Friday, May 30, 2014

Hsieh Forbes Column: Three Factors That Corrupted VA Health Care

My second Forbes piece in two days again discusses the VA health scandal: "Three Factors That Corrupted VA Health Care And Threaten The Rest of American Medicine".

Here is the opening:
Veterans Affairs Secretary Eric Shinseki has resigned in the wake of the waiting times scandal. But the problems at the VA go much deeper than a single man. His eventual successor will have his hands full dealing with the toxic combination of problems that fueled the crisis: a shortage of doctors, perverse incentives, and a widespread culture of dishonesty. And these problems could affect the rest of America under ObamaCare...
The first two of the three factors are already in play under the Affordable Care Act (aka "ObamaCare") and there are troubling early indicators that the third may take root as well.  If this happens, Americans had better watch out.

Thursday, May 29, 2014

Hsieh Forbes Column: VA Denies Coverage to USAF Veteran With Brain Tumor

My latest Forbes piece is now up: "VA Denies Coverage For US Air Force Veteran With Malignant Brain Tumor".

I discuss the bureaucratic hurdles that USAF veteran Robert LeChevalier had to endure when diagnosed with glioblastoma multiforme (a very malignant brain tumor).  Fortunately, he and his wife Monica Hughes have a lot of grit and tenacity.

I'm glad to publicize their open letter to the VA, and I hope it gets some attention!

Monica also posted this photo, which I used in the Forbes article with her permission:  "Here are the 58 claims denials, totaling $250,000 of emergency care, that we have received by the Veteran's Administration. Excuse? Robb was too healthy. He hadn't sought any care at the VA in the prior 5 months. Really."

Adalja on Sovaldi

Dr. Amesh Adalja has a new Forbes piece on the innovative new drug Sovaldi: "The Price is Right: New Hepatitis C Drug is Really a Priceless Breakthrough".

From his piece:
Hepatitis C is a scourge that is the leading cause for liver transplantation infecting close to 4 million Americans and over 180 million individuals globally. The historical treatments for this virus have been long, cumbersome, and laden with horrible side effects. The newest drug in our armamentarium, Sovaldi (sofosbuvir), offers the promise of substantially shortening treatment regimens while, at the same time, enhancing treatment response. In short, this is a wonder drug that we all should be grateful to scientists for developing and pharmaceutical companies for funding...
(Read the full text of "The Price is Right: New Hepatitis C Drug is Really a Priceless Breakthrough".)

Wednesday, May 28, 2014

Life Imitates The Onion On Physician Satisfaction Surveys

The Daily Beast just published an interesting article on, "You Can't Yelp Your Doctor" (5/21/2014).

One of their take-home points is that some of the country’s best doctors have the worst patient satisfaction scores (and vice versa).

From the article:
Armed with the idea that “patient is always right,” Washington figured that more customer satisfaction data “will improve quality of care and reduce costs.”

That turns out to have been a bad bet.

In fact, the most satisfied patients are 12 percent more likely to be hospitalized and 26 percent more likely to die, according to researchers at UC Davis. “Overtreatment is a silent killer,” wrote Dr. William Sonnenberg in his recent Medscape article, Patient Satisfaction is Overrated. “We can over-treat and over-prescribe. The patients will be happy, give us good ratings, yet be worse off.”

It’s Economics 101. If we ask drug-addicted patients to grade their physicians on how satisfied they are with the “service,” then a high score will likely indicate they got the opposite of good medical care. It doesn’t take a genius to figure out how putting addicts in charge of the patient encounter contributes to the $24 billion in excess medical costs caused by prescription opiate abuse.
[U]nnecessary antibiotic prescriptions are also on the rise, adding to the deadly menace of drug-resistant bacteria. A patient demanding unnecessary antibiotics is one of the things that doctors hate most, yet nearly half of physicians surveyed said they’ve had to “improperly [prescribe] antibiotics and narcotic pain medication in direct response to patient satisfaction surveys”...

“The mandate is simple,” wrote Dr. Sonnenberg. “Never deny a request for an antibiotic, an opioid pain medication, a scan, or an admission.” So instead of better care and cheaper care, satisfaction scoring is making patients sicker and driving up costs...

