For most of the past 20 years I have had the privilege of talking with and learning from medical students in small group discussions. As medical students leave the classrooms of the first and second year and transition into the third year, they confront a new reality: they are now actually encountering patients directly for the first time and are working with physicians in the daily care of patients. The more encounters they have with patients and their families and with their clinical mentors, the more stories they have to tell, which often lead to vexing questions that shed light on many of the problems of our health care system in the United States. 

One of the common themes throughout each year is the growing disenchantment with primary care, for a variety of reasons. Most of the students are assigned at some point to a clinical mentor who is a practicing internist seeing many patients each day in a primary care setting. Students often present cases of patients with complex medical and psychosocial issues that require interaction with and support from the physician. Not infrequently do we hear accounts of how patient non-compliance is a barrier to a constructive outcome. The idea of seeing patients over time with the same medical problems, while not heeding medical advice, strikes many students as a frustrating aspect of primary care. Also the students talk of these same physicians continuing to work into the evening, doing mountains of administrative work because of multiple insurance forms to complete. 

The Alden March Bioethics Institute offers graduate online masters in bioethics programs. For more information on the AMBI master of bioethics online program, please visit the AMBI site.

In August of this year, the Department of Health and Human Services announced that, as part of its preventive health initiative under the Patient Protection and Affordable Care Act, insurance companies would be required to provide birth control with no co-pay beginning in August of next year. This decision empowers women to have more control over their reproduction and should (hopefully) decrease the percentage of unintended pregnancies, which currently stands at a shockingly high 50 percent. Evidence shows that the medicalization of contraception—that is, positioning physicians as gatekeepers to contraception—increases cost and decreases access. In evaluating what contributes to unplanned pregnancy, 54 percent of women stated cost as an obstacle to contraception use and 66 percent claimed that an inability to obtain contraception played a role.

Today there are eleven contraceptive options for women: female condom, tubal ligation, cervical cap, diaphragm, implant, injectable, IUD, patch, pill, ring, and sponge. On the whole, female methods tend to be more expensive than male methods because most require at least one physician visit and some involve a renewable prescription. Only two of the eleven female-only contraceptives—the sponge and the female condom—do not require seeing a physician. This means that 82 percent of female methods require at least one physician visit in order to acquire the contraceptive. Moreover, 36 percent of female methods require a prescription (injectable, patch, pill, and ring), which means women must continually renew their contraceptive by going to the pharmacy or doctor. Most doctors will not continue renewing prescriptions without seeing their patients yearly, so the initial visit when the doctor prescribes the contraceptive is not enough to ensure continued access to the contraceptive.   

Due to the expense of initiating and maintaining contraception, women spend 68% more out of pocket toward their reproductive health care than men of the same age. Currently 28 states mandate insurance companies to cover contraception to the same extent as they do for other prescription medications. However, 20 of these states have provisions in place for providers, plans, or employers to deny contraceptive coverage for religious or moral reasons.

The Alden March Bioethics Institute offers graduate online masters in bioethics programs. For more information on the AMBI master of bioethics online program, please visit the AMBI site.

A student recently shared her concerns about one of her patients, Mrs. R., a 51 yr. old woman who had multiple medical problems which landed her in the hospital but who had no insurance. It seems her husband, who is her primary caretaker at home, is disabled himself and on disability. The two of them have a joint income of $200 per week, which is too much to meet Medicaid eligibility.  With pre-existing illness and no possibility of prospects for health insurance, they are about to lose their home to foreclosure. The hospital will likely not be paid.

With all the talk of budget crisis and concerns about government spending and particularly about an expanded role of government in providing health care insurance, it is easy to lose sight of patients like Mrs. R. Everyone agrees that the US financial crisis is far from over and that health care is very expensive. However, we need to think about the role of government in helping citizens who have health problems which drastically affect their ability to live, day to day, and who currently are out of the loop for insurance. We have laws in place to insure that in an emergent situation, patients must receive life-saving treatment in the ED, regardless of ability to pay. But what good does it do to pull someone back from the brink if you can’t give them the assistance to prevent the same thing from happening repeatedly? If we were to agree to a plan to cover everyone (universal health care) because it is the “right” thing to do there is still the problem of paying for the service. Like the unpopular suggestion to raise taxes, limits to services would be difficult to put in place although essential to make a plan viable. Mrs. R is a classic teaching case for tomorrow’s physicians, who are asked to put a Band-Aid on a large and gaping wound. In a way, she is a paradigm for what ails us a country….we want a fix without paying and make “progress” by pretending that an insufficient remedy is fine for now.

