Category: In the News (page 1 of 2)

A Pre-existing Dilemma

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Tom is a forty-three year-old self-employed painter and father of two.

He’s currently in remission from lung cancer, having been first diagnosed five years ago. At the time of his diagnosis, he did not have health insurance.  Thankfully, for him, American law had finally made it illegal for health insurance companies to discriminate against individuals with preexisting conditions.

This means Tom had to be offered insurance at community rates. And, this was a good thing for him. His medical expenses exceeded $100,000 annually for his first two years of treatment. No one deserves to go without care for a serious medical condition.

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Jenny is a married mother of two.

She in employed by a local small business where she has worked for the last 12 years. Her daughter has an uncommon but treatable blood disorder that requires occasional laboratory testing and infrequent blood transfusions.

Jenny’s employer has provided for the health insurance of both Jenny and her daughter for the last decade. It has been a part of Jenny’s benefits plan.

Unfortunately for Jenny, over the last few years, the cost to her employer to provide this plan has risen dramatically. The small business she works for has had no choice but to pass down many of these rising costs to her.

Jenny now pays her employer a markedly higher monthly premium for her family to be included on her plan. Her medical deductible is 10 times what it was just six years ago. And, her coverage is far worse.

Forced to cut costs even further last year, her employer only offered insurance options with more narrow networks of physicians. Jenny is currently driving 90 minutes for her daughter to receive the specialist care she requires. Five years ago, she drove four miles down the street.

Thankfully, Jenny has still found a way to make ends meet despite these obstacles. But, next year is looking to be even worse regarding the cost and quality of her insurance.

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Healthcare is once again a major focus of political conversation, so it’s important we understand a few things.

Our President-elect has said he will work to repeal “Obamacare,” but at this point, the details are not clear. Will his replacement product be better than what it’s replacing?

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Evidence Based Medicine & The Art of Flipping Coins

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It’s become a major problem in our quest to obtain a perfect healthcare system.

It’s called science.

Now, don’t get me wrong. I have nothing against observation and experimentation. But, since blind pursuit of anything can lead to destruction, it’s time to take more notice.

To be fair, it’s not science, per se, we are talking about. It’s our interpretation of it—how we perceive its role to be within the framework of medicine.

I’ll begin with a simple illustration.

I will flip a coin 10 times. I will tabulate the number of instances the coin returns heads or tails. Then, I will repeat the experiment 10 more times.

In fact, here are the results:

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How Arbitrary Feels

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We are assembling too many panels of people in the name of health these days. Too many.

They usually seem like a good idea. I’ve been supportive before. I assumed we needed them. More of them.

I might have been wrong.

There was a day when I believed my food would be toxic, my medicine harmful, and my safety gone without them. But, I’ve come to believe I was mistaken.

I was wrong because the medical world is now full of panels. And, paradoxically, it seems more confusing and arbitrary than ever before.

Recently, I’ve taken some interest in economics. I thought I understood it before. That was when I didn’t understand it at all. I used to believe the goal was to create jobs, since jobs obviously drive the economy. I was almost on the right track. Until I realized I wasn’t tracking at all.

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Open Letter Response to CMS on MACRA & MIPS

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My recent post appeared to catch the attention of Mr. Slavitt, Acting Administrator for the Centers for Medicare and Medicaid Services (CMS):

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My article recapped another day of insanity within our healthcare enterprise, and yes, taking a look, Mr. Slavitt, would be greatly appreciated.

Choosing to see, however, is my challenge for you—for as a friend reminded me, you seem to be very good at “feeling our pain.”

But, I must admit, thanks to you, I was contacted by a CMS official overseeing the startup of MACRA.

For those that don’t follow healthcare policy closely, MACRA is our government’s latest medical project. Another soon-to-be-implemented healthcare law with 962 pages of rules, including the most recent method devised to pay physicians, something known as the Merit-Based Incentive Payment System (MIPS).

CMS was seeking my perspective on MACRA and MIPS.

My written response to them—edited only somewhat for brevity—is shared below:

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The Bullfight For Evidence

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It’s been a chatterbox kind-of-week for evidence-based medicine.

First, an article appeared in the New England Journal discussing its limitations. Then, a rebuttal came from an established bull in the China shop, and we were well on our way. Ultimately, all sides made a point.

