Benefit Concert for Africa Surgery in Morristown, NJ

Dicey Riley Band

To present a BENEFIT concert for Surgical Efforts in Sierra Leone, West Africa

Featuring Traditional Irish and Celtic Music and Song, Plus the

Bethel AME and Assumption Children’s Choirs

Singing selected choral works

Refreshments donated by parishioners

Saturday, May 12, 2012, 7:30-9:30 pm

Assumption Church

91 Maple Ave., Morristown, NJ 07960

Suggested donation: $15 per adult, Children Free

All proceeds go directly to procuring badly needed medical care and surgical

Treatment for poor farmers and villagers in Sierra Leone.

For more information call, 973-539-2141

[Ed. Note: I've said it before and I'll say it again: Africa Surgery does God's work. They accomplish a great deal with very little.]

The New York Times Hasn’t Scratched the Surface: For-Profit Catholic Healthcare

President Obama has begun the process for healthcare reform by improving access through insurance reform, but achievement of his aspirations will require reform of our healthcare delivery system as well.  Changing where and how healthcare is delivered and paid for is of particular importance given the emerging and generally non-acute needs of the aging baby-boomers, and the lack of sufficient primary care to serve the many who will become insured as health insurance reforms are implemented.  Healthcare providers realize this, and the market is indeed adjusting as we speak.

Three examples of these changes to the delivery system include, first, moving much of the delivery of services out of hospitals and into the community.  Healthcare systems are rapidly affiliating with or employing physicians to facilitate this change, in the hopes of enabling the various parts of the health care system to work more collaboratively, efficiently and cost-effectively.  In many parts of the country, hospitals have been too cash-strapped to invest in necessary updating to their hospital facilities. Now that we are thinking differently about how to use the physical plant that hospitals occupy, and investing in new technology, these investments need to happen.  As a third example, President Obama is infusing money into hospitals and physician offices to enable the United States to catch up to other developed nations in the digitizing of its medical records.  The benefits of this change are numerous, but it is a very expensive transformation.

In order to provide quality service and compete in the fast-changing healthcare market, hospitals and the systems of which they are a part, need money to pay for these changes.  A February 21, 2012 New York Times article on the expansion of Catholic hospitals provides a glimpse of this phenomenon of market reform.  Cash-poor hospitals unable to access capital to invest in the new initiatives necessary to keep them competitive are looking for financially stronger partners with this investment ability.  There are currently 56 Catholic healthcare systems in the country, ranging from the financially successful to the distressed.  Thus it is unsurprising that a potential partner for some hospitals might be found among Catholic systems.

But there are some Catholic providers who are struggling and require an affiliation to survive; other Catholic providers are simply considering alternative business models which might provide more market flexibility as well as increased options for access to capital.  The former Catholic Healthcare West is an example of the latter situation.  CHW was sponsored by six religious orders and operated 25 Catholic and 15 non-Catholic hospitals; just weeks ago, it announced changes to its name — it is now Dignity Health — and its corporate and governance structures.  The parent holding company for Dignity Health is no longer Catholic, and is no longer sponsored by the religious orders — those orders now sponsor directly the Catholic hospitals that are part of Dignity Health.  These Catholic hospitals adhere to the Ethical and Religious Directives for Catholic Health Services, of which each hospital’s local bishop is the ultimate arbiter.  The non-Catholic hospitals adhere to a Statement of Common Values, which preclude assisted suicide and euthanasia, as well as pregnancy terminations and assisted reproductive procedures that deviate from Catholic teaching; the Statement of Common Values does allow the performance of direct sterilizations, which is something precluded at Catholic hospitals.  I would venture to say that many, whether Catholic or not, likely embrace the content of this Statement of Common Values.  I would also suggest that many secular hospitals operate according to similar policies, but it just doesn’t get talked about.

The religious orders hope to perpetuate their evangelical influence on the culture of Dignity Health and its constituent non-Catholic hospitals — if successful, I would suggest that this will be an important and significant contribution to those providers who are the beneficiaries of the Catholic ethos of healthcare delivery, because it can be transformational.  The change from CHW to Dignity also sought to clarify the confusion among patients about which hospitals are Catholic, and provide market flexibility with respect to future affiliations with service providers.    A statement by San Francisco Archbishop Niederauer provides a helpful description of the reasons for Catholic Health West’s transformation to Dignity Health, and the process by which deliberations occurred.

Other Catholic hospitals are engaging in even more “radical” transformations in order to put themselves in a position to survive and/or thrive in the emerging healthcare market.  After years of unsuccessful attempts to prop up the six Boston-area hospitals that comprised Caritas Christi Health Care, Cardinal Sean O’Malley surprised many when he agreed to sell the system to Cerberus Capital Management, which is a private equity firm.  The system was burdened with debt, its pension was underfunded, and its physical plant was in desperate need of significant upgrades. The sale to Cerberus transformed this Catholic health care system, now named Steward Health Care System, to a for-profit Catholic health care system. Cerberus agreed to ensure that the Steward hospitals adhere to the Ethical and Religious Directives, subject to the authority of the Cardinal who has the power to strip a hospital of its Catholic status, as happened to a Phoenix Catholic Healthcare West hospital, St. Joseph’s, in 2010, over a disagreement regarding an interpretation of the Ethical and Religious Directives regarding abortion.

Cardinal O’Malley was not the first person to find salvation for financially distressed hospitals in the private equity world.  St. Vincent’s Hospital in Worcester, Massachusetts is owned by for-profit Vanguard Health Systems of Nashville, which owns both Catholic and Baptist hospitals, primarily in the south and west.  And Ascension Health, the nation’s third largest health system with a 2010 net income of $1.2 billion has teamed up with Oak Hill Capital Partners to build a new for-profit enterprise with an eye towards “offer[ing] a lifeline to capital-starved Catholic hospitals.”

Myriad questions arise from this new mechanism for infusing capital into Catholic healthcare.  No precedent exists for a Catholic for-profit healthcare ministry.  In terms of the issue about access to services raised by the February 21 New York Times article, “Catholic Hospitals Expand, Religious Strings Attached,”  it is likely that the public will become even more confused about what rules govern hospitals as for-profit systems include both Catholic and non-Catholic entities.  While the interpretation and application of Catholic teaching will vary by diocese and the deal reached by the parties, it is certainly possible that, as was the case with Catholic Healthcare West (now Dignity Health), some or all of the Ethical and Religious Directives will be extended to the secular hospitals which are part of any system that includes Catholic facilities.  This makes sense, as Catholic teaching encourages Catholics to distance themselves from acts which are deemed immoral.  Sometimes, the act in question, such as abortion or euthanasia, is held to be so fundamentally immoral that Catholics can have no association with the situation, which would be the case if a Catholic hospital belonged to a healthcare system in which affiliates offered these services.  As such, even though a hospital may itself be non-Catholic, if it participates in a system which includes Catholic hospitals, its services may necessarily be circumscribed.  Again, most of these proscriptions are ones with which many Americans likely agree.  Transparency should prevail nonetheless. As I discussed in my February 22, 2012 blog post, there are significant benefits from affiliating with a Catholic entity, including commitment to the care of all segments of society and an ethos of care that attends not only to the physical, but to the mental and spiritual as well.  Catholic healthcare is also an important voice in public debates about reforming our healthcare system and the dignity of every person.  These attributes of Catholic healthcare should be given significant weight in assessing collaborative arrangements.

