Cleveland Clinic CEO: Health Reform is “Already in Place”

Cleveland Clinic CEO: Health Reform is “Already in Place”

Solstice. The first day of internship.

The first day of internship fell on solstice. There is probably some symbolism in it, something about fertility. Ten days of orientation were certainly fertile on the amount of information and welcomes. Some smart folks were writing the names people they met in notebooks. So many times we were assured that by this time next year we will be pros. I really believe it when my program director said that whatever problem we would encounter, they have had already solved it. So, technically, there should be no problems. 

Still I wanted to hear something else on the first day of internship and every time when things go south down in the trenches, why I volunteered for this. And this is why I am writing it down, so that when I am in doubt I can get back here and re-read it. 

 

Seven hundred thousand people declare bankruptcy every year due to medical bills.

 

There are three types of care: necessary, preventive-sensitive, and supply-sensitive. Necessary care is care that is, well, necessary. It constitutes the smallest fraction of Medicare expenditure, but is under the heaviest regulatory oversight. Preventive-sensitive care is care that has more than one option, care chosen is determined by opinions. For example, PSA testing, mastectomy/lumpectomy. This type of care also makes up a smaller fraction, about 25%. Supply-sensitive care is the type of care that is determined not by specific treatments but by frequency of treatment. This type of care makes up 60% of Medicare expenditure and includes imaging, consults, ICU admissions. This type care sees the least regulatory oversight. 

Some interesting observations: the more hospital beds, the more admission; the more cardiologists, the more angios; the more cath labs, the more catheterizations. This is what supply-sensitive care is about. When Atul Gawande talked about El Paso, TX vs McAllen, TX, this is what he meant. A larger number of doctors in McAllen made McAllen the most expensive town in the US to get health care. And by far not the best care.

One third of Medicare goes to care in the last 2 years of life. One sixth of Medicare goes to care in the last 60 days. "Medicalization of death." Google it.

Benefit vs expenditure plateaus, and even goes down. 

 

The number of men needed to have their PSA checked to avoid one death due to prostate cancer is one thousand per ten years. While doing this, we will miss 4 prostate cancers that will result in death. At the same time, fifty men will be overdiagnosed. But can we talk this math with a patient? Success stories are what we hear and what shape our measure of chance of survival. How many people do you know who tell you about failures? This is not unlike playing a lottery. We all want to play a lottery because we only see winners. But how many losers are on the news telling that they lost? Watch Dan Gilbert. 

 Obesity and diabetes trends.

Cancer. The same tumor has different cells. Cancer cells in mets are different from those in the parent tumor. Responses to the same treatment are different. Genetics of tumors and people matter more than ever. No longer can we apply the same treatment to people with the same disease.

How we track and understand health care determines implications for the heath of our patients.

Three are more than 6 billion cell phones. The wireless future of medicine.

 

 Internship will be over by the next solstice. With these issues and promises, the question is why would one not do medicine?

eFax allows free receipt of faxes.

Many blue moons ago I used to have a free eFax account to receive occasional faxes. Then eFax went rouge on its freebie crowd, yanked all free accounts, and now only has two options, Plus and Pro. Either of these options cost more than a fax machine. Turns out at this day and age I still need to receive very occasional fax from someone who is not fully living in clouds. All free fax-in options I've checked are setup in some way that essentially makes the whole service moot. For example, faxdesk offers a free fax-in service but the phone number lasts only 4 hours, and you cannot order more than one number every 48 hours. Technically can work, practically, not very much.

Turns out that eFax still has this free fax-in option. It is located here. Go and get, and have your faxes sent to your mailbox free. The number is going to be chosen randomly for you, but who really cares.

Alcoholism among Native Americans

In the May 5 column, the Times Nicholas Kristof cites Anheuser-Busch, the company that makes the Budweiser and the bestselling beer in the US, Bud Light, for perpetuating alcohol dependence and addition among Native Americans and as an example of corporate greed and predatory practices. He calls for the boycott of Anheuser-Busch's products.

A small liquor shop in the town of Whiteclay, Nebraska (population 10; yes 10) sells about 13,000 cans of beer and malt liquor a day. Whiskey Tango Foxtrot? Most of this alcohol ends up at the Pine Ridge reservation that is located just a stone-throw away over the state line in South Dakota, and which bans alcohol on its territory. With the a closest major city more than two hours away, Whiteclay is where residents of Pine Ridge go to get alcohol. The most of it ends up on the reservation.

Pine Ridge is home to approximately 45000 Oglala-Sioux Native Indians living on the swath of land roughly the size of Connecticut. Last year tribal police made more than 20000  alcohol-related arrests that made up more than 90% of all arrests. But tribal police has no jurisdiction over Whiteclay since it is in Nebraska. The drink of choice at Whiteclay is Hurricane High Gravity Lager, a malt liquor brewed by Anheuser-Busch. The tribe alleges that the whole purpose of Whiteclay is to sell to Natives since there is no one else around to sell alcohol to. The tribe sues A-B and other brewers for $500M arguing that they sell alcohol knowingly of its illegal import and consumption on the reservation.
 The effects of alcohol on the reservation residents are visible and severe. Kristof gives the following statistics: "As many as two-thirds of adults there may be alcoholics, and one-quarter of children are born suffering from fetal alcohol spectrum disorders." Alcohol feeds crime, domestic violence,  suicide, risky behaviors that lead to significant health problems such as injuries and sexually transmitted infections including HIV, unintended pregnancies, etc.

