Blogged Arteries

Opinion and Commentary from TMA

Becoming a Better Physician ”Thanks” to Cancer

(Public Health) Permanent link

The last thing a nonsmoking asymptomatic female physician expects during her usual hourly aerobic exercise is a phone call from her internist about a “spiculated lung nodule.” There was no need for the rest of the radiologist’s sentence: “suspicious for malignancy.”

Kang_BlogShock. Denial: Can’t be! Wrong patient? Perhaps it’s benign. It has to be. I have never been a tobacco smoker; I maintain a healthy lifestyle, exercise, take my medications, eat right, (try to) sleep enough. I do all the “right” things. Anger: God! I cannot possibly have lung cancer! So UNFAIR!

Jumping onto “Dr.” Google Scholar, I found a reputable book chapter summarizing lung cancer in never-smokers. Lung cancer is the leading cause of cancer-related mortality in the world. Of 1.37 million annual deaths or 18% of all cancer deaths, 71% of lung cancers are caused by smoking. However, approximately 15% of men and 53% of women are never-smokers, or have smoked fewer than 100 cigarettes in their life. Aside from this remarkable gender bias, lung cancer incidence rates are higher and more variable among East Asian women. East Asian females who do not smoke tend to have adenocarcinoma on the periphery of the right upper lung. A nagging cough or shoulder pain that develops gradually is shrugged away – until the primary lung cancer rears its ugly presence by way of hemoptysis or seizures.

Rationally accepting that lung cancer can occur even in nonsmokers, I wanted action: Cut out that cancer pronto before it metastasizes!

As an academic physician, I have the privilege and responsibility to help train future physicians. How often do patients have the luxury to watch the surgical and anesthesiology resident physicians develop into capable attending-level physicians? I knew and trusted both my personal anesthesiologist and my thoracic surgeon.

Within 18 days of learning of that spiculated lung mass, I underwent video-assisted thoracoscopy (VAT). (Mercifully gone is that painful long slash between the ribs of an open thoracotomy.) I was still bargaining with God that the pathologist would diagnose a benign tumor or some noncancerous, infectious “-oma.” I still have so many things I want to do on this Earth, places to travel, young people to see grow up. Please, God, spare me the bitter cup of cancer!

I remember a jumble of activities, of being moved, people’s faces, then darkness. Awakening, I found myself in the ICU. Smacking my right chest and chest tube, I grinned: no pain – for now.

I gained new perspective and empathy for asthmatics and emphysema patients. Losing the entire right upper lung to adenocarcinoma left me starved for air-despite “normal” pulse oximetry readings off my finger. Catch-22: I felt short of breath but couldn’t inspire deeply due to a dull internal stabbing sensation. (Note to self: Visceral pain still hurts.) My unwillingness to cough warred against the relentless bodily reflexes to clear out bronchial secretions. How can COPD or cystic fibrosis patients with their preoperative air hunger tolerate the post-thoracotomy feeling of oxygen deprivation?

I understand better now why patients become delirious in the ICU: sleep deprivation. The compression stockings alternately squeezed my legs all night long. The noninvasive blood pressure monitor throttled the life out of my left ulnar nerve every hour. Demonically timed as I drifted asleep were the temperature probes under the tongue and monitor alarms (which never brought any human monitors to bedside). The chest tube preventing my usual right lateral sleeping position, I tried the left lateral position only to have my Foley and the chest tube tugging from the opposite side of the bed. Flattening out the bed increased my air hunger. Taking a sip of air triggered violent coughing. At 3 am (why?), the nurse drew blood out of my peripheral IV for lab work. Since the door to my illuminated ICU room did not close appropriately, I listened all night long to Fiesta celebrations at the nurses’ station.

Medical practice has changed. Instead of seeing the surgeon at the end of a long day of surgeries, I saw the surgical team the following day. I was prepared to be scrutinized on Postop Day 1 at the crack of dawn – before operating rooms start. The surgical residents stuck their heads in, said hello but did not examine. So I examined my chest tube drainage (minimal), my Foley (excellent diuresis), and my chest dressings (dry). The nurse practitioner (NP) made her rounds midmorning. I was freed of my Foley to walk two laps around the ICU with the physical therapist with only the chest tube to drag around. Observing the intubated comatose patients, I felt grateful to be alert and talking.

Still starving for food and sleep, and wishing to avoid hospital-acquired infections, I begged for day-one discharge from the surgeon. He wanted more observation time after the painless removal of the chest tube.

As I nestled under the clean sheets, after a blissful hot shower, ready to fall asleep to the muted television, at 10:15 pm, another very young nurse entered, flicking on the concentration camp room lights. She began undressing the clean IV infusion pump, announcing that she needed to give me my IV antibiotic. Was this another facet of the new medicine: patients receiving IV antibiotic the night before discharge in the morning? I asked the name of this miracle antibiotic as she scanned my arm band prior to hanging the medication. “Zosyn” was the reply, followed by a pregnant pause, then the slow utterance of “Oh, you’re not the one to get the Zosyn.” I was internally spastic. Did that near adverse event get self-reported? Maybe another entry about obnoxious physician/patient?

