In vitro fertilization and the Catholic Church

Earlier today, Pope Benedict reiterated the Catholic Church’s ban of sperm or egg donation and in vitro fertilization.  According to an article in USA Today, the Pope urged its faithful to resist “the fascination of the technology of artificial fertility” and cautioned against “easy income, or even worse, the arrogance of taking the place of the Creator,” an attitude he indicated underlies the field of artificial procreation.  “The human and Christian dignity of procreation, in fact, doesn’t consist in a ‘product,’ but in its link to the conjugal act, an expression of the love of the spouses of their union, not only biological but also spiritual.” 

Although I have long been aware of the Church’s archaic opposition to many forms of birth control, I wasn’t aware of its opposition to in vitro fertilization until I asked my medical-student son for some in vitro information a couple of years ago and he told me that he didn’t know anything about it because his Catholic medical school refused to teach the subject.

I was interested in learning about in vitro fertilization because my oldest son and his wife were using the process to have the baby they had been unable to have naturally.  Today, because of in vitro fertilization, I am the grandfather of 10-month old twins – Katelynne and Hayden.  I am amazed that Pope Benedict places more importance on the “dignity of procreation” and “the conjugal act” than he does on the babies who needed a little help from science.

Down syndrome – an update

 

This week’s issue of Time magazine has an excellent article on the status of Down syndrome in America. 

The focus of the article is on the effect of scientific advances that enable earlier and easier detection of Down syndrome.  Because 90% of the women who learn that they a carrying a fetus with Down syndrome have their fetuses aborted, the article assumes that earlier and easier detection will result in an America that is populated (currently 400,000) with fewer and fewer people with Down syndrome.  Paradoxically, the article suggests that that diminishing population will result in reduced government services because large numbers and scalability often facilitate improved services.

I was shocked at the 90% termination rate of fetuses found to have Down syndrome.  Not surprisingly, however, the one woman who was extensively reported on in the article ultimately decided to have the baby.  Despite the widespread support in America for abortion rights, there is still widespread disapprobation awaiting any individual woman who acts the right.

Because of the advancing age of women in America having babies, and because the age of the mother significantly affects the likelihood of having a baby with Down syndrome (1 in 100 for a 40-year-old mother as compared to 1 in 691 for all mothers), you might think the population of Down syndrome babies would be exploding.  But it isn’t.  Over the past 20 years, the advancing age of mothers should have resulted in an increase in Down syndrome births of 42%, but in fact the numbers decreased by 11%.  That is clearly the cause/effect of testing and abortion. 

Regarding the scientific developments on testing, it has three key components:

1. Detection can be as early at 10 weeks (before the mother is visibly pregnant);
2. Instead of a scary amniocentesis, testing involves a blood sample; and
3. The risk of miscarriage is eliminated.

Another significant scientific development with Down syndrome babies is that, because of a new surgical technique that corrects a heart-defect found in half of the Down syndrome babies, their life expectancy has gone from 25 in 1983 to 60 in 2011.

Sarah Palin is one of the 10%, and I admire her action, but I sympathise with the other 90%.

Friends and oxytocin

A couple of days ago, I posted in by blog about man as a social being, with a strong suggestion that I needed to be more social.  After reading the posting, a reader reached out and invited me to a “conversation and a brew” at my convenience.  Because I was having an especially difficult time yesterday (not even two Xanaxes helped), I reached out to him immediately.  I had yoga from 6-7 pm, and we agreed to meet at Hills & Dale’s ice house immediately afterward.

Although Wednesday night at H&D’s is biker night, we were able find a reasonably quiet nook and had a wide-ranging conversation.  He promptly confronted my social/personal issue and quickly helped me understand what was going on and what I needed to do.  But most importantly, he was able to motivate me to want to do it.  All of which reminded me of Jack Black’s 2001 movie “Shallow Hal,” in which motivation speaker Tony Robbins helps Hal Larson overcome some of his social difficulties.  Perhaps the connection with Tony Robbins is that my friend has been a professional motivational speaker for 30 years.

