Archive for the ‘Healthcare’ Category
I found this article, “A Common Language: Ron Capps served in Rwanda, Darfur, Kosovo, Eastern Congo, Afghanistan, and Iraq. When he got back, writing was the only thing that could truly bring him home again.” in Believer, by Kristina Shevory, to be extremely interesting (and very powerful). I was struck by this paragraph:
“Healing happens only in community, and it’s mainly a community of veterans, a circle of people you get to trust and understand your experience,” said Dr. Shay. “You can’t define what it means to be understood, but it sure as hell matters. The heavy lifting is done by and for the veterans. Time itself doesn’t heal.”
I was struck by the thought that one is healed by communication and a community. This struck with extra force because I just watched the (excellent) interview I blogged in this post, which talks about how efforts to go it alone do not work.
Shay is the author of two excellent books that I’ve read: Achilles in Vietnam: Combat Trauma and the Undoing of Character and Odysseus in America: Combat Trauma and the Trials of Homecoming. Both are well worth reading. (Links are to inexpensive secondhand copies; new copies are, of course, readily available from on-line vendors such as Amazon.) These were early entries in a growing field: book written to deal with the reality of the terrible psychological, moral, and spiritual damage that war does to those involved. Some examples:
Soul Repair: Recovering from Moral Injury after War
Warrior’s Return: Restoring the Soul After War
Killing from the Inside Out: Moral Injury and Just War
Afterwar: Healing the Moral Wounds of Our Soldiers
There are many others. I have not read these, but the Amazon reviews are 5-star or close to it (greater than 4-star).
The growing number of such books is some indication of the toll America’s non-stop wars have had on those who fought it, but course the damage and deaths from such wars goes far beyond the damage to the US: for example, look at Iraq today.
Why has the US constantly waged war in recent decades? Perhaps because those who make the decision to go to war do not fight in it and (of late) have never fought in any war and thus lack any read understanding of the costs of war. Similarly, the pundits and news analysts who comment on US decisions to wage war also lack war experience for the most part. When you think about how the Iraq war inaugurated by the Bush Administration, based on deliberate falsehoods, and about how the cost and consequences of that war continue to reverberate, it should make you question the wisdom of war.
UPDATE: From another article (also well worth reading) this chart hints at the suffering our wars cause our own troops.
In the Washington Post Terrence McCoy has an inspiring story about a police initiative to help addicts:
The coastal Massachusetts town of Gloucester was in the middle of a quiet Friday evening this March when a phone call disturbed the police chief relaxing at home. Another deadly heroin overdose had just hit the city, the chief learned. It marked Gloucester’s fourth that year. Leonard Campanello put down the phone. He turned the grim math over in his head — four deaths, three months, in a city of 30,000 people.
Then Campanello, a stout commander who more growls than talks, stood up and rumbled over to the computer. He’s the sort of police chief who maintains an active presence on social media. He posts frequent “Gloucester Police Chief Updates” — episodic fireside chats delivered from his desk — to the police department’s Facebook page. Most of those remarks barely ripple — a dozen ‘likes’ at most.
But that was about to change. “Since January of this year, we have responded to dozens of opiate-related overdoses and, unfortunately, the City has seen 4 deaths in this time that are heroin related,” he wrote, adding: “4 deaths is 4 too many.” Then in a moment Campanello now recalls as extemporaneous, he continued. “If you are a user of opiates or heroin, let us help you. We know you do not want this addiction. We have resources here in the City that can and will make a difference in your life. Do not become a statistic.”
The response was staggering. The post collected 1,226 “likes” and more page views than there were people in the city. It was then Campanello knew he was onto something. The community, he said, was hungry for different ideas. The number of heroin-related overdoses quadrupled between 2002 and 2013, when more than 8,200 people died, according to the Centers for Disease Control and Prevention. The trend has hit Massachusetts — and Gloucester — especially hard.
“The war on drugs is over,” Campanello said in an interview. “And we lost. There is no way we can arrest our way out of this. We’ve been trying that for 50 years. We’ve been fighting it for 50 years, and the only thing that has happened is heroin has become cheaper and more people are dying.”
So he started making calls. He got in touch with the local mayor. He wanted to talk about a plan that experts say is unique across the country — and would ultimately bring a national debate over the criminalization of addicts to this small, coastal town. It was simple, Campanello said. He didn’t want to arrest more drug addicts battling what he calls the “disease of addiction.” He’d been doing that for too long. Seven years he spent as a narcotics officer, watching drugs or the system swallow families.