The problem of being a physician/patient is awareness of unintended consequences. Hence my thought: “Thank you, God, for the requisite zapping of my name band!” I could have received an unnecessary medication. I could have developed anaphylactic shock. Another patient would not have received the necessary antibiotic to ward off infection.

I was ready to fly the coop by 7 am on post-op day two. Midmorning the NP wrote the discharge orders and instructions. The paperwork stated breast cancer. Again, aware of unintended consequences of incorrect medical information living in perpetuity inside electronic medical records, I refused discharge until the inaccuracies were corrected. I have faced patients who adamantly denied medical diagnoses listed on their EMR. Mine was going to be accurate: lobectomy, not mastectomy!

The outpouring of love and affection after cancer surgery is heartwarming. Having cancer makes one feel vulnerable. Mortality becomes more palpable. Nurses, scrub techs, anesthesia techs, my administrative assistant, anesthesia resident physicians, medical students, even my elementary school to university classmates covered me with warm emotional support. The flowers, cards, notes, even groceries with flannel pajamas were wonderful to counter my depression. I attribute to these lovely people my recovery to return to work after six weeks.

The nagging fear of cancer recurrence stays constant. I literally and figuratively hold my breath for a low dose CT of the chest every three months awaiting the radiologist’s verdict. Negative. A sigh of relief. Another CT … Wait! What do you mean the insurance company refuses to authorize the sixth-month CT? My internist appealed the denial. I tried, equally unsuccessful. My sixth-month CT finally occurred in the seventh month. Not looking forward to the next battle with the insurance company.

An authorization for medically necessary procedures or tests is not a guarantee of payment of insurance benefits. The letter from the insurance company says that. I can undergo the tests or procedures, but surprise, it determines how much it wants to pay. I have to suck up the rest of the bill. Balance billing become more personal as a patient. It is more of a shock than a surprise. The physician part of me also gets shocked from the arbitrary low value assessment of our services. How can the typical patient pay? A secretary friend who also has suffered a bad health year answered that question. She can’t. Her paycheck barely covers essential necessities. She stopped opening the latest bills. Our health care system and insurance coverage need massive overhauls. What’s the right answer?

The practice of medicine has changed since I started in 1980. I have benefitted from my personal compassionate and competent physicians. As a physician/patient I have knowledge to protect myself from the cookbook practice of medicine and potential medical errors. Most of our patients do not. Having undergone the trials of being a patient and sharing with you my experiences, I pray that we physicians remain vigilant in protecting our patients. But first, please, get your CXR!

Wendy Kang, MD, is a clinical professor in the Department of Anesthesiology at UT Health San Antonio Long School of Medicine.

I Won’t Take the Nurse Practitioners’ Bait

 Permanent link

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The American Association of Nurse Practitioners (AANP) is obviously intent on picking a fight with physicians. No thanks. We’ll take the high road, fully aware of the dangers of their plans, and stick with what we know is best for our patients: the physician-led health care team. 

In a recent commentary published in USA Today, two of AANP’s allies repeated the trope that authorizing independent practice for nurse practitioners would somehow solve the shortage of physicians we all know America faces. In their misguided quest, the authors have twisted and misinterpreted the research they cite, and in the end hurt the very patients they say they want to help. 

Fleeger_MugI won’t rebut, point by point, the authors’ argument. I’ll leave it at this: My problem is not with NPs. They are an integral part of the health care team. We need them on the team to help with disease management and education. Indeed, it is hard to imagine our health care system without them. My problem is with independent practice and the false argument that this will somehow improve access to and decrease the cost of medical care for our patients. The data are clear: Regardless of whether or not they work in states that allow independent practice, the vast majority of NPs locate just where physicians do – in the big cities. Without appropriate supervision, they order more tests and consultations to compensate for a more limited diagnostic knowledge base.  

Meanwhile, members of the American Medical Association’s Scope of Practice Partnership shared an insightful slide presentation from a recent AANP meeting. I was drawn to one slide that lists AANP “Board Initiatives.” Parts of it are repeated in more detail in the AANP’s 2019 strategic plan. I call your attention to two bullet points on that slide: 

  • “Patients nationwide will have full and direct access to high-quality care and will choose NPs as their health care provider” (emphasis added); and
  • “NPs will have parity with physicians and other providers in reimbursement, payment, and government funding.” 

These kind of statements might be good for AANP membership, but they’re awful for our patients. A nurse is not a doctor. And a doctor is not a nurse or physical therapist or an audiologist or any other type of clinician on the team that has to work together on behalf of our patients. 

As I stated when I proudly took my oath to become your TMA president, “It is because we are professionals that we lead, supervise, educate, and monitor the other members of our health care team. They do not know what we know. They cannot do what we do.” 

Nonphysician practitioners work with physicians – but under our direction. That’s not a put-down. It makes little sense to create more fractionation in our already confusing health care “system.” That’s what we work for at the Texas Legislature, in the U.S. Congress, in the courts, and in regulatory agencies. That’s why we defeated more than 20 scope-of-practice expansion bills during the 2019 legislative session. Your association – and I – remain firm in this principle. (See our strong letter opposing President Trump’s plan to grant NPs payment parity in Medicare.) 

In 2013, with the full support of the nurse practitioners and physician assistants here, the Texas Legislature passed a groundbreaking law that replaced the old site-based restrictions for prescriptive delegation and supervision with a more flexible, collaborative model for physician-led, team-based care. 

