Archive for the ‘Medicine’ Category.

Obamacare Tax Is Here for Individuals Too

Pity the small business. The federal government treats small business owners as cheats and shows them no mercy. Every month small businesses regardless of size must file payroll taxes which include the other 7.5% of each employee’s FICA plus withholding taxes. Every quarter the business also must file estimated taxes for the current fiscal year. Life is simpler for W-2 employees. Most of the work is hidden from them because if the average worker was responsible for carrying his or her share of the burden to comply with local, state and federal regulations, there would be riots in the streets. So instead governments burden the employers who must write it off as the cost of doing business in our society, and workers believe their tax refund is a “gift” from a benevolent government.

Much is being said about Matt Drudge’s “Liberty Tax”, and it’s clear that none of the critics have ever had to file a small business corporate return. If they had they’d understand how taxes are collected in this country and would recognize that Drudge isn’t lying. One issue I haven’t seen mentioned, however, is the individual penalty. Although Congress has raised the issue of delaying the individual penalty for those who opt out of Obamacare, it doesn’t appear likely to pass anytime soon, meaning that the penalty is already in force. We just don’t feel it yet.

Those who opt out, or carry a policy that doesn’t meet Obamacare’s minimum criteria of providing maternity care to men or Viagra to women, should increase their withholding amounts immediately or risk a surprise tax bill next year. How much will the penalty be? Here is an ACA Penalty Calculator that will estimate the amount due next year. For example, if you are filing as single with no dependents and make $75,000 this year, you will pay an additional $649 in 2014 rising to $1,339 next year and $1,725 the year after that (assuming 3% wage growth). Assuming the worker didn’t want to be stuck with that bill and was paid 26 times a year, she’d have to boost her withholding amount by another $25 a check this year, another $26.50 the next, and another $15 in FY2016. Things get complicated real quick with other permutations. Nothing the IRS does is simple, and handling Obamacare penalties is no different.

Most people don’t think about taxes until a few weeks before they are due, so I don’t expect this issue to get much airplay until early next year. But if you don’t have employer-sponsored health care or your plan isn’t qualified, then don’t kid yourself. You’re paying the penalty now.

 

The Ethics of Altered Time Perception

The Daily Mail has a thought provoking article on the use of drugs and other methods to prolong the sense of time for criminals, making their incarcerations seem longer than their actual sentences. While the article does a fair job of covering the morality of using such drugs on prisoners, it completely ignores uses of the technology for more benign purposes.

Imagine a drug one could take that could make a two day vacation feel like a month. Or prolonging those instants of joy that spontaneously arise in our lives into minutes, hours or perhaps even days. Would any of us not take a drug that would allow us mastery of time, to fight the inexorable rush forward, reducing it to a creep at certain times of our lives? There are moments we want to last forever. Soon there will be an app for that.

The article raises profound concerns about what justice means, and as the technology comes into existence we as a society should consider each of them carefully. But are we prepared at all for the opposite? Could there be a downside to stretching out those joyful moments artificially?

The Painful Implications of Invertebrates Feeling Pain

Do invertebrates feel pain? Evidently some, like crustaceans do. “Brown crabs rubbed and picked at their wound when a claw was removed, as it is in fisheries. At times the prawns and crabs would contort their limbs into awkward positions to reach the injury…”

But the same article says we don’t have to feel guilty when we smash a stink bug. “Even in extreme cases, insects show no evidence of pain. Imagine a praying mantis eating a locust, [Wageningen University professor Hans] Smid says. With its abdomen opened up, the locust will still feed even while being eaten.” Good to know because I’ve become a regular American Psycho when it comes to stink bugs.

So Science has decided that animals as simple as hermit crabs feel pain. Yet we are led to believe that human embryos and fetuses prior to birth do not, and the research that states otherwise remains controversial. This isn’t a philosophical problem for me since I eat animals and oppose laws outlawing abortion in the first trimester. I accept both are murder. But it strikes me as a bit of a conflict when my liberal friends support abortion without restriction yet won’t touch an egg because of the suffering the hen went through making it.

I’ll start taking vegans seriously when I meet one who opposes abortion for the same reason they oppose consuming animal products.

ICD-10: An Acronym Everyone Will Know Soon

Stephen Hayes has a must read article about the coming implementation of new medical coding standards known as ICD-10. I have personally met doctors who promised to retire before these standards go live in October due to their complexity. Perhaps more will quit once they learn about ICD-10’s Kafka-esque logic. For example, code T63813A is “toxic effect of contact with venomous frog, assault, initial encounter.” There is not a single venomous species of frog on the planet at this time. Oh and you can see a doctor several times for the same malady and each can be considered an “initial encounter.” Last I checked a dictionary I’m pretty sure initial had a very strong connotation of “beginning,” because the adjective “subsequent” would be used to describe encounters coming after the initial one. Not according to the geniuses behind ICD-10.

The expectation is that insurers will reject all claims due to “incorrect coding” soon after implementation, forcing the smallest providers out of business. Larger providers are expected to survive. Thinking about this though, I’m not so negative. There are already hospital administration coding specialists. While healthcare providers enter the initial codes, these specialists are used to figure out better ways to code patient treatments and educate the providers on using better codes next time. ICD-10 implementation is guaranteed to thicken this relatively new layer of bureaucracy in the health care system, perhaps by having the health care providers document the patient encounter in a traditional way, leaving the coders to determine the proper ICD-10 code later. Eventually you will have a war between the ICD-10 specialists working for providers and those working for the insurers, including the federal government. As I’ve learned with the business of Medicine or any other extremely complex system, unintended consequences are the norm. It’s way too early to predict complete disaster.

That’s the optimistic view at least, and it’s only optimistic insofar as it decreases the burden on physicians and other providers. It will not save money; that layer of bureaucracy is going to become critical and expensive, meaning that health care costs will rise. Add in the disappearance of small practices who can’t afford to implement ICD-10, and you will have fewer providers competing with each other.

The pessimistic side of course is that providers like my wife will spend even more time on on unpaid documentation than she does now, and I remind her that whatever is free is abused. For example, today she spent an hour looking up formularies and speaking to an insurance company trying to find a patient a drug her patient’s insurance company would pay for. All that time was gratis. She is therefore considering her career options, as I’m sure many providers are. Medicine is a vast field with many different ways to earn a living, and the skills she has developed will serve her well. She loves treating the sick and she still shows the passion that I saw nearly 20 years ago in the African bush when she helped African villagers. But she didn’t go through medical training to spar with desk-jockies and the coding schemes they pulled out of their asses. Everyone’s favorite example? Code V9027XA: “Drowning and submersion due to falling or jumping from burning water-skis, initial encounter.”

