swimming to shore

When I experienced an injury that was temporarily disabling, I had certain expectations of what was to come that I now realize were not helpful.

I originally thought that my recovery would be like flying on a plane. Transportation (in other words, my progress back to health) would be essentially passive; the discovery several months in that my injury was more severe than originally thought would be merely a diversion to another airport en route for bad weather (round two of surgery); and it would be clear when I had reached my destination and would be able to disembark. Oh, and I would be able to get work done inflight.

Well, it hasn't been like that.

The last year or so has been more like swimming across a lake fully clothed. Transportation (making progress back to health) has been arduous. Just when I thought I was reaching the shore, the water got deeper on me again. I'm back in shallower waters again, feeling my feet on the ground, but I'm still struggling to get to dry land with waterlogged clothes. I can't tell for sure where the edge of the water actually is. And trying to get all the way out of the water is still requiring all my concentration (heck, I still can't walk and talk at the same time), so I'm not getting anything else done. Which is a constant disappointment to me.

I imagine those around me have been puzzled as well as disappointed in my persistent lack of productivity, but I now realize: they think I've been on a plane, but all along I've been thrashing around in the water.

financially-driven medical decision-making

One of my assumptions about medicine is that continuity of care--that is, working with the same set of providers for a long time--has benefits. They flow mostly from the trust that is established with a primary provider, but can also come from information-sharing. This is something I really work at: I took my kids to the same pediatrician and followed him from a convenient office near our house, to a less convenient office in another suburb, to a really inconvenient one in yet a third for twenty years. I also make sure records get sent between specialists, etc., etc. IOW, I'm kind of a pain in the ass in the interests of making sure me and mine are well-cared-for.

I need to have a dilated eye exam every year because of one of my chronic conditions, and I'm due for that exam now.

I went to the same ophthalmologist for many years (as have my other family members who need eye doctorin'). He dropped out of our network last year, for which I do not blame him one bit.

Because I don't need my current doc's artistry with vision correction any more, having two bionic eyes, I found a new guy in the state to which I am moving by referral from my main provider in the new state a few weeks ago. I made an appointment for September (the earliest available) to establish that new, coordinated relationship.This was a little later than ideal, but I can live with it.

Found out yesterday, however, that our high deductible, which we have already satisfied for 2017, *resets* at the end of July. So my options are: (1) go back one last time to my long time guy, and pay the high out-of-network rate; (2) keep my September appointment with the new guy and pay his in-network rate, but applied towards our reset deductible; or (3) find a rando in-network before I move, and have a single eye exam at the cost of our modest co-insurance. It's a several-hundred dollar decision.

After due consideration, I conclude that establishing a relationship with my new eye guy next year rather than this year, since I'm not having eye problems right now, is probably not worth paying that much. Sigh.

The layer of complexity that financial considerations add to what should be a simple scheduling decision is exhausting at times.

we must all cultivate our gardens

As it turns out, the federal government is heavily involved in managing/subsidizing crop insurance for producers. "Under the Federal crop insurance program, private-sector insurance companies sell and service the policies, and USDA’s Risk Management Agency develops and/or approves the premium rate, administers premium and expense subsidies, approves and supports products, and reinsures the companies."

It's easy to see why the federal government has stepped in to play a role in this. After all, if our farmers go out of business, and there is a famine because there are no farmers to grow our food, people will die. We certainly want to prevent starvation. Well, I do. Maybe some will extend the free market even this far, but I personally will draw the line well before famine as a market correction tool.

As I understand how the crop insurance program is administered, we don't spend a lot of time worrying about whether the farmers are bad farmers. We don't moralize about their poor crop choices. We just insure them, because a harm to the farmers is a harm to the public if there is not adequate food.

If you agree that the federal government has a legitimate role in providing crop insurance, but does not have a legitimate role in providing health insurance, please explain how you view the goals of these two programs as differing. Because it seems to me that although people die more quickly from lack of food than lack of health care, they do die from both. Although I suppose you have to offset the number of people who die from botched health care annually.

In the case of both food and medical care, insurance provides the safety net for our economy as currently structured. If you're okay with one, why not the other?

suppose it's an obligation, and not a right?

