Lots of Health Policy Still in Play!

I had the good fortune to be able to travel abroad and at home for most of the fall.  I confess I still have a foot-high pile of newspapers to look through.  It is immediately clear that a number of things have happened related to items I have been commenting upon in these pages.  Among these items:

  • The state legislature, not surprisingly, followed through with its support for a new concept of optometry by approving new regulations.
  •  The Veterans Administration listened to the overwhelming resistance by veterans and others to placing a new Veterans Hospital in downtown Louisville but also, reasonably in my opinion, felt that remaining on the existing Zorn Avenue site was impractical.   This decision has not disarmed the proponents of another downtown hospital who will no doubt continue to bring political pressure to bear against the remaining suburban locations.
  •  Drug companies continue to behave like tobacco companies.
  •  Everyone agrees our healthcare system is in big trouble but almost no one agrees with what to do about it.   My prediction: it will get worse before it gets better.)
  •  For sheer volume of public concern however, nothing comes close to the resistance against a vaguely revealed merger or acquisition of University of Louisville Hospital by the religious organization, Catholic Healthcare Initiatives.  In some as yet undisclosed way, University of Louisville Hospital will combine with Jewish Hospital & St. Mary’s Healthcare.

I will try to comment on these and other issues.  Please join me.

Peter Hasselbacher

New Public Health Director for Louisville: Follow-up (or lack thereof).

On June 24, I sent a copy of the June 18  Blog entry below to Louisville’s Mayor Greg Fischer, and to Mr. William Altman, Chairman of Louisville’s Department of Public Health. I repeated my request to reconsider the employment structure of Dr. LaQuandra S. Nesbitt, the new Director of Public Health and Wellness. (Cover letter here.)  The letter contains the mission statements of the Louisville Board of Health emphasizing its independence.

I have not had a response, nor am I aware of any new information.  What do you know, and what do you think?  Add your two bits.

[Addendum Dec 14, 2011:  When I wrote the above letter to the Board of Health and the Mayor’s office, I somehow thought that the Louisville Metro Department of Public Health and Wellness  reported to the Louisville Board of Health– imagine that!   While the details of accountability still elude me, it seems that the LMPHW Department is a branch of Louisville Government, reports to the Mayor, and is only “advised by the Board of Health. The Board of Health is “independent,” and is appointed by the Mayor.  Its Chairman was on the search committee for the new Director, Dr. Nesbitt.  If anyone can straighten me out about this, please do so.  The details of the organizational chart do not affect the substance of my letter nor my concerns.  I still think her dual employment it is a bad idea. The absence of her counsel in the current debate over the acquisition of University Hospital is appropriate given her conflict of interest, but missed.

Peter Hasselbacher, MD

Apologies!

I am in the process of upgrading the site and its software.  Please excuse the dust and any intermittent lack of access.

As of August 6 I am still working on this. I had to repair all the links to images and documents.   I also hope to have a less generic header soon!  Managing a website has been a continual learning experience for me.  The new format and theme should allow us greater flexibility and security.

Peter Hasselbacher

New Director for Public Health in Louisville:

Who should she serve?

Compared to the tumultuous search for a new school system superintendent, the announcement of the appointment of a new Director of the Louisville Metro Department of Public Health and Wellness seemed to come out of nowhere. Since the departure of the previous Director, Dr. Adewale Troutman, the announcement in the Courier Journal on June 14 was the first indication of progress of which I was aware. Did I miss something– like a public hearing? Was there any public input into the process? Perhaps the search became invisible in the shadow of the school superintendent search. Yet both searches are equally critical for our future. As our failing private health system continues to eject middle income Americans (employed or otherwise), a new form of systemic health disparity is growing rapidly. The widening income gap in America is causing a pernicious denial of access to affordable health care within a system that is tailored for the well-employed and the wealthy. In a health system where even the “haves have not,” I predict that our public health departments will become increasingly important. They will likely be incubators for whatever our future system of health care looks like. As a society, we are only as healthy as the sickest among us.