Who will not be served well will be the patients of the providers who leave primary care because of ICD-10, on top of the already burdensome documentation requirements, buggy and poorly written EHR software (no fax capability within the system – so the providers have to print out the prescription and carry it over to the fax machine), declining reimbursement rates, and patients who are overmedicated, overweight and over-indulged.

Here’s a tip: Make sure you get sick before the end of the year, and hope you stay healthy afterward.

 

Free Justina Pelletier

A family from Boston decides to take a trip across the country for a vacation. While in Nebraska their 16 year old son falls ill and is taken to an emergency room. While there a doctor notices that the son is homosexual. When confronted with this news the parents admit that yes, their son is openly gay. What the parents don’t know is that in Nebraska, homosexuality is viewed as a disease that can be cured through behavior modification techniques. The doctor suggests enrolling him in a program to treat his homosexuality. The family refuses. The state’s department of children’s services is called in. By withholding this therapy from their son, the state alleges the parents are abusing their child. The state removes him from their care, slaps a gag order on the family preventing them from discussing the situation with the Press. Later the child is placed in foster care while he undergoes aversion treatment for his homosexuality.

Sound crazy? Well this situation is actually happening to a family, except it’s not in the Midwest, it’s in the liberal Northeast. And the child isn’t gay. She has Mitochondrial Disease – a disease recognized in Europe and the United States with the exception of backwaters like Boston’s Children’s Hospital. In January 2013 she was a happy figure skater. The next month she fell ill while in Massachusetts and was taken to Children’s Hospital where a newly minted doctor denied the existence of Mitochondrial Disease and called in Children’s Services believing the parents were abusing their daughter by treating her for the condition. The State swept in, took the daughter into their care, and have limited her family to only brief supervised visits. They have forced the child psychiatric therapy of dubious scientific validity with disastrous consequences. Just over a year later the girl can’t walk anymore and is stuck in a wheelchair.

Stop for a moment and consider: The family was not refusing medical treatment. In this case the State of Massachusetts is the one refusing medical treatment. When I first saw the headline I thought that maybe they were pulling a Christian Scientist/Jehovah Witness stunt by refusing to allow medical treatment of their daughter. This is not the case with the Pelletiers, who have had several children with the disease, and whose daughter Justina was undergoing treatment at nearby Tufts University. Is Tufts some medieval institution that uses barbaric treatments on its patients? If so, then the Cleveland Clinic is guilty as well. In fact it’s more difficult to find an institution that views the disease as in the patient’s head as Children’s Hospital in Boston apparently does.

This story has been making the rounds of the right wing and libertarian blogospheres but it is also beginning to pop up on the left wing as well as this HuffPo article proves. The more I read I keep thinking there’s got to be more to the story, that something this heinous cannot happen in a modern society. A State refusing medical treatment, especially one supposedly as “progressive” as Massachusetts? This story resonates with people on the Right who are naturally shy of government intervention especially when it comes to family life. For us it’s just one more step towards state control of every detail of our personal lives. But this argument usually arises when a parent refuses a life-saving medical treatment for their child, not when the State is barring the treatment. It should also raise alarm on the Left as well, since the State’s behavior – taking a child away from her family and forcing her to undergo psychiatric therapy – is a reminder of the mental health abuses the Left attacked during the 1960’s and 1970’s that appeared in the movie One Flew Over The Cuckoo’s Nest.

It’s also yet another instance of the State telling a woman what to do with her body. I’m sure if Justina wanted to have an abortion she would be free to decide what to do with her body. So why can’t she have the same freedom to choose another treatment?

It simply does not make any sense from any perspective. The only solution is to Free Justina Now.

 

What Pro-Life Groups Can Learn From Death Penalty Opponents

NPR ran a story about the difficulty state governments are having acquiring the drugs they need to execute criminals using lethal injection. No American pharmaceutical companies make the drugs, and the EU bans their sale to US authorities because capital punishment is illegal in the EU. The sensible choice would be for states to source the drugs from China, which executes more people than the US and harvests their organs to boot, but currently the quality of the drugs is below standard.

Perhaps the Pro-Life movement could learn from the EU and target the makers of equipment used in abortion. Companies are very sensitive to bad publicity, especially over sales that provide a tiny fraction of their profits, and it wouldn’t take much effort on the part of Pro-Life groups to make it more difficult for abortion clinics to buy or repair equipment.

As for the states, they can get by on firing squads, the gas chamber or the electric chair. Sure the condemned prisoners will suffer more but at least death penalty opponents will be able to sleep at night, at least until the Chinese pharmaceutical companies take over.

 

The Dollars and Sense of a College Education

If you peruse this website you’ll see I think deeply about many subjects. Two subjects that are dear to my heart are medicine and higher education. Why? The first is obvious: I’m married to a doctor and have a nice perch from which I can view the industry’s operation and development. The second is not so obvious. Although I am a college graduate I have no particular love for my alma mater. In fact when I visited it a few years ago I was surprised by how little a connection I felt on campus. It had changed as I had, but there was something else. I felt that I had been processed, just one of thousands that graduated from the university that by-gone year. It was a very mechanical operation. I paid my money, got my card punched for the required classes I needed, and received a certificate and a handshake at a forgettable ceremony at the end.

Yet I still think about and worry about higher education. I recognize its importance in a free society, which is why I rail against its takeover by leftists and fret over its cost. I also I have a child who will soon be college age, and so I’m mindful about the choices and opportunities higher education offers him.

Medicine and higher education also share one thing in common. Their prices are completely opaque. I recently lost my health insurance as a direct result of  Obamacare, and as I get older I worry more about how long my body can last without seriously breaking down. Take for example a hernia repair. I had one done in 1999 and was similarly under-insured at the time. The price back then was $3,000 and was split 50-50 between my insurer and me. As I begin to prepare the farm for Spring (funny to think about considering I’m waiting to be walloped by a deadly winter storm as I write) I’m moving heavy things around. Every once in a while I get a twang in my lower gut on the opposite side of the repaired hernia and it scares me.

How much would a hernia operation cost me today?

I have absolutely no clue. I can go online and find the price of nearly any car. I can search real estate sites and learn the prices of houses in any neighborhood in North America. I can even find out how much companies charge to clean out my septic tank, but I cannot tell you how much the local hospitals are charging for hernia repair. All I know is that it’s probably going to cost me more than $1,500. Probably a lot more.

Why is this?