Our legislators understand that our patients benefit when each member of the team brings his or her special talents, skills, and training to the bedside. They understand that the path to independence is through education, not legislation. We will not stand by and watch the AANP and their supporters try to pretend that our years of medical school training and residency do not make a difference. No one has the skills and education that physicians have that qualify us to lead the patient care team. And ultimately, we have the responsibility for our patients’ health. 

I won’t take the bait. I’ll just continue to stand up for Texas physicians and our patients. 


Expanding APRNs’ scope of practice will increase the cost of care   

• Research comparing APRNs to physicians found a 41-percent increase in hospitalizations and a 25-percent increase in specialty visits among patients treated in the same setting by APRNs.1  

• Collaborative care models, such as the patient-centered medical home, have demonstrated reductions in emergency department visits of up to 29 percent2, reductions in hospitalizations up to 40 percent3, and reduction in total medical costs by 9 percent.4  

Sources:  

1 Hemani A, Rastegar DA, Hill C, et al. “A comparison of resource utilization in nurse practitioners and physicians.” Effective Clinical Practice 1999 Nov-Dec; 2(6):258-265. 

2 Reid R, Fishman P, Yu O, et al. “A patient-centered medical home demonstration: a prospective, quasi-experimental, before and after evaluation.” American Journal of Managed Care, September 2009.  

3 BD Steiner et al, “Community Care of North Carolina: Improving care through community health networks.” The Annals of Family Medicine 2008;6: 361-367.  

4 Geisinger Health System, presentation at White House roundtable on Advanced Models of Primary Care, August 10, 2009. 

Making Prescribing Less Painful for Physicians

(Legislature, Public Health) Permanent link

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No one likes to be told what to do. 

We physicians, especially, are tired of government agencies and insurance companies and hospital administrators telling us how to take care of our patients. So I won’t be surprised if physicians around the state are feeling a little angst and anger over the coming March 1 requirement for physicians to check the Texas prescription monitoring program (PMP) before writing prescriptions for opioids, benzodiazepines, barbiturates, and carisoprodol. 

Fleeger_MugI don’t fault them one bit. This is just one more administrative burden placed on physicians. But I want all of you to understand just how much worse it would have been without the intervention of the Texas Medical Association. 

TMA began our work to simplify physicians’ administrative burden when prescribing opioids and other controlled substances early in the last decade. We claimed two important successes during the 2015 session of the Texas Legislature. Until that point, Texas doctors needed both a state controlled substances registration (CSR) permit and a federal Drug Enforcement Administration permit to write prescriptions for any controlled substance. Also, until that point, the state PMP was a law enforcement tool housed in the Texas Department of Public Safety. And, physicians who wanted to check a patient’s controlled substance history had to perform that task personally. 

Thanks to TMA's advocacy during the 2015 session, the CSR permit was eliminated, the PMP was moved to a new online system created by the Texas State Board of Pharmacy, and physicians were authorized to delegate checking the PMP to members of their staff. (That's a valuable time saver for our doctors that I encourage you to use.)

As the opioid abuse epidemic raged across the country, elected officials clamored for a crackdown on prescribing practices. In 2010, Colorado, Delaware, Louisiana, Nevada, and Oklahoma were the first states to require prescribers to search patients' drug histories before prescribing. By January 2017, when the Texas Legislature was ready to convene, 26 more states had imposed that mandate. (Currently, that number is up to 43 states.) 

Political pressure to do something was growing here in Texas. State lawmakers already had filed some extremely onerous pieces of legislation. It was obvious that Texas was about to join the list. It became TMA’s job to buy time for you and make sure the state was pushing a useful clinical tool for physicians, not another useless administrative burden. 

As we do so often, TMA and organized medicine went to work educating senators and representatives about the real-world impact of the bills they had filed. We pushed back hard against a proposed sweeping mandate for physicians to check the PMP before issuing prescriptions for any controlled substance. We persuaded lawmakers to limit the requirement to the four drug classes I mentioned above. And we won a two-year delay in the mandate so physicians, the Pharmacy Board, and other key players could prepare for this massive change. 

Finally, during the 2019 legislative session, we obtained two more big improvements for physicians. While at that point, most of the major electronic health record (EHR) vendors were working to integrate the PMP into their systems, they were not likely to be done with their work before the Sept. 1, 2019, deadline. We persuaded lawmakers to delay the mandate until March 1, 2020, to give physicians and EHR vendors time to properly integrate their systems with the PMP. Plus, the legislature appropriated an additional $5 million for the Pharmacy Board to upgrade the PMP to make it easier to integrate, as well as to cover the integration licensing fees for all state prescribers and pharmacists. 

To use a bad pun, this mandate is still a pain, but it hurts far less than it could have because TMA has been there for you. We also have a new PMP Resource Center on the TMA website that includes all the background on the mandate and a way to check if your EHR is connected to the PMP. We put together a webinar with 1.25 hours of CME (free to TMA members) to make using the PMP easier for you and the staff you delegate the task of checking the database, and more beneficial for you and your patients. We also are working on a public campaign to make sure your patients know the PMP mandate is coming and what it may mean the next time they visit their doctors. 

