Unnecessary Medical Care and Over Prescription by Doctors

cover--310x465New Orleans      I go for a physical annually, like you’re supposed to do.  I basically trust my doctor, largely because she keeps it simple, doesn’t make me do some tests I don’t want, stretches out the EKGs for years, and sometimes forgets to make me, how should I say this, bend over.  To get insurance to pay, they require the calendar to be rigidly followed no more than one year after the last one, which put me having my visit after I came back from Montana in 2014.  Having taken a bit of a dive over a piece of a mountain to fortunately be stopped by a tree, I had a bump still protruding on one leg weeks after the fact, so there I was, and there the doctor was, so what the heck, I asked her about it, rather than just going with Google.  She was worried that it might be a clot in the vascular system and wanted me to immediately, as in that minute, go have an ultrasound to make sure. I tried to push back a bit, and she basically snapped at me that, hey, it was up to me if I lived or died.   Needless to say, I drug my ass across town to a hospital and was lucky to get the test done and find out that it was a problem that only time could heal.

The moral of this story is simple.  Doctors do have a way of getting you to take tests with some unanswerable arguments, no matter what we might think or feel about our health and well-being, so it’s an awesome power, and often unaccountable power.  In this case, she was likely right, and I was undeniably stubborn.

The other side of this problem is the fact that doctors and their institutions have until recently had huge incentives to order tests by the truckload.  Dr. Atul Gawande writing in The New Yorker recently reported that “thirty per cent of healthcare spending, or some seven hundred and fifty billion dollars a year” is waste.  In painful detail, he documented the vast number of tests that are simply useless and not even predictive in determining the problems at hand.  He noted elsewhere that “twenty-five to forty-two per cent of Medicare patients received at least one of…twenty-six useless tests and treatments.”  Maybe that’s not painful to read, but reading the whole article about surgeons seeing something as successful, simply if someone lived through the operation, regardless of whether or not it prolonged life, much less added quality to life, was just heartbreaking in addition to stupid and wasteful.  What happened to the Hippocratic Oath’s requirement for doctors to “do no harm?”

Gawande, some six years ago, had written a path breaking piece on Brownsville, Texas and why it was the most expensive place for medical treatment in the country.  The good news in this report is that his earlier article – and important new incentives provided by the Affordable Care Act to allow doctors and healthcare facilities to share hugely in sharing in the savings – had shamed and shuffled them into doing better.  This needs to catch on around the country!

In the meantime, having read all of Gawande’s pieces in The New Yorker and earlier his recent book, Being Mortal: Medicine and What Matters in the End, the only thing I’m one-hundred percent clear about it is that as much as I like my doctor and have learned to live with her, I have to admit that I wish Gawande would be my doctor whenever I come to have a serious problem.  Not having that, I hope I end up with a doctor who has read his stuff and drunk his Kool-Aid.   In fact I wish that for all of us!
10cc – The Hospital Song

Using Local Property Taxes to Push Hospitals on Charity Care

shriverNew Orleans      John Bouman, the President of the Sargent Shriver Poverty Law Center based in Chicago was my guest on Wade’s World recently on KABF/FM talking about a number of subjects but especially the handles for pushing nonprofit hospitals to provide care for lower income families as part of their nonprofit status and especially their federal tax exemptions under the 501c3 classification of the Internal Revenue Service.  He continues to have hope that the Affordable Care Act can decrease inequality and particularly can advance racial equality since African-Americans and Hispanics have gotten such short shrift from the health care system of the country.  He argued vigorously, and correctly, that the Affordable Care Act was the most significant piece of social legislation passed and implemented over the last fifty years.

Bouman mentioned that in Illinois, thanks to unions and community pressure including from the old ACORN affiliates, they had enjoyed a version of the new national rule that forces nonprofit hospitals to actually deliver more free and reduced price health care to lower income families for some years.  Their rule seems like it might even be a model for best practices for all of the hospitals now under the federal mandate to produce a rule that would allow them to keep their tax exemptions.  The Illinois standard is transparent.  A family would be eligible for such care at 200% of the poverty level.  I like a “no ifs, ands, and buts” standard, and that’s what we need to push for everywhere.  The Illinois standard also was clear about remedial practices before more strenuous collection efforts.

