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Patients can be the greatest teachers

What physicians do isn’t normal.

I remember leaving the soccer fields of Emory University, where I was an All-American player, to arrive in medical school to a room full of cadavers.

Dr. Scott A. Kelly

Dr. Scott A. Kelly

That’s just not normal.

Several years later, I was working as a resident in the emergency room at Atlanta’s Grady Memorial Hospital. I had to tell two girls, ages nine and 10, that their mother had just expired as the result of a car accident,  that she wouldn’t be there to hold their hands and walk them through life.

I wanted to linger with those children and comfort them as best as I could. Yet duty called. Grady is a major trauma center, and I was informed that another patient in critical condition required my immediate attention.

Having to leave those two young girls like that — that’s just not normal.

I am not unique. My experiences as a spine specialist with Resurgens Orthopaedics are no different than those of any other physician. We have all been present during emotionally grueling circumstances. Over the years, we have hardened ourselves to these situations, perhaps owing to necessity, to one degree or another. I know that I have been guilty of misplacing my priorities at times.

Being a physician is a great responsibility and not something to be taken lightly. I treasure that responsibility. Part of that responsibility, I believe, is to bring compassion back to the doctor-patient relationship.

I think back to when I was at the Medical College of Georgia and I was struggling with the vision of medicine that was being presented. It was quite different from what I expected, and I was somewhat disillusioned. So I went during office hours to seek the advice of Dr. Thomas Weidman, an assistant anatomy professor.

“Create your own vision,” he told me.

Those are words I have tried to take to heart during my career as a physician. When I ponder the subject of showing more compassion to patients, a couple of passages from the modern Hippocratic Oath come to mind (the italics, for emphasis, are mine):

“I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug.”

“I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.

“I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.”

 

A young mother’s illness

 

The surgeon’s knife and the chemist’s drug – those are the skills that we learn in medical school, during our residencies and as young physicians. They are the skills of the trade and without them, we cannot practice.

However, we must remember the humanity in our patients and, perhaps equally as important, in ourselves. Think of an orchestra conductor who only looks at his sheet music without listening to the efforts of the musicians performing before him. If he does not feel what they are emoting and respond in kind, his efforts will fall flat. He will fail.

Such is it with medicine. As a young medical student, resident and impressionable young doctor, I kept journals. I can think of a memorable instance in which listening to a patient helped me to make a correct diagnosis and, significantly, offered the patient some peace.

It was the fall of 2000 and I had just started private practice. A married mother of two young children – I’ll call her Katie – had begun experiencing numbness. She was training for a marathon and her primary care physician counseled her to rest.

The symptoms, however, continued. She visited her primary care physician again and was referred to a psychiatrist. She was advised of the effects of stress on her body, which the psychiatrist thought might be causing Katie some depression. He offered a prescription drug.

A friend of hers encouraged her to see me for a second opinion. I sat and listened to her story. A highly educated woman, Katie suspected that she might have multiple sclerosis and asked me if I would order an MRI of her brain. I agreed. Her relief was palpable.

I spoke to the radiologist the next day. The MRI revealed, in fact, that Katie had MS. As I waited in my office later that day for her to arrive and hear the results, I kept thinking of the impact the disease would have on her life, her marriage and her children.

I tried to comfort her as I broke the news. “I knew it,” she said. She was laughing and crying at the same time.

Katie told me that even though the news was terrible, she felt relieved in a way to know that she was not crazy, that what she felt was “real.” Again, what we physicians do is not normal, so we should try to bring as much “normality” as possible to a patient in a moment like that. In a way, listening to a patient can be empowering.

In recounting this story, my intention is not to gloat. I detest few things more than a doctor’s gloating when another misses a diagnosis. In a case like Katie’s, I don’t feel I deserve any credit for making the diagnosis. Katie did it. All I had to do was to listen to her.

