The Nighthawk Protocols

An elderly woman suffers a cardiac arrest in church and collapses. Henry Stevens, a retired physician and part time FBI consultant gets dragged into what turns out to be a successful resuscitation attempt. And so begins his downward spiral into the world of digital medicine and the corporate practice of medicine.

His journey begins when he takes on the responsibility of supervising a group of nurse practitioners utilizing a new computer algorithm to deliver patient care. It continues when he determines that its use is occasionally resulting in patient harm and offers his help in improving it.

But do the developers really want his help? And do his suspicions threaten to endanger the marketing prospects of the product? The action shifts back and forth: from his hometown to the corporate offices; from nursing supervision to product analysis; from providing patient care to kidnapping.

This is a wild ride through the world of cutting edge medicine and another opportunity for Henry Stevens to bring his own brand of investigation to the table.

Available on Amazon.com and in e-book format on Kindle

Is Tiering the Answer to the Current Health Care Crisis in America?

The Declaration of Independence, one of the cornerstones of our democracy, states that we have unalienable rights to “life, liberty and the pursuit of happiness”. If we still consider this to be the case, a corollary to having life is having access to health care. But many can’t afford that health care. The Affordable Care Act was meant to help our countrymen purchase it. But it has clearly fallen short. It leaves, unprotected, much of the middle class. Even with subsidies, health care has simply become too expensive.

One solution which has been broached is that of a universal health care program for all; essentially a Medicare for all. But with health care costs spiraling out of control, it is difficult to imagine what this would do to the national debt. Just ask some of our neighboring countries. But is there room for a tiered system of benefits?

Many rail against tiering, claiming that health care benefits should be equally available to all. That it is un-American to provide different levels of service based on an ability to pay. And yet, isn’t that what our current Medicare system does? Medicare only pays for 80% of a patient’s expense. Leaving it up to the individual to decide whether he can afford to take his medications or get his required therapy. Those whose retirement nest egg is large enough, can buy additional insurance plans which pick up the remainder of the costs. And, of course, we see it in other areas of our lives. Some can afford basic transportation, the Volkswagen Bug of old, while others can enjoy the luxury of a Mercedes, Audi or BMW.

But if life and health are to be considered unalienable rights, shouldn’t everyone be entitled to good health care? Absolutely. But are there extras we have come to expect, that may not be essential? Should we return to wards in the hospital setting, accommodating 6 to 10 patients, instead of the current semi-private or private rooms that have become the norm? Is it important that all elective surgery occur immediately when, by waiting, the current number of specialty surgeons can be more efficiently scheduled? Does everyone need to have multiple confirmatory tests for their diagnoses, when one or two are sufficient?

Clearly this is something that the UK has had to address. They have a basic tier of health care which is available to all. But the population can purchase supplemental insurance which can tailor the care to one’s wishes. Does this smack of elitism. I suppose that it does. But it depends on your priorities. At worst, even if health care is not a priority for you, you will be entitled to a basic level of services. Which is all we can truly expect from our taxes or our government.

But doesn’t the present system provide these basic services to everyone? I don’t see hospitals turning away the sick. Why should I pay for insurance to get what my neighbor gets for free?

A good question. And I suppose that this is at the crux of the matter. Our hospitals are currently required to provide “free care” to all those who present to them for care, who require it. And this mandate has resulted in the shuttering of many hospitals in recent years, whose bottom lines have not been able to support this benevolence. If we continue on the current trajectory, we may find, within another decade, that we have no safety net left for the uninsured.

But what about the cost? How can our economy afford taking care of its sick? Won’t the same economic forces threatening the closures of our hospitals, threaten the solvency of our country?

The short answer is yes. Unless we can rein in the costs of that care. Something that policy wonks have been struggling with for years. But what costs are we talking about? Medical tests have certain expenses associated with them which dictate their costs. Physicians are forced to adjust their fees to compensate for astronomical fees associated with their education. At present we have no ability to limit our exposure to the escalation of drug costs. And hospitals are confronted with the brick and mortar costs of their buildings and the attendant costs of staffing them.

So any solution to the current health care crisis must include an examination of the costs of the current system and how to modify them. Currently the price tag in its present iteration is 3.2 trillion dollars per year. Next time we will consider a couple of radical approaches that could be considered in devising a solution.

What to do when you don’t know what to do

 

You have been losing weight. You feel weak and fatigued all the time. You’re not sure if you’ve simply been working too hard or have just been more stressed at work. You feel an occasional pain in your stomach and more heartburn than usual and, moreover, you have no appetite. You’re worried that it might be something more serious than simply stress and decide to call the doctor who asks if these are new symptoms or just chronic ones. You answer that you’re not sure and so you’re given an appointment three months in the future.