Suppose we frame the current health insurance* debate in a different way?

*It is about insurance. "Health insurance"=/="health care," although the former should lead to the latter.

Rather than arguing whether American individuals have a right to health care (beyond what you can already find in EMTALA, and please God let's not consider repealing that), because people get very huffy about this concept, can we ask a different question?

Should we Americans collectively assume an obligation to "promote the general Welfare" by providing everyone access to basic health services, in the way that we have obliged ourselves to provide all children with access to a free public education (largely from each state's constitution, with the exception of protections for disabled children)?

Consider this: we have already agreed, by enacting EMTALA in 1986, that as a society we don't want to see people die because an ER turns them away if they can't pay. We have already assumed that obligation. But waiting until people are very nearly dead before we assume any obligation for their care is extremely expensive, and in the case of many ailments, just cruel. Think heart disease. Think diabetes. Think cancer.

We have already agreed, by enacting mandatory vaccination laws (although we have wobbled a little on this one with exemptions), that we have an obligation to protect the herd by requiring this simple public health measure. We also have quarantine laws to fulfill our obligation.

We have already agreed that we have an obligation to provide safe water to all (coughs Flint coughs), also pretty basic for health.

We have also agreed, via our Supreme Court, that it is a violation of the Eighth Amendment prohibition against cruel and unusual punishment to deprive prisoners of necessary medical care in Estelle v. Gamble, 429 U.S. 97 (1976). Let me repeat that. People in prison have a right to medical care (although even they can be charged co-pays).

It does not seem like that far a reach to propose that we have an obligation (collectively) to provide people who are not incarcerated access to health care before they show up at the ER, if for no other reason than to reduce the expensive ER visits that we are already obligated to fund.

Given the way our system is currently set up, rather than nationalizing the health care system, which sounds like quite the disaster, or providing everyone with a government doctor (which also sounds like a disaster, given how the VA has been struggling), making sure everyone has health insurance coverage seems the least disruptive path. Although nationalizing the insurance companies has a brutal appeal to me, and eliminating the middlemen in the long run through gentler measures will probably be helpful.

So for those of you who don't want to grant other people individual rights in this area, ask whether you might be shirking the societal responsibility that you have already undertaken. And see also this interesting analysis of the free rider problem in this area.

Not your brother's keeper, you say? Can we have a talk about the corporal works of mercy?

bite me

I had what should have been a routine dentist's appointment a few days ago that ... wasn't. It took me a while to figure out why this bothered me so.

I live in an upscale suburb of a major metropolitan area. The area is rife with dentists, all of whom are trying to outdo each other in their luxe experience, starting with a fancy lobby with a nicely stocked refrigerator, continuing on to the offering of a wide array of cosmetic services (whitening, veneers, Invisalign) to creature comforts such as warm blankets and sedation.

Until this week, the practice I selected (which I shall not name) just cleaned and examined my teeth and otherwise more or less left me alone (they replaced an ancient filling last year to keep a tooth from falling apart). My teeth are straight enough, and they are as white as I can ask them to be given my love of coffee. My fading beauty is unlikely to be revived by any changes to my teeth, and no one there ever pushed cosmetic dentistry on me. I suppose this makes me a not particularly lucrative patient.

This week, I had my teeth cleaned by a dental hygienist who is new to my dentist's office. I will give her credit for two things: she was very personable, and she did not push cosmetic dental services on me.

But.

We began on a strange note. Although I arrived at the office when it opened, right on time for my 8 a.m. appointment, she asked if she could take a moment to brush her teeth before we got started. I said, "Sure," because I'm not a monster, but at the time I wondered why she couldn't have done this before work. My appointment began about ten minutes late because of this.

I needed to give her significant updates to my recent history, including my second round of orthopedic surgery after my last dental appointment in October, and my stellar current A1C.

