Supreme Court to Debate Affordable Care Act Next week – and plaintiff's case has imploded

With the impending, and unprecedented, 3 days of arguments over the Affordable Care Act occurring early next week, it’s interesting to see that the test case being used to challenge the law has now become a test case demonstrating the necessity of the law.
Mary Brown, the woman who asserts no one has the authority to make her buy health care is now bankrupt, at least in part due to medical bills. From theLA Times article:

Mary Brown, a 56-year-old Florida woman who owned a small auto repair shop but had no health insurance, became the lead plaintiff challenging President Obama’s healthcare law because she was passionate about the issue.
Brown “doesn’t have insurance. She doesn’t want to pay for it. And she doesn’t want the government to tell her she has to have it,” said Karen Harned, a lawyer for the National Federation of Independent Business. Brown is a plaintiff in the federation’s case, which the Supreme Court plans to hear later this month.
But court records reveal that Brown and her husband filed for bankruptcy last fall with $4,500 in unpaid medical bills. Those bills could change Brown from a symbol of proud independence into an example of exactly the problem the healthcare law was intended to address.

I think at this point the solicitor general just has to point at the plaintiff and say “See! See!”.
People without health insurance are still covered by the ethical obligations of EMTALA. They can still see doctors and get treatment and not pay their bills. Then who pays for it? All of the rest of us.
The “individual mandate” should be called a “personal responsibility” provision, because the fact is all these rugged individualists are parasites. They are refusing to pay into the system then benefiting when they, inevitably, need to use it.
And how about the argument that the commerce clause can’t for such an individual responsibility provision?

The couple owed $2,140 to Bay Medical Center in Panama City, $610 to Bay Medical Physicians, $835 to an eye doctor in Alabama and $900 to a specialist in Mississippi.
“This is a very common problem. We cover $30 million in charity and uncompensated care every year,” said Christa Hild, a spokeswoman for the hospital center. “If it’s a bad debt, we have to absorb it.”

So, this couple has generated bills in three different states that they now will not be able to pay and the rest of us have to eat the bill for them. It’s amazing how the plaintiff’s own actions have justified nearly every argument for the bill. When healthcare now represents something like 1 in 7 dollars spent in this country, how can we argue that the commerce clause does not allow congress to regulate it?

Accountability in Science Journalism: two recent examples of failures in the NYT and Forbes

ResearchBlogging.orgEd Yong demands higher accountability in science journalism and has made me think of how in the last two days I’ve run across two examples of shoddy reporting. These two articles I think encompass a large part of the problem, the first from the NYT, represents the common failure of science reporters to be critical of correlative results. While lacking egregious factual errors, in accepting the authors’ conclusions without vetting the results of the actual paper, the journalist has created a misleading article. The second, from Forbes, represents the worst kind of corporate news hackery, and shows the pathetic gullibility of reporters regurgitating the fanciful nonsense of drug companies without any apparent attempt to vet or fact-check their story. With a google search the facts are smashed.
The first article Digital records may not cut costs, I think is typical of most science reporting. That is, it’s not grossly incompetent but it overstates the case of the article involved and fails to amplify the shortcomings of the research.
The NYT article is describing this article from Health Affairs, which caught my eye before the NYT article was even published because I believe electronic medical records (EMRs) will prevent redundancies and lower costs. So, am I wrong? Will EMRs save us money or possibly increase redundancy as the HA article suggests?
I haven’t given up hope. This article is a correlative study based on survey data, and proves precisely nothing.
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What is the cause of excess costs in US healthcare? Take two