Similarly I can look up the cost of tuition at any college or university in North America. In many cases such numbers aren’t easily found, and when they are they really don’t mean much. For one thing the costs don’t include many mandatory fees that one has to pay. They also often don’t provide the cost of living one has to pay to attend. And finally, the tuition figure is a lot like “manufacturer’s suggested retail price.” Hardly anyone pays that number except for wealthy foreign students who tend not to be price sensitive thanks to their parents being members of some kleptocracy in the Third World. In most cases the cost of tuition will be lowered by need-based grants or scholarships.

Other costs are never mentioned. For example opportunity costs. For arguments sake let’s imagine that my son will attend college and graduate in four years. Not only will I have to account for the direct cost of his education such as tuition, fees and books, but I’ll have to include indirect costs like room and board, transportation, food, entertainment, clothing etc. On top of that there’s the cost of lost wages. During those four years he could have worked full time and earned say, $20,000 a year. That’s $80,000 in earnings he’s forfeited and that he will have to make up through better earning power of his degree. If he graduates and earns just $20k a year, then he’s wasted his time and I’ve wasted my money.

But by far the largest unmentioned cost is compound interest. As Einstein once said compound interest is the most powerful force in the Universe, and anyone who’s ever paid back a student loan knows he was right. Every month I cut a check to pay back the Wife’s medical school loans and the balance barely budges, and the reason it doesn’t is compound interest. Students may not understand that when they borrow $10,000 at 5% interest to attend school, they aren’t paying back $10,500 after they graduate. While they are in school that loan is capitalizing, and the interest is compounding so that by the time they pay back that $10,000 loan ten years after graduation they will have paid back $20,000 on top of the $10,000 they borrowed.

So how much does a year of college really cost?

Again, it’s difficult to say. The best I can do is estimate it.

I’ll start with my alma mater, University of California – San Diego which is to education what factory farming is to the poultry business. UCSD off-campus cost including tuition, estimated room, board, transportation is roughly $30,000 for the 2014-15 school year. I’ll assume my kid gets some grants, knocking the cost down to $25,000.

Say I throw in $15,00o leaving him to come up with $10,000. Since he’s a typical teenager, he won’t understand compound interest, so he’ll borrow his $10k and pay it off after he graduates. Because it will take time for him to pay it off, that original $10,000 will become $30,000 by the time he authorizes the last debit to his account for his student loan creditor. Adding in my original $15k means his year at my alma mater will really cost us both $45,000.

To reiterate, that’s the cost for one year at a public school in California based on the following assumptions:

  1. He graduates in 4 years. This is a big if these days. Many kids are taking 6 years or longer. The longer they take, the worse the compound interest on their student loans as the interest on the deferred loans compounds while they are in school.

  2. He gets $5,000 or roughly 17% in need based grants or scholarships. UCSD provides need-based aid to 70% of undergraduates, and some of that includes loans according to an admissions officer at the university I spoke to.

  3. I provide $15,000. That’s more than my entire stay at UCSD cost back in the 1980’s by the way…

  4. He borrows $10,000 and takes 10-15 years to repay it.

One of the dirtiest yet most effective ways to manage one’s time I’ve learned as a per-hour professional contractor is to determine the cost of whatever I’m doing or not doing in terms of a dollars per hour figure. What would it really cost my son to attend an hour long class at UCSD?

UCSD requires 180 units to graduate. So based on our assumptions that’s 45 units per school year of 30 weeks. Dividing the cost of the school year $45,000 by 30 weeks gets us $1,500 per week. In order to maintain our assumptions and finish in 4 years, our student will need to take 15 units per quarter, which translates into 15 classroom hours a week. Dividing the cost per week ($1,500) by classroom hours per week (15) provides us the cost of a classroom hour: $100.

We’ve all heard about dumb classes kids take.  Rutgers University is offering “Polticizing Beyonce” ostensibly to explore race, gender and sexual politics. Assuming Rutgers charges the same as UCSD, I wonder how popular the class would be if students had to peel off a Benjamin each time they entered the classroom. Would they be as willing to explore race, gender, and sexual politics in a classroom for the same price they could explore race, gender, and sexual politics with a moderately priced hooker in private? Granted one doesn’t have to worry about catching an STD by attending class; then again with some of the types I’ve seen on university campuses these days, I’m not so sure about that.

People alter their spending habits when they know what the price of something is and can estimate its value, and the fact that both are hidden from us whenever we consider medicine or higher education should make us stop and ponder “Why?” The free market is a ruthlessly efficient thing. If students had to pay for each class they took when they took it, one could bet that higher education spending would be revolutionized.

Universities would focus on providing better teachers that students would be willing to pay for. They would be forced to cut costs, cutting back on the administrative bloat that inflates the cost of tuition. After all, a typical undergraduate core subject class at UCSD might have as many as 150 students in it. Multiply that number by a $100, and it’s quite likely the adjunct professor teaching the class and the dozen graduate students TA’ing the course see a pittance of that $15,000, the TA’s working for free and the adjunct prof earning about $25/hour. Where did that $14,975 go?

It went several places. To pay down the loan on the new student rec center. To pay off the new training equipment for the track and field team. And on administrators, hordes of administrators, a veritable plague of administrators. As this article shows, a new study finds the number non-academic administrative employees at US colleges and universities has doubled at the same time the number of part-time faculty has grown from a third in 1987 to half of all teachers today. University presidents contend they are doing everything to cut costs, but Richard Vedder, an economist and director at The Center for College Affordability, calls them liars.

“I wouldn’t buy a used car from a university president,” said Vedder. “They’ll say, ‘We’re making moves to cut costs,’ and mention something about energy-efficient lightbulbs, and ignore the new assistant to the assistant to the associate vice provost they just hired.”

Some of my friends have commented that my arguments attack the liberal arts and that I focus too much on STEM courses that provide good job opportunities after graduation. I don’t have a grudge against the liberal arts per se. In fact one of the most useful courses in terms of my career as a systems analyst I ever took was a philosophy course on logic. Some of the English courses were excellent too in terms of value.  Being able to communicate to a broad audience is critical in business these days, yet so many students lack the basic ability of crafting a memo let alone being able to articulate complex subjects to non-technical audiences. If I could go back in time, I would happily peel off a Benjamin to pay for an hour of that logic course. It was worth it to me, and would likely be worth it to others. I’m advocating a system of price transparency and reform that will likely save such classes because the administrators who are waking up to the threat posed by parents like me are scrambling to cut costs by cutting teachers and courses instead of cutting their own jobs. Maybe Politicizing Beyonce is a great course well worth the cost, but the market, those paying for the class, should be given the opportunity to decide its true value.