He now wanted to turn Gloucester’s police station into an oasis of amnesty in the drug addict’s perilous world. No heroin addict who entered the police seeking help — unless they had outstanding warrants — would face charges or arrest. Even if they toted their drugs and paraphernalia. Instead, they would get help. “Our argument was you don’t cut off the head of the snake,” he said. “You cut off its food chain.”In another Facebook post in early May, he laid it out. “Any addict who walks into the police station with the remainder of their drug equipment (needles, etc) or drugs and asks for help with NOT be charged,” he wrote. “Instead, we will walk them through the system toward detox and recovery. We will assign them an “angel” who will be their guide through the process. Not in hours or days, but on the spot.”
No one was quite sure what would happen. Think about it, said communications director John Guilfoil. The chief was asking a bunch of addicts who until that point had violated the law to suddenly walk into the police station — armed with drugs. It was crazy. It was madness. It worked.
The post collected more than 30,000 “likes,” an additional 30,000 shares and millions of clicks, the chief said. Things then happened fast. The force opened a non-profit called the Police Assisted Addiction and Recovery Initiative. Addicts started flooding the police station — dozens of them. And reporters arrived to a curious sight of cops greeting addicts rather than charging them.
“A reporter asked one of my officers last night, ‘Do you see a common thread in all addicts?’ one Facebook post said. “Without hesitation, the officer responded: ‘Absolutely. They’re all human beings.”
The chief approached a local CVS to talk about a drug that reverses overdoses. Nasal Narcan administers a burst of a drug that binds with the brain’s opiate receptors and can reverse an overdose. Without insurance, it costs $140. But Campanello told the CVS about the agency’s new program, and it lowered the cost to $20 per pack. He then started providing it to the addicts for free. “The police department will pay the cost of the Nasal Narcan for those without insurance,” Campanello wrote in a post. “We will pay for it with money seized from drug dealers during investigations. We will save lives with the money from the pockets of those who take them.”So far, Campanello said, 109 addicts have sought help at the police station. . .
That’s via this report in Salon by Scott Eric Kaufman:
Massachusetts Senator Elizabeth Warren was none too pleased with Republican’s attempt to grandstand on the issue of women’s health as the first GOP primary debate approaches, and she voiced her displeasure to her senate colleagues in no uncertain terms on Monday.
“I come to the Senate floor today to ask my Republican colleagues a question,” she began. “Do you have any idea what year it is? Did you fall down, hit your head, and think you woke up in the 1950s? Or the 1890s? Should we call for a doctor?”
“Because I simply cannot believe that in the year 2015, the United States Senate would be spending its time trying to defund women’s healthcare centers. On second thought, maybe I shouldn’t be surprised. The Republicans have had a plan for years to strip away women’s rights to make choices over our own bodies.”
Warren explained that in 2013, the GOP threatened to shut down the government if they couldn’t change the Affordable Care Act in a way that would allow employers to deny access to birth control. In March 2015,they stopped a bill that would’ve curtailed human trafficking because it could have allowed for the private funding of abortions. In June, Republicans passed a budget that eliminated Title X.
Moreover, she said, . . .
Turns out that Ronald Reagan was very far off the mark. Jon Schwarz reports in The Intercept:
Fifty years ago today, on July 30, 1965, President Lyndon B. Johnson signed the bill creating Medicare.
Two years before Medicare’s enactment, only 54 percent of Americans 65 and over had insurance that covered hospital expenses, and private insurance companies regularly terminated coverage for older “customers” who’d become too expensive. The elderly faced not just their bodies breaking down, but the simultaneous terror of financial ruin.
Within three years of Medicare’s creation, 96 percent of people 65 and over had hospital insurance, and it could never be cancelled. It’s hard to overstate how large a boon Medicare has been for the whole country.
But it’s worth remembering that this gigantic step forward in Americans’ quality of life was rabidly opposed by — among many others — Ronald Reagan. In 1961, Reagan, then known just as an actor, now the ultimate iconic Republican, was hired by the American Medical Association to record an LP record called “Ronald Reagan Speaks Out Against Socialized Medicine.”
And it was completely nuts. Here are some of the highlights; a complete transcript ishere.
