Progress Notes

Note: good news.  Since this post was written, the Susan G. Komen Foundation reversed its decision and is reinstating funds for Planned Parenthood!  We celebrate on behalf of doctors like Dr. Prabhakaran and patients like Leslie.  - Ed.

As I’m sure you know, there’s been a lot of press in the last day or two about two important organizations in women’s health parting ways.  Susan G. Komen which has partnered with Planned Parenthood to provide access to life saving breast cancer screening for the last 20 years, has decided it  can no longer provide grant funding to Planned Parenthood. 

For those of us at Planned Parenthood, it is baffling and saddening.  Many of us, myself included, have supported Susan G. Komen, because we believe the work they do is vital to women and men’s health. I still believe that, which makes the decision even more confusing. 

I want to give them the benefit of the doubt.   Maybe they believed the rumors. . . we all can fall victim to this, so I’ll try to set the record straight. 

Maybe they believed the rumor that Senator Kyl started, that 90% of our services are abortion.   While Planned Parenthood is proud to offer safe, legal abortion services, over 90 percent of our services are toward prevention, including  breast-, cervical- and testicular-cancer screening, HIV and STD testing and counseling and contraceptive counseling.  

Maybe they believed that Planned Parenthood isn’t somewhere that many people go for healthcare.  In fact, 1 in 5 women has been to a Planned Parenthood in her life.  And each year we care for 3 million people in our health centers, including 170, 000 over the last five years through Komen projects.Maybe if they just knew the stories of our patients with breast cancer who get their diagnoses earlier because we provide inexpensive access to screening services, they would come around, so here goes: 

This is my patient Leslie’s story in her own words: 

I have been a patient of Planned Parenthood since I was 18 years old. It has always been a safe, caring and affordable place for me. 

Last year, because of their referal (sic) for a mammogram, I found out I had breast cancer.  Due to the early diagnosis, I am doing well so far. 

I have only had insurance once in my life, the rest of the time I have relied on Planned Parenthood to be my main doctor.  I get my yearly exam there for about 1/3 of what it would cost elsewhere.  I get my breast exam and my referal for my mammogram. 

I don’t know how I would take good care of my female parts if not for Planned Parenthood. 

Thanks for Everything . . . my heroes. 

Love , Leslie  

As organizations, Susan G. Komen and Planned Parenthood share the goal of improving access to breast cancer screening.  Hopefully we can come back together, the work to improve women’s health is difficult enough, women can’t afford for those of us doing this work to split apart. 

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In the past few years, we have made some big strides forward for people with mental illness, and the Affordable Care Act promises more help on the way.

We made some strides in 2008 with the Mental Health Parity and Addiction Equity Act (MHPAEA), which said that health plans that cover mental health services have to provide the same level of coverage as they do for other health services.  In other words, if you pay at $25 copay at your primary care doctor's office, you pay the same $25 at your psychiatrist's office . . . if your health plan covers mental health services.

Enter the Affordable Care Act, which brings help. With the new provisions of the law, people with mental health disorders will get help in three key ways. First, the expansion of Medicaid in 2014 to everyone under 133% of the federal poverty level (approximately $26,000 for a family of four) will cover many people with mental illness who currently can't afford insurance.  Second, removing pre-existing condition restrictions means that whether you have asthma or depression, insurance companies can't refuse to sell you insurance. Third, Medicaid and insurance plans in the new state exchanges will have to cover 10 categories of essential health benefits, which includes mental health.

Finally, as pointed out in a New England Journal of Medicine Perspectives piece by Colleen L. Barry and Haiden A. Huskamp, the Affordable Care Act will help also by improving integration of services so people don't get lost in the system. 

We have a ways to go yet, but the Affordable Care Act makes me hopeful that we are moving to a future where we can make sure that everyone with mental illness can get the help they need.

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Journal Watch Psychiatry reported this week a pretty sobering statistic about people who injure themselves:

"A single emergency department (ED) visit for deliberately self-injurious behavior is associated with a sixfold increased lifetime risk for suicide. To examine how patients with self-injury are treated, researchers reviewed Medicaid records for adults treated in EDs for self-harm in 2006. Of 7355 visits, 4595 visits (62%; 4440 patients) involved discharge to the community, and 2760 visits (38%) involved admission to the hospital.

