they are any more likely to agree on a good plan than before, although there’s always the possibility of something worse.   To borrow a friend’s words, “If you didn’t have the time to do it right the first time, how are you gonna have the time to do it over?”  If any of you think they were just hoping for 12 days at the end of September to pull out the real fix, you are also smoking something.

 

Most likely, they won’t kill Medicaid outright.  But whatever they do instead, it won’t likely get done in 12 days.  Once October 1 gets here, without the assurance of adequate funding for the year, Medicaid will have to operate on the stripped down budget, followed by probably a federal takeover but accompanied by the loss of participating doctors.  If we lose the doctors, it doesn’t matter how much we put back into Medicaid later.  The program will be dead.   Or, there’s what Dr. Don Williamson is calling the “drunken sailor” option—spend it all up, knowing it will run out by August, in hopes the state will figure out something else by then.  There are people quoting this and changing it to us “not feeling the pinch” until August, but that’s grossly misleading—a pinched budget and slap out of money are different, and Dr. Williamson appears to have been trying to get that point across by using the words “drunken sailor.” Hint, hint, he means it would only sound like a good idea if you’d taken leave of your faculties. 

 

Some of you have said, ok, that’s terrible, but we’re tired of this continual incompetence.  Let it happen, let there go ahead and be that suffering and even death.  It isn’t our fault, it’s theirs, and when people see their children and elderly suffer, they’ll know who to blame.  Not hardly.  First of all, it is very difficult for me to believe my friends are willing to risk that scenario—even a 1% risk—when there are innocent children involved.  Second, you are forgetting who some of our voters are.  People who deny global warming, deny evolution, and believe God takes sides in football games.  People who think doctors are happy to get paid in chickens.  People who believe there’s enough hidden money in the education budget and that teachers are paid too much or get too much in health insurance and retirement.  Will they look around at the resulting suffering and say “Oh, we get it—we should not elect people like this!”?  Hell, no, they’ll say “More Cowbell.”

 

So what are the funding options, if this amendment fails?  Despite the bewildering and conflicting statements from Governor Bentley over the summer, no one I know seriously thinks there is any chance we will get a tobacco tax or any other tax in the short term, and there is probably not time to bring in other new revenue.  We could try to run that program again this spring, with the same code—unless someone can demonstrate to me opinions have substantially changed, why is that worth leaping into the void with a no vote?  Our state legislators are not going to legalize marijuana or quit incarcerating non-violent offenders to save money in the prisons.  They are not going to quit prosecuting the death penalty, which is many times more expensive than life without parole.  They are not going to undo any of the corporate incentives they’ve handed out.

 

Governor Bentley wanted to cut into the education money before but couldn’t get the support— it is hard to tell if enough would have changed since then to open that back up, but that doesn’t mean he and his supporters won’t try—which means they would try to block other options, just like everyone did last spring with ideas not their own.  What about bingo?  Stan Pate has thrown that hat openly in the ring and says he’s putting his money on it.  The history of electronic gaming politics in our state is OMG complicated, and there is all sort of maneuvering around with the current law already.   I concede that in terms of predicting this Legislature, all bets are off.  But unless someone can give me a vote count on legislators who say they will support bringing in funds from gambling and a reason this is a stable platform to land on when we jump off the cliff, bet your play money and not my patients’ health insurance.

 

When you hear any of our legislators who are advocating a no vote next week, call them on the carpet and insist they not only propose a better solution but give you names of colleagues who will back their plan.  And for those who say they’ll pull a rabbit out of the hat, a new plan, on September 19 if the amendment fails, ask yourself why they won’t spit it out now.  If it’s something that would require such delicate finesse and strategizing that they can’t go public today, is it really that likely to succeed?

 

I’ve seen comments that people don’t trust this crowd.  The amendment sends money to the General Fund, and it doesn’t specifically earmark which program gets what—that’s in the budget itself, and only for 2013.  People are saying they could do anything they want to with the money—put it into prisons, for instance.  For this year, they’d have to re-do the main budget, but sure, I suppose that could happen.  Earmarking in the amendment would NOT help that problem, because the money going to various parts of government, including Medicaid, is only part of the overall budget.  If it were earmarked and they wanted to undo that, all the legislature would have to do is pass a cut to the rest of the Medicaid budget in the amount provided by the amendment.  I don’t trust them any more than you do, but the only way you could make certain money is used the way they say they will, with or without the amendment, is if the entire budget had to be passed by referendum.

