Musings on Medicine and the Health Care System

Who’s In Charge? You or Your Doctor?

babyshowerSunday was the first baby shower I’d been to since. . . well, let’s just say that my youngest kid turned 19 a few days ago. There were the mandatory sherbet-colored decorations; a watermelon fruit bowl designed to look like a sleeping infant (complete with pacifier); infused water; chattering ladies; a table piled high with gifts. Only one thing was missing: the guest of honor. For even as everyone arrived for the shower, she was already in labor. And, ever the obliging young woman, she delivered a healthy baby boy before the shower ended.

I’m assuming she had great care in the hospital. Most women who have babies do. But far from the cozy, wood-floored, prettily painted maternity suites lies the healthcare system the rest of us have to deal with. Like another young woman at the shower, 26-year-old Mary.

I happened to overhear her talking to someone else and caught the words “migraine,” and “doctor,” and “frustrated.” Manna to my ears. “What’s up?” I asked.

Turns out she’d been having horrific, daily migraines and vertigo for months. The urgent care doctor told her … Continue Reading

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blog healthcare reform healthcare system; patient-centered healthcare

A Letter to a Friend (or, I’m Sorry I Lost My Temper Last Night”)

Sibling RivalrySo I did something last night that I’m not proud of. I got into an argument – complete with raised voices – with a friend. Over health care and the Affordable Care Act (ACA), of course. (Note that he continually called it “Obamacare” in a somewhat sneering tone, which, as those of you who read my blog regularly or know me, know I consider a derogatory term for a very important piece of legislation).

I felt terrible after we left and tossed and turned all night coming up with things I wished I said (not to mention wishing I hadn’t lost my temper).

So I decided to write my friend a letter via this blog.

Dear Friend:

I am really sorry about last night’s discussion, er, argument. I should have remained calmer (I’m blaming it on the martini you made me, which, by the way, was very, very good). So here is a cooler version of responses to some of the points you made.

The government should not be paying for health insurance.

Well, I notice that you are quite … Continue Reading

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Affordable Care Act blog health insurance healthcare costs healthcare reform healthcare system; Obamacare

Why Repealing the Affordable Care Act Won’t Stop Healthcare Reform

So the election is over. The Republicans now control both houses. And several are promising that one of their first jobs is to repeal the Affordable Care Act (ACA). I’m sure there are lots of people jumping up and down with glee.

This reaction reminds me what one doctor told me a couple of weeks ago after I spoke to his group (abdominal surgeons) about healthcare reform (you can read more about the experience here). “This (the ACA) is going to go away and things will return to normal.”

Um, not quite.

Sure, if the ACA goes away we’ll return to more than 40 million uninsured Americans who can’t afford health care. States that have expanded Medicaid will have to pick up the full tab for those expansions (instead of 10% beginning in 2020). Young adults who are still covered on their parents’ policies will now have to buy their own — if they can afford them. Women will once again be discriminated against in terms of premiums and plan designs. People with preexisting conditions will be unable to find affordable health insurance on the individual market. We’ll have no guarantee of a basic set of benefits (for instance, some … Continue Reading

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Affordable Care Act cost health insurance healthcare costs healthcare reform healthcare system;

Doctors Are Angry. I Get That. But . . .

surgeonI knew this would be the toughest audience yet in my three years of teaching/speaking about the US healthcare system and healthcare reform. I even put on a flak jacket at the beginning of my talk as a way of breaking the ice (and protecting myself; I mean, these guys pack scalpels!). And I made it through the two-hour talk and their anger without losing my composure or my sense of humor (thank god for that sense of humor).

Now I’m sitting in the airport waiting for my flight home and find myself tearing up. Not because the doctors were mean or cruel — they weren’t — but because of how much distance there is between  reality and perception, how much anger is out there, how too many people rely only on anecdotes and commentary instead of facts to develop opinions, and how scary it is to look at where we are and where we need to be — and realize that, more and more, it is unlikely we will ever get there given the rhetoric and anger in this country.

The doctors this morning, most of whom have been in practice … Continue Reading

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ACA Affordable Care Act health insurance healthcare costs healthcare reform healthcare system; malpractice insurance Obamacare patient-centered care patient-centered healthcare Uncategorized

Why You Need a Second Opinion

Early in the summer I wrote about a good friend who was diagnosed with ovarian cysts and endometriosis. She saw a gyn oncologist because there was a small chance it was cancer (thankfully, it wasn’t). The doctor drained the cyst and started my friend on  oral contraceptives to control the hormonal shifts that contribute to endometriosis (which contributes to the cysts).