Of the patients who were sent home, only 48% had a mental health evaluation in the ED, and 52% received outpatient follow-up in the next 30 days."

As any doctor of any specialty knows, mental health is a major contributor to physical illness. Treat the mental illness, and it becomes far easier to take care of chronic diseases like diabetes and heart failure and to keep patients from landing in the hospital. And yet too often, patients with mental illness don't have access to the help they need (see prior Doctors for America posts by neurologist Dr. Laura Davies and psychiatrist Dr. Dora Wang). See our next post for how the Affordable Care Act will help.

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When President Obama was elected, many of us working in women’s healthcare anticipated a positive shift in health policy regarding women.   

There have definitely been some disappointments: 

• Inclusion of the Stupak amendment in health care reform
• HHS rejection of application to make Plan B available over the counter for all women and girls including those under age 17. 

Particularly after the HHS ruling on Plan B, some of us DFA members were concerned about what both the Obama administration and DFA had really done for women’s health.  So we did some research. 

Among the Obama Administration policies improving or supporting women’s health: 

• Rejection of the Republican Plan to defund Planned Parenthood
• Suspension of the Global Gag Rule 
• Passage of the Affordable Care Act with the following provisions that benefit women’s health: 
  • Full contraceptive coverage and rejection of the exemption request for religious employers
  • Prohibition of higher insurance premiums solely based on gender
  • Mandatory full coverage of preventive services including:  Screening and counseling for intimate partner violence, cervical cancer screening, mammography, sexually transmitted infection counseling, HIV testing 
  • Mandatory coverage of maternity care including gestational diabetes screening, lactation consults

And how about Doctors for America: 

• Work to assure passage of the Affordable Care Act
• Publicly opposed the Stupak amendment
• Joined National Women’s Health Law Center on letter to President Obama opposing religious exemption to contraceptive coverage
• Published multiple blog posts on Progress Notes about women’s access to healthcare including contraception and abortion
• Communicated with HHS regarding concern about lack of scientific support for Plan B access decision  

While abortion access and coverage continue to be weaknesses of both the Obama administration and Doctors for America, both groups have made strides to overall improve women’s access to health care.    As DFA members, we’d like to see DFA join organizations such as the AMA, ACOG, AMWA and PRCH among others, and take a clearer stance on abortion access as it is an issue of significant importance to women’s health. We also support DFA’s One Million Campaign which will be important in helping women understand and access the benefits afforded them by the ACA and in assuring the ACA, which is the most important improvement in women’s health access in the last few decades, continues to be implemented.  

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The other night over dinner I had a conversation that left me bewildered.  This was on two counts:  my coworker across the table actually countenanced the idea that the world would end in 2012, and later she stated that the reason her health insurance premiums had been going up was because of “ObamaCare”.  You can imagine the tact with which I tried to deliver my skepticism of the former idea and rebuttal of the latter in order to not too deeply offend my colleague.  It was hard, and she didn’t really seem convinced by my explanations, so deeply rooted was she in her own popular education on Mayan calendars and Fox News analysis.  [Sigh.]

Misinformation, particular the kind rooted in dogma, is everywhere.  And this is particularly true during an election year, when the opponents of health insurance reform will continue to try to rally their troops around repealing ObamaCare on day one – because, you see, it represents a threat to the greatest health care system in the world, not to mention unvarnished tyranny.   We could really use periodic reality checks as our leaders on the right try to feed us this grade-A bologna throughout the year ahead, because, unfortunately, they’re not going to stop. 

But before you get depressed all over again about the state of American political discourse –  about how ideology, not evidence, seems to inform so many of our debates  – don’t feel too bad, for we are not alone.  Let’s look at another country where dogma is trying to trump good public health.  I give you the Philippines.

Like the Affordable Care Act, pending legislation in the Philippines is trying to make birth control universally accessible.  This doesn’t mean abortion.  Rather we’re talking about the pill, condoms, etc,  that are cheap and widely available here, but completely unaffordable to most poor Filipinos living on just a few dollars a day and spending 70% of their income on food.  Birth control is a big deal in the Philippines because almost half of all pregnancies there are unintended, abortion is illegal, and the country already struggles to feed its burgeoning population.  All in the all, the Philippines is the world’s largest importer of rice despite having very productive farmland and high-yield rice strains.  Meanwhile, across the sea to its west, Thailand has effectively brought down poverty rates partly with family planning.  Parents generally choose to have only as many children as they can afford, and as a result Thailand is a net exporter of rice.  So, get the birth control pill to every woman that wants it, some condoms to everyone that needs them – these are safe, cost-effective public health measures that will also improve the economy…what could be simpler? Enter the Catholic Church.