Almost in passing, Bouman mentioned that in Illinois the state and some cities and counties also had the ability to punish hospitals that were scofflaws on the act or really just wolves in the sheep’s clothing of nonprofits.  I asked Bouman how could they do that, and he said of course they could take away any local or statewide property or revenue tax exemptions or allowances that they were getting as nonprofits with their charitable status.  Whoa, I thought!  We had overlooked the obvious handle there that could help us bring the fight to a very local level.

In Louisiana, where we might not have a chance with the state, the local assessors at the parish or county level are elected and often very close to the ground in terms of their responsiveness to community pressure and organizing.  Furthermore, there are absolutely property tax exemptions enjoyed by all of the big, and many of the small, tax exempt organizations from the huge outfits like the universities and colleges as well as the small housing operations holding properties for development.  Immediately, I could see organizationally how we could challenge a host of property tax exemptions that are worth millions.

In Arkansas, a quick look comes down to a test of how “public” the service or facility might be.  My point is that in each state and in many local jurisdictions there might be handles available to increase the pressure for hospitals to do right. The fight itself might be enough to force some change, as we have already seen in the reaction of St. Joseph, Missouri’s Heartland Hospital and its jump to attention when they received an inquiry from Iowa’s Senator Charles Grassley asking them to defend their exemption given their collection practices.

It might be one thing for nonprofit hospitals to turn their backs on community organizations and unions asking about their policies and asking them to do better, but it would be a whole different problem if they had to defend such inadequate programs and cutthroat collection efforts in public before a board of adjustment, an assessor, a tax equalization board or any other public forum.


Please enjoy The Danielle Nicole Band’s You Only Need Me When You’re Down, thanks to KABF.

Salud Promodores, Barefoot Doctors, Home Health Workers, and Iranian Health Houses Come Knocking

Healthcare Workers in Iran

New Orleans   In organizing the process of strengthening weak ties to build the strong welds of solidarity can be very personal, tediously time consuming and therefore prohibitively expensive, and involve huge scale human engineering in order to create deep organizations, which is partly why organizers use other tools like actions and demonstrations to achieve scale and create polarization.  There’s no better or more intensive process than home visits, the door-to-door work that was the ACORN hallmark.

For a long time I have found it fascinating the way similar systems have been successfully adapted in developing countries to provide health care, particularly preventive care.  In Lima and elsewhere many of our organizers were originally salud promodores or health promoters, similar to home health aides doing outreach.  In fact when I was consulting with Casa de Maryland they had an excellent program working among immigrant populations in the suburban counties outside of Washington, DC.  The role of barefoot doctors, who were home health organizers after the Chinese revolution, was well regarded and carefully studied in my generation as both hopeful and inspirational.  The huge explosive growth of home health workers in the USA was more about cost saving than prevention or intervention, but there’s no doubt that when the service worked it allowed better health and independence for millions.

It wasn’t surprising to that Dr. Aaron Shirley, a veteran doctor and civil rights activist in Mississippi, would be attracted to these kinds of programs in dealing with the persistent, scandalous, and tragic heath care crises in Mississippi, but the New York Times Magazine feature advocating a move to an Iranian model of health houses or mini-clinics serviced by promodores of sorts was fascinating.

The Iranians built ‘health houses’ to minister to 1500 people who lived within at most an hour’s walking distance.  Each house is a 1000-square foot hut equipped with examination rooms and sleeping quarters and staffed by community health workers – one man and one or more women who have been given basic training in preventive health care.  They advise on nutrition and family planning, take blood pressure, keep track of who needs prenatal care, provide immunization and monitor environmental conditions like water quality.  Crucially, in order to gain trust, the health workers come from the villages they serve.

All of that seems to make enormous good, common sense.  The article drifts a little towards the direction of being a solicitation for government or private funds for the $3 million the Mississippi organizers and advocates want to build 15 such “health houses” over three years, but it makes me wonder why this wouldn’t be a vital system in not only rural areas, but also cities, and why with some energy and ingenuity and community support versions of this couldn’t be created by community organizations using the talents all around them.  Given the costs of health care, the shrinking of the safety net, and the fact that it’s life-or-death if we don’t start embracing preventive care and create a real ground-level health care system, it seems like it’s worth some thought and work for community organizations to adapt something similar and do so PDQ.

salud promodores training

Community Paramedics; Good Idea, No Reimbursement

N470_ambulanceew Orleans A fascinating story ran in the New York Times by Kirk Johnson about “community paramedics” being used in Colorado along with earlier experiments among homeless populations in San Diego, San Francisco, and Washington, D.C.  There was nothing about the program that involved rocket science, but in cutting back on emergency 911 calls costing an average of more than $1000 for each call, these programs focused on prevention; getting out there, spreading the word, and creating a system of care before the crisis.  How smart is that?  Very!

