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lindafrancois · 4 years ago

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Home Dialysis Myths

Deciding with your doctor what mode of dialysis best suits your clinical needs and lifestyle can feel daunting. The idea of performing dialysis at home may seem overwhelming and may yield mixed emotions such as relief, confusion, sadness or fear. Despite the large amount of information available, the ins and outs of home dialysis are not as well-known as other forms of dialysis. This may lead to misconceptions, or “myths” regarding home dialysis. Let’s take a look at five popular myths and truths related to home dialysis.

Myth #1:

“I do not need to follow a kidney diet on home dialysis”.

Truth: The kidney diet may be more liberal on home dialysis since daily peritoneal dialysis (PD) and some nephrologist-prescribed home hemodialysis (HHD) treatment schedules may more closely mimic the function of natural kidneys. However, it is still important to watch your intake of foods high in phosphorus, potassium, fluid and sodium. With monthly lab monitoring, your home dialysis kidney diet will be tailored to meet your specific needs. Your home care team will educate and support you.

Myth #2:

“Once I start home therapy, I will be all on my own.”

Truth: While home patients have trained care partners to assist with treatments and care at home, your home care team will also be available to support you. Patients typically come into the clinic once or twice a month for routine lab work and to visit with the nephrologist and health care team. They can also visit the facility more often if any questions or concerns arise. During your training, you will be provided with contact numbers and information to reach out for help. Regardless of your concern, a licensed DaVita clinician is available 24/7 via a phone call to discuss any questions or concerns. DaVita home dialysis patients also have access to enroll in the DaVita Care Connect app, which allows them to send secure messages to their care team from their smartphone, connect via telehealth and also connect with other home dialysis patients through virtual support groups.

Myth #3:

“All home therapies require sticking myself with needles.”

Truth: There are two methods of home dialysis—one method uses needles during treatment and the other does not. Peritoneal dialysis (PD) does not require you to stick yourself with any needles to perform the treatment. This type of dialysis is done using a catheter inserted into the abdomen and no blood is exchanged during this method. One exception is the needle stick required for lab work. Home hemodialysis (HHD) does require needles but special techniques, such as the buttonhole technique, are used to help make the process less painful.

Myth #4:

“I need a large home to be able to store all of my medical items.”

Truth: Medical supplies are needed for each treatment and the delivery of these supplies can be scheduled to meet your needs. If you do not have a lot of storage space, adjustments can be made to accommodate inventory and timed delivery. Home dialysis can be successful, even in small homes.

Myth #5:

“Frequent dialysis is hard on my body.”

Truth: Home dialysis may actually more closely mimic the functions of the natural kidneys and therefore may be easier on your heart and body. Your nephrologist will develop a treatment plan for you that is designed to extend remaining kidney function and improve your physical health.

Your dialysis team is available to support you. We want you to succeed in the dialysis modality you choose. Ask questions about dialysis myths and other questions and learn about all your options so you can find the treatment that fits you best.

Additional Kidney Diet Resources

Visit DaVita.com and explore these diet and nutrition resources:

DaVita Food Analyzer

DaVita Dining Out Guides

Today’s Kidney Diet Cookbooks

DaVita Kidney-Friendly Recipes

Diet and Nutrition Articles

Diet and Nutrition Videos

Kidney Smart® Virtual Classes

This article is for informational purposes only and is not a substitute for medical advice or treatment. Consult your physician and dietitian regarding your specific diagnosis, treatment, diet and health questions. Service provider and modality selection are choices made exclusively between the patient and nephrologist.

Home Dialysis Myths published first on https://dietariouspage.tumblr.com/

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vanessa-0188 · 7 years ago

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I feel like you make up stuff for attention. Like there's ALWAYS something going on with you to make others feel bad for you.

