Dr. Malia Reckons

I got a good laugh today, in an unlikely way. It was while reading a physician's take on the current national health care discussion. Consider the low probability of such a thing!

In the mail I received the October Forum, the monthly newsletter for the Rochester General Hospital Medical & Dental Staff. As usual, the President's Message led on the first page, and this month, the president, Richard Constantino, MD, offered a perspective about the national conversation couched in terms of Yogi Berra quotes. Never before had I considered that Yogi's sayings, utterly glib illogic mixed with a profound inherent truth, fit so well in our health care debate. I may not agree with every point Dr. Constantino makes, but I thought the essay was nicely done. And I appreciate the call for us all to remain in the discussion.

So, as a baseball fan, and a physician who cares about the national conversation for health care reform, I happily offer Dr. Constantino's President Message for October, 2009. Enjoy!  (Note that emphasis, with bolding, is my own for Yogi's sayings)

October, 2009

Forum, President's Message

Richard Constantino, MD

As we approach the height of the baseball season with the playoffs and World Series coming up quickly, and as we are approaching the height of the political season with debate over healthcare reform, I thought we should enlist the opinion of a well known philosopher and pragmatic thinker as we move ahead. Many have an opinion regarding who will win the World Series and even more have opinions on healthcare reform. Who better to advise us on both than Yogi Berra? Over the years he has uttered a variety of statements that I think have application to healthcare reform. See what you think.

Yogi has uttered many memorable things, but none more memorable than "I knew I was going to take the wrong train so I left early." Many feel that healthcare reform is moving too quickly and that although necessary, we aren't really at the point where we could make  final decisions and any artificial time deadlines or goals represent leaving early, but perhaps on the wrong train.

The application of this one of Yogi's quotes is remarkable: "If you don't know where you are going you will end up somewhere else." In healthcare reform we certainly don't know where we are going and many don't even recognize where we want to be. A good number of individuals are happy right where they are.

Yogi once said, "you better cut the pizza in four pieces because I am not hungry enough to eat six." Many people feel that the changes we are making in healthcare will reapportion the pieces of the pie, but not make it any smaller and may not make it any better. We all recognize that we cannot afford the rise in healthcare that we have experienced, but all want to be sure the changes we make will be meaningful in reducing costs, and along those same lines, Yogi's statement, "a nickel isn't worth a dime today," does raise the specter of how we'll pay for our current standard of healthcare in the future or costs under a new program.

I think all of us fear creating a new healthcare system that misses the mark and even those things that have "slam dunk success" written all over them, may not be. Who could have envisioned that the very "successful" "Cash for Clunkers" program would lead to a significant impact on the used car and automotive repair business? Along these lines Yogi warns "90% of putts that are short don't go in."

Yogi's quote, "this is like deja-vu all over again" seems made for healthcare reform when one considers what happened to the Clinton healthcare reform of the early to mid 90s. It certainly does seem that many of the occurrences of that decade are being experienced again. And lastly, with remarkable logic, Yogi states, "nobody goes there anymore, it's too crowded." Certainly the healthcare reform field is crowded with many opinions, biases, thoughts, proposals and agendas. Rather than following along like lemmings or withdrawing from the entire arena because of its complexity and emotionality, I hope we'll all remain involved in our thoughts, opinions and desire to influence healthcare reform to create the best healthcare system we can. I know most of us wish that political agendas were less evident in proposals and debate. I know most of us believe that all Americans should have basic health coverage and when it comes to our politicians I hope they will work together in a nonpolitical way. I almost hear Yogi exhorting our leaders, "Let's play ball."

Disheartening moments are too frequently part of my day. A recent Sunday evening I got online to check emails and preview my schedule for the week. It was about 9pm and I was struck by three of the emails waiting for me. After considering them and replying to each, about 20 or 30 minutes later, I was disheartened about the options for health insurance reform discussions.

Each email related to financing of health care and was distinct in character from the other two.

And each was relevant to the current discussions of health insurance reform.