Dr. LaQuandra S. Nesbitt, MD, our new Director, looks like a great catch. She has impeccable credentials of training and experience. She most recently held a senior public health role in the cauldron of Washington, DC. The challenges she faced there provide relevant experience for our needs. I wish her well. I hope I can help.

As far as I know, Dr. Nesbitt’s successful candidacy was without controversy. Therefore, let me introduce some! One sentence in the C-Js reporting positively gave me the shivers. It was reported that half her salary of $180,000 and half her benefits will be paid by the University of Louisville. I think this is a bad idea: a very bad idea. No doubt the fiscally-strained city was glad to have someone else pick up part of the tab, but I think this is bad public policy. This is not simply the customary gratis faculty appointment that honors Dr. Nesbitt, allows her to teach, and otherwise participate in the academic life of the University. Hundreds of other physicians in Louisville have such privileges. The current arrangement makes her an employee of the University of Louisville. By placing her in a position of having two very different employers, she will start on day one with conflicts of interest. Continue reading “New Director for Public Health in Louisville:”

An Apology, and a Renewed Invitation.

I apologize for the hiatus in my entries which was probably a predictable consequence of my New Year’s resolution. I have a new and unbounded respect for journalists and commentators who turn out material regularly, week after week. I got sidetracked by an illness and death in my family, but so do the real journalists I admire.

It probably doesn’t make any difference anyway, because I may be the only one who reads these pages! I have no way of knowing how many people have visited the KHBI Website or Blog. To make it easier for you to contribute, I have relaxed the requirement to register in order to add comments. The anti-spam capabilities of WordPress (the software I use for this initiative) are pretty good. If things get out of hand, I can always reinstate registration. I only ask for civility. Inappropriate comments will be deleted.

Peter Hasselbacher, MD
June 13, 2011

OPTROT: A big win for Optometrists and Legislators Alike!

A few weeks after their stunning legislative maneuver that fundamentally changes the practice of optometry in Kentucky, the Kentucky Optometric Association hosted a reception to thank our legislators. Such receptions are quite common and provide legislators food, drink, and company for what otherwise might be a lonely evening in Frankfort. They are fun. They also provide further opportunities for networking (a.k.a. lobbying). According to Frankfort’s rules, as long as all legislators are invited (even the 17 who voted against) no ethical problem exists. We doctors (and presumably optometrists) have long allowed drug companies and medical device manufacturers to shower us with meals, travel, and gifts. How can we object? If everybody does it, that makes it OK– yes? The optometrists pulled off a wildly successful legislative campaign and they deserve to celebrate. I do not hold it against them.

Not to be overlooked is the fact that our legislators had a big victory to celebrate as well. The optometrists won big, but our legislators won even bigger. The bar for the amount of money it will now take to reliably pass a piece of legislation has been raised. There is an old political joke, that the top three priorities of elected officials are all to get reelected. It would be a funnier joke if there was not so much truth in it. I was immersed in federal and state legislative processes for more than 15 years. I have spoken with or interviewed hundreds of lobbyists. I have hired lobbyists. I was one once! Money counts, and that is why the job of getting reelected in Kentucky has just gotten a little easier. Yes, the optometrists did other things right, like sustained coordinated personal contacts with their representatives. However, in electoral politics, money trumps most everything, including good policy. A new blueprint has been drafted. It will be interesting to watch the cash flows next legislative season.

Peter Hasselbacher, MD

OPTROT? Business as usual? Or both?

Passage of Kentucky’s Optometry Bill into Law.

Gov. Beshear signed Kentucky’s optometry practice expansion bill into law yesterday. Thus ends the remarkable passage of Senate Bill 110 that in one fell swoop transforms the practice of optometry in Kentucky from correcting vision with lenses, to the practice of treating eye disease with medicine and surgery.

