No one said this would be easy.

Really interesting article over on slate.com recently that discusses how 3rd year of med school is the real beginning of a subtle but profound transition between being an idealistic and empathetic med student to being jaded and bitter. Finishing up my 3rd year of med school, I can completely empathize with this (no irony intended).

Dr. Danielle Ofri writes “I discovered that the third year of medical school is when these high-minded traits begin to erode, an observation that won’t come as a surprise to anyone who’s been through traditional medical education…It’s no wonder that the third year of medical school figures prominently in studies that document the decline of empathy and moral reasoning in medical trainees.”

I definitely have experienced these feelings from time to time. Sometimes it’s fairly subtle, for example, thinking a patient in pain is being kind of whiny to keep getting Dilaudid. Being in the hospital seems to make everyone, doctors and patients, kind of whacked out after awhile.

On the worst days, I think this whole medicine thing is a sham and the most therapeutic action to take is to create social conditions that make it easier for people to realize their deep connection with not only all of humanity, but with all of existence. It’s more important now than it ever has been for people to step up and provide guidance for the field of medicine – that unique combo of art and medicine – to grow, or we’ll continue to stagnate under the weight of profiteering, bureaucracy, and the delusion that what we’re doing is 100% pure evidence-based science. 

It’s not. 

Overall, the year has definitely not left me feeling hopeless. If anything, it’s provided first-hand insight into the problems we’re facing, and for that, it’s been invaluable. It’s provided opportunity for personal reflection, even though I haven’t always taken advantage of it. 

I’ve observed that the people who really seem to struggle are those who have difficulty with humility. I don’t think it’s entirely their fault – they’re selected to attend medical school because they’ve achieved highly from an academic standpoint (though whether we’re choosing the “right” type of person for medicine is a separate but related topic). They’re rewarded for performing better than their medical school peers. It hit me recently how ridiculous a message it sends to assign class rank to medical students on one hand while telling them “you need to learn how to work in a team!” on the other – look, it’s not so easy to switch those mindsets at the drop of a hat. yet it is necessary to have some type of criteria to determine how to select candidates for residencies. I don’t blame those individuals for being hyper-competitive – it’s an impulse I certainly feel at times – but I do think we need to seriously re-evaluate how we’re training doctors. I’m definitely excited about reading Dr. Ofri’s book. The Mindful Medical Student by Dr. Jeremy Spiegel is a book that seemed to go under the radar of most reading lists, but I found it very helpful before I started med school, and I’d like to read it again after third year.

But I don’t have the time – I’m too busy cramming scientific facts for the next multiple-choice test.

 

Grand Frowns at the VA

I’ve been on my Internal Medicine rotation at the local Veterans Association (VA) hospital. I’ve really enjoyed it – the Veterans are almost all super appreciative, friendly people and make great patients to learn from. They’re used to medical students and mostly don’t mind our repetitive and lengthy interviews and exams. In fact, many seem to enjoy being part of future doctors’ educations and often wish me good luck after I see them. Maybe it’s the culture of service and commitment to their country that the Veterans really seem to take to heart (despite the shady deeds of the US military in the name of “protecting” Americans but in reality pushing imperialism and exploiting other less powerful countries – but that’s way beyond the scope of this post!) One Veteran told me the other day, “The VA is a great place to learn! You’re going to see some really sick patients!” As morbid as that sounds, it’s true. The patients at the VA seem to have a disproportionate amount of medical complications and coexisting conditions that are generally highly predominant in the working class (and, well, all of the developed world)– COPD, heart failure, obesity, diabetes, often all at the same time. I’ve found them to be extremely trusting of and grateful to physicians and even medical students. Like many patients with complicated medical conditions affecting multiple organs, they can be shuffled from specialist to specialist. They sometimes will start explaining a medical problem only to be told by that particular doctor that they are there to manage only a certain organ system. I’ve seen them often leave appearing pretty frustrated and confused.

I feel compassion for all patients I see, but I find myself feeling extra protective towards the VA patients. They require much care and coordination and it’s no surprise the VA is an expensive system. It highlights the importance of a large, motivated, talented primary care workforce and having a single competent person overseeing the care and referral to specialists. Yet, our American healthcare system rewards specialists with more money and prestige.

Often, I’ve heard residents and fellows talk about how inefficient the VA is and how much better private hospitals are. I’m not exactly sure what experience they have with those hospitals as the other training hospital for the program is a large public tertiary care center, taking on a ton of disproportionately uninsured patients. If you qualify for the VA and choose to use this service (as I understand it, Veterans can also choose to be privately insured through a job or otherwise), you have to use only VA facilities and doctors unless the technology isn’t available at the VA, in which case they will refer you to a place that has the appropriate services. Some of the patients end up traveling hours to get to the clinic. I can’t help but think this problem would be solved if the veterans’ care extended to any hospital or doctor. If we had single payer, national health insurance.