While I believe that there is much that is wonderful about the culture, ethics and ethos of Catholic health care, there may be some other consequences of affiliation that some would fine unappealing. The United States Conference of Catholic Bishops opposes the health care reform mandate that would require employers to offer health insurance to employees that includes contraception as a covered benefit. In addition, some bishops have refused to comply with laws requiring equal treatment of spouses and gay partners with regard to eligibility for employer-sponsored health insurance. While it is unclear to what extent Catholic hospitals have followed these policy positions (the Catholic Health Association has announced that it is pleased with President Obama’s contraception compromise), the obvious question is whether they will be extended to secular affiliates as well.

Most of the questions that arise from the transition to for-profit status must obviously be resolved by the religious congregations and others that sponsor Catholic healthcare.  What makes a service or entity essentially Catholic, and whether that can be preserved in a for-profit context is likely unanswerable without experimentation.  For-profit providers ultimately exist to make money for investors.  Non-profit providers must operate in fidelity to their mission.  If a hospital is truly unable to survive, which was apparently the case with the six Boston hospitals that comprised Caritas, then for-profit conversion was the only means to continue its mission.   Even less dire situations may call for serious consideration of this alternative: a provider unable to access the resources to provide quality care irrespective of patients’ ability to pay is not in a position to actualize its mission.

The biggest question for stakeholders, presumably, is how long the private equity firms that are acquiring Catholic hospitals will hold on to them, especially if they are losing money.  The co-head of Cerberus was quoted in the Boston Globe as saying that Cerberus would own the Steward hospitals for at least three years; the article also suggested that it would not close any hospital for the first three years of its ownership, and would extend that time for an additional two years unless a hospital operated at a loss for two consecutive years.  So, one risk of these arrangements might be that they are simply stop-gap measures.  What happens if the private equity firms and their shareholders aren’t making enough money?

Another question is whether the for-profit model will result in the discontinuation of unprofitable yet essential services, which some empirical evidence suggests occurs more frequently with for-profit as opposed to not-for-profit providers, although it is important not to generalize.

This conversation will continue for some years, as we assess the on-going experiment that is for-profit Catholic healthcare.  This month, Seton Hall Law School is looking at some of the issues raised from the Catholic sponsors’ perspective, at a Symposium entitled Is a For-Profit Structure a Viable Alternative for Catholic Health Care Ministry? Return to Health Reform Watch for future discussion of this fascinating issue.

A Broader Perspective on Catholic Healthcare

A February 21, 2012 New York Times article entitled “Catholic Hospitals Expand, Religious Strings Attached” addresses the challenges that arise when Catholic healthcare systems acquire healthcare providers and extend religious proscriptions to the newly acquired facilities and practitioners.  Specifically, the article raises concerns about women’s access to reproductive health services, particularly in communities where Catholic ownership of hospitals and other providers dominates.  Much of this same kind of market activity occurred in the early 90’s in anticipation of market reforms associated with Clinton healthcare reform.  So, while these are not new issues, they are no less difficult to resolve, perhaps in part because we have all become more politicized in our approach to problem solving, which almost seems impossible to imagine, but there it is.  In a 1995 Houston Law Review article entitled DECIDING THE FATE OF RELIGIOUS HOSPITALS IN THE EMERGING HEALTH CARE MARKET I attempted to propose a middle ground of accommodation that would facilitate access to care while providing Catholic healthcare providers with the space required to continue to be true to their religious beliefs.  I believe that the prescription remains as valid today as it was when written over a decade ago.

Catholic healthcare comprises a ministry, whereby the sisters or diocese that provide the health services are committed to ensure that they act in way that is true to the teachings of the Catholic Church.  Catholic healthcare providers are living the gospel, which is replete with instances of Jesus ministering to the sick — he attended to healing the mind, body and spirit. This holistic healing mission began when various religious orders first established their hospitals, and continues today, albeit with fewer religious and more laypersons continuing the legacy of the Catholic healthcare mission.  Catholic healthcare has served an essential role in the United States since the nation’s inception, frequently being the only provider of care to the poor in numerous communities.  That dedication to the vulnerable segments of society continues today. Catholic healthcare providers were the first in many communities to treat compassionately, without judgment and without discriminating, those with HIV/AIDS.  Mission statements for Catholic providers focus on ensuring care to the homeless, to immigrants, whether documented or not, and to the underserved and uninsured. According to statistics available on the Catholic Health Association web page, Catholic healthcare is a national leader in its provision of birthing rooms and breast cancer treatment, geriatric services, nutrition programs, social work services and pain management programs. The disappearance of Catholic hospitals would decimate access to care in rural communities. Catholic hospitals have long been on the forefront of the call for healthcare reform that provides access to all, and support President Obama’s health reform efforts.

Catholic hospitals’ delivery of healthcare is informed by Catholic Social Teaching broadly and specifically by what are called The Ethical and Religious Directives for Catholic Health Care Services, which are promulgated by the United States Conference of Catholic Bishops.  Catholic Social Teaching rests on centuries of philosophical and theological learning to guide not only the Church but society in general on such questions as the relationship between labor and capital, the respectful treatment of employees and the importance of unions to workers, distribution of goods and services, and human rights to social goods such as health care.  The Ethical and Religious Directives, which are informed by Catholic teaching, are moral guidelines specific to healthcare, to aid in resolving such ethical issues as pregnancy termination, contraception, and euthanasia.  Obviously, the clinical situations in which these guidelines are implicated can be extremely complex, and sometimes require nuanced analysis by those with a deep understanding of Catholic moral theology and medicine.  Like any intellectual discipline, theologians, bishops, and healthcare providers sometimes disagree among themselves as to the appropriate application of these guidelines to a specific situation.  So, yes, it is true that Catholic healthcare providers are committed by their religious beliefs to operate in ways that may be different than secular providers, but these differences extend far beyond the moral limitations on the kinds of reproductive and end-of-life care they provide. This moral framework serves to unleash the kind of compassionate care that has been a hallmark of Catholic healthcare since its inception. Even in the face of severe budget cuts, Catholic hospitals continue to provide pastoral care to their patients, caregivers, and families; engage in constant assessment of fidelity to mission; and have been leaders of all hospitals with regard to measuring tax-exempt facilities’ provision of community benefits.

My ultimate point is two-fold.  First, Catholic healthcare is too important to the country’s healthcare system to be reduced in our assessment of its value to religious proscriptions that may interfere with access to a limited universe of services, albeit what are sometimes characterized as essential healthcare services. While some may dissent from application of Catholic teaching in particular instances, the continued and pervasive presence of health providers committed to the dignity of every person whom they treat is an ultimate societal good.  Where disagreement persists, it is important that the Church engage in sincere dialogue with all segments of society, with a willingness to be informed from medical, ethical, and sociological perspectives.