Much can be said about many aspects of this episode.  For example, the erosion of the monopoly of MDs to practice medicine. However the special privilege of caring for the sick has been drifting away from us physicians for some time. Some of these sharings are not all bad: you don’t have to be a brain surgeon to manage an immunization schedule or treat a sore throat. I predict that we physicians will continue to share the responsibility of treating illness and that the pace of the sharing will increase dramatically with the inclusion of the concepts of wellness and disease prevention into our financial structure of treating illness. (There is no limit to the demand for wellness, disease prevention, or screening by the public; nor limit to the willingness of healthcare workers of all levels of competence to provide.) This optometry bill was not the only scope of practice legislation before this General Assembly. Why have not the others passed as well? Is this optometry bill a crack in the dam? Did we physicians do something to bring this on ourselves?

Changes in scope of practice are not occurring in isolation from other major shifts in the landscape of healthcare delivery. I am informed that the considerable majority of primary care physicians in Louisville are now direct employees of hospitals. A large and increasing fraction of specialists are also hospital employees. I predict this trend will do more to change the practice of medicine than the sharing of professional responsibilities with optometrists, or nurses for that matter. What is happening is that systems of medical care are largely replacing Mom and Doc operations. That’s probably for the better. Even in a given specialty, there is too much to know, too much to do, and too much efficiency required. What is most important is that the primary obligation of the physician to their patient retains its primacy. That is what we are most at risk to losing. That may not be for the good. Continue reading “OPTROT? Business as usual? Or both?”

The Best Law Money Can Buy?

Or good public policy?  How can we know?

In follow-up to an earlier posting, the wheels were greased sufficiently well that Senate Bill 110,  an Act relating to Optometry, raced through the Senate committee structure and floor in less than 4 days. In less than 4 more work days it passed through the committee and floor of the House. moving through both chambers in spectacular time and with overwhelming majority votes. Only a single other non-housekeeping bill has passed both chambers so far in this session. Talk about “inside-track!”   The bill now goes to the Governor who has promised to meet with interested parties before he makes a decision to veto or not. What facts does the Governor want to hear? Facts that might have come out of testimony in the Health and Welfare Committee that might properly have heard the bill in the first place?

Over the same days, the legislature rejected a bill protecting the public from the usurious interest rates of the Payday Loan industry (that also paid big bucks for the privilege of exercising their free speech),  and allowed a bill to review child deaths from abuse or neglect to falter.   I rather suspect the abused children did not have a PAC to counter the political influence of the anti-abortion lobby who placed their suicide belt around the bill.

SB 110 is a complete overhaul of existing law defining the lawful practice of Optometry. The traditional role of Optometrists in refraction and fitting lenses is no longer central. Instead, Optometrists are now authorized to correct and relieve optical abnormalities using surgical procedures and prescription drugs. The bill is pretty much silent on what kinds of surgery is permitted. “Optical abnormality” is not defined and I interpret it to mean disease of the eye. Instead, the bulk of the text itemizes prohibited surgery, including non-laser surgery of the cornea, sclera, lens, etc. The exclusions are so outrageously obvious that they obscure the implications of what can be done. Much is made of the distinction between laser and non-laser surgery, but this is a false dichotomy. Lasers are used to excise tissues as an alternative to “the knife” in a wide variety of traditional surgeries. In my reading, this bill appears to authorize laser surgery on almost any part of the eye! Curiously, the bill prohibits “laser or nonlaser injection into the posterior chamber of the eye…” I have no idea what “laser injection” into the eye means. This phrase appears to me to be an error in the writing of the bill reflecting its rocket-speed passage. If a nonsensical medical procedure is present in the bill, how well discussed or understood could the rest of the legislation been considered? [I will be happy, even reassured, to stand corrected.] Continue reading “The Best Law Money Can Buy?”

New Site for Louisville Veterans Hospital?

Pending Sign at Bronsboro Site

Actually, this is just my guess, or perhaps wish. Nonetheless, something is happening at one of the finalist sites for the new Louisville Veterans Hospital in Louisville. Over the past few weeks, ground preparations were made for the sign above. Today I noticed that the blank sign itself was erected. I am willing to accept a bet for a drink at your favorite bar that soon there will be a VA Hospital sign there.