My hope is that because of all the work we’ve done, the PMP will actually be a valuable tool to help physicians prevent drug abuse, drug diversion, and doctor shopping, and that it will not delay, thwart, and complicate care for our patients.

Beyond Burnout: Docs Decry Moral Injury From Financial Pressures of Health Care

(Under Pressure) Permanent link

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 This story was originally published on the Kaiser Health News website. Illustration by Maria Fabrizio for Kaiser Health News.

Dr. Keith Corl was working in a Las Vegas emergency room when a patient arrived with chest pain. The patient, wearing his street clothes, had a two-minute exam in the triage area with a doctor, who ordered an X-ray and several other tests. But later, in the treatment area, when Corl met the man and lifted his shirt, it was clear the patient had shingles. Corl didn’t need any tests to diagnose the viral infection that causes a rash and searing pain.

All those tests? They turned out to be unnecessary and left the patient with over $1,000 in extra charges.

The excessive testing, Corl said, stemmed from a model of emergency care that forces doctors to practice “fast and loose medicine.” Patients get a battery of tests before a doctor even has time to hear their story or give them a proper exam.

“We’re just shotgunning,” Corl said.

The shingles case is one of hundreds of examples that have led to his exasperation and burnout with emergency medicine. What’s driving the burnout, he argued, is something deeper — a sense of “moral injury.”

Corl, a 42-year-old assistant professor of medicine at Brown University, is among a growing number of physicians, nurses, social workers and other clinicians who are using the phrase “moral injury” to describe their inner struggles at work.

The term comes from war: It was first used to explain why military veterans were not responding to standard treatment for post-traumatic stress disorder. Moral injury, as defined by researchers from veterans hospitals, refers to the emotional, physical and spiritual harm people feel after “perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations.”

Drs. Wendy Dean and Simon Talbot, a psychiatrist and a surgeon, were the first to apply the term to health care. Both wrestled with symptoms of burnout themselves. They concluded that “moral injury” better described the root cause of their anguish: They knew how best to care for their patients but were blocked from doing so by systemic barriers related to the business side of health care.

That idea resonates with clinicians across the country: Since they penned an op-ed in Stat in 2018, Dean and Talbot have been flooded with emails, comments, calls and invitations to speak on the topic.

Burnout has long been identified as a major problem facing medicine: 4 in 10 physicians report feelings of burnout, according to a 2019 Medscape report. And the physician suicide rate is more than double that of the general population.

Dean said she and Talbot have given two dozen talks on moral injury. “The response from each place has been consistent and surprising: ‘This is the language we’ve been looking for for the last 20 years.'”

Dean said that response has come from clinicians across disciplines, who wrestle with what they consider barriers to quality care: insurance preauthorization, trouble making patient referrals, endless clicking on electronic health records.

Those barriers can be particularly intense in emergency medicine.

Corl said he has been especially frustrated by a model of emergency medicine called “provider-in-triage.” It aims to improve efficiency but, he said, prioritizes speed at the cost of quality care. In this system, a patient who shows up to an ER is seen by a doctor in a triage area for a rapid exam lasting less than two minutes. In theory, a doctor in triage can more quickly identify patients’ ailments and get a head start on solving them. The patient is usually wearing street clothes and sitting in a chair.

These brief encounters may be good for business: They reduce the “door to doc” time — how long it takes to see a doctor — that hospitals sometimes boast about on billboards and websites. They enable hospitals to charge a facility fee much earlier, the minute a patient sees a doctor. And they reduce the number of people who leave the ER without “being seen,” which is another quality measure.

But “the real priority is speed and money and not our patients’ care,” Corl said. “That makes it tough for doctors who know they could be doing better for their patients.”

Dean said people often frame burnout as a personal failing. Doctors get the message: “If you did more yoga, if you ate more salmon salad, if you went for a longer run, it would help.” But, she argued, burnout is a symptom of deeper systemic problems beyond clinicians’ control.

Emergency physician Dr. Angela Jarman sees similar challenges in California, including ER overcrowding and bureaucratic hurdles to discharging patients. As a result, she said, she must treat patients in the hallways, with noise, bright lights and a lack of privacy — a recipe for hospital-acquired delirium.

“Hallway medicine is such a [big] part of emergency medicine these days,” said Jarman, 35, an assistant professor of emergency medicine at UC-Davis. Patients are “literally stuck in the hallway. Everyone’s walking by. I know it must be embarrassing and dehumanizing.”

For example, when an older patient breaks an arm and cannot be released to their own care at home, they may stay in the ER for days as they await evaluation from a physical therapist and approval to transfer to rehab or a nursing home, she said. Meanwhile, the patient gets bumped into a bed in the hallway to make room for new patients who keep streaming in the door.

Being responsible for discharging patients who are stuck in the hallway is “so frustrating,” Jarman said. “That’s not what I’m good at. That’s not what I’m trained to do.”

Jarman said many emergency physicians she knows work part time to curtail burnout.

“I love emergency medicine, but a lot of what we do these days is not emergency medicine,” she said. “I definitely don’t think I’ll make it 30 years.”

Also at UC-Davis, Dr. Nick Sawyer, an assistant professor of emergency medicine, has been working with medical students to analyze systemic problems. Among those they’ve identified: patients stuck in the ER for up to 1,000 hours while awaiting transfer to a psychiatric facility; patients who are not initially suicidal, but become suicidal while awaiting mental health care; patients who rely on the ER for primary care.