This past Friday, the day I leave for the Students for a National Health Program summit, we had a Grand Rounds presentation from a senior staff attending about the ACA and Medicaid in Virginia! For the most part, the presentation was mostly numbers about how coverage in Virginia would change if Medicaid expansion was implemented and the state of Medicaid in Virginia. It seemed pretty nonpartisan until he began to use buzz words like “large government program” and it started to become clearer which team he was batting for. When he mentioned Delegate John O’Bannon’s position on the panel involved in deciding whether and under what conditions Medicaid expansion will occur in Virginia, it seemed pretty apparent. He said that Virginia was set to become one of the states that did not accept Medicaid expansion until “the Left” colluded to put the transportation bill in jeopardy. He did not mention how an independent economic study determined that Medicaid expansion would cost less than not expanding it, which I’ve written about in previous posts. He also didn’t mention the terms of the Medicaid expansion. I was feeling pretty irritated. I’m in a pretty vulnerable position though, since I’m interested in going into general Internal Medicine, it’s to my advantage to not do anything that would negatively stand out and might result in a bad evaluation. No one wants to hear a med student get ornery during Grand Rounds when people by and large just want to get on with their day.

But the temptation was too much. After the presentation, I couldn’t pass up the opportunity to ask a single question which I attempted to frame as diplomatically and non-confrontationally as possible. “One of the criticisms I’ve heard about Medicare and Medicaid is that as soon as they are contracted out to private insurance companies, they become more expensive. What’s going to happen with the Virginia Medicaid expansion – will it get contracted to private companies and will it become more costly then too?” He replied that whether it was more expensive was a matter of some debate (it’s not), and that the commission was trying to make certain that every person’s Medicaid was contracted out to private insurance, and that would be a very good thing. He did not elaborate why, and I didn’t think it wise to keep pressing him.

a sampling of privatized Medicare logos

 A few minutes later, as I was reviewing charts for the morning, one of the attendings in the presenter’s own department (and an attending that I had worked with!) came to the exam room I was working in and told me he thought the presenter should have included some information about Medicare Advantage (the version of Medicare that’s contracted to private insurance companies) to the presentation. He said it was proven that Medicare Advantage cost more than traditional Medicare and didn’t have any proven better outcomes, which is true. He then gestured around and said “For all the imperfections of a single payer system, it’s what we need.” Comrades! Sometimes taking a tiny risk and speaking out helps people reach out to you. I just wish he had given the Grand Rounds.

It bears mentioning how harmful it is to present biased and only partially accurate but incomplete information to groups of physicians. A senior attending is a trusted source of material, and doctors are often too busy to do primary research about every issue. Grand Rounds exists to educate with facts, not half-truths. It was an informative and well-researched presentation in many ways that happened to conveniently neglect some key data.

 When reading info about the superiority of single payer over existing systems, I am often struck by how obvious of a solution it becomes from all angles – reduction in bureaucracy, centralization of records, marketing power to bring down pharmaceutical and medical device costs, thus providing incentive for pharmaceutical companies to develop truly innovative drugs instead of  “me-too” substitutions that are guaranteed to make money, just to name a few. And when one simply steps back, how much sense could it ever make to rely on companies whose main goal is to produce profit for shareholders to reduce healthcare costs? It’s a fundamental conflict of interest. Yet, in the face of presentations like today which I’m sure are a common occurrence, physicians are given biased views and told about the bloated, complicated Medicaid system that covers millions of US citizens and costs taxpayers billions of dollars (with a special emphasis on the low provider reimbursement rates) without explaining how much more inefficient and wasteful private insurance is.

We have much work ahead of us and much misinformation to put to rest, but every day the road becomes a little clearer and the facts speak more loudly for themselves.

Students for a National Health Program Summit

Over the past few months, I’ve been helping to organize the 2nd annual Students for a National Health Program summit – a conference designed to help health professions students learn more about how to advocate for single payer national health insurance. It’s getting down to the wire – the conference is this Saturday, May 11 at Physicians for a National Health Program headquarters in Chicago. It’s been a pretty sizable amount of work – I feel like I’m sending a million emails a day – but it’s shaping up to be a great conference. This is the first time I’ve helped to organize something like this, and I’ve actually kind of enjoyed it, despite never considering myself someone who was particularly good at logistics or details. I’ve been incredibly impressed with the other organizers who are all busy med students too. It seems like this has run WAY more smoothly than I anticipated, and it’s no doubt because the other students are doing it because they believe strongly in the cause (not to mention they’re super smart and talented!). I’ve noticed that when counting on people who are volunteering their time, you can unfortunately expect about a third to half of them to flake on some tasks, even if they specifically said they would do them. It just seems to be the nature of the beast. These guys have not only NOT done that, but they’ve been incredibly proactive in volunteering to take on extra work during our organizing conference calls. It’s made me work even harder to ensure we provide a good conference for the other attendees.

One of the things I’m really excited about (which was also true last year when I attended the first conference) is that the group chose to invite other health professions students, and I was able to meet with people in different training programs – nursing, public health, etc. We have several other professions represented this year too, including some premeds, which is great! I think interacting with other health professionals is something that my school has been a bit weak on so far. We’re all working towards the same goal and we’re all in the same system, yet sometimes we don’t even understand what the other’s role is.

