VA Scandal: Long Waits for Treatment Resulted in Preventable Deaths

Any person who has a health issue that can be cured or prevented should want three things related to their medical care.
1. Access to Care which can be defined by in this manner: Your ability to quickly secure an appointment with the physician of your choice and quickly undergo and obtain all tests, regimens, and procedures necessary for treatment.
2. Affordable Care which can be defined in this manner: Your (or your proxy like an insurance policy or a government health care coverage program like Mecdicare, Medicaid, or the VA Health System) ability to afford to pay for you required health care related costs.
3. Quality Care which can be defined in this manner:Your ability to obtain the most appropriate treatment for your medical condition which should be guided by the most current clinical trials and evidence based best practices.

Obviously, in the real world, we have to deal with tradeoffs....The highest quality of care may not always be the most affordable care. That is where people (or societies or the representatives of society who are usually politicians) need to decide how money is allocated towards different necessities (like food, shelter, and healthcare) as opposed to being allocated towards luxuries or optional items (like the newest smart phone, Air Jordan sneakers, Chloe hand bags, or that even that frappuccino at Starbucks...)

Do veterans who obtain their medical care at VA Medical Facilities receive care that balances the above three issues appropriately?

It would seem that a better job can certainly be done.

One major problem with providing high quality,affordable health which can be obtained quickly when needed is that some people in the U.S. view health care as a right which should be able to be obtained for free if necessary while at the same time also wanting the most cutting edge health care treatments on the market which are usually expensive.

People from other countries, specifically European countries, are acutely aware that although they enjoy much easier access to health insurance coverage than their American counterparts (they have  socialized medicine to varying extents and people tend to obtain their health care coverage through the government), they generally do not have easier access to medical treatment.  Medical treatment includes the most cutting edge screening tests and treatments along with the newest and most expensive pharmaceutical drugs. People who have socialized medicine tend to need to wait very long times to see specialists and undergo procedures compared to their American counterparts.

The VA shares structural similarities to socialized medicine health insurance coverage. The government allocates a fixed amount of money annually to treat all qualifying veterans who need medical care in a given year. The VA is unable to use price as a mechanism to turn away people for treatment because  veterans pay either nothing or very low prices for their care. So another mechanism used to  lower the amount of health care provided is to use what economists call supply side rationing or what we call long waits for appointments. And people may die as a result from these long waits. Or medical conditions may worsen and become more difficult to treat. America needs to decide if this is the system it wants in place at the VA.

Access to health care coverage (like through the VA or Blue Cross or Medicare or Medicaid) does not automatically mean access to medical care.
People in England have known this for a long time.
People in America are now beginning to wake up to this reality because of the scandal at the VA.

Justification for Strike on Syria: Because Syria Used Chemical Weapons or to Stop Mass Murder

I am usually at first bemused but then aghast by the lack of moral courage or logic displayed by pundits regarding whether the world's leading military powers should choose to strike Syria for its recent use of chemical weapons. I know I sound callous, but are people any more or less dead when they are murdered with a chemical agent than with a bullet or machete?
I understand that the world justly views Nazis as the paradigm of evil, but were the Jews and other non-Aryan enough people killed by the Nazis any less dead at the begining of WWII when the Nazis weapons of mass murder happened to be carbon monoxide being piped back into trucks (really a chemical agent) and bullets? Were they more dead after the Nazis began to use Zyklon B gas?
Perhaps the West is against mass murder when it can be carried out in a relatively quick and impersonal manner? Is this why people have such an aversion to chemical (and nuclear) weapons?
Is the West against any type of mass murder, or is the West only concerned with mass murder by chemical agent. Or is the West only against quick modes of mass murder, but slow death from torture and starvation (think Nazi Ghettos, Soviet Gulags, or North Korean Prison Camps) are somehow more palatable?
Or is the West only against mass murder when it judges that it is in its own strategic self interest to be against mass murder?
Or maybe the West is only against mass murder when in their own view the side being murdered cannot defend itself?
Regarding Syria, mass murder has been going on for an extended period of time. Suddenly the use of chemical weapons to carry out the mass murder has aroused the consciousness and consciences of the West.
Personally, I am just against mass murder. 
Of course, military calculations need to be made to ascertain if and how mass murder can be stopped completely or at least minimized. But to act morally indignant when chemical weapons are used while ignoring mass murder seems to be morally obscene.