My friend also seems to be a modern-day polymath – i.e. a Renaissance man.  Before our first over-sized brew was finished, our conversation drifted into the bonding that takes place between a man and a woman, and he explained to me that much of that bonding is due to oxytocin, a hormone that is released when men and women have sex, especially during orgasm.  That helps explain the truism that a good sexual relationship is a key ingredient to a strong marriage.     

After returning home from H&D’s, I did some additional research on oxytocin.  Two especially good insights on bonding were as follows:

• “Consider the major feel good hormone, oxytocin. What makes orgasm feel so good is the release of this powerful chemical at the time orgasm occurs. Oxytocin is also known as the bonding chemical. It helps dissolve the sense of boundaries and gives that sense of being at-one in large or small ways with yourself, your partner, or for those who achieve more mystical states, the world.  Interestingly enough, women tend to have oxytocin levels that are ten times larger than men have. No surprise then, that women tend to get more bonded to their partners when orgasm occurs. For a man, shortly after orgasm (in an hour or two), the oxytocin level drops off. His testosterone and vasopressin levels have done their work. He has achieved orgasm. Now that his work is finished, time to move on and shift focus. But, for the woman her higher levels of oxytocin, which can last in her system for two days, combined with other female hormones move her towards a greater sense of fusion and vulnerability with the man she has just had a sexual experience with. After all, for a woman to even reach climax she is required to surrender, open up, and become vulnerable in a deep way to the man she is with. No surprise then, the woman tends to feel more attached. It is her biological & chemical makeup that motivates this.”  Dr. Lisa Love.

•  “In women, the secretion by the hypothalamus of the hormones serotonin and oxytocin is greater than in men. Serotonin calms us down….  Oxytocin is the bonding chemical….  During sex the increase in oxytocin causes a woman to bond intensely with her partner, creating romantic attachment.  About the only time a man experiences a surge of oxytocin is during orgasm which allows him to bond with his partner as well.  However, after orgasm, a man’s oxytocin levels return to their normally low levels, while the woman’s levels remain consistently higher than the man’s.  This is why a man may be compelled to say, ‘I love you’ during sex, but may not feel like saying it much afterwards when the woman is longing to hear reassuring words of love and affection.”  Terri Saunders, NCHP.

I have previously been aware of the compulsion to say “I love you” during sex, but wasn’t aware that it was a shared trait. 

The Wellness blog provides additional information on things woman and men can do to facilitate the beneficial effects of oxytocin bonding. 

Last night at H&D’s was time well spent.

Coverage for preventive care under ObamaCare

Although much of ObamaCare was deferred until 2014, some provisions were implemented in 2011.  One of the most notable of such provisions was a requirement for health-insurance policies to extend coverage to dependents up to 26 years of age.  Because my 24-year-old son Tommy, who was living with me and attending college, was my dependent, he once again became covered under my Humana insurance policy for a few months.  Because my 17-year-old son Jimmy was already covered under the same policy, the addition of a second dependent cost me nothing.  In fact, the ObamaCare coverage enabled us to drop the bare-bones health-insurance policy that I had been buying for Tommy through UTSA and receive at no additional cost Cadillac-quality coverage under my policy from Humana.

That’s sounds like a win-win situation, at least from the perspective of Washington as a regulatory, welfare state.  Tommy receives better coverage essentially free.  Except we all know that nothing is free; instead, the cost is merely obfuscated.  In fact, the cost of Tommy’s coverage will eventually be passed on to my former employer who provides the policy to me as a retiree.  As the premiums increase, the insurance will become less affordable, and employers will be driven to pull back from providing health insurance.

I was prompted to think about this issue of “free coverage” when I read an Associated Press article in the San Antonio Express-News on Saturday about additional free coverage.    The article was titled, “Preventive care: It’s free except when it’s not.”  The supposed scandal described in the article was that Americans had been led to believe that ObamaCare mandated that all preventive care was to be free – i.e., no deductibles or co-pays – but because of a loophole in the law, some evil insurance companies were categorizing some medical care as a diagnostic test instead of a preventive screening and thereby subsequently charging deductibles and co-pays.