As Catholic providers partner, merge or otherwise collaborate with secular healthcare providers, community stakeholders, including licensing agencies, should demand and receive a clear understanding of the implications for healthcare access of the proposed alliance.  Each bishop acts as the ultimate arbiter of the Ethical and Religious Directives, which means that interpretations can vary by diocese.  For example, a minority of bishops have raised questions about the kind of emergency care administered by hospital emergency departments to rape survivors, out of an over-abundance of medical and moral caution, in my view, that the treatment might interfere with a pregnancy.  Thus, it is essential that regulators understand the implications of Catholic teachings for healthcare access, so that patients clearly understand the limitations of Catholic providers and, where appropriate, have alternatives to access services.  Our healthcare system has and will likely always be extremely pluralistic.  We have, and should continue to make every effort, to accommodate the religious beliefs of providers, while ensuring access to care to which patients are legally entitled.

Further, the public debate about what kind of care should be legally available should take seriously the perspective of those whose viewpoints are informed by moral concerns, whether those concerns arise from religious or philosophical principles.  Finally, both The United States Catholic Conference and individual bishops should ensure that they receive a robust analysis of ethical issues related to healthcare from the Church’s best theologians with relevant expertise before promulgating guidance to those engaged in healthcare ministry.  Importantly, bishops should also hear from those who are involved daily in caring for and ministering to patients.

The ultimate goal of reform is one upon which both Catholic healthcare providers and proponents of women’s health agree — increased access to healthcare for all.  Collaboration on the pursuit of this unified goal should enable us to identify means by which the plural interests of the stakeholders can be accomplished.  Transparency and conversation are key to achieving these ends.  In my conversations with those concerned about changes in the healthcare delivery system, I have always found them to be very respectful of religious freedom, appreciative of the role religious providers play in society, and desirous of finding a common way forward.  While the number of religious sisters is shrinking in the United States, women remain a significant presence in the leadership of Catholic healthcare.  A cursory review of the areas where Catholic healthcare predominates reveals a strong commitment to women’s health and wellness.  For these reasons, I feel confident that common ground exists to ensure access to health care for all, while carving out space for Catholic fidelity to the demands of their religion.

To Err is, Apparently, More Common Than Reported

A recent article in the WSJ Health Blog, considering a survey of 1,891 doctors  published in Health Affairs, is worth considering for a moment or two.

The survey/study is said to have had a response rate of roughly 64% (3,500 physicians from seven specialties were queried) and was published by doctors Lisa I. Iezzoni, Sowmya R. Rao, Catherine M. DesRoches, Christine Vogeli and Eric G. Campbell.

The Journal reports that the study found

…a significant chunk of doctors — 34.1% and 35.4% respectively — said they only somewhat agreed or disagreed with the notions that they should disclose all significant medical errors to affected patients and that they must tell patients about relationships with drug and device companies.

What about actual practice? Well, 55.2% of respondents said they’d described a patient’s prognosis in a more positive way than was warranted at least once in the past year. More than 28% said they’d revealed confidential medical info to an unauthorized person (intentionally or not), and nearly 20% reported not fully disclosing an error to a patient out of fear of being sued. Finally, 11% admitted to outright telling an adult patient or child’s guardian “something that was not true.”

Soft peddling a diagnosis can be a form of mercy, with this I have no qualm. And I imagine there can be a number of reasons, under the same tent as mercy, for telling an untruth to a patient or a  parent. And maybe even a 28% HIPAA violation rate can be explained through some further form of altruistic behavior. But the fact that over the last year, of these 1,891 physicians, “20% reported not fully disclosing an error to a patient out of fear of being sued,” is reason for pause.

To admit to such is, in a sense, an admission against interest; which is to say that one would not be surprised if the actual number was higher than admitted. In fact, according to the study’s abstract, “Overall, approximately one-third of physicians did not completely agree with disclosing serious medical errors to patients.”

But take the 20% number on its face for a moment and consider the math:  of 1,891 physicians that’s 378 errors during the course of one year which, in their professional opinion, could have led to a malpractice suit– and so were not disclosed.  With less than 2,000 doctors, 378 errors that people are walking around with– or at least the lucky ones are walking around with– unknown and uncompensated.

Granted, with a J.D. after my name and given my own experiences with malpractice and the sound and fury I regularly hear regarding “malpractice reform,” I may look at this number differently than some. But it seems large to me– and I’m guessing it would seem a little large to its victims too, if only they knew.

Still Alive and Well

For those of you keeping track at home, an update of sorts is in order. My surgery went well on Monday. I awoke from the anesthesia, and I now write this without the roughly 15% of my kidney which had shown itself to be stubbornly  non-compliant. I am told “they got it all” and that it doesn’t look as though any further remedial therapy (i.e., chemo, radiation) will be necessary.

I’m told I awoke from the operation talking law, which had at least one surgeon laughing and saying that I was “hopeless” while muttering something else (she was right)  about lawyers. Having had my stomach muscles cut through in what appears to be about a ten inch gash, it hurts to cough or laugh but not anymore to walk–slowly. To leave the hospital I needed to walk a total of 14 laps around, equivalent to one mile.  I did either 20 or 21 and was discharged after 2 and a half days.

My stomach is strangely distended and, because of the cut to the core muscles, no longer symmetrical: it looks like an oddly flattened but fully inflated beachball. I’m told this will dissipate in time. But really– I woke up– surrounded by friends and family, still alive, the rest is just details.

But I am struck by how lucky I was– if I hadn’t had health insurance I probably wouldn’t have went to the hospital when struck by a pair of kidney stones in the first place, despite the excruciating pain. And even if I did go, I would have balked at the expense of the CT Scan which initially found the tumor. In addition (thank you Cigna), after a second opinion I was able to articulate my needs and have a world class surgeon in a world class hospital perform my surgery. The tumor, though small, was in a tricky spot– and a less skilled surgeon could have opted to have taken the whole kidney, a result which bears far greater risk for hospitalizing events over time, everything from heart problems to fractured hips.

Not everyone is so lucky.

The twelve-year survival rate for partial nephrectomy patients similarly situated to me is 96%. As the tumor grows and the stage progresses, that number drops significantly. And unfortunately, kidney cancer is largely asymptomatic. Men age 40 to 60 are most susceptible, and the most common symptoms are lower back pain and exhaustion. I know very few middle aged people for whom those aren’t just the symptoms of life. The other major symptom is, sometimes, blood in the urine–which is often pushed aside as just the result of kidney stones. And so undetected, the tumor grows. But, thank God, not this time.

And for all of you who offered your kind thoughts, advice, experience and prayers throughout this– thank you so very very much– it made it all so much easier.

Are Fat Taxes All the New Rage?

The world’s first fat tax is finally here. Well, it’s not actually here (New Jersey’s Star Ledger Newspaper took the time to say “fat chance” to such a plan working in the U.S.), but it has been officially enacted in Denmark.

The tax applies to all foods that have a saturated fat content greater than 2.3%. The tax rate is 16 Danish kroner per kilogram of saturated fat (roughly $1.29 per pound). Danish officials expect the tax to generate somewhere between 1.5  billion and 2.75 billion Danish kroner annually. According to the Danish Agriculture and Food Council, a family with two adults and two children that does not change their eating habits can expect to pay an extra 1000 kroner a year (a little less than $200).