I wish you'd messaged me with your URL so I could answer this privately, but alas... For clarity, and transparencies sake I'm going to clue you in on a little bit about my life story.I was born at 24 weeks gestation to teenage parents who, frankly, weren't ready to be parents (though I don't know what teens WOULD be). My mom got her shit together pretty rapidly after I was born; my dad was a different story but we'll jump back to him in a second.I, because of premature birth, was born with two underlying conditions that have caused the rest of my health problems. I am not a medical professional, so I am going to google/copy-paste the definition of these conditions here, and then relay to you how they've informed my life.1. Cerebral Palsy: While Cerebral Palsy (pronounced seh-ree-brel pawl-zee) is a blanket term commonly referred to as “CP” and described by loss or impairment of motor function, Cerebral Palsy is actually caused by brain damage. The brain damage is caused by brain injury or abnormal development of the brain that occurs while a child’s brain is still developing — before birth, during birth, or immediately after birth.Cerebral Palsy affects body movement, muscle control, muscle coordination, muscle tone, reflex, posture and balance. It can also impact fine motor skills, gross motor skills and oral motor functioning. (Source: cerebralpalsy.org)2. VATER Syndrome: VACTERL or VATER association is an acronym used to describe a series of characteristics which have been found to occur together... Babies who have been diagnosed as having VACTERL association usually have at least three or more of these individual anomalies. There is a wide range of manifestation of VACTERL association so that the exact incidence within the population is not exactly known, but has been estimated to occur in one in 10,000 to 40,000 newborns. (Source: cincinnatichildrens.org)Cerebral Palsy has left me permanently wheelchair bound (I have 0% walking or standing capabilities), and sometimes causes me motor issues with my hands (I.E. they shake during activities, are never fully non-spastic). As far as VATER I've tried to spare myself a little dignity by omitting the exact definition of the acronym, but google it for your own knowledge if you'd like; I don't have all of the conditions in the acronym, but this syndrome has caused me a lifetime of debilitating gastro-intestinal issues, furthered orthopedic problems, and most damningly- it KILLED my left kidney completely when I was two days old. Suffice it to say my life has never been medically easy.I mentioned before that my dad never really got his shit together to be a dad. My parents never had a formal custody agreement. But my mom did what she thought was right in trying to give my little brother and I opportunity to maintain a relationship with our dad. She'd drop us off with him at our paternal grandmothers house every-other weekend. I could sit here and tell you countless stories of abuse and neglect, but I'll just give you dear-old-dad's greatest-hits:* 1:00a.m. one night when I'm about eight years old (this would make my brother about four). My dad has friends over playing dominoes and drinking. We're awake still. I pipe up, "dad, we're tired, please take us to bed...", He threw a pillow and my head and said "if you're so damn tired make beds for you and [your brother] on the floor. When I protested he came over, knocked me down to a laying position, got inches from my face and screamed "shut the fuck up!"* Again, another friend-gathering. I really REALLY had to pee. He was in the bathroom on the phone. I waited HOURS for him to come out (there was only one bathroom I could use, and I needed his help). When his friends begged him to come help me. I ended up having an accident on the floor. He violently shoved my nose in it like a dog.I never told my mom or teacher or grandparents about any of this because I didn't know any better; I thought that was what all dads did. Until I was 10.* At age 10, on my dads birthday, we wanted to have a dinner for him. My mom obliged, inviting him to our apartment. It was also Super Bowl Sunday... he agreed to come over after he watched the game with his friends. My brother and I were so excited- we made cards and helped my mom bake a cake. That night we picked my dad up from a friends house, drove through and got dinner, and on the way home he and my mom started arguing. We got inside, they served us dinner, my mom set me up on a dining chair to eat, and they went to her room to "talk". Sometime later I heard violent screaming, and instructed my brother to go investigate. I'm sparing my own-psyche and the dignity of the other victims by withholding too-many details but that ended in holes in walls, my mom almost dying in front of me, injuries to my brother,a grade-three concussion for myself, and threats of death for us all by gun violence.I didn't talk to my dad again til I was 22. At that time I was struggling emotionally, longing for a relationship with him, and there were growing-pains at home as I was a young-adult who wanted to live a certain way that didn't conform with my moms house-rules. My dad and I had been in contact again for a short time. After a heated argument with my mother and stepfather (she married when I was 13), my father offered to let me stay with him. Things were great living there, until* One night he decided to push my boundaries, taking a trivial disagreement over taxes and house payments of all things, and bringing my mother into it. My anxiety flaired, and I tried to flee to my room. He followed me, grabbed me by the wheelchair, and held me in place, grabbing my hands and imploring me to hit him. He continued antagonizing me for hours, at one point when I called my mother terrified for my life, he taunted her as well. Through ingenious planning by Sheriffs and family, I was saved with only a split bottom lip and chipped-tooth.(And I guess I should note here that my sperm-donor of a biological father has spent time in jail for abusing us.)I spent time after that trying to heal my soul. Got to a good place in life where I was happy. Moved to my own assisted-living apartment. Then my bladder failed, resulting in me needing a permanent catheter. A month later my remaining kidney failed, resulting in my need for dialysis (for your reference, "The main purpose of dialysis is to help impaired renal function. When your kidneys are damaged, they are no longer able to remove wastes and excess fluid from your bloodstream efficiently. Wastes such as nitrogen and creatinine build up in the bloodstream. If you have been diagnosed with chronic kidney disease (CKD), your doctor will have these levels carefully monitored. Before dialysis, patients often felt weak and ill. Dialysis brings relief from these symptoms. This is the primary benefit of dialysis.Dialysis is done by using a special fluid called dialysate. Dialysate, a mixture of pure water and chemicals, is carefully controlled to pull wastes out of your blood without removing substances your body needs. A semipermeable membrane (one with microscopic holes that allow only certain types of particles to pass through) keeps the blood apart from the dialysate. This membrane lets the wastes and fluid in your blood flow through into the dialysate. Your blood cells and larger molecules, like protein that you need, cannot fit through the holes. There are two main types of kidney dialysis: hemodialysis (HD) and peritoneal dialysis (PD). [Source: DaVita]). I do hemodialysis: three days a week, four hours each time, I go to my dialysis clinic where they hook me up to my dialysis machine. My blood is filtered through a catheter that has been surgically connected to my heart. As I mentioned in my concert post, this process makes me vomit, and can sometimes induce symptoms that make me feel like I'm having a heart-attack. I'm on the transplant list, but due to my various GI surgeries I may not be a viable candidate. Time will tell. If not, I will have to do dialysis for the rest of my life.I had a best friend who, due to things that were my own fault, I've now lost my friendship with. In areas where I lacked support, she was my number one. This loss has been so hard in conjunction with my health issues; I'm grieving it right now.So yes, I'm aware it seems there's always something; that's because unfortunately there is. My life is messy, and complicated as hell. I'm very emotional, and I require a lot of support- something I'm not afraid to reach out for here on tumblr (even if it's in the form of fic distractions). If that bothers you, please scroll by- and if you feel the need to say something on anon, it's probably best left unsaid.Oh, and because we're at this point where you've got me airing dirty laundry, I'll be posting picture proof of some medical problems in my next post (I'm on mobile so I can't do it here 😉)Love Always,Vanessa

