Healthcare rationing, whether on the supply side (i.e.shortage of specialists or MRI machines) or on the delivery side (i.e. like when the U.S.S.R. would give their elderly populations placebos and not "waste" money on them or when in the U.S., until a few years ago, Medicare would refuse to pay for (or ration) preventative care) needs to be carefully scrutinized and its ethical implications fully understood.
Whatever your view of Obamacare, I want to report a story that occurred yesterday at one of the VA Hospitals here in Chicago, Illinois.
For the past several years, I take an elderly gentlemen, Mr. G, to the VA hospital for his various appointments...including to his GP who monitors his general health, and to the Vascular Surgery Clinic who monitor his aortic aneurism (it sometimes is frustrating to deal with the vascular surgeons because every time we go we see a different resident or fellow who is evaluating the case for the first time...so much for continuity of care.) FYI, 2-4 hour waits at the Vascular Surgery Clinic is the norm, not the exception. Quite frustrating! Also, it frequently takes a relatively long time to receive appointments with specialists even when there is a medical necessity.
In late March or early April he had an eye exam and ordered his new eye-glasses. Those glasses were finally ready this week...over 3 months later. We went yesterday to pick them up. The waiting area was overcrowded with people waiting with much patience for their turn to see the opticians. I sat on the floor due to the overcrowding. Yes, the glasses were very cheap but that is only true if your time has no value and you can live 3 months without your new glasses.
Why can't the VA use a system like the Medicare reimbursement system and allow veterans to go to any optitian, dietican, physician, etc. and just reimburse the practitioners...that way we can chose to go an optician who can deliver the eye-glasses in less than 3 months.
And, more importantly, we can choose to go the Vascular Surgeon of our preference and have one physician following the case over an extended time period.
And now for the good that occurs at the VA...This elderly gentlemen. Mr. G, was declining precipitously a few months ago. His bp was 200 over 140, he was dizzy, filling up with water, having trouble seeing, falling down, and becoming more and more incoherent. His GP, Dr. Caprio, (who just finished up his residency and who we are sorry to lose because he really cared about Mr. G) pulled out all of the resources of the VA to keep him in his own apartment and out of a nursing home (which would be tremendously more expensive to Medicaid or to the VA, whoever would have ended up paying for it.). He ordered a visiting nurse 1-2 times a week and a visiting occupational therapist 1-2 times a week. I contacted the Council for the Jewish Elderly (CJE) who now drop off 5 meals a week and send in a lady who cleans his apartment, does his laundry, and does his chores for him.
The bottom line is this....does the VA offer some good services? Yes. Could a non-VA physician have organized a visiting nurse? Yes. Would Medicare have paid for it? Most probably yes.
I just don't see why veterans cannot receive services under a health plan styled after Medicare and the government can eliminate almost all copays and make the coverage for Veterans even more generous and not age dependent. I also think that veterans would probably receive speedier service and would be able to go to any physician who accepts Medicare and they would not have to schlep out to the VA Hospital for every appointment.
Implications for the implementation and operationalization of the amorphous healthcare bill known as Obamacare? Draw your own conclusions.
I guess at least we are not being forced into VA style healthcare. Yet.
Friday, July 13, 2012
Thursday, June 28, 2012
Which Type of ESRD Treatment Modality Correlates with the Longest Life Expectancy (and intermediate and shortest, too)
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Tuesday, June 12, 2012
The Human Toll of Kidney Failure
While this blog tends to deal with macro issues related to ESRD/kidney failure it is important to keep in mind the truly devastating affect of kidney failure on the individuals suffering from kidney failure.
A brief vignette:
I am in contact with a ~60YO male suffering from ESRD who goes to dialysis 3 times a week to stay alive. He is extraordinarily depressed by his situation. He has practically no chance of getting a kidney transplant because of his advanced diabetes and emphysema. He also is basically blind. He is morose, forlorn, and morbid. He suffers terribly. His life expectancy is quite short (although hopefully he will continue to live for a long time) and his quality of life is atrocious.
Application:
It is important to keep in mind every individual in mind when making organ transplant allocation policy. Every action has a reaction.
A brief vignette:
I am in contact with a ~60YO male suffering from ESRD who goes to dialysis 3 times a week to stay alive. He is extraordinarily depressed by his situation. He has practically no chance of getting a kidney transplant because of his advanced diabetes and emphysema. He also is basically blind. He is morose, forlorn, and morbid. He suffers terribly. His life expectancy is quite short (although hopefully he will continue to live for a long time) and his quality of life is atrocious.
Application:
It is important to keep in mind every individual in mind when making organ transplant allocation policy. Every action has a reaction.