ESRD Stats in Focus:Prevalence, Annual Number of Kidney Transplants, Costs Per Patient, and Patient Survival Rates

ESRD Prevalence and Prevalent Rate

• At the end of 2009, more than 871,000 people were being treated for ESRD.
• Between 1980 and 2009, the prevalent rate for ESRD increased nearly 600 percent, from 290 to 1,738 cases per million.

Kidney Transplantation

After rising steadily from 1980 to 2006, the annual number of kidney transplants declined in 2007 and 2008.

Costs per Patient

• ESRD annual expenditures per patient have increased slightly in recent years.
• From 2006 to 2007, transplant costs per patient decreased but increased again in 2008.
• Yearly costs for treating a patient on HD are nearly triple the costs for treating a transplant patient.

Patient Survival Rates for Dialysis and Transplant Patients

At 85.5 percent, the 5-year survival rate for transplant patients is more than twice the 35.8 percent survival rate for dialysis patients.











Special thanks to the

National Kidney and Urologic Diseases
Information Clearinghouse (NKUDIC)

and the

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

 for the graphs which were taken from

http://kidney.niddk.nih.gov/kudiseases/pubs/kustats/

 on 8/16/12.

Random Thoughts on Innovation: Application to Healthcare: Inspiration Based on the Life of Rav Chaim Brisker: Post from Toronto's Pearson Int'l Airport

I often feel a bit let down when people accept the status quo or the orthodoxy of any given field. Each and every thinking person should analyze for themselves if things are being done in the best possible manner to induce the best possible results. Humans are inherently imperfect so obviously the actions which humans take are merely reflections of themselves and are thus sometimes going to be imperfect.
I want to now depart from a direct discussion about healthcare for a moment to bring out an idea about a philosophy about life (to which I zealously subscribe).
I have had the very lucky merit to have been a student of Rabbi Ahron Soloveichik before he passed away and continue to merit to be a student of his son Rav Moshe Soloveichik. Many people have fine teachers, mentors, clergy, and leaders. What is so special about these two giants among men? They continue in the glorious path of their illustrious progenitor Rav Chaim Soloveichik who was the Chief Rabbi of  Brisk in Lithuania. So what was so unique about Rav Chaim?
When a person analyzes any problem, they can be overwhelmed by the apparent challenges, contradictions, and roadblocks presented by the obstacle and they can be overwhelmed and become dispirited and give up on attempting to solve the given challenge...or, even worse, a person may not even attempt to solve the problem. They can become slaves to the status quo.
 Rav Chaim brought to the world of Torah scholarship in particular, (as well as to the world of acts of chesed or loving kindness more generally) a new brazen weltanschauung that every problem can be solved with a deep analysis of the given texts of Talmud or passages of Maimonides (or social ills) and therefore harmony can be created from apparent contradiction and chaos. He rejected the status quo and strove to attempt to mold the world into a more perfect state (by decreasing the number of apparent contradictions which exist) by being the innovator par excellance.
 Rav Chaim applied his innovative approach to the sphere of acts of loving kindness as well. One such example is from well known occurrences in Brisk where Jewish and even non-Jewish young mothers who had their children out of wedlock would drop their babies at Rav Chaim's doorstep at all hours of the night and that he would arrange for the best care for these babies and he would continue to look after them until they were married off.
Rav Chaim didn't see problems. He didn't see challenges. Instead of focusing on the problems and challenges of every social situation or Rabbinic textual difficulty, Rav Chaim would focus on the solution to the problem. Now, Rav Chaim wasn't naive. With his great and legendary power of incisive analysis, he understood how difficult it would be to raise children born out of wedlock (especially in those days when there was certainly a much stronger stigma attached to these children). He understood that there had been apparent contradictions in Maimonides that scholars had struggled to understand for 800 years.
But Rav Chaim understood that to solve problems you cannot be constrained by the past, by social pressure, or by the accepted norms of the intelligentsia of the era. In fact, when Rav Chaim was innovating his new approach of textual analysis, he was often scorned and derided by the "old-guard" of Rabbinic leadership who derided him as "the chemist." Basically, Rav Chaim applied the logic of the scientific method to Torah learning. If you have two phenomenon with apparently the same inputs but you obtain two different outputs, logic told Rav Chaim that obviously you don't have the same inputs as you originally thought. So Rav Chaim labored to analyze, and, if he was successful, he was able to detect the differences between the two inputs.  While it might have appeared at first glance that the 2 cases had the same inputs, Rav Chaim with the precision akin to that of the precision needed by a neurosurgeon, was able to realize the differences and answer the apparent contradictions. If 2 given passages of Maimonides or Talmud contradicted themselves, or if Maimonides apparently contradicted the Talmud (which is theoretically impossible because Maimonides codified and organized the various halahkhic (AKA Jewish Law) holdings and precedents of the Talmud), Rav Chaim would read the texts extraordinarily closely to discern which passage had an extra phrase or was missing a certain passage to harmonize the apparent contradictions.
 Rav Chaim saw that which everyone thought wasn't there. It took tremendous fortitude to change the style of Torah learning. Rav Chaim innovated. He applied the logic of the scientific method to Torah study. Rav Chaim had such a strong belief in the inherent harmony of the Torah,the Talmud, and of Maimonides'es writings, that he was able to "solve" contradictions that had been unexplained or poorly explained for around 1400 years from when the Talmud was finished being organized.

