Are You A Person Or An URP (Unit of Revenue Production)? Part 1

I have been treated at different medical centers and by different physicians over my life. I also have been able to observe clinical care as an observer when I have taken family and friends to the hospital.

I feel that care can be delivered either by viewing the individual who has come seeking medical attention as a human being (what I describe as the Mayo Clinic Model) or, sadly, as merely a way to make more money for the hospital or physicians. I describe the latter approach to medical care delivery as viewing people not as human beings, but, instead, as URPs, or Units of Revenue Production.

Human being needs to be treated with the highest level of clinical excellence while making sure that they are treated with as much respect and dignity as possible while they receive medical attention. Many mornings I drink out of a Mayo Clinic mug which has the Clinic's motto written on it. Mayo's primary value is that "the needs of the patient comes first." See the Mayo Clinic Mission and Values here.

I think that one of the reasons that Mayo is able to be so successful at treating people well is because their physicians are paid a set salary so they can spend the time necessary with each person to treat them appropriately. They don't get additional salary for hitting revenue and volume targets dictated by some number cruncher from hospital management. 

Then there are medical centers and physicians who focus on what is best for them and their bottom line. One situation where this is particularly problematic is when a new procedure or technique has become adopted in a particular medical specialty which creates better results for patients. Physicians who are "early adopters" are able to treat their patients as soon as a better mode of treatment is available. Then there are physicians who continue to use the old procedure even at increased risk to the patient relative to the new procedure.

Case and point: When either procedure is medically ok to perform, should a urologist who only removes kidneys the old-fashioned method - through surgery - let his patient know that the kidney could be removed laproscopically and that the laproscopic procedure correlates with a much quicker and easier recovery? Does he have a duty to inform his patient? If you view the patient as an URP, then the urologist will just go ahead and perform the procedure. If the Mayo Clinic Model is used, then the urologist will inform the patient of the risks and benefits and encourage the patient to do what is best for the patient.

More on this issue later....

(FYI, here are some of the hospitals I have been at...mostly as a visitor and not as a patient: The Mayo Clinic and its 2 hospitals - St. Mary's and Rochester Methodist; Mount Sinai Hospital in Miami; Kaplan Hospital in Rehovot, Israel; Jesse Brown VA Hospital in Chicago; and many other Chicago Hospitals including Loyola; Northwestern; Children's Memorial; Evanston; Skokie; Highland Park; Glenbrook; Swedish Covenant; St. Francis; Northwest Community; Lutheran General; Holy Family; and many others...)

Live Donor Donation: Kidney donated by Rabbi Chaim Soloveichik

I am proud to be friends with some of the family of the late Rabbi Ahron Soloveichik.
Rabbi Ahron Soloveichik was renowned for his kindness and sensitivity towards all human beings...especially towards people who in reality had problems or people who were just considered by society as lowly, poor, ill, downtrodden, handicapped, unusual, or just plain different.
To give only a very small vignette about his extreme righteousness and piety, a mentally disturbed woman once pushed Rabbi Soloveichik onto the NY Subway tracks in front of an oncoming train. Rabbi Soloveichik jumped out of the way and saved himself. But the story goes on. The disturbed woman fell onto the tracks as she was pushing Rabbi Soloveichik in front of the train. She was unable to get herself away from the oncoming train under her own power so Rabbi Soloveichik risked his life and also pulled this women who had just try to kill him to safety.
With such an illustrious lineage, I am not that surprised that Rabbi Chaim Soloveichik of Ramat Beit Shemesh,Israel, who is the youngest child of Rabbi Ahron Solloveichik, made an altruistically donated one of his kidneys to a women in need of a kidney a few weeks ago. A short article about it is found here.

I hope Rabbi Soloveichik and the women are both feeling well.

Organ Transplant Policy: Goal

This equation should guide and be the goal of all people who research access to transplantation regarding ESRD/kidney failure:

Supply of Kidneys Available for Transplantation = Demand for Kidneys Needed for Transplantation


Other Considerations:
1. Goal: All organs should be obtained in an ethical manner.
Operationalization: ??? Work on moral and legal issues. ???
2. Goal: Medicare should provide coverage for kidney transplants in the most cost effective manner possible.
Operationalization: All changes should be budget neutral (or even create savings) for Medicare's expenditures on ESRD treatment.

