Category Archives: citizen responsibility

Cruelty or Care? The Choice is Yours


Well.  From the beginning, I have been telling you all that the so called “Patient Protection and Affordable Care Act” is neither protective nor affordable to patients.  We can keep the same PPACA abbreviation and call it what it is:  The Profiteering Protection and Affordable Cruelty Act.  Although I read the whole darn thing, I lack a background in law or politics.  As the specific corporate protections emerge from this convoluted mess, I have to say I didn’t foresee some of them.  I knew it would be bad, just not all the details of said badness.

 

The latest in our story of woe?  Insurers and some employers have discovered an irresistible loophole that allows skimpy policies covering only a few outpatient services.  The key phrase is “minimal essential coverage”, previously defined in federal law under the IRS Act of 1986.  I noticed some folks had conflated that term with “essential health benefits”, but EHB are mandated items on state Exchange policies starting in 2014.  No plan will be allowed to put lifetime or annual dollar limits on coverage, but outside of the Exchanges, other details of minimal essential coverage are minimally described.

 

I think I was fooled by the ACA’s opening paragraphs allowing insurers to temporarily restrict annual limits on essential health benefits until 2014.  I missed the absence of any requirement to offer those benefits at all, at any date, except on the Exchanges.  Insurer can’t restrict annual dollar amounts of those benefits if they are offered.  In a stunning twist on catastrophic coverage, it is possible for insurers to cover only the required preventive services and omit the catastrophes.  You can get your colonoscopy “free” if you have a non-grandfathered plan, but any follow-up surgery is entirely on you.     

 

The most minor effect is that employers who offer bare-bones policies and employees who get them are exempt from the ACA penalties.  I see some reference to this loophole only applying to large employers, but I don’t know how that was determined.  I don’t see it in the IRS code that I found, which includes as minimal essential coverage “B) any other plan or coverage offered in the small or large group market within a State.”—it may be elsewhere.  It seems to me it would apply to any size group policy offered outside of the Exchanges. If one of you can find me the relevant law making this only applicable to large employers, I’d be grateful.

 

The worst effect is that employees who have minimal essential coverage are not eligible for premium subsidies on the Exchanges, as far as I can tell.  This also seems to be the IRS’s interpretation: “A month is not a coverage month for an individual, and thus no premium tax credit is allowable for the individual’s coverage, if the individual is eligible for minimum essential coverage other than coverage offered in the individual market for that month.” If you can show me in the law itself or in administrative policy how it can be read otherwise, please post a link.  Maybe the IRS can do some creative adjusting.  Generally their creativity seems to apply only to corporations.

 

How many employers will use these plans to avoid penalties and thus apply this affordable cruelty to their employees in the process?  You know it will start with those who already pay poor wages.  As healthcare costs rise, don’t be surprised if you get this offer you can’t refuse in your own benefits package.   

 

Do I have grounds to put the word “cruelty” in place of “care” in the ACA?  The law is no longer new.  It is now part of our healthcare system.  I don’t know what else to call a system that not only allows but entrenches the abuses I see in my office.  Children who desperately need skilled child psychiatrists but whose insurance does not have a single child psychiatrist, skilled or unskilled, on the panel.  Children who don’t get the care they need because their parents delay over co-pays and deductibles.  Parents who work long, hard hours at low pay, producing goods and services we use without gratitude or notice, whose “non-emergency” pain goes untreated because of money.   Who try to smile at me in front of their kids, as if it doesn’t hurt, but cry when I take them in another room.  I refuse to make excuses for this awfulness or play around with euphemisms.  Cruelty, brutality, callousness—many words apply, and none of them is “care.”

 

I can hear the defensive talk already, from people who won’t be able to believe their beloved party would intentionally expose us to this treatment.  It was an oversight, right?  The law is complicated.  We missed this problem, and they did too.  We have a bumbling, well-meaning but hapless government, like a dog that’s so ugly it’s almost cute.  Don’t buy it.  Somebody had better ask what the President and insurers knew and when they knew it.  Remember the industry was mighty cozy with our Executive Branch during construction of the law.  Is it just now that this minimalist option has been discovered?  Or is this a convenient time for discovery, well into the second term?  Will we allow the President to wash his hands of the disaster and pretend he never imagined anyone would behave so?