Unfortunately, despite the rave reviews one could feel the double edged knife of the coming health care regime sending contradictory messages about care for at risk populations.  On one hand these programs are being driven by an emerging Medicare rule that will bar reimbursement for any hospital readmission within 30 days of a discharge if it is established to have occurred from “a preventable repeat of the previous diagnosis.”  On the other hand existing rules only allow reimbursement if a paramedic actually gives someone a ride to the emergency facility.  The bottom line is that preventive care extends life, most importantly, and saves money, which is also very important, but all of the bean counters know that having the paramedics out there in the community is unpaid in the sense of unreimbursed.

In such a situation how many cities and counties are really going to take this very important and much needed step in preventive care?  Damned few, I’ll wager, unless this cash flow is right sized.

Impacting Healthcare: Organizing Medical “Hotspots”

v41Toronto Dr. Atul Gawande writing in the current issue of The New Yorker (1/24/11) interjects himself once again into the national (global?) health care debate by pointing out that hard data often reveals, as it did in Camden, New Jersey, that as much as 30% of health care costs are generated by as few as 1% of the patients.  Drawing from the Comstat work in policing, where computer aided analyzed systemic data collection and pointed to crime hot spots, arguably allowing police departments to focus more energy and personnel to deal with such problems, some of the same applications Gawande reports are shifting attention to patients with significant results in Camden, Atlantic City, and other innovative hospitals and health plans.

This would seem to be an “ah ha!” moment, it seems so obvious.   In union organizing and administration it has long been an understood fact in the tension between organizing model and service model unions that the same rough distribution of resources, if not more, are true in membership maintenance:  1% of the members require 30 to 50% of the contract administration and grievance handling resources.  In community organizing among lower income families I was introduced to the insights about “multi-problem” families virtually from the day I hit my first doors with welfare rights in Springfield, Massachusetts.  I would run into other organizers in Boston who had gone to social work schools and they would joke about it all the time in a general way before computers allowed any of us to understand what such families said about gridlocks in resource and personnel distribution.  Inevitably changing such patterns caused huge conflict, because inexperienced organizers would get drawn into virtually personal service relationships with particular members or leaders, which might have seemed a good idea to them when they were trying to win trust “on the cheap,” but always caused conflict when more real organizing programs more equitably distributed staffing to goals and membership production, rather than individual leader or member service.  My memory of “firing” a volunteer when I began in Arkansas, upon realizing he had become little more than the chauffeur, lender, and problem solver for one old leader, made it possible to work with everyone, but was something the “leader” never forgave me for!

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Gold Hidden in Dodd-Frank

Dodd-Frank-ReformNew Orleans Wow!  A seasonal surprise!!  It turns out that there were a couple of pieces of gold hidden in the hills and valleys of the Dodd-Frank Financial Reform Act that I had overlooked and that have international impact.   Retailers are required to report annually on the origin of minerals used in products from war-torn central Africa, thereby looking to strike a blow against “conflict” resources!

According to the Wall Street Journal our buddies Wal-Mart and Target had waged a huge war of their own to try and convince the Securities and Exchange Commission (SEC) to exempt them.  As we all remember Wal-Mart was somehow successful in its battle first for and then against healthcare reform to win an exemption from the provisions of that new act based on its slim pickings health plan currently in place.

The retailers association head whined that the SEC just didn’t understand the “supply chain,” which only means that they want the rule to be caveat emptor – the buyer beware rather than having to take any responsibility for how much blood might be on their hands and later wiped off not by them as the purchaser but by the consumer way down the line.  For a change the SEC held strong.

In another good play the SEC is requiring big oil to disclose how much they pay foreign governments for resource rights, hoping to bring some transparency to the global casino of bribery and corruption in the name of natural resources for developed countries at the rack and ruin of developing nations.  This is also very, very good news.

What’s up these days that we find out what’s going on diplomatic work seems mainly about business and we learn about it from Wikileaks and we can’t curb Wall Street or the banks, but their reform produces international victories?  We must be living in an era of the head fake and the sleight of hand, but for a change score one for us, rather than another for them!