Nurse Practitioners Aren’t the Solution to the Collapsing American Medical System

Let me begin by stating that my primary care provider is a nurse practitioner, as is my son’s. My mother’s is a physician’s assistant, and she trusts him more than some of her children. But let’s make something very clear: physicians, nurse practitioners and physician assistants are not the same. They do not receive the same training, do not have the same responsibilities and do not treat the same. They all have their role in health care, but you cannot replace one with the other and expect the cost of treatment to go down and quality to remain the same.

And there is no shortage of primary care physicians.

Walter Russell Mead disagrees. He quotes Amelia Thomson-Deveaux’s piece in American Prospect who argues the solution to this shortage is to allow nurse practitioners to practice on their own without supervision of a doctor.

As you know my wife is a primary care physician (PCP) practicing in a rural underserved area. I’m a systems analyst who once ran a non-profit dedicated to fighting Industry’s efforts to flood the market with cheap H1-b and L-1 visa holders from abroad as they decried a “shortage of IT workers.” There was never a shortage of IT workers, just a shortage of those willing to work for the money IT companies wanted to pay.

Why is it that people become irrational when talking about professionals? If the price of something goes up, it means demand outstrips supply. This is a concept we innately understand. We know that the price will remain high until demand weakens, or the high price encourages producers to expand supply. This combination of reduced demand and increased supply inevitably leads to the price of that something declining. It could be natural gas, LCD televisions or salaries.

There is no shortage of primary care physicians. There is a shortage of PCPs willing to work long hours in disadvantaged areas for less money.  I’d love to see where that $189k average PCP salary quoted by Thomson-Deveaux comes from because it sure isn’t paid out here in the Styx. Salaries out here should be higher to encourage docs to come here, and they are somewhat higher than in big metropolitan areas with lots of amenities. But a shortage means salaries are rising, and they should be rising faster out here than elsewhere – but they aren’t. Why not? Because there is no shortage.

The shortage is a myth perpetuated by those who want to manipulate the market to their advantage. Hospitals want nurse practitioners because those in our area are paid $50k per year, roughly 2.5x less than the average PCP salary here, but they bill out at 75% of a PCP. NP associations are working to remove obstacles for allowing NPs to practice unsupervised. That’s fine – as long as physicians aren’t held accountable for their mistakes.

There is a reason a primary care physician goes through 4 years of medical school, followed by 3 years of residency and internship: exposure to a much broader range of conditions and treatment modalities than an NP receives. According to the American Academy of Family Physicians, a family physician receives 21,700 hours of training verses 5,300 for a nurse practitioner. This added training teaches doctors to differentiate between horses and zebras, to know when a condition is presented is either common or uncommon, and to do so without additional tests.

NPs order more tests than physicians, and since those tests are conducted often within their practice or hospital, these tests benefit the providers who pay them. But the cost of that testing is then passed to the insurance company and patient, so they do not benefit from the lower salaries paid to NPs, while the patients suffer the consequences of inexperienced care. Most of the time it won’t matter – remember, I go to an NP  as does my teenage son – but I’m healthy as is he. It would be a different matter if one of us were chronically sick.

KevinMD believes this argument between family physicians and nurse practitioners is a red herring. The problems with primary care go way beyond the threat posed to PCPs by nurse practitioners. He cites statistics showing specialists providing 41% of primary care office visits. He believes this is due to patients skipping the gate-keeping role of the PCP and going directly to the specialist because of the perception that they are more qualified. There is no reason for someone with a cough to see a pulmonologist unless he has been directed there by a primary care physician  first. This only makes sense because a patient does not incur the cost of seeing the specialist beyond the extra few dollars in the co-pay.

Look, everyone knows the medical system in the USA is a disaster. I’ve lived under socialized medicine (the Kid was even born under it), and I’m not instinctively opposed to it the way some are. But we need to be honest about the problems and avoid scapegoats; there is plenty of blame to go around, starting with the patients themselves. But that’s another essay…

What a Survey of 1,400 Sued Doctors Can Tell Us About Health Care Reform

Ever wonder how malpractice lawsuits turn out and what their effects on physicians are? Then click here for a slideshow showing the results of a study of 1,400 physicians who were sued for malpractice. There are several interesting points to take from this survey, including the fact that the majority of plaintiffs, 57%, received no monetary reward. But the one thing that stands out by far should be the advice these doctors give on slide 22:

  • Follow up even when you think you don’t have to.

  • Practice more defensive medicine.

  • Document more often, more thoroughly.

  • Get rid of rude, demanding, noncompliant patients.

Anyone who expects doctors, particularly primary care physicians (who also happen to be the most likely to be sued) to take on the responsibility of lowering health care costs by ordering fewer unnecessary tests and procedures (I’m looking at you Professor Mead) are simply delusional. Doctors do not have any incentive to stop ordering these procedures, quite the opposite. Whenever they rule out a particular test they must consider a bullet-proof and infallible reason why the test is not required in case they have to testify on the Stand to support their decision. In medicine, as in life, there are few situations that can attain such a level of infallibility. A runny nose can indicate a cold or allergy in a hundred thousand cases but it can also can result from a leak of cerebral-spinal fluid into the nasal cavity in rare instances. Should a doctor order the highly invasive – and expensive – test to rule out this leak in the snot-faced six year old kid sniffling in front of her? This is an extreme example of course, but the point stands: why should doctors risk being sued, a type of punishment judging by the emotional toll the survey shows,  for trying to contain costs?

It would seem to me that if you want to reduce unnecessary testing you would address the reasons why they are ordered in the first place, yet this has not been done. While some states have attempted to limit the maximum amount a  plaintiff can be awarded from a successful malpractice suit, none have made laws to make it harder to file them in the first place. The cynic may see the hand of self-interest here, with the lawyers who write the laws the ones also profiting from malpractice lawsuits. After all, scientifically dubious malpractice lawsuits almost elevated former Sen. John Edwards to the White House. But to ask doctors to refrain from ordering unnecessary tests and procedures without legal reform is like asking them to commit professional suicide.

The last item is particularly interesting. Legally doctors in private practice do not have to treat everyone who comes through the door. They can turn down patients for any reason. Once they establish a relationship with a patient they can also terminate that care at any time as long as they do not abandon them, usually by offering to care for them for a period of time when they can establish care with another provider. Many medical system reformers have talked zealously about basing payments to doctors on the success based measures, for example, on how well their diabetes patients’ blood sugar levels are controlled. Every practice has a coterie of diabetes patients who are non-compliant. They come in suffering from associated illnesses and for whatever reason refuse to control their blood sugar levels through exercise and diet, then expect the doctor to fix them. Such outcome based reimbursement schemes will only lead to doctors drafting letters telling these patients to find another provider. But even for doctors who aren’t reimbursed partly based on outcomes, it is in their interest to get rid of these patients who are more likely to complain and perhaps sue them.