Man Survived 39 Years on Dialysis: A Call to Action

Dr. Robert Rigolosi reminisces about his patient Ed Strudwick who lived for 39 years on dialysis. And Dr. Rigolosi was Ed's physician for all 39 years that he was on dialysis. Read Dr. Rigolosi's thoughts about his patient here.

Let Ed Strudwick's great example of living 39 years on dialysis give hope to the ESRD community that dialysis is not a death sentence, but rather it can be a life giving process which enables people to live long and productive lives!

Researchers (and ESRD patients themselves) should study and analyze dialysis centers and physicians whose patients are on the far side of the bell curve to try to figure out what increases life expectancy among these ESRD patients so that best practices can then be shared among the general ESRD population so that all people can benefit from what these physicians and dialysis centers are doing to elongate the lives of their patients.

Here is a very interesting excerpt from the article regarding longevity of patients on dialysis in Dr. Rigolosi's own words:

"Remind your dialysis patients that compliance is key. Ed's longevity was due to his full compliance with diet, medicine, scheduling, and follow-up. If you have a compliant patient like this, you can expect long-term survival."

"We have about 200 patients on dialysis in our center, and I would guess that 10% or 15% of them have been on dialysis for more than 35 years. We may have another 10% that have been on 20 to 30 years.[italics added] Patients do best when they embrace their new disease-driven lifestyle and accept what they have to do. Be sure they understand that they can't be too careful."

And it is important to keep in mind that according to the US Renal Data System 2011 Report, that 5 year survival probability rate in 2004 for people on hemodialysis was only 34%!

Update: Hospital Relents: Little Amelia Has Hope for Life - She Can Get a Kidney Transplant !

We have a nice update to a post from a few weeks ago. The post is found here. Basically, the family of 3 YO girl, Amelia Rivera, understood after meeting with their physician that their daughter was being denied a kidney transplant because of her "mental retardation."

CBSNews reported here that The Children's Hospital of Philadelphia issued a joint statement with Amelia's family that "as an organization, we regret that we communicated in a manner that did not clearly reflect our policies or intent and apologize for the Riveras' experience." Amelia's parents said in the joint statement that "despite an unfortunate encounter a few weeks ago, we hold The Children's Hospital of Philadelphia in high regard. Our hope is that this experience will heighten the medical community's sensitivity to and support for the disabilities community."

Let's hope that a suitable donor kidney is found for little Amelia expeditiously and that the transplant goes as smoothly as possible.

Kudos to everyone who inundated the hospital with comments and complaints which surely helped encourage them to get their act together and not to deny a transplant to one of the most vulnerable members of our society.

Raising Awareness for Live Donor Kindey Donations through Social Media

How can the power of social media and multimedia be utilized to increase live donor kidney donations?
Some random thoughts...
1. A youtube channel where people who need a kidney tell their story to the world in hopes of finding an altruistic donor.
2. A reality show about the apprehension and angst of an individual and their family as they wait on the kidney transplant waiting list hoping to get a kidney before it is too late.
3. A reality show/youtube channel dedicated to following a person on dialysis who then gets a transplant and compare the drama relating to the transplant surgery and also to compare their (quality of) life before and after the transplant.
4. There already is a twitter feed to monitor all things related to ESRD and kidney transplantation here. Dr. Robert Hickey, a great hero and advocate for all things related to kidney transplants, constantly tweets all types of info and links to articles related to ESRD (fyi, he also tweets strong political stuff there so you'll either hate it, love it, or you can ignore it.)


Anyone else have suggestions???
Dr. Hickey's comment:
Robert F. Hickey, Ph.D.Feb 17, 2012 12:04 PM

We would be well served by implementing every option available to encourage human organ transplants as long as they are legal and ethical. However, unbelievably, there are those, individuals and so-called non-profits, doing evrything they can to discourage patients from advocating for themselves. More on that issue below.

A reality show focusing on the frustration, anguish, and fear of patients waiting for organ transplants and their families would be extremely revealing. CBS attempted to bring a weekly show, Three Rivers, to the audience. It didn't catch on!

