The Profit-Making Costs On Our Health

photo: Library of Congress
The profit-motivated US healthcare system not only makes our healthcare more expensive than other industrialized nations, it also changes our our culture and our behavior to make us less healthy.

One of the biggest problems with the American healthcare system is that it is a rigged economic game where you don't know the price of what anything costs, and yet the price of the unavoidable healthcare needs could bankrupt you.

This price blindness is a fundamental flaw in our so called free-market system, but it is far from the only flaw tied to profit-driven healthcare.

Since so many people fear the boogeyman of socialised medicine, let's talk about some of the problems with the alternative system we now suffer through.

As an aside, please don't equate Obamacare or the ACA with socialised medicine -- it is not. The ACA simply required people to get health insurance and required private insurance companies to sell it to them. These companies are still profit motivated and opposed to cooperating with each other for the sake of good patient care.

For profit corporations are poor actors in the healthcare business, and yet we continue to place more of our lives in their greedy hands. Drug companies in particular have finally been exposed to the spotlight as they have cranked up prices on life saving medications just to boost the share on Wall Street and the bonus of the top executives. While a few high profile examples have recently gotten attention of the media, this practice is widespread and continuing unabated.

As Fortune Magazine reported:
More than two-thirds of the 20 biggest pharma companies used price hikes to drive revenue growth in the first quarter of 2016, according to an analysis of corporate filings and earnings statements by the Wall Street JournalThe review also found that drugmakers have been relying on this tactic more and more and raising prices by higher amounts than before despite multiple Congressional inquiries into the practice and proposed reforms to tackle drug costs from President Obama, Hillary Clinton, Donald Trump, and others. The findings underscore the enormous power that the biopharmaceutical industry maintains in a system where negotiations over prices and discounts are stratified across a decentralized mix of private insurers, government health programs, and drug benefit managers.
Yet another way that for profit companies negatively influence our healthcare decisions is through twisting science and lobbying government.

A recent episode of Tom Ashbrook's On Point had an excellent sampling of the horrifying impact on our nation's health.

Investigative reporters have recently uncovered evidence that drug makers lied to doctors to push the aggressive prescription of addictive oxycontin as "less addictive" alternative to drugs on the market. Documents show the drug makers knew this was not true. 

Moreover, these same pharmaceutical companies were responsible for lobbying to implement increasing the aggressive treatment of pain with narcotics. This is where the whole "pain is the 5th vital sign" originated.

Thus doctors in the United States are being penalized for creating an epidemic of narcotic addiction while at the same time their compensation is linked to surveys of patients asking if they got enough pain medication. That's why the United States -- which has only 5 percent of the world's population consumes two-thirds of the world's prescription pain medication.

It's not an accident of culture, but a concerted, planned out lobbying effort on multiple fronts designed to increase demand for a product. Millions of dollars are spent each year to boost demand for a product that is detrimental to the nation's well being.

In the same show, Ashbrook interviews researchers who discovered that a few well placed science papers in the 1960s allowed the sugar industry to divert scientific research away from carbohydrates and toward saturated fats as the cause for chronic health problems.

Of course this lead to the marketing of products with reduced fats and greatly increased the consumption of sugars.

On both issues we see the way our health culture has been altered by the pursuit profits at the cost of American lives.

Required reading:

Secret Trove Reveals Bold Crusade to Make Oxy a Blockbuster

The LA Times Series on the Oxycontin

How the Sugar Industry Shifted the Blame to Fat

To Make Big Profits, Drug Companies Use Monopoly Shenanigans

Drug Rep Arrested in Opiod Kickback Scheme

The whole On Point podcast is available and worth listening to.


Healthcare Ain't Hamburgers: Why Bills from the Emergency Room Are so High

A few weeks ago, I was working the night shift in the Emergency Room and I got a call.
"My two year old have a fever of 100.4, that's bad right?"
"Not really," I said. "Kids get sick all the time, the fever is the body's way of fighting an infection."
I got a few more details, made a suggestions for dosing Tylenol and Ibuprofen and to encourage hydration.
"So I don't need to bring him in?"
"You are always welcome to," I said. "We're open 24 hours a day. However, we'd probably just give her some Tylenol. Based on what you've told me, it doesn't sound like an emergency."

