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
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?”
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?”
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?”
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”
I read with interest today’s report in the Courier-Journal by Tom Loftus summarizing the lobbying efforts of the Kentucky Optometric Association in promoting a bill that would expand their scope of practice and give their licensure board more freedom to define what other things they can legally do. The administration of medications and the ability to perform laser surgery are among them.
Two things are remarkable to me. The first is the swift and overwhelmingly bipartisan support for the bill. The second is the remarkable amount of money spread so widely among legislators of both parties. The money, also called campaign contributions, was given to 137 of the 138 members of the state legislature and both gubernatorial candidates. It was good business for the lobbying community as well: at least 18 of them helped to spread the fertilizer. The only legislator who did not receive a contribution was representative David Watkins, who also happens to be a physician of the MD variety. His position appears to be similar to that of the Kentucky Medical Association and might be paraphrased as, “If you want to practice medicine, go to medical school.” (Disclaimer: I am a member of the KMA.)
Some $400,000 in political contributions were spread around in the past two years alone. To put things in perspective, the Kentucky (MD) Physicians PAC gave only $70,050 during the same period, and the Ophthalmologic (MD) Physicians pack gave $20,750. The MDs were obviously outbid by the ODs. The bill passed out of the Senate by a vote of 33 to 3. I did not think anything could pass out of the Senate with such cooperation nowadays! Continue reading “Seeing Green in Kentucky: Money in Politics”
I clipped an article from the Courier journal in December, 2010 entitled, “Pfizer issues 4th Lipitor recall” that was released by the Associated Press. Although I had planned to focus on articles from the new year, a subsequent article about a recall of multiple products by Johnson & Johnson made the pair fair game.
The Lipitor recall was the most recent of a series reacting to an “uncharacteristic” odor. The smell is blamed on a wood preservative often applied to wood pallets that might have been used to transport products. The article quotes Pfizer that the use of such chemicals in the shipment of its products is prohibited. (Are we are left to assume that the chemical tainted the pills in some other as yet unknown manner?)
The article goes on to mention that over 360,000 bottles of Lipitor have been recalled so far; that Lipitor is the best-selling prescription drug in the US; that other drug companies such as Johnson and Johnson have had trouble with smelly pills; and that the risk of serious harm from this particular contamination is remote.
The story about Johnson and Johnson is quite interesting. As reported by Wall Street Journal and other sources, Johnson & Johnson recalled tens of millions of packages of over 40 different medicines in 2010. According to Reuters, at least one American Johnson & Johnson manufacturing plant “was closed to fix quality control lapses, including unsanitary conditions.” The recall has generated citations from federal regulators and criticism by congress because of the “phantom” nature of the recalls. This is a far cry from the actions of McNeil during the Tylenol poisoning incident in 1982 which brought the Johnson & Johnson subsidiary praise for its bold and definitive response.
Continue reading “Safer to Buy Your Prescription Drugs in Canada?”
My discussion of the reporting on the extremely high rate of major spinal fusion surgery in Louisville has generated its own follow-up. On Jan 17, Courier-Journal reporter Patrick Howington contributed a front-page article about the legal battle of five Louisville orthopedic surgeons over an estimated $60 million in royalty fees.
Wow! The Chamber of Commerce must be proud. This is the kind of big-time health care and research money on which Louisville’s city fathers, and its business and university communities have pinned their hopes for the future. So why am I embarrassed over this? Should I be? Would I be if the money were coming to me? I think there is plenty of embarrassment to go around.