Doctors have done a poor job at getting their point across in the health care debate in America. This is partly due to the nature of the profession, which tends to operate in solo or small groups and not think in broader terms the way other professions such as teachers and lawyers have done. It is also due to the corruption of the American Medical Association through years of operation in Washington DC reaching it’s pinnacle in the organization’s support of Obamacare in 2010 against the best interests of its own membership (but in line with the leftist ideology of the organization’s staff). But doctors had better learn quickly because if they don’t their profession will become extinct, and the healthcare of Americans will be even worse than it is today.

 

Primary Care Physicians: Between A Rock and a Hard Place

I’m the husband of a primary care physician and although I may be biased I’m not stupid. I’m intelligent enough to recognize my own biases and think around them. Besides like everyone else I’m human and consume health care as does my Wife. People seem to forget that every doctor is also a patient at one time or another, and while one might think the White Coat gets you special treatment from other doctors, it doesn’t. For example the Wife had to wait 3 months to see a GI specialist just like her patients do. She refers to this specialist all the time but that didn’t get her special treatment. I was actually annoyed and told her, “But you send this guy revenue. The least he can do is give you a kickback by fitting you into his schedule.” I come from a long line of Democrats, so corruption is in my genes. She said she had to wait like everyone else.

We know health care is a mess in the United States and recognize it’s a complex problem. So whenever someone comes up with a bright, simple solution, or as is often the case the sole blame for the mess, it’s always wrong. Are lawyers and malpractice suits the sole cause of our system’s dysfunction? No.  Inflated doctors salaries? Nope. Greedy health insurance companies? No. The system is so bad now that there is plenty of blame to go around for everyone – and I do mean everyone. The system is so corrupted that if you even touch it you become part of the problem. No one seems to get that.

The esteemed Walter Russell Mead has written extensively about the health care crisis in America but lately has been falling into a trap where he focuses his blame on doctors. Case in point: A recent survey of doctors conducted by the Journal of Medicine that found the vast majority of physicians see themselves as having some responsibility for holding down health costs, but saw themselves as a minor contributor compared to other groups.

“What physicians are trying to tell us is that they don’t see themselves as necessarily any more responsible for health care costs than all of those stakeholders,” said Dr. Jon Tilburt, an associate professor at the Mayo Clinic and the study’s lead author. “They see themselves as a contributor, not a main contributor,” he added.”

Mead takes issue with this statement. “(Doctors) seem (to) overlook the fact that the current system, based on fee-for-service payments, is stacked in favor of the doctors. Health care can probably never be a fully level playing field. But if patients could inform themselves about prices before going through with various tests and treatments, they could contribute to lowering costs by opting out of unnecessary or overly expensive ones.”

Evidently Mead has forgotten the problem caused by insurance. If a patient patient pays only the fraction of the total cost of a procedure through his deductible and co-payment, there is no incentive for him to forgo the procedure. For example, a Medicaid patient comes into the office with a sprained wrist and demands an MRI. The primary care physician may examine the wrist and if she suspects it’s broken, perhaps orders an X-ray. But the patient will not be happy unless she gets an MRI, a procedure whose costs are not borne by the patient  but by the state’s taxpayer (in the case of Medicaid) or other policyholders (if privately insured). Publicly funded insurance schemes like Medicaid and Medicare particularly are ripe for abuse. Patients demand all types of medicines and procedures because they bear so little of the cost. With $3 copays doctors visits for minor ailments such as colds or the ubiquitous “sinus infection” cannot be discouraged, contributing to overuse of the medical system. Dr. Wife has been trying to do her part to stop the overuse of antibiotics, but she has been challenged by patients who insist on getting one even if taking it can cause other problems, believing that they are not getting their money’s worth unless they go home with a pill.

Patients are exhibiting signs of viewing medicine as a service industry, like a restaurant where they can order and eat whatever they want but then aren’t responsible for the bill.  In the case of the MRI, a diagnostic test that wasn’t warranted by the complaint, the woman complained to the staff about the Wife’s refusal to order it, and threatened to badmouth the practice to her friends. Since the Wife is paid according to a system that is based on the number of patients she sees, such a complaint could impact her salary. Such patients aren’t rare, and are increasingly becoming the norm. After diagnosing a patient with a minor stomach ailment the patient told the staff, “$25 and I’m told to eat yogurt.” People aren’t interested in treating their ailments; they are interested in only treatments that are active, invasive and often expensive. Their expectations and concepts of health care are seriously out of whack.

Doctors have known for years that the happiest patients are the ones who get what they want, whether its antibiotics for colds or even pain pills. There’s a scene from an episode of the British comedy “Doc Martin”, a series about a socially inept and rude but brilliantly skilled general practitioner who takes up residence in a small Cornish seaside town, when he visits the local pharmacy and learns the doctor who replaced him prescribed inappropriate treatments to his patients. “You didn’t give me these pills,” one patient says chirps, obviously glad to have a different GP, “But she did.” Dr. Martin answers “You have asthma, and those beta-blockers will kill you.”

Doctors who practice “evidence based medicine” where they do not prescribe or treat unless the illness warrants it aren’t popular with patients who are emboldened by the Internet and commercials telling them to “talk to their doctor” about the latest pharmaceutical wonder drug that doesn’t outperform existing lower-cost generics. Will they be happy with the cheaper generic instead of the pill they see on TV? As long as they are shielded from the full cost of that pill through a low co-pay, it is unlikely.  So should the doctor prescribe the new pill and make the patient happy or the generic and risk an unhappy patient who may not come back or worse, bad mouth him to their friends? Is the customer, or patient, always right? Or should the doctor always give the patient what is in his or her best interest? Most doctors strike a balance between the extremes but as patients see doctors more like waiters in a restaurant and less as health care ally it will be harder for doctors to balance doing the right thing by the patient while making him or her happy, especially when doing so can lead to negative reviews on Yelp! or its medical practitioner equivalent.

Mead is also a fan of cheaper medicine provided by physician assistants and nurse practitioners. These are mid-levels with less training than physicians who in most states must be supervised by doctors. Doctors are not paid for this extra supervision yet are the ones held responsible for any mistakes done by the mid-levels under their supervision. Some health care systems are replacing doctors with these mid-levels, finding mid-levels are able to bill at roughly the same rate as doctors yet cost half as much. Traditionally primary care physicians were viewed as the gate-keepers to specialists and inpatient admissions where the real money was made by hospitals and health care systems, so primary care practices weren’t expected to be profitable. That has changed and primary care practices are expected to be profitable as well maintaining their traditional referral role. Mid-levels are key to that profitability.