 

What will it be, folks?  Do you want to keep trying to pass legislation to close loopholes, even though the insurers are always one step ahead?  How long will you continue to support and vote for people who cater to them?  When will you finally say “don’t let the door hit your butt on the way out”—and insist on real insurance and real representation?

 

Improved, expanded Medicare for All is a simple, achievable, affordable, practical next step.  It doesn’t require revolution, utopia or socialism.  Even conservatives can embrace it.  We have the structure in place.  We are only waiting for you.  Will you speak up?

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Filed under citizen responsibility, Exchanges, Healthcare reform

Alabama HB 360: It’s Not About the Truth


Long before I entered medical school, physicians in the US were under no professional obligation to be truthful to patients.  They prescribed placebos, kept secrets from the dying, and made decisions without expecting or wanting input from patients.  The rules have changed—no more Dr. God, and thank goodness for that!

 

There is still a power imbalance though.  We have the almighty power of the prescription, the referral, and the scalpel.  Even more, we have the power of knowledge and experience our patients usually don’t possess.  That power carries enormous responsibility.  No matter how much my non-medical parents and patients read, they are in my exam room because they require my honest, best assessment of their health and my honest, best advice.

 

It is, therefore, absolutely critical that physicians attempt to avoid using knowledge manipulatively.

 

A legislator’s job is different.  Even the most sincere elected leader must construct convincing reasons for action, depending on what will resonate with voters.  Sometimes it’s the only way to get good policy through.  Like it or not, that’s politics!  HB 360 is an attempt to have physicians play politics, in the exam room, by giving women carefully selected information about abortion and leaving out what our legislators don’t like.

 

Here’s what they want women to be told, before consenting to abortion:

 

“Your chances of getting breast cancer are affected by your pregnancy history. If you have carried a pregnancy to term as a young woman, you may be less likely to get breast cancer in the future. However, you do not get the same protective effect if your pregnancy is ended by an abortion. The risk may be higher if your first pregnancy is aborted”; “If you have a family history of breast cancer or clinical findings of breast disease, you should seek medical advice from your physician before deciding whether to remain pregnant or have an abortion. It is always important to tell your doctor about your complete pregnancy history”; “Abortion terminates the life of a whole, separate, unique, living human being”; and “There are many public and private agencies willing and able to help you to carry your child to term, and to assist you and your child after your child is born, whether you choose to keep your child or place him or her for adoption. The State of Alabama strongly urges you to contact those agencies before making a final decision about abortion. The law requires that your physician or his or her agent give you the opportunity to call agencies like these before you undergo an abortion.”

 

The bill is full of problems, everything from calling a fetus a child to determining that “psychological” emergencies and suicide risks are not real.  It prohibits a woman from being coerced into abortion and in the next breath urges her to let pro-birth “counseling centers” coerce her into giving birth.  Of all the possible risks to disclose, it goes for the jugular—a woman’s fear of breast cancer—and repeats false information as well.  If the goal is to present risks, benefits and alternatives in an honest and non-coercive manner, HB 360 is unacceptable.

 

Here is a more honest version—bear in mind that I’m not an obstetrician and am not proposing this as legislation.  It is by no means comprehensive, and it has some editorializing at the end. You may have seen infection risks of 1 in 10 on some pro-birth sites—however, this is not the risk of upper tract infection and mainly reflects infections already present prior to the procedure.  There are also much higher quotes of “retained products of conception” in some studies—this may reflect excessive findings on ultrasound of uncertain clinical significance.  The correct way to get a standardized consent/ education form, if we need one, is to ask the Department of Public Health to create or select a reputable, updated version they can distribute to physicians.  But here goes:

 

“You are pregnant with an embryo or fetus which is incapable of living outside of your body.  The United States of America recognizes your right to a safe, legal termination of this pregnancy or a decision to continue the pregnancy and give birth to a baby.

 

The risk of breast cancer if you have an abortion is the same as if you never have a child.  If you are under twenty, giving birth can lower your risk of breast cancer.  If you are over thirty, giving birth for the first time can increase it.

 

Some of the health risks of pregnancy include intractable vomiting (0.5 to 2%), high blood pressure (2 to 3%), diabetes or impaired glucose regulation (3 to 10%), severe bleeding from placental abruption (0.4 to 1%),  rupture of your uterus (0.07%), and severe tears of your vagina and/or rectum (0.25%).