About 90% of Filipinos are Roman Catholic, and polls suggest a majority support the proposal for universal access to birth control.  But the clergy contend that birth control is just the gateway to abortion, and have put their full political weight into defeating the bill.  Catholic Bishops are even threatening to excommunicate the President, Benigno Aquino III, if he signs the bill into law.  When asked about this religious pressure on pro-public health politicians, Archbishop Oscar Cruz uttered this threat to Public Radio International, “Don’t fool with the church, ‘cuz she will bury you.” 

                                                                                                       marketplace.org

Now good Christians can disagree about whether it is better to follow the command to be fruitful and multiply, or to feed my sheep , but back in the United States, we have already litigated this fight about the benefits of basic birth control.  It turns out that people are freer, and families are more prosperous, when they have some say over how many kids they have.   And for heaven’s sake, using a condom is not the same thing as having an abortion.  Rather, barrier methods like that one are unabashedly pro-life, in that they actually save lives.

Meanwhile, our own conservative dogma continues to haunt us as the same people who chanted “kill the bill” in 2010, crusade on to repeal health insurance reform in 2013.  In the Philippines, the Church may or may not have the political clout to block progress, but right-wing ideologues on this side of the Pacific do seem ready to undo many important reforms.  They would have us believe that the Patient’s Bill of Rights and covering pre-existing conditions are fascist ideas, that a guaranteed right to appeal claims denials and shopping Insurance Exchanges are against the free market.  Well, in this New Year we here at Doctors for America resolve to not let this nonsense go unchallenged.    The world will not end in 2012, and neither will health reform. 

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I share this personal story in the spirit of a new year…in the spirit of optimism for a bright future. Herein is vision that lies in wait and motivates me each day in my journey through medical school…

It happened at the gym, in a whirlpool. We exchanged pleasantries. Soon came the coy questioning…the naughty teasing…the fiery passion…and then, she took me…

We flirted for years. She enchanted me with her dynamic spirit and gallant grace, but I knew of her smothering demands and pricey habits. I deftly evaded her advances, yet she always returned for the thrill of the chase. Today was different. Using bubbles as bait, the muse of medicine lured me into a debate that left me simultaneously speculative and resolute, vexed and inspired, overwhelmed and lucid.

She embodied herself in Bruce, or so I recall. The introduction came somewhere between his vilification of my future medical career and his cursing the U.S. health care system. I had never met pessimism incarnate, nor had I ever met Bruce, but today I had the company of both. He blindsided me with a bluntness that struck like a sucker punch. It was completely unwarranted, but it triggered a defense mechanism that I had yet to wield with such conviction. Bruce presented a final test. I emerged unscathed, battle tested for the front lines.

I was beyond the point of rationalizing my career plans with strangers, but this guy obstructed a path down which I endlessly vacillated.  To be or not to be an MD? If only Shakespeare had clarified. I am convinced that integrative medicine—the synthesis of disease prevention and treatment—must be the future of health care, but would it be best to effect that transition from within? Should I go the policy route? Or would it be best to take an administrative approach?

By this point, I had a rehearsed response to the frequently asked “what-are-you-doing-now” question.  Dutifully, I told Bruce “I just finished a health policy internship in D.C., I am exploring various interests before medical school, and”—CRASH! It must have been “medical school” Or perhaps “health policy”? Somewhere in my comatose monologue I hit a nerve.

I came to learn that Bruce had been diagnosed with Type II diabetes. Despite the diuretic medications, the edema in his feet had reached the point that doctors discussed amputation. “And you know what I did?” he recounted. “I said (expletive) you to the doctors and I started to swim. Every day, I swim and my blood sugar drops. They prescribe more drugs and try to cut my feet off. Doctors don’t give a (expletive) about health. I get sick, and they get rich. Follow the money trail and you’ll see why the system is so (expletive).” And like that, I became his punching bag.