But do patients really benefit from the lesser trained mid-level? In the vast majority of cases a mid-level can offer care as good care as a physician.  Since mid-levels are salaried they can spend more time with patients unlike physicians who are on productivity or paid by RVU. Where physicians excel is their additional experience and training for less common illnesses and disease processes. A doctor receives several extra years worth of training to differentiate the sounds of horses and zebras, as the old adage goes about recognizing the difference between common and uncommon disease processes. A nurse practitioner may recognize the sound of horse hoof-beats but does he recognize the sound a zebra’s hooves make? Do mid-levels order more tests than physicians to make up for their lack of training? That is a study I would like to see done, and if true would encourage health care systems to continue to replace physicians with them because extra testing generates even more revenue for hospitals. From a payer’s perspective the overall benefit of the mid-level may be lost through the additional testing costs.

As mid-levels are added to the rosters of practices and hospitals either doctors will have to be compensated for taking on the added oversight and risk (doctors can be sued for malpractice for mistakes made by the mid-level they are supervising), or the system and patient expectations will have to change to accommodate them.

There are very good reasons why medical students vote with their feet and avoid primary care specialties. GPs are earning less and seeing more patients to compete with cheaper nurse practitioners and physician assistants. They are becoming overwhelmed with paperwork, all of it unpaid: employees needing doctor’s notes for time off, requests for electric scooters, treatment justifications from insurance companies who refuse to cover a procedure or medicine, prescription refill requests, lab results and patient notes. Paperwork is free and like anything that is free it gets abused and grows; attempts at taming the paperwork beast like the panacea offered by electronic record system adoption simply lead to even more paperwork. Some systems have cost hospitals nearly a billion dollars EACH to implement, an investment that threatens some with bankruptcy and leads to even more pressure on staff to pack the patients in. Most primary care physicians just want to do what they’ve been trained to do, practice medicine and do what’s right by the patient. Instead they have become unwitting players in a vast economic and social experiment.

There are many intelligent people in the health care debate with many ideas and contrasting positions. The system is so screwed up there is plenty of blame to go around. We need more people like Walter Russell Mead to weigh in on the subject but only if they accept the truism, attributed to Einstein, Churchill and even HL Mencken that for every complex problem there is a simple solution, and it’s wrong.

UPDATE: See this essay for what a survey of 1,400 sued doctors tells us about health care reform.

Obamacare Rate Shock In California

Although I’ve been characterized as a rabid right winger on some topics, by my wife no less, when it comes to health care I’m pretty open minded and non-dogmatic. As recently as 2006 I had advocated for a single-payer system aka “socialized medicine” arguing that health care is similar a public good as fire and police protection. What changed my opinion was the government involvement in the economy in 2008-09 with the default nationalization of General Motors, AIG and a large swathe of the banking industry. While there may be good reason for government involvement in the health care industry, such involvement cannot be done in an environment whereby the government is expanding its reach in other areas. That’s why I have switched my viewpoint towards a more libertarian one whereby the federal government’s power is curtailed throughout society, and that includes in the health care industry.

But I am open to what works. Our son was born under socialized medicine in Japan, and I am familiar with its benefits and drawbacks first-hand. I remain at least in principle more accommodating to the idea than most libertarians and conservatives, as long as it works. We live in a medical system that is the most expensive in the world yet provides middling care, one that provides perverse incentives to participants that work against cost containment and better quality of care, and one with bureaucracies – that’s plural – which go beyond the Byzantine to the Kafkaesque. It’s a system that is loathed by anyone with “skin in the game,” from care givers to care receivers. It’s only the bureaucrats who delight in it and those who benefit monetarily and politically from the current regime. For most the system is collapsing, but slowly and painfully.

Obamacare makes the situation worse, which is why the conspiracy minded have viewed it as a  morphine overdose  that destroys the system and allows its replacement by socialized medicine. Honestly at this point, I’m not sure this would be a bad thing given what I’ve been seeing with Obamacare.

Last week Obamacare supporters were trumpeting cost containment. Evidently they grabbed their tin horns too quickly. It turns out that Californians, particularly the young and healthy that will be forced by law to buy insurance if its not provided by their employers, will face rate hikes as high as 146%. A catastrophic plan for a healthy 25 year old today costs roughly $92/month. After January 1, 2014 the same plan will double to $184/month.  While an extra $92 isn’t a lot to me, I remember the time particularly when I was starting my career with a young family in my late 20’s when it was. That was a week’s worth of groceries back then. Perhaps today’s 20-somethings are wealthier than I was when I was their age, but given the job climate I doubt it.

Perhaps today’s 20-somethings are much more idealistic than I was back in the day and believe Obamacare will work for them, but it seems to me that it is the continued war on the young as the rates are meant to keep costs down for older and wealthier rate payers. When I was their age I went without health insurance; that is not an option for them today.

 

 

Electronic Health Records: The $6 Billion Cure for Bad Penmanship

David Gerstman has an interesting piece up at Legal Insurrection about the IT panacea for Obamacare. He notes an op-ed by Thomas Friedman that received an endorsement by Health and Human Service Secretary Kathleen Sebelius that paints a glowing picture IT investments made under the act will have at providing better and cheaper medical care. Gerstman then follows up Friedman’s breathless piece with another that asks a simple question, if the impact of IT on health care is so wonderful Why Is Your Doctor Typing? Forbes’s Steve Denning writes about his experience at his doctor’s office where he watches his doctor typing on a computer during his exam.

Surely, I said, computerized medical records generate benefits. They are easily retrievable. They can be transferred from one practice to another and accessible to the many different service providers—hospitals, laboratories, specialists, radiology and so on—that might be involved in any one patient.

“In theory, perhaps,” he replied. “But in practice, it’s a horrible and costly bureaucracy that is being imposed on doctors. I spend less time with patients, and more time filling out multiple boxes on forms that don’t fit the way I work. Often I am filling out the same information over and over again. A lot of it is checking boxes, rather than understanding what this patient really needs.”

What about retrieving information? Isn’t that easier?

“Again, in theory, retrieval should be easy and quick,” he said, “But you can’t flip through these records the way you do with a paper file and easily find what you want.

I mentioned the articles to Dr. Wife and she said, “The only thing EHRs have done is make it easier to read a doctor’s handwriting.” Since the US is projected to spend $6 billion on EHRs by 2015, that’s a lot of money spent trying to make up for the failure of primary education to teach penmanship.