The Alden March Bioethics Institute offers graduate online masters in bioethics programs. For more information on the AMBI master of bioethics online program, please visit the AMBI site.

An NPR story this morning caught my attention. The Julie Royner report title is “Medicaid Makes ‘Big Difference’ in Lives, Study Finds.” It is available online by clicking here.

A new Harvard-National Bureau of Economic Research-State of Oregon project shows that Medicaid patients are happier with Medicaid coverage than they are when they are uninsured. But this wasn’t the principal point of the story. The report began with the notion that Medicaid patients themselves are not happy with their Medicaid coverage. Medicaid patients say they can’t find doctors who accept Medicaid patients, that the services they do receive when compared with those that have regular insurance are not as good, and there are strict limits on the services available. Moreover, politicians are not happy with Medicaid because the costs keep going up – taking a larger slice of the revenue pie – and it’s a very difficult program to manage.

Ms. Royer seemed surprised with the study findings because it contrasted so sharply with the commonly held view of the past 40 years that the Medicaid program didn’t really help patients as originally intended and it was for the most part a failure.

The Alden March Bioethics Institute offers graduate online masters in bioethics programs. For more information on the AMBI master of bioethics online program, please visit the AMBI site.

As we're all aware, the U.S. is the only developed nation that does not provide its citizens with some form of universal health care. Are we special, or are we stupid?

We're certainly not special. The U.S. is near the bottom of the rankings for two critical measures of a nation's overall health - infant mortality and longevity. And we're near the bottom for many more health care parameters.

Yes, the U.S. has the most technologically advanced medical care. But as a Dartmouth Institute study - Health Care Spending, Quality, and Outcomes - showed with crystalline clarity, more is most decidedly not better.

So are we stupid? Yes, and what's worse we're blindingly selfish. Health care is a right. The polity of every other developed country recognizes this. Universal health care is necessary in the U.S.

The Alden March Bioethics Institute offers graduate online masters in bioethics programs. For more information on the AMBI master of bioethics online program, please visit the AMBI site.

Although the ranters rant that those without health care insurance should "get a job", investigating the facts tells a different story. But in early 21st century America, facts are easily swept aside as mere inconvenience.

Who needs facts when we have opinions? Blather, posturing, speciousness, and irresponsible inanities are the coin of our public discourse.

A few Americans do inquire as to the state of the facts. A substantial proportion of the 47+ million uninsured Americans are employed. And many millions more of those who do have health insurance have less than satisfactory coverage. Cost-shifting has burdened Americans with high annual deductibles and exorbitant co-payments.

The Alden March Bioethics Institute offers graduate online masters in bioethics programs. For more information on the AMBI master of bioethics online program, please visit the AMBI site.

The free market has not fared well in recent years. Adam Smith's "invisible hand" has had its thumb on the scales for a very long time. In the last 75 years U.S. markets have been free only in the sense that businesses are free to seek as much government protection as they believe necessary.

The financial sector is a glaring testament to the infinite ways in which greed and corruption can distort the workings of a presumably free market. If finance was forced to return to "free" practices the big players would lose all their "free" money. Paradoxically, heavy regulation of the financial sector is now necessary to restore the mechanisms of a free market.

Similarly, the health care market as we know it is not "free". Supply and demand factors are not applicable to health care. Supply of services is necessarily limited - these resources are not infinitely available. Demand is always 100% - demand is not able to fluctuate. A consumer may put off purchasing a new car for many reasons. But she cannot delay a life-saving medical service.

The Alden March Bioethics Institute offers graduate online masters in bioethics programs. For more information on the AMBI master of bioethics online program, please visit the AMBI site.

