Thursday, February 15, 2018

Welcome to the DOG Patch: first in a series?

Lately my dander is up so often and so copiously, over what's happening in health care and the world at large, I'm exhausted. Covered with nasty dander. Cowering under the sheets. Others seem to share this dysphoria. But I found if not a cure, at least a palliative. There's so much dander I can scrape it off with a great big shovel and toss as much as I can your way. Here's my first Dander Omnium Gatherum, or DOG, from the Cetona DOG Patch. Remember, these stories are all DOGs.

  • Litmus Test for New HHS Secretary. The new sheriff at Health & Human Services, Alex Azar, has barely had a chance to wipe his feet in front of the now ironically-named Hubert Humphrey Building in DC. And already the attorney and former Eli Lilly big shot gets his big shot at letting us know whether he'll go up against his fellow plutocrats when it comes to the Affordable Care Act. WaPo has a good story on how, in Idaho, Azar's fellow rich white guy, multi-million dollar livestock owner and red state governor Butch Otter, is considering a truly insidious gem of a way to gut sick folks' access to health care in the Gem State. Allow insurors to sell ACA-noncompliant policies, which, if the sheriff doesn't come to town and say not on my watch, allows risk pools to be invidiously divided. Which of course drives up sick folks' premiums to untenable levels. What's it going to be, Alex?
  • Opioid Addiction Industry: the Gift that Keeps On Giving. Hard to be snarky when so many people are dying including my own patients. But I'll try anyway. Actually, this is a slightly more hopeful comment than my recent ones on the depredations inflicted by this industry, especially Purdue Pharma and its founders from the Sackler family. Can you guess the cost to society of this crisis? Oh, about a trillion dollars in the past decade and a half. I'd not seen it quantified heretofore, but Altarum has given it a go here. In any case, pressured by who knows who--for sure not HCRenewal, but maybe some inordinately publicity-shy latter generation Sackler family members--Purdue just announced they'd no longer promote OxyContin to providers. Oh, wait. Could it have anything to do with the fact that doctors are sick of them? Or, even more likely, that earlier this week Senator Claire McCaskill (D-MO) released a report on the back-door support this industry's been slipping to advocacy groups. A telling quote: "'The question was: Do we make these people suffer, or do we work with this company that has a terrible name?' said U.S. Pain founder Paul Gileno, explaining why his organization sought the money." Read McCaskill's report here.
  • The Soul of the Texas GOP. What's it got to do with health policy and HCRenewal? Antivax, folks, antivax. In Houston--not exactly the most rabidly extreme, left or right, among Texas cities--a PAC and Facebook (surprise surprise) offshoot called "Texans for Vaccine Choice" is mounting a challenge to Republican Sarah Davis, re-election candidate for the state legislature. (This is in the heart of Texas medicine: Baylor, M. D. Anderson, etc. Seems an awful lot of ultraconservatives go to Harvard Law then come back to Texas. This challenger edited an in-house law review featuring Ted Cruz and Neil Gorsuch.) Seems Davis committed the mortal sin of opposing a proposal to prevent physicians from vaccinating foster children. I guess this is normalized. In Texas we already knew there's a rift between business moderates and ideologues. And anti-vaccination is rampant nationwide, backed by celebrities. Rugged individualism, and resistance to empathic concern for one's neighbors, has brought us antivax, the gun death epidemic, and so so much more. It's all about choice, folks. Texas GOP seems to be divided on this matter, actually, so again, Watch This Space.
  • California Probes Aetna Medical Director. Funnily enough, I can easily see how and why this happens. But it don't make it right. The insurance commissioner in the Golden State is investigating Aetna after one of its medical directors (who's now moved on) admitted to CNN that he never looked at any of the patient files he was adjudicating for health care approvals. (Aetna, of course, denies.) How could this happen, you ask? Guy (under direction from non-physician bosses) sits there and judges patients' futures without a glance at their records? If you ever sat on hold for an hour waiting for one of this guy's lieutenants, typically nurses or even lower-rung than that, you wouldn't ask. Then you argue for an hour with the nurse. Sometimes (s)he sees the light and coaches you in how to game the system--which didn't really need to be gamed in the first place--but you end up outraged at the arbitrariness. Then this guy, in the present instance family physician Jay Ken Iinuma MD, pushes out the denial letter to your patient. You appeal. Eventually, if you had your act together in the first place, on behalf of your patient, you win. The inefficiency of it of course is just the point. I appeal. Many don't. Aetna makes out. And our system costs double anyone else's.