Being married to a doctor and an IT professional specializing in “big data” in the financial industry, I have watched the Wife’s experience with various EHRs with levels of amazement and dismay. It’s as if the lessons learned by the financial industry in the 1990s, such as poorly designed software that is incompatible with other software will cost more money to replace than it did to implement in the first place,  have been completely lost by the lemming-like rush towards electronic health record (EHR, also known as electronic medical records EMR) systems.

The basic problem is that EHRs are not designed to suit the ways doctors practice. This is complicated by the fact that the way doctors practice varies between specialties, an orthopedic surgeon doesn’t practice medicine the way a primary care physician does, and by the additional complication that how doctors practice varies within the same specialty, often the same office. Even the same doctor will treat patients differently depending on what he feels works best for each patient. Yet these variances between specialties are only rudimentarily addressed within EHRs, and handle variance within specialties one of two ways, providing either a set workflow that dictates to the doctor the way she should practice, or one that provides so much flexibility that she is lost trying to get basic tasks.

The key decision in any software development is to address who the software is for and the key needs it is meant to address. Judging by the current EHR systems available none were designed for doctors. Instead they were designed for the employers of doctors such as large health systems, insurance companies and the federal government who are interested in aggregated data in order to answer questions such as “How many patients are uncontrolled diabetics?” or “How much is being spent on obesity-related illness?” These are questions which might be of interest to a doctor in general, but they are not what he’s thinking about when he’s facing his patient, say a morbidly obese, uncontrolled diabetic medicaid patient. Instead he is interested only in that particular patient’s problems. Is her agoraphobia contributing to her obesity, or is it the result of it? How can he wean her off HFCS soda and begin to move and diet when getting her into his office requires so much effort? Most of all, how can he encourage her to take an active role in her own medical care and help him treat her?

Current EHR systems will be very good at picking up his patient as an uncontrolled diabetic, and the data can be used by medicaid to threaten to cut his reimbursement for her treatment as is under discussion to control health care costs. But his patient’s needs and his attempts to deal with them will be lost in the sea of data the EHR generates because current systems are modeled on existing software developed in the financial industry which was the first to successfully integrate the technology with its existing business. Even that integration wasn’t painless, occurring over decades after many fits and starts, adoption of dead-end technologies and gargantuan piles of wasted money.

A key difference between the medical and financial industries is in the nature of the data itself. Financial data is transactional, meaning that money is traded for a good. Transactional systems are repetitive. For example, a store will sell a loaf of bread for $2.59 to every person who comes into the door and asks for it, but a doctor seeing a sore throat today knows 99% of the time her patient likely only has a viral condition, and that remaining 1% can present with a sore throat but have much more serious, perhaps even fatal, underlying conditions. Doctors are taught in medical schools to “think horses when you hear hoof beats, not zebras,” but the problem is that in reality zebras are not limited to the Serengeti Plains: they are mixed in with the horse. So while a doctor should think horses when he sees an 8 year old with a high fever and sore throat, he always must rule out he’s hearing a zebra. This is why when you see your doctor complaining of head and neck pain she makes you touch your chin to your chest: doing so rules out meningitis, a rare but very serious infection, a zebra running with horses.

The equivalent of this repetition and poor data is handling would be going to the store and buying a loaf of bread with your debit card. This bread would be tailored to your specific needs on site. Prefer no crusts? The crusts would be removed. Like thicker slices? The store would slice the bread to your exact specifications. The cash register would report the sale to your bank via fax. A person at the bank would read the fax transaction and key it into the bank’s debit card system which would then debit your account for the payment to the store. Since the store’s financial records are kept at another bank, your bank would then email the credit to the store’s systems, and someone at that bank would open the attachment, read it and add the amount to the store’s bank account. Such a transactional system would be costly to run, inefficient with the same task performed multiple times, and time consuming. A similar system already exists today with check processing, but that is limited to a handful of data elements such as the bank, amount paid and the account number of the person writing the check, and the name, the account number and bank of the payee depositing the check. That’s six pieces of data that costs banks billions to process every year. Banks hate checks which is why they have backed the current system of debit cards working to replace them.

From a physician’s perspective, what should an electronic medical records system do? It should provide her with the treatment plan from the previous encounter. Most systems hide this information from a doctor, making her search for the notes from the last visit. The system should provide lab work and test results directly from the laboratory providing the test results. Currently labs do not have set data standards, and electronic medical records systems do not have the capability to receive these records directly. Instead the records are either faxed or sent via email where they are “attached” to a patient record. This is akin to attaching a picture to an email, meaning that the contents of the picture remain completely unreadable by the system. The email system doesn’t know if the picture is a snap from your trip to the beach, whether its of a sunset or a personal portrait. Data in a picture or as commonly sent PDF format cannot be read and translated into a data record directly. Instead either the doctor, mid-level or medical tech must look at the results in the attachment and physically key them into the system.

Dr. Wife tells me her current system, one of the top used in the US, can only report weight and BMI results from last visit. Lab values and other pertinent information is hidden in attachments or non-indexed patient notes. Prior to the EHR she would open a patient’s chart and look at the lab result for a patient’s hemoglobin a1c result. Since the labs were in a separate section of the paper chart she could open it up then flip backwards through the stack to immediately find the results of previous tests. Similarly she could open the chart and see the notes from the patient’s last visit to see what recommendations she had then, or flip back further to see how the patient’s condition had changed with time. To do this in her current EHR is much more difficult than flipping through pieces of paper. Instead she has to search for and find lab result attachment which may not only be located in the lab result folder, but which may have been filed mistakenly by a medical tech into the fax folder because the lab result may have arrived via fax, and was scanned and added as a patient communication. Since the information is not indexed, there is no way for the physician to type in a search box “hemoglobin a1c” and have all documents that contain the phrase pop up. Instead she has to open each attachment to determine what it is and whether it’s the lab result she is looking for. Since EHRs are rarely known as fast and responsive, opening each attachment takes 5-15 seconds depending on size and EHR file complexity, making a search which would have taken three or four seconds flipping through a paper charts several minutes to complete. When a doctor is allotted 15 minutes per patient, anything that makes a doctor’s job harder for no benefit to him or his patient whatsoever will not be appreciated. Yet hospital administrators and software companies wonder why medical practitioners loathe electronic medical records systems?

Here’s what Dr. Wife described as her dream medical records system. First, the entire encounter would be recorded to protect her from future litigation or in case anyone needed to review or document anything from the patient encounter later. Next she would be able to choose from a set of predefined dropdowns or checkboxes the treatment plan for the patient. Lab values would be available on the right side of the screen, and she would be able to click on any one of them to see details or trends. These would be automatically populated by the labs themselves without any input from the doctor or practice staff, and could be signed off by the doctor simply by clicking the value. It would be a simple app that would run on an iPad. Suri would be used to transcribe a brief note after the visit, which would allow Dr. Wife to spend more time with her patients and doing what she is paid to do, diagnose illnesses and develop treatment programs, instead of typing, filing and other busy work skills that is so devalued in today’s workplace that much of it is offshored.