Seemingly bored by the chatter, however, may have been Medical Progress herself. She has and will continue to move forward on her own terms—sometimes with and sometimes without randomized controlled trials.

There are not many novel ideas to discuss here. Evidence frequently has claimed to be guiding medicine. Sometimes it has originated from the experience of a single person or two. Sometimes pseudo-clarity has required the trials of ten-thousand. Only very recently has evidence even existed for some in hierarchical structure—”hard” or “soft” these people now say.

But, what does “hard” or “soft” evidence really mean anyway? And, who gets to define these terms?

The policy makers?

The New England Journal?

The bull? The baker? The candlestick maker?

Almost contrary to what the gnostics of evidence proclaim to be best, the majority of individual medical decisions are made using so-called “soft” evidence. And, no, this isn’t some atrocity.

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Creating Our Own Hardships

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I enjoy documentaries. My wife says she enjoys watching them with me. The way I usually see it, they help her fall asleep.

But, not this one.

Not Poverty, Inc.

If you haven’t watched it, you should. We both enjoyed it.

It’s not one of these pick-a-political-side kind of shows. For the record, people across the political spectrum have endorsed it. The film has won like forty honors and twelve awards that I know absolutely nothing about. But, if you watch it, you’ll get the gist why.

We occasionally need disruptive thinking. Something to challenge our perception of reality. We actually need more of this when contemplating healthcare delivery, too. But, I’m not talking about that right now.

Poverty, Inc. is about poverty… and the humanitarian aid we use to fight it.

It’s also about government. And, business. And, how the collusion of these things isn’t solving poverty at all. Like I said, you should watch it. It provides you a fascinating perspective.

I won’t give it all away, but there are a few predominant themes that unfold in the film as you watch it.

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To be Great is to be Misunderstood

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In this post, I examine the firestorm surrounding Dr. Lisa Rosenbaum’s article, N-of-1 Policymaking — Tragedy, Trade-offs, and the Demise of Morcellation, which was published in the New England Journal of Medicine in March 2016. To appease the medical pious everywhere, I disclose that I have never met Dr. Rosenbaum in person. I do follow her on twitter @LisaRosenbaum17. I have no financial stake in power morcellation, a medical procedure that I will discuss below. And, yes, I dislike bullies. 

Mostly normal people leading normal lives don’t speak out very much.

They just sit there. They read stuff. They watch news stories.

They may very well be engaged with a topic. But, they will infrequently write reviews or give comments. That kind of stuff usually always comes from the extremes. And, as you know, the extremists either love you or they hate you.

Dr. Lisa Rosenbaum got the extremists juiced up earlier this month by writing an article about the tradeoffs and demise of a medical procedure known as power morcellation. If you’re a normal person that happens to run in my professional circle and have been following this saga, I suspect that you have moved on. That’s what normal people do with non-stories.

If, however, you are an extremist, you continue to write about it. That’s me.

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The War on Judgment

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wrote previously about the ongoing federal approval process for a medical device known as the WATCHMAN™, now available to treat certain patients at risk of stroke.

As expected (and really just because it’s how things get done around here) the Centers for Medicare and Medicaid Services (CMS) has compiled a 32,000 word decision memo related to how it intends to pay (if at all) for patients receiving this approved device. This memo is commonly referred to as a coverage determination.

A thoughtful piece was also written recently by Dr. John Mandrola on this very topic. He and I usually share many of the same goals, although admittedly, we differ from time to time on how best to obtain them.

Regardless, Dr. Mandrola’s piece is full of clarity and is very supportive of CMS’s intent to require an evidence-based formal “decision tool” to be used by the physician and the patient prior to implanting the WATCHMAN™.

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Perspective For All (It’s Free!)

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Sometimes perspective is helpful.

Even when given just a little bit of it.

Presidential candidate, Sen. Bernie Sanders, has recently released his “Medicare-for-All” plan. Similar to his make college education free plan, there are a number of things admirable about it. No healthcare deductibles. No co-pays. No fighting with insurance companies. We all get, seemingly for “free,” whatever the government thinks we need.

And, I get it. In 4th-grade, I once ran for student council touting a “No Homework For All! slogan. I’m not even saying this is the same strategy being used by Sen. Sanders. Instead, I’m just trying to imagine the ideal:

A world where all of us have (1) the healthcare we need, (2) when we need it, (3) at the most reasonable cost to all of us, collectively.

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