 

You don’t believe them when they say they will pay the money back to the Alabama Trust Fund, because that isn’t in the amendment itself.  Fine, I don’t think they will either.  Remember that old rule of Dear Abby—don’t lend money to friends, just make a gift? I’m not thinking of this as a loan from the Trust Fund.  It’s a transfer.  That could cause problems down the road, but not as severe and hard to repair as cuts to Medicaid now. 

 

A politically savvy friend of mine told me I should mention constitutional reform, even though I haven’t heard much chatter about that lately on this particular amendment.  But just in case, I know there is a group who decided to vote No to every amendment, no matter what it was, to force our state to go ahead already and replace our awful Constitution.  My friend made an excellent point. He told me to ask you if you really want the people now in office, Americans United for Life, ALEC, and Karl Rove to rewrite our Constitution.  This is not the time.  We need to wait until people with good sense are in charge.

 

Some of you think a No vote will send a message.  Again, you are forgetting that you are a small group in the general voting Alabama public.  I’m working so hard to convince you because I know you do get out and vote and the turnout might be small, but that doesn’t mean a failed amendment will send the message you think it will.  Some of the Democratic legislators are pushing a No vote, even when they voted to let you have this referendum.  Why?  Because it is safe for them—they think they aren’t going to be blamed for the outcome of this budget.  They just don’t realize that even if they come back into majority in 2014, they will not be able to overcome the damage for years.  They will be blamed, and I’m here to do it.

 

I hope you don’t get to see the spin that would be put on a No vote.  It would be all about how people want less government and more cuts.  Don’t encourage them.

 

There are definitely times to send messages.  There’s no point, though, if there are so many reasons from the opposition for a no vote that your message will get drowned out.  A third party candidate in an election or a write-in can be a message, although I prefer to see it as a building process.  A public protest is a message, and we did that successfully last spring over the ultrasound bill.  Whenever possible, I would strenuously avoid the strategy of taking the lesser of two evils.  To do that, though, you have to have a viable alternative or a way to build momentum for the future.  In this case, there is no alternative we want on the table, and I’m just not going to count secret plans behind door #3.  We would get damage to hurt better legislators in 2014 and after, damage to children that can’t be undone, and a door left open to unpredictable wild schemes this spring.  I know you don’t want those things.

 

Some of you think I am assuming incompetence and that our legislators can’t pull it together if we help “focus” them with a no vote.  I don’t think they are incompetent, and I do want to say I believe there are genuinely good and smart people in both parties, just not enough of them.  What I think is that they are so much at cross-purposes that they are not going to be able to function effectively on this issue. The Republican party is divided into factions with different leaders and they are gearing up for their next primary season.  Neither side wants to support the opposition’s plan in case it makes the other side look good.   This is not a good recipe for compromise or long-term solutions, any more than it was last spring.   Each side will try to hold out the longest so the other will feel forced to cave in, and if they miscalculate so that Medicaid money falters… I’ve given you that scenario.  Now they want you to let them at it again, at our expense.  Make them find something else to play tug of war with, or poker or chicken, whatever it is they are playing. If they are sorry now they gave us a chance to end their game, too bad.

 

In all fairness, I need to tell you I could be biased.  Even though I’ve tried to remove myself from the partisan arena, I still have employment that depends on Alabama’s budget.  Most comes from the education budget, and some comes from the money generated by seeing patients that goes to my employer, mostly from Medicaid.  I’m salaried, and you know state employees haven’t gotten raises in years.  So no matter what gets cut, Medicaid or education, my job could go on the chopping block.  I’ve worked in other settings, including owning a solo practice, so I guess I’d figure it out, but I don’t know.  I prefer employment to running a business, because I want to spend all my work time on patient care and teaching, not ordering supplies and figuring out paychecks.  We’re close enough to Tennessee that if Alabama can’t employ me, I might go north.  Or heck, Vermont’s looking pretty good right now.  I could go cry on Bernie Sanders’ shoulder.