When a patient’s symptoms fall outside the norm, I often think of Katie. She serves as a constant reminder to me to listen to my patients. She has made me a better physician.

And what I learned from her remains true. Regardless of how technologies change, we actively seek as physicians to improve quality of life and relieve pain, and the most important tools that we physicians will ever have are our ears.

 

Scott A. Kelly, M.D., is the co-medical director of Resurgens Orthopaedics’ Spine Center and the author of “What I’ve Learned From You.”

 

Complaints about health insurers’ ‘narrow networks’ are misleading

Premium increases for Georgia’s insurance exchange health plans beat regional and national rates, according to a recent study by the Urban Institute, cited by Georgia Health News.

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Graham Thompson

This is good news, as many Georgians shopping on the exchange will see only a modest increase from 2014 options, and some rural parts of our state will experience a significant decrease.

What is driving this good news?

The study’s conclusion cites increased plan competition and “high-value” medical provider networks — used by health plans to reduce costs and provide incentives for high-quality and cost-effective care — as holding down premiums.

It should be noted that all Georgia Association of Health Plans (GAHP) members offer plans on the exchange, with three member plans offering options statewide, continuing our commitment to serve all Georgians. It should also be noted that high-value networks are working as an option for cost-conscious consumers.

Detractors often label high-value provider networks as “narrow networks.” Although there is no recognized definition of this term, lobbyists for high-cost doctors use it to portray some plans as insufficient.

The word we really should be focusing on is not “narrow,” but “affordable.” Consumers demand affordable options with access to doctors and hospitals with the best track record of delivering high-quality, cost-efficient care.

These plans are real, robust insurance products, as current federal and state laws ensure consumers have access to an array of physicians and hospitals and require coverage of “Essential Health Benefits.”

GAHP plan members are committed to providing timely, accurate information about doctors participating in all plans, utilizing websites and 800 numbers aimed at enhancing customer education.

Given the challenges of provider consolidation and health insurance taxes, health plans need the flexibility to offer high-value products as an option for Georgians to continue to hold down higher health plan premium increases.

If Georgians want a plan with a broader group of providers, they can pick such a plan. Those options are definitely available.

But if consumers are not picking plans with more providers — and most consumers are not — it’s simply because they favor high value over high cost.

 

Graham Thompson is executive director of the Georgia Association of Health Plans.

State’s benefits decisions hurting the health of the working poor

Before the ACA (Obamacare) was enacted, one in five Georgians were without insurance, one of the nation’s highest rates. But Gov. Nathan Deal and state legislative leaders have opposed the law, refusing to put together a state insurance exchange to help our citizens to get affordable health insurance policies.

Jack Bernard

Jack Bernard

Deal and the legislative leaders also have blocked expansion of Medicaid, although 60 percent of Georgians support this measure (per Schapiro Group poll) and our state now has the second-highest rate of uninsured people in the nation.

The case for expansion becomes even more compelling when one considers that expansion is 100 percent paid for by the feds for the first three years, eventually falling to a 90 percent federal share permanently. Further, a Georgia State University study finds expansion would create 70,000 sorely needed jobs in a state that has one the nation’s worst unemployment rates.

We currently have more than 850,000 uninsured Georgians. In 2014, Gallup issued a report which showed that states with full ACA implementation had a drop in the rate of the uninsured that was over three times as fast as that in states like Georgia, where expansion is resisted and where there is a refusal to accept federal monies for expansion.

Lately, the situation deteriorated even further. According to Deal’s proposed budget (now modified by the House, see below), part-time “non-certified” public school employees would lose their health care benefits in 2016. Who are these 11,500 people? They are the folks driving our children to school every day (bless them) and serving their lunches.

To make matters worse, many of these employees are not eligible for Medicaid, because Georgia decided not to expand the program to more of the working poor. They will also be ineligible for federal insurance premium subsidies, because the ACA assumed all states would be required to expand Medicaid and therefore ended the subsidies. (The Supreme Court has since said expansion can’t be required.) The state’s failure to expand Medicaid created a “gap.”