Colonoscopies are apparently the principal bone of contention because polyps are often removed during the procedure (that has happened with both of mine), and this removal shifted the expensive procedure from being a preventive screening into being a diagnostic test, which triggers deductibles and co-pays.  The article reports that this “loophole” is especially costly to those with high-deductible insurance policies who may have been advised by their doctors that the procedure was free, and there is a legislative move to fix the loophole.

From my perspective, this is not a loophole that needs fixing.  Preventive care should not receive preferential coverage.  Providing preferential coverage will incentivize enterprising medical providers to encourage the over-utilization of services that deductibles and co-pays are designed to discourage. 

Furthermore, requiring a high-deductible policy to provide a lot of coverage without applying the deductible will defeat the purpose of the policy – i.e., a highly affordable policy because the insured is self-insuring for all but catastrophic expenses.

Let’s fix the preventive-care provision by eliminating special treatment.  If free preventive care made economic sense, the insurance companies would already by doing this.

For those who don’t like taking orders – Discharge Against Medical Advice

As one of my favorite presidents (Bush-43) famously said, “When I was young and foolish, I was young and foolish.”  An example of this occurred in my life when I was a novice attorney working in Huntsville and living in Austin.  One night, I was driving my girlfriend’s (later she became my wife and ex-wife) so-called motorcycle – a 125-cc Honda – and collided with a guy in an intersection who made a left-turn in front of me.  I was knocked unconscious and dragged for a long distance before the other guy dislodged me and vanished into the night. 

Initially, my doctor thought I was only scrapped up, but later they discovered I had a non-displaced cervical fracture, which required extreme immobilization for a few days.  As with most people, I became enormously anxious to get out of the hospital, and my doctor kept putting it off.  Finally, on the day that I was certain to be discharged, my doctor never came by on his rounds.  In a fit of frustration, I checked myself out and went home.

According to Wikipedia, there is a term for what I did – Against Medical Advice, or AMA:

• “Sometimes known as DAMA, Discharge Against Medical Advice, is a term used with a patient who checks himself out of a hospital against the advice of his doctor. While it may not be medically wise for the person to leave early, in most cases the wishes of the patient are considered first. The patient is usually asked to sign a form stating that he is aware that he is leaving the facility against medical advice, and the AMA term is used on reports concerning the patient.  This is for legal reasons in case there are complications to limit liability on the part of the medical facility….  When a patient checks out against medical advice, the patient’s insurer may not pay for subsequent stays for the same condition.”

Although I earlier said that my personal DAMA was an instance of being young & foolish, I actually believe in the concept.  I suspect this belief is rooted in my 60s, libertarian values.  People from my generation don’t like big institutions telling us what to do, even if they are right. 

Further, although the U.S. Constitution does not specifically address false imprisonment, the Fourth Amendment prohibits unreasonable search & seizure, which has been interpreted to mean that individuals have a valid cause of action if they can prove: (1) willful detention, (2) without consent, and (3) without authority of law.

So for years, I have been telling my DAMA story to anyone who will listen – i.e., “you don’t have to kowtow to the Man.”  But my son, Mikey, who is now a resident ER doctor at the Mayo Clinic, recently told me that they actually have security to prevent people from discharging themselves if they are a risk to themselves or to the community.  That sounds like a police state that I am unfamiliar with, something that certainly deserves more investigation.

Surprisingly, one of the best DAMA resources on the internet is an article on the Mayo website that discusses the scope of the problem – approximately 2% of hospital discharges are DAMA – the reason for them, and methods to minimize them, but nothing about police or security:

• “At the heart of the problem is an ethical dilemma for physicians. When a patient wishes to leave against medical advice, this may be contrary to the physician’s attempt to do what is believed best for the patient. The struggle is between patient autonomy and physician beneficence.”

After a painstaking search of the internet, I concluded that hospitals do not have a right to hold patients against their will unless they think the patients are mentally incapable of making their own decision.  Patient autonomy wins over physician beneficence.