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heroesclimbfind · 8 years ago

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One Climber’s Opinion

In Response To: When Feminism Goes Too Far by Davita Gurian

Among the 294 people certified as rock, alpine, or ski mountaineering guides by the American Mountain Guides Association in 2010, only 26 were women. Betsy Novak, the association’s executive director, says among 60 guides certified in all three areas, just seven are women, which, she explains, is more than in other countries.[1]

Why are women so underrepresented in climbing and mountaineering?

“The reason why there are fewer women is not in the nature of the profession,” explains Novak.

“I think it’s rooted in our own cultural history.”

And that’s the problem I have with Davita Gurian’s article, “When Feminism Goes Too Far: Are female climbers oppressed? Not really.”

Gurian supplies anecdotal evidence that she has not been oppressed as a result of her gender in climbing. In fact, she claims that a woman should “[try] voicing her fears openly to her male climbing partners, instead of harboring an internal resentment toward them.”

As a woman, climber, and feminist, I don’t harbor resentment toward my male counterparts. In fact, many stand alongside me today in combatting our misogynist cultural history, one that still favors a patriarchal society. On the eve of one of the largest demonstrations for women’s rights in U.S. history, faced with real threats to reproductive health rights and gender equality, I think it’s necessary to address the dangerous logic of Gurian’s article.

Language Matters

Let’s start with this story in Gurian’s article. The male boss of a female climber wants to call an all-female climbing night, Beta Babes, a term that the female climber finds “deeply offensive, oppressive, and demeaning.” After all, “Babe” is a diminutive term for “baby” and used either for female romantic partners, the sexualization of women, or, well, a shy Yorkshire piglet.

Gurian writes, “Sure, she’s got a right to that opinion, but please show me the harm in that term.”

Ok. Let’s discuss it.

As it turns out, language matters. Don’t take my word for it, Dr. Lera Boroditsky, associate professor of cognitive science at UC San Diego, dedicates her career to examining how different languages encourage different cognitive abilities.

For example, in a study comparing Mandarin speakers and English speakers, the difference in the vertical versus horizontal shape of the written language changed the way those speakers thought about time. Mandarin speakers were faster to confirm that the month of March comes earlier than the month of April after they had just seen a vertical array of objects, than after they had just seen a horizontal array of objects. The reverse was true for English speakers.

In the same way, there is evidence that gendered language reinforces traditional gender stereotypes.