What I could have said, but didn't, was that the Tylenol at the hospital would probably cost $500.

That's not really true of course.

 The cost of the medicine we give is not the cost of the service we provide. Staffing an emergency room with highly trained trauma and emergency doctors, nurses and technicians, keeping x-ray and lab technicians on call throughout the night -- costs a lot of money.

When you get into a car accident, or have chest pain at 2 am, all those resources are put to good use -- we work hard and earn every dime.

However, the Emergency Department (it stopped being a single emergency room years ago) is not really the place you want to take your non-emergencies.

By far the majority of patients I see on a daily basis do NOT need emergency care. A generation ago, few would have thought to go to the ER for a child's fever or abdominal pain after gorging on all-you-can-eat tacos.  Things we would have waited out at home, or just massaged with an ounce of regret, we now rush to the ER for an instant cure.

Not only do we want fast-food medical cures, we also want fast food bills. McDonalds sells $1 hamburgers for that price because they pay their workers nothing and make up for it on buying and selling in huge volumes.

Healthcare is not a hamburger. 

The Emergency Room can't pay teenagers to do our job at minimum wage. We have to pay highly trained people what they are worth. We have to keep the doors open and the trauma team ready to spring into action because real emergencies happen. When you come in needing only and band-aid, we are happy to help. If your 6 year old bumps his head, we are happy to reassure you.

However, you aren't paying for a hamburger, you are paying for our expertise -- education that costs thousands of dollars to establish and maintain. Emergency room doctors and nurses have to be ready for anything, so we study pediatrics, cardiac care, trauma, respiratory care.

Two recent articles illustrate the public confusion over what an emergency department is for and why it appears that visiting the ER is so expensive.

In The Case of the $629 Bandaid, Vox examines what happened when a came in to the ER for a little cut on his child's finger. The doctor (!) washed it off and put on a bandaid - then had the audacity to charge $629 for the service.

The article never questions why the parent didn't wash the cut off and put the bandaid on at home -- like millions of people do every day, instead it focused on how horrible our healthcare system was for charging a lot of money for this misuses of resources.

Going to the ER for a bandaid is like buying a Bugatti Veyron for a 1 mile commute to work.  You could just walk -- and it would be better for you. If you are choosing the wrong tool for the job, don't blame Bugatti for charging $1.3 million.

Part of this is the loss of the intergenerational knowledge that would allow us to turn to an older parent for advice and reassurance. Now we have the internet which deals only in horror and rare catastrophes.

It is also part of our on-demand culture that we expect immediacy and instant gratification from our services. The other side of this issue is from the Kevin MD blog.

In ER Misuse and Our Instant Gratification Society, we learn that many of the people who use the ER have access to other less expensive forms of healthcare, but they choose the ER because it provides the instant gratification that we have come to expect in our service-oriented consumer culture.

I have had patients in the ER at night who tell me they have a doctor's appointment for their complaint first thing the next morning but "I don't want to get up that early."

Where this really comes into conflict is when the ER is actually treating emergencies. The people who are in ER for something minor, often don't comprehend that we prioritize care based on the sickest first -- not on first come first serve.

I have had a 30 year old walk into a patient's room where we were doing CPR on a baby to ask why it was taking so long to get seen for her ear pain. I have turned around from putting a patient having a stroke on a helicopter to care for a 12 year old with belly-button lint.

The split is generational, too.

I see older adults who worry about their bills and avoid going to the doctor or the hospital when really they should. I struggle to reassure them that we just want them to have the best care they can and that the price to protecting their heart or their life is worth it.

On the other hand, I try to warn away people who probably don't need to go. I try to explain that it costs at least $500 just to walk through the door.

This is a fear I hear expressed by providers when there is talk about making healthcare free.