Interestingly enough, the goal of the tax is not to target obesity. The obesity rate in Denmark is 13.4%, which is 2.1% less than the European average. The last time the U.S. had obesity rates as low as Demark was in the 1970s. Instead, the fat tax is aimed at increasing the Danish life expectancy of 79 by three years over the next decade.

This type of legislation is not new for Danes. Denmark was actually the first country to institute a ban on trans fats in 2003, and last year the country instituted a 25% tax on sugary items like ice cream, chocolate and sweets. Sin taxes for soda, alcohol and cigarettes also exist. Advocates of these taxes note the benefit to preventative health and also the advantage of filling the government’s coffers. According to the secretary general of the European Public Health Alliance, Monika Kosinska,

“Denmark will not only increase general health amongst the population but will also ease the burden on the public health care system and increase its resources at a time of recession when [European] Member States are cutting public expenditure.”

Benefits aside, the criticisms of the new tax are numerous. In an article for The Atlantic, Edward Tenner notes the rich irony that Denmark, one of the world’s foremost producers of butter, cheese and bacon, is the first country to implement a tax on fat. Critics include, of course, the numerous producers of affected foods like butter, milk, cheese, meat and oil. One CEO of a Danish meat manufacturing company called the tax a bureaucratic nightmare.

Producers are required to pay the tax, and these costs will be passed on to consumers, suggesting that more Danes will shop abroad. Denmark’s central association of margarine producers (MIFU), has already filed a complaint with the European Union (EU) Commission arguing that the tax is noncompliant with EU free trade rules.

Other critics note that the tax may not be high enough to actually change behavior.

Given the similarity to soda taxes (previously discussed on this blog), it’s worth referring to a 2009 article published in the New England Journal of Medicine by Kelly Brownell and his team. They considered the public health and economic benefits of taxing high-sugar beverages and found that the 5% soda taxes that many U.S. states have enacted are too small to affect consumption. Their team proposed that a sugar tax on beverages would have to be much higher to lower soda consumption, at around 1 cent per ounce of beverage.

A 2007 study by the Forum for Health Economics and Policy focused on the ability of a fat tax to change behavior and found that a 10% fat tax on dairy would not reduce consumption by even one percent. The authors suggest that the tax rate would have to be much higher, but even a 50% tax may only reduce fat intake by 3%.

Some critics have offered suggestions on how to better address the problem both of obesity and shortened life-spans. Dr. Mike Rayner, Director of Oxford University’s Health Promotion Research Group, argues that Danes may switch from high fat foods to other unhealthy foods. He proposes that the overall unhealthiness of food should be taxed instead, not just a single nutrient. Simultaneously lowering taxes on fruits and vegetables could promote a healthier behavior change.

Dr. Yoni Freedhoff, medical director of the Bariatric Medical Institute in Ottawa, points to the public health issue of obesity as a societal problem. He notes,

“If we want to have legislation that deals with this problem, perhaps legislation that would deal with advertisement to children and zoning laws for fast foods around school would be a better place to start than a tax that is simply going to raise money and will not, in fact, change anything.”

NYU professor Marion Nestle finds the fat tax to be troubling for a different reason. To see individual behavior change, she argues that we must change the behavior of corporations “that make and market unhealthful products, spending vast fortunes to make them available, desirable and socially acceptable.” She cites a recent Lancet article on food environment factors that sees food processing, cost and marketing as drivers of consumption. She concludes, “[G]overnments seriously concerned about reducing rates of chronic disease should also consider ways to regulate production of unhealthy products, along with the ways they are marketed.”

Despite the multitude of criticisms, several other European countries have expressed a desire to follow suit– including France, Finland, Romania, Sweden, Norway, and even Britain. Americans should also be watching this social health experiment. But given that our country’s favorite condiment is mayonnaise, maybe the Star Ledger is right– it may not be time for a U.S. fat tax just yet.

I never really liked that part of my kidney anyways

I’ve been putting off the writing of this update, thinking perhaps that in writing these words, that which seemed surreal enough to be a part of someone else’s life would become more painfully my own. My last trip to Sloan-Kettering (thank you Cigna) did not go as I had hoped: “Mr. Ricciardelli, it turns out that thing we thought was a cancerous mass on your kidney is actually a stray piece of popcorn,” is not what anyone said. Turns out that although blessedly small, that thing on my kidney has blood flow to it and is a prime candidate for removal.

But again, at 2cm x 2.5cm it is blessedly small– 3cm to 7cm is considered small, this is, in a sense, despite the way it feels in my life, smaller than small. It is, however, in a tricky spot–lower portion of the upper pole–but inside the kidney itself, as opposed to outside and more readily accessible.  I’m told that this position narrows down the number of surgeons in the world who can actually perform this surgery, and there is a chance, if things go wrong, that I can lose my whole kidney instead of just part.

I have the surgeon (thank you again Cigna) and I have the date (beginning of November), what I don’t have is any sense of how I should be taking all this. I postponed the surgery a few weeks in order to attend to some work projects that simply needed to be done, and I was able to lose myself in them sufficiently to not think about much otherwise. They are now done.  I went to see my primary care physician today for an OK physical for surgery–I apparently am.  All that’s left is a few weeks and my appointment with the scalpel and the dreaded anesthesia.

And as I prepare to have a piece of my kidney removed, my mind, a decently read but unruly thing, turns to the admonitions of the 19^th century French symbolist poet turned gunrunner in Africa, Artur Rimbaud. Cancer ridden and returned to France he lay misdiagnosed and amputated on what would be his deathbed and wrote:

Where are the paths between the mountains, the cavalcades and promenades, the deserts, rivers and seas? And now living a legless existence!

….Were someone to ask my advice, I would tell him: You’ve come this far: now don’t let them amputate. Get hacked up, ripped apart, torn to pieces, but don’t tolerate amputation. If death comes, it’s a far better thing than life with too few limbs. Many have said as much; and if I had to do over again I would do it differently. Better to live a year in hell than to be amputated.

Losing a kidney or a part thereof is not losing a leg. And it’s probably never good policy to get one’s medical advice from a dead French symbolist poet–especially one I tried so hard to emulate in my teens. But I’d be lying now if I said that a part of me didn’t want to pack that same old traveling duffel bag I have stored in the trunk of my Jaguar and set out reckless again for “the paths between the mountains, the cavalcades and promenades, the deserts, rivers and seas.”

Second Opinion

Perhaps two of the nicest words in the English language: second opinion. Mine went better than expected as evidenced by my full complement of kidneys this week. Actually, as the right one has a mass on it, perhaps the complement is fuller than I would like– but not quite as full as my local community hospital had warranted.

The community hospital had initially, through ultrasound and CT scans with an without contrast, diagnosed the mass of the “worrisome,” and hypodense lesion as being 1.5cm– a measurement they adjusted upwards to 3.1cm after an MRI with contrast (it struck me at the time that even the average government economist forecasts better than that).