 

I’m going to close with a metaphor.  I’ve told you before our budget is like a person with bad anemia that needs a cash transfusion, not a Band-Aid.  This fall, it is even worse.  Our budget is like a person with bad anemia whom our legislators and Governor have placed teetering on the edge of a cliff.  They had some rope to save it from falling, but instead they’ve tossed it to us.  If we use that rope wisely, we’ll haul our ailing budget back from the edge.  It will still need a real transfusion soon, but if we let it fall based on promises of a net we can’t see, it could be too injured to save. Whose fault will it be if that happens?  Their  fault, for the anemia.  Their fault, for the teetering on the cliff’s edge.  Their fault, for not using the rope themselves.  Our fault, if we don’t use the rope now.

 

Case closed.  I’m voting Yes next week.  Yes to save our Medicaid program, Yes for the children in our state, Yes for my job.  I’ll send the rest of my message loud and clear in 2014, when I say Yes to candidates who can behave more responsibly.  Please say Yes with me.

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The Life of a Child is Worth More Than Proving a Point: Vote Yes on September 18


I’ve given you my reasons a Yes vote next Tuesday is essential to preserve the medical system in rural Alabama.  Today, I want to talk about the semi-urban and urban parts of our state, where the situation is slightly different.

Part of the primary care doctor shortage in our state is because of distribution—not enough doctors in rural areas.  There’s an access problem even in the cities, although you might not see it by just looking in the Yellow Pages.  Too many doctors in private practice don’t take Medicaid at all, and a larger group limits the percentage of patients with Medicaid they will accept.  Because of this, the doctors who do take Medicaid without restriction get inundated, especially when the economy worsens and children who used to have private insurance or All-Kids lose their coverage.   I have several families in my practice that saw other pediatricians for years but were kicked out as soon as they got Medicaid cards.  The rest of us then become overloaded and sometimes have to close temporarily to new patients—the lower payments from Medicaid make it hard to hire new doctors to fill the gaps.  What results is a jerky, uneven and shifting access hard to pin down from one month to the next.

This is already a problem right now and has been a problem for years.  If Medicaid suffers cuts to the very minimal budget the upcoming amendment would fund, what is an annoyance now will rapidly become a disaster.

Children entering the Medicaid Patient First program are assigned a primary care doctor—a pediatrician or a family medicine physician.  If offices near the family are closed to new patients, they might be assigned to someone in a nearby town instead—that has happened to several patients I see.  For families without reliable access to transportation, this is a serious hardship and can even prevent them from getting to our clinic instead of going to the ER.  Just being assigned isn’t enough—even though this isn’t supposed to happen, I’ve had families tell me they called their assigned doctor only to be told that doctor was full and couldn’t accept them.  Some have children in multiple practices around town because they couldn’t get all the children in one spot.  Imagine taking 3 children with the flu to 3 different doctors in a day. 

Doctors who are firmly committed to serving children in their community without regard to source of insurance definitely have more difficulty with their overheads.  If the cuts become too severe to keep the practice open at all, they close rather than limit their practices to the well-off.  Sometimes this is the choice of their employers, not the doctors themselves.  More doctors, especially younger ones just finishing training, are choosing to be contract employees of hospitals or other healthcare agencies rather than starting or buying into physician owned practices.  When the employing agency can’t make ends meet, the practices are shut down. That has happened already because of the delays last spring.

Every time we go through fits and starts with Medicaid payments, there’s another group of doctors who stays here but limits the percent of patients with Medicaid they’ll accept.  A third subset decides the rollercoaster practice finances are just too much.  They withdraw from Medicaid completely—it’s awfully hard if not impossible to get them back in later.  So you might as well just count them gone when it comes to access for almost half the children in our state

As Grant Allen, President of Alabama’s chapter of the American Academy of Pediatrics, told me last week when I asked him for a comment, “I may be able to keep my practice open on 55% privately insured patients—I may be able to pay my bills and keep food on the table.  But without payment for the 45% who have Medicaid, I will not be able to send my children to college.  With better paying work available in other states and the high demand for pediatricians, why would I stay in a place where I can’t meet the needs of my own family?”

Specialists are important in the larger cities.  We need experts in childhood diabetes, cancer, sickle cell anemia, ulcerative colitis, heart defects and seizures, to name a few.  Although in adult medicine, it seems we have over-done the specialist training and not brought enough doctors into primary care, in pediatrics we are lacking both.  Pediatric specialists are paid far less than their counterparts who see adults, so their work is hard.  They have trouble finding call coverage, even in cities.  We try to be considerate and not burn them out, but when we have a child in distress and really need them, we will call their cell phones wherever they are, on vacation or not—they are, like the rural doctors, never really off call.

