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Saturday, June 30, 2012

What does the Supreme Court decision about the Affordable Care Act actually say?

On June 28, 2012, the Supreme Court of the United States voted to uphold most of the disputed provisions of the Affordable Care Act, allowing the legislation to stand. I read the syllabus and some reasonable portion of the opinions. The link is here:

The two issues considered by the court were:
1. Does the constitution allow the government to withhold Medicaid funding from states which do not choose to participate in expanding Medicaid to citizens who sit below 133% of the poverty line?
2. Can the government require citizens to buy health insurance?

There was lively discussion. Chief Justice Roberts argued that it is not constitutional for the government to take away Medicaid funding as a way of forcing states to comply with Medicaid expansion. Justice Ginsberg felt that this could be construed as amending the Medicaid program and was within Congresses legislative prerogative. Eventually they agreed that Congress definitely had the right to share costs with states for Medicaid expansion, as provided in the law, but could not constitutionally withhold funding from states that chose not to participate. This change would not invalidate the ACA.

The argument about the "individual mandate" to buy health insurance was livelier. All of the justices seemed to understand the issue: everyone needs health care at some time, they don't know when, and because it is so expensive, the uninsured rarely can pay their bills. Since someone has to pay their bills, providers such as hospitals do, passing the cost off to paying customers by way of their insurance, thus raising the cost of health insurance. If the uninsured only get emergency care when they are sick rather than getting preventive and primary care which cost less, the cost of health care is higher. We all pay for health care, no matter how you look at it, and the ACA's individual mandate is just a way to more equitably distribute the costs. Requiring healthy people to buy insurance before they get sick will likely keep them from costing so much, plus will allow the insurance companies to continue functioning in the black since they won't be insuring only the sick. Other provisions of the ACA do require the insurance companies to provide affordable coverage to everyone, and if there were no new healthy folks in the pool, their profits might fall to the point that they couldn't economically survive. (I'm not entirely sure that would be a bad thing in the long run, but it is not the intention of the ACA to kill the health insurance companies.) Justice Ginsberg noted that the government would have been within its rights and precedents to enact a single payer system, a "tax and spend" solution, but they decided to support the current system instead.

The question that was raised, however, was whether the government, under the commerce clause, has the right to require people to buy health insurance. This clause was originally enacted because states often acted with respect to commerce in ways that were beneficial to the states but not to the country. The clause gives the federal government the right to "regulate commerce." Since running up huge medical bills, thus driving up insurance costs and bankrupting hospitals and those who purchase health insurance is certainly commerce, enacting something to alleviate this problem could definitely be viewed as "regulating commerce." Several justices felt, though, that allowing the federal government to require people to buy something that the don't want is a dangerous expansion of federal powers. The justices then looked at it another way. If an individual does not buy health insurance, he or she is required to pay a certain amount of money as a penalty and as a way of defraying the costs of the burden they place on the health care system by not buying health insurance. This amount of money is to be payed along with income taxes. It can be viewed, then, as a tax, and the federal government can levy taxes. The individual mandate stands, then but can be more accurately read as "you can either buy affordable health insurance in a timely manner or pay a tax and not be insured."

It is definitely worth reading some of the judicial opinions, especially those of Justices Ginsberg and Roberts, just because they are so smart and express themselves so well. They manage to be conversational and engaging while presenting elegant logic. They also have this sort of sparring match going on. I would love to watch them having dinner together.

I'm glad this is over. The ACA is not perfect, and the solution to our health care problems is not in it, but it is a powerful incentive to move in a direction that will eventually be beneficial. In fact it is already beneficial. The fact that the whole country is watching health care, and we all know it, is profoundly motivating for us to get our acts together and make the changes that are totally obviously needing to be made.

Thursday, June 21, 2012

Thank you doctor for finding that blood clot in my lung--you saved my life! (not)

Pulmonary embolism is a condition in which a blood clot that forms somewhere in the veins of the body moves with flowing blood into the right heart and then out into the lung (or lungs.) It is a common cause of sudden death, since a very large clot can cause the heart to fail and reduce the oxygen level in the blood. The blood clots that cause pulmonary emboli usually form in the deep veins of the legs, sometimes in the large veins of the pelvis and rarely form in the heart. Some people with pulmonary embolism have symptoms that are vague, like dizziness, cough, chest pain or shortness of breath. When they are evaluated they usually have an increased pulse rate, often a low-ish oxygen level, and occasionally report coughing up blood. A person who has a small pulmonary embolus may have really mild symptoms and then flip a very large clot later which can be devastating, so we evaluate many people for pulmonary embolism who have very atypical symptoms. We have a blood test, the d dimer, which, if it is low and symptoms are minimal, is enough to be pretty sure there is no clot. We have a couple of good imaging tests, the CT angiogram and the ventilation perfusion scan, which are even more accurate unless a person has pretty significant underlying lung disease.

