Sunday, March 25, 2018

Hepatitis C - Silent Killer or Innocent Bystander?


For a few decades, I did not treat patients with Hepatitis C (HCV) infection, despite aggressive marketing by the pharmaceutical companies and cheerleading by academics.  I was an iconoclast as most of my gastroenterology colleagues were HCV treatment enthusiasts. They argued that if the virus could be eradicated, that there was evidence that these patients could avoid some horrendous HCV complications, such as cirrhosis, liver failure and cancer of the liver.

I’m certainly against cancer and liver destruction, but I have thought that the evidence that HCV patients who vanquished the virus would be saved from these fates was somewhat murky.  Treatment proponents would argue that the medical evidence for thes claims is solid, but I wonder to what extent their favorable bias toward treatment influenced their judgment.  We physicians know that a doctor or a drug company will seize on  particularly studies that supports their views.  Studies that challenge their beliefs may be criticized for 'study design flaws' and other defects.  I am generalizing here, but we all know how we tend to pursue confirmation bias, seeking out sources and opinions that support what we already think. This is not quite a pursuit of the truth.

Additionally, there is a well-known phenomenon called publication bias when favorable treatment results are more likely to be published than negative treatment results.  In other words, a study that shows a drug is effective is more likely to be published than a study that shows a failed result. This means that physicians like me who read medical journals may receive an over optimistic view of drugs because of this cherry picking.

In my 30 years of practice, I have never had any of my untreated HCV patients develop any measurable deterioration of their liver status.   In fact, nearly all of them were asymptomatic and felt
entirely well. 



Illustration of the liver created 100 years ago.


Consider these facts:
  • Most patients with HCV are not ill.
  • HCV is not easily transmissible to other individuals.  It is spread via contaminated blood, such as with sharing IV needles.
  • The majority of HCV patients will never develop liver cancer or liver failure.
  • The majority oF HCV patient have had the infection for decades and remain well.
  • Until recently, HCV medications had very limited efficacy and had numerous complications.
Like all of you, I harbor my own biases.  I am a very conservative practitioner, as readers know well.  I am never among the first to jump aboard the New Treatment Train.

Until groundbreaking HCV treatment emerged in recent years, I had been unable to convince myself, let alone my patients, that they should accept a complex medical regimen that included injections, that didn’t work well and would make them feel sick.   

While my academic colleagues would have accused me of nihilism, not a single HCV patient in my practice has seemingly progressed.  (Of course, my academic friends would claim that many of my patients may have 'silently progressed' even though they still feel well.)   There is always a medical argument a physician can wield to justify his or her recommendation or belief.

I'm not claiming that my view here is the only legitimate one.  I do suggest that it deserves to be heard.

In an upcoming post, I will share why I have jumped, with some reluctance, into the HCV treatment arena. 

Sunday, March 18, 2018

Thousands of High School Students Protest Gun Violence - Should We Give Them a Free Pass?


This past week high school students across the country walked out of school for 17 minutes to show solidarity with the 17 fallen Florida students and their families. There is not a human being among us who disagrees with their mission, except for a few deranged and cowardly murderers.  These kids are crying out for more restrictive gun laws.

Although I will offer a controversial view below on the walkout, let me say with clarity and sincerity that I am proud of these kids.  Since the horror in Florida, I watched them speak to us with passion, poise and eloquence.  While many of us may not agree on the best path forward, we can all agree that we have great kids in this country.

These kids are right and have a right to demand to be safe. Schools have always been an oasis for our children, places where they are to be nurtured, educated and protected.  I know that there are many teachers who would serve as a shield for their students in any situation, as they have so nobly demonstrated. 


Safe in School

Some public and private schools have  authorized the demonstrations, assuring the kids that no disciplinary action against them would be taken.  Moreover, Yale, MIT, Dartmouth, UCLA, Harvard and other colleges have announced that no high school protester’s college application would be adversely affected by their participation. 

Many high schools have differing views on the propriety of the protest.  Here’s my concern.  If colleges and high schools are taking a permissive stance on this protest, because they support the cause, have they opened a door that will allow future students to walk through?

My personal view is that students should not be permitted to leave the school during school hours without permission in accordance with established school policy.   Students, like the rest of us, are free to protest and express themselves when school is not in session.  Why must the demonstrations occur during the school day?  If school policy is violated, then violators should be prepared for the consequences, which should already have been codified and known by all those concerned.  Many students opted to protest and were prepared to be held to account.

What if the students' message was not for more gun control?  Would we expect equal treatment?

How would high school administrators, school boards, teachers, students, parents and colleges react to the following protest themes?
  • Students walk out demanding that teachers be armed.
  • Students walk out demanding that an NRA spokesman be permitted to address the student body during assembly.
  • Students walk out protesting against teachers who have been advocating for stricter gun control during class time.
  • Students walk out to express their pro-life view and demand abstinence education.
  • Students walk out demanding an end to standardized testing alleging they are racially biased.
  • Students walk out demanding changes in the curriculum reflecting a more multicultural approach.
  • Students walk out protesting the FBI and law enforcement who missed so many opportunities in Florida to intervene and prevent a horror. 
I don’t think we should have an elastic policy that stretches when we support a cause but contracts when we oppose it.  True fairness is when we have the same tolerance regardless of the content.  Free speech, for example, doesn’t mean free speech only when we agree with it. 