Small in terms of kidney cancer is basically 3 to 7 cm. At my community hospital, that 3.1 cm read was enough to have me on the fast track to losing at least a part of my kidney– “the quicker the better.”

The doctor at Sloan-Kettering, one of the top surgeons in the US (thank you Cigna),  did not find the images of any of those tests sufficiently clear to determine size– and told me, he “was not impressed” with the mass on my kidney. I was never so happy to be unimpressive in my life. A subsequent reimaging put the size at 2.5cm. A horse of a different color. A smaller and slower horse. A horse that can wait. A relief I don’t think I can sufficiently describe in words.

My conversations with my local urologist and two similarly situated kidney cancer patients who had already had portions of their kidney removed, as well as a tremendously helpful Yale trained oncologist introduced to me by a friend and colleague at another blog, gave me the reasonable belief that this week I would be sans a part myself. My worst fear was that because the mass was said once to be in the middle of the kidney (another time it was described as higher), it might not be suitable for a partial nephrectomy and that I would lose the whole kidney. But all that was based on  3.1 cm and my relaying that  diagnosis to others. 3.1 is not 2.5.

I had not even hoped to be so unimpressive.

With a serious instruction to make some lifestyle changes, as this particular doctor at Sloan “treats the whole patient,” I go back at the end of the month for another consultation. Truth is, with an approximate general growth rate of 1/2 cm per year, in 6 months part or all of that kidney may still have to come out. We’ll see. But I’m living, at least for now, in the 40 to 45% chance that nothing at all may have to be done. Roughly a third of all suspected kidney tumors turn out to be, upon removal, benign. Ten percent are said to be indolent– or aggressively lazy. I’ve always been fond of that word, “indolent,” and can at times be so. I’m hoping this mass on my kidney is as well.

I am relieved, but honestly exhausted. I spent last week preparing for what I reasonably thought (based on bad information) was inevitable. I spoke with my priest, made arrangements for my children, and began shopping for a used Jaguar.

And there it was, the two sweetest words in the English language: “second opinion.” My local urologist insisted I get one. Smart man.

I’m still thinking about the Jaguar.

Cancer, Garlic, and Leafy Green Vegetables; or, “How my Italian Grandmothers were Right”

Left with a diagnosis of kidney cancer and awaiting a second opinion, the feeling of powerlessness is, at times, overwhelming.  My appointment for that second opinion at Sloan Kettering  is this coming Tuesday (thank you Cigna).

My research, along with conversations with people who have actually been through the process makes it fairly probable that very soon after my appointment, I’ll be under the knife. Simply put, the treatment of preference is either the full or partial removal of the affected kidney, with further removal of the adrenal glands and lymph nodes if necessary. And waiting doesn’t make much sense. The cancer could spread.

In the meantime, however, I wait.  And of course, I research and fret, but not necessarily in that order.  My most recent foray into the scholarly has turned up something worth considering: my Italian grandmothers were right. Garlic actually is the answer. And so is spinach– and brussel sprouts.

After being diagnosed, feeling utterly powerless, I began feeling the need to do something. And, having been raised by an Italian family, I instinctively began putting loads of garlic into everything I ate–something, because of early training,  I tend to do whenever I am sick. I know researchers over the years have shown garlic to be bio-beneficial, but when I mentioned that I had begun doing so to a lawyer/nun friend of mine, she said “Why?”

The research I found subsequent is actually rather extraordinary. In a petri dish, garlic concentrations and leafy green vegetables actually inhibited the growth of various types of cancer cells. Entitled “Antiproliferative and antioxidant activities of common vegetables: A comparative study,” the paper was authored by researchers  from the  Laboratoire de Médecine Moléculaire and the Service d’hématologie-oncologie, Centre de Cancérologie Charles-Bruneau, Hôpital Ste-Justine, Université du Québec à Montréal.

The results?  Garlic, leeks, spinach, kale, brussel sprouts and curly cabbage are all now an integral part of my diet.

The researchers

evaluated the inhibitory effects of extracts isolated from 34 vegetables on the proliferation of 8 different tumour cell lines. The extracts from cruciferous vegetables as well as those from vegetables of the genus Allium inhibited the proliferation of all tested cancer cell lines whereas extracts from vegetables most commonly consumed in Western countries were much less effective. The antiproliferative effect of vegetables was specific to cells of cancerous origin and was found to be largely independent of their antioxidant properties. These results thus indicate that vegetables have very different inhibitory activities towards cancer cells and that the inclusion of cruciferous and Allium vegetables in the diet is essential for effective dietary-based chemopreventive strategies.

The cancer cell lines tested were PC-3 (prostate), AGS (stomach), U-87 (glioblastoma, brain), DAOY (medulloblastoma, pediatric brain), MCF-7 (breast), A-549 (lung), Panc-1 (pancreas), Caki-2 (kidney).

The vegetables which showed the most antiproliferative effect? The results varied by type of cancer, the researchers write:

Tumour cells derived from prostate and stomach cancer were most sensitive to the extracts while cells from kidney, pancreatic and lung cancers were much less affected by the tested extracts. For example, 23 of the 34 the tested vegetable extracts inhibited the proliferation of prostate tumour cells by more than 50%, while only 7 extracts were active against kidney cancer cells.

There’s a chart for each kind of cancer which shows the impact of each kind of vegetable tested. It’s worth a look and a read or just check out the video linked below and go back to the document for more specific information on the type of cancer you’re most interested in. For kidney cancer, leek, garlic, curley cabbage, brussel sprouts, kale and spinach did well. With leek inhibiting growth completely and the garlic imbued tumor cells growing to only around 5% of the control tumor–which was merely left to its own devices. Iceberg lettuce? Bock Choy? Not so good.

As you might imagine, I now have a refrigerator filled with cruciferous vegetables, garlic pre-sliced in 1lb. jars, and leeks. I also have enough spinach in cans to keep Popeye square for a month.

I should be clear though: the law degree and the tumor I have do not in any way, shape or form entitle me to dispense medical advice. I am not doing so. And I am not saying that vegetables are a substitute for medical care; I fully intend to have this thing (the tumor, not the law degree)–along with whatever part of my kidney has been compromised–cut out of me as soon as my doctor says he wants to do so.

You make up your own mind as it regards your diet–but mine has just seriously changed. Garlic was first in  antiproliferation among every kind of cancer except one (mine), in which it was second. Dr. Michael Greger over at NutritionFacts.org called that discovery “one of the most important findings of the year.” My grandmothers would agree.

Oh, why canned spinach? Because it’s fast and amazingly easy. Saute a ton of garlic along with some cut leek in extra virgin olive oil and dump in two cans of spinach–I use a little salt and sometimes paprika. Heat. Maybe add some parmesan cheese. It works for pretty much any of the leafy greens and cancer antiproliferation never tasted so good.