We’re going to start the day with an introduction to single payer and a presentation about the role of advocacy that health professionals have played in the past, and what we can do in the future.Then we’re going to talk about HR 676, the House single-payer bill. From there, we’re giving students options of attending one of two breakout sessions which are designed to be more interactive. I’m helping with two of them. The first is a co-presentation with Paul Demos, a former drug rep who is now a medical student. We’re giving a presentation about – my favorite topic – the role of privatization and for-profit corporations in health care! And who better to speak about this than someone who has been in the trenches and really knows what it’s like as a former drug rep. The next presentation that I’m giving is really going to be an interactive session about communication/conversation skills and responding to difficult questions about single payer. I was feeling a bit uncomfortable giving this, to be honest! I was wondering if I even have these skills – sometimes I feel after walking away from someone who disagrees with me we’ve both just annoyed the other. I kind of tried to get out of this presentation or at least get someone to help, but then I realized that it’s completely fine to admit that effective communication skills are a constant learning process. Expecting to always be perfectly poised, articulate, and calm when speaking with someone about something you feel passionate about is unrealistic. The healthcare system is complicated (to say the least), and understanding the economics behind it is something I feel like I’m only beginning to grasp. Instead of giving a presentation, I tried to come up with a framework where we could all learn from each other. There is no doubt that some of the people attending will be much better at this than me, naturally, and I hope that we’ll be able to learn from them. So I designed a couple of scenarios for people to act out. I hope this will be a good experience for everyone, but we shall see! Other presentations/breakout sessions focus on transitioning from sympathizer to activist, a workshop on writing letters to the editor/speaking out, healthcare economics, and more! I have really high hopes for the conference and I hope that I can learn to better convey my optimism that single payer is the most realistic, humane goal for a better future.

On serving the Underserved as an incredibly privileged person

Prior to starting medical school, I was a research assistant in a pilot program, a multi-disciplinary assessment of community reintegration in people diagnosed with HIV and recently released from incarceration. My job was to conduct detailed psychological interviews and perform neuropsychological testing in order to establish history of trauma, previous psychiatric and psychological treatment, and any cognitive challenges patients faced. I had expected the project to be challenging, but I had not anticipated the depth of my own emotional reaction. This project would set in motion my understanding and subsequent commitment to social justice. It would highlight the necessity of responding to suffering, which includes not only caring for individuals but also combating systemic barriers to health and human flourishing.

My patients felt they had paid their debt to society, but society would not give them a chance. Most had limited education and job training, and during the recession, it was difficult enough to find a new job without a conviction. Prior to incarceration, many had suffered mental illness, including substance addiction and depression. All of them now faced complicated HIV medication regimens and doctors’ appointments despite frequently unstable housing, transportation, and employment status. After release, many met criteria for devastating post-traumatic stress disorder, some resulting from horrifying events occurring while under the “care” of the State. Almost all were from poor backgrounds and the majority were people of color. During the interviews, many expressed themes of detachment, a sense of alienation from society starting in childhood. Some intimated a sense that outcomes many Americans view as basic rights or inevitabilities were never options for them, like freedom from an abuser, a safe home and school environment, or deciding what to be when they grew up.   

How do we interpret and respond to another person’s experience outside of our own perspective? When we consider the background of ourselves and our peers, perhaps even the process of becoming a health professional could be a hindrance to meeting the needs of the Underserved. Consider: to even become a doctor almost demands that we are from a background where adults took time to read to us, encouraged our intellectual development, loved us, and met our needs. Without emotional and financial support and some degree of stability, it would be impossible to achieve the sustained academic excellence required to even gain acceptance to medical school. We are told that we are here because of merit, when the reality is far more complicated.

We are taught to feel negatively toward those who have committed crimes, yet most of us do not understand the complex criminal justice system, including how we decide what a “crime” is and is not, how we determine its punishment, and how incarceration affects not only the individual’s psychological and physical health, but that of their families, their friends, and our entire society. People don’t commit crimes in isolation of social influences. The medically Underserved do not exist in a vacuum of poor decisions and bad luck.

What if our way of life has necessitated an underclass, and all attempts to attend to their medical needs are stopgap measures?  

For me, the process of dedication to attending to the needs of the Underserved has been continuous and ongoing, requiring learning and re-learning, questioning, research, and learning about the history of my own privilege. My work with individuals has informed understanding of the effects of a profit-oriented medical system that is incentivized to treat disease instead of promote health. This is in the context of a short-sighted economic and political environment that values the accumulation of capital and wealth to such an extent that even its pursuit is an act of violence against the poor.

On an immediate level, meeting needs of the Underserved involves helping individual patients develop self-efficacy while also helping people learn to meet challenges as a community. These are skills that must be promoted in medical and other health professional schools; it is much easier to tell patients what they need to do than it is to figure out why they aren’t already doing it, especially in a time where patients will often come in having googled symptoms, diagnoses, and treatment options. As healthcare professionals, we must unravel the previous paternalistic view of physician-as-expert. We are partners in promotion of the health of our patient, who visit us in recognition of the training we have undergone to provide medical knowledge and perform procedures as safely as possible, free from the influence of those who simply view the provision of healthcare as a commodity to be bought and sold.