Sure it will help all those people who can't afford their medications, or put off coming in when chest pain because they are fear the bills that will follow, but it will also increase the casual misuse of emergency resources by those who can't be bothered to wait for their doctor's appointment the next day.

Moreover, patient satisfaction surveys now play a big role in how much or whether medical providers will get paid.

Yet they only survey people who use the ER but aren't admitted to the hospital (thus, likely not having an emergency) This pushes hospitals to enable those demanding emergency resources for non-emergent conditions. A doctor may spend three hours in critical care saving a man's life from a septic infection only to see if rating drop because he had to ignore the 25 year old who came in complaining of a sore throat for two days.

In the end, we all need someone to tell us that we're not having an emergency for all the things that likely are not going to kill us or cause permanent damage. We can wait until morning to go to the urgent care or see our doctor.

Until we understand that emergency rooms are for emergencies, we are all going to be less than satisfied.

Required Reading:
ER Misuse and Our Instant Gratification Society
The Case of the $629 Bandaid
The ER and Our Inverted Priorities
The ER is for Emergencies, from the Washington State Hospital Association


The Myth of Islands

An Island is a lie.

On my way to work, I drive along Willapa Bay and pass by the two Islands that can be seen from the mainland. Long Island crowds just feet from the highway that hugs the shore. Heavily forested it stretches away to the horizon, appearing as solid shoreline. Long Island holds a grove of ancient forest and in days past was inhabited with settlements. There is a ferry landing just off the road that used to bring trucks back and forth across the narrow thread of water that separates it from the rest of Washington state.

A little farther on is a defiant little islet several hundred yards from where the tourist pass by on their way to the beach.. The US Geographic survey named it Round Island back in 1858. Locals call it Baby Island. Its shoulders’ hunched and spiked with snags and cedar that burl in the winter storms. Only a few acres of brush and trees, it appears a picturesque myth centered in the waters of the bay. Steep rocks rising from the silver gray waters and lonely alone.

We like to think of ourselves as islands, as individuals, as ecosystems wholly within ourselves. We like to believe that our actions affect no one beyond our ragged shore. We like to believe ourselves surrounded by waters isolated from the world outside. We like to think ourselves individuals, the center of our own solar systems -- centered yet separated by time and space from mothers, wives, children and friends who dip into our orbit for time only to swing away again.

It is easy to feel alone.

It is easy to think that our actions do not shatter the mirrored water that flows around us, yet the decisions we make ripple out into the world.

We see it in politics, where the temptation is to live and let live, assuming no responsibility for the community, the state, the nation or the world.

I hear it all the time. I’ll take care of myself, do what I want, and it won’t affect anyone else. If other people make bad choices, can’t access health care or mental health services or run out of money when they are too old to work, that’s their problem. It won’t affect me.

Yet it does.

I work as a nurse in an emergency room. It is the front line of the consequences of bad choices.

I meet a lot of people who until that moment thought they were islands. Many thought their decisions affected no one but them and them alone.  Some have long suffering loved ones at bedside, others have long since burned those bridges to the mainland. Perhaps they justified this as a way to limit that damage they caused, or perhaps the connection was never very good in the first place.

If not family and friends, there are always the professionals -- the police officers, EMTs, nurses, doctors and socials workers -- who crash in waves trying to make a difference until the last breath.

Every wave recedes taking a little away from the beach and leaving a little of itself behind. Yet, the ocean itself is not unchanged.

I have watched as addiction destroys families and devastates public resources. I have seen suicide shatter communities. I have seen health care professionals struggle to make a difference in the face of increasing needs and decreasing resources.

I have seen doctors and law enforcement officers that I worked with take their own life.

Studies have shown that nurses experience depression at twice the rate of the general population. Doctors have a suicide rate that is at least twice that of the general population and that rate is even greater for female physicians. The stresses come from long hours, increasing work loads and the crushing expectations of health care systems that are always demanding more and paying less. Unfortunately, few seek professional help.