The hygienist took one look at my mouth and we were off to the races. She told me that I should have the dentist replace all my "silver" (more properly called amalgam) fillings, because "we don't like to see people with more than one or two." She said that they "probably" had decay underneath them. Mind you, there was no sign of decay in my bitewings taken six months ago, and no mention of decay by the dentist, so it was unclear on what she was basing her conjecture. In looking at this babe's blog afterward, I confirmed that she recommends removal of amalgam restorations because she deems them to be "unsafe." The American Dental Association says that this is unethical.The research she was touting to "prove" the lack of safety was an associational study of mercury levels in people with more than eight amalgam restorations (from what I can tell through the paywall). Which is not me. But I digress.

At this point, I felt like saying, "Excuse me, I did not realize that today's quiz was going to be on amalgam restorations. I only studied the material on fluoride. This is not fair."

Then it got stranger.

After checking my tongue, which I naively assumed was for signs of oral cancer, she informed me that I had a "moderate tongue-tie" and recommended that I have a lingual frenectomy. As she rattled off the problems caused by ankyloglossia, I couldn't help but notice that they were largely moot, for example difficulty in nursing. I contented myself in telling her that my mom had not reported any difficulty in nursing me when I was an infant. Meanwhile, the clock was ticking, and she still had not touched my teeth.

Next, she took a sample of plaque from my mouth (finally! She picked up an instrument!) and put it on a slide to inspect with her phase contrast microscope. "Say," I said, "I have never seen one of these in a dentist's office before," thinking that this was a new practice. She proudly informed me that she had been using this microscope in her work since 1985. I have been in various dentists' offices frequently since 1985. If no one else is doing this, that tells me something about the value of this practice.

After cleaning my teeth, the hygienist showed me the "bugs" (her term) on the slide, and pointed out a spirochete, a few white blood cells, and a few red blood cells for me. Did she think I was still blissfully unaware, at the age of 58, that the human mouth has bacteria in it? What made me even more skeptical of this piece of dental theater was her followup that if I had a healthy mouth, we "wouldn't see any movement" on the slide. Huh, so my mouth will be a sterile field? Right. She didn't make any attempt to quantify the bacteria, identify them specifically or record her observations in my chart. Since then, I have tried to determine to what uses a phase contrast microscope is typically put in clinical dentistry. The most honest article I found came right out and called it a "highly useful motivational tool," which the other articles I found in places like Dental Economics also implied. Okay then. It's show-and-tell.

She dispensed with taking any actual measurements of my periodontal pockets with a probe, the tedious process with one person calling out numbers to another who records them, probably because the dentist was not there. She opined that there were "changes" in my gums since they were checked in "2005" (actually, it was 2016, oops!) and that I now had periodontal disease. This meant, she said, that I would have to come back for an hour-and-a-half appointment, which might not be covered by insurance, of course, we would then come up with a "plan" for "oral wellness" for me, and she would be my "oral health coach." Then she hustled me out the door. I never saw the dentist, who had "not arrived yet" by the time I left. In other words, a dental hygienist had just diagnosed me with a condition, which is beyond her scope of practice (she is allowed to inspect and measure my periodontal pockets, but not make a diagnosis).

At this point, I figured that my situation must be dire, and expected an immediate recall appointment with the actual dentist for the massive overhaul of my mouth that was apparently necessary. Imagine my surprise when the receptionist booked me six months out. Not a dire emergency after all. I have, of course, canceled that appointment already.

Now that I have had the opportunity to reflect, here is what bothers me about this dog's breakfast. It had surprised me to hear that my gums looked worse than the last appointment (assuming for the sake of argument that her perception was accurate). After surgery in December that put me on crutches, I started flossing a lot, because there wasn't much else I could do, so I had been expecting a glowing report. Rather than exploring possible causes of this condition with me further, however, I gather she assumed that I am just bad at oral hygiene. She quickly loaded me up with a ton of new tasks, some of which contradicted what the last one had told me, so she could get back to the important work of trying to upsell me on her "oral health coaching" using meaningless demonstrations.

What she didn't bother to understand about her own patient is that the cumulative complexity of my medical care is already high. It was arrogant in the extreme for her to presume that I would want to place her in the center of my medical care as my savior, when in fact I am already working with a health coach, dietician, physical therapist, surgeon, pharmacist, primary care physician, ophthalmologist and dentist as necessary. This hygienist is not going to become the star of my medical show.