We’ve discussed it before, why are costs so much higher in US healthcare compared to other countries? The Washington Post has a pointless article which seems to answer with the tautology costs are high because healthcare in America costs more. How much more? Well, we spend nearly twice as much per capita as the next nearest country while failing to provide universal coverage:
In the WaPo article they make a big deal of the costs of individual procedures like MRI being over a thousand in the US compared to $280 in France, but this is a simplistic analysis, and I think it misses the point as most authors do when discussing this issue. The reason things costs more is because in order to subsidize the hidden costs of medical care, providers charge more for imaging and procedures. For instance, Atul Gawande, in his New Yorker piece “The Cost Conundrum” wonders why is it costs are higher to treat the same conditions in rural areas and in a major academic centers like UCLA than at a highly specialized private hospitals like the Mayo Clinic? I think the reason is it’s not nearly as expensive to administer and provide care for a select group of insured midwesterners at the Mayo than it is to provide care to the underserved in the poor areas of inner-cities and in poor rural locations.
When you are serving a poorer, under-insured population like you get in LA or Baltimore for that matter, the insured are charged more because EMTALA requires hospitals to treat all comers, regardless of insured status. Medical centers like UCLA or University of Maryland are the final common pathway for the sickest and poorest patients who, even if stabilized at smaller local hospitals, are immediately transferred to such centers. These patients are expensive to treat, often have more co-morbidities like HIV or drug use and mental illness, and there is no reimbursement guarantee for taking care of them even though it is our legal and ethical responsibility to do so.
Further, the cost of defensive medicine, which applies to this patient population as much as any other, ramps the costs of all hospital admissions and medical practice in general. It is also incredibly hard to quantify its contribution to the overall costs of care.
As a result, to pay for excessive care of the uninsured, all procedures, all tests, all imaging, and all hospitalizations cost more. Caring for inpatients and the uninsured is expensive, so the costs are transferred to the prices of outpatient elective care and procedures which are often administered in a fee-for-service model. Hospitals have an incentive to provide as much outpatient elective care as possible in order to offset these other costs and to generate revenue. The providers that perform procedures or expensive testing then become far more expensive to pay as they are the major revenue generators for the hospital (hence surgeon vs pediatrician pay). Especially because in order to generate more revenue they are paid based on how many procedures they perform. All the incentives are towards more utilization, more procedures, more revenue generation. This is the hidden tax of the uninsured.
In a way, we have universal healthcare already, but we pay for it in the most irresponsible and costly way possible. We wait for small problems to become emergent, treat them in the most expensive outpatient provider possible (the ER), and then when we can’t pay the bills for the uninsured, we transfer the balance by increasing the costs of the care of insured patients showing up for their cholecystectomies or back surgery. Tack on the costs of defensive medicine and the fear of being sued unless everything is done to cover your ass, and you have a recipe for extremely costly care.
Other factors figure into higher costs as well, including hugely higher costs of medicare administration since Bush privatized it, higher prescription drug costs since Bush passed medicare part D and prevented bargaining with drug companies, and our incredibly high ICU expenditures at the end of life. the McKinsey report on excess costs demonstrated most of these issues in 2008. This is not news. The US spends far more on medical administration, outpatient/ambulatory care (with hospital-based outpatient care increasing most rapidly in costs), drugs, doctors salaries, and end-of-life care than we should as a percentage of our GDP.
So what should we do about it? At every step we need dismantle the tendency towards increasing costs. Here are my suggestions:
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Conservatives crow over push for privatization in British NHS, compare apples to oranges

Hot Air and the daily caller are excited to pronounce socialized medicine dead as the British NHS plans to contract with private hospitals and providers on top of socialized care. From The Caller:

Joseph A. Morris, a former Reagan White House lawyer who now serves on the board of the American Conservative Union, told TheDC that socialized medicine has turned out to be a threat to Britons’ health, and to their economy as well.
“Europe’s message to the world is no longer that the socialist dream of the cradle-to-grave welfare state is an easy achievement,” Morris said. “Rather, it is the shouted warning that it is a fool’s paradise. The bills are coming due and the only real alternatives — serious financial reform of government or national bankruptcy — are not pleasant.”
Morris added that the British government, “unlike the Obama administration, is hearing the warnings, identifying its greatest vulnerabilities, and trying to race ahead of the deluge.”