Certainly if the Vets themselves had any say in the matter, the deal would have been settled long ago. I attended two major public hearings early in the selection process. Both were heavily attended by veterans and officers of veterans’ organizations. Except for a veteran or two who came with the official party from the University of Louisville and its Hospital, to a person they vigorously opposed a downtown location for the new hospital. One or two representatives of major organizations said they personally had no objection to a downtown hospital, but that their members were overwhelmingly opposed. The most common reason I remember was that they did not want to deal with the parking and traffic of downtown Louisville. They also like the thought and culture of a dedicated facility and staff of their own. They feared being farmed out to other downtown hospitals– indeed this possibility was part of the original planning.

The University and its hospital, and perhaps a partner hospital or two, lobbied very heavily and at the highest levels for a downtown location. They were able to convince the Mayor’s office to take their side. It was and still is big-time politics. The University’s reasons are pretty apparent: the VA is important to them. They desperately need the patients for their various teaching and residency programs. The University likes the faculty salary money that it gets from the government. VA salaries are “hard” money that can be used largely at the discretion of clinical chairmen. The University can place faculty there who cannot qualify for a regular Kentucky medical license. It likes the VA research money that has traditionally been easier to get than NIH money. It likes like having the captive veterans around on which to do commercial drug studies and other research. Like other hospitals in town, University Hospital would like to more easily subcontract for specialty services at its own hospital, or even take over some traditional Veterans Hospital programs. University Hospital by itself does not attract enough of some types of patients to support its training programs. It and the University would clearly benefit from another closer and captive group of patients. No matter where the hospital ends up, I expect to see some maneuvering for access to its patients. Continue reading “New Site for Louisville Veterans Hospital?”

On Excellent Medical Reporting

In an earlier entry, I was critical of what I call the “press release” variety of medical reporting in which the news report is based heavily or entirely on a press release by individuals or institutions who have a financial or other vested interest in shaping the presentation.  In many, if not the majority, of these the difference between informing and marketing is not discernible to me.  It is therefore only fair to give credit for what I think is an example of excellent medical reporting. As described below, I was also impressed at the value added to conventional newspaper reporting by its associated Internet capabilities. The article provides an example of the pre-publication embargo system used by some major medical journals with what I think are both positive and negative implications.

The Article and Report.
On Tuesday, February 8, New York Times reporter Denise Grady published an article, “Lymph Node Study Shakes Pillar of Breast Cancer Care.” My sometimes faulty memory tells me I saw her article Monday evening on the New York Times website. The article Ms. Grady reported on was officially published in the February 9 issue of JAMA, the Journal of the American Medical Association: “Axillary Dissection vs No Axillary Dissection in Woman With Invasive Breast Cancer and Sentinel Node Metastasis, ” by Armando E. Giuliano and coauthors; vol. 305:569, 2011. I received my personal copy of the Journal on Wednesday the 9th.

I spent over two hours studying this seven page paper. It was heavy going for me and would have been largely impenetrable to a layperson. It goes against my grain to be paternal, but there is no way for a layperson to understand the significance of the research or how it might relate to them without help. In fact, even I needed some help to put things in perspective, and I confess some of that help came from Denise Grady.

To summarize the paper in an obscenely brief manner, 891 women with breast cancer that had already metastasized as far as the lower lymph nodes in her axilla (armpit) were randomized to 2 different treatment plans. Half the women went on to what was then the standard treatment of extensive removal of all the lymph nodes in their axilla. The other half had no additional surgery beyond the biopsy of the low sentinel node that showed the metastatic cancer. All of the women had a lumpectomy and radiation to the breast, and almost all had additional adjuvant or prophylactic chemotherapy. The patients were followed for as long as eight years. There was no difference in the survival or cancer recurrence rate in either group. Continue reading “On Excellent Medical Reporting”