Another alternative would be to hire scribes, medical technicians who are trained to enter data into the EHRs. Many optometrists who must use their hands and eyes in concert use scribes already to notate lens dimensions and other key patient facts, so their presence in the exam room wouldn’t be completely new. Such positions would pay $12-15/hour with benefits, about what medical technicians commonly earn today, and would offer advancement thanks to the coding skills and familiarity with the software developed with experience. Of course adding a scribe for each physician would increase personnel costs, but ask yourself, does it make sense to pay someone $75 an hour to do a job that can be done by someone making $15 an hour? And from the patient’s perspective, would they rather pay an extra $4 a visit to have the undivided attention of their doctor for 15 minutes instead of watching him divide his attention between them and his computer?

 

Oregon Study: Medicaid ‘Had No Significant Effect’ On Health Outcomes vs. Being Uninsured

This is surprising, even to me. Maybe it’s because I still have a left0ver Socialist streak in me from my liberal days when it comes to health care.

So, what did the Oregon study authors find? They found no statistically significant difference in elevated blood pressure (1.33 percent less incidence in Medicaid vs. control, p=0.65); high cholesterol (2.43 percent less than control, p=0.37); high HbA1c (0.93 percent less, p=0.61); or Framingham risk score (0.21 percent less than control, p=0.76). According to the p values, the blood pressure result has a 65 percent chance, the cholesterol result a 37 percent chance, the HbA1c result a 61 percent chance, and the Framingham score a 76 percent chance of being statistical noise. Again, statistical significance requires a p value of less than 0.05.

I think it’s critical for those of us who tend to be political ideologues to try to act based on the evidence and not on our beliefs whenever possible, to maintain a balance between completely closed minds and those that are so open our brains fall out. It isn’t easy, and we’re only human, but we need to try.

NJ Teacher Not Angelina Jolie Is The Brave One

Update 5/22/2013: As Julianne points out in the comments, Debbie Gentile-Abbood, Dr. Wife and I are all wrong when it comes to insurance coverage. The Women’s Health and Cancer Rights Act of 1998 mandates insurance coverage for the preventative removal of the breasts as well as their reconstruction. I have confirmed this here and here. I still haven’t been able to confirm whether Medicaid/Medicare covers these procedures, but with the law on the books I’d be surprised if they didn’t. Given the daily battles Dr. Wife faces with the insurance companies, and my cynicism towards anything that stinks of corporate or bureaucrat involvement in healthcare  we both assumed such coverage was not available to women. In this case, I’m very happy to be wrong. I know too many women who have been cut down early by the disease, and if there’s any chance of preventing it I’m all for it.
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A New Jersey teacher has taken issue with Angelina Jolie’s decision to remove her breasts before contracting breast cancer. Evidently Jolie tested positive for the BRCA gene mutation that makes one likely to develop breast cancer and had mastectomies before the cancer developed. Debbie Gentile-Abbood says “It upsets me… That’s good for her; she’s got the best health care and she’s got money. She doesn’t have to worry about taking off of work.”

I discussed Jolie’s decision with Dr. Wife who said it was a smart idea – if you had the money. She pointed out that a positive BRCA mutation test would likely not convince an insurance company to cover the cost of the  radical mastectomies without evidence of cancer beforehand, and they would definitely not cover the reconstructive surgery Jolie underwent at the Pink Lotus Breast Center, considering it purely cosmetic. While many have commended Jolie for her courage to face a positive test and then act upon it, her actions seem less commendable for those of us who struggle getting tests pre-authorized, or writing letters to insurance companies on behalf of patients whose life-saving medicines aren’t covered in the company’s formulary. Gentile-Abbood won’t even take the test because doing so would put her family into a predicament caused by a positive result. Get the life-saving surgery and ruin the family financially, or play the odds and hope she doesn’t develop cancer. It is an appalling choice, but one that is faced every day by hundreds of women nearly all of whom lack Jolie’s means.

I don’t begrudge Jolie for her decision, but I don’t laud her either. Instead I would hope that cancer detection and treatments improve so that all women regardless of their economic background could live life without fear. Now that would be truly worth noting.

British Youth Paying Price Of Wakefield Vaccine Scare

Measles cases have soared in the UK, making it second in Europe behind only Romania in the number of cases. Last year the UK had 2,000 cases and so far this year it has had 1,200, putting it on track for another record breaking year. Of those sickened, about 20 have been hospitalized with serious complications including pneumonia and meningitis. In 1998 a paper published by Andrew Wakefield and others suggested there was a link between the measles vaccine and autism. As a result, measles vaccination levels plummeted in the UK, from 90% of children down to 54%. The measles epidemic now hitting the UK is a direct consequence of this failure.

I had a child when the scare hit, and I sympathize to a degree with the parents who thought they were doing right by their children by avoiding the vaccine. The parental instinct is to protect your child, and exposing him or her to dangerous agents intentionally, trusting faceless authorities to have done their due diligence and provide a safe vaccine isn’t easy, especially while no vaccine has zero side effects and every instance of those who did experience them gets press while nothing is written about those vaccinated and exposed to measles who were protected from the disease. Wakefield’s paper and the press he received from it fed into a natural suspicion people have for authority. Skipping the vaccine seemed sensible, especially since doing so had no immediate effect as herd immunity offered some protection for the unvaccinated.

Around my hometown of St. Louis there are several high schools and colleges run by Christian Scientists, a religious sect that believes in the power of prayer instead of the science of Medicine. While this may seem quaint or irrational to those of us in the 21st century,  at the time Mary Baker Eddy founded the group in the late 19th century Germ Theory had yet to become orthodoxy in Medicine and it wasn’t until the 1920’s that going to a doctor offered any benefit as opposed to staying at home. In fact hospitals at the time were good places to get sicker. Students at these schools are not vaccinated, and measles outbreaks are common and deaths from the disease are not unknown. Either God had an ax to grind with the Christian Scientists or measles vaccination was a pretty good idea. Perhaps the Brits would have benefited from the presence of this sect on their territory to see what happens when children aren’t vaccinated, but it’s doubtful. The specter of Autism is pretty powerful, especially when authorities have been wrong so often in the past.

But in this case they weren’t wrong; Dr. Wakefield was, and kids are paying the price for his mistake and their parents’ bad decisions.