When I was just a wee baby newly fledged doctor, we had to do a test called a pulmonary angiogram if we wanted to be really sure that a person didn't have a pulmonary embolism. This involved putting a catheter into a large vein and threading it into the right hear to inject a contrast material into the pulmonary arteries whereafter an x-ray could show the pulmonary arteries and delineate any clot that obstructed them. We tried not to do this test because it could kill people, either by causing rhythm disturbances in an already stressed heart or by killing their kidneys with a large load of potentially toxic contrast material. The catheter in the large vein was also potentially harmful. We can still do this test but the CT angiogram, which uses a smaller amount of contrast material in a smaller vein and gives us great images has mostly replaced it.

The CT angiogram is not without risk. It can cause kidney damage and does deliver a sizeable dose of radiation. It is also hard on the national budget, since we do it very often now at a few thousand dollars a pop.

CT scanners have gotten faster and more accurate, with multiple detector machines becoming increasingly common. These machines can see really little clots. How cool is that? 

It turns out that the new multidetector machines detect many more small clots than the standard machines, about twice as many. A study that looked at 22 studies comparing the two types of machines and the outcomes of patients scanned with them, showed that even though the standard single detector machines probably missed a portion of clots, the people who walked away with no treatment, because their tiny clots were not detected, were no more likely to have evidence of blood clots three months later than were the people screened with the multidetector machines and thus treated with anticoagulant medications. This is the link:

Treating a pulmonary embolism is no small endeavor. People usually spend several nights in the hospital on medications that reduce blood clotting, and receive oral medications that will work when they go home. There is a not so small risk of bleeding, either in the hospital or after discharge, and a first blood clot is then treated with an anticoagulant medication for at least 3 months, requiring multiple blood draws and visits to the doctor. All of this is a reasonable price to pay for not dying, but not if the tiny blood clot was meaningless.

Today a patient was admitted to me to the hospital who had come to the emergency department with shortness of breath and a swollen leg after a long car trip. Long car or airplane trips are classic inciting events for blood clots. He had a d dimer that was a bit high and a CT angiogram showing that he had, maybe, a subsegmental pulmonary embolus. Even with the multidector machines, these tiny clots are hard to be sure of. He was also already on a therapeutic dose of a standard anticoagulant for a heart arrhythmia he'd had for years. The level of that was fine. He shouldn't have gotten a clot. 

But did he have a clot? Or if he did, was it significant? 

It turns out that his shortness of breath had started before he even went on his car trip, that he had a weakened heart from previous valve disease, and that both legs were actually swollen and he had been eating higher than normal amounts of salt as he headed across country. So he probably doesn't have a clot and his symptoms are probably due to congestive heart failure. But I can't really know that.

If this were an unusual case it wouldn't be worth mentioning at all. But it wasn't. It is more and more common to see tiny maybe pulmonary emboli in patients who have symptoms that have another likely cause, but then they require months of treatment and are forever worried about their risk of blood clots. Aargh. What messes we make for ourselves with our everso nifty technology.

Thursday, June 7, 2012

More tongue clucking about the cost of medical supplies: why do veterinary supplies cost so much less?