I am grateful, though, to her, in the end, because in hate-reading her blog, I picked up on something that she could have realized if she'd just stopped blathering for a moment and listened to me more carefully.

From my history, she knew or should have known that I am on several medications, middle-aged, and have type 2 diabetes. I think I shrugged when she asked about dry mouth, which is very common in type 2 diabetes, although the research is lousy. I have been thinking about that question, however, and realized that I frequently do feel what I have been interpreting as slight thirst, but could just as easily be dry mouth (subjective) or hyposalivation (objective). Further research also tells me that hyposalivation can be present without the perception of dry mouth. Compared to my ongoing recovery from reconstructive surgery, it has been a trivial annoyance and easy to ignore, but it can have consequences.

All the flossing and water-Piking in the world can't be expected to address my gum problems if I don't address my hyposalivation as well (if in fact I have it). I, therefore, as the director of my own healthcare, have started simple, harmless treatments for my (possible) dry mouth, with only indirect thanks to the hygienist. We will see what the next dentist says.

And I can hardly wait to see what's on my EOB.

on mandates, and mandates

Let me begin with a rant.

Look, I know headline writers and Twitterers have to shorten stuff up.

But let's keep in mind that reforming "health insurance" is not the same thing as reforming "health care." Because insurance for care is not the care itself.

Is the cost of care relevant to the care that people get? Of course! Do insurance companies effectively practice medicine when they deny coverage for expensive treatment? You betcha!

But relying on changes to only one component of a very complex system to produce systemic *and positive* change strikes me as ... overoptimistic.

Words are all we have to articulate our goals. Let's be clear about what our goals are.

Now that I have that out of my system, let's talk for a moment about mandates.

No, not that mandate. I want to talk about the mandate that, if you own a motor vehicle in the United States, you, generally speaking, have to have a verifiable way of making good on the damage that your car does to other people and property. The way vehicle owners do this varies from state to state. In most states, it's through automobile insurance. In Virginia, if you "go bare," you have to pay the state an annual $500 fee. Mississippi lets you post a bond (which is just another form of insurance if you squint at it) rather than purchasing conventional auto insurance. New Hampshire only requires you to carry auto insurance if the state concludes you're at high risk of damaging somebody.

The general principle is this: you are required to carry auto insurance (or its equivalent) to protect other people from your screw ups. And it's prudent, frankly to have auto insurance to protect yourself from your own. As far as I can tell, the idea that you have to carry auto insurance to protect other people, that is, the general public, is not particularly controversial.

What is a requirement to carry insurance? It is a mandate.

Fast forward to the much more controversial mandate to purchase health insurance, or pay a penalty to the feds--much like the Virginia uninsured vehicle requirement above.

The most commonly-heard argument for the mandate has to do the economic necessity of getting young healthy people buying insurance they probably won't use to pay for the cost of old sick people using the heck out of their insurance. That isn't what I want to discuss in this post.

There is an entirely different risk-sharing/policy setting issue. Maybe it is discussed a lot and I've been missing those discussions.

Let's consider a young person. Our hypothetical young person ("HYP") is healthy, living independently, but of modest means. HYP therefore does not purchase health insurance, because it seems to be an unnecessary expense in a tight budget. HYP is gambling. Oh, sweet bird of youth!

On a dark and stormy night, HYP, crossing the street in a clearly marked crosswalk, is hit by a speeding car which vanishes into the night (because this is a hit-and-run, we can't file a claim against the motorist's theoretically mandated automobile policy--if he or she even has one). HYP is rushed to the emergency room and proves upon examination to have a shattered pelvis, a ruptured spleen, a lacerated liver, and a possible concussion, and is also noted to have a blood glucose level of 330, suggesting hitherto-undetected type 2 diabetes. Okay, the last is piling on a little bit.