Well, yes and no. The British government is interested in passing a bill that would allow private providers to be contracted by NHS and ostensibly compete with NHS where NHS is lagging. It’s hard to tell from coverage exactly what provisions will ultimately be in this bill, although the overriding goal seems to be to introduce “competition” into the NHS. Although, it’s hard to imagine the NHS being more efficient with introduction of competition as the Brits spend roughly half as much per capita and a much smaller fraction of their total GDP on health care compared to the US.
But are our right wingers correct that this is the death of socialized medicine and should be a warning about Obama care?
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Drug Shortages Reveal the Free Market is Failing Our Sickest Patients

**Update, the NYT has an editorial in their Sunday edition recommending the passage of two bills in congress requiring advanced notice from drug manufacturers in event of likely shortage.
i-1ae05c713060a45402a652d348e56148-pngHealth affairs discusses the increasingly frequent shortages of critical, life-saving, generic drugs. This is a serious problem that seems mostly limited to the U.S. healthcare system, and may adversely affect you or someone you know.

Many of the same drugs are not in such short and unpredictable supply in Europe, where in some cases they carry higher prices. This provides one major clue to the root cause: It’s the money.
Three of every four drugs on the US government’s shortage list were sterile injectable drugs, according to a report by HHS. For the most part, these are relatively low-cost generics. Simply put, most of those drugs are not very profitable to produce and sell, or supplies of them would not have dried up.
At an online presentation for journalists in November, Valerie Jensen, associate director of the FDA’s Drug Shortage Program, provided a casebook example. She mentioned the price of the tried-and-true sedative propofol, a lethal dose of which was found to have caused the death of singer Michael Jackson: The cost is forty-eight cents for a twenty-milliliter vial. “The older, sterile injectables are not economically attractive” for manufacturers to produce and market, Jensen said. Other generic drugs can have higher profit margins.

Propofol, one of the most frequently used drugs by anesthesiologists, is in increasingly short supply. I get emails from my hospital about which drugs are in short supply as physicians then try to ration these drugs for the most critical cases. In my own experience in the last year I’ve seen shortages of everything from injectable calcium gluconate (for electrolyte deficits), to levophed (a life-saving pressor used in critical care), metoclopramide (anti-nausea), and fentanyl (a powerful and useful short-acting narcotic). The FDA has a full list of recent shortages and it’s scary. Parents are having trouble finding drugs for their kids’ ADHD, vital chemotherapeutics like daunorubicin and doxorubicin are in short supply, dexamethasone (a powerful steroid), valium, digoxin (a staple of congestive heart failure and anti-arrhythmic treatment), diltiazem (hypertension and anti-arrhythmic), phenytoin (anti-epileptic also often used in acute brain injury), furosemide (an ubiquitous diuretic), haloperidol (anti-psychotic and sedative), isoniazid (a antibiotic used in TB), ketorolac (an excellent anti-inflammatory and analgesic), levofloxacin (a quinalone broad spectrum antibiotic), methotrexate (immune modulator), midazolam (a great short acting sedative), naltrexone (for reversing opioid overdose), vasopressin (another pressor) all are in short supply.
The drugs affected span all classes, what they have in common is they are all generic. Since there is too much competition in generics and too little profit margin, drug companies do not have a financial incentive to maintain adequate stocks to keep the drugs cheap and available. Shortages, if anything, increase profits because then the prices become artificially inflated.
Manufacturers, not surprisingly, blame the FDA, however the FDA hasn’t changed its standards despite increasing problems with shortages due to contamination or impurity. And that’s just for manufacturers in this country, fully 80% of the medications are produced, or active ingredients are produced, abroad. The main problem seems to be a concentration of production to a handful of companies that have adequate production capacity to compete in the generic market:

There is also a high level of concentration in US manufacturing for such drugs. That leaves little redundancy in the market as there would be for, say, generic statins. Three companies in particular–Hospira, Teva, and the Bedford Laboratories division of Boehringer Ingelheim–have been involved in selling 71 percent of the sterile injectable market by volume, the government says.7 All three have had manufacturing problems in the past two years.
With such consolidation as well as tight inventory management practices, the specialized manufacturers of injectable drugs lack the flexibility to adapt to manufacturing disruptions. If one plant shuts down, it may overburden the limited remaining competitors or choke off the supply entirely.