The video below will take you through the research and the charts–showing what vegetables did best for what. Bon appetite.

http://nutritionfacts.org/videos/1-anticancer-vegetable/

A Squeaky Wheel Awaiting Results [and a further update]

A week has more or less passed since my last update, and I find myself again waiting on results. The poet John Keats speaks in laudatory terms of negative capability– “when man is capable of being in uncertainties, Mysteries, doubts without any irritable reaching after fact & reason.” Keats, of course, was not waiting on a potential cancer diagnosis when he wrote this; but a trained and licensed doctor, he was only a few short years away from his own diagnosis of the tuberculosis which would kill him soon thereafter. So who knows.

My capability, negative or otherwise, varies. The results I most recently waited for were, according to the CT scan diagnostician regarding the 1.5 cm lesion on my kidney, “inconclusive, but worrisome.” At the end of the narrative, in case the import was missed, the diagnostician reiterated, “I repeat, the findings are worrisome for the presence of cancer.” To boot, he made note of sundry cysts and a 2 cm mass on my liver– which is believed, but not known,  to be a hemangioma– a noncancerous mass made up of a tangle of blood vessels.

But there was also good news:  a) even if the mass on my kidney is cancerous, it does not appear to have spread– no metastasis; and, b) I am told that if it had migrated from somewhere else it would look very different. I was scheduled for a follow-up MRI with contrast and without  to try and reach more definitive conclusion– which I underwent on Tuesday.  I should have results on Thursday.

And therein lay a tale perhaps worth telling. With the MRI I had demonstrated, once again, in clear and unequivocal terms, the importance in medical care of either having an advocate or being one for yourself. My own history with hospitals over the years has made this clear; a number of studies have shown the same: proactive patients get better care. In this instance, I was initially told that there could be no appointment for me on Tuesday. I balked. I was assured that none was available. I explained: it takes two days to get results, my doctor does not have Friday office hours. If I take this MRI on Wednesday, I will have to wait until Monday for results– and by that time, I’ll have lost my mind. They said no. They conferred about something; I asked rather brusquely if there were a problem. I was told there was none. They conferred again. I was then given an appointment for Tuesday at 5:30 pm.

I arrived early with my son, who is 17 years old, signed in, presented my prescription and took a seat to fill in forms. A single parent, I have taken one of my children  to each of my appointments so far–except one. Although my 20 year-old daughter had offered to accompany me on a first bloodtest prior to the 2nd CT scan, I declined. I would merely have to give blood. As I walked towards the outpatient entrance I slowed, descending into myself. I sank as I entered and came to realize that I had made a mistake– I was, in that state, far less capable of advocating for myself if need be. Perhaps it’s as simple as having someone to talk to, or, as the case may be, make faces at. But I am better for their presence, less trapped in my own.I haven’t made the same mistake again.

I sat with my son in the MRI waiting room as a number of patients left. Finally, it was just us and three elderly women– none of whom could have been a minute over 92. Alone, the women sat waiting and quiet. When the room had cleared and the waiting room attendant asked their status it turned out that the one woman had a grandson on the way to pick her up, but the other two had seemingly slipped through the cracks. The one was primarily Spanish speaking and wheelchair bound. Having finished her test a while ago, records showed she had been waiting more than two hours for someone from the nursing home to come back and pick her up– a phone call to the nursing  home from the attendant seemed to indicate that no one had called the home prior to apprise them of this. The other woman, though ambulatory, had been taken from somewhere else in the hospital to have an MRI done, but no one remembered to sign her in– she, seeming somewhat confused, explained how she had been brought over–and it seems had been waiting for more than an hour, maybe two or more. They took her in right away as the techs were winding down and getting ready to close shop for the day.

I tell this because it was in such sharp contrast to my own experience. Just being there that day only happened because I was willing and able to advocate for myself.  In addition, my MRI prescription failed to direct an examination of my liver– despite the yet to be definitively determined mass thereon. I, however, had brought the printed results of the CT Scan with me, and as I sat and spoke with the MRI technician about both the intricacies of his job, some aspects of mine, and enough about my condition to have shown that I had done my research– he agreed it would be best to focus on my liver as well as my kidney as we’d “already be there anyways.” It was the reasonable thing to do. Not a huge victory by any means, but an important one. The prospect of having to come back for another test and await even further results would have served no one. And at 6pm it is highly unlikely that calling my doctor and sorting it out was all that much of a viable option. But the point is this, I was able to advocate for myself– having graduated from law school and passed the NY Bar I have, in fact, been trained to do just that. I was significantly better off for having done so. The two older women in the waiting room simply did not have that advantage, and suffered on account of it.

Truth is, whether with parent, spouse, child or friend– this, over the years has become clear to me: a patient needs an advocate. The MRI events were just a small, but telling, example.

And yes, no longer capable of “being in uncertainties,” tomorrow I will be engaged in the  “irritable reaching after fact & reason.”

UPDATE, 12:19 PM, 8/18/11: All in all I preferred the uncertainty. It seems I have kidney cancer. And although it has shown no sign of spreading, what was thought to be a 1.5cm tumor showed to be 3.1 cm in the MRI– a horse of a different color. I now await reasons for the discrepancy in size while attempting to schedule a second opinion. Sloan-Kettering (God and Cigna willing) here I come.

Of Kidneys, Cancer and Time

It’s been roughly 8 hours since I underwent the pleasures of a barium shake and a contrast CT Scan (Cigna willing) with the hope of identifying the 1.5cm lesion on my kidney. As I’ve written before, an ultrasound exam last week was unable to rule out cancer. At present, I wait for results on the CT scan with an ETA of somewhere around a grueling 24 to 48 hours. It’s hard to concentrate on much of anything else.

And the truth is, since hearing about this lesion of yet to be determined gravity, the prospect of a bout with cancer simply looms– it hangs like a cloak over every word I utter and every thing I do.  Work, on occasion, gives respite. At other times, I simply cannot free myself sufficiently to apply myself in the manner I must to do my job. I’ve managed to stay abreast of my workload, which is heavy, but am not entirely sure how. I work in bursts– and am truly fortunate to have a flexible and understanding employer.

So…left alone with a sense of my own mortality and some research skills, I have begun to learn about kidney cancer. I can honestly say that until last week I knew almost nothing about it–so it presents itself as a tabula rasa with the urgency that few things other than one’s own mortality can bring. KidneyCancer.org has been a tremendous help, as has a number of kidney cancer patient message boards. Something about hearing from someone who has been through the process–someone other than a doctor–is just wildly reassuring. In fact, in one of those coincidences that seems somehow divinely inspired, over the weekend I dragged myself to a barbecue/meeting where a close friend was speaking– and found myself sitting across a picnic table from someone who had survived a bout with kidney cancer two years ago. He was someone I knew in passing but had never gotten to know. Though sans 10% of one of his kidneys, at 62 he looked the picture of health. No amount of research could have benefited me the way his presence and reassurance did–not to mention the name and phone number of his surgeon. No small matter this, as it has been noted by some within the medical community that the removal of whole kidneys (radical nephrectomy) for early stage Kidney Cancer persists within the practice despite the equally efficacious  removal of only portions of a kidney (partial nephrectomy). Partial nephrectomy has the benefit of “renal functional preservation which can prevent or delay the onset of chronic kidney disease (CKD). CKD is an independent risk factor for hospitalization events, cardiovascular disease, and worse overall survival.”  I am told that a partial nephrectomy is much more difficult from a surgery skill perspective than simply removing the whole kidney. Who knew?