Yet I empathized with Bruce’s frustration.  My work in D.C. was an eye-opener to the insidious financial incentives of pay-for-treatment “disease care” and the ruinous physical and fiscal consequences of a disjointed system that acts (or more aptly, reacts) downstream. I sensed an alarming disconnect among the health care, transportation, agriculture, food and drug policy spheres, each of which impacts health yet exists as an isolated silo.  Horizontal integration is imperative to craft a comprehensive vision of health.

On the ground, as a personal trainer, each day I see clients who are victims of the communication gap between the medical and wellness professions. Vocations that share such similar values, goals, and patrons must exchange ideas, share knowledge and coordinate health care. As a trainer, I compile medical history reports, monitor physical indicators, prescribe tailored regimens, teach biomechanics, and design dietary plans. I build trusted relationships with other human beings. With weights and sweat, I construct camaraderie and humanity from ferocity. My clients have ranged from elite athletes to obese children, from pregnant women to those afflicted with degenerative diseases. I act as a confidant, a therapist, and above all, a friend who gives his undivided attention and concern in the gym (office hours) and at home (on call). In certain respects, I am literally a physician in training.

A paradigm shift is imperative. True change starts on the front lines and emanates from those who exude trusted expertise, emotional investment, and devotion to the well being of each patient separately and all humans collectively. I thrive under such demands. I told Bruce how I hope to connect evidence-based medicine with wellness to broaden the spectrum of holistic health care. I envision lifestyle counseling, fitness training, dietary instruction, rehabilitation therapy, and medical treatments under one comprehensive health insurance plan. “Physicians must play the central role in coordinating this shift,” I explained.

Bruce chuckled. “So you have a vision, huh? Well, give it up. You went to Yale, so you must have brains. And you know what smart folks do?” he asked rhetorically. “They sell out and so should you. Keep people sick and make money. Now, if by some miracle you become some philanthropic doctor, I will find and congratulate you,” he promised. “But when you start pocketing checks from pharmaceutical reps, just think of me saying, ‘I told you so’.”

I returned the challenge with a grin. The muse was singing and I sang back. “I appreciate the advice,” I responded, “but I train for unknown terrain.”  I thanked him in earnest. If Bruce is a man of his word, I eagerly await his future visit. 

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Even as the dominant item in the news continues to be the GOP presidential race, the topic of health reform doesn’t exactly take a back seat; in fact, unlike the frontrunner candidate, which seems to change on almost a weekly basis, the Affordable Care Acts holds a rather steady position in the GOP debates: the reliable punching bag.  The call to repeal “Obamacare” is an easy “go-to” for a candidate when he is up against the ropes, always garnering loud applause and cheers from the audience and restoring unity to the otherwise contentious exchange.

The general public’s opinion about the ACA has fluctuated a little bit more than that of its staunch opponents in the one political party—but only recently. The Kaiser Family Foundation’s monthly Health Tracking Poll for December 2011 reported that support for the ACA is back up to the level it saw for most of 2011, after having a rather rocky fall season. For most of the year, about 40% of Americans favored the law and about 40-45% had an unfavorable view, a relatively even split according to Kaiser’s public opinion research team. But in October, those who had an unfavorable view of the ACA were 51% and only 34% found it favorable, the lowest proportion since its passage. This was largely due to many Democratic voters backing down in their support. Beginning in November, the numbers started to come back but not all the way, with 37% favorable and 44% unfavorable, demonstrating that there was a real change in thinking.

Why would there be this dip at all? To be sure, it looks now to be a minor, temporary blip. But the Law certainly hasn’t changed, and in fact, the provisions of the ACA that have already gone into effect are among the most popular, such as allowing parents’ children to stay on their health insurance until age 26 and requiring insurance companies to provide easy-to-understand explanations of benefits.

The answer seems to be in the details of the poll, which reveal that well over 18 months after it was passed, a large portion of Americans still feel they know little about the law or its potential impact on them.  In December, about 55% said they knew a “fair amount” but 42% said they   did not know enough to estimate its impact. These numbers are almost identical to the numbers in April 2010. Perhaps most unfortunate is that even those Americans who stand the most to benefit have a poor sense of how the ACA will help them. Of the uninsured, 40% say they know little about what the law will do, and nearly 50% of the low‐income also are uncertain.