Some illnesses and treatments are so well-established there is an actual algorithm for what medications to prescribe. Diagnosing and treating high blood pressure comes to mind. While there is still a need for a careful history and physical exam to rule out other causes, many people could read the JNC-7 report and figure out what blood pressure medication they should be taking. Some have criticized that our move to evidence-based medicine instead of intuition, prior practice,  and “expert”-based medicine has taken the human element out of care. A recent study provided some evidence that artificial intelligence can apply treatment rules better than doctors and with better outcomes! What will be the role of medicine as these technologies are further developed? Will there even be one? I think there will be; human behavior is much more complicated than knowing what one should do and simply doing it. I am interested in how contributions from the fields of positive psychology (the study of human flourishing) and behavioral economics (the study of how people make choices) may inform the practice of medicine.  The human element of the patient-physician relationship provides room for encouragement, some accountability and motivation, and identifying other barriers the patient may not have considered. To be a good physician requires training developing these skills. Yet it is not the primary focus of current medical training, which overemphasizes memorization of scientific facts. Knowing the specific enzymes and substrates in the cholesterol synthesis pathway may help us understand how cholesterol-lowering medications work, but choosing a medication for a particular patient is often based less on how it works, but more on how well it works and its side-effect profile.

On a broader level, helping the Underserved demands recognition that all people’s struggles are related. It requires the development of an empathic mindset starting in childhood.Maybe it means that terms like “Underserved” are themselves divisive and kind of perpetuate themselves without solving the problem.

When it becomes especially challenging and seems overwhelming to address all injustices, it might be helpful to try doing something like a silent prayer: May we be able to recognize the common vulnerability to disease, suffering, death that all people share.

 

Role of Profit in Virginia’s Medicaid Expansion Drama

Since I last wrote about Virginia’s foot-dragging on expanding Medicaid back at the beginning of January, a number of interesting developments have taken place. Fortunately, after what can only be described as a beating with evidence, public outrage, politicking, manipulation, and extreme waste of resources, it looks like Virginia is starting to consider accepting the expansion of Medicaid and joining the ranks of such progressive states as oh, Florida.

There is a back story to why this is happening now, and why Virginia’s uber-conservatives are allowing it at all. It involves the opportunity to profit. To understand why, let’s go through a quick summary of the events of the past couple months.

When the House of Delegates and Senate worked on their budget bills, the House agreed to accept Medicaid funding only if Virginia could have authority to “reform” Medicaid, and only after a likely special session meeting. The Senate bill was slightly less strict, saying Medicaid expansion would happen without approval from the General Assembly, but that “reforms” were still necessary.

Earlier this week, McDonnell really gave us a good scare by implying that no matter what kind of reforms Washington allows Virginia to make, it was unlikely Medicaid would be expanded. He wrote a letter to the chairmen of the House and Senate budget committee on Wednesdays, including the following, “Please understand that I cannot and will not support consideration of an expansion of Medicaid in Virginia until major reforms are authorized and completed, and until we receive guarantees that the federal government’s promises to the states can be kept without increasing the immoral national debt.”  It’s worth noting that McDonnell vehemently opposed cuts to the national “defense” budget, yet the US spends, as this article very nicely elaborates, “nearly as much on military as the rest of the world combined.”

Virginia’s Democrats in the House, seeming to recognize how ridiculous this was all starting to get, started to talk about blocking the Transportation Bill if the Medicaid expansion didn’t happen*. So, yesterday, the Senate and House voted to, uh, if not exactly accept federal money and expand Medicaid, then to pave the way towards accepting it in July with the stipulation that there be major reforms to the way Medicaid is handled in Virginia. Completely and utterly confusing, I know. This article in the Richmond Times-Dispatch reported, “The budget actions give a green light to negotiations already under way between state and federal officials on flexibility in how Medicaid is administered in Virginia — from the benefits that would be provided to newly eligible participants and their share of the costs, to the eventual use of managed care for all Medicaid services to control costs.”

Aha! Virginia wants to have more flexibility to use managed care for Medicaid. Read this as : Virginia wants to contract out the administration of Medicaid to private companies, like in Florida. They want reassurance that the federal government will allow this. With Florida setting precedent earlier in the week to move forward with increased privatization of Medicaid, Virginia was able to breathe a little sigh of relief. We might get the government out of our Medicaid after all! Florida state representative Mark Pafford remarked, “Whenever you inject the profit motive into medical decision-making, there’s a tension between patients’ interests and stockholders’ interests…We haven’t seen any hard evidence that privatizing Medicaid will actually help people.” Well said. So why is the federal government allowing this?? Well, it’s giving lip service to critics like Pafford, saying that Florida has 3 years to prove that privatization provides effective coverage and keeps costs down. On Wednesday, when Florida Gov. Rick Scott announced Florida would be expanding Medicaid, he stated, “Quality healthcare services must be accessible and affordable for all, not just those in certain zip codes or tax brackets.” It’s interesting how quickly Republican governors take up the language of real health reform advocates when the opportunity presents itself to make a profit off Medicaid.