Following my search, I asked my son to validate my conclusion, and he confirmed, with one caveat (that drunk were mentally unsound) and with one exception – i.e., that hospitals were required to report gunshot wounds to the police and hold the patient until the patient arrived.  We know that New York has a similar law because one hospital got in trouble for not following the law when a famous athlete was involved in a shooting:

• “On November 28, 2008, Burress suffered an accidental self-inflicted gunshot wound to the right thigh in the New York City nightclub LQ when his Glock pistol, tucked in the waistband of his sweatpants, began sliding down his leg; apparently in reaching for the gun he inadvertently depressed the trigger, causing the gun to fire. However, the Manhattan District Attorney stated Burress was in fact wearing jeans. The injury was not life-threatening and he was released from an area hospital the next afternoon. Two days later, Burress turned himself in to police to face charges of criminal possession of a handgun. It was later discovered that New York City police learned about the incident only after seeing it on television and were not called by New York-Presbyterian Hospital as required by law. New York Mayor Michael Bloomberg called the hospital actions an “outrage” and stated that they are a “chargeable offense”. Bloomberg also urged that Burress be prosecuted to the fullest extent, saying that any punishment short of the minimum 3½ years for unlawful carrying of a handgun would be ‘a mockery of the law.’ Burress had an expired (concealed carry (CCW)) license from Florida, but no New York license.”

Burress went to jail; how much you want to bet that no one from NY-Presbyterian did?

Some good decisions re: the implementation of ObamaCare

A couple of months ago, I posted an entry in my blog titled “ObamaCare takes shape.”  In the entry I reiterated a major concern about ObamaCare, and then reported on a recent development that had somewhat ameliorated the concern.  Now this past week, the Obama administration has given us further good news about its implementation of this controversial program. 

My major concern with ObamaCare, in addition to the unconstitutional individual mandate, is that the law appears to require gold-plated coverage for everyone.  This concern is based on a provision in the law that requires HHS Secretary Sebelius to define a mandatory package of preventive, diagnostic, and therapeutic services and products called “essential health benefits.”  ObamaCare provides that this package of essential benefits should be “equal to the scope of benefits provided under a typical employer plan.”  In my blog entry, I described my concern as follows:

• “My concern is that employee health coverage, especially when unions are involved, is often gold-plated, and it is nonsensical to make gold-plated coverage the minimum standard for a welfare-type program like ObamaCare, especially if we are trying to restrain over-utilization.”

And I described the ameliorating development as follows: 

• “Today, the NY Times reported that a shocking display of common sense and good judgment may prevent my fears from materializing. According to an article in the Times, the Institute of Medicine (IOM), in providing the Secretary of HHS with a framework for deciding what coverages should be deemed essential, recommended that (1) the cost of providing the coverage should be considered so that the policy remains affordable, and (2) ‘a typical employer plan’ should be that of a small employer, not of medium or large employers, who tend to provide more generous (expensive) coverage.”

So what is the further good news this week?  The good news was reported by the Washington Post in an article titled, “Feds would allow states to tailor basic health benefits under Obama’s overhaul.”  The article reports that the Obama administration was adopting the IOM’s recommendation regarding small-employer coverage as a minimum or floor:

• “The new proposal would let states pick a benefits package from several federally approved options. Those range from benefits offered to federal and state employees to the most popular small business plans in the state and to a large health maintenance organization, or HMO.

An article in the NY Times took a similar take on this development.  In an article titled, “Health Care Law Will Let States Tailor Benefits,” the Times reported:   

• “In a major surprise on the politically charged new health care law, the Obama administration said Friday that it would not define a single uniform set of “essential health benefits” that must be provided by insurers for tens of millions of Americans. Instead, it will allow each state to specify the benefits within broad categories.”

Neither article, however, makes it clear how the small-business coverage will be reconciled with the ObamaCare requirement that “the benefits package must include such fundamentals as inpatient and outpatient care, emergency services, maternity and childhood care, prescription drugs, preventive screenings and labs.  It must also cover mental health and substance abuse treatment, as well as rehabilitation for physical and cognitive disorders, and dental and vision care for children.”  As the Post article noted, “such additional benefits are often not fully covered by frugal plans that are now the best that many small businesses can afford.”

Fortunately, due to the wonders of the internet, we have access to a news release and detailed bulletin issued last Friday by the Department of Health and Human Services, and these documents answer the questions left unanswered by the Times and Post. 

