Tuesday, March 27, 2018

Health Savings Accounts: Are Lawmakers Being Target-ed or Getting Amazon-ed?

Health Savings Accounts (HSAs) allow individuals to use pre-tax dollars to pay for high deductibles and other uncovered medical expenses.  Currently, individuals are ineligible for tax-advantaged HSA contributions if they have “other” coverage in addition to a High Deductible Health Plan (HDHP.)  Expanding HSAs to fund out-of-pocket expenses for routine healthcare places control directly in the hands of patients, a move that could bring down health expenditures.  Large corporations are wrestling for control to direct where patients spend their hard-earned money.

A group of lawmakers recently introduced the “bipartisan” Health Savings Account Improvement Act of 2018 (H.R. 5138). This bill allegedly “expands” HSA coverage to allow use at “retail-based” (think CVS/Target) or “employer-owned” clinics (think Amazon) without losing eligibility to make tax-advantaged contributions to their HSAs.  Increasing the flexibility of HSAs is a laudable goal yet, this legislation herds Americans like sheep into Minute Clinics for the benefit of corporate shareholders. 

This bill should not become law.  If HR 5138 passes, retail and employer-based clinics will become profit centers.   Alternative legislation, known as the Primary Care Enhancement Act (H.R. 365), amends the definition of “qualified medical expenses” to include fees paid to physicians as part of a “primary care service arrangement.”  This common-sense legislation flounders in Congress every year. 

A minute clinic seems convenient, but that is an illusion. In my experience, approximately one-third of patients are misdiagnosed at retail-based clinics, which drives up cost exponentially.  Many years ago, a little girl was seen twice at a “retail clinic” without improvement.  Presenting initially with abdominal pain, she was diagnosed with a urinary tract infection.  She returned the next day with a rash and was examined by a different “provider.”  He concluded her rash was caused by an allergy to an antibiotic.

On Monday morning, the mother brought her daughter in to my clinic.  She did not have hives.  She had petechiae --purplish spots that do not blanch-- covering the lower half of her body.  She had an uncommon pediatric condition known as Henoch-Schonlein purpura, an auto-immune condition, which causes complications when it goes unrecognized.  How many visits to the retail clinic would be necessary to get it right?  I do not want to know.

The lawmakers sponsoring this misguided legislation are Rep. Mike Kelly [R-PA-3], Rep. Brian K. Fitzpatrick [R-PA-8], Rep. Blumenauer [D-OR-3], Rep. Erik Paulsen [R-MN-3], Rep. Ron Kind [D-WI-3], and Rep Terri Sewell [D-AL-7].  Why are lawmakers giving “retail clinics” a leg up on the competition?  It appears they have been either Target-ed or Amazon-ed.

Representatives Kelly and Fitzpatrick appear to be afflicted with Amazon fever; two cities in their great state of Pennsylvania are currently under consideration as Amazon HeadQuarters 2.   Rep. Paulsen hails from Minnesota, where two of the nations’ leading retailers, Target and Best Buy, have their corporate headquarters.  The Target Corporation is the top contributor for his entire legislative career.  The Target Corporation also contributes heavily to Rep. Ron Kind from Wisconsin, another co-sponsor, hailing from the Midwest.

HSA expansion will be a bonanza for the banking, finance and credit industries, who hold and service HSA funds.  Rep. Terri Sewell from Alabama has close ties to these sectors, which make up some of her best contributors when separated by industry.  Rep. Blumenauer, from Oregon, is strongly supported by the Retail Industry Leaders Association (RILA,) a trade group for the world’s largest retailers and distribution centers [translation: Amazon].  In the financial sector, Berkshire Hathaway, a multinational holding company, is a top contributor to the Blumenauer re-election campaign. 

Our Government should be Of the people, By the people and For the people – not Of Target, By Amazon, and For Berkshire Hathaway.  Being seen by a midlevel provider at a big box retailer cannot save money.  Lawmakers sponsoring H.R 5138 are doing the nation a grave disservice by sponsoring this atrocious legislation.  The playing field should, at least, be level.  Health Savings Accounts (HSAs) must be expanded to allow patients to choose independent physicians, direct primary care practices, retail-based, or employer-based clinics.  Americans are quite capable of spending their healthcare dollars wisely.