As the poll results are broken down further, the fluctuations of public opinion become more understandable: When the Kaiser poll would inform respondents about individual reforms and then ask them to comment on their favorability, even the most popular reforms were unknown. For example, over 85% of respondents favored the requirement that health plans provide straightforward summaries of benefits for customers, but only 42% of them knew it existed. Similarly, around 60% of people were unaware of the requirement for insurance companies to spend 80% of their premium collections on health services (the medical-loss ratio), but 60% found this to be a favorable rule. Other “pleasant surprises:” nearly 80% support the Health Exchanges and subsidies to small businesses to buy insurance, and even 69% support the expansion of Medicaid, another much-maligned piece of the law.

The most telling finding is that the message matters: the individual mandate is the least popular at 33% favorability. But, when respondents were informed that for most Americans, their employer-provided coverage would qualify for the mandate’s requirement, the favorability jumps to 61%, completely flipping the ratio. However, when they are told that the Supreme Court is going to rule on whether the mandate is constitutional or not, 74% disapprove of it.

Myth about the law still prevails: Nearly 70% either think or do not know if the law includes a new government-run insurance plan. And a third (35%) believe a government panel will make decisions about end-of-life care for Medicare recipients, the infamous and mythical “death panel”       

The ACA’s supporters, the politicians who passed it as well as the advocacy groups who fought for it, have made a smaller impact on informing the public than its detractors have. Using the ignominious name “ObamaCare,” opponents have not only called for its repeal, they have falsified its contents, labeled it as socialist and worse, and have successfully scared the public into fearing it, especially the most vulnerable, our senior citizens. The Kaiser poll points out that Americans get their information about the ACA from a variety of sources, most popularly from the cable news networks (both supporters and detractors).  Among those who get their information solely by word-of-mouth, the information is mostly negative, demonstrating the poor understanding of the complex law and ability to explain it to one another.

This is why DFA has launched the One Million Campaign, to help serve as a corrective to the current climate of myth and propaganda and to aid those in understanding this complex but important law. The campaign will aim to reach its target of educating Americans, other physicians and the general public, on the facts, the benefits, and the still-to-be determined elements of the ACA. Please join us in this effort, to help take back control of the health reform debate. 

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As a female physician-in-training, there is no moral issue as fraught with anxiety and self-reflection as the one of abortion. As we enter our journey into medicine, we swear to leave our assumptions and personal experiences at the door in order to serve our patients first. After serving terms as both school president of the American Medical Women’s Association and as chair of Medical Students for Choice, I have entered countless discussions with my colleagues about how challenging it is to feel like we can do it right, and this is why it’s hard: Access.

As we move into the wards and our discussions turn from philosophical to practical, what we experience firsthand is what one case-worker told me after managing women’s access to care for twenty-five years. “The rich get richer, and the poor have children.” In this day and age, with so many contraception options, it’s so easy for the public to be judgmental towards women who end up with an unwanted pregnancy. Still, when you meet these women face to face, you meet the frightened fifteen-year-old girl who puts on headphones, closes her eyes, and cries through the entire procedure and realize with frustration later that she lives in a community where birth control is truly folklore because of cost. There’s the twenty-one year old who comes in for a late-term abortion because she started saving money for a procedure when she found out she was pregnant, and this is how long it took her. Unintended pregnancies among poor women is twice the national average. Abortion would be a simpler issue to debate if it was not so entrenched in poverty and access.

This is why the Friday announcement is so awesome. The Obama administration announced that soon women will not have to pay out of pocket for birth control. On August 1^st, many insurance plans nationwide will be fully required to fully cover contraception without co-pays or deductible. Increasing access to birth control is phenomenal and allows women to be empowered with the care of their own body and plans for their family.

 Announcements like these are what make the Affordable Care Act so pivotal. Its very existence allows us to redefine the priorities of the health care system. It forces us to re-examine the system, and to advocate for the changes that we need.

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By Dorice Arden, Submitted by Linda Burke-Galloway, MD, MS, FACOG

Sometimes it is our patients and readers who become our greatest teachers. On March 16, 2011, I turned in my resignation from a public health position that I held for almost 15 years. I simply could no longer practice medicine in the manner upon which I had been trained. I blogged about that experience and one of my readers, Dorice Arden, who I now consider an online friend wrote a poignant comment that I’d like to share with you. It speaks from the heart. I hope we all have the ability to listen.