The first email was the most benign. I had seen the patient the day before, on a Saturday morning, for severe rib pain related to a fall a few days earlier. I highly suspected a fractured rib or two. But she needed pain relief more than anything else. A final part of the plan was to get an X-ray of the ribs on Monday to document the problem.

Her email was to report that the pain was doing a bit better and to ask if she can skip the X-ray. She explained how she has a high-deductible plan and would be paying out-of-pocket for the X-ray. Honestly, since she was doing better, the X-ray of the ribs would not be adding much to the plans. So I did not mind her skipping the study at that point.

The second email was different in character. The patient has a family history of early heart disease and uses two medications to treat his high cholesterol. He has traditional insurance with co-payments for appointments and his monthly prescriptions. In October he is scheduled for blood testing and a follow up appointment.

Though he continues with his overnight job, he is no longer working his part-time day job. Finances will be tight for the next few months and he is searching for ways to save money. His email was to report that he is planning to skip his two prescriptions the next few months and wanted to reschedule his October appointment for later so he can save his co-payments. His message closed with:

"I hope you understand for this time ... Please forgive me." 

My heart ached as I thought of him struggling financially so much that he would send me that message. And, professionally, I thought of how the plan to skip his medicines for a few months would potentially increase his risk for long-term heart and vascular disease, or, with high triglycerides, increase his risk of acute pancreatitis.

I replied with some ideas about saving money for his medicines and his care such as invoicing his copay that he can cover later, or checking other pharmacies for cheaper out-of-pocket costs for his medicines, but I have not heard back from him.

The third email that evening was from a young woman who has no insurance. She has some baseline mental health diagnoses which require two prescription medicines daily. She is working hard to improve herself and move forward in a positive way by attending a community college full-time on financial aid loans; plus she is looking for a part-time job.

Since last spring I have had concerns the medicines I am prescribing her are causing problematic side effects. I made adjustments and asked that we follow up more closely. Primum non nocere (First, do no harm) is a primary edict in medicine dating back to ancient Greece, so monitoring prescription medicine side effects is paramount to my job.

This young patient needed her prescriptions updated. Without them she likely could not continue in school. But she has no medical insurance and can not afford another appointment. Actually, she already owes me for the equivalent of three or four prior appointments and has from time-to-time gotten me some extra cash. So she was stuck between a rock and a hard place, and, professionally, I felt the same.

I have known her family for 16 years, have worked closely with her through many hard times and have been there as she worked to improve her health and life. She owes me money and needs medicines which I worry are causing problems. Another appointment would increase her debt, or lead to charity work by me.

No easy answers, but my soul ached. I did what I can for her and offered a plan to work together on these issues. After a few email messages back-and-forth I felt confident she was doing better after the medicine adjustments from the last appointment. She is continuing on her medicines which help her maintain a positive trajectory in life. We are planning an appointment in the next couple months so I can properly assess her. And she will continue doing her best to pay off the amount due for her appointments over time.

Our relationship as patient and doctor has been long and rich -- that richness gives value to what I do and, I hope, nourishes her life. I am not willing to drop out of her life professionally due to her life's current stresses. In the years ahead I look forward to her success and trust these difficulties will be only memories. Yet her struggles, and the need for that email, and her need to balance mental health problems with medications with school and with finances, are painful to see.

And so, late that Sunday evening, just a few hours before another week of patient appointments was to begin, I was disheartened. Patients faced financial challenges with traditional insurance, high-deductible insurance and when having no insurance. As a physician I feel a moral obligation to care for them, a feeling that goes beyond the business of health care. But, in the end, society has made health care a business, and there is only one way to keep the doors open in the American marketplace. I used time to try to help these three patients, but my soul's bruising made me less effective the rest of that evening, and each time I thought of the three of them since then.

What are the answers for financing health care so patients can at least get the treatments they really need and doctors can focus on providing reasonable services?

Those three emails related to only the most basic aspects of care, nothing exotic, and nothing that should not be part of primary care. Is it too much that I, as a family physician, can hope my patients did not struggle with the costs of only the most basic and reasonable services? And why do we as a nation not think that we all would be better off as a society, as a community, if health care financing allowed that?