It is well-documented how privately administered Medicare Advantage programs increase costs to taxpayers and lower quality of health services delivered. These programs have wasted $283 billion dollars in taxpayer money from 1985-2012. It’s a complicated story, but just one of the ways this happened is because the programs select for the healthiest seniors, leaving the sickest, poorest, and most expensive seniors to the standard Medicare program. Private corporations that administer these programs go home with a profit; American taxpayers literally get sold out.

The always-eloquent health justice activist, pediatrician, and role-model Dr. Margaret Flowers put it best in 2011 when she wrote about privatization of publicly-funded healthcare. “Medicare and Medicaid must be left out of the discussion entirely until leadership has the courage to address the real reasons why our health care costs are rising, the toxic environment created by investor owned insurances and the profit-driven health care industry.”

*Transportation funding plans in Virginia are particularly near and dear to my heart as there was serious discussion about re-adding a toll to I-95 South effectively throwing poor, rural southern Virginia – where I am originally from – under the bus. Making the poorer areas of the state subsidize the wealthier parts is NEVER a good idea. Ultimately this didn’t make it into the transportation bill, fortunately, but it bears mention that it was McDonnell’s idea, and given his high-falutin’ talk about “morality,” it’s interesting how selectively morality can be applied.

A criticism of my own criticism

Based on a conversation yesterday, I began to consider the problems inherent to criticism that only seeks to expose problems in a system without proposing solutions. Such criticism, – well-founded, researched, and presented – would at its best leave informed people galvanized for action. But what action? Action should be organized and directed in order to be effective. At the worst, the criticism would leave people feeling hopeless and helpless, especially for those less familiar with the inner workings of health care systems. It could potentially discourage a growing sense of empowerment that would encourage people to learn more and fight for a better future. That is of course the last thing I’d want to do.

Presenting problems in any system, then, brings up the question of whether we have an obligation to provide some form of hope. This could be as concrete as a suggested action or as abstract as a vision of what a better system would look like. Kind of in the vein of “a journey of a thousand miles begins with a single step” – should we provide a step, any step? Without entering in a rigorous philosophical and ethical discussion, in short, I think we should. From now on, when I speak and write about the problems in the system, I’m going to endeavor to provide at least the framework of a potential solution.

Of course, a potential solution to the problems in American health care is a HUGE undertaking (and one that I am only beginning to realize the magnitude of as I sat down to write this post!). Considering a theoretical perfect system seems more proactive than reverse engineering the current system.

It seems 3 main goals/themes start to emerge when I imagine a just and sustainable, prevention-oriented health care system. The specifics of these  will change as our collective knowledge improves, yet the over-arching principles should remain.

1) keep healthy people healthy

2) heal the sick quickly, efficiently, and effectively

3) provide compassionate, human-centered end of life care.

Such a system would prioritize these goals above all others. There does not seem to be any room for the pursuit of profit within this framework, yet there is a clear role for continued research into cost-effectiveness. These goals necessitate that we consider an individual as a collection of smaller systems (individual organs down to cells) but yet a part of larger systems (families up to societies and species).

Obamacare and Virginia

My privilege is this much bigger than yours!

The ACA/Obamacare is a flawed piece of legislation. It will not provide universal coverage, and there is little reason to think it will control costs. I find arguments against incremental reform in health care (and indeed, almost all systems) very compelling. While the debate of incrementalism vs. true reform/revolution is deserving of much reflection, that isn’t the intention of this particular post. I want to talk about how the implementation ACA/Obamacare is playing out in Virginia and what the implications of this are for the 99%.

There are two large issues in the short term regarding how the ACA will affect Virginia. The first is that Gov. McDonnell has said Virginia will not be setting up its own health care insurance exchange, and as a result will not be getting the federal money for Medicaid expansion.

Go ahead and skip this paragraph if you know what the exchanges are – this is just a refresher. The exchanges are based on the idea that by pooling small businesses and individuals together to function as a large company, they can buy insurance at rates comparable to what big businesses already pay. It was in recognition that because of less bargaining power, small businesses and people buying insurance on their own often pay far higher than what large businesses are able to negotiate. —States can lump individual and small business together in the same pool or they may be separate. There are four levels of benefit packages offered with varying percentages of health care costs covered (certain minimum coverages included) – from bronze (pays 60% of actuarial value of plan benefits) to platinum (pays 90%). People under 30 who would not be required to purchase insurance because it exceeds 8% of income will be able to buy “catastrophic” coverage. The exchanges must limit cost-sharing, with no annual or lifetime caps in coverage, and a maximum of $2k for premiums of individuals and $4k for families (the actual number is subject to change in the future). Yeah, it gets really complicated. The exchanges are supposed to be in place by 10/1/13 so people can start shopping, buy their plan, and have their coverage start on 1/1/14.

The states were given the option of setting up their own exchanges, or they could default to a federally-operated exchange. The catch is that by defaulting, they lose the federal funds to expand Medicaid.