Sawyer, 38, said he has suffered moral injury from treating patients like this one: A Latina had a large kidney stone and a “huge amount of pain” but could not get surgery because the stone was not infected and therefore her case wasn’t deemed an “emergency” by her insurance plan.

“The health system is not set up to help patients. It’s set up to make money,” he said.

The best way to approach this problem, he said, is to help future generations of doctors understand “how decisions made at the systems level impact how we care about patients” — so they can “stand up for what’s right.”

Whether these experiences amount to moral injury is open for discussion.

Cynda Rushton, a nurse and professor of clinical ethics at Johns Hopkins University, who has studied the related notion of “moral distress” for 25 years, said there isn’t a base of research, as there is for moral distress, to measure moral injury among clinicians.

But “what both of these terms signify,” Rushton said, “is a sense of suffering that clinicians are experiencing in their roles now, in ways that they haven’t in the past.”

Dean grew interested in moral injury from personal experience: After a decade of treating patients as a psychiatrist, she stopped because of financial pressures. She said she wanted to treat her patients in longer visits, offering both psychotherapy and medication management, but that became more difficult. Insurers would rather pay her for only a 15-minute session to manage medications and let a lower-paid therapist handle the therapy.

Dean and Talbot created a nonprofit advocacy group called Moral Injury of Healthcare, which promotes public awareness and aims to bring clinicians together to discuss the topic.

Their work is attracting praise from a range of clinicians:

In Cumberland County, Pennsylvania, Mary Franco, who is now 65, retired early from her job as a nurse practitioner after a large corporation bought out the private practice she worked in. She said she saw “a dramatic shift” in the culture there, where “revenue became all-important.” The company cut in half the time for each patient’s annual exam, she said, down to 20 minutes. She spent much of that time clicking through electronic health records, she said, instead of looking the patient in the face. “I felt I short-shrifted them.”

In southern Maine, social worker Jamie Leavitt said moral injury led her to take a mental health break from work last year. She said she loves social work, but “I couldn’t offer the care I wanted to because of time restrictions.” One of her tasks was to connect patients with mental health services, but because of insurance restrictions and a lack of quality care providers, she said, “often my job was impossible to do.”

In Chambersburg, Pennsylvania, Dr. Tate Kauffman left primary care for urgent care because he found himself spending half of each visit doing administrative tasks unrelated to a patient’s ailment — and spending nights and weekends slogging through paperwork required by insurers.

“There was a grieving process, leaving primary care,” he said. “It’s not that I don’t like the job. I don’t like what the job has become today.”

Corl said he was so fed up with the provider-in-triage model of emergency medicine that he moved his ER clinical work to smaller, community hospitals that don’t use that method.

He said many people frame burnout as a character weakness, sending doctors messages like, “Gee, Keith, you’ve just got to try harder and soldier on.” But Corl said the term “moral injury” correctly identifies that the problem lies with the system.

“The system is flawed,” he said. “It’s grinding us. It’s grinding good docs and providers out of existence.”

A Plan for the Uninsured in Texas

(Legislature, Public Health) Permanent link

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I have a book that is very dear to me. It is not a rare book, nor a valuable book. 

But this book on World War II military campaigns means a lot to me because it was given to me by a patient. After many office visits we had learned of our mutual interest in history. My patient, knowing my father went to West Point, gave me the book as a token of his appreciation of my care. The relationship that all of us have with our patients is a special one, and I know my fellow physicians have similar stories that demonstrate the mutual respect inherent in the patient-physician relationship.

But, of course, there is more to this story. For my patient had been experiencing rectal bleeding for over nine months. He worked on a food truck selling snow cones, and was poor and uninsured. By the time he presented for medical evaluation he had metastatic disease. All I could do for him was give him a colostomy. My colleagues gave him chemotherapy to no avail. He ultimately passed from metastatic rectal cancer.

I’ve always wondered if my patient lived in a state with ACA expansion would he have been covered by Medicaid? Would he have had access to a primary care medical home? Would he have had access to a screening colonoscopy that could have prevented his disease? Would he at least have had access to early diagnosis and treatment with a greater chance of survival?

But we live in a state where that is not possible. We live in a state where 17.7% of Texans are uninsured. That’s 5 million Texans. That makes us 51st. That makes us last. We live in a state where 873,000 children – and growing – are uninsured. This represents 20% of all the uninsured children in the country.

I’m not telling you anything new. You – we – see this in our clinics, hospitals, and emergency departments every day. But as I’ve traveled around the state as your Texas Medical Association president, I’ve met many who feel the situation has reached a critical stage. It has become more difficult for Texas doctors to sustain this unwritten tax on ourselves, our clinics, and our hospitals as we care for the uninsured poor.

Yet our state seems to expect this from us.

Likewise, insured patients and employers and local property taxpayers are becoming increasingly more vocal about the cost shifting that occurs to pay for the care of uninsured patients.

And yet when we go to the Capitol, we tiptoe around this issue because we don’t want to offend the legislative majority.

It is the policy of our TMA that our patients have universal coverage.