In a different study, Boroditsky investigated how the gendering of objects in certain languages affects the way speakers describe those objects.[2] For example, Spanish and German speakers were asked to rate similarities between pictures (of both females and males) and pictures of objects (the names of which had opposite genders in Spanish and German). Boroditsky found that both groups rated grammatically feminine objects to be more similar to females, and grammatically masculine objects more similar to males, even though the objects had opposite genders in the two languages. Furthermore, her research found that German speakers were more likely to use stereotypically masculine descriptions such as “hard, heavy, jagged, metal, serrated, and useful,” while Spanish speakers were more likely to use stereotypically feminine descriptions, such as “golden, intricate, little, lovely, shiny, and tiny” for the same objects according to their linguistic gender.

Although certainly more recent, these are not the first studies to argue that gendered language matters. Philosopher Douglas R. Hofstadter wrote a parody in 1986 on sexist language. In his satire, society spoke in generics based on race rather than gender. So, instead of “chairman”, people said, “chairwhite” or even “you whiteys.” After reading his work, it becomes impossible to argue that black men and women who hear “all whites are created equal,” should be expected to feel included. Hofstadter concludes in his paper[3]:

Only by substituting “white” for “man” does it become easy to see the pervasiveness of male-based generics and to recognize that using “man” for all human beings is wrong.

So, when Gurian asked, “please show me the harm in that term,” I didn’t take it as a rhetorical question. Gendered language matters, and I’m happy to explain further how this happens. Female-gendered word “whore” is bad, but “pimp” is good. Think of all the pejorative words you know, most take a feminine gender. Now, try to think of the male ones. Even Gurian’s use of the word “sensitive” is used almost exclusively to degrade women--we are overly “sensitive". It perpetuates this stereotype that women are somehow slaves to their hormones, which was one of the earliest reasons for why it was said that women shouldn’t be allowed to vote.

Logically, it doesn’t follow that because Flash Foxy exists, we should be ok with creating Beta Babes. In fact, one solution might be, let’s rename both groups.

As gender identity is brought to the forefront of ethical and political debate, there is even more reason to be better educated on words—cisgender, transgender—as well as generics—he, she, ze—that do matter. The debate is about education, not politically-correct rhetoric or sensitivity, and by educating ourselves, women can achieve equal positions in both language and society.

Minorities matter

One of the more frightening statements in Gurian’s article is when she states, “I wrote this essay because I don’t believe that we should be making enemies and villains out of men in response to our own fear of discomfort.” Feminism does not make an enemy of men. Fighting for minority rights does not come to the detriment of the majority. It is not one or the other.

Talking about social injustice, marginalized identity, or gender oppression doesn’t make women “overly dramatic.” In climbing, is it a problem that 65 percent of women, as opposed to 29 percent of men, are uncomfortable in the gym? Does your opinion change if we replace “in the gym” with “in the workplace”?

To those women, Gurian says, “[they] might do well to begin by analyzing themselves first before demanding that everyone around them cater to their every sensitivity.” I’m going to give Gurian a pass on this part—I choose to believe she was channeling a bit of the “overly dramatic,” herself. Respondents from the Flash Foxy survey in question made it perfectly clear that while the climbing community can be wonderful and welcoming, there is still room for improvement.

Citing recognition of Lynn Hill, Beth Rodden, or Ashima Shiraishi doesn’t mean women have equal place in the climbing community. If we want to keep talking anecdotes, I have experienced sexism inside and outside the climbing gym. Both men and women have made me feel marginalized for sexist reasons on certain occasions. Sometimes it’s been hurtful, and sometimes I haven’t even noticed until it was brought to my attention. It certainly won’t make me stop climbing. Often I choose not to address it.

I prefer to talk about evidence rather than about anecdotes. Unfortunately, there is not enough empirical evidence to show that the climbing community is some sort of gender equality oasis. Statistically-speaking, it’s unlikely. So, if you believe that sexism exists in society at large, I feel it is only rational to assume it must exist to the same extent in climbing.

It is indisputable that minorities, whether via race, religion, age, disability, or gender, have been persecuted throughout American history. The fact that Gurian is 23 years old and doesn’t see the same plight, well, good for her. It likely means, all that feminist complaining—the political marches and female-focused news—have accomplished their goal of raising awareness about lingering sexism in society and, sometimes, in the sport of climbing.

Tiffany Skogstrom, setter at MetroRock Climbing Centers, said to Crux Crush[4]:

“Up until recently, climbing was considered a male-dominated sport. Thankfully, more women are climbing strong and closing that gap. It would be nice if the route setting demographics matched the climber demographics.”

Sexism in rock climbing is perpetuated when women get less of a voice about route setting in the gym, when routes are deemed “girly”, when “small fingers” becomes a substitute for the more accurate “strong fingers”, or when any person—male or female—defines physical strength with male-centric words, like “burly” or “butch.”