According to the news release:

• “Consistent with the law, states must ensure the essential health benefits package covers items and services in at least ten categories of care, including preventive care, emergency services, maternity care, hospital and physician services, and prescription drugs.  If a state selects a plan that does not cover all ten categories of care, the state will have the option to examine other benchmark insurance plans, including the Federal Employee Health Benefits Plan, to determine the type of benefits that will be included in the essential health benefits package.”  

The bulletin provides even more detailed guidance:

• “Section 1302(b) of the Affordable Care Act directs the Secretary of Health and Human Services (the Secretary) to define essential health benefits (EHB)….  Section 1302(b)(1) provides that EHB include items and services within the following 10 benefit categories: (1) ambulatory patient services, (2) emergency services (3) hospitalization, (4) maternity and newborn care, (5) mental health and substance use disorder services, including behavioral health treatment, (6) prescription drugs, (7) rehabilitative and habilitative services and devices, (8) laboratory services, (9) preventive and wellness services and chronic disease management, and (10) pediatric services, including oral and vision care.”
• “The statute distinguishes between a plan’s covered services and the plan’s cost-sharing features, such as deductibles, copayments, and coinsurance. The cost-sharing features will determine the level of actuarial value of the plan, expressed as a “metal level” as specified in statute: bronze at 60 percent actuarial value, silver at 70 percent actuarial value, gold at 80 percent actuarial value, and platinum at 90 percent actuarial value.”
• “Generally, according to this analysis, products in the small group market, State employee plans, and the Federal Employees Health Benefits Program (FEHBP) Blue Cross Blue Shield (BCBS) Standard Option and Government Employees Health Association (GEHA) plans do not differ significantly in the range of services they cover. They differ mainly in cost-sharing provisions, but cost-sharing is not taken into account in determining EHB.  Similarly, these plans and products and the small group issuers surveyed by the IOM appear to generally cover health care services in virtually all of the 10 statutory categories.”
• “One of the challenges with the described benchmark plan approach to defining EHB is meeting both the test of a “typical employer plan” and ensuring coverage of all 10 categories of services set forth in section 1302(b)(1) of the Affordable Care Act. Not every benchmark plan includes coverage of all 10 categories of benefits identified in the Affordable Care Act (e.g., some of the benchmark plans do not routinely cover habilitative services or pediatric oral or vision services). The Affordable Care Act requires all issuers subject to the EHB standard in section 1302(a) to cover each of the 10 benefit categories.  If a category is missing in the benchmark plan, it must nevertheless be covered by health plans required to offer EHB. In selecting a benchmark plan, a State may need to supplement the benchmark plan to cover each of the 10 categories.  We are considering policy options for how a State supplements its benchmark benefits if the selected benchmark is missing a category of benefits.  The most commonly non-covered categories of benefits among typical employer plans are habilitative services, pediatric oral services, and pediatric vision services.”
• “Below, we discuss several specific options for habilitative services, pediatric oral care and pediatric vision care. Generally, we intend to propose that if a benchmark is missing other categories of benefits, the State must supplement the missing categories using the benefits from any other benchmark option.” 

Thus, it appears that the Obama administration is shifting away from its “one size fits all” strategy and is granting states the flexibility needed to craft an affordable insurance policy that satisfies its needs.  The law does not allow flexibility re: gold-plated coverage for habilitative services, pediatric oral services, and pediatric vision services, and perhaps that can be fixed by amendment.  Further, the administration still needs to address the issue of cost-sharing (co-insurance, co-pays, deductibles), and state flexibility will be needed there, too.  But HHS Secretary Sebelius should be commended for her recent decisions in the implementation of ObamaCare.

p.s., Washington Post columnist Robert Samuelson just came out with a lengthy column suggesting the Sebelius’s action was good politics, but bad policy.

Sunday Book Review #55 – Your Medical Mind by Jerome Groopman and Pamela Hartzband

During this past year, one of my best friends, Kevin Brown, and I started experiencing osteoarthritis in our left knees.  Osteoarthritis is often called wear-and-tear arthritis, and it occurs when the protective cartilage on the ends of your bones wears down over time.  Because Kevin and I are both southpaws who played basketball into our 50s, we suspect that contributed mightily to our similar problems. 