 

Risks of abortion include perforation of the uterus (0.009%), heavy bleeding (0.007%), infection (0.5%), a cervical tear (0.01%) and incomplete abortion (0.03%).

 

You have a risk of death from abortion of about 0.6 in 100,000.  The average risk of death from giving birth in the United States ranges from 12 to 15 in 100,000.

 

The average risk of major depression and other mental health problems after abortion is the same as for women in the general population.

 

If you are addicted to illegal substances, there is a chance you will go to prison if you decide to give birth.

 

If you continue your pregnancy, you may be instructed by your physician to reduce work hours or take bed rest, causing you to miss time from work.  The average risk of a cesarean section is about 32%.

 

If you give birth and decide to keep your baby, you should know that the average parent has lower income and higher expenses than a childless person.

 

There are families in our state who want to have children and cannot give birth to their own.  You may decide to take the physical, emotional and financial risks of giving birth out of compassion for one of those families.  However, you should be aware that the bonds between a parent and child are not easily disrupted and that you may experience chronic grief.  You have no duty to provide a child for another person.

 

Most women who have abortions already have children whose needs they must consider.  Others want to have children later, when they can plan ahead to take good care of them.  Abortion does not decrease your chance of being able to have healthy children later.

 

Being a parent is one of the most meaningful, joyful, difficult and life-changing experiences a human can have.  It requires great dedication, responsibility, self-sacrifice, and effort.  People who are willing to take the work of parenting seriously provide a critical service to humanity.  It is not a task to be entered into lightly.

 

If you live in Alabama, do not keep up with what your legislators are doing in Montgomery, and say nothing to change their minds, your risk of losing access to honest, safe, and legal reproductive care is high.”

 

We’ve asked our legislators not to play doctor—now we need to remind them not to make doctors play politician.  Y’all do your job, and let us do ours.

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Filed under Alabama Legislative Session 2013, citizen responsibility, women's healthcare

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.

4 Comments

Filed under Children's Issues, drug companies, Medicaid

Settin’ the Woods on Fire: What’s Your Personal Advocacy Plan?


It’s November 8—the results are in, and once you’ve finished celebrating or grieving or both, we should talk about what to do next.  Please don’t take too long!  Promoting your chosen candidate is actually NOT the most important part of politics—what counts is the pressure you apply to those in office.  We can’t vote and then turn on reality TV for 3 years.  We need a plan.

 

Ever feel like you have advocacy ADHD?  New issues pop up all the time and suddenly require massive attention.  Of course, we all have to be prepared to move quickly and adjust our plans in the face of emergency.  On the other hand, having an intentional agenda, with room for last minute flexibility, might be a good thing.  Would you like to try this?  I’d love to hear what you come up with, and why.

 

It’s ever so easy to get stretched thin.  One opportunity after another presents itself that we just can’t bear to turn down.  This Monday evening, for instance, I was fortunate to be part of a committee meeting after work for a “Member in Discernment” at my church, who is entering the process to become ordained.  He picked me partly because he wanted an activist/ unconventional perspective, so he’d better watch out, right?  Tuesday night I had a meeting at our local NAMI (National Alliance on Mental Illness), Wednesday was ballroom dancing with my sweetie, and Thursday, tonight, I’m speaking for the local PFLAG group.  A wonderful but jam-packed week, one of 52 others that probably look very similar to yours.

 

How do you, personally, decide what projects to take on?  My goal has been to ask myself if a project is 1)important/ necessary;  2) something I REALLY care about 3) possible, even if it is both a long-shot and far in the future;  and  4) my personal contribution is filling a hole that would possibly not be filled without me.  I think I’ve mostly fallen down on #4, because if it is important and cranks my tractor, I want to jump on even if there are plenty of others who could probably do it better.

 

Of course, advocacy isn’t the only community work needed—there are all sorts of tasks that are more of a service or maintenance nature.  Why do we need to include advocacy as a special category?  By definition, advocacy is “the act of pleading or arguing in favor of something, such as a cause, idea, or policy; active support.” To me, it means participating in intentional, directional, strategic changing of a situation currently unacceptable.  I believe all of us ought to pick one or two areas of advocacy, unless we are either perfectly satisfied with the way all things are now, and then come together in groups to accomplish our goals.