It’s hard to estimate the effects of these shortages, I don’t have good data on the damage done nationwide, only my personal experience. In particular, I remember during an ICU rotation running out of levophed, an incredibly important pressor that helps patients who are in shock from becoming fatally hypotensive.
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More Evidence that Universal Health Care Would be Less Expensive

We’ve written quite a bit about single payer health care systems as well as other models that are a mixture of public and private spending.
We’ve also analyzed some of the sources of excess cost of US healthcare to other countries. What is uniformly true about universal health care systems is that they all spend less on medical care per capita than the US. The next nearest country in spending to us, France, spends 50% of what we do per capita while providing top notch care, possibly the best in the world. And while the cause of our excess costs are multifactorial, one of the greatest sources of excess cost is likely due to increased use of emergency rooms over primary care providers. We already have universal healthcare, if someone shows up injured or ill, hospitals are obligated to treat them. But forcing people to come to the ER when their problems have become critical increases the costs of treatment dramatically. Now a new paper in Health Affairs demonstrates the cost of ER use over PCPs and their findings confirm that as much the costs of the uninsured to the health care system dropped by 50% once low-income uninsured patients received health coverage. This is good news as it suggests as health care reform is enacted we should see huge savings just from having a universal system.
See more below…
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What Illegal Abortion Looks Like

Many are linking to this story around the blogosphere and I encourage everyone to read it. In it, a Ob/Gyn describes her emergency care of a woman who arrived in her ED in hemorrhagic shock from a botched illegal abortion. Though clearly it was touch and go and there was some panicky action, our heroine thought fast and saved a life. My mother once worked in a labor and delivery ward to put herself through medschool in the days before Roe v Wade and this type of situation was common.
This is a great story because it illustrates two points. One, the war on abortion by the right wing is futile. We know abortion is more common where it is illegal and cases like these are more common. Banning abortion does not save lives. It results in more abortions, and more lives lost. Worse, in countries with strict bans even treatment of ectopic pregnancy is forbidden where there is still a beating heart detected by ultrasound. Doctors in these countries can literally go to jail for saving a woman’s life, all for the sake of a non-viable embryo that will kill the mother. The hypocrisy of calling this position pro-life is demonstrated by cold hard data. More women die. More fetuses are aborted.
Second, it shows how a well-trained doctor can save a life with some quick thinking. Hemorrhagic shock is something I’m pretty familiar with after my second year rotation in Shock Trauma, and in a few spectacular cases of bleeding on the wards. There are many times when as a doctor you think you’ve probably saved a life. Every case of appendicitis, dropped lung, or kid with a gastroschisis technically is a save but situations like those don’t have quite the same visceral terror and immediacy of someone who is bleeding to death right in front of you. It’s hard to keep a cool head when you’re elbow deep in a pool of blood. One case in particular that sticks out in my mind was during a nice calm Saturday in the fall. I had just finished assisting in an open appendectomy and was doing my usual neurotic repetitive rounds through the ICU I always did when I was on call. At this particular hospital, when on call I was responsible for all ED surgical consults, all the surgical floor patients, as well as the surgical ICU (I had to carry 4 pagers). So since I’d been in this case for the last hour or so I decided to check in with the ICU folks. It wasn’t the sickest ICU I’ve ever worked, nothing like the U Maryland Surgical ICU or Cardiac Surgery ICU, but, like the ocean, it’s never a good idea to turn your back on the ICU patients. So, I was passing by one patient’s room and I seen on the monitor a blood pressure of 60/40…
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Why no one should take Nexium and it should never have been approved

As Chris discussed Saturday the WSJ had a silly article in which a woman demands a prescription drug from a flight attendant, asking for the wrong drug to treat her problem acutely, and then shockingly was refused this service. Worse, Nexium is mentioned by name, multiple times, and Nexium is actually a drug which should never have even been approved by the FDA. It really is only prescribed because of intense marketing because, logically, it has no business on the market and is no different than an existing drug, prilosec. Why would doctors irrationally prescribe this drug then? Because advertising encourages irrational choices.