Although our problems are similar, and we have the same health insurance, our approaches to the problems couldn’t be more different.  Kevin doesn’t have a lot of faith in doctors, worries about possible side effects of treatment, and often turns to the internet to find home-spun remedies that are generally not FDA-approved.  Sometimes this strategy works, but it hasn’t worked with his knee.  By contrast, I have a lot of faith in doctors and don’t pay much attention to their pro forma warnings about possible side effects of treatment.  If something is FDA-approved, it’s good enough for me.  When my doctor recommended that my knee be replaced, all I said was “when?”

According to Your Medical Mind, more people act like Kevin than me:

• “Studies show that some 60% of people in the United States pursue so-called alternative or natural therapies.  This indicates a naturalism orientation, the notion that the body can often heal itself if given the proper environment, harnessing the mind-body connection and supplementing with herbs, vitamins, and other natural products.  On the opposite end of the spectrum is the technology orientation, the belief that cutting-edge research yielding new medications and innovative procedures holds the answers.”          

The difference in approaches between Kevin and me is what Your Medical Mind examines.  The authors distinguish patients by a variety of characteristics.  Some prefer maximal treatment; others prefer minimal treatment.  Some have a naturalism orientation; others have a technology orientation.  And then there are believers and doubters:

• “Believers approach their options with the sense that there is a successful solution for their problem somewhere. …  Doubters approach all treatment options with profound skepticism.  They are deeply risk-averse, acutely aware of potential side effects and limitations of drugs and procedures.  They question how much benefit a therapy really offers them and whether there might be deleterious consequences.”

The book’s subtitle is “How to Decide What is Right for You.”  Although the book does not directly mention ObamaCare, it is clear that the authors do not favor the D.C.-based, centralized planning.  The authors argue that deciding on treatment is not an objective analysis, but rather is a subjective process that necessarily differs dramatically from patient to patient.  One size does not fit all. 

The chapter that I found most interesting is titled, “End of Life,” and it provides highly-emotional, anecdotal evidence of how complex and subjective medical care must be.  The chapter focuses on two individuals who were dying and how these individuals and their families dealt with this fact. 

Both Mary Quinn and Ruth Adler had initially had issued stern advance directives against aggressive measures (CPR, intubation) that their families thought too restrictive.  In the case of 64-year-old Mary Quinn, she gradually changed her mind about fighting her incurable biliary cancer and eventually decided to fight death up to her last moment.  This change of heart prompted her to authorize a moderately aggressive drainage procedure (“I want to keep trying.  I want to fight.”).  But Mary never reversed her directive against aggressive measures, and when the drainage procedure led to unexpected complications, the family was forced to confront complications that involved a ventilator and more.  Ultimately, the family took Mary off the ventilator and she died in peace without knowing how much the family had deviated from her directive.

In the case of 75-year-old Ruth Adler, she was dying of aortic stenosis.  Although she agreed to serious surgery, she issued a directive for no heroic measures and no effort at resuscitation.  Complications from the surgery required that Ruth be placed on a ventilator for a few days, and although she surprised her family by agreeing to the ventilator, she refused to undergo more problematic surgery.  In the end, the family adhered to Ruth’s wishes, and she died peacefully.

The Quinn and Adler cases are instructive in that, “Patients deviate from their own advance directives because, like Mary, they often can’t imagine what they will want and how much they can endure when their condition shifts from healthy to sick and then to even sicker.”

These cases are also instructive because they reveal how dynamic the end-of-life process can be and how families and doctors have this great struggle in deciding what is best for the patient (substituted judgment).  Is it more important to accept what the patient wants (patient autonomy), or is it better to overrule the patient and do what you would do (so-called beneficence)?  The authors persuasively argue that this is a “gray area” with no single answer, although studies reveal that doctors as a practical matter are much more inclined toward beneficence – i.e. they know best what is good for their patients.

Much of Your Medical Mind is devoted to explaining how Kevin and I ended up with such different strategies in dealing with medical issues.  But the key point of the book is that both strategies need to be accorded respect and that can only occur when patients, doctors, and families talk and listen to each other.