A couple of weeks ago, however, my friend texted me to say that her leg/foot was really hurting. She thought she might have a deep vein problem. I immediately told her to go to urgent care because it might be a blood clot, which can be quite serious. Her own primary care physician had left his practice, so found another that took her insurance.

Here’s her story:

“I went to the primary care physician my insurance company recommended. I specifically asked her if my leg problem could be a blood clot and she said “no” and sent me to a sports medicine doctor who then sent me to physical therapy. My leg still hurts and I thought they were wrong so I decide to go back to the gyn oncologist  who sent … Continue Reading

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healthcare costs healthcare system; ineffective procedure

Should You Listen to Your Doctor?

moneyWhen I speak about the US healthcare system, I always like to tell the story of my mother. A couple of years ago, she emailed my sisters and I. “Good news!” she wrote. “My nuclear stress test was normal!” (The test  involves injecting a radioactive dye into a vein after which a special camera scans the heart to determine if there are any blockages).

At the time, my mother was 70 and, with the exception of very-well-controlled high blood pressure (that she’d had all her life), extremely healthy. No sign of heart disease. No angina. No shortness of breath. In short, no indications for an expensive, invasive, potentially dangerous, test. So why, I asked her, did she have the test? “Because my doctor told me it was time,” she said.

At which point I began banging my head against the wall.

Even regular stress tests (where you run on a treadmill or ride a bike) are only recommended in people with heart disease or symptoms of heart disease, same with an EKG. Yet a survey of nearly 1200 people ages 40 to 60 with neither found that 39 percent had an EKG … Continue Reading

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healthcare costs healthcare reform healthcare system; patient-centered care patient-centered healthcare Unnecessary tests waste

How Much is Three Extra Months Worth?

I’m in the middle of a project about the future of cancer care in this country. And you can’t talk about cancer treatment these days without also talking about cost. That’s because cancer drugs are among the most expensive in the world, with several costing more than $100,000 a year. If you have a 20% copayment, that means $20,000 out of your pocket.

Yet most of these drugs extend life just a few months and most have significant side effects.

Let’s take a look at one drug approved this year: Zykadia, indicated for a type of late-stage lung cancer. It costs $13,200 a month, or $158,000 a year. It works exactly the same a drug approved three years earlier for the same type of cancer, Xalkori, which costs about $2,000 a month less (although still pricy at $11,500 a month). In clinical trials, it staved off cancer progression for a median of seven months (meaning half the patients in the trial saw their cancer begin growing again in less than seven months; half in more than seven months).

I’m not saying that an extra seven … Continue Reading

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cancer cancer drug cost

Welcome to the Roller Coaster Ride of the Affordable Care Act

I’m behind in the blog, I admit it. Last week I was planning a blog on all the good news about the Affordable Care Act (ACA), including the 10 million people who signed up; the lower-than-expected premiums; the lower-than-anticipated medical inflation predicted for the coming year, the result of which is due, at least in part, to the ACA.

Then came the ruling from a federal circuit court that the government could not provide subsidies for people to buy health insurance in states that did not set up their own exchanges. The ruling comes from a couple of sentences in the huge bill (about 900 pages) that states that the subsidies are available for people who sign up through state exchanges. Of course, that was when we thought the states would all set up their own exchanges (since the feds were paying for it).

How naïve were we?

Today, just 16 states and the District of Columbia run their own exchanges, with residents of the remaining 34 states buying insurance through the federal exchange. That means that about 5 million people who bought health insurance on the federal exchange and received subsidies may find themselves back where they started – … Continue Reading

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ACA Affordable Care Act Obamacare

Help! I’ve Lost My Insurance and I Can’t Get Up!

indexThe serendipity of the universe never ceases to amaze me. A couple of days ago I gave the keynote speech on healthcare reform at the Texas Medical Association’s CME Association’s annual meeting in Austin. A physician in the audience brought up an issue that was trumpeted in the press when the health care exchanges rolled out for open enrollment; namely, that people had lost their insurance and couldn’t see their doctors. I knew that a very small minority of people had actually “lost” their insurance, and that, in most cases, that insurance provided pretty bad coverage at fairly high prices. But I didn’t want to get into it with him, so I just agreed that yes, the Affordable Care Act certainly has flaws, then moved on to the next question.

If only I’d checked the news before my talk. I could have told him about a Kaiser Family Foundation survey of non-group enrollees (ie, they don’t have employer-provided insurance and bought their own insurance, most on the Exchanges). Among the findings:

About  two-thirds of those with non-group coverage are now in ACA-compliant plans, while three in 10 have coverage they purchased before … Continue Reading

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ACA Affordable Care Act health insurance health insurance exchanges healthcare costs healthcare reform healthcare system; Obamacare Obamacare