What would this situation mean for these employees and their families? Let’s take a look at a few real-life examples from the Augusta area:

John Palmer

John Palmer

Employee 1: She is fighting for her life, having fought breast, ovarian and lung cancer. Treatment has become more expensive with each occurrence. She goes for chemo and scans, but still reports to work every day she can. If her insurance is lost, there will be no treatments.

Employee 2: A bus driver’s husband had six heart attacks within 48 hours. During his ICU stay, doctors found severe inherited arterial coronary disease. There is no cure, only constant monitoring by physicians and multiple prescription medicines.

Employee 3: She takes an array of medications for severe COPD, seeing specialists several times a year. Even a minor cold or allergy flare-up can force her into the hospital.

Under political pressure, the House has recently reworked this portion of the Deal budget, leaving the school workers’ benefits in, but dumping the cost ($102,825,000) on local governments and local taxpayers. Our state elected officials have generally managed to shortchange education, teachers and education support personnel over the last decade. This trend continues in the latest budget. We will soon see how the Georgia Senate will handle this item.

We all understand the need for fiscal responsibility, but do we want to balance the state budget on the backs of the working poor and educators? We can, and should, expect more from our elected officials.

 

Jack Bernard was the first director of health planning for the state of Georgia. He also was an executive with several national health care firms and an elected official.

John Palmer is a Georgia public school teacher and spokesperson for TRAGIC, an educational advocacy group.

 

Shunning productive Georgia workers is bad for us all

For individuals with developmental disabilities, the typical choices after finishing high school — getting a job or going to college — are difficult to accomplish, if not impossible. There are thousands of Georgians with developmental disabilities, and the unemployment rate for this group is more than 85 percent.

Kathy Keeley

Kathy Keeley

As the 2015 Georgia General Assembly begins working on the budget, advocacy groups are like ours are asking legislators for an increase in appropriation of state funds of $1.96 million in the FY 2016 Department of Behavioral Health and Developmental Disabilities budget. This would fund a program covering “supported employment” for students with developmental disabilities transitioning out of high school.

Supported employment is an individualized approach to match individuals with developmental disabilities with employment opportunities in typical workplaces in the community. The goal is to have them working alongside people without disabilities earning minimum wage or above.

In fiscal 2015, DBHDD authorized just $10.9 million for supported employment services, but the need far exceeds what that amount can provide. Current waiting lists can be as long as nine years or more through waiver-based services.

Currently, Georgia lags far behind the rest of the nation in helping people with disabilities find gainful employment. Developmental disabilities are defined as severe, lifelong disabilities that limit critical life functions that occur before the age 22. They include autism, Down syndrome, and cerebral palsy, among many others.

For every $1 spent on helping individuals by investing in supported employment programs, the state gets an economic return of $1.61. Beyond that, the return to the workers and their families is incalculable. It means the difference between a life of isolation at home and full participation in the world of work and the community.

Without this program, these students would likely finish high school, only to return home and sit on the couch, waiting until they qualify for a Medicaid waiver to pay for their services.

Through our “HireAbility” campaign, All About Developmental Disabilities is educating Georgia’s employers, dispelling their fears and preconceptions about hiring individuals with developmental disabilities. Some employers worry that these employees will not be able to keep up with the pace of work or that their customers will disapprove.

In fact, the opposite is true. Studies have shown the benefits of hiring people with developmental disabilities. Lower turnover, lower absenteeism rates, strong job loyalty, increased employee morale, and enhanced corporate image are just a few of the benefits when employers hire people with disabilities.

Many Georgia employers have experienced the benefits of hard-working, reliable, committed and caring workers who often can outperform their non-disabled peers. Publix, Walgreens, the Home Depot, the Georgia Aquarium, PF Chang’s, Kroger, and Hamilton Health Care in Dalton can testify to the strengths and abilities of these workers.

