Author: Ann Marie Marciarille

Those individual mask respirators are becoming increasingly scarce in the Bay Area.  I am concerned to see individuals with no respiratory protection at all working outside this afternoon.  This makes me wonder why we haven't heard much about public health distribution of these items to those unable to afford them at their local hardware store or simply unable to locate any for sale.  Why is unhealthy air quality not a public health concern?

Then comes the assertion that such distributions, to the extent they have been undertaken at local fire barns (I'm looking at you Sacramento and Daly City), should be halted.  The chief rationale for this is that individuals use the respirators incorrectly.  I have to wonder if this isn't based on some post-Katrina research indicating that, without training, respirators are likely to be used incorrectly.

Of course, some people make the same argument about condoms.

I am hard pressed to understand, one week into smoke-ageddon in the Bay Area, public health authorities have not focused on distribution of and training/education on how to wear an appropriate mask/respirator.  After all, if a significant percentage of incorrect use comes from wearing the mask upside down, couldn't a sticker be added to the bag containing the respirator indicating "this end up" or "this covers the bridge of your nose"?  Heck, my Flonase applicator comes with a warning: "for nasal use only."  Yes, some people will spray the Flonase some other ineffective place, but shouldn't we consider whether that extra warning will make the number of people spraying Flonase somewhere other than their nose lower?

People are motivated. Every time I venture out (infrequently), someone stops me and asks me where I got the mask/respirator I am wearing. I tell them mine are left over from the Tubbs Fire but some should be available at a local hardware store. I would rather tell them where the nearest fire barn distributing such mask/respirators along with instruction on how to wear them is.

Cough cough.

 

Reports of a case like the recent action by the FTC against Simple Health Plans in Florida seeking to close the business down for, among other things, selling thin health insurance as comprehensive health insurance catch my eye.   Now, I understand Simple has a history of being a bad actor and that their marketing practices were also dishonest and illegal, but it always interests me when we talk about who gets to decide which health insurance product is right for the consumer and how aggressively the consumer may be "sold" on the product.  Because there is  pretty good data indicating most Americans do not understand their health insurance coverage very well and choose to delegate the choice of appropriate policy to someone else: employer, broker, etc.

So, how weak is our health insurance knowledge?  Well, some of Simple's  customers were apparently paying  $500 a month for insurance coverage that maxed out at about $3,000 a year.

 

 

 

 

 

 

 

Talk of pre-existing condition exclusions was everywhere in the mid-term elections.  Few, of any political persuasion, want to publicly state that our health care system should abandon those with pre-existing conditions to the free market where the richest may be able to support expensive coverage and the rest may not.  

It is rare that we look health care access issues directly in the face. Instead, we argue that some people really don't want health insurance, some people don't really need health insurance, that a small regulatory fix targeted only at the most difficult to insure would be better than a universal ban on pre-existing condition exclusions in the sale of health insurance, and so on. We never want to be the ones to say something like: "some people will be uninsurable and that is just the way it is."

Why not?  Because, it turns out, Americans are pretty good at understanding that they may someday (if they are not already) be part of that pre-existing conditions exclusion group.  In fact, in the last weeks of the mid-term campaigns, some candidates were confronted by organized groups of cancer survivors.  And no candidate wanted to go there.

So, supporting a ban on pre-existing condition exclusions may end up being like Motherhood and Apple Pie, tough to dislike. But how strong a ban is supported remains to be seen.  Advanced genetic testing is able to tell us more about what health challenges lie ahead. So, you may already be in the pre-existing condition group — broadly defined– and not know it, though your health insurer may.  Or, vice versa.

Think fast. Is a pre-disposition to a certain disease state a pre-existing condition?

 

 

Larissa MacFarquhar's New Yorker article looking at different approaches to the illusions of the demented offers, along with the inevitable discussion of whether lying is ever morally good, a good look at the treatment of dementia patients now living almost exclusively in the past.  I regret that all this Kantian discussion was not rounded out — and made more difficult — by the fact that powerful drugs are the norm in many residential facilities for elders.  How common?  Well, here's Norway worrying about it and here's our own CMS trying to reach the problem by requiring reporting and expanding the definition of psychotropic medication. The New York Times reports that one third of nursing home residents take psychotropic medication and a significant percentage of them are individuals without a corresponding diagnosis.

MacFarquhar's article presents the rise of memory houses as a response to possible overuse of chemical restraints but doesn't linger on how psychotropic medications administered off label for the convenience of staff and facility are a lie as well.  Yes, psychological placebos are a lie and psychotropic medications administered not for therapeutic purposes but for institutional purposes are a lie.They are a lie about how many skilled nursing facilities lack the staff and the funding to promote human flourishing.

I wish her article had spent less time dancing on the edge of "to lie or not to lie" and had lingered much longer on the fact that living the truth is expensive, drains caregivers, and does not seem to increase resident happiness even if it is considered to increase resident dignity. Some lying may be inevitable, considering human frailty. 