Doctor-owned hospitals under ObamaCare

When I had my knee replaced a couple of months ago, my doctor assigned me to Methodist Texsan Hospital, a shiny, new hospital with all private rooms near Crossroads Mall.  I had been to the hospital a few years ago for a heart evaluation when it was brand new and was known as Texsan Heart Hospital. 

The hospital name change, as well as a change in ownership and mission, was precipitated by ObamaCare.  The original Texsan Heart Hospital was co-owned by a corporation and 70 physician-investors.  Under ObamaCare, Medicare would not do business with physician-owned hospitals that were opened after 1/1/11 or expanded effective immediately (3/23/10).  Although Texsan Heart Hospital remained eligible for Medicare patients (60% of its business) because it was built in 2004, ObamaCare would create significant limitations on its ability to expand in the future, and apparently its owners decided avoid those limitations by selling the hospital to Methodist.

Nancy Pelosi famously said that we needed to pass ObamaCare to find out what was in there, but the law’s attack on physician-owned hospitals was not a hidden item.  Within a week of the passage of ObamaCare, healthcare websites were reporting on its effect on physician-owned hospitals:     

• “After President Obama signed healthcare reform legislation last week, there was much joy for Democrats (at least for Democrats). For physicians who own hospitals, it meant upheaval.  As of now, there are about 260 physician-owned hospitals in the U.S. About 58 are undergoing construction and expansion plans, with an estimated $5 billion that has been expended or financed. With healthcare reform, those projects are frozen, going nowhere, or in the midst of confusion.  The new law restricts existing physician-owned hospitals from adding beds, procedure rooms, ORs and especially reduces funding for Medicare patients. Most of the physician-owned hospitals have an average of 2 % doctor ownership.  At least 28 new hospitals were scheduled to open by August 1, 2010, and another 74 are in the planning stages to open after that date. Dozens are trying to meet a Dec. 31 deadline to “grandfather” in some new hospital expansion plans or allow some new facilities. While some new hospitals may be approved, Molly Sandvig, executive director of Physician Hospitals of America, the advocacy group for physician-owned hospitals, says it doesn’t seem current hospitals meet the complicated standards imposed to carry out billions of dollars in construction projects.”

Almost lost amongst all those numbers is the fact that doctors owned an average of only 2% of the hospitals.  That makes you wonder whether the doctors were involved to contribute money or patients.

In November 2010, USA Today reported on the hospitals that were frantically trying to beat the end-of-year ObamaCare deadline:

• “They are on a tight deadline. The health care overhaul law closes the door on future physician-owned hospitals, requiring new ones to be open and certified by Medicare by Dec. 31. Otherwise, they’ll be barred from taking part in Medicare, the health program for the elderly, as well as other federal health programs. That would be a fatal blow to most hospitals because about half of their revenue comes from those programs….  Besides barring new doctor-owned hospitals after this year, it prohibits the 269 existing institutions from expanding unless they meet stringent conditions….  To get the OK to expand, doctor-owned hospitals must be located in states with a shortage of hospital beds, and in counties that are growing 50% faster than the overall state, among other requirements. They could also ask permission to expand if they see more Medicaid patients than other hospitals in their county.”

The USA Today article noted, however, that lobbyists for physician-owned hospitals were biding their time until the House Republicans took control.  Already leading Republicans in Congress, like Joe Barton and Jeb Hensarling, were suggesting that existing physician-owned hospitals should be allowed to grow. 

Well, a year later, the Republicans have finally acted.  According to news reports earlier this week in the NY Times and the website FierceHealthcare, congressional Republicans, while passing a law to hold down payroll taxes and extend unemployment benefits, inserted a provision to allow under-construction physician-owned hospitals to be completed and existing ones to expand.     

All of this leads to the question – Why was ObamaCare so tough on physician-owned hospitals?  As I noted above, physicians have a 2% ownership interest in these hospitals, so one might suspect that their ownership is intended to provide money-paying patients, not significant ownership equity.  And the NY Times article confirms this:

• “Numerous studies have found that when doctors have a financial stake in a hospital, they tend to order more tests and procedures, raising costs for Medicare and other insurers.”
• “The Congressional Budget Office said allowing the spread and expansion of these types of facilities would increase federal spending by $300 million over 10 years.”