The New York Times reported last year that virtually every state is making or planning significant cuts in Medicaid benefits.¹ These actions are taking place while demand for Medicaid grows. This entitlement, originally conceived as a support for those in lower socioeconomic classes and disabled persons, now is a necessary lifeline for those formerly in middle income groups who have lost their jobs. Medicaid enrollment soared by 7.5% from June 2008 to June 2009 (3.3 million new enrollees). The 2009–2010 increase is expected to be even larger.

The American health care crisis is not a doomsday scenario concocted by shrill socialist Chicken Littles. State governments can’t afford to pay their health care bills. It’s not surprising that individual Americans can’t afford to pay for health insurance and are dropping coverage by the millions.

The Medicaid news is the canary in the coal mine. When the canary dies, it’s time to pack up your gear and get out. In terms of health care, the demise of Medicaid is the clearest possible signal that the entire edifice is about to come crashing down.

The Alden March Bioethics Institute offers graduate online masters in bioethics programs. For more information on the AMBI master of bioethics online program, please visit the AMBI site.

In March, Congress reintroduced a bill: the “Part D Off-Label Prescription Parity Act.” (H.R. 1055) (See info here)  Currently, Part D covers off-label drug treatments for cancer but not for those patients who suffer other chronic conditions.  These patients can seek payment for off-label use under Medicare Part B, for those off-label drugs that are supported by peer-reviewed medical literature or in a compendium.  The goal with the Part D legislation is to adopt the standard under Part B to allow for chronic conditions, including others than cancer, to have payment for off-label drugs that not only are listed in compendia but also are supported in peer-reviewed literature.  Currently, the bill is still stuck in the Subcommittee on Health.

This is important legislation to create parity across the Medicare plans but also to recognize the balance needed in allowing for off-label drug use.  It has been shown that off-label drug use varies somewhere between 21% to 50% depending upon the drug and classification (1).   It is important that this legislation recognizes that off-label drug use can be beneficent for patients, but may also have harmful effects.  I have argued elsewhere  (2) that we need to have some regulation for off-label drug use because of the potential for harmful side-effects, and the legislation proposed along with Medicare Part B regulations demonstrate that need for off-label drug use to be governed by the standard of care either as noted in a compendia or supported in peer-reviewed literature.  A case heard by the federal court in the Southern District of New York, upheld this by stating that Medicare must cover off-label drug use for treatment that is medically necessary as supported by compendia or peer-reviewed literature.  

Off-label drug use can be extremely beneficial and it is important to not the overly limit the art of medicine.  It is equally important that we not draw arbitrary lines by not allowing patients to access and be covered for these important off-label drug uses that have been supported in the literature or compendia.  The healthcare system already has enough hurdles to jump through and Congress creating more hurdles by singling out certain diseases or not being consistent in their coverage is unjust and detrimental to patients, physicians, and the physician-patient relationship.  We need to set regulations to both protect patients and physicians but also respect the physician-patient relationship by being consistent and allowing for innovative uses that have been established as effective treatment.  

(1) Danielle Holley, Comment, Balancing on the Edge: The Implications and Acceptability of Off-Label Drug Use, 19 ALBANY J. SCI & TECH 633, 633 (2009).  
(2) Id.

The Alden March Bioethics Institute offers graduate online masters in bioethics programs. For more information on the AMBI master of bioethics online program, please visit the AMBI site.

The March 25th New York Times carried an article titled “Approval for Drug That Treats Melanoma” which reported the benchmark FDA approval of a new drug that benefits patients with almost-always fatal skin cancer. Click the photo below to be taken to the article. 

(photo from www.nytimes.com)

The novel infusion drug, YERVOY™ (ipilimumub, Bristol-Myers-Squibb), “is really the first time in the melanoma field that there is a drug that extended survival in a meaningful way,” as stated in the article by Dr. Gerald P. Linette, an Assistant Professor of Medicine at Washington University in St. Louis, who participated in the clinical trials.

In the prospective randomized studies that led to FDA approval, patients with metastatic melanoma lived about 10 months as compared with 6.4 months for those patients in the control group that received standard therapy.