Until there are real answers, however, I am certain I will continue to be disheartened; often.

--Timothy Malia, MD

I have had a busy couple weeks in the office (thankfully) so I have not had time to post on the blog. But my thoughts and perspectives are building, and one of these days the dam may break! I guess I'll just have to focus on a handful of brief posts and limit my diatribes. So, late this evening, just before bed, I wish to make a simple connection of the United States Constitution and the current health insurance reform debate.

Today, September 17, is Constitution Day in the United States. On this day, 222 years ago, the Constitution was signed by the representatives of the states thus forming a "more perfect union" than the Articles of Confederation before it. That Constitution was the boring part that explains how the federal government would be shaped and function. The Bill of Rights, the first ten amendments of the Constitution, which I would say is better known today, would not be passed until March 4, 1791, about two years after George Washington had taken office, and a year and one half after the first Congress had proposed the first set of amendments to the states (there were twelve offered, but two were not ratified, so the Bill of Rights had just ten amendments). A very good website with transcripts, images and plenty of interesting bits of history and information about the Constitution can be found at http://www.archives.gov/exhibits/charters/constitution.html

So today is a fine day to reference the Constitution in relation to the current health insurance reform debate.

There is a comment I hear mentioned from time-to-time in the media, most often by folks at demonstrations against the reform efforts, that I find asinine. The basic idea is: "Where in the Constitution does it say Congress can change our health care?!" or "what makes Congress think they can make these changes?!"

Honestly, to me this is a ridiculous question and suggests the person asking it has not tried to check the answer him/herself. Also, I believe it demonstrates how many people think of the Bill of Rights as the Constitution and do not understand that those were just the first ten amendments and have nothing to do with the original document.

Having spent the last hour or so reading the Constitution (OK, I admit it, some sections were perused while others were looked at more closely, but I did get through it), I am happy to point out the two sentences I feel make it absolutely obvious that Congress does have the right to address issues with our nation's health insurance and health care industries. Whether they should or not I feel is a reasonable debate, but I do not think there can be a question they have the right to.

First, see the first sentence of the Constitution: "We the People of the United States, in Order to form a more perfect Union, establish Justice, insure domestic Tranquility, provide for the common defence, promote the general Welfare, and secure the Blessings of Liberty to ourselves and our Posterity, do ordain and establish this Constitution for the United States of America." (emphasis mine)

If one of the primary goals of the Constitution is to "promote the general Welfare," then I certainly would argue that taking measures in an effort to expand access to medical services or to make more affordable those services that improve health and well-being while often lessening suffering and allowing our citizens to maintain their optimal quality of life should be included.

Second, see Article 1 (which pertains to Congress), Section 8: "The Congress shall have Power ... To regulate Commerce with foreign Nations, and among the several States, and with the Indian Tribes;"

Considering that health care in the United States currently is about 16% of our entire economy (about US$2.5 trillion), a sum and a percentage that the Founding Fathers likely could never have fathomed, I certainly believe it is "commerce" of sufficient size, which also is "among" the states that Congress should have the right to make efforts at shaping it, and, hopefully improving it so as to "promote the general Welfare."

Now, as I mentioned, I do think a debate of how Congress should make changes to the health insurance industry, or if they should do it at all, is worth having. But, please, let us move beyond the asinine idea that the Constitution does not give Congress the right to make relevant laws.

And with that, please, stop the ludicrous idea that the 10th amendment has any relevance. Yes, it says, "The powers not delegated to the United States by the Constitution, nor prohibited by it to the States, are reserved to the States respectively, or to the people." But since the Constitution does delegate such power to Congress, it is ridiculous that any politician should speak of it as an actionable plan for a state to ignore a federal health insurance reform law that might be passed. And, sadly, too many ignorant Americans are getting riled up by this bunk.

Let us have a reasonable discussion of the issues, but let us stop wasting time on nonsense.

Happy Constitution Day!

Read it, discuss it, live it, love it!

--Timothy Malia, MD