The Medicaid expansion is a tricky subject. In order to get an idea of what Medicaid currently is like in Virginia, consider these facts: Unemployed parents in a family of three with incomes over $4,772 make too much to receive Medicaid coverage (25% of federal poverty line), while employed parents in a family of three who earn over $5,744 make too much to receive Medicaid coverage (31% of federal poverty line). Obamacare expands Medicaid eligibility to 133% of the federal poverty line. In 2014, that corresponds with an income of  $14,856 for a single person and $19,378 for a family of three. This would result in about 420,000 more Virginians covered, 84,000 of them kids.

The Supreme Court ruling that upheld Obamacare in June 2012 also said that states could not be forced to use their money to expand Medicaid. This was still decided even though care was taken during the crafting of the bill to not impose excessive burden on the states which tend to have more variable expenses and incomes. In fact, the federal government would pay 100% of Virginia’s Medicaid in 2014, and gradually reduce to 90% starting in 2020. However, if Virginia waits until 2016 or 2020, that drops to 95% or 90% immediately.

There is absolutely no reason to refuse this money from the federal government. It is especially important to take this money because the amount of federal dollars given through the Disproportionate Share Hospital (DSH) program for hospitals serving lots of uninsured patients is decreasing.  This means that in states like Virginia that won’t be receiving federal money for Medicaid expansion, hospitals serving the poor will be disproportionately hurt. Even the argument that McDonnell is using regarding the instability of the federal money holds no weight:

“I don’t believe the federal government can possibly deliver its commitment to fully fund the program, and I don’t want to be part of contributing trillions of dollars to the national debt.”

If in subsequent years Virginia found that it was unaffordable to continue the expanded Medicaid, it could withdraw from the program (and lose federal funds). The Virginia Chapter of the American College of Physicians, an organization of Internal Medicine specialists and medical student members (including yours truly), recently released a report detailing how the Medicaid expansion will benefit Virginia. It’s pretty compelling stuff. Basically, Medicaid saves lives, and reduces racial and ethnic disparities in health care, with over 40% of the those affected by the Medicaid expansion being people of color.

Let’s review what happened immediately after Obamacare passed in March 2010. The Virginia General Assembly passed the “Virginia HealthCare Freedom Act,” which was basically written by the corporate-backed American Legislative Exchange Council as the “Freedom of Choice in Health Care Act.” This made it illegal for the government to require the purchase of insurance.  Our Provocateur-ney General Ken Cuccinelli then used this as the basis to file suit against the federal government, which, of course, ultimately failed.

What is the purpose of fighting the Medicaid expansion so hard if it would genuinely help the poor of Virginia? The purpose is to chip away, undermine, and sully the reputation of publicly funded and administered health care. If Medicaid works for the people of Virginia, then that is yet another weak link in the argument that complete privatization of health care and voluntary coverage is the only “right” way (never mind that Obamacare essentially ensures this anyway).  Conservatives love to demonize Medicaid, continuously underfunding it and fighting attempts to improve it. Medicaid, like the current Medicare, is highly flawed, pays much less than private insurance, and is mostly inaccessible for all but the poorest of the poor. (But people with Medicaid are still better off than with no insurance at all!)The reason is because the powers that be have vested interests in profiting off health care, and Medicaid stands in their way.

Take action to help the Medicaid expansion happen in Virginia. Contact your state senators and delegates.

Market-based ideas: option or coercion?

I recently saw the new film Escape Fire and felt like it provided a pretty good introduction to the problems with American health care at the moment. It was up to date in detailing why Obamacare is an imperfect solution, and it did explore the issue of why for-profit corporations might not be in the best position to reduce health care costs. Just because of the wide variety of issues the filmmakers chose to look into, it was naturally limited in the depth it could go, but it seemed to provide a reasonably fair assessment overall.

I was struck by one example of lowering costs and improving health that I hadn’t heard about before – that of the grocery store Safeway. Faced with rising health insurance premiums like most companies, Safeway decided to implement a behavioral motivation program where it based the costs of its (non-union) employees’ premiums on a variety of health indicators: “tobacco usage, healthy weight, blood pressure and cholesterol levels” according to an article written in the WSJ by Safeway CEO Steven Burd in 2009. He claimed that insurance costs almost immediately stabilized after implementation of the program in 2005 and that they were “building a culture of health and fitness.” The idea, of course, is that if people are financially motivated to behave themselves in a way that will reduce their future need for health care utilization, everyone will benefit.The movie showed happy-looking employees jogging around the building.

I got a feeling of unease when I heard this story, although I couldn’t immediately figure out why. What’s wrong with giving people an extra reason to improve their own health? After all, they’re the ones who are benefiting from losing weight, quitting smoking, etc. It took me awhile, and I had to dig into it a little bit, but I think I have an explanation.

Burd’s tone in the article struck me as condescending and infantilizing to the workers, although I’m sure he didn’t see it that way. To me, the subtext was, “if only these fat smokers would just QUIT IT ALREADY, they would save us all a ton of money.” He emphasized that 70% of health care costs are the direct result of behavior. (I wasn’t able to find sources in his article, but it very well may be true.) Regardless, such statements are oversimplifications that grossly devalue the truly transformative experience of changing an unhealthy habit. And it shames and punishes people who are unable to make the changes.