“Back in 1927 an American socialist, Norman Thomas, six times candidate for president on the Socialist Party ticket, said the American people would never vote for socialism. But he said under the name of liberalism the American people will adopt every fragment of the socialist program.”
This is the very beginning of Reagan’s recording, and, appropriately enough, is completely made up. Norman Thomas never said this.
“One of the traditional methods of imposing statism or socialism on a people has been by way of medicine.”
Medicine has never anywhere in history been a method of imposing communism (what Reagan means by “statism or socialism”). Communism was established in the Soviet Union, China, North Korea, Vietnam and Cuba via armed revolution, not national health care.
“From [Medicare] it’s a short step to all the rest of socialism, to determining his pay and pretty soon your son won’t decide when he’s in school where he will go or what he will do for a living.”
Yes, I well remember when I received my orders to report to the Patrice Lumumba Pod to begin my career as People’s Blogpost Writer 9784B.
“Write those letters now [to Congress] and call your friends and them to write … If you don’t do this and I don’t do this, one of these days we are going to spend our sunset years telling our children and our children’s children, what it once was like in America when men were free.”
Stephen Engelberg writes in ProPublica:
We’ve had a remarkable response in the two weeks since we published Surgeon Scorecard. The online database has been viewed more than 1.3 million times by people looking up doctors. Surgeons and others pored over the intricacies of the data and methodology. Some praised it as a long overdue, transformative in the data and what they viewed as flaws in the analysis.
Perhaps the most striking response, though, came from one of our readers, the husband of a nursing supervisor at a medical/surgical unit in a respected Southwestern hospital.
“When my mother required gallbladder surgery, my wife specifically ensured that a certain surgeon wasn’t on call for the procedure,” he wrote. “While I was at the hospital visiting my wife, I mentioned casually to two of her coworkers (separately) that my mother was upstairs awaiting surgery. Both nurses asked cautiously who was on call and when they found out it was Dr. [redacted] … they breathed a sigh of relief.”
That doctor that hospital insiders protected their loved ones from? The nurses called him “Dr. Abscess.”
For decades, the shortcomings of the nation’s Dr. Abscesses have been an open secret among health care providers, hidden from patients but readily apparent to those with access to the operating room or a hospital’s gossip mill.
The author of this email, whose name we’re omitting for obvious reasons, asked his wife to rate the surgeons she assisted every day, and compared her thoughts to what we reported in Surgeon Scorecard. “I randomized the names as I listed them to her, and she hadn’t read about the Scorecard and didn’t know anything about the results. She simply told me her choice for the best and worst and was right across the board.’’
Dr. Abscess? He had the highest complication rate of any doctor operating at the hospital.
Surgeon Scorecard marks ProPublica’s first attempt to make data available about surgeons. Like any first attempt, version 1.0 can be improved, and we plan to do so in the coming months.
But it’s worth noting that some of the most frequently cited concerns reflect basic misunderstandings about how Surgeon Scorecard works. I’d like to address some those questions in detail.
There aren’t enough data to learn anything useful about individual surgeons.
Many critics have noted that Surgeon Scorecard draws only on records of procedures paid for by Medicare’s fee-for-service program. “I can’t reiterate enough the paucity of the data that is analyzed,’’ Dr. Jeffrey Parks, a general surgeon in Solon, Ohio, wrote in one typical critique.
In fact, study after study of the nation’s health care system by some of academe’s most prestigious scholars draws on similar data from Medicare. Medical research is typically done using far smaller groups to represent even larger populations. Even in large clinical trials, new drugs are tested on a few thousand people who serve as stand-ins for all 320 million Americans.
Overall, Surgeon Scorecard looked at 2.3 million surgical procedures and rated nearly 17,000 doctors. The complication rates we’ve computed for surgeons have been adjusted to control for each patient’s age and health, and the differences among the hospitals where they work. For each doctor, the rate is reported in a range called a confidence interval.
The width of a surgeon’s interval can vary depending on how much information is in our data about him or her. Surgeons who do a large number of Medicare operations requiring overnight stays will have a narrower interval that hones in more precisely on their true performance. Surgeons who’ve done fewer operations have a wider range. Our critics have said this means we can’t know anything about how they compare to peers.