Yes, more and more, women are gaining ground and recognition in rock climbing. But does that mean we should stop vocalizing our feelings about being marginalized at times? Absolutely not.

I am so happy that Gurian has the strength to speak out against naysayers, to feel unafraid in uncomfortable situations. However, I believe the persistence of voice and action by so-called complaining feminists is the reason she has that luxury today. Women have dedicated decades, centuries even, to earning that equality and the right to speak out without fear of professional, personal, or physical reprisal.

In my mother’s time, there wasn’t a single woman sports broadcaster on national television. In my time, I watched multiple women boulder V14. And, I hope, in my daughter’s time, she won’t remember that sports were once separated in gender binary. But, as always, it’s important to remember how hard women worked to get here and how much farther we must go.

It is impossible for feminism to go too far when it simply refers to equal rights for all.

-Wendy

References & Reading:

[1] http://www.nytimes.com/2010/05/23/sports/23guides.html

[2] Lera Boroditsky, Linguistic Relativity, in 2 Encyclopedia of Cognitive Science 917 (Lynn Nadel ed., 2003); and Janet B. Parks & Mary Ann Roberton, Development and Validation ofan Instrument to Measure Attitudes Toward SexistlNonsexist Language, 42 SEX ROLES 415, 415-16 (2000).

[3] Read the full paper, “A Person Paper on Purity in Language”, here: https://www.cs.virginia.edu/~evans/cs655/readings/purity.html

[4] http://cruxcrush.com/2013/06/10/secrets-of-the-female-route-setter/

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kristinsimmons · 4 years ago

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Hospitals Must Give Up Power to Save Healthcare

By KEN TERRY

(This is the sixth in a series of excerpts from Terry’s new book, Physician-Led Healthcare Reform: a New Approach to Medicare for All, published by the American Association for Physician Leadership.)

As hospital systems become larger and employ more physicians, healthcare prices will continue to rise and independent doctors will find it harder to remain independent. Hospitals will never fully embrace value-based care as long as it threatens their primary business model, which is to fill beds and generate outpatient revenues. To create a viable, sustainable healthcare system, the market power of hospitals must be eliminated.

Federal antitrust policy is not adequate to handle this task. Even if the Federal Trade Commission had more latitude to deal with mergers among not-for-profit entities, the industry is already so consolidated that the FTC would have to break up health systems involving thousands of hospitals. Such a gargantuan effort would be practically and legally unfeasible.

All-payer Systems

The government could curtail health systems’ market power without breaking them up. For example, either states or the federal government could adopt “all-payer” models similar to those in Maryland and West Virginia. Under the Maryland model introduced 40 years ago, every insurer, including Medicare, Medicaid, and private health plans, pays uniform hospital rates negotiated between the state and the hospitals.

It would be difficult for other states to replicate this approach because commercial rates are now so much higher than Medicare and Medicaid rates, said Paul Ginsburg, chair of the medicine and public policy department of the University of Southern California and a fellow of the Brookings Institution, in 2016 testimony to the California Senate Committee on Health. A more feasible approach, he said, would be to emulate West Virginia, which sets only commercial insurance payments to hospitals. In either case, however, an all-payer system would eliminate the ability of dominant health systems to extract very high rates from private payers.

Before Maryland implemented its all-payer model in 1977, the average cost of a Maryland hospital admission was 26% above the national average. In 2007, the average cost per case was 2% below the national average. However, in 2000, after the state eliminated payment adjustments based on the volume of hospital admissions, those admissions began to increase rapidly.Consequently, in 2014, Maryland started setting a global annual budget for each hospital in the state. Hospitals bill payers per admission (for inpatient care) or per service (for outpatient care) but are now expected to raise or lower their prices to remain on budget.

In the first three years after this program was fully implemented, Maryland hospital spending rose only 1.4% annually, well below the CMS target of 3.6%. Acute care admissions and gross hospital spending fell 2.7% and 2.3%, respectively, between fiscal years 2015 and 2016. Moreover, quality improved: Maryland saw a 6.1% reduction in readmissions and a 43.3% drop in hospital-acquired conditions over the three-year period.

As might be expected, providers responded to global budgets by shifting more care to the ambulatory and post-acute care sectors. Consequently, non-hospital spending in Maryland grew by 4.2% in 2016, greatly exceeding the national rate of 1.9% and offsetting the decrease in hospital spending.