Implications for healthcare policy:
 Constant experimentation, questioning of "accepting truths", insistence on comparative effectiveness research not just for the entire populations but for as many unique sub-populations as possible, which interventions lead to actual provable increased life expectancy and quality of life, etc.
Don't forget, surgeons though until not very long ago (~70 years) that a heart should never be cut into....the dictum of "don't touch the heart." There was nothing wrong with this approach...this was true for the level of medical technology and progress that existed at that time. But it wasn't an immutable law. It was an accepted norm based on the reality at that time. Times change. Innovation spreads. Medical progress marches on. Alfred Blalock and Vivien Thomas at Johns Hopkins dared to think differently about the dictum of "don't touch the heart." Since then, millions of heart procedures have been done in the world saving countless lives of humans of every age, creed, and color.
There are always manners to improve the world in general and the healthcare environment (both the clinical and financial aspects) in particular. Do we accept the imperfect status quo or do we strive to innovate and improve the healthcare environment? The legendary example of Rav Chaim Brisker instructs us how to proceed.
To be continued...

Main Principles of Increasing ESRD Life Expectancy, In Formation

 Theses are some ways to increase life expectancy in people with ESRD:
In no specific order...
1. Increase AV fistula use.
2. More frequent hemodialysis 
3. Increase pool of organs available for transplantation
a. Expand usage of expanded criteria donor (ECD) organs. Many kidneys currently not being used for transplantation may not be ideal but they will increase ESRD patients life expectancies compared to remaining on dialysis so it is a no brainer from a humanistic perspective or from a utilitarian perspective or from a rational decision making model based on probability. So why are so many kidneys being thrown away?
b. increase live donor pool
         i. increase live donation from family and community
         ii. incentivizing live donors with monetary and other means (repeal parts of the killer legislation AKA National Organ Transplant Act.) I don't like complimenting Iran, but they have a real functioning  market for kidney sales where buyers and sellers can transact business and a kidney can be bought and sold for a government mandated price of approximately $2,000 (as of a few years ago that was the price.)
4. Medicare should cover anti-rejection meds for life after transplantation. This will elongate the survival of the transplanted graft which will keep people healthier and alive. Currently, anti-rejection meds are only covered for 3 years after transplantation so if a person cannot afford the anti-rejection meds, some transplant centers won't even allow the person to receive the transplant! In some other circumstances, the person undergoes transplantation, then after they can no longer afford the meds, their bodies eventually reject the graft and then the person ends back on dialysis and Medicare will pay for that for life.....which is much more expensive and is only a treatment and not a cure which the transplanted kidneys (actually) are for as long as they do continue to function.
        To be continued...

Outrageous Care and Incompetence at the VA (Veterans Administration) Outpatient Clinic