It would be great if every surgeon did thousands of operations. That would make differences between surgeons more clear cut. But patients have to choose now based on the procedures actually performed. The complication rates we report are the most likely based on what we can know. They give a strong signal that some surgeons perform better than others, even if the differences aren’t always as conclusive as some might like.
You can read the calculations that support that finding here.
Parks and other general surgeons have raised a reasonable question about gall bladder removals, one of the eight elective procedures we studied. Because of the way Medicare compiles billing records, our data only includes patients whose operation required an overnight hospital stay. Many doctors also perform this procedure on an outpatient basis.
There is no question that patients would know more if we could publish complication rates that include the outpatient procedures. We are now trying to obtain the records needed to do this.
Counting readmissions to the hospital and deaths is not a fair way to track surgeon performance since Medicare data does not say who precisely was at fault. . .
Linda Greenhouse has a very interesting column on what a mess the Roberts Court has created with its Hobby Lobby decision. From her column:
. . . At issue are the options the Obama administration has made available to a category of employers deemed “religious nonprofit organizations” that object to including birth control in their employee health plans. These groups differ from “religious employers,” a category essentially limited to churches, which are deemed exempt under the Affordable Care Act regulations. Rather, these are religiously affiliated nonprofits such as colleges, seminaries and religious orders like the Little Sisters of the Poor, which runs nursing homes and describes itself as an equal-opportunity employer in its hiring practices for lay staff members. These nonprofits do have to provide contraception coverage unless they accept the administration’s offer to opt out of the requirement by passing the legal obligation on to their insurance carriers.
Under pre-existing regulations that the Obama administration fine-tuned in the aftermath of the Hobby Lobby decision, all these organizations have to do to qualify for the exemption is to ask for it, by filling out a two-page form, or even more simply by sending a letter to the Department of Health and Human Services declaring that they have a religious objection to paying for birth control. At that point, their obligation ceases and the coverage has to be provided by the organizations’ insurance carrier or, in the case of a self-insured plan, by the third-party administrator, without any financial involvement by the organization.
Dozens of these organizations promptly filed suit claiming that they couldn’t possibly fill out the form or sign the letter because to do so would make them complicit in the ultimate choice their employees might make to use birth control.
It’s important to understand the difference between these cases and the lawsuit by Hobby Lobby’s owners. As a for-profit company, Hobby Lobby had no accommodation available. It had either to provide the coverage or pay a huge fine. In fact, the court’s majority opinion, written by JusticeSamuel A. Alito Jr., strongly suggested that the problem, as the majority saw it, could be solved if only the administration would offer Hobby Lobby the same choice it was giving the religious nonprofits. Justice Alito wrote that the Department of Health and Human Services “itself has demonstrated that it has at its disposal an approach that is less restrictive than requiring employers to fund contraceptive methods that violate their religious beliefs.” In a footnote, he added: “The less restrictive approach we describe accommodates the religious beliefs asserted in these cases.” Justice Anthony M. Kennedy, who provided the fifth vote to the majority, wrote in a concurring opinion that the accommodation as described “does not impinge on the plaintiffs’ religious beliefs.”
The Hobby Lobby case had not been argued on this basis, and Justice Alito noted that the court was not deciding whether such an accommodation would suffice “for purposes of all religious claims.” To that extent, the statements were nonbinding “dicta,” not part of the holding. But they have had a powerful influence in the lower courts. Cases challenging the adequacy of the accommodation as applied to religious nonprofits have now made their way through six of the 12 federal appellate circuits. Remarkably, every court has rejected the religious claims.
Not all the decisions have been unanimous; there have been dissenting opinions by individual judges, a fact that may lead the Supreme Court to accept one or more of the pending appeals despite the absence of the “conflict in the circuits” that the court usually waits for. But, notably, judges across the ideological spectrum have ruled for the government. One of the country’s most conservative federal judges, Jerry E. Smith, wrote the opinion last month for a unanimous panel of one of the country’s most conservative courts, the United States Court of Appeals for the Fifth Circuit.
The Supreme Court’s Hobby Lobby decision “is of no help to the plaintiffs’ position,” Judge Smith wrote in East Texas Baptist University v. Burwell.The reason, he explained, was “not just that there are more links in the causal chain here than in Hobby Lobby.” Rather, it was that “what the regulations require of the plaintiffs here has nothing to do with providing contraceptives.”