But when physicians don’t acquiesce, they pay a price. Last year, The Atlantic profiled a physician who quit due to the pressure to prescribe narcotics. In many cases, doctors can’t keep their jobs or make partner if their scores aren’t—not just good—but stellar. And many physicians claim that hospital administrators explicitly tell them to do whatever it takes to raise scores even if it means compromising their professional standards...
Of course, The Onion was able to make a very similar point more succinctly in their satirical piece, "Physician Shoots Off A Few Adderall Prescriptions To Improve Yelp Rating" (4/17/2014):
Noting that his practice’s rating on the business review website had dipped to just 3.5 stars, local primary care provider Dr. Frank Hawley reportedly dashed off several Adderall prescriptions Monday to give his Yelp average a needed boost.

“I keep a pretty close eye on my reviews, and whenever I see my number fall below four stars I just write out a few extra Adderall or Dexedrine scripts and it’s back up in no time,” said Hawley, adding that he usually ups the dosage to 30 milligrams and makes sure to prescribe two refills to ensure he stays near the top of the local general practice rankings. “Patients are always happy when I sign that prescription slip and hand it to them—it’s pretty much a guaranteed five-star rating. In a business that survives by word of mouth, good reviews are absolutely essential.”

In addition, Hawley confirmed he hasn’t advised a single patient to exercise regularly or maintain a healthy diet since 2011, saying he learned his lesson after receiving a devastating one-star review.

Dr. Hal Scherz on the VA Scandal

Dr. Hal Scherz of Docs4PatientCare has a powerful OpEd in the Wall Street Journal, "Doctors' War Stories From VA Hospitals".

The whole thing is worth reading, but here is an excerpt:
In my experience at VA hospitals in San Antonio and San Diego, patients were seen in clinics that were understaffed and overscheduled. Appointments for X-rays and other tests had to be scheduled months in advance, and longer for surgery. Hospital administrators limited operating time, making sure that work stopped by 3 p.m. Consequently, the physician in charge kept a list of patients who needed surgery and rationed the available slots to those with the most urgent problems.

Scott Barbour, an orthopedic surgeon and a friend, trained at the Miami VA hospital. In an attempt to get more patients onto the operating-room schedule, he enlisted fellow residents to clean the operating rooms between cases and transport patients from their rooms into the surgical suites. Instead of offering praise for their industriousness, the chief of surgery reprimanded the doctors and put a stop to their actions. From his perspective, they were not solving a problem but were making federal workers look bad, and creating more work for others, like nurses, who had to take care of more post-op patients.

At the VA hospital in St. Louis, urologist Michael Packer, a former partner of mine, had difficulty getting charts from the medical records department. He and another resident hunted them down themselves. It was easier for department workers to say that they couldn't find a chart than to go through the trouble of looking. Without these records, patients could not receive care, which was an unacceptable situation to these doctors. Not long after they began doing this, they were warned to stand down.

There are thousands of other stories just like these...
For more, read the full text of "Doctors' War Stories From VA Hospitals".

(Although the story is behind a subscriber paywall, the WSJ often allows readers to type "WSJ <article title>" into a Google search window to access their "Free Pass" version.  In other words, type "WSJ Doctors' War Stores from VA Hospitals" without the quotes.)

Thursday, May 15, 2014

Flawed Quality

At the website, Dr. Karen Sibert explains, "Why the quality measures used in health care are deeply flawed".

Given the increasing reliance on government-backed "quality" measures to control costs, doctors will be increasingly pressured to follow measures that might not actually be best for patients.

(Via Dr. Art Fougner.)

Wednesday, May 14, 2014

RebelMD: "The Voice of Hippocratic Medicine in America"

I've been enjoying reading some of the health care commentary at a new site, RebelMD, which calls itself, "The Voice of Hippocratic Medicine in America".

Some of their recent posts include:
"The Doctor Rebels" (Dr. Meg Edison, 5/1/2014)

"Got Cancer? Dude, Get Over It" (Dr. Jane Huges, 5/8/2014)

"Patient-Surgeon, Rebel-Doctor" (Dr. Kris Held, 5/13/2014) 

If you like what you see, here's more about them:
This is where doctors from all specialities, all ages, from all over the country can speak truth.  We’ve reached a tipping point in American medicine, the ACA only adding to the crushing regulation and mandates we face. The docs who write here have drawn a line in the sand and said “Enough. My patients and my profession matter too much to sit quietly.”

Monday, May 12, 2014

Online Firms Bring Concierge Medicine to the Middle Class

Kaiser Health News and Wired recently published a story, "Online Firms Bring Concierge Medicine to the Middle Class".