Tuesday, March 13, 2018

National Walkout Day, March 14... These Boots are Made for Walking.

A National School Walkout Day is planned for March 14, 2018 at 10 a.m. and will last 17 minutes in honor of the 17 students and staff members killed at Marjory Stoneman Douglas High School in Parkland, Florida, on Valentine’s Day.  The heart of the nation has seemed to shift overnight regarding the debate on guns, but this change has been almost two decades in the making.  United and Delta Airlines pulled their support for the NRA, Dicks’ Sporting Goods will not sell assault-style weapons, and Walmart plans to raise the minimum age to purchase a gun to 21 years old. 

I am a pediatrician.  I have sat on the sidelines for far too long --  I watched from a front row seat as frightened, grieving children who survived the shooting at Columbine High School on April 20, 1999 struggled to put their lives back together.  My pediatric internship began June 23, 1999, at the Children’s Hospital in Denver, Colorado, approximately 20 miles north of Columbine High School.  Up until that time, a mass shooting inside the walls of a high school had been almost unimaginable.  Many students who had survived by hiding under a desk in the library that tragic day crossed my path over the next three years.  In reality, every student and teacher inside Columbine High School was irreparably damaged forever; they lost a huge part of themselves on that solemn, heartbreaking day. 

Why has so little changed in almost 20 years since Columbine? I don’t know.  Why has so little changed since the mass shooting at Sandy Hook where 20 children and 6 adults were gunned down in cold blood?  I cannot understand.  Why has the mass shooting in Parkland, Florida galvanized the nation?  Because now, it is our innocent children leading the fight for meaningful change. 

“Silence in the face of evil is itself evil.  Not to speak is to speak.  Not to act is to act.”  These are the immortal words of Dietrich Bonhoeffer, a German pastor and theologian, who was executed for his anti-Nazi beliefs in 1945.  Unspeakable damage is being done to our children and it is time we, as parents, teachers, administrators, and community members stand with them. 

Now is the time to speak and the time to act, before more children die.  At Columbine High School, it took only six minutes to kill 10 and wound 12.  At Sandy Hook Elementary, it took a mere five minutes to kill 26 and wound 2.  At Marjorie Stoneman Douglas High School, it took just 7 minutes to kill 17 and wound 14.  These statistics are sobering. 

As a pediatrician, I have spent over two decades acquiring knowledge on adolescent growth and development. Teenagers acquire higher-level thinking in the form of cognitive competence, which includes the ability to reason effectively, problem solve, reflect, think abstractly, and make plans for the future.  Linear, black-and-white develops into a broader understanding of the shades of gray.   These new capacities allow them to engage in mature decision-making with a depth they did not previously possess. 

Society is not giving them enough credit.  Teenagers are capable of a great deal more than we recognize.  This is the moment where we should stop talking, give these young people the floor, and listen to their words.  Their opinions matter.  Their continued growth and development matters.  Their mental health and safety matters.  Their contributions matter.  Their future should matter to all of us.  

While there are no easy solutions, I support the efforts of every student participating in National Walkout Day as they endeavor to bring much-needed attention to gun violence inside our schools.  Our children are actively engaging in a form of civil disobedience for likely the first time in their lives about a critical safety issue they face every day.  Young people are depending on the courage of the nation and our lawmakers to do what is right, which includes enacting bipartisan common-sense gun safety regulations that could literally save their lives.    Please join this generation of motivated students from Parkland, Columbine, Sandy Hook, and many other schools across the country to support their efforts, on March 14, National School Walkout Day.  While I may not agree with every idea or proposal of these young people, I respect them, I salute them and I validate their strong stand against what they see as injustice. 