It is embarrassing for me as a physician to see other physicians fighting so publicly over money. While certainly within their legal rights, this dispute over money by these professionals reminds us that even for physicians, the practice of medicine is at its base a business. There has always been an inherent tension in the patient-physician relationship: what is best for the patient may not always be what is best for the physician. The professional ideal resolves any such conflicts in favor of the patient. As more and more outside players insert themselves between and around the patient-physician relationship, the vectors of tension become more complex and more difficult to resolve. I predict we will increasingly appreciate such policy difficulties as the structure of our healthcare system changes. Our debates over capitation, managed care, or physicians as employees provide examples where the nature of the patient-physician relationship has been tested. During the last year in Louisville, several prominent contract battles between insurance companies, doctors, and hospitals continues to disrupt the vulnerable contract between patients and their physicians. Continue reading “Battles Royale in Louisville”
On the second day of the new year, the front page of the Courier Journal highlighted the fact that one of our local hospitals was third in the United States in the number of spinal fusions performed. Since the Louisville business community has identified generating healthcare revenues as a top long-term strategic priority, the headline could easily be interpreted as a success story. However, the full-page article by John Carreyrou and Yom McGinty reprinted from the Wall Street Journal was not very flattering. (The article is not present on the Courier Journal website, but is available on the Wall Street Journal’s.)
The article emphasized the multibillion-dollar annual market and the medical controversy over when and if this extremely expensive major surgery should be done. Also highlighted were the large amounts of royalty money paid by the manufacturers of surgical equipment directly to surgeons who make the decision to operate. The article reported that five of the surgeons at my local hospital received more than seven million dollars in less than a year from the manufacturer of the implants used in the surgery. This was in addition to the clinical charges billed. It was reported that total Medicare reimbursements for spinal fusion at my local hospital were almost $48 million. The article proposes, and I and would have to agree, that the amounts of money involved are enough to distort the medical decision-making process. Since the hospital and doctors involved are part of our academic medical center, one might also reasonably assume that young physicians in training will perceive these activities as the standard of care.
There is not room here today to summarize the medical literature pertaining to spine surgery for disc disease and arthritis. Suffice it to say, most national organizations of general physicians and rheumatologists are arguing for fewer operations than in the past. In my own career as a rheumatologist, I personally recommended spine surgery for only three patients with arthritis. It is possible for you to suspect that I think too much spine surgery is being done in general. The hospital and doctors involved will likely offer their own explanations: indeed I think they will need to.
What I do want to talk about today, is the methodology that brings such observations to the forefront. It has been called study of “small area variations.” You see these kind of studies all the time. They were popularized by Dr. Jack Wennberg and the group at Dartmouth. I have always been drawn to this approach because the mapping of results appeals to my visual sense. For example, here is one of the earliest health policy studies I ever did. Continue reading “Area Variation. Is Doing the Most a Good Thing?”
Courier-Journal reporter Darla Carter led off New Year’s Day with a front page article “Health news [is a] prescription for confusion.” I agree with her. Is coffee bad for you of not? Should postmenopausal women take estrogens or not? Should men get a routine PSA test for prostate cancer or not? When and how often should I get a mammogram? Should I get chest x-rays to screen for lung cancer or not? Should my child get immunized or not? Our daily media is full of headlines and stories that address medical scientific issues and their application to medical care. Even if one is not paying attention, it is obvious that the recommendations appearing in these news articles and segments conflict with each other on a regular basis.
It is this article that stimulated me to get off my duff with this blog. For years I have been pulling my hair out about the way medical information is presented to the public. The volume of health and medical information presented to the lay and professional public daily is overwhelming. I don’t know about you, but I can hardly stand to watch television any more because of all the drug ads. The only thing that is worse are the campaign ads, but at least these are with us only part of each year.
We are assaulted by print, broadcast, and electronic media everywhere we go. The nature of the information ranges widely. It ranges from “news,” advocacy sponsored material, through press releases supporting every possible position. The content passes further down the social-value scale through entertainment, snake oil, and outright fraud. The overwhelming volume of health-related material with which we are sandbagged is advertising: somebody is trying to induce us to buy something that will translate into income for them. There is nothing wrong with information: more and better information is badly needed. But we live in a time when food is sold like medicine, and medicine sold like soap powder. Which hospital in my town really has an infection control problem? What is the basis of a claim that a given product or service is the “best,” or even works at all for that matter? Such information is hard to come by– if it is available to the public at all. Continue reading “Does Medical Reporting Help or Hurt?”