The show was set, ironically enough in Pittsburgh, considered by some to be ground zero in the transplant world. It also happens to be the town where the University of Pittsburgh kidney transplant center was recently shut down. Patients were given contaminated organs. The show was stilted and not a reflection of what actually happens from a patient/family perspective.

The transplant establishment has engaged in unfair and unethical efforts to minimize the impact of social networking by patients to find living donors. This week I received 2 calls from patients who were told they could not get kidney transplants if they found donors through www.matchingdonors.com or any other such Internet site!

Two weeks ago, Dr. F. Coors, at University of Colorado made a public statement indicating that social network sites were dangerous because you never know what you're getting. Nonsense! A prospective donor and Transplant recipient will go through 6 to 9 months of testing and intrusive interviews before any transplant will be approved. I've been through along with my donor in 2004.

Some transplant centers claim they will accept prospective donors who are identified through social media while not being sincere about their intentions. This happened this week to 2 patients at Cedars-Sinai in LA. Both presented with altruistic, non-related, living donors for kidney transplants. One was told Cedars transplant team would not accept any donor without insurance. The other was told no donor who had to travel to the hospital would be accepted. First, in the case of kidney transplants, Medicare/Medicaid will pay living donor medical expenses. This includes any medical issue arising from the transplant for several years. Many recipients also have private insurance in partnership with the government coverage. Secondly, there is no valid or ethical reason to disqualify a prospective donor based on where they live within the USA. These are smoke screens.

The point is, we can do all we can to promote organ donation. However, if the powers that be in the transplant industry don't stop erecting manufactured hurdles to transplantation, nothing is going to help. The so-called non-profit structure of the US transplant system is a complete sham. UNOS and the 58 Organ Procurement Organizations across the country and their managers have become millionaires on the monopolistic system they control. When that monopoly is broken innovation will come and the transplant waiting list will be resolved within 24 months.

As long as we have Organ Procurement Organizations making $50 million to $140 million annually on procurement fees, organ sales prices, the system will not change! As long as executives at UNOS and the OPO are being paid $500,000.00 to $700,000.00 per year, the system will not chgange.

Scarcity of Kidneys: A Physician Making a Child Ineligible for A Kidney Transplant because of "Mental Retardation"

Read this mother's heart wrenching story here of how a transplant physician at the Nephrology Department at Children’s Hospital of Philadelphia has reportedly denied a little 3 YO girl with a rare genetic disorder the chance of getting a kidney transplant because she is "mentally retarded."
Here is a partial transcript of the emotionally charged conversation according to the mother's account:
(Start Transcript)
[Mom]“So you mean to tell me that as a doctor, you are not recommending the transplant, and when her kidneys fail in six months to a year, you want me to let her die because she is mentally retarded? There is no other medical reason for her not to have this transplant other than she is MENTALLY RETARDED!”

[Transcript Surgeon] “Yes. This is hard for me, you know.”
(End Transcript)

Nobody should pretend to be omniscient, or to "play God", and certainly, nobody should revel in "playing God."
While I certainly understand the mother's position, I can see the physician's position although I vehemently disagree with it. I hope to write an extensive post on why I feel this way.
But, the mother reports she offers to find a live donor.

[Mom]“Oh, that’s ok! We plan on donating. If we aren’t a match, we come from a large family and someone will donate. We don’t want to be on the list. We will find our own donor.”

[Doctor] “Noooo. She—is—not—eligible –because—of—her—quality– of –life—Because—of—her—mental—delays”
If the family finds a live donor match from their family, surgeons are able to implant even an adult kidney into a child's body by implanting the kidney into a different part of the child's abdomen. (See here to read about cutting edge research being done at Stanford's Lucile Packard Children's Hospital where they have pioneered a method to keep adult kidneys alive even in small children where blood tends to pool and clot in the relatively large kidney causing the organ to stop functioning.)

Assuming the family is able to obtain its own donor, the transplant surgeon should keep his opinion completely to himself... the family is not getting involved with the transplant waiting list so he should not "play God" and pretend to be omniscient...he should allow the parents of this little girl to do everything they want to keep their child alive.