Tuesday, March 6, 2018

The Peril of Online Physician Reviews

You may have heard that before you pick a doctor you are supposed to look them up online and see what other people have to say about them before you set up an appointment.
In the Age of Amazon this makes sense. Why wouldn’t you?
Allow me to give you a little insider information.  While they may well be a good idea in theory, Yelp.com and other online physician review sites have evolved in recent years to become the bane of my and fellow doctors existence. 
This past summer, Physicians Working Together, a non-partisan physician organization, started a petition on Change.org requesting Yelp remove online reviews of doctors.  To date, more than 30,000 physicians have signed it but I doubt Yelp will pay much attention.
Recently, the highest-level court in Germany ruled Jameda, an online physician rating site, must remove the name of a disgruntled physician.   A dermatologist from Cologne filed the case in the Federal Justice Court demanding Jameda remove her name due to the fact the anonymous nature of the rating site inspires the public to leave spiteful, vindictive comments.  Interestingly enough, in 2014, a gynecologist asked to be removed from Jameda, however the Court ruled the right of patients to be “well informed” about their doctor took precedence over freedoms of the physician.
What is the value of rating physicians online?  Are consumers becoming “well-informed?”
Patient advocates would argue rating sites for physicians improve transparency for consumers.   Physicians would counter with the argument that a medical clinic is not like a restaurant, hair salon, or shopping mall.  We engage in a highly personal way with the public that is quite different from sitting down for a meal.  The larger concern is whether or not Yelp.com patrons are actually “well-informed” by reading online physician reviews. 
After a little research, it appears the answer is no.  I used a local medical community as an example.  The reviews overall are not very good; on average the medical clinics are 3.0/5.0 stars.  Some reviews extol on physical appearance of the physician, be they female or male.  One reviewer discusses being offended by seeing a transgender physician, an element which has little to do with the provision of medical services.  At first glance, one might believe moving to Kitsap County, WA is akin to choosing between life and death.  Rest assured, most of the populace is alive and well. 
Online reviews are not a reflection of medical care quality.  Patients do not like receiving medical bills and do not like rude clinic staff.  They are unhappy if the physician disagrees with them, they abhor long wait times, and they detest prior authorizations, (news flash, so do physicians!) Yet these criticisms are not a reflection of the healthcare quality provided by the physician.  It is doubtful these grievances even have an impact on the mortality rate. 
According to “well informed” consumers, which qualities make a physician “good”?
Actually, the answer is amusing.  It is best if a physician is in fact, not a medical doctor at all.  It turns out EVERY naturopathic doctor, homeopathic doctor, chiropractor, and acupuncturist in my community is providing five-star-rated care.  One patron gave a few alternative practitioners only one star, but those reviews were more than nine years old; alternative medical practitioners were not as “well-accepted” by a “well-informed” public at that time.  As with other service businesses, the internet is unlikely to replace good, old fashioned “word-of-mouth” referrals. 
While internet ratings are not an accurate way to measure medical care quality, they are a way for angry individuals to air grievances, whether those are truth, lies, fiction, or somewhere in between.  For example, a one-star rating was left by a woman who did not like the way a staff member answered the phone at one clinic; she went on to give 5 one-star ratings to other physicians nearby at other clinics.  Interestingly enough, googling her name brings up a Yelp.com review describing her as having borderline personality disorder. 
What is the public being informed of exactly?  Not much.  Physicians may have difficulty responding to patient reviews without compromising protected health information, ultimately rendering them defenseless.  If the goal is to keep everyone accountable, where is the balance between physicians and consumers?  Should physicians have a database to rate patients?  Accountability is where the rubber meets the road and it cannot be found in online reviews of physicians.  Ironically, the lawyers in my community have very solid 5.0-star ratings, that is, unless they delivered a summons, then they were given a 1.0-star rating. 
Yelp and other physician rating sites should remove the physician reviews entirely because these entities are selling something they cannot deliver.  Until a physician wins a case against Yelp, Google, or another physician rating site, it seems wise to give every patient exactly what they ask for, never argue or tell them the truth, hire staff members who are like Mary Poppins and “practically perfect in every way”, and prioritize timely visits no matter if a patient is dying in the next room.   
Is it any wonder the U.S. mortality rate continues to fall?