So too some of the stress comes from our own expectations. Physician Pranay Sinha, in a 2014 essay entitled “Why Do Doctors Commit Suicide?”  in the New York Times explained it this way:

“There is a strange machismo that pervades medicine. Doctors, especially fledgling doctors like me, feel the need to project intellectually, emotional and physical prowess beyond what we truly possess. We masquerade as strong and untroubled professionals even in our darkest and most self doubting moments. How, then, are we supposed to identify colleagues in trouble -- or admit that we need help ourselves?”

Individual strength, resilience  and freedom are cultural virtues in our nation.Yet we achieve most when we come together and recognize our connections and that through those connections our individual decisions have repercussions on the world around us.

This far north the tides are impressive - a dozen feet in sea level change can drastically alter your perspective in a few hours time. When the tide is low, the water drains out of old Shoalwater bay and Round Island is exposed as connected to mainland by mudflats that the unwary may be tempted to walk across.

Drain away the oceans that appear to separate us, and you will find underneath the connections that tie us all together. 

What we do and say and how we act affects those near and far.

How we treat each other and how we take care of ourselves matters.

If you think you are an island, just wait until low tide.


This essay was originally written for the The Daily Astorian and published on 4/29/2016.


Why Food Science is So Bad (And So Often Wrong)

VOX.com Graphic
This week the World Health Organization put processed meat on the list of 478 other things that could cause cancer.

Eating an extra 50 grams of processed meat each day will increase a man's risk of colon cancer by 18 percent from baseline risk over a ten year period.

That said, your risk of getting colon cancer is small, but if you eat 50 grams of processed meat every day, it may increase a bit.

However, the WHO article, which appeared in the British Medical Journal Lancet Oncology elevates processed meats - like bacon and hot dogs to the same carcinogen threat level as tobacco.

Of course, the headline you read this morning probably said something like "Meat Causes Cancer" because leaving out the "processed meat" and the other niggling bits of detail makes for a boring story. Red meat was considered, but the WHO working group was unable to make a link between red meat and cancer.
"Chance, bias and confounding could not be ruled out with the same degree of confidence for the data on red meat consumption, since no clear association was seen in several of the high quality studies." 
Despite that, WHO still listed red meat as "probable" even though they couldn't find clear evidence.

It's worth putting these risks in perspective. The strongest evidence that the IARC uncovered focused on one type of cancer — colorectal — and the risks related mainly to heavy meat consumption. Still, the panel did find that a person's cancer risk "increases with the amount of meat consumed." So if you're eating five hot dogs a day, there's a lot more to worry about than if you have a steak a month. - VOX

That is, of course, just one of the problems with the near daily inundation of reporting we get on nutrition and diet. The research is often poor, biased or stretched to draw the conclusions we wish to draw based on the mood of the moment. We grasp at straws to make conclusions.

The WHO's rulings on carcinogens will likely carry more weight than most nutritional research that makes headlines, but the evidence is still problematic.  That's because studies on dietary changes are difficult. You can either look backwards at self reported or cultural dietary differences. Or you can set up a true double blind controlled study -- which is tricky because it is food. It tastes different.

As the UpShot column in the New York Times explains.
"Almost everything we know is based on small, flawed studies. The conclusions that can be drawn from them are limited, but often oversold by researchers and the news media. This is true not only for the newer work we see, but also the older research that forms the basis of much of what we already believe to be true."
Remember when we thought eat fat made us fat and clogged our arteries? For 30 years we were told that fat was what was wrong with our diets -- so we made fat free products -- replacing the fat with sugar to help it sell. Only to find that there was never much of a connection between eating fat and getting fat at all. Gary Taube's famous piece "What If It's All Been A Big Fat Lie" is a case study in the different factors tugging at what and how we eat.