So why is Nexium such a scam? Read below the fold.
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Healthcare reform

With the recent victory of this administration in passing health care reform I felt it was time to talk again about the importance of this issue and some of my own experiences in the last year of my surgical training.

I was, and still am of the belief that reform, whatever form it might take, will be successful as long as we manage to make health care universal. Partly because our system already is universal but defective. No matter if you have insurance or not, if you show up in a hospital with a problem that needs to be addressed, we’ll treat it. We ethically can not turn people away because they lack insurance. People therefore who lack insurance regularly show up in the ER for primary care, or worse, with a problem that could have been addressed by a primary care doc weeks before but now has become so severe they have no choice but to get treatment whether they are insured or not. For instance, I had a patient who arrived in the ER with a gaping, necrotic sore on his cheek. It had started as an abscess, gotten progressively worse, and he tried draining it himself, inadequately, because he was uninsured. Over the course of a week though the sore had eaten through his face until it actually communicated with the inside of his face. The result? Two teams of surgeons later, an ICU stay, and an extensive reconstruction, a 10 dollar problem became who knows? A 50 thousand dollar problem? More?

We have a choice here. We can have an ethical system that treats people who need care in a thoughtful, sensible fashion, addressing problems through prevention, and appropriate care at the right time. Or we can have a system where people get their primary care in ERs, often showing up long past time their problem becomes critical and inevitably, more expensive. Guess which is less expensive? It’s not necessary to have a single-payer system like Great Britain, Canada or New Zealand. It’s not even necessary to have a public option as countries like the Netherlands demonstrate. You can even have a very generous system that is based on highly-regulated private insurance with subsidization for the poor, as in France or Germany. All of these systems beat ours with regards to cost and performance. What do all these systems have in common but is lacking in ours? It’s simple, they’re universal.
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This day in Crankery, November 16th

So who here has actually read the health care bill?. I’ve been devoting a bit of time each week to peruse more and more of it, and while there are endless obstacles to a complete understanding of it (including legalese and the annoying tendency of legislation to contain edits to other bills without including the text of the other bills being edited) it is telling that opponents of the bill are having some difficulty coming up with real criticisms of it. For example, the now infamous death panel fiasco was a willful misunderstanding of a completely wholesome concept, the idea that physicians should be compensated for having end-of-life discussions with patients. It makes sense on multiple levels to reward such discussions. For one, they are hard conversations to have, and without a motivating factor, they are avoided by many physicians. The result is a situation in which many patients fail to communicate their desires for the end of their lives, they fall in the default pathway of over-utilization of resources at the end-of-life, with invasive and often pointless interventions that have no benefit and burden and overwhelm the health-care system. The ideologues who sank that language in the bill should truly rot in hell, because they destroyed a good thing just to create a bogus political argument.

And speaking of the death panel conspiracy theory, has anyone been checking out Arthur Goldwag’s coverage of Sarah Palin’s conspiratorial beliefs? How sad is it that we still have candidates for national office that believe things that fail the test? Palin gives me the creeps, she represents my worst nightmare, a crank candidate with inroads towards a national campaign. Goldwag’s writing on the birther movement is also excellent and I’m glad to see these crackpots are being laughed out of court for the fools they are. In particular I liked the text of Judge Carter’s decision describing what it’s like to deal with cranks in court:

The hearings have been interesting to say the least. Plaintiffs’ arguments through Taitz have generally failed to aid the Court. Instead, Plaintiffs’ counsel has favored rhetoric seeking to arouse the emotions and prejudices of her followers rather than the language of a lawyer seeking to present arguments through cogent legal reasoning. While the Court has no desire to chill Plaintiffs’ enthusiastic presentation, Taitz’s argument often hampered the efforts of her co-counsel Gary Kreep (“Kreep”), counsel for Plaintiffs Drake and Robinson, to bring serious issues before the Court. The Court has attempted to give Plaintiffs a voice and a chance to be heard by respecting their choice of counsel and by making every effort to discern the legal arguments of Plaintiffs’ counsel amongst the rhetoric.
This Court exercised extreme patience when Taitz endangered this case being heard at all by failing to properly file and serve the complaint upon Defendants and held multiple hearings to ensure that the case would not be dismissed on the technicality of failure to effect service. While the original complaint in this matter was filed on January 20, 2009, Defendants were not properly served until August 25, 2009. Taitz successfully served Defendants only after the Court intervened on several occasions and requested that defense counsel make significant accommodations for her to effect service. Taitz also continually refused to comply with court rules and procedure. Taitz even asked this Court to recuse Magistrate Judge Arthur Nakazato on the basis that he required her to comply with the Local Rules. See Order Denying Pls.’ Mot. For Modification of Mag. J. Nakazato’s Aug. 6, 2009, Order; Denying Pls.’ Mot. to Recuse Mag. J. Nakazato; and Granting Ex Parte App. for Order Vacating Voluntary Dismissal (Sep. 8, 2009). Taitz also attempted to dismiss two of her clients against their wishes because she did not want to work with their new counsel. See id. Taitz encouraged her supporters to contact this Court, both via letters and phone calls. It was improper and unethical for her as an attorney to encourage her supporters to attempt to influence this Court’s decision. Despite these attempts to manipulate this Court, the Court has not considered any outside pleas to influence the Court’s decision.
Additionally, the Court has received several sworn affidavits that Taitz asked potential witnesses that she planned to call before this Court to perjure themselves. This Court is deeply concerned that Taitz may have suborned perjury through witnesses she intended to bring before this Court. While the Court seeks to ensure that all interested parties have had the opportunity to be heard, the Court cannot condone the conduct of Plaintiffs’ counsel in her efforts to influence this Court.

Plaintiffs have encouraged the Court to ignore these mandates of the Constitution; to
disregard the limits on its power put in place by the Constitution; and to effectively overthrow a sitting president who was popularly elected by “We the People”-over sixty-nine million of the people. Plaintiffs have attacked the judiciary, including every prior court that has dismissed their claim, as unpatriotic and even treasonous for refusing to grant their requests and for adhering to the terms of the Constitution which set forth its jurisdiction. Respecting the constitutional role and jurisdiction of this Court is not unpatriotic. Quite the contrary, this Courtconsiders commitment to that constitutional role to be the ultimate reflection of patriotism.
Therefore, for the reasons stated above, Defendants’ Motion to Dismiss is GRANTED.

You can just taste the crankery. The complete looseness with the truth as long as it conforms to the warped worldview of these crackpots is part and parcel of cranks the world over. Reading the follow-up of this case from right wing sites like Free Republic, and Storm Front, it’s impossible to tell the difference between the conservative ideologues and the unrepentant racists. All the appeals to patriotism and the constitution are such weak cover for the fact these cranks are angry we have a black president.

I continue to work the long hours of a surgical intern and must say, it’s a lot of drudgery. Internship is much more about paying your dues than about learning a whole lot, although my daily routine is occasionally punctuated by moments of extreme excitement. For instance, I will not forget the first time I placed a chest tube in a patient in the bedside, the blood that poured out of the guys chest that was keeping him from breathing, or the time I walked into a room to discover a patient in the midst of having a heart attack. Luckily, the training sets in, and we have a lot of supervision, so even when things get crazy I’ve always got someone with me who has seen it all before.

I also am increasingly motivated to write more as I feel less plugged-in than ever to the outside world since writing at least forced me to read tons of diverse information on lots of different topics. Cranks and crankery are all around us and I’m constantly reminded of the problems they create. It seems every time I see some topical show, and the commentators pause to reflect for a moment on the problem they’re all facing, it seems like they all know what the problem is but just don’t have a good name for it. The problem is that lies can be equally effective as the truth, and denialism creates very real problems for us and our democracy every single day. Denialism works, and cranks run amok throughout our country and the world. We have to keep writing about it until rather being on the tip of everyone’s tongue, people are willing to come out and call out denialism for what it is, and shout it down when it rears its ugly head.