Renewed Interest in States

A few decades ago, several other states used all-payer rate setting, but they all abandoned it for various reasons. Most of these laws fell prey to gaming by providers and to political infighting within the states.Today, however, other states are following the path blazed by Maryland. In 2019, for example, Washington enacted a law under which the state will contract with private insurers to offer low-cost, tightly regulated plans on its ACA exchange. These plans will pay hospitals no more than 160% of Medicare rates. While this is much higher than the law’s proponents had hoped for, it was the best they could do to get the program enacted.

It’s unlikely that most states will go in this direction; however, the federal government could adopt a national all-payer rate system. Early in the transition to Medicare for All, Congress could pass legislation requiring all private insurers and self-insured employers to pay the same rates to hospitals, with adjustments for charity care and rural needs. Such rates would have to be negotiated by the government, which would continue to pay current Medicare rates; current state Medicaid rates would also remain in place until Medicaid was folded into Medicare during the transition period. Eventually, after private insurance disappeared, hospitals would be paid at negotiated rates across the board.

If the concept of a national all-payer system seems quixotic, no less an authority than Donald Berwick, MD, former acting administrator of CMS, recently proposed limiting hospital charges to 120% of Medicare rates across the board. “This is enough revenue to offset Medicaid underpayments and should provide appropriate pressure on hospitals to become more productive,” Berwick and Robert Kocher argued in a Health Affairs Blog post. The authors also recommended that future hospital price increases be limited to the annual increase in the consumer price index.7

Ginsburg supports the idea of unified administered pricing for hospitals. As quoted in my previous book, Rx For Health Care Reform, he noted that with universal coverage, states would no longer have to funnel money to inefficient hospitals to subsidize charity care. If all hospitals received the same risk-adjusted payments for the same procedures, he said, the inefficient ones would be likely to cut their costs or go out of business. On the other hand, he pointed out, the government would have to make allowances for special circumstances. For example, CMS would still have to subsidize teaching hospitals and trauma centers, he said.8

Hospitals must divest practices

Even under all-payer rate setting for hospitals, healthcare systems that employ a lot of physicians would still have bargaining power. To eliminate their ability to raise costs by negotiating higher rates for their employed physicians, the government could simply prohibit hospitals and other non-physician-owned entities from hiring doctors or owning their practices.

There are several good reasons for doing this. Besides raising costs, hospital employment of doctors can reduce the quality of care by forcing physicians to admit patients to lower-quality facilities. Hospital-owned practices have more preventable admissions than do physician-owned practices. In addition, burnout is more prevalent among employed physicians than among independent doctors because the former lament their loss of autonomy, notes Farzad Mostashari, CEO of Aledade and a former national coordinator of health IT.

The reluctance of healthcare systems to embrace value-based care must also be considered. Compared to independent practitioners, employed physicians have less incentive to restrain hospital utilization, so the divestment of owned practices would liberate physicians who are now “aligned” with hospital business strategies to pursue value-based care under a different set of financial incentives. Hospitals’ divestment of their practices is thus a cornerstone of the physician-led reform model I’m proposing.

Corporate Practice of Medicine Laws

Many states already have “corporate practice of medicine” laws that bar corporations from employing physicians. These statutes were enacted to avoid conflicts of interest between physicians’ duty to provide the best care for their patients and their employers’ dictates—exactly the kind of conflict in which many doctors find themselves today. Most states with such laws allow hospitals to hire doctors, however, since they’re also in the business of medicine.

The sole exception is California. That state’s corporate practice of medicine law prohibits any non-professional organization except for a public hospital, a narcotics treatment program, or a nonprofit medical research firm from directly employing physicians. Unfortunately, the California corporate practice of medicine law has not had the intended effect. Instead of hiring doctors, private hospitals and health systems simply lease their services from “foundations” that stand in for professional corporations.

The federal government could enact a stronger law that prohibits hospitals from directly or indirectly employing doctors. The statute should be written so that it also applies to insurance companies that employ doctors, such as United/Optum and Anthem. The venture capitalists that have recently been snapping up physician practices to turn them over for a profit should be forced to divest those practices as well.

It’s unclear how much it might cost the government to compensate insurers and private equity firms for divesting their practices. Optum’s recent $4.3 billion purchase of the giant DaVita Medical Group might be a marker for that expense; but however much it costs, corporations cannot be allowed to buy physician practices and use them for their own purposes. Healthcare is a public good, and its overriding goal must be to improve individual and population health.

Hospitals’ Objections

Hospitals would not have to be compensated for returning physicians to private practice. As noted earlier in this book, it’s unclear whether most hospitals would be worse off economically if their medical staffs were independent rather than employed. Considering the losses that hospitals incur on practice management, some hospitals would benefit financially from divesting their owned practices. The hospitals’ main concern, consultant Michael La Penna points out, would be to prevent competitors from controlling their referring doctors. If no health system could employ physicians, that wouldn’t be a problem.