But this amount of money is considered nominal in Washington.  The real opposition to physician-owned hospitals is coming from the lobby for non-profit community hospitals, who argue that “physician-owned hospitals tend to focus on narrow, profitable specialties, such as orthopedics and cardiac care, while leaving important but money-losing services, such as emergency departments and burn units, to community hospitals.”  

What’s a conservative to think about all of this?  Although some say the physician-owned hospitals are cherry-picking the profitable aspects of the hospital industry, I say that is the nature of capitalism.  The Postal Service doesn’t like UPS and FedEx cherry-picking either, but that is how the American economy works.

But I am more persuaded by the argument that physicians should not have an economic incentive to over-treat or over-utilize.  Most experts agree that over-utilization is one of the biggest drivers in the increasing medical costs, and I don’t think building a wall that prevents doctors from profiting from their prescription for ancillary services will do serious damage to free-market principles.

Dr. Berwick leaves Medicare/Medicaid

The New York Times reported today that the federal head of Medicare/Medicaid for the last 17 months, Dr. Donald Berwick, had his last day on the job on yesterday.  According to the Times, Berwick believed “20 percent to 30 percent of health spending is ‘waste’ that yields no benefit to patients, and that some of the needless spending is a result of onerous, archaic regulations enforced by his agency….  [He] listed five reasons for what he described as the ‘extremely high level of waste.’ They are overtreatment of patients, the failure to coordinate care, the administrative complexity of the health care system, burdensome rules and fraud.”

One of the reasons that Republicans in the Senate refused to confirm Berwick was his statement in 2009 that, “The decision is not whether or not we will ration care — the decision is whether we will ration with our eyes open…. My point is that someone, like your health insurance company, is going to limit what you can get. That’s the way it’s set up. The government, unlike many private health insurance plans, is working in the daylight. That’s a strength.”

Sounds to me like Berwick is the kind of guy we need in Washington, at least until we can repeal ObamaCare.

 

 

A perfect storm

The past few days I think my life has run into a perfect storm.

Just a few weeks ago, everything was hunky-dory.  I was working out every day with an hour bike ride in the hill country and another hour practicing yoga with friends.  My knee was acting up, so I decided to have knee-replacement surgery in early November.  Enjoyable blogging and reading consumed much of my day.  My college son graduated and moved out of my apartment to move in with his girlfriend, and the additional space seemed fine.  Everything was going so well that I decided to stop using the anti-anxiety mediation, Lexapro, that I had been using since my divorce.

Then the perfect storm hit.  The after-effects of the knee surgery were worse than I expected.  I have a low pain threshold, so I used the hydrocodone as much as authorized, but still experienced significant pain because the dosage was too weak.  Then when I started weaning myself from the pills, I felt like I was in a funk, and a friend has told me that it is common to feel that way when getting off pain pills.

But another friend has told me that it is also common to feel that way when a person is suddenly prevented from exercising.  Even though I am now riding a stationary bike for 30 minutes a day, she said that is no substitute for the one-hour outdoor ride I did for 68 straight days before the surgery.  She said something about endorphins and such.

And what about the fact that I discontinued the Lexapro just prior to the surgery?  That certainly can contribute toward a funk.

For good measure, let’s add that one of my best friends moved out of town, the stock market is in a dive, and Washington D.C. is justifying its 9% approval rating.  Further, I finished a fascinating book on Lincoln.  Finishing a great book is always depressing, but this was even worse because of the sad ending.  And finally, the shortest day of the year is just around the corner.

Because of this perfect storm, I was so depressed about politics last night that, for the first time in forever, I simply turned off the TV at 7PM and went to bed.

Now, to snap out of it, I have resumed taking Lexapro, I am going to redouble my efforts get back on my road bike and back into yoga class.  And most importantly, I have concluded that my life was already getting too solitary, and in the past month it became significantly worse.

Time for a mid-course adjustment.