Sunday, December 16, 2007
Tower Apartments
We just bought a new camera and I thought I'd try to get a picture of the tower behind the building, which is lit up for the holidays.
Friday, December 14, 2007
Sicko
After months of intending to see the movie, Diana and I finally rented it at the movie store. Like other Michael Moore films, it is entirely anectodal, too emotional to allow the viewer to actually consider the issues (without extreme amounts of guilt, anyway), and utterly aggravating. Still, you should see it.
The basic premise is that the US health care system is based on the for-profit insurance system, and for-profit insurance companies have a financial incentive to deny care. As one psychiatrist recently told me, the most cost-effective form of health care is death. This should come as no surprise, since almost by definition, capitalism is amoral ("invisible hand", anyone?).
On the other hand, hospitals and doctors have a financial incentive to provide medical care and perform medical procedures that they can get insurance companies to pay for, even if it may not be an absolute medical indication.
So the patient is caught in the middle of one system (the insurance industry), whose interest it is to deny care; and another (doctors and hospitals) whose interest it is to bill for care that will be reimbursed. Ideally, somewhere in the middle is what the best medical evidence indicates is the best medical treatment for the patient.
So far, I have not seen much of this tug-of-war. It occurs to me that this is because I have spent most of my 3rd year at public (Harborview) or federal (the VA) hospitals.
As I was watching Sicko, the idea that those responsible for paying for care would limit the care they pay for, was not foreign. The same is true at the VA, where there are numerous restrictions on what care is available to patients, for the same financial reasons. There are at least two main differences, however.
First, there are established protocols to access normally unavailable procedures or drugs. For example, I saw a patient this morning with Parkinson's disease in neurology clinic. He was on a medication called rivostigmine, which has been shown to prevent cognitive decline seen in Parkinson's (it is also one of the only drugs approved by the FDA for the treatment of Alzheimer's). This drug is not usually available to VA patients, and requires that the physician fill out special paperwork (an "extra-formulary request") to obtain the medication. Sometimes this works, and other times the established protocol for provision of these drugs makes such a request impossible, depending on the patient's circumstances. But as far as I have seen so far, drugs on this list have proven to be only marginally effective (rivostigmine shows only a 2% improvement over placebo), and I have not yet seen a situation where a restricted drug was medically necessary.
Second is the issue of accountability. Is there any recourse to the insurance company that denies treatment? I'm not sure, but I can't think of any. Is there any recourse at the VA? I'm not sure of that either, but at least there is some transparency. From my perspective as a medical student, it seems that there is at least documented logic for why certain treatments are provided at the VA, and others are not (for the record, I only know of a few of these treatments that are not provided). And at least there is some distant, democrat feedback loop to file complaints.
One final note on the VA: make no mistake, it is the most "socialized" form of medicine in the U.S. Veterans are cared for regardless of their ability to pay, and as far as I have seen, they receive excellent care. Many highly respected, extensively published physicians practice at the VA and provide care consistent with standards of evidence-based medicine. The VA also has a national medical records system, which is a massive database of patient information and outcomes data. For this reason, some very influential clinical trials have been done at the VA, and ironically, VA patients (at least here in Seattle) have access to many clinical trials and experimental treatments that are part of research protocols. Though antiquated and a bit bureaucratic at times, the VA seems to me to be on the same cutting edge as the rest of the private medical establishment.
In the end, most of you who haven't seen Sicko have probably already made up your mind about whether you will. I encourage you to see it. As Atul Gwande, a surgeon at Brigham and Women's Hospital in Boston, said in his review of the movie, "the movie brings to light nothing that the media haven’t covered extensively for years". There are no new revelations about the American health care system, but neither are there solutions. That, apparently, is left to the presidential candidates. . . .
The basic premise is that the US health care system is based on the for-profit insurance system, and for-profit insurance companies have a financial incentive to deny care. As one psychiatrist recently told me, the most cost-effective form of health care is death. This should come as no surprise, since almost by definition, capitalism is amoral ("invisible hand", anyone?).
On the other hand, hospitals and doctors have a financial incentive to provide medical care and perform medical procedures that they can get insurance companies to pay for, even if it may not be an absolute medical indication.
So the patient is caught in the middle of one system (the insurance industry), whose interest it is to deny care; and another (doctors and hospitals) whose interest it is to bill for care that will be reimbursed. Ideally, somewhere in the middle is what the best medical evidence indicates is the best medical treatment for the patient.
So far, I have not seen much of this tug-of-war. It occurs to me that this is because I have spent most of my 3rd year at public (Harborview) or federal (the VA) hospitals.
As I was watching Sicko, the idea that those responsible for paying for care would limit the care they pay for, was not foreign. The same is true at the VA, where there are numerous restrictions on what care is available to patients, for the same financial reasons. There are at least two main differences, however.
First, there are established protocols to access normally unavailable procedures or drugs. For example, I saw a patient this morning with Parkinson's disease in neurology clinic. He was on a medication called rivostigmine, which has been shown to prevent cognitive decline seen in Parkinson's (it is also one of the only drugs approved by the FDA for the treatment of Alzheimer's). This drug is not usually available to VA patients, and requires that the physician fill out special paperwork (an "extra-formulary request") to obtain the medication. Sometimes this works, and other times the established protocol for provision of these drugs makes such a request impossible, depending on the patient's circumstances. But as far as I have seen so far, drugs on this list have proven to be only marginally effective (rivostigmine shows only a 2% improvement over placebo), and I have not yet seen a situation where a restricted drug was medically necessary.
Second is the issue of accountability. Is there any recourse to the insurance company that denies treatment? I'm not sure, but I can't think of any. Is there any recourse at the VA? I'm not sure of that either, but at least there is some transparency. From my perspective as a medical student, it seems that there is at least documented logic for why certain treatments are provided at the VA, and others are not (for the record, I only know of a few of these treatments that are not provided). And at least there is some distant, democrat feedback loop to file complaints.
One final note on the VA: make no mistake, it is the most "socialized" form of medicine in the U.S. Veterans are cared for regardless of their ability to pay, and as far as I have seen, they receive excellent care. Many highly respected, extensively published physicians practice at the VA and provide care consistent with standards of evidence-based medicine. The VA also has a national medical records system, which is a massive database of patient information and outcomes data. For this reason, some very influential clinical trials have been done at the VA, and ironically, VA patients (at least here in Seattle) have access to many clinical trials and experimental treatments that are part of research protocols. Though antiquated and a bit bureaucratic at times, the VA seems to me to be on the same cutting edge as the rest of the private medical establishment.
In the end, most of you who haven't seen Sicko have probably already made up your mind about whether you will. I encourage you to see it. As Atul Gwande, a surgeon at Brigham and Women's Hospital in Boston, said in his review of the movie, "the movie brings to light nothing that the media haven’t covered extensively for years". There are no new revelations about the American health care system, but neither are there solutions. That, apparently, is left to the presidential candidates. . . .
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