It is the policy of our TMA that we draw down the tens of billions of dollars that Texas has passed up since the ACA became law a decade ago.

Yet, is it a TRUE goal of our TMA?

When we sit down with our legislators, do we ask them if they are going to use a waiver, or block grants, or expansion to help the uninsured? And exactly WHEN are they going to do that?

I understand the political realities. They are difficult.

We, as an association, can’t change this alone. We will need to build a coalition with county medical societies and specialty societies, along with hospitals, other health care professionals, patient advocacy groups, leaders in city and county government, the leaders of the major employers in Texas, and, yes, even the health plans.

I call for our TMA to bring all of these groups together to directly address the issue of the uninsured in Texas, to plan a strategy, and to put it in motion.

I believe we can, as an association and as a profession, create the change that our patients need and deserve.

I believe we can do so in a fiscally responsible manner.

I believe it is OK for legislators to feel the same discomfort I feel when I see an uninsured patient who can’t get good care in a timely manner because she is poor.

I know that if we stay true to our core values of uncompromising and unconflicted regard for our patients’ benefit and best interest that good things can and will happen … and I hope you believe the same.

(Dr. Fleeger’s made these comments at TMA’s 2020 Winter Conference on Jan. 25.)

The Math of Medicare for All

(Legislature, U.S. Congress) Permanent link

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This is an excerpt of a post originally published on Sarah Fontenot’s website. The opinions expressed are Ms. Fontenot’s. Texas Medicine Today is sharing them to further the conversation on the future of health care reform.

Support for Medicare for All has swept the nation – or at least Democratic primary voters.

In a September Kaiser poll of likely Democratic voters, 40% said they were in favor of replacing the Affordable Care Act (ACA) with Medicare for All. Of that segment 14% said they would only support a candidate who would bring Medicare for All to America (as opposed to other solutions, such as the Public Option).

With two of the current top Democratic candidates – Sens. Bernie Sanders (I-Vermont) and Elizabeth Warren (D-Massachusetts) – espousing Medicare for All, supporters and detractors alike are asking more in-depth questions about the proposal, particularly how much it will cost.

What do Senators Sanders and Warren mean by “Medicare for All”?

Medicare for All is a concept that has been around since the early 1900s, was an unrealized component of President Franklin Roosevelt’s New Deal, and was in the background of the Medicare law President Lyndon Johnson signed in 1965.

Senator Sanders picked up the banner in 1987 and has run on it ever since – most memorably in the 2016 presidential election.

In April, Senator Sanders updated his Medicare For All plan (the fifth time he has done so) in Senate Bill 1129. Among his 14 co-signers were four senators who were running for president at the time: Elizabeth Warren, Cory Booker, Kamala Harris, and Kirsten Gillibrand.

SB 1129 would create a single-payer health system in America, eradicating private health insurance and current government health care programs over four years.

The insurance described in the Sanders plan would be more comprehensive than any policy currently available on the market, more generous than Medicare as we know it now, and more generous than any government program in the world (including Canada, the United Kingdom, and Norway).

Almost every resident of the United States would be entitled to comprehensive health care through a new government program modeled on Medicare (not included: veterans, who would continue to receive health care through the U.S. Veterans Administration; and Native Americans, who would be served through Indian Health Service).

Under Senator Sanders’ plan, Medicare for All would include:

  • Care in any hospital;
  • Care outside of a hospital (free-standing facilities, labs, etc.);
  • All preventative health care and chronic disease management;
  • Comprehensive reproductive, maternity, and newborn care, including abortion;
  • Emergency health care services and treatments;
  • Primary and specialty health care;
  • Palliative and long-term care (including home-health);
  • Care for vision, hearing, and oral health problems;
  • Mental health and addiction services;
  • Prescription medication (the first $200 a year out of the patient’s pocket);
  • Medical equipment and supplies;
  • Diagnostic tests; and
  • Other services (this list is not all-inclusive) 

All this care would be available at no out-of-pocket cost to the patient, and there no longer would be insurance premiums, copays, or deductibles in America.

It is understandable why the concept of Medicare for All has proven so attractive to many Americans.

It is also apparent why the cost of the plan has remained one of the most consistent arguments against it. What level of investment by the federal government will be necessary to make Medicare for All possible?

What does Senator Sanders say about the cost of his plan?

He has historically been vague about the cost of Medicare for All. The last time he ran for president, the “false charms” of his plan were widely criticized (and that was before he added long-term care to the 2019 version of his proposal). 

Variables make projections of the cost of Medicare for All difficult: How many new patients will enter the system? How many health care services will be requested when insurance companies no longer act as gatekeepers? How low can payments to hospitals and physicians go before the health care community closes and creates access issues for patients? What will it cost to build an administrative agency large enough to manage the health care of the entire country? 

Even so, many economists have attached a specific price to Medicare for All. Senator Warren released her price tag recently. Senator Sanders remains more opaque, and inconsistent. 

For example, in an interview in July with the Washington Post, Senator Sanders quoted the price to the government at $30 trillion to $40 trillion over 10 years. 

However, during the September debate in Houston, Senator Sanders did not refute former Vice President Joe Biden’s assertion that Medicare for All would cost over $30 trillion. Instead he added, "Status quo, over 10 years, will be $50 trillion." 