Now you’re not sure what to do. You’re not sure if it’s safe to wait that long. You consider calling the doctor back and saying that your symptoms have been much worse recently and you need an appointment much sooner. But you don’t want to seem to be calling wolf for no good reason. So what should you do?

This is one of the biggest problems in American medicine today. Access to a provider. There are many reasons for this as has been outlined in previous articles. But the real question is what can you do about it.

The first option is to see a mid-level provider: a nurse practitioner or a physician assistant. Many clinics utilize these folks because they know that their physicians are stretched beyond their capacity. They can be found populating urgent care centers, some pharmacies, emergency rooms and sometimes, depending on state guidelines, their own offices.

They can often be a fine gateway into the system and can sometimes give you the necessary initial advice that you are seeking. However they are not physicians. They are wonderful for routine matters and for providing good preventive health care advice. But if the diagnosis is potentially complex, like the example illustrated above, they will likely have to refer you on to someone else. That is if they recognize that it is a more complex problem. In most health care settings they have physician backup immediately but not in all settings.

Another option is to choose a concierge practice. Here, the primary care physician has chosen to limit the number of patients in his or her panel. In order to do this they charge an additional fee, on the order of fifteen hundred dollars a year, in addition to your usual health care premium. The advantage is that, for the fee, they agree to see you anytime that you feel it is necessary. The disadvantage is the cost. And the fact that as more primary care physicians choose this practice model, there are fewer physicians remaining to see everyone else.

At this point, it is estimated that only about twenty percent of medical students are choosing to go into primary care which further limits access to physician care as the present providers are retiring.

There are clinics available where patients aren’t assigned to any one physician provider and one of their providers will try to see you whenever you call. But they, like the urgent care centers, usually try to use a registered nurse or a mid-level provider to triage your problem. Although they often have specialty backup if the problem is too complex for the primary care physician. This model is often found in academic medical centers.

Some patients actually choose to make an appointment with a surgeon that they may have had a prior relationship with, or even with their chiropractor. But choosing someone without the requisite background in your problem may unnecessarily delay your diagnosis and treatment.

The bottom line is to assume that if your symptoms are not “normal” for you, if they deviate from what you are used to, there is something wrong and don’t delay being seen. Develop a timeline for the development of your symptoms. When did each symptom appear. Then be prepared, when you call for an appointment, to document their development and why you are concerned. And if you don’t have a primary care physician when the symptoms develop, go to an urgent care center, ideally one affiliated with the local hospital. They will be more likely to have access to specialists who can help as well.

Remember this problem of access is only likely to worsen over the next decade or more. And aligning yourself with a physician before you need one is always best.

But is this access problem insurmountable. Isn’t there something that can be done to improve things. I know at the beginning of this series I said that I was not planning on offering any solutions to the problems that exist. However in the next couple of articles I will discuss some possible directions that might be considered in redesigning the health care system to make it more responsive and less expensive than it currently is. It will not be easy. The current system is pretty firmly entrenched and the various stakeholders will be reluctant to changing the status quo. But it is not impossible. It just needs a little flexibility and a willingness to think outside the box.

 

Drug Costs: The Hit That Sinks the Ship

We have talked about the cost of medications in the past. Currently they make up about 10 percent of health care expenditures and threaten to represent even more as time goes by. New biological agents are being developed. Genetic solutions to such things as cancer, by the targeting of specific DNA sequences, are on the horizon.

But as the number of options increase, insurance companies are hard at work playing various brands of medication against each other, trying to bring down the cost of these medications through competition. But what happens when you find that one medication from a certain group of medications makes you sick and that’s the only one covered by your insurance? Are you out of luck. Maybe. There are usually mechanisms to appeal the denial for a certain medication. But even if it gets approved, there is no guarantee that you won’t be saddled with a higher co-pay.

And while generic medications must contain the same active ingredient as the brand name, sometimes the inactive ingredients are not; and can consequently cause intolerances that their brand name cousins do not. And even if your physician writes for a brand name medication, if he fails to make it clear that a generic can’t be substituted, many states mandate that a generic must be given.

Of course, costs continue to rise. And the lobbying interests for the pharmaceutical industry ensure that Congress won’t negotiate prices for the Medicare population making it nearly impossible to curb those costs. One need only go to another industrialized nation to find drug costs significantly cheaper for the same medications. In fact, many in this country send away to Canada to get their medications for significantly cheaper prices, even though doing so is illegal.

But this isn’t the only problem. Many insurance companies prefer to give a 3 month supply of medications rather than one month, keeping the co-pay for each the same. So when you go to your physician you will likely insist that you be given a three month supply. But for a new medication, what happens when you have a bad reaction to that medication after the first dose? It’s likely that the rest of that expensive medication gets flushed down the toilet. Moreover, this may happen several times before a satisfactory medication can be identified.