It’s worth quoting Judge Smith at some length, including his reference to the Religious Freedom Restoration Act, the federal law under which the Hobby Lobby case and the current cases were brought:
“The plaintiffs urge that the accommodation uses their plans as vehicles for payments for contraceptives. But that is just what the regulations prohibit. Once the plaintiffs apply for the accommodation, the insurers may not include contraceptive coverage in the plans. The insurers and third-party administrators may not impose any direct or indirect costs for contraceptives on the plaintiffs; they may not send materials about contraceptives together with plan materials; in fact, they must send plan participants a notice explaining that the plaintiffs do not administer or fund contraceptives. The payments for contraceptives are completely independent of the plans. . . The acts that violate their faith are the acts of the government, insurers, and third-party administrators, but R.F.R.A. does not entitle them to block third parties from engaging in conduct with which they disagree.”
And of course, the choices and the rights of third parties, in this instance, the female employees, are the whole point. It is not only that female employees, and not their bosses, make the choice to use birth control. It is that the employers’ religious objections, if honored, would cause these third parties actual harm — harm that would be avoided if the employers simply signed the form or sent the letter. The extreme to which the plaintiffs’ refusal takes their “complicity” argument is what the appeals courts have found so alarming. The organizations don’t want to pay for birth control and they don’t want anyone else to pay for it either.
The United States Court of Appeals for the 10th Circuit had this to say in a decision last week, Little Sisters of the Poor v. Burwell: “Plaintiffs sincerely oppose contraception, but their religious objection cannot hamstring government efforts to ensure that plan participants and beneficiaries receive the coverage to which they are entitled.”
The Religious Freedom Restoration Act, the court said, “does not prevent the government from reassigning obligations after an objector opts out simply because the objector strongly opposes the ultimate goal of the generally applicable law. Plaintiffs’ complicity argument therefore fails. Opting out would eliminate their complicity with the mandate and require only routine and minimal administrative paperwork, and they are not substantially burdened by the government’s subsequent efforts to deliver contraceptive coverage in their stead.”
Writing in The National Catholic Reporter last week, Michael Sean Winters, author of a blog on the publication’s website called Distinctly Catholic, praised the 10th Circuit decision, saying: “If you think the form used to object to participation is itself a form of participation, I am not sure how we, as a nation, can ever carve out religious exemptions.”
Evidently, the religious groups pressing this litigation would rather keep fighting than declare victory. . .
The idea of grading surgeons, given lower marks whose work produces more post-surgery complications or results in more deaths, seems simple and, on the face of it, valid. But we are familiar with how the presence of an observer can affect the thing observed and change its behavior. Sandeep Jauhar discusses in the NY Times some adverse effects of ranking surgeons:
ONE summer day 14 years ago, when I was a new cardiology fellow, my colleagues and I were discussing the case of an elderly man with worsening chest pains who had been transferred to our hospital to have coronary bypass surgery. We studied the information in his file: On an angiogram, his coronary arteries looked like sausage links, sectioned off by tight blockages. He had diabetes, high blood pressure and poor kidney function, and in the past he had suffered a heart attack and a stroke. Could the surgeons safely operate?
In most cases, surgeons have to actually see a patient to determine whether the benefits of surgery outweigh the risks. But in this case, a senior surgeon, on the basis of the file alone, said the patient was too “high risk.” The reason he gave was that state agencies monitoring surgical outcomes would penalize him for a bad result. He was referring to surgical “report cards,” a quality-improvement program that began in New York State in the early 1990s and has since spread to many other states.
The purpose of these report cards was to improve cardiac surgery by tracking surgical outcomes, sharing the results with hospitals and the public, and when necessary, placing surgeons or surgical programs on probation. The idea was that surgeons who did not measure up to their colleagues would be forced to improve.
But the report cards backfired. They often penalized surgeons, like the senior surgeon at my hospital, who were aggressive about treating very sick patients and thus incurred higher mortality rates. When the statistics were publicized, some talented surgeons with higher-than-expected mortality statistics lost their operating privileges, while others, whose risk aversion had earned them lower-than-predicted rates, used the report cards to promote their services in advertisements.
This was an insult that the senior surgeon at my hospital could no longer countenance. “The so-called best surgeons are only doing the most straightforward cases,” he said disdainfully.
Research since then has largely supported his claim. . .
In effect, the operation of a grading/ranking system creates perverse incentives that lead to lower quality medical care.