What kind or which kinds of lying to those who have demented illusions that may bring them comfort, if any, are moral? While we await the promised land of well funded well staffed dementia care, is the answer to the first question still the same?

 

 

 

 

 

In early October 1942, the Richmond shipyards run by Kaiser established a health plan for employees.  It provided "unlimited medical and hospital care" to 70,000 shipyard workers for 50 cents a week, less than $60 a month in today's dollars. Narrow networks and lifetime caps came later, of course.  Good to remember they were not present at the creation, though.

This FDA field visit warning/corrections letter to an Illinois pharmaceutical testing lab has been making the press.  Really, do click through, and don't miss the section on non-pharmaceutical uses of the lab by  a co-located micro-brewery. I mean, if that's not entrepreneurial, I don't know what is.

The whole letter is worth a read to get a sense of how long this lab has been non-compliant and still allowed to operate.  Would they be regulated more strictly as a brewery? 

Breweries and distilleries are subject to FDA inspection, though the states may play a role as well. And what if the brewery inspectors find a co-located pharmaceutical testing operation? Well, that letter should surely be forthcoming.

 

 

I recently took a prescription for pregabalin/Lyrica to my pharmacy.  Lyrica is a controlled substance, so I hand carried the paper prescription myself.  My pharmacist took one look at the prescription, consulted her computer, and quickly advised it could not be dispensed as written, as my insurance would only cover Lyrica in a limited quantity format — in my case, two thirds of the prescription could be covered under my insurance. 

So, I took what I could get and decided to tell my prescribing physician what had happened.  Indeed, my pharmacist had taken me aside when I was picking up the Lyrica prescription to note, again, that it had not been dispensed as written. My prescribing physician was sanguine and told me to proceed with the lyrica build up — that we could address doses on the higher end if and when we got to it.

Nonetheless, I was intrigued by the question of who can change a doctor's script once it is submitted.  I began to ask about the basis for the quantity limitations. I am not certain I got the story straight, but here is what I think I learned.

It turns out that Lyrica's controlled substance status is the tail wagging the dog more than anything else.  A Lyrica prescription can be altered in certain limited ways, including change of quantity and dose.  On the federal level, Lyrica is a Schedule V controlled substance. Pregabalin is known as the "new Valium" in the U.K. or by its nickname "Budweiser". On the state level, California's Health and Safety Code restricts how a pharmacist may dispense a Schedule V controlled substance.

That means appropriateness of use is at issue, particularly for patients with a history of prescription drug abuse, and appropriateness of dose is also an issue. And I learned that quantity limitations on prescription drugs are quite common.

But what drives the quantity limitation is harder to identify. Many plans appear to be relying on CDC guidelines for the prescription of opioids.

Why pin it on the insurance company?  Because they have brought their drug formulary into their best understanding of  dispensing guidelines found in federal and state law as well as CDC Guidelines.

With so many cooks in the Schedule V dispensing broth, I have to wonder about liability if anything goes wrong. All of this is further muddied by Lyrica's high dispensing cost, surely a further incentive to limit both access and quantity.

 

 

 

Maycee Wieczorek, a 17-year-old in Rapid City, S.D., said it felt odd as a student to hear grown-ups dismissing the significance of Mr. Kavanaugh’s character in high school.

“For me and my friends his past is our now,” she said.

I laughed out loud, when viewing the documentary Three Identical Strangers this weekend, when one of the triplets explained how it was possible for an uninsured triplet to obtain a needed appendectomy by impersonating another triplet who had health insurance.

Of course, we are all inured by now to having to provide photo identification at the start of the clinical encounter, so we have some sense of the desperation of people who attempt to use the health insurance of others. Good thing for the triplets involved that the statute of limitations for the  crime of medical identity theft or fraud has run.

A mostly unspoken sub-text of the documentary is how class shaped their life chances. We get a whiff of it when David Kellman (working class triplet) recounts how he couldn't believe that Bobby Shafran (well off triplet) drove a beat up old Volvo to college, despite having a prominent physician for a father.

But the need for health insurance fraud should have made us all sit up and take notice. 

 

Our kids are grown. I freely admit I must be hopelessly out of touch.  But I have to wonder how much the world has changed when a New York Times article nonchalantly accepts a BusyKids chore chart that indicates chore compensation for taking a shower and brushing your teeth is appropriate in many U.S. homes, albeit more likely a compensated task for a boy than for a girl.

What is this?  Personal hygiene as a household chore?  Aren't these really health-seeking incentive payments? And, if so, aren't the boys in this study being way over-compensated for chores that do not contribute to the collective good?

The article makes a good point that we continue to socialize our children to sex-based division of labor in household chores and in sex-based rates of compensation for those chores. But aren't those paying for pro-social behavior also sending a strong message about the nature of a family life where the small accommodations of communal life must be bought and not given?