In another interview in October, it appeared Senator Sanders was frustrated by the cost question: “We’re trying to pay for the damn thing” [through, in part, taxes on the top 1% in income in the country]. He later added, “You’re asking me to come up with an exact detailed plan of how every American – how much you’re going to pay more in taxes, how much I’m going to pay. I don’t think I have to do that right now.”

What does Senator Warren say Medicare for All will cost?

Senator Warren does not have a separate plan for Medicare for All, saying instead, "I'm with Bernie on Medicare for All," as she said in the Democratic candidate debate in June. But the two candidates differ on how to pay for the plan, and how much it will cost.

Senator Warren released her plan for funding Medicare for All in November. Her lack of an explanation on how she could deliver it without a tax increase on the middle class, as has been her promise, was a prominent moment in the last Democratic debate.

And here is her number: $26.6 trillion. (I know the headlines said “$20.5 trillion, but that was ignoring the $6.1 trillion she expects the states to chip in to support the program.)

As reported by the New York Times:

Ms. Warren would pay for the new federal spending, $20.5 trillion over 10 years, through a mix of sources, including:

  • Requiring employers to pay the government a similar amount to what they are currently spending on their employees’ health care, totaling $8.8 trillion over a decade.
  • Changing how investment gains are taxed for the top 1% of households, raising $2 trillion, and ramping up her signature wealth tax proposal to be steeper on billionaires, raising another $1 trillion.
  • Creating a tax on financial transactions like stock trades, bringing in $800 billion.
  • Beyond the $20.5 trillion total, she is also counting on states and local governments to contribute an additional $6.1 trillion to help pay for the system. 

Senator Warren explained more details on her plan in November, but for our purposes, here is the crucial line: “We don’t need to raise taxes on the middle class by one penny to finance Medicare for All.”

Senator Warren’s announcement immediately prompted criticism from Republicans as well as fellow Democrats. Saturday Night Live parodied her talking about her plan on the Cold Open the following night.

In the meantime, Senator Sanders retorted that his plan is “far more progressive” than Senator Warren’s. Recognizing his proposal includes raising taxes on the middle class, Senator Sanders predicts those taxes would balance with lower health care costs, while Senator Warren’s plan “might have a ‘very negative impact’ on job creation because of funds it could take from employers.”

(Vox.com has more details on the differences between the Sanders and Warren plans.)

What do economists say?

The Congressional Budget Office (CBO) provides Congress with financial estimates on proposed legislation, including Senator Sanders’ SB 1129. In May, the office released a detailed report on the primary features of establishing Medicare for All in America, explaining that the magnitude “is difficult to predict because the existing evidence is based on previous changes that were much smaller in scale.”

The CBO refrained from providing a specific, detailed cost estimate (as it would usually do), noting “that such a system would be so different from the country’s current situation that any hard estimates would be difficult, even with all the specifics laid out.”

However, economists outside of the government have been willing to derive specific numbers for the cost of Senator Sanders’ plan.

For my money (pun intended), the best guide to the Medicare for All cost estimates from economists (as opposed to politicians) is an interactive article in the New York Times.

I like this resource because it has dynamic, interactive visuals for each estimate, and compares figures from very conservative sources (such as the Mercatus Center) to very liberal ones (such as the Urban Institute).

I encourage you to access the resource yourself, but here are the bottom-line projections for the total costs of Medicare for All from that publication:

  • Gerald Friedman, a professor of economics at the University of Massachusetts, Amherst, whose estimates were frequently cited by the Sanders campaign in 2016: $2.76 trillion
  • Charles Blahous, a senior research strategist at the Mercatus Center at George Mason University, and a former trustee of Medicare and Social Security: $3.46 trillion
  • Analysts at the RAND Corporation, a global policy research group that has estimated the effects of several single-payer health care proposals: $3.24 trillion (plus $506 billion*)
  • Kenneth E. Thorpe, the chairman of the health policy department at Emory University, who helped Vermont estimate the costs of a single-payer proposal there in 2006: $3.20 trillion (plus $706 billion*)
  • Analysts at the Urban Institute, a Washington policy research group that frequently estimates the effects of health policy changes. $3.87 trillion (plus $514 billion*)

(*Some estimates of the Medicare for All price tag are not inclusive of all health care costs.)

What will voters say?

This is, of course, the most important question of all.

We will get the voters’ answer in November.

Sarah Fontenot is both a nurse and an attorney. Today, as a professional speaker, she travels the country, helping people understand how health care is changing and what it means for them as consumers.

Why I am Hopeful for Health Care (And You Should Be, Too)

(Public Health) Permanent link

MD_School_Accreditation

This story was originally published on Sarah Fontenot’s blog, Fontenotes.

As the visiting associate professor for health law in the Health Care Administration program at Trinity University, I am responsible for teaching our students about multiple legal issues – from criminal liability associated with billing and kickbacks to patient rights regarding consent, end-of-life choices, and privacy; medical malpractice to Medicare/Medicaid; state regulation v. federal initiatives such as the Affordable Care Act and beyond. It is a chock-full semester.

As we approach the end of our time together, I assign a brief memo so the students can each describe their vision of the future of the field they are entering.

Every year, their enthusiasm is inspiring in equal measure to the difficulty of the field they have chosen.