The other day at my home hospital (which I love and think does a great job of controlling costs and treating patients appropriately) I was sitting around with the intensive care unit nurses and discovered some more irksome facts about how much things cost in hospitals. I had just learned how to place a PICC line (peripherally inserted central catheter) from a nurse anesthetist. When a person is critically ill it is important to have access to the blood stream in such a way as to allow lots of fluid to go in quickly or to make sure that medications that can be irritating to small veins (like potassium and blood pressure support medications) get where they are going without causing damage. That means that a catheter (an IV) needs to go into a central vein. It can go by way of a large vein in the neck or upper chest (the internal jugular vein or subclavian vein) or it can start in a smaller vein in the arm; that catheter is a PICC line. PICC lines can get clotted off, because they are longer and go through smaller veins (maybe that's why) but have less risk of causing significant bleeding and don't result in puncturing the lung. The centrally placed catheters do have higher immediate risks, but if they are placed correctly they have some advantages. In the US, physicians (rarely midlevel providers like PAs or nurse practitioners) put in central lines and nurses put in PICC lines. Physicians almost never put in PICC lines, and will fuss around waiting for a nurse to do it even if that means delaying giving some medication unnecessarily. It's not hard to put in a PICC line, maybe easier than a central line. Maybe not. Just less risky. So it makes no sense that we don't do it, just as an option. So I learned how.

That was a bit of a tangent.

We were sitting around after putting the PICC line in and the nurse scanned the little price tag and said "You know that kit costs $1300."  Whoa! So we scanned the central line kit, a little different but not that different, and it was $879. Still too expensive, but not as expensive. I'm thinking that with nurse vs doctor putting in the line, probably placement of these catheters adds up to about the same amount of money to whoever pays the bills. How weird!

So we scanned some other things, and learned that a foley catheter bag (only the graduated plastic bag that collects the urine, not the tube that goes in the bladder) was $62 and that a regular IV, like what goes in everybody's arm when they come to the hospital, cost $40. Impressive.

I got online to see if there was some value pricing available on such things, but there is no way to access prices or even buy central lines or foley catheters online in the usual competitive marketplace that allows me to buy, say, an iPod for less than Apple would charge. I couldn't find any prices. No "buy now" button, no shopping cart. If you have to ask, you can't afford it?

After wandering around on the interwebs, lonely and frustrated, for a half hour or so, I happened on some veterinary sites, and it turns out you can buy central lines and foley catheters for non-humans online. I priced a triple lumen central line kit, about what I have used on humans, or at least it looks like it, and was able to buy one for.....$29. A central line kit consists of a finder needle, a syringe or two, a little anesthetic, a needle for anesthetizing, an introducer, a springy wire that goes into the vein and the actual central line which goes over the wire. There are sundry other items for sewing it in and such. In a human kit they also include a surgeon's gown and a large head to toe sterile drape, which isn't in the veterinary kit, but I priced those things too, on the vet site, and they cost maybe 3 or 4 dollars each. On the vet site you couldn't buy just a foley catheter bag, but the whole kit, tube and all, cost just shy of $5. A peripheral IV, the kind that costs us $40, was $1.

You can't buy PICC kits for animals, not that I found. They would be really inappropriate for animals, because they could easily reach them with their teeth and chew them out and so the whole advantage for humans would be a disadvantage for non-humans. A PICC kit is a little different than a central line kit in that the long catheter, since it is smaller and less firm, goes through a harder introducer, over the wire, and the hard introducer is then peeled away. It is clever, but I can't imagine that it is costly to make.

When I look at a central line kit I notice that the individual items are made in all sorts of places that can make stuff really cheaply, like China, Southeast Asia and the Dominican Republic. They put central lines in all over the world and I just can't imagine that in resource-poor countries they are paying close to $1000 just for a kit.

The company that produces most of the venous catheters that we use is Arrow International, which was just bought by Teleflex, an multinational multibillion dollar company that produces all kinds of interestingly manufactured products. Arrow has been in business since the 1980s and has been an innovator in the medical business since its inception. From what I read, it looks like they kind of invented the multi-lumen catheter and were the first to use polyurethane and to work out various bugs. They make dialysis catheters and intra-aortic balloon pumps which can bridge a failing heart to a life-saving operation. I don't know how much these products cost, but I'm guessing it's immense. They have been a very successful company.

The company that produces the foley (bladder) catheters that we use is Bard, and is the company that invented the technology years ago and remains active in improving it. Good for them.

So the story is complicated. Companies that are successful are also making important innovations. They are also charging obscenely huge amounts of money for objects that doctors in hospitals are dependent upon and we have no idea how much money we are spending when we use them.

I look forward to getting my box of goodies from the veterinary supply company so I can see how closely the stuff they use resembles what we use. I'm not sure how to tackle a problem like this. Competition does seem key. I'm sure we don't do it by buying veterinary equipment. Probably technologically advanced but resource limited countries have something to teach us.