Why is that a problem? If 70% of health care costs truly are the result of unhealthy behaviors, then that must mean those behaviors are probably pretty hard to change. I don’t think that people were totally ok with making themselves ill and just looking for an insurance discount to provide that final incentive to get rid of their pesky congestive heart failure caused by a combo of uncontrolled hypertension, high cholesterol, and diabetes-induced heart attacks.

What seems to be difficult for most super-rich people to grasp is that behaviors aren’t just about an individual’s choices. An individual isn’t isolated from the influences around them, but certainly does suffer from them. Not having a car because you are poor, work a low-paying job with weird hours, take a bus home to a neighborhood where there aren’t any grocery stores, and as a result end up eating crap from the local corner store which contributes to your early-onset diabetes certainly could be considered a “behavior” but I think it’d be more accurate to call it a “complete failure of our unjust society.” Granted, most people’s situations are not that drastic, but it’s an illustration of how even calling something a “behavior” neglects the complexities inherent to real people’s lives.

I’m reminded of a (by all accounts middle-class, relatively privileged) person I met whose weight-loss efforts had stalled recently because of severe depression accompanied by some pretty terrible family and social circumstances through absolutely no fault of their own. Any one of us would have found it difficult to continue losing weight in their shoes, despite this individual being highly motivated. It seems incredibly uncompassionate to just toss that person into the policy. It contributes to the myth that meeting these objective, population-based benchmarks are possible for every person at every time if they’d just work hard enough and take personal responsibility, dammit!  It pits workers against each other – hey, fatty 2 cubicles over! Put down the donut and take a walk around the damn building to get your blood pressure down! I don’t wanna have to pay for your expensive, fancy diabetes drugs!

And perhaps most frustrating of all, it’s based on the premise that absolutely everything, even our own health and well-being, has a price and can be commodified.

I should note that in no way am I attempting to minimize the accomplishments of Safeway employees who actually did make these changes and come out far healthier. I have no doubt that such a program was just what some people needed to provide that extra oomph to get the exercise ball rollin’. But even if that were the case for every employee, isn’t it a bit creepy and invasive that your boss cares so much about your waistline and your cholesterol level?  A “culture of health and fitness” starts to look a little more like a culture of coercion, shame, and anxiety.

And what does this market-based solution do to fundamentally address the inequities in accessing health care? That is, even if every employer had a similar program, what would that mean for people who are unemployed due to say, chronic illness? Would they be further shamed and isolated from society? The program is based, by definition, on employees, so that means the people participating were at least healthy enough to work. Almost certainly this would mean that the care of the very sick would continue to fall in the public domain, decreasing private, corporate health care expenditures, but further increasing publicly funded healthcare (ie., Medicare). Though this type of system, Medicare will continue to be fantastically expensive, making it easier to demonize until we finally move toward a total privatization of health care, dissolution of Medicare and Medicaid entirely, with safety nets only being provided by voluntary, charity care.

Well, it turns out that even though Safeway medical costs did stabilize from 2005-2009, it may not have really been related to the incentive program at all and was heavily weighted towards the early years. That is, costs dropped 12.5% in 2005 when the company drastically changed the benefits it was offering. However, 2009 was the first year that insurance premiums were tied to test results at Safeway. According to David Hilzenrath in the Washington Post, “Even as Burd claimed last year to have held costs flat, Safeway was forecasting that per capita expenses for its employees would rise by 8.5 percent in 2009. According to a survey of 1,700 health plans by the benefits consultant Hewitt Associates, the average increase nationally was 6.1 percent.”  When Safeway Senior Vice President Ken Shachmut was asked why premiums rose so much despite their terrific program, he said “we frankly did not have as much control over things as we should have.”

Maybe they had too much control.

Of note, the idea of financial incentives being not only ineffective in reducing health care costs and improving societal health, but actually impeding these goals is one that I intend to explore in future posts!

The Drug Rep

Drug reps. You always hear about them, but as a med student you don’t often get a chance to interact with them. This is because they don’t care about you – you can’t prescribe drugs yet! (Also related to my school’s policy regarding them.) I’ve been on my family medicine rotation in a private practice outside of Richmond, and for the first time I’ve really gotten the opportunity to see exactly how they function. A few days ago a friendly, well-dressed attractive woman came in to see the doctor I was working with that day. She said she wanted to follow-up on how patients were doing after the doctor started them on a new diabetes drug her company was marketing. The doctor introduced me to her, and she started to tell me about the drug as well. Apparently the main benefit over other similar drugs made by competitors is that this drug is minimally excreted through the kidney, thus making it a good choice in patients with co-existing kidney disease. It is true that kidney disease often accompanies diabetes, so I could see how this could be a benefit. Yet how important of a contribution to diabetes treatment is this drug really? Without going into too much detail, it’s one of a class of drugs that acts to increase a substance normally found in the body that acts to increase insulin release and decrease glucagon release, leading to lower blood glucose levels (which is the big problem in diabetes). All of the drugs in this class are relatively new (and extremely expensive), so there are no long-term data on the safety. Overall they appear pretty safe (although have been linked to pancreatitis in some people), and don’t seem to cause dangerously low blood sugar like some older diabetes drugs. Unfortunately, they just don’t really work very well, measured by %hemoglobin A1C levels which are used to estimate average blood glucose levels over the past 3 months. It would be difficult to make an argument to start with them instead of a tried-and-true drug like metformin, which is the first-line, much cheaper drug to treat type 2 diabetes.