I don't intent to appear to be picking on the VA's medical care but I really can't help myself at this point from writing about (against) a medical system that is in need of a complete rebuilding...not just some improvements at the margins. I have seen good and bad at the VA during the last 5 years but recently I have witnessed or been told about such egregious occurrences that I feel the need to dedicate another post to the VA. See last week's article here. 
For the past month or so, my friend's father, who just turned 90, has been declining precipitously. His father used to go the health club at least 3 times a week and the last month he was completely lethargic and only wanted to stay home. My friend told me last Saturday that his father was entering a new and difficult health stage and I told him although it is possible to quickly decline, I tended to doubt that there wasn't an underlying cause to his decline. I told my friend to have his father checked out for a urinary tract infection (UTI) (or other possible infections) because I remembered that his father had become lethargic a few previous times and it ended up he had UTI's.  He told me that he doesn't need to have his father checked out because he had brought  his father to the VA to see his physician on June 22, 2012. I told him that he better check it out anyways because the infection could have come right after the lab work was done or that the VA is incompetent and they forgot to let him know that there is a problem.
My friend contacted his dad's non-VA physician who took a urine specimen. Low and behold, it showed that his father has a UTI and he is now on an antibiotic and his energy level is beginning to rebound.
Then, this afternoon, his father's VA doctor called with results from the June 22 appointment (4 weeks ago) and the doctor tells him that his father had a UTI. My friend told the doctor that he already knows about it and his father is being treated. This specific healthcare provider at the VA is extraordinarily negligent. But is this incident an anomaly at the VA or a pattern...I am beginning to think it is a pattern. My friend's father suffered needlessly for an extra 3 and a 1/2 weeks.
People love throwing around buzzwords relating to healthcare like Accountable Care Organizations (ACO's) and continuity of care.
 President Obama, you already control the VA Medical System. Is this system to be revered and glorified? Practice what you preach. Add real accountability into your healthcare organization, not just some joke government plan which makes it look like there is accountability while veterans are being treated with negligence and an overall lackadaisical attitude.
If not, maybe the government should look into closing VA medical centers and allowing veterans to go to the healthcare provider of their choosing by issuing them Medicare type cards which will allow healthcare providers to be reimbursed for treating veterans similar to the manner in which they are reimbursed for seeing senior citizens.

Physician's Dilemna: Pro-active Patient Management or Reactive Treatment Only

In my last post, I discussed some of Mr. G's experiences with the VA. See here.
Mr. G's main problem was that he had stopped taking his medications. FYI, Mr. G gets his medications shipped to him from the VA for only a few dollars per prescription. The VA has an EMR (electronic medical record) of when the last time he reordered his prescriptions. His GP was able to see he had not reordered his prescriptions for some time. (When I went into his apartment to do an intervention in ~February 2012, he had a prescription which had expired in 2008! Needless to say, I threw out all of his expired meds and had to schlep to the West Side VA Hospital to pick up all of his meds so that he would begin his blood pressure meds immediately. Reminder, his blood pressure was ~200/130.)

Medical adherence/medical compliance (meaning does the patient follow the physician's advice)  is a field where a lot of important research needs to be done to determine how to enable patients to better follow their physician's advice so that hopefully they will be able to lead healthier and longer lives. Once more is understood about the interaction between the physician and the patient, and how the physicians can best convey the information to different types of patients (i.e. visual learners vs. audatory learners vs. kinesthetic learners),best practices in the field of doctor patient communication could hopefully be quickly diffused throughout the medical profession. On the most basic level, an after visit summary is a piece of paper which tells the patient what happened to them and what are they supposed to do when they go home. I assume this increases medical adherence to a certain extent.

But back to Mr G. The VA's EMR system showed that it had been a really, really long time since Mr. G had reordered his medications. Does the VA's EMR system have built in alerts to let his GP know that Mr. G is overdue in ordering his meds? Does Mr. G's GP notice while he examines Mr. G and looks at the computer that he has not reordered his meds? Or is it completely the patients responsibility to reorder his meds and the physician should take a laissez-faire approach to whether their patients are ordering their meds? Or does it depend on the sophistication of the patient...meaning that regarding a patient who is of sound mind the doc should take a hands-off approach towards medical adherence but regarding an elderly patient with the beginnings of dementia, the doc should take a proactive approach in assuring the patient's medical adherence.

Finally, since shortly after Mr. G's sky high blood pressure incident, the VA sends a nurse once or twice a week to lay out his pills in a pill container and check to make sure all of the boxes are empty (so that it can be assumed he actually took the meds and didn't discard them in some other manner.) Also, she takes his blood pressure to ascertain whether his bp is in check so that it can be assumed with more evidence to back it up that he really has swallowed his pills. (Personally, I benefit from this practice because the first few weeks after the incident I needed to lay out his pills and go upstairs to his apartment every day to make sure he really took his meds. Now, Kate, the nurse does everything.)
It is possible the VA will eventually stop sending the nurse at some point (to save money) like it stopped sending the therapist at a certain point.
 I think an interesting study the VA can do is to enroll patients in automatic prescription ordering (like Walgreens has) so that their patients always have their meds and determine if this increases those patients medical adherence to taking their meds. Another study the VA can do is whether sending the patients meds already laid out in the weekly pill containers will improve medical adherence because I can attest to the fact that Mr. G cannot lay out his pills correctly so even of the VA would automatically send the meds, I doubt he would end up taking them correctly.