Specialists don’t have the option of limiting their practices to privately insured patients for the most part, but those who can afford it are too ready to shut the doors to referrals when Medicaid is floundering.  The others, who can’t sustain a specialist practice on half the patient base, will leave, because they are always heavily in demand somewhere.  As I’ve said before, this will hurt not only children with Medicaid but all the state’s children.  And without such specialists, there will be no Children’s Hospitals.  Why Med-Flight your baby hours away when there’s no one there who can help her?

It’s hard to recruit new specialists.  Cities all over the country are trolling for them well before they get close to finishing their fellowships.  If we want expert medical care here, we have to do our part to keep those we already have.

I’m not going again into the long list of rippling effects on other parts of the medical system and the economy.  I just want you to understand that damage to the medical system is not fixable in the short term, even if funding is only briefly lost or delayed and then restored. 

What else can’t be undone?  Children with gaps in preventive care and chronic illness management can’t get what they need at the emergency room.  The ER does not do checkups or asthma rechecks.  With illnesses like asthma, the most important and life-saving treatment is not what we do when they have a bad flare—it is what we do to prevent those flares.  Unless we can see them and start a good preventive treatment plan, they can die from a bad episode, even with the school nurse frantically giving them breathing treatments.  They can die before the ambulance comes.  It happens, even now—it will happen more without enough doctors

Will you even know about these deaths if they happen?  Probably not, because they’d be mainly in rural areas and in poor families.  That’s why politicians feel secure saying we shouldn’t send out emails with “haunting stories.”  That’s why some of my progressive friends are tired of hearing me say the sky is falling, because they don’t realize some of it has already crumbled.  Well-off families can go out of state to get their care if they need to.  You might not have known about the incredible infant mortality rates I showed you yesterday in some of the poor counties—if not, you will not know if the rate of 27 in 1000 infant deaths I saw in one area, more than 3 times the national average, goes to 28 or 29.  But the families of those babies will know.

We can do many pretty amazing things these days in medicine—there are even surgeries on fetuses, months before birth.  There are limits, though.  We can’t undo death.  If just one child dies from a completely unnecessary gap in funding of the Medicaid program, that is too many.  One child’s life to prove a point?  No.

I’m voting Yes on September 18.  Yes, to the children in my practice, I will be here to take care of you as long as my employer has the building open and wants to keep me.  Yes, for the children in our state to have a heart doctor to see or a cancer doctor if they ever need it.   Yes, I will put children first, before my personal frustration with our legislators and Governor.  I’m voting Yes.  What about you?

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I’m Voting Yes on September 18—Here’s Why


Next week, Alabama voters will have an opportunity to do direct democracy.  We, the voters, not our elected representatives, will make the call.  Will we continue to operate essential state functions by using our state savings account, the Alabama Trust Fund?  Or will we fold and hand the decision back to folks who have already shown they can’t do it right?

 I’m voting Yes.  It was not an easy decision.  Like many of you, I am frustrated that our elected representatives could not do an effective job and that this has been thrown in our laps for political convenience, not because they really care what we think.  There are more responsible ways to manage our state budget, and it is tempting to think we could force a better choice by voting no.  I’ll get to my thoughts on why that isn’t likely in my last piece this week.

There’s another reason progressives give for their No, and this one chills me to the bone. Some people think that if we vote no and Montgomery fails to fix it, enough suffering will happen that voters will cry foul and either immediately force a funding change or vote this crowd out of office in 2014. I can’t go there, for both political and ethical reasons, because the suffering will fall too heavily on the voiceless, the children, who shouldn’t be held to account for the votes of their parents.  I know there are other groups served by Medicaid, including persons who are disabled or elderly, and that there are other functions of the state affected by the vote next week.  Right now, though, it’s hard for me to think about anything but the children.