And what else has my research and new found friend taught me? For one, relatively speaking, Kidney Cancer is somewhat less common than many other cancers. According to Kidney Cancer.org

Last year, more than 1.3 million new cancers were diagnosed in the United States. According to the American Cancer Society, more than 50,000 of these individuals were diagnosed with kidney cancer. But there is hope: More than 200,000 kidney cancer survivors are living in the United States right now. Recent advances in diagnosis, surgical procedures, and treatment options will allow even more patients to live with the disease, continuing to maintain their normal schedules and lifestyles.

That means that only 3.84% of cancers diagnosed in the United States were of the kidney. The American Cancer Society estimates the incidence of Kidney Cancer in the U.S. for 2011 to be 56,046 cases-with 12,020 fatalities–or 21.5%. By way of comparison, the expected incidence of Breast Cancer (female) for 2011 is 230,480–with 39,520 fatalities, or 17.1%; Prostrate Cancer, 240,890–with 33,720 fatalities, or 13.99%; Lung Cancer, 221,130 with a whopping 156,940 fatalities, or 70.97%.

The problem with Kidney Cancer is that although fairly treatable, it is often not discovered until late in the process–after the tumor has grown–and, perhaps, spread. And the 5 year survival rate diminishes quickly with the rush from the least, Stage I, to the most, Stage IV. As of 5 years ago, there is a 73% difference between survival rates for Stage I and Stage IV. There is a phrase in Law which gives notice that within a contract, considerations of time are paramount, the breach of which is material: “Time is of the essence.” It is so with Kidney Cancer.

Unfortunately, the disease is readily capable of eluding detection–and often does. According to Kidney Cancer.org,

Many kidney cancers are found fairly early, while they are still only in the kidney. But others are found at a more advanced stage. There are a few reasons why kidney cancer may not be found until later:

• The cancer can become quite large without causing any pain or other problems.
• Because the kidneys are deep inside the body, small kidney tumors cannot be seen or felt during a physical exam.

There are no recommended tests that can be used to look for kidney cancer in people who are not at increased risk. Small amounts of blood in the urine could point to kidney cancer. But there are many other causes of blood in the urine, including infections and kidney stones. And some people with kidney cancer don’t have blood in their urine until the cancer is quite large.

While tests like ultrasound, CT scans, and MRI can sometimes find small tumors, these tests cost a lot and can’t always show whether a tumor is cancer. They are recommended routinely only for those people who have a high risk of getting kidney cancer.

It is important to tell your doctor if members of your family have had kidney cancer or other problems linked to kidney disease.

Often kidney cancer is found “incidentally,” meaning that the cancer is found by accident during tests for some other illness. The survival rate for kidney cancer found this way is very high because the cancer is usually found at a very early stage.

And here I sit– awaiting results– and thinking fondly of the kidney stones which were painful enough to reduce me to a shrieking mass and a trip to the hospital– which may well have “incidentally” uncovered a ticking time bomb in my kidney. And I don’t want to even consider what this would be like without health insurance– but I can tell you this, there’s no way I’d have gone to the hospital for those kidney stones without it.

Medicaid Incentives for Healthy Behavior: Turning That Cigarette Back Into Cold Hard Cash

The Centers for Medicare and Medicaid Services (CMS) recently announced a $100 million program through which states can reward Medicaid enrollees who adopt healthy behaviors. The grant program is part of the Patient Protection and Affordable Care Act and allows states to offer incentives for tobacco cessation, controlling or reducing weight, lowering cholesterol or blood pressure, and avoiding the onset of diabetes or improving management of the condition. The goal of the program is prevention, as spending on chronic conditions is said to account for more than 75 percent of annual healthcare expenditures in the U.S.

According to CMS Administrator Dr. Donald Berwick,

With the right incentives, we believe that people can change their behaviors and stop smoking or lose weight. Not only can preventive programs help to improve individuals’ health, by keeping people healthy we can also lower the nation’s overall health care costs.

States are not limited to direct cash incentives– proposed plans could include waiving premiums, deductibles and coinsurance payments, or offering coupons or gift certificates for weight management classes or tobacco cessation counseling.

CMS has based the program on data suggesting a short-term change in behavior when people are offered monetary incentives. Current research shows that while people may be internally motivated to make healthier decisions because of future consequences, they don’t often weigh those delayed outcomes with the immediate reward of engaging in the behavior. For example, knowing that smoking increases lung cancer risk 20 years from now isn’t always going to stop someone from smoking a cigarette. The benefit of monetary incentives is therefore their immediacy– they replace one unhealthy reward with another less harmful one. In short, CMS is betting that someone would put down that cigarette right now if you just paid them to.

But the experience of making healthy decisions seems to align more with what Mark Twain opined in Following the Equator,

He had had much experience of physicians, and said “the only way to keep your health is to eat what you don’t want, drink what you don’t like, and do what you’d druther not.

Though an individual may make a healthy choice now because they would prefer a cash incentive, that doesn’t automatically change their instinctual behavior. Someone could theoretically be convinced to take a grocery store gift card instead of buying a fast food dinner, but that does not change how much they enjoy the taste of a cheeseburger. In many circumstances, people engage in certain behaviors simply because they like to. For this very reason, critics are quick to point out that monetary incentives are unlikely to spur long-term changes in unhealthy habits. Critics also note that there is little research on whether these incentives will be successful in the Medicaid beneficiary population.

What may redeem the initiative from these criticisms is that CMS is candidly calling it a  ”demonstration program,” designed to figure out which strategies produce long-term behavioral changes. By allowing states to develop their own programs and keep data on the experience, CMS seems to be hedging its bets, wagering that at least one program will provide a successful model. Further, CMS can use the data to evaluate other factors such as the administrative costs incurred by states in rendering the programs.

Could $100 million federal grant dollars be used to support preventative health in a different way? Of course. But as long as this money is being set aside to incentivize healthy behavior, we may get an answer to whether external motivators spur long term behavior change. I, for one, would love to know just how much money it costs to convince someone to stop smoking, or to consistently trade in that Big Mac for some broccoli. It almost has to be cheaper than what we’re doing right now.

New Year’s Resolution #1: Preventive Care and Negotiated Costs

Happy 2011, folks!  It’s a new year of reformed eating, exercising, spending, and no-smoking habits.  It’s a new Congress with promises or threats (depending on your view) of healthcare repeal.  And with the help of U.S. Preventive Medicine, Inc., it’s a new year for Sam’s Club shoppers to reach their health goals with the “The Prevention Plan.”  Or is it?

For $99 a year, Sam’s Club shoppers can access:

a personalized, step-by-step health management program designed to help people take control of their individual health.  Via an online health assessment and at-home blood test [measuring cholesterol, blood glucose, and Hemoglobin A1c levels]… members can take the first steps in identifying potential individual health issues.  From there, a personalized plan is created to address risks.  Personal health coaching, ongoing support, a variety of tools and a plan-wide health challenge are provided through The Prevention Plan to keep members motivated to maintain a healthy lifestyle.