Now. As a policy matter, we decided as a society in 1986 that the public should have access to emergency services regardless of ability to pay, by means of a federal statute known as the Emergency Medical Treatment and Labor Act ("EMTALA"). So the ER doesn't demand insurance information or cash up front from HYP, which is good, because HYP is unconscious and losing blood rapidly. The hospital just treats HYP. Because really, what is the alternative? Should we as a society say that it's OK to let HYP die? Or do we as a society assume the cost of HYP's care, one way or another?

Because HYP doesn't have health insurance, HYP can't get the negotiated in-network rate from the hospital. In a certain sense it doesn't matter, though, because HYP is of modest means, and couldn't pay even the in-network rate, let alone the hospital's pretend rate for the uninsured (which is another complex issue for another day--what are the hospital's actual losses from uncompensated care).

Patching HYP up even to the point where s/he can be discharged from the hospital is going to take some time. Meanwhile the bills are racking up, up, up. HYP might qualify for "charity care," depending on state law, or HYP can discharge the bills for the uncompensated care in bankruptcy. In either case, we as a society bear the cost when HYP gambles and loses. I personally would rather we bear this cost, as a policy matter, than let HYP die, or create a culture where we encourage our HYPs to just die already to save us all money. Having said that, I would still like to see a better method of risk distribution than we have now.

In the public debate, I see an occasional (well, okay, frequent) strain of blaming the sick for being sick, which I think is quite unfair, for no other reason than that accidents happen (speaking as someone who incurred a catastrophic injury in the blink of an eye last year). And people fall victim to bad genetics all the time.

In the realm of automobiles, Americans as a society have come to accept that accidents happen, that you're not "bad" just because you cause financial losses with your car, you just have to be a responsible adult and make arrangements for the unexpected. We agree as a society (other than New Hampshire, where you live free or die) that the "arrangements" should be auto insurance.

In the realm of bodies, it would make sense for Americans as a society to accept that accidents happen, that you're not "bad" just because you cause financial losses with your body (by having unexpected medical expenses), you just have to be a responsible adult and make arrangements for the unexpected. We clearly do not agree as a society that the answer is health insurance, even though having health insurance can protect other people from catastrophic losses.

I am not sure why.

Perhaps it is because insurance is such a boring subject.

the solution never works if you haven't identified the problem

I have a bias, I admit it. I am sensitive to studies with a subtext of "those stupid patients, what are we going to do about them?" Read the following rant with that in mind.

A pharmacy benefits manager a/k/a PBM funds a study of patients nonadherent to chronic prescription medication. The premise of the study, Effect of Reminder Devices on Medication Adherence: The REMIND Randomized Clinical Trial (hiding behind a paywall, by the way), is that "forgetfulness is a major contributor to nonadherence to chronic disease medications and could be addressed with medication reminder devices." Thus, the intervention consisted of sending a population which included folks taking meds for schizophrenia and bipolar disorder either "a pill bottle strip with toggles, digital timer cap or standard pillbox" along with their mail order meds. There was of course a control group who received neither notification or a device. Surprise, surprise! Getting a prize in your Crackerjack box from your PBM does not improve medication adherence. Those stupid patients! Why won't they do what's good for them?

Well, let's take the most basic first step and look at the evidence that the REMIND paper cited in its very first footnote to support its premise that patient "forgetfulness" is the problem. The paper cited is not, thank you very much, behind a paywall. Its very title should have been a tipoff: "Unintentional non-adherence to chronic prescription medications: How unintentional is it really?" This study concluded that "For our study sample, unintentional non-adherence does not appear to be random and is predicted by medication beliefs, chronic disease, and sociodemographics. The data suggests that the importance of unintentional non-adherence may lie in its potential prognostic significance for future intentional non-adherence. Health care providers may consider routinely inquiring about unintentional non-adherence in order to proactively address patients' suboptimal medication beliefs before they choose to discontinue therapy all together [sic]" (emphasis added]

Reading further in the paper I've just linked to (which I highly recommend you do), "medication beliefs" include such things as "perceived need for medication"--statins, anyone?--and perceived medication affordability.