Well, that type of thing is all interesting and plays into bigger conversations about the incentives for new drug development, including truly novel drugs to treat important diseases like diabetes. But I was more interested in finding out how this drug rep viewed her role in medicine and what she thought about the industry she was working in. I asked her about the Avanda fiasco. Briefly, GlaxoSmithKline, the maker of Avandia, recently pled guilty to intentionally suppressing information that the top-selling diabetes drug  increased risk of heart attacks and continuing to market it as safe. This was always a controversial link because diabetes itself is a huge risk factor for heart attacks. Now, I can’t speak to quality of all the complex data analysis that went into teasing out how many heart attacks were due to use of the drug and how many would have happened anyway, but it has become pretty clear that GlaxoSmithKline did hide information when there was cause for concern.

So, what did she think about it? She told me that her company was viewing it as an opportunity because there was now a gap in the market with one less diabetes drug. She also said she had spoken with people who were familiar with the types of data analysis and the risk of heart attack was overblown as a scare tactic in the media. And what if, I asked, it was later determined that her company had suppressed information about the safety of the drug she was promoting? What if it turned out it had a terrible side effect? How would she feel? She artfully dodged the question and attempted to side with me, “I’m a skeptic too! I like to see the data! And the data in these trials shows that this is a safe drug and a good option for patients with diabetes and kidney disease!”

Then the doctor I was working with returned. One of the realities of 3rd year is that grading is very subjective, and I don’t want to seem like an argumentative person who is difficult to get along with, so I gave up on the questioning. The doctor is way more important to talk to anyway, and she quickly turned her attention to asking about his family and some interests that they shared.

To a certain extent, each physician practice setting can develop its own rules as to how it will deal with drug reps, and a considerable amount of attention has been brought to the issue of salespeople influencing physician prescribing habits. The influence of Big Pharma is wide-reaching and often one step ahead of public information and policy-making. Indeed, one has to appreciate the ingenuity of approaches Pharma has taken in order to butter up physicians.

The common denominator of these approaches involves exploiting that most doctors think of themselves as pretty smart people. As a result, most doctors think they’re immune to the tricks of salespeople and resist the idea that they would alter their drug-prescribing habits based on talking to a salesperson or even getting to know them. This isn’t the case. In fact, physicians may be in a particularly dangerous and even vulnerable situation. Medical school is hard, and there is considerable emphasis given to the importance of development of critical thinking and analytical skills in classes. It’s pretty difficult to know how well those analytical skills have sunk in or remained over the years, as most of the national medical licensing exams are multiple choice (there is at least one national required test where you’re evaluated by seeing patients). What is probably more important is that in medical school we are taught to believe that we HAVE developed these skills and are thus less susceptible to influence by outside sources.

Thinking of oneself as intelligent is not something I’m faulting doctors for – everyone, of course, wants to feel this way! Doctors deserve to be respected for dedicating a substantial part of the prime of their lives to learning an enormous amount of information in order to be able to relieve some suffering one day. I honestly believe most people go into medicine because they are interested in the subject matter and want to provide a valuable service to humanity. Drug reps know this, and take great pains to emphasize how the drug is better for the patients and how smart they think the doctors are. They give them glossy information packets about new medications that include copies of relevant research studies (as if a busy doctor in private practice is going to actually not only read every study handed to them by a rep, but critically evaluate strengths and weaknesses!) They give samples of the medication to the office, which seems to me to have the undertone of emphasizing they are trying to make expensive medications available to patients who otherwise wouldn’t be able to afford them, playing on most doctors’ tendencies towards altruism. Unfortunately, when the samples run out, the patient is still taking an expensive brand-name drug and may prefer it because it’s what they’re used to.

Another way drug reps appeal to doctors’ desires to think of themselves as pretty smart folks is asking them to be a (paid) speaker, calling them things like “thought leaders.” They’re supposed to give talks to other doctors about the condition the drug is for and the side effects and advantages of the drug. They view themselves as providing a good service to other doctors and their patients. In reality, something about the psychological effect of getting paid by the company actually influences the prescription writing of the doctors (who were only approached as a “thought leader” because they already wrote a lot of prescriptions for the drug!) It may be that they have to justify it to themselves to prevent cognitive dissonance of speaking for something they don’t truly believe in.

So how can doctors protect themselves from this type of coercion? One very simple way seems to be to refuse to meet with drug reps and rely on obtaining information about new treatments through other, less biased sources. In reality, every source has a bias, but it seems hard to imagine a less objective source than a person whose very career depends on convincing people of the superiority of their product.

In 2013, every doctor that takes money from drug companies will be available to the public. Here’s a database in the meantime. And here’s the website  of No Free Lunch, an organization that’s dedicated to making sure that patient care isn’t dominated by the coercion of drug companies. They have their work cut out for them.