Wednesday, May 23, 2012
Expanded Criteria Donor Organ: New Hope
Many people who are on the kidney transplant waiting list die while they wait for a kidney transplant. Many other people die without even being put on the transplant list.
"Performing renal transplant with a perfectly healthy kidney to all the patients with ESRD is
an ideal scenario. But growing waiting lists and shortage of kidneys makes it necessary to
make some compromises. Use of so-called, marginal or borderline donors can increase
donor pool by almost 20 to 25%." (Renal Transplantation from
Expanded Criteria Donors. Renal Transplantation – Updates and Advances. Pooja Binnani, et al). See here to see the full article on the subject from which this quote was taken.
To put it in plain english, if a person cannot a brand new BMW does that mean he doesn't buy a car at all or does he buy a used Toyota Camry? Obviously, the person takes what they can afford to drive. A person would much prefer an Expanded Criteria Donor (ECD) kidney and significantly increase his probability of 5 year survival than insist on a Standard Criteria Donor (SCD) kidney and being dead by the time it would be his turn on the waiting list.
According to information on UC Davis Transplant Center website found here, "[s]tudies have shown that transplant patients who receive either SCD or ECD kidneys have a superior survival when compared to remaining on dialysis." It also states that, "[a]ccepting an ECD kidney may significantly decrease the amount of time a person waits for transplant. The ECD kidney comes with some risk for earlier graft loss but the exact risk is unknown. A good estimate is that 8 of 10 ECD kidneys will still be functioning at one year while 9 of 10 SCD kidneys will be functioning at one year. At 5 years, half of ECD kidneys will still be functioning compared to 7 of 10 SCD kidneys."
Below is the survival percentage for people with ESRD depending on their mode of treatement at the 5 year point of time. Kidney transplantation offers highly superior survival rate - 33%-39% increase in 5 year survival - compared to the other treatment modalities (See Below). Even if the use of Expanded Criteria Donor Kidneys shaved a few percentage points off the 5 year survival, most people will still benefit from receiving these organs that are currently frequently discarded.
Again, while in an ideal world everyone would receive the highest quality kidney possible, people's probability of 5 year survival is greatly increased even if they receive an ECD kidney.
"Performing renal transplant with a perfectly healthy kidney to all the patients with ESRD is
an ideal scenario. But growing waiting lists and shortage of kidneys makes it necessary to
make some compromises. Use of so-called, marginal or borderline donors can increase
donor pool by almost 20 to 25%." (Renal Transplantation from
Expanded Criteria Donors. Renal Transplantation – Updates and Advances. Pooja Binnani, et al). See here to see the full article on the subject from which this quote was taken.
To put it in plain english, if a person cannot a brand new BMW does that mean he doesn't buy a car at all or does he buy a used Toyota Camry? Obviously, the person takes what they can afford to drive. A person would much prefer an Expanded Criteria Donor (ECD) kidney and significantly increase his probability of 5 year survival than insist on a Standard Criteria Donor (SCD) kidney and being dead by the time it would be his turn on the waiting list.
According to information on UC Davis Transplant Center website found here, "[s]tudies have shown that transplant patients who receive either SCD or ECD kidneys have a superior survival when compared to remaining on dialysis." It also states that, "[a]ccepting an ECD kidney may significantly decrease the amount of time a person waits for transplant. The ECD kidney comes with some risk for earlier graft loss but the exact risk is unknown. A good estimate is that 8 of 10 ECD kidneys will still be functioning at one year while 9 of 10 SCD kidneys will be functioning at one year. At 5 years, half of ECD kidneys will still be functioning compared to 7 of 10 SCD kidneys."
Below is the survival percentage for people with ESRD depending on their mode of treatement at the 5 year point of time. Kidney transplantation offers highly superior survival rate - 33%-39% increase in 5 year survival - compared to the other treatment modalities (See Below). Even if the use of Expanded Criteria Donor Kidneys shaved a few percentage points off the 5 year survival, most people will still benefit from receiving these organs that are currently frequently discarded.
Again, while in an ideal world everyone would receive the highest quality kidney possible, people's probability of 5 year survival is greatly increased even if they receive an ECD kidney.
| 2004 ESRD cohort: 5 year survival based on treatment modality | ||
| Dialysis | 34% | |
| Hemodialysis | 34% | |
| Peritoneal dialysis | 40% | |
| Transplant | 73% | |
| based on http://www.usrds.org/2011/view/v2_05.asp | ||
Wednesday, April 25, 2012
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...)
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...)
Friday, March 30, 2012
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.
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.
Sunday, March 11, 2012
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.
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.
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