Let's go a little further and consider something obvious about clinician-patient dynamics in an era of managed care. How many clinicians take the time, or have the time, to initiate a thoughtful discussion with a patient regarding the benefits and risks of a course of long-term medication being recommended? A statin, say, or low-dose aspirin for primary prevention, in someone who feels just fine? How many patients will push through the clinician's subtle (or not-so-subtle) signals that s/he is pressed for time to initiate and then persist in a discussion, which might persuade a patient on the fence about the recommendation that there is an actual need for the medication? Or might even lead the patient and provider to jointly conclude that this long-term medication is not, after all, warranted?

Consider this: the more important you believe something to be, the easier it will be to remember to do it. "I forgot" is a convenient excuse we offer, after all, to our doctors. It is more polite, and less time-consuming, than initiating an uncomfortable conversation by saying, "I don't see the point of this/I am experiencing unpleasant side effects/I cannot afford this/I am overwhelmed by the 'treatment burden.' " Such comments can be taken as a direct challenge to the provider's authority, although they might stem from the provider's failure to communicate with/empathize with/educate the patient adequately in the first place.

A patient on insulin therapy is unlikely to forget to use insulin. It's obvious that insulin is important. This suggests another possible flaw in the study design. It excluded patients taking more than three medications, apparently because their dosing regimes are just too complicated (math class is tough!). It would be interesting to learn if patients taking more medications might actually be more adherent because they feel that the stakes are higher. Alas! We will never know, at least from the authors of this study hellbent on reminding these silly patients who just cannot remember what is good for them. Although the study design notably did not include smartphone apps such as Mango Health that "gamify" taking medications and could use more investigation.

I feel compelled to point out as well that patients getting their meds mailed from their PBMs are by definition not in regular contact with an overlooked, underrated member of the patient's care team: a flesh-and-blood pharmacist who reinforces dosing instructions, and provides that human touch. Yes, it is possible for a patient to make contact with an actual pharmacist at a PBM, but I wonder how many nonadherent patients are aware of that.

I should finally note that many patients view PBMs as an arm of their insurance company (which in fact they are) and may have viewed what appeared to be medical advice coming from their insurer as inexplicable and suspect. Indeed, "[b]ecause the study devices are currently available for commercial use and because participants received the devices by mail and could choose not to use them, patient-level consent was waived by Chesapeake Institutional Review Board." Not obtaining consent may have made the study less useful, but I'm sure it was cheaper, amirite?

The writeup of the REMIND study grudgingly concedes towards the end that "because nonadherence is a multidimensional problem, addressing forgetfulness alone may have been insufficient to improve actual medication taking." This spectacularly misses the boat. Because it's not truly a problem of forgetfulness at all.

when a provider gets it right

I sent a thank you note today (from time to time, I like to use my powers for good).

Dear Doctor X [Chief of Anesthesia at Big Hospital]: I wanted to take this opportunity to commend your entire team for its thorough engagement with me after my inquiry about glucose control protocols while I prepared for my most recent surgery at Big Hospital at the end of last month.

Doctor Y herself [Head of Preoperative Clinic] took the time to review my preoperative instructions with me the week before surgery, including explaining the rationale behind stopping supplements, etc.  On the morning of my procedure, which was mercifully scheduled as first case, Ms. Nurse Manager made it a point to introduce herself upon my admission to the pre surgery unit and to explain the improvements that Big Hospital is making, giving me the chance to calibrate my home meter against the first reading taken. I noted also an intraoperative and a postoperative blood glucose reading in eCare. I would like to commend your team for their thoroughness in my treatment, which I know encompassed much, much more than blood glucose monitoring, and their detailed record-keeping.

As a person with diabetes, I am accustomed to managing my own condition for the 99% of the time that I am not in contact with the medical system. I take this responsibility seriously, and so I am prone to remain somewhat vigilant even amidst the medical system absent a very clear handoff. It was a relief to be able to turn over the reins, so to speak, of my diabetic care with confidence for the time when I was unconscious.

Finally, I remain impressed that the "Patient Feedback" button on your department's website goes straight to the top. It speaks well of you and your team that you seek to interact with patients without hiding behind rank. I can only say that my anesthesia experience has proven very positive and I thank you all sincerely for your efforts, your time, and your knowledge and skill.