Beyond a boycott or a variation thereof, solutions suggested in readers' comments included shutting down the liquor store hoping those without cars won't be able to go very far to the next liquor outlet (you can see how those with cars will make all the profit), eliminating the demand (no word on how), closing down the reservation (!), expanding the reservation to include the White Clay store and thus making it illegal (you can see how this is an especially doomed solution),  taxing sales and using proceeds to fund education and alcohol detox and rehab programs. The blame is invariably poured on reservation residents for the lack of personal responsibility, on A-B and the likes for corporate greed, and tribal leaders for inadequate and incapable governing, incompetence and corruption. There is no

Several readers suggested decriminalizing drinking and possession of alcohol on the reservation. This might seem as a sure recipe for worsening the situation, but studies and experience in countries like Netherlands showed that legalization of (some) drugs (and certainly alcohol) moves the issues from the criminal system into the realm of public health, where it belongs.  Several more countries like Belgium and Portugal have decriminalized drugs. In the case of Portugal, which abolish all criminal penalties for personal drug possession including cocaine and heroin, illegal drug use by teenagers had declined, the rate of HIV infections among drug users had dropped, deaths related to heroin and similar drugs had been cut by more than half, and the number of people seeking treatment for drug addiction had doubled. None of the nightmare scenarios such as increases in drug usage among the young and the transformation of Lisbon into a haven for “drug tourists” have occurred. (http://www.cato.org/pubs/wtpapers/greenwald_whitepaper.pdf). It is worth noting that decriminalization does not mean legalization. In Portugal, drug possession for personal use and drug usage itself are still legally prohibited, but violations of those prohibitions are deemed to be exclusively administrative violations and are removed completely from the criminal realm. Instead of prison sentences, drug users and alcoholics are targeted with therapy and harm reduction.

Alcoholism is a severe problem on many reservations across the country; there are a number of causes that feed it, and no single solution is going to be sufficient. But whatever approach is used, it must be non-penalizing. Instead it should be protective of harms of alcohol and drug use.

Health disparities and IHS

Indian Health Services (IHS), an agency within the Department of Health and Human Services, was created in 1955 to broader effort to reform health care on the reservations. In its initial survey IHS found that total mortality was 20% higher, infant mortality was 3 times higher, life expectancy was 10 years lower, and infectious diseases and accidents were more prevalent; however, heart disease and cancer were less common. In 1970s life expectancy was two thirds the national average, and the incidence of infant mortality (1.5 times), diabetes (2 times), suicide (3 times), accidents (4 times), tuberculosis (14 times), gastrointestinal infections (27 times), dysentery (40 times), and rheumatic fever (60 times) also were above the national average. Although still above the national level, by 1990 incidence of  tuberculosis was reduced by 96%, infant mortality by 92%, pulmonary infections by 92%, and gastrointestinal infections by 93%. However, disparities persisted. American Indians and Alaska Natives die at higher rates than other Americans from tuberculosis (500% higher), alcoholism (514% higher), diabetes (177% higher), unintentional injuries (140% higher), homicide (92% higher) and suicide (82% higher). Life expectancy at birth is five years less than that of the U.S. All Races population (72.5 vs. 77.5  years).

Congress passed several bills aimed at improving conditions on reservations. In 1975 Congress enacted Indian Self-Determination and Indian Assistance Act followed by 1976 Indian Health Care Improvement Act. These acts gave tribes more control over their health services. For the fiscal year 2012, the budget of IHS is $4.6B (for comparison, Veteran Administration total budget was $127B).

Despite a significant progress, disparities remain. Many causes were proposed and debated throughout several centuries, from invocations of providence in environmental factors such as diet, living conditions, and climate to more deterministic causes such as behavioral, genetic, and socioeconomic. Some blamed personal choices, others argued that roots of disparities lie in disrupted social conditions following colonization and continues to this day due to exploitative policies of the federal government (e.g. uranium mines, water rights). That disparities cut across a number of diseases challenges the belief the disparities are the product of inherent susceptibilities of American Indians. Instead, and rather much more likely, the health disparities arose from the disparities in wealth and power that have endured since colonization.

Going West

For the next four or five weeks I am working at Gallup Indian Medical Center (GIMC) in Gallup NM, on the border of the Navajo Reservation. Located about half way between Albuquerque, New Mexico, and Flagstaff, Arizona, Gallup was settled in 1881 as a coal mining town and became a stop for the railroad and the Interstate Highway of Route 66 in the past and the present I-40. Route 66 still goes through Gallup, and much of local sites bear history of that era. In the 1930s, 40s, and 50s Gallup has seen a lot of motion picture crews with a long list of movie stars and even two presidents, President Reagan and President Eisenhower. GIMC is a 100-bed Indian Health Services hospital that serves American Native patients, primarily Navajo. While here I will do inpatient medicine, HIV, ID, and general medicine clinics, and do home visits to Navajo patients. And of course hope to do a lot of traveling and site seeing.