  • Tech Industry: the Impossible Dream. It's fun to tilt at windmills a la Don Quixote. Tech entrepreneurs--I know a lot of them--come up with a lot of great ideas. Most are DOGs. But a few are pretty neat. Here's one just maybe in the latter group. Year before last, in the Research Triangle of North Carolina, some IBMers came up with a patient-centered navigation tool whereby sick folks could look up symptoms and see their options. The company is already defunct. “'The short answer is nobody really used [it],' according to Ateev Mehrotra from Harvard. 'For a variety of reasons, they just forgot about it. This is what I would say in my defense: I still think it’s a good idea.'” But this one's a little bit complicated. Mehrotra, who spends a fair amount of time investigating such tools, had previously authored a BMJ article showing that a whole bunch of these tools, net net, are right about half the time at best. A Kaiser article on the matter noted that "[h]alf the sites had the right diagnosis among their top three results, and 58 percent listed it in their top 20 suggestions." Jury's out on this one. On top of which, the only tech applications, thanks to ACA and HITECH, that've really made it in the health care marketplace are EHRs (see InformaticsMD's many great pieces in this blog) and--actually a little better--patient portals. For now, they may just be crowding everything else out.
  • When are Ted Cruz and Diane Feinstein on the Same Team? Rarely. But WaPo now reports an instance of "real change to drug pricing being ignored by Congress." The so-called CREATES act is procompetitive in the generic space. It's supported by the ultraconservative FreedomWorks caucus, AHIP, and AHA. So why not pass it? It got left out of the recent deficit-swelling spendthrift legislation that broke the back of the threatened Can you spell Big Pharma? What's there to be said. The drug lobby and the gun lobby together practically run this country. Is it a democratic country? Do patients, who're also voters, count? Or do lobbyists' contributions to the characters writing the legislation? Oh, wait.... Why do I even pose that as a question?
  • Postmodernism Yet Again. Dr. Poses, your editor, has written eloquently and often in this blog about the baleful effect of pomo thinking on modern science and medicine, especially in the scientific and medical education spaces. This writer has stayed away from the topic, mostly because they believe the postmodern "turn" since the 1970s has been confined largely to the realms of architecture and the academy. (Lots of the academy.) But the topic is suddenly very much in the news again of late, mainly because of the truthiness--or lack thereof--on the part of so many political actors. A recent NY Times piece by Thomas Edsall, entitled "Is President Trump a Stealth Postmodernist or Just a Liar?", is especially juicy. Edsall has a truly admirable Rolodex of people to whom he can reach out and ask the question embodied in his title. If "truth is not found but made," than who among us can be righter than the next guy--say our president? Some on Edsall's Rolodex made the point that pomo just made it a lot harder to rely glibly on western "grand narratives." That much we can concede, for sure. But the truth (whoops) is: we're left in a state of ambiguity. A decade or so ago historian Charles Rosenberg, in a superb essay based on his book Our Present Complaint, said this of the "inconveniently subjective object, the patient [creating] the characteristic split screen that faces today’s clinician": we're left with "a feeling of paradox, the juxtaposition of a powerful faith in scientific medicine with a widespread discontent at the circumstances in which it is made available. It is a set of attitudes and expectations postmodern as well as quintessentially modern." But maybe the last word should go to New Republic columnist Jeet Heer, who quotes Fredric Jameson in characterizing pomo as the "transformation of the ‘real’ into so many pseudoevents." In other words, the fractionation of our political and cultural understandings of policy and society. As Roger Cohen recently wrote, the fact that politicians and lobbyists have so successfully divided us into warring tribes, where everything and everyone is self-serving and convinced of its own reality, there's the real danger. And many traditional institutions, outside of those still harboring Received Truth, have abdicated their former bridging roles along with in loco parentis.
Cetona looks forward to hearing your responses to any of these emanations from the DOG Patch.

1 comment:

Afraid said...

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