It’s vital for us to work together to make sure job opportunities exist for all. This funding will allow individuals with developmental disabilities to experience the satisfaction and economic security that only a job can provide. By focusing on their abilities, not their disabilities, we can promote workplace success and improve lives.

Kathy Keeley is the executive director for All About Developmental Disabilities (www.aadd.org)

 

A smarter way to make health care more available in Georgia

Kelly McCutchen

Kelly McCutchen

Georgia, like many states, faces a host of health care challenges: access to care, too many people without health insurance, failing rural hospitals and unsustainable health care spending that is crowding out other priorities – for government and for families.

The debate over how to address these challenges has Georgia seemingly stuck between two options: Expand a government program (Medicaid) with its own long list of challenges . . . or do nothing. It is a false choice; Georgia has an opportunity to put forth a better solution.

It won’t be easy. You start with the high hurdle of political acceptance by conservatives in Georgia and liberals in Washington. But it’s worth the effort. What if Georgia became the leader in creating innovative ways to provide better health for more people at lower cost?

There are three principles to keep in mind:

First, at a minimum, we should be willing to spend what we are already spending, but in a more rational manner. Hundreds of millions of dollars are spent annually in Georgia on uncompensated care for the uninsured. The uninsured may not have insurance, but they do get sick. One way or another we all pay for their care in a way that is terribly inefficient.

Second, money should follow people. Yes, we need to make sure we support the institutions and providers that make up our safety net, but the solutions should be people-centered instead of institution-centered.

Third, innovation requires flexibility and choices. Micromanaging every last detail is a recipe for the dismal status quo.

Keeping these principles in mind, what if we convert the funds we spend subsidizing the care of the uninsured (after the fact) into vouchers or refundable tax credits? Low-income individuals could use these funds to buy into an employer’s plan or purchase private insurance. The amount could be adjusted by age and health status, providing purchasing power for older and sicker individuals and creating an opportunity for cost savings by keeping these people healthy.

Flow of funds to the safety net

But what if these low-income individuals can’t find insurance at a price they can afford? Or what if they simply choose not to sign up? The unused funds should follow the people to where they get their care: the safety net providers in each community. Instead of seeing low-income uninsured patients or patients with Medicaid’s low reimbursement rates, rural hospitals and clinics would see patients with private insurance coverage or receive a predictable flow of funds to subsidize the care. Even if no one signed up for insurance in the first year, needed funding would immediately flow to safety net providers. Eventually, these newly empowered low-income individuals would create the customer demand for new ways to provide access to affordable health care.

Georgia is the perfect state to allow the powers of disruptive innovation to attack our health care challenges. Georgia already is a leader in telehealth and health information technology. We have one of the largest and most successful charity care networks in the nation. Visit almost any technology incubator in Georgia and you are likely to find a startup company focused on using technology to provide better care to people with chronic diseases. Combining these assets in unique ways could make Georgia a leader in solving the nation’s health care problems, too.

This initiative would require approval from the General Assembly and the governor, then a waiver from the federal government. Copying the successful model of Georgia’s criminal justice reforms, a bipartisan commission could be tasked with hammering out the details of the proposal. This approach resulted in the criminal justice reform bills passing the General Assembly unanimously. Broad, bipartisan support of a health care reform bill would make a veto from the federal government very difficult.

The cost of the program would be less than what the federal government is willing to spend on Medicaid expansion, so Georgia would be in good position to limit the cost to the state’s taxpayers.

Georgia’s Republicans and Democrats can work together to solve this long-term problem and, in the process, empower individuals and local communities. If it’s successful, both sides could claim some political credit. More importantly, it would improve the lives and health of hundreds of thousands of Georgians.

 

Kelly McCutchen is president and chief executive officer of the Georgia Public Policy Foundation. He is a native of Ellijay,  and a graduate of Georgia Tech.  He writes on education, tax, health care and economic policy.

 

 

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