As Taubes wrote more than a decade ago:
"Scientists are still arguing about fat, despite a century of research, because the regulation of appetite and weight in the human body happens to be almost inconceivably complex, and the experimental tools we have to study it are still remarkably inadequate. This combination leaves researchers in an awkward position. To study the entire physiological system involves feeding real food to real human subjects for months or years on end, which is prohibitively expensive, ethically questionable (if you're trying to measure the effects of foods that might cause heart disease) and virtually impossible to do in any kind of rigorously controlled scientific manner. But if researchers seek to study something less costly and more controllable, they end up studying experimental situations so oversimplified that their results may have nothing to do with reality. This then leads to a research literature so vast that it's possible to find at least some published research to support virtually any theory. The result is a balkanized community -- ''splintered, very opinionated and in many instances, intransigent,'' says Kurt Isselbacher, a former chairman of the Food and Nutrition Board of the National Academy of Science -- in which researchers seem easily convinced that their preconceived notions are correct and thoroughly uninterested in testing any other hypotheses but their own."
This leads to confusing contradictions in what is healthy and not healthy, what is good for you and what will kill you. It takes little in the way of scientific rigor to get on the Good Morning America show with the latest finding.

Yet one week of media blitz based on a small, flawed study could lead to years of misleading information and dozens of diet books as follow up research fails to attain the same level of sensationalism. As the UpShot notes:
"Although it's easy to point fingers and make a case that there are huge gaps in our evidence when it comes to food, it should be kept in mind that it's incredibly hard to do this kind of work. The reason we have to rely on small, poorly designed trials is because that's often all we can get. Because of this, we will probably continue to see results from mostly small, sometimes-flawed, short term studies of nutrients and additives. Treat the results of that research with the respect they deserve, but ignore the grandiose proclamations." 
Required Reading:

Vox has the best coverage with links to critics of the WHO Working Group's conclusions. Wonkblog at the Washington Post puts the issue into the larger perspective of politics and culture.

The WHO's New Warnings About Bacon and Cancer, Explained Vox

Hot, Dogs Bacon and other Processed Meats Cause Cancer, WHO Declares Wonkblog at Washington Post

Gizmodo Does a Good Job explaining Why You Shouldn't Panic

What If It's All Been A Big Fat Lie? Gary Taubes classic

Red Meat is Not The Enemy and
Unexpected Honey Study Shows Woes or Nutritional Research

How Red Meat Joined 478 Other Things That Can Cause Cancer

Carcinogenicity of Consumption of Red and Processed Meat

Scientific Criticism of the WHO report.


Best Thing on the Worst Day

 via Library of Congress
It was a busy night.

That is saying a lot.

All of our Monday nights are busy these days, but this was bad even by our standards. We had our fastest night shift ER doc working and extra staff, but still the patient's kept pouring in all night long.

We had sick patients too.

It was so bad that we woke up the morning shift doc and brought him in at 4 am because the department and the waiting room were full and the night shift doc was still ten charts behind.

That wasn't the only thing that made it unusual.

It was that rare night in the Emergency Department when all my patients:

1) Have a good reason to be in the ED.
2) Actually appreciated my help.

A night like that can carry you for six months -- it usually has to since it is about as common as hen's teeth these days.

With the onset of the Affordable Care Act,  Emergency Departments have seen huge increases in patient volume. Many more people have access to health insurance under Obamacare, but there has not been a huge increase in primary care providers to see them.

Yet it is not just people with new access to insurance. A 2013 studies found that only about one third of the people who come to the emergency room require immediate attention and 70 percent at that time had private health insurance.

The emergency rooms are filled around the country with non-emergent conditions and unrealistic expectations. We don't dole out narcotics like candy. We don't solve mystery conditions that you've been to every specialist to see. We give toddlers with fevers over the counter medications that parents could have given at home. We get sent patients from clinics because they can't get a same day appointment -- or don't want to wait until morning. People call ambulances because they don't have gas money and don't want to pay for a taxi.

The least sick, it seems, are the most rude and impatient. It is tempting to be rude right back, but that's what they want. They want to start a fight, to get into a tug of war. Something to tell their friends and post on social media. The only way to win that sort of power struggle is to not engage, to not pick up the rope.