For those who can grit their teeth and consider the nuclear No option, I’m wondering if this rests on the expectation that once funding is fully restored, whether after a few months in 2013 or later in 2014, we can quickly revive services we lost.  For medical care, that simply isn’t true.  A short lapse in adequate funding, including payment delays from “temporary cash flow” problems, could create a disaster that will take years if not decades to overcome.  If you think Obama got a raw deal inheriting the Bush economy, you need to think twice about your No.  A new group in 2014, no matter how good they are, could not possibly repair the damage in time to let voters notice a difference.  Don’t set your candidates up to fail.

Today, I’ll focus on rural medicine, and later this week I’ll address the somewhat different situation in semi-urban and urban areas.

The life of a rural physician is hard, not only for financial reasons.  In fact, rural life can just be hard, period, for people who are not accustomed to it.  I come from Tuscaloosa, and I did practice for about 1.5 years in rural North Carolina before my family returned to our home state.  It was lovely, and the people were marvelous, but Lord, have mercy.  There was no pediatric emergency room, no neonatologist, no pediatric specialist—we were it, at all hours. 

In small places, a doctor is really never off call.  My residency program had an arrangement with the only pediatrician in a small town nearby.  Once a month, a senior resident would drive down and stay in a hotel to cover the practice for the weekend.  The pediatrician had learned the only way he could use this time off to be with his family was to leave town completely and tell no one where he was going.  Otherwise, the patients would find him.  For parents with young children, this is wearing.  I left my daughter’s 5year old birthday party to help one unexpectedly busy Saturday when I was supposed to be off.  It might sound trivial, but she can’t get that day back, and as you can see I still feel bad about it.  I have tremendous admiration for doctors with enough commitment and character who stay and serve their patients.  They are truly heroes in my book.

That’s why the retention rate for doctors is far higher for those who grew up there and appreciate the wonderful parts so much they return after training.  It is higher when they have mentoring contact during training with established rural doctors.  And it is higher when there are other doctors already in the community, so that they can share call responsibilities and have a network of support.

We have in our state two initiatives that take these factors into account, the Rural Medical Scholars Program and the Rural Medical Program.  Simple loan repayment plans that help doctors afford training in exchange for a term of work in an underserved community have a degree of success, but far too many graduates leave the area when they’ve finished their obligation.  Alabama’s programs have a different approach—they identify potential doctors in rural areas years in advance and begin prepping them for long-term practice.  The results have been phenomenal.  I help teach many of the students and Family Practice residents who participate—it is an honor to contribute to the health of rural communities in my state.

These rural doctors are the first who will feel the effects of Medicaid payment cuts or delays, even if short term.  Sure, some will take out loans as they had to last spring during the payment delays, but if this is the second time in a year, maybe not.  They may just have to make the painful decision to relocate, perhaps even out of state.  They are talking about it already, because of the constant uncertainty.  Others close to retirement may decide the time to end their careers is at hand.  When these doctors leave—uproot their families, sell their homes, and get established in new locations (hard and stressful to do for doctors in primary care, where we are used to building long-term relationships with patients)—they will not turn around and come back upon the restoration of funding. 

How long would it take us to get other doctors into those places?   The work of recruiting through the Rural Medical Program begins at least 7 to 8 years in advance- at the end of college, followed by 4 years of medical school and 3 years of residency. There is even some contact with interested high school seniors.  Those close to finishing residency next summer will hesitate to go into practice in communities where the established doctors have just left the state, and they are making these decisions and interviewing for jobs right now.  The others, if they lose access to rural mentors during earlier parts of their training, are less likely to choose rural practice at all.  I’ve told you about the domino effect before—the doctors leave, the nurses and other medical employees have nowhere to work, and the hospitals without staff can’t help you.

I talked to Dr. Bill Coleman, director of Huntsville’s Rural Medicine Program, a few days ago.  He told me that interest in rural practice, partly because of all these years of effort, has been increasing—he said we were “on the cusp” of significantly expanding our rural physician infrastructure.  He is dismayed at the possibility we could lose the doctors serving as mentors, already at maximum capacity and serving at financial cost to themselves.  He has put his heart and soul into this work, now coming to fruition.  What a useless waste, for all that time and sweat to be undone in a fit of political posturing.

I’m voting Yes next Tuesday.  My Yes is not to the politicians who have failed us or to the irresponsible misuse of funds.  My Yes is to these honorable men and women who have put their lives into serving the rural poor and to the children in their care.  Will you join me?

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Filed under Alabama Fall 2012, Children's Issues