Although the Plan includes a 24/7 nurse line, 20 online education programs, recommended prevention screenings, and a detailed member report, it isn’t a substitute for regular health insurance… or for a primary care physician.  In a CNNMoney report, U.S. Preventive Medicine CEO Christoper Fey suggested that shoppers “[t]hink of it as what a financial planner does.   He takes all the information you provide, assesses the risk and gives you a plan on how to improve your financial health.  The prevention plan does a similar thing, but for your health.”  In the same report, a director of health policy at Families USA, a consumer advocacy group, said that she “worr[ied] about people thinking of this prevention plan as a substitute for an annual checkup at a doctor’s office.”

Participating in preventive care and services makes a lot of (dollars and) sense.  Okay, a little lame joke.  Seriously, though, why sit around when you can take measures to try to maintain your health and to prevent certain diseases from occurring?  The Patient Protection and Affordable Care Act recognizes the benefit of preventive care and services — remember, there’s that provision concerning free access to important screenings, tests, vaccinations, and the like.

Yet I’m somewhat skeptical about the benefits of paying $99 to enroll in this Sam’s Club Plan.  For starters, it sounds like the same kind of educational information and health tips can be found on other sites such as WebMD… and at no cost to the consumer/patient.  Okay, well, maybe WebMD doesn’t come with a 24/7 nurse line.  Yet after you take the at-home blood test, upload the results, and figure out your health summary, you’ll still need to consult a doctor to figure out whether any additional screenings are required.  So take that $99 and add to it the cost of your co-pay… or whatever you might pay out-of-pocket if you don’t have insurance.

Speaking of which, be sure to check out a recent New York Times article which reminds us how (most of) everything in life is negotiable, including healthcare and prescription costs.  Similarly, a NPR blog post discusses how some drug manufacturers offer coupons or subsidy cards to reduce prescription costs–but as Kate Matos mentioned the other day here at HRW, that too comes with a cost.

Impact of Free Preventive Healthcare

Benjamin Franklin famously once said, “an ounce of prevention is worth a pound of cure.” The statement has that ring of truth– especially when it comes to American healthcare.  Numerous studies have shown that early detection of diseases as well as interventions for bad habits (e.g. overeating and smoking) can potentially avert thousands of deaths each year.  Additionally, reported by Reuters, these preventative cares can lead to massive health care savings because preventable diseases such as heart diseases, cancer, and diabetes account for 75% of the national health care spending.

Considering the potential of prevention, just last week, the White House laid out rules requiring health insurance companies to provide many preventative medical services at no cost to the consumer.  The NY Times reports,

The rules will eliminate co-payments, deductibles and other charges for blood pressure, diabetes and cholesterol tests; many cancer screenings; routine vaccinations; prenatal care; and regular wellness visits for infants and children.

Other services that must be offered at no charge include counseling to help people stop smoking; screening and counseling for obesity; and tests for infection with the virus that causes AIDS.

The rules stipulate that no co-payments can be charged for tests and screenings recommended by the United States Preventive Services Task Force, an independent panel of scientific experts. The rules apply to new health plans that begin coverage after Sept. 23 and to existing health plans that make significant changes after that date. The administration said the requirements could increase premiums by 1.5 percent, on average.

Currently, the government reports that Americans use preventive services at about half the rate recommended by doctors and public health experts.  The Obama Administration, including many experts and consumers groups, is hoping that these new changes will eventually have a huge impact and Americans will take advantage of the free preventative care.

But, how much impact would it really have?

While costs have deterred some consumers from preventive care, others have avoided doctors’ offices for other reasons.  For example, people with unhealthy lifestyles avoid checkups, not because of cost, but out of fear.  According to the NY Times,

Recent studies have shown that people who know they have health-endangering vices (like smoking or drinking) put off appointments because they do not want a healthy-living lecture. Others do not go because they feel doomed despite medical treatment. At the other extreme are the overly optimistic who are convinced they will get better no matter what. And then there are those who are embarrassed to discuss their symptoms, such as incontinence or impotence.

The bottom line for many people is fear: fear of bad news, fear of an uncomfortable test, fear of discussing something intimate.

And other people, namely men, do not regularly see their primary care physician because men generally tend to overestimate their health.  According to a survey by the American Academy of Family Physicians:

● Almost one in five men (18%) 55 years and older have never received the recommended screening for colon cancer.

● More than half (55%) of all men surveyed have not seen their primary care physician for a physical exam within the past year.

● Four in 10 (42%) men have been diagnosed with at least one of the following chronic conditions: high blood pressure (28%), heart disease (8%), arthritis (13%), cancer (8%) or diabetes (10%).

● More than one out of four men (29%) say they wait “as long as possible” before seeking help when they feel sick or are in pain or are concerned about their health.

● Despite this, almost 8 in 10 (79%) men describe themselves as in “Excellent,” “Very Good,” or “Good” health.

The “missing” men in these statistics would seem to be among those who would benefit, arguably most, from regular  checkups and screenings; unfortunately, it would seem that free preventive care will not drive these groups running to the doctor.  While the new rules will undoubtedly increase the number of people receiving preventive care, it is uncertain how much impact it will actually have as some groups will continue to avoid doctors regardless of costs.

Micro-Chipping (and then pulling the plug on) Grandma as part of HIT and the Public Option

I had the opportunity to speak with one of our Health Law professors from private practice the other day (some professors teach full time, others teach only part time in addition to working full time as attorneys or judges), and he had been practicing (and teaching) health law for decades. He was both amazed and incensed: at our inability as a country to have a reasonable discussion about health care; that a provision to remunerate consultations regarding end of life issues somehow turned into “pulling the plug on grandma” and “death panel” sound bites–from people who should (or do) know better; and that people somehow believe that “rationing” doesn’t exist right now in the for profit health insurance system. “They speak as though their insurance policies are unlimited. They are not. There are insurers denying coverage all the time.”

This article in the New York Times’ Prescriptions won’t make him feel any better. It regards a recent chain email which tells of the impending forced implantation of microchips into patients as part of a government sponsored health plan.

Prescriptions reports:

…fears of death-panel bureaucrats voting to euthanize elderly Americans may pale in comparison to the latest fright point: according to a widely forwarded chain e-mail, the Democrats’ health care bill would require anybody who enrolls in a new government-run health insurance plan “to have a data-receiving microchip implanted in their bodies.”

The assertion would seem to tie together policy points from both the House-passed health care measure, which would create a government insurance plan, or public option, and the economic stimulus measure earlier this year, which approved billions of dollars for health information technology.

The widely distributed email is said to have prompted House Speaker Nancy Pelosi to issue a Myth Buster fact sheet:

Myth: People who enroll in the public health insurance option will be forced under the law to have a microchip implant.

Fact: The Affordable Health Care for America Act does not have any provision requiring any person to have a microchip — or anything else –implanted on their bodies for any reason.

The Times also notes that “Ms. Pelsoi’s office also noted that “PolitiFact — the Pulitzer-prize winning Web site — labeled this claim a ‘Pants on Fire’ lie, its highest degree of untruth.”

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