“Reading your post this morning was a shocking reminder of just how low the value for humanity has sunk. The notion that patients are considered a commodity has far-reaching consequences. The very thread that ties us to our humanity is the value we place on life and life-sustaining measures. The attention and care we share with each other sets the tempo for the future. Infants are now born to an environment that welcomes them with the ringing of a cash register.

Likewise, how we spend our last days can also be symptomatic of an accounting exercise. My personal experience with the care of my mother’s treatment for cancer, at a renowned NYC hospital was appalling. My brother was in high school, I had just graduated from college and our mother was dying. She had colon cancer yet, a young doctor ordered a brain scan test. When I asked why the test was ordered he replied, do you want to know the truth? Stunned with not understanding an option I assured him I did. Well said he, "it is to beef-up the file.”

“Beef-up the file” are words I shall never forget. To consider my 51 year old mother’s fate and the inhumane attention shown her by this doctor was despicable. However, it speaks to how health care has diverted away from giving attention to the humanity it is charged with protecting and defaults to pledging a profit.

Assuredly, I did not permit a brain scan to be done on my dying mother but, that experience affirms the need to question and question again the principles that guide the medical profession.

Though, it is not only the medical profession that has lost its way. The conscience of this nation has been altered by marketing mavens who craft messaging to a level of persuasion that views life as a business opportunity.

We the people must revisit critical thinking as an asset and not an inconvenience. Simply ask why; make the truth be heard and be certain the answer has value that resonates with your better angels.

Dr. Linda Burke-Galloway, though we have never met, somehow I sense that your good work will persist and we shall be the better for it. Wishing you peaceful moments…”

Thank you, Dorice. 

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The triple aim of health care, as defined by the Center for Medicare and Medicaid Services (CMS) is: improving the experience of care, bettering the health of populations, and reducing the per capita costs of health care.

This struck me as odd when I first read it.  Why should the stated aim of any system become to decrease the costs associated with that system?

Which led to the next logical questions: What should be the stated aim of health care in America?  And where would we need to put our money to reach that aim?

I went into family medicine, the land of community health, behavior change and health promotion, because I believe the aim of a health care system is to keep people healthy. I wanted my work in medicine to prevent disease and promote health (offering vaccines and health screenings and diet advice), as well as curing sickness as needed. But my personal aim in medicine doesn't jibe with the American medical system.

A few years ago, my department chair summed up the underlying aim of American medicine: “to cure disease and keep people from dying.” We’re pretty good at this.  Our medical system cures lots of diseases really well, thanks to surgeries and antibiotics. Intensive care units return some people to life, and for others postpone inevitable death.

And yet truly, the purpose of a health care system is to provide care to promote health.  Give health? Keep health?  Restore health?  Who cares!?!

I do.

How we define "health" and what services we define as part of the “health system” changes the way our society allocates scarce
resources.  Right now, our society devotes an enormous portion of our budget to the medical system—curing sickness and keeping people from dying. A medical system and a health system, however, are two different things.

If we redefine a health system as any system within our society that delivers the goods that promote or destroy health, we can restructure our funding priorities to promote population health rather than individual medicine.

Is "health" turning on a faucet to obtain clean water, free of the microbes that take up residence in our intestines to kill?  We’d need to allocate health care dollars to monitor our water and sanitation system.

Is "health" eating wholesome fruits and vegetables, devoid of the high fructose corn syrup that makes us fat, gives us diabetes, and kills? We need to see politicians end the era of King Corn and misguided
agricultural policies.

Is "health" breathing pure, clean air, devoid of dangerous diesel exhaust and factory emissions? Let’s fund the Department of
Transportation and the Environmental Protection Agency.

Is "health" having food on the table, a roof over our heads, the warmth of heat in the winter, a cool pool of water to soothe the summer, bodily comfort in a cruel world? These are the works of the departments of labor, housing, energy, parks and recreation.

Right now we define “health” as having access to the doctors and medicines and hospitals we need, as we need them, to restore health to our sick bodies so we can return to being happy, healthy, productive citizens.  This is the work of the Department of Health and Human Services, and their triple aim is to improve medical care, improve population health, and do all this for less money.

Cost savings will come when all the departments of our government unite and receive the resources they need to promote health.  Then we will have a health system.

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