 

I made a list, a really long list, of things I think ought to and could be changed, even if it would be a long shot or take a long time.  I meditated on that list and slept on it.  For quite a few of the items I really care about, I don’t have personal skills or means to tackle, but fortunately there are others who do—in that case, I can probably help the best just by saying I agree when the time comes and showing up for their rallies.  The rest gradually arranged themselves into a range of short, medium and long term projects, all centered around one of two things—access to healthcare and quality healthcare.

 

I’m going to stick with the push for Medicare for All, no matter how long it takes.  If we get that even one year earlier than we would when we run out of other alternatives, that’s 45,000 people who didn’t have to die early.  In the short term, I will do my best to advocate for secure and sufficient funding of Medicaid and all children’s healthcare services, the Medicaid Expansion, and the best possible construction of Alabama’s Exchanges (all for the purpose of improving access to care), at the same time as I make sure you know our fractured insurance system isn’t solving the problem.   I’m going to keep working with my NAMI friends (the National Alliance on Mental Illness) at the state and local level for improved access to good mental healthcare.  I’m going to stand with the other women of this state to insist on access to reproductive health services.

 

Of course access to insurance is not enough to provide access to care.  Having an insurance card is meaningless not only if you can’t afford to use that card but also if there is no doorway of care open to you.  We need to convince our physicians to accept all forms of insurance, especially the public and military versions, to strengthen the networks of care in our rural areas, and to allow allied health professionals such as nurse practitioners, nurse midwives, and physical therapists to practice independently.  They are trained to do this, and the evidence is strong that they can do so effectively.   I tried last year to convince some groups of organized medicine in my state, but the turf battles rage on.  This year I’m planning to go straight to the public, in hopes that this will encourage other physicians in agreement to speak out.  Our outdated state licensing is certainly possible to change in the near term, but only if we can show legislators the public is strongly behind them.

 

Another kind of access barrier is trickier and could persist even with good insurance and sufficient provider distribution—the barrier of social attitudes that close our minds towards both persons and evidence.  In this category, I’d place persistent public misunderstanding of mental illness and addiction, which creates shame in those so affected and makes it less likely they will seek help.  Such stigma also means a higher likelihood patients will receive ineffective treatment or be jailed, instead of having access to the most current, evidence-based services.  Attitudes towards sexual orientation do the same thing, if either a patient or physician avoids discussing sexual health questions.  Even marriage rights fall into this category.  Because same sex couples are unable to share legal parenthood of their children in our state, one parent must have written permission from the other to obtain medical care for the children.  I believe the opportunity to repeal DOMA may be near.  How do we advocate for social change?  A lot can happen with simple willingness to share our understanding openly in conversation, to stand in public solidarity with those who are marginalized, and to object when we hear or see hurtful language and actions.

 

In terms of healthcare quality, I’m going to continue advocating that we limit legislation of specific medical treatments, because the science changes too rapidly for us to be legally bound to a given regimen of care.  I’m going to argue against all manner of pay for performance measures, because the evidence shows they create more problems than they solve.  I’m going to let you know about specific issues in healthcare quality as they arise, and uncover biases when I can.  For instance, drug and device company money influence far too many of our published studies and guidelines.  Sadly, physician and researcher biases driven by personal opinion or greed rather than science also turn up, as in the case of circumcision, and those of us who know it are obligated to say so.   I will continue to speak for evidence-based practice with my students and within my professional organizations.

 

Once you know what you want to do, the next step is finding your advocacy partners.  One of my goals in this blog is to attract interested friends to help me get a particular piece of the work accomplished.  For something as big as stable funding sources for Medicaid, we will need a substantial coalition.  I proposed one idea so far but haven’t gotten much feedback (thanks to the few who did respond), so maybe it was a dud.  I need to know if anyone is able and willing to help me with a plan.  Do any of you want to volunteer to form a study group to explore other options and bring them back for discussion?  We can’t wait until February to start, and I sure can’t do it by myself.

 

What’s on your list?  Do you have a theme?  Have I left out any pressing aspect of healthcare access and quality you think I need to address?  Included too many?  Please chime in.

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Filed under citizen responsibility, Healthcare reform, specific advocacy ideas

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