And if this is an opioid/narcotic, given for short term pain control after an operation, this leaves a three month supply available to fuel the drug crisis in this country.

But this is not likely the biggest complaint that patients have about their prescriptions. They often find it incomprehensible that if they have been on the same medications for years, why, when they go to a new doctor, these prescriptions aren’t renewed as a routine matter.

The answer is simple. Some medications are made obsolete with the advent of newer medications. Some medications’ safety profiles are adjusted as new information becomes available. Thalidomide was thought to be a wonderful drug to control nausea during pregnancy until it was found to be responsible for severe birth defects among mothers using it. And sometimes diagnoses which were made in the past are subsequently found to be incorrect. Or found to have resolved themselves over time.

And with the expense of the medications, to say nothing of their interactions with each other, there is a significant argument for regular reassessment. Where this is particularly true is in the elderly population. Within the nursing home industry, it is not uncommon to find patients taking in excess of 10 medications a day. And if the over-the-counter supplements are included, the number can exceed 20. And the more medications a person takes, the more likely that they will be subject to deteriorations in memory and balance among other things. Which can result in falls and institutionalization. Which results in further expense to the health care system.

So if you find yourself at odds with your doctor about your medications, some of this may be financially driven. But in most cases, it is more likely being driven by the need to improve your care.

But what do you do if your physician is too busy to address your concerns about your medications. Or about your physical ailments? What are your options? That will be our topic next time.

The Sinkhole That is Modern Day Healthcare Testing.

Have you had the experience of waking up with back pain? When you went to get out of bed you couldn’t? Finally rolling out of bed you made your way to your computer and checked on the Internet for a diagnosis. Your conclusion? A herniated disc. The website you consulted told you that you needed an MRI of the back. You called your primary care doctor for an appointment, shared your symptoms, and asked for an MRI. But he refused! What’s with that?

It is just the tip of the iceberg. Sophisticated testing can account, by itself, for consuming nearly ten percent of the health care dollar. Initially when Insurance companies were looking for the “low-hanging fruit” to pluck, they targeted such testing. And they continue to monitor its usage.

Take the example of your back pain. While it is true that testing could determine whether your pain is due to a slipped disc, the reality is that whether this is the cause or not, whether anything is to be done for it, or not, in the majority of cases the pain will resolve on its own within six weeks. Only if it doesn’t would a surgeon consider operating. And only if an operation was necessary would an MRI be useful, to target the area needing attention.

So the only use for the MRI, earlier than that would be to satisfy the curiosity of you, the patient, or that of your primary care physician. And quite frankly, the health care system can’t afford to pay to satisfy your curiosity. So the MRI gets postponed.

Another reason for excessive testing, besides satisfying curiosity, is confirming a diagnosis. With an increasingly litigious society, doctors want to be able to prove, beyond a shadow of a doubt, that they have made the correct diagnosis and instituted the correct therapy. But this can be carried to the extreme. For example, someone with chest pain sees their primary physician where an EKG is done. It’s unremarkable but the physician is still worried so he refers you to a cardiologist. He/she is not satisfied with the EKG you provided to them so they repeat their own. There may be a legitimate reason for doing so (eg. they were concerned about the placement of the chest leads) but just as likely they are repeating it because it provides an augmentation to their income.

They proceed to order a stress test, followed by a nuclear stress test or a cardiac ultrasound stress test. Then they may order a cardiac MRI or even angiography. All to confirm that what the history suggested or the stress test revealed, was indeed accurate. While it could be argued that each test provides another bit of information about the status of your heart disease, it comes with a substantial cost. And as resources dwindle, the ability to provide confirmatory evidence may be sacrificed.

This is not to say that all testing is bad. But as some of the genetic testing becomes available, which can predict what ailments you might be at risk for, the price tag continues to rise. And knowing that Alzheimer’s might be in your future, when we have no effective treatment for it at this point, does nothing more than increase your anxiety, at an exorbitant price.

However insurance companies have tried to take this a little bit too far. While there are expensive tests out there, of dubious value, some basic testing probably still has a place. There has been a lot of controversy about Pap smears and PSA. Whether they are useful screening measures. Or mammograms. The medical literature is still ambivalent about our current screening strategies. Are we just increasing costs still further by pursuing false positive results? But the expense of these tests pales in comparison to some of the more complex tests. And they may help identify a problem when it is still in its nascent form. Still easily treatable.

But here is where a discussion with your doctor is important. But, of course, as was mentioned before, without adequate time to have that discussion. So how are you to get what is necessary without getting more than you need? This remains a bit of a conundrum but we will provide some alternatives in some of the following articles.