Moreover, these days nurses live in fear of the dreaded "Patient Satisfaction Survey." Federal insurers want to pay hospital based on patient satisfaction -- but it is a rigged game. It assumes the patient is a customer in a restaurant, but it is the doctor that places the order. Patient advocacy is the nurse's primary motivator, but sometimes what is best for a patient is not what the patient wants or expects -- because they aren't the medical experts and they don't always want what is best for their own well being.

When our surveys dropped a few years ago, our corporation ran us through a bunch of training to teach us how to be better service workers rather than professionals.

Unfortunately the first day of these classes they explained the methodology of the survey.  Satisfaction with care was rated on 1-10, but everything below an 8 was scored as a "0." The results were not randomized, sample sizes and response errors were big problems.  We were rigged to fail. Why? I suspect is has something to do with the fact that the companies that do these surveys also profit from the consultants and seminars and education products sold to hospital systems that panic at less than perfect scores.

So we are taught how to be kind and patient with people exhibiting behavior that would get them kicked out of the lowest dive bar in town.

This night was different.

My patients were sick. I had a brain damaged man having increased seizures because of a change in his medications. I had a cancer patient on chemotherapy with a fever -- he and his wife were kind and jolly despite a terminal diagnosis. He kept making jokes as I accessed his port and drew blood cultures.

"I'm terminal," he said. "What else is there left to do with my time, but laugh as much as possible?"

Late in the night I helped with a trauma patient. An elderly lady had fallen down a flight of stairs. She was on Warfarin and had a head bleed, broken ribs and hemo-pneumo that required a chest tube. She was deteriorating. We moved her to a trauma bay to get her chest tube in and possibly intubated for the flight to Portland.

The room was filled with nurses and techs -- so often when you have a sick patient, the staff appears when you need it most.

So I lingered to cover the other rooms and found myself standing with the woman's husband in the hall. I brought him a chair, which he leaned on, but did not want to sit.

This is nursing sometimes, standing with a family member while they come to realize how this night will never leave their memory.

The doctor came out -- and behind them, I saw the Lifeflight crew shouldering their bags and walking away. Our doc had got a call back from the receiving hospital. He was told by the neurologist that the prognosis was so poor that it was not worth risking a helicopter flight.

The doctor returned to the room to put in the chest tube and I stood with the husband as he started to cry. I just stayed there, stayed present with him and we talked.

He had bad nights before. He was a World War II veteran. He had been wounded twice and saw the war end while he was in Austria. The first time he had been wounded, he pulled the shrapnel out himself and kept going. He explained that if he was medivac'd out, he would have lost contact with this unit.

"Those were the guys you were fighting for," he said. "Those were the people who had your back. You didn't want to leave them. They're your family."

While nothing like combat, his story made me think of how the whole department pulled together when there was a disaster or trauma, or critically ill patient that needed extra hands, extra help.

In the room, three nurses and two techs helped the doctor secure the chest tube which quickly drained the blood from the woman's chest and allowed her lung to re-inflate.  The radiology tech stood by with the portable chest x-ray, respiratory therapists were at bedside.

All that staff in that one room meant that somewhere a call light wasn't being answered as quickly as would otherwise have been the case. Someone was waiting for a warm blanket. Other less acute patients were still waiting to be seen. Our critical care of this one patient would probably reduce our patient satisfaction surveys.

Most nights I'm the charge nurse, directing traffic and solving problems and rarely doing hands-on care. I love my one or two nights a month where I get to take care of patients. It reminds me why I got into this business in the first place.

When I first got into medicine -- as a volunteer EMT -- someone told me that I'd have the opportunity to be the best thing on the worst day of someone's life.

Being present doesn't have a billing code. Standing with a family member at a horrible moment during a tragic night might not move the needle on a patient satisfaction survey.

Yet sometimes, that's what nursing is.


Further Reading:
The Problem with Satisfied Patients
Seven Things You May Not Know About Press Ganney Statistics
Emergency Room Visits Continue to Climb
The Ten Types of ER Patients
The Yelp-ing of Emergency Rooms