Nevertheless, many hospitals would undoubtedly file lawsuits—or a class action suit—against the government. They might claim they were being unlawfully deprived of revenues that their employed physicians generated in excess of what those doctors would generate if they could refer to other hospitals, but this might be a hard case to make in court. Government attorneys would point out that hospitals cannot legally require employed doctors to refer to them. They could also observe that hospital employment of doctors has driven up health costs and, in some cases, resulted in inferior or unnecessary care.

The hospitals might also argue that they were being forced to divest their practices without compensation for their intrinsic value. Most hospital-owned practices, however, were acquired for little more than the value of their hard assets (equipment, fixtures, etc.) and receivables. Since most of these practices are losing money, it would be difficult to maintain that the hospitals should be compensated for giving them up.

Certain kinds of physicians should continue working for or exclusively contracting with hospitals because they are indispensable to inpatient or ED care. Among these are radiologists, pathologists, emergency department specialists, and critical-care physicians. Hospitals should also be allowed to employ hospitalists, who can increase the efficiency of care; however, at-risk physician groups should also have their own hospitalists. Hospitals would continue paying members of faculty practices for teaching and supervising residents, but the clinical practices of these physicians should also be divested.

Eliminating hospitals’ market power and prohibiting them from owning practices are only the beginning of the restructuring that physician-led healthcare reform would require. But these changes are the prerequisites for the new system, and nothing else is possible without them.

Ken Terry is a journalist and author who has covered health care for more than 25 years. He tweets @kenjterry.

Hospitals Must Give Up Power to Save Healthcare published first on https://wittooth.tumblr.com/

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lauramalchowblog · 4 years ago

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Hospitals Must Give Up Power to Save Healthcare

By KEN TERRY

All-payer Systems

Renewed Interest in States

Hospitals must divest practices

Corporate Practice of Medicine Laws

Hospitals’ Objections

Ken Terry is a journalist and author who has covered health care for more than 25 years. He tweets @kenjterry.

Hospitals Must Give Up Power to Save Healthcare published first on https://venabeahan.tumblr.com

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stephenmccull · 4 years ago

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At A Time Of Great Need, Public Health Lacks ‘Lobbying Muscle’

SACRAMENTO — If there were ever a time for more public health funding, health experts say, it’s now.

Yet California Gov. Gavin Newsom and the state’s Democratic-controlled legislature are expected to reject a plea from local public health officials for an additional $150 million a year to battle the COVID-19 pandemic and protect against future public health threats.

“I’m not holding my breath,” said Riverside County Public Health Director Kim Saruwatari. “Right now, more than ever, the gaps that we have in our public health infrastructure have been exposed.”

Public health officials vow to continue making their case. But persuading lawmakers to increase spending in a time of cuts will be even more difficult because public health doesn’t carry the same political clout in the Capitol as other power players such as hospitals, doctors or public employee unions, which plow millions of dollars into lobbying each year.

“I’ve not met anybody who is a lobbyist for public health,” said Assembly member Jim Wood (D-Santa Rosa), who chairs the Assembly Health Committee. “The organizations that wear the whitest of hats have the least resources. Consequently, it’s easier to say ‘No.’”

The novel coronavirus has decimated California’s economy and, like local and state governments around the country, the state faces unprecedented budget challenges. Newsom is projecting a $54 billion deficit for the 2020-21 fiscal year, and says the state must make painful decisions before his July 1 deadline to sign a balanced budget into law.

The budget lawmakers are poised to send to Newsom on Monday does not include the additional public health funding.

Similar funding battles are taking place elsewhere, such as in Wisconsin, where the state faces budget cuts and officials are asking for more public health money.

“We need to have a plan to build up public health,” said Dr. Georges Benjamin, executive director of the American Public Health Association. “We have to figure out how to afford it, otherwise we’re going to have the same kind of economic consequences the next time something like this happens.”

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California’s 61 local health departments are the backbone of the state’s public health system, and the two leading public health organizations representing local health officials have spent pennies on the dollar to lobby the governor, lawmakers and state agencies compared with big-name groups.

The Health Officers Association of California spent almost $7,000 on lobbying from January 2019, the start of the current legislative session, through March 2020, according to lobbying disclosures from the California Secretary of State office. The County Health Executives Association of California spent $191,000 over the same period. And while other groups employ in-house lobbyists to influence Capitol decision-makers full time, the public health organizations’ executive directors pull double duty, serving as head lobbyists when they can fit it in.