From the article:
Grand Rounds is one of many healthcare startups bringing on-demand, concierge-like services once reserved for the ultra-rich to the middle class – similar to what tech outfits like Google, Amazon, Uber, and Lyft have done for personal shopping and transportation.

These budding companies offer basic access to medical advice, appointments and other assistance. Some operate regionally, others nationally. Their services and prices vary substantially—but all aim to fill gaps in the existing health care system, in part by using the Internet.

Often they charge monthly or annual subscriptions – say $50 a month or $149 a year for primary care services -- although physical exams, surgeries, and second opinions from specialists can cost more. At Grand Rounds, an online second opinion runs $7500 and an appointment with a specialist is $200.
To the extent that the free market is allowed to operate, these services help bring quality care to willing consumers at a reasonable price.

I'd love to see these services take off (just as I'd like to see companies like Uber thrive).

Here's the official website for Grand Rounds.

Tuesday, May 6, 2014

Sissel's Challenge To ObamaCare

Two recent commentaries about Matt Sissel's legal challenge to ObamaCare.

The first comes from David Catron, "Iraq Vet Continues Battle Against Obamacare" (American Spectator, 5/5/2014).

Catron explains the core issue as follows:
Sissel v. HHS is the only remaining lawsuit that has any chance of actually killing Obamacare. Neither the Hobby Lobby challenge to the egregious HHS contraception mandate nor the various lawsuits challenging the IRS decision to funnel tax credits and subsidies through ineligible federal insurance exchanges have this potential. Even if the government loses all of those cases, the much-despised “reform” law will continue to bedevil us. On the other hand, if Matt Sissel prevails against the administration’s lawyers, Obamacare is history.

Sissel’s challenge to Obamacare is based on the Constitution’s origination clause, which stipulates that all tax laws must be initiated by the House of Representatives. In June of 2012 the Supreme Court ruled that the health care law’s most conspicuous provision, the individual mandate, was a tax. Pursuant to the Court’s ruling, the Pacific Legal Foundation (PLF), which represents Sissel, filed a cause of action based on the well-documented fact that the “Affordable Care Act” originated not in the House but in the U.S. Senate.

This was accomplished by a devious series of unconstitutional procedural gimmicks concocted by Harry Reid, Nancy Pelosi, and the White House. The Democrat-controlled Senate took a piece of unrelated legislation passed by the House, the “Service Members Home Ownership Act of 2009,” removed every word from the bill, and filled the empty shell with the health care legislation that was eventually passed by Congress and which its authors endowed with the Orwellian title, the “Patient Protection and Affordable Care Act.”

Thus, the “reform” law signed by Obama—a law bursting with new taxes—contains not a syllable written in the only legislative body permitted by the Constitution to pass revenue bills. A variety of Constitutional scholars have weighed in on this skulduggery, of course, including Georgetown Law Professor Randy Barnett. Barnett writes, “If any act violates the Origination Clause, it would seem to be the Affordable Care Act. The Supreme Court has never approved the ‘strike-and-replace’ procedure the Congress employed here.”
George Will has a related piece, "ObamaCare's Doom" (Washington Post, 5/2/2014).

Will notes:
Case law establishes that the origination clause does not apply to two kinds of bills. One creates “a particular governmental program and . . . raises revenue to support only that program.” The second creates taxes that are “analogous to fines” in that they are designed to enforce compliance with a statute passed under one of the Constitution’s enumerated powers of Congress other than the taxing power. The ACA’s tax, which the Supreme Court repeatedly said is not an enforcement penalty, and hence is not analogous to a fine, fits neither exception to the origination clause.

The ACA’s defenders say its tax is somehow not quite a tax because it is not primarily for raising revenue but for encouraging certain behavior (buying insurance). But the origination clause, a judicially enforceable limit on the taxing power, would be effectively erased from the Constitution if any tax with any regulatory — behavior-changing — purpose or effect were exempt from the clause.
It's entirely possible that this case may end up in the Supreme Court.  Stay tuned...

Monday, May 5, 2014

Two Doctors In WSJ

The Wall Street Journal recently published two OpEds by physicians on ObamaCare.

Dr. Scott Atlas wrote about, "The Coming Two-Tier Health System" (4/30/2014)

Dr. Daniel Craviotto wrote, "A Doctor's Declaration of Independence" (4/28/2014).

(Ari Armstrong has this nice commentary on Craviotto's piece.)