How do you think the Academy, high school leadership and the press would have reacted if high schoolers poured out during the school day carrying signs and shouting in unison, Build That Wall!  Do you think that colleges and universities would be racing for the microphones to give these kids encouragment and a free pass?


Sunday, March 11, 2018

Insurance Company Denial of Emergency Care - Part 2

Last week, I opined about a decision by Anthem to deny paying for Emergency Room (ER) care that it deemed to be non-emergent.  My point was that insurance companies should not be obligated to pay for routine, non-emergent care, recognizing that we need a fair and reasonable method to define a medical emergency.   In my view, payment should not be denied to a patient who reasonably believes he needs ER care, even if the symptoms are (hopefully) found to be innocent after a medical evaluation.

For example, if a patient develops chest pain at 10 o’clock p.m., and is worried about an acute cardiac issue, he should call 911.  If the ER determines that chest pain is simple heartburn, it would not be reasonable for Anthem to deny payment for this ‘non-emergent’ condition.   We’re all a little smarter after the fact once we know the outcome.

Some medical complaints, however, are never medical emergencies.  If you want ER care for a runny nose, a cough or a sore knee, and you proceed to the ER, explain why you think your insurance company should pay for this. 



Coronaviruses Cause the Common Cold 
True Emergency?

Emergency Rooms must accept every patient who seeks care there by law.  A patient cannot be turned away regardless of how trivial the medical issue is.

One approach would be for every ER to have two tiers of service – Tier 1 for true emergencies and Tier 2 for all the rest.  Some ERs have such a system, but I think this should become the standard of care.  The Tier 2 facility could be equipped to provide efficient, low cost care for appropriate medical issues.  ER personnel are already highly skilled in triaging patients and could direct incoming patients toward the correct Tier. 

Here are the benefits.
  • Patients with minor complaints would be seen without waiting for hours while ER personnel attended to truly ill individuals.
  • Tier 2 facilities would be designed to provide lower cost care.
  • Tier 1 could operate more smoothly since patients with routine medical issues would be siphoned off.
  • There would likely be an overall cost savings to the health care system.
Ohio legislators are already threatening legislation to attack Anthem’s ER denial of care policy.  As a gastroenterologist, this craven political grandstanding nauseates me.  Politicians, who spend a career spending other people’s money irresponsibly, aim to lecture a private company who wants to exercise reasonable cost restraints.  Give me a break.

Would Anthem and her sister companies cover Tier 2 care?  Could they assert that since the patient was determined in the ER to have a non-emergent condition that the care should be on the patient’s dime?  I’m not answering this question, I’m merely posing it.  I do think that the present system when a patient expects or is entitled to any ER care being covered needs to be reformed.

When insurance companies pay millions of dollars for unnecessary care, guess who’s really paying for it?

Sunday, March 4, 2018

Insurance Company Denial of Emergency Care


We live in an era of demonization.  Political adversaries are not opponents, they are villains.  Commentary that contrasts with our views is labeled ‘fake news’.   Presumption of innocence?  R.I.P.  Civil discourse has become a quaint memory.  Why would one debate respectfully when today’s tactic is to talk over and demean your adversary? 

On the morning that I prepared this post, I read an article reporting that one of Ohio’s largest insurance companies, Anthem, is denying payment for non-emergency care provided at emergency rooms  (ERs).   In my view, this article was slanted, unfairly tilting away from the insurance company, an easy target to attack.   I think that a typical reader would conclude that the company was greedily trying to claw money away from sick customers.  An anecdote was offered describing a denial of payment for emergency care for abdominal pain that did seem improper, although there were no medical facts provided.

I felt that the journalist did not adequately present the insurance company’s motive and point of view.
Of course, I expect true emergency care to be covered.  And, I do not expect ordinary folks to reliably distinguish between a medical nuisance and an emergency.  Patients are not doctors. But, there should be some standard in place.  There should be a version of a reasonable person’s belief that an emergency is present. 


Insurance Companies are Easy Targets


Consider the following points.

  • Insurance companies are businesses and must be run responsibly, just like your business and my medical practice.  You may believe you are entitled to every imaginable medical benefit, but someone has to pay for it.
  • Many emergency room visits are clearly for non-emergent reasons.  This wastes health care dollars, leads to medical overutilization and clogs up emergency departments.
  • Insurance companies should object to paying for expensive ER care that could have been rendered elsewhere. 
  • A patient who presents to an ER with complaints such as a cough, a headache or stomach distress will likely undergo significantly more testing than would typically occur in a primary care physician’s office without an improved outcome. 
  • Do we expect an insurance company to pay for an ER visit for a splinter?
  • Do we expect an insurance company to pay for an ER visit to evaluate a child’s cold?
  • If a patient is offered an appointment at his physician at an inconvenient time, and he opts instead to proceed to the ER, should the insurance company be expected to pony up?
  • What would our position on this issue be if we were insurance company administrators?
I read (but cannot verify) that $40 billion are spent each year in this country on unnecessary ER care. Do you think there might be a better use for these funds?

It’s easy to vilify corporate America.  The pharmaceutical and insurance industries have large targets on their backs.  But, just because we can hit the target easily, doesn’t mean that our aim is true.


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