Among the top spenders on lobbying were the powerful California Teachers Association, at $7.4 million, and the Service Employees International Union California, at $5.3 million.

Deep-pocketed health industry groups have also outspent public health interests. DaVita Inc. and Fresenius Medical Care, the two dominant dialysis companies operating in the U.S., spent $5.3 million on lobbying during that period. The California Hospital Association spent $3.4 million and the California Medical Association, representing doctors, spent $2.7 million. The groups collectively employ at least 15 in-house lobbyists.

In addition to paying for lobbyists, the money is used to curry favor with the governor, lawmakers and agency officials. California lobbyists are allowed to give gifts, and to wine and dine officials.

In October, for example, the California Medical Association hosted a “legislative reception” and dinner that included lawmakers, with the tab at the Napa Rose restaurant at the Disneyland Resort totaling more than $22,500.

Although political spending doesn’t always get big industry groups everything they want, it has gained them more access to the governor and other state leaders steering pandemic response plans. It has also enabled moneyed health industry groups to continue working on other legislative priorities, such as relaxing hospital seismic safety standards and opposing a proposal granting nurse practitioners the ability to work without doctor oversight.

By comparison, lobbying by public health groups consists primarily of visiting lawmakers’ offices, often accompanied by health officials from the lawmakers’ jurisdictions.

Public health leaders are regularly invited to testify at legislative hearings tackling issues like measles outbreaks, the opioid epidemic or teen vaping, but they don’t have anywhere near the “lobbying muscle” that major health industry groups have cultivated, said Kat DeBurgh, executive director of the Health Officers Association of California.

“We have no money; we advocate with our ideas,” DeBurgh said. “We don’t have millions of dollars to spend on billboards, and we can’t call in a hundred people to stand up at a hearing and say ‘I didn’t get sick because of public health measures.’”

State spending for state and county public health programs has declined over the past decade. The governor’s budget proposal for 2020-21 would continue that trend, reducing the current $3.4 billion public health budget to $3.2 billion.

Counties also are confronting a $1.7 billion loss in public health dollars due to pandemic-related declines in sales tax revenue and vehicle license fees, county health officials said, and they have asked Newsom to provide $1 billion from the state’s general fund to help make up for it.

Newsom has said the state may not be able to afford to do that given other financial demands.

Health officials say the additional $150 million they’re requesting would help them hire public health nurses and disease investigators, fund public health labs and purchase protective gear. They say addressing the underfunding of public health is especially critical now because counties are primarily responsible for providing adequate testing and contact tracing before easing stay-at-home restrictions.

“That $150 million, that doesn’t even get anywhere close to where we need to be because so much of our funding has eroded away,” said Mimi Hall, president of the County Health Executives Association of California, who is also the director of the Santa Cruz County health department.

State Sen. Richard Pan (D-Sacramento), who chairs the Senate Health Committee, is also a pediatrician. Pan has consistently pushed for public health funding during his time in the legislature, and Capitol insiders view him as a de facto lobbyist for public health.

Pan said he plans to continue to advocate for the additional public health funding — despite the economic turmoil.

“It’s hard because what public health does is invisible and you have to move people’s hearts,” Pan said.

Other lawmakers acknowledged concerns about public health shortfalls but said it would be difficult to increase spending this year. However, organizations that can afford to hire high-priced lobbying firms “will probably do OK in this budget,” said Wood, the Santa Rosa Assembly member.

He is among the lawmakers considered most friendly to public health and said he supports more money, but wants to understand how it would be spent before deciding.

“They have been underfunded for years,” Wood said. “But some of that happens at the local level, too.”

Last year, public health officials sought $50 million a year from state lawmakers to help rebuild public health infrastructure following years of recession-era budget cuts. Newsom denied their request.

County health directors say chronic underfunding has forced them to make difficult decisions to curtail spending and cut programs like public health labs — 11 of 40 have shuttered in the past two decades.

And for years, they have warned California leaders that the state would be quickly overwhelmed should a public health crisis strike. Their pleas have gone largely ignored.

The impact of the relentless cuts has been felt across the state, including in Riverside County, which has slashed its public health staff by about 60% over the past decade, leaving just 30 disease investigators, contact tracers and public health nurses to serve the sprawling region of 2.5 million people, said Saruwatari, its public health director.

“Had we had the ability to test earlier, I think we would have been able to get out in front of this a little bit more,” she said.

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

At A Time Of Great Need, Public Health Lacks ‘Lobbying Muscle’ published first on https://smartdrinkingweb.weebly.com/

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