The role of a hospital administrator

To understand why the positivity of my students impresses me, I must explain the role of a hospital administrator for those of you who might not know.

Being a health care executive is a career of stress and change.

A hospital represents the worst fears and the highest hopes of your community. You need to be ready every day to face the intolerable tragedy of the death of a car-crash victim on one floor while celebrating small steps (literally) on the stroke unit, or another day lived in your oncology clinic.

An administrator must manage the non-technology/homey ambiance in labor and delivery favored by young parents, while also supporting the cockpit-like machinery of the ICU next door.

You are the face associated with the entire enterprise – especially in a smaller community where you embody all of these intensely human moments every time you are seen in a restaurant or are addressing your local civic organization.

As a health care executive, you are a huge employer – in rural America, second only to the public-school system. You must care for your caregivers: from your professional staff to those who maintain your physical plant at the highest standard of cleanliness and safety.

As a hospital executive you are running a city. Issues regarding power (keeping the respirators alive if the electric grid fails), transportation (how to safely and compassionately roll patients through miles of hallways), traffic and access (can you take more ambulances in your ER or do you need to divert trauma to other hospitals?), public health (controlling infectious diseases), communication (continually updating and protecting digital records that allow all members of the team to understand each patient’s needs), and law enforcement (are you ready for the combative patient in drug withdrawal or an active shooter in your ER?).

Increasingly the public expects you to do all this while maintaining a facility with delicious food options and a lobby plucked from a high-end hotel.

You invest in technology that is quickly made obsolete in an environment where the physicians you depend on to care for your patients can be lured away by a shiny new toy at another radiology or surgical suite. And you can’t fight back with offers of any financial benefit to those same physicians – that would be illegal.

Speaking of which, the number of laws on both the state and federal level that dictate how you perform most of your processes would shock other business executives. Compliance with all is critical. Many of those you employ will never touch a patient: They exist to keep your facility within legal bounds to avoid all the penalties, both civil and criminal.

Those penalties could close your doors permanently because you are running your enterprise with a trajectory of decreasing revenue and tighter profit margins (I use the term “profit” lightly when referring to publicly owned and community hospitals).

To be a leader of a hospital requires inordinate skill in managing finances and budget.

What you charge is never what you are paid. Government programs and private insurance companies are continually changing your payment (always lower) without the negotiation standard in other industries.

And in this world, health care executives face each day’s list of priorities knowing that invariably there will be a crisis waiting to sabotage all other essential duties – loss of internet service because a road repair team nearby cut your cable, a sheriff serving your hospital with a medical malpractice complaint, a surprise visit from an auditor or Medicare-required compliance review (the unscheduled accreditation team from The Joint Commission will be on-site at least three days).

Then, of course, there is always the possibility of mass casualties streaming in from the explosion of a nearby plant, responding to an environmental hazard from a chemical spill at a local train crash, or transporting your patients from an incoming weather disaster such as a hurricane or tornado.

And all this time, 46% of surveyed physicians don’t trust you, you must address accusations that you don’t sufficiently appreciate your nursing staff (nurses are increasingly joining unions in the U.S.), and the majority of the public has no idea what you actually do.

This is the career my students have decided to enter.

What my students say

Understanding all of what I have said about being a health care executive, these are samples of what my students say when asked about the future of American health care:

1) They are excited about technology that can make health care more humane – not less so:

“Health care in the U.S. is notorious for being clunky and confusing … The only way that these problems can truly be solved is through utilizing data in a thoughtful manner and pairing it with technology that works for patients, rather than for administrators.”

“The expansion of technology in medicine has created more access to health care and, therefore, to information … as our consumers become more informed, our care delivery will have to adapt to become more patient-centered.” 

2) They view their role as administrators as facilitators for the greater good:

“To stay relevant, health systems will need to adapt to fit the patient’s experience and convenience, rather than the provider’s schedule.” 

“Health care in the U.S. may be fragmented and siloed, but now is the time to fix it. I believe aligning incentives and controlling costs are the key components to solving this problem.”

3) They demonstrate compassion for the patients who are the reason why:

“We need to move back to a time where physicians, patients, and their families were responsible for making important medical decisions, not the individuals taking and giving money for that care to be administered.”

“I believe that quality of life and conversations about what patients value are going to be more common … I see people being more comfortable with having these conversations and more forward in asking for them. I think it will be a shift in both physician training and patient culture that will help move us forward in this area.”

4) They see themselves as guardians of the future:

“For me personally, beginning my career at this time in the scheme of health care in America, I am excited and anxious to be a part of the changes we will experience over the next 10-20 years … How will we, as new [master’s in health administration] students, be able to affect such a large complex system? I believe it will come through the support we offer to new ideas, and the new ideas we will bring to our companies during residency.”

“I believe that health care will have vast changes midway through our careers in 2040 and towards the end of our careers in 2060. The way we mine and utilize data, improvements to technology, and changes to patient and provider behaviors will drive the outlook of our health care delivery system over the next 50 years.”

The positivity, professionalism, and commitment demonstrated by my class at large (and each student therein) leave me every December with a smile on my face and a confident outlook for American medicine.

Sarah Fontenot is both a nurse and an attorney. Today, as a professional speaker, she travels the country, helping people understand how health care is changing and what it means for them as consumers.