Coronavirus Information and Misinformation

As a physician, I have been fascinated by the rapid acquisition of knowledge about the novel coronavirus and the deadly disease it causes, COVID-19. True, that knowledge may not be coming as fast as we like. But the pace of vaccine development, for example, is remarkable. But along with knowledge come ignorance, misinformation, and deception.

First, a bit of ignorance. At a rally in Phoenix, in June, President Trump fired up his audience with anti-China rhetoric. In doing so, he displayed his lack of understanding of how COVID-19 got its name. “I said, ‘What’s the 19?’” Trump said. “COVID-19, some people can’t explain what the 19, give me, COVID-19, I said, ‘That’s an odd name.’” Trump apparently thought names like kung flu, Wuhan virus, and Chinese flu were more appropriate.

We can all be forgiven for not knowing something like how COVID-19 got its technical (and not intuitively obvious) name. First, the virus that causes COVID-19 is the novel (meaning new) coronavirus SARS-CoV-2, which stands for severe acute respiratory syndrome coronavirus 2. The first coronavirus caused an outbreak of SARS in the early 2000s. This new coronavirus appeared in 2019; hence, the disease it causes, COVID-19 – CO for corona, VI for virus, D for disease – carries the number 19 for the year it started (2019), not because it is the nineteenth disease (it is not). There’s your – and Trump’s – science lesson for the day.

On to misinformation and deception. Some misinformation is due to inaccurate information. For example, this paper published that while the number of COVID-19 cases has exploded in Texas nursing homes last month, Angelina County is bucking that trend. That turned out to be based on either inaccurate or delayed information, as local physicians are aware of many local nursing home cases. The paper has updated the story as more information has come available. What is certain, however, is that our case count continues to rise.

Lack of information or incomplete information is different from deception. I have written previously about the importance of wearing masks. But mask wearing took another hit recently when our own Congressman Louie Gohmert (TX-01) not only caught coronavirus, he released a video suggesting it was the mask that gave it to him. In his own self-deception, he believes he wears a mask often, but many eyewitnesses (not to mention ever-present news media) suggest otherwise. Gohmert loves history, but history will not be on his side on this one. Deception to support a false narrative is no different than writing history to support a political agenda. Our country has seen too much of that.

When it comes to treatment, President Trump famously has advocated for unproven therapies, from bleach to the anti-malaria hydroxychloroquine. Regarding hydroxychloroquine, the results are in. With strong data that hydroxychloroquine is not effective either as therapy or as postexposure prophylaxis, the Food and Drug Administration (FDA) recently revoked its Emergency Use Authorization, saying it is “unlikely to be effective in treating COVID-19” and that “in light of ongoing serious cardiac adverse events and other serious side effects, the known and potential benefits … no longer outweigh the known and potential risks” for authorized use. Our national coronavirus guru, Dr. Anthony Fauci, minced no words in saying, "The overwhelming prevailing clinical trials that have looked at the efficacy of hydroxychloroquine have indicated that it is not effective in coronavirus disease.” 

This has not stopped President Trump from practically practicing medicine without a license. 

Trump literally is the most famous and influential person in the world. He is not alone in equating personal or anecdotal experience (I did X and Y didn’t happen; therefore, X prevented Y) with rigorous scientific study. My patients do it all the time. However, they do not have an international bully pulpit. His hubris throughout the pandemic in suggesting treatments (like bleach) is jaw-droppingly astounding. (Bleach works on your countertop, right? Why wouldn’t it work inside your body?) Not only is his medical advice suspect at a minimum, it has been dangerous. And just this last week, Trump had his election campaign Twitter account temporarily blocked and a Facebook post deleted when he posted that children are “almost immune from this disease.” When it comes to your health, listen to the doctors.

But don’t listen to quacks, especially those with pseudo-religious and anti-scientific claims. The bleach treatment claim (touted by a family of swindlers who formed a “church” in Florida) falls into that category. But the icing on the cake – so far – has to go to a true charlatan, Dr. Stella Immanuel, a Houston physician of questionable medical training and even more dubious religious authority. She famously believes in alien DNA, demon sperm and that the government is run in part not by humans but by “reptilians” and other aliens. That didn’t stop Donald Trump Jr. declared a video of hers a “must watch,” while President Trump himself retweeted the video.

Unfortunately, attempts to set the record straight regarding coronavirus misinformation by referencing scientific data are considered by far too many to be “fake news” or viewed as a conspiracy theory. Just look at Facebook for examples. I implore you to use this information for how it is intended. Educate yourself on the facts of coronavirus. There is much we don’t yet know, of course. And the vast majority of us – anti-vaxxers excepted – eagerly await a vaccine. In the meantime, please DO wear your mask – over both your mouth AND nose, please! – and DO social distance. DO use hand sanitizer or soap and water often. Together – caring for each other – we can get through this. 

Pandemics and Personal Responsibility

We have been dealing with the COVID-19 pandemic for many months now. What an emotional roller coaster ride it has been. Early thoughts of “flattening the curve” have not panned out in Texas. In Angelina County, there has been a steady rise in cases since early April.  From a healthcare standpoint, much has been written of the way the virus – as if it had a mind of its own – discriminates against minority populations. Of course, the virus itself is colorblind. However, many of the social and economic factors that affect health are not.

The Economist, in a column titled Black America in peril , quotes WEB DuBois, an African American sociologist, who said that the “most difficult social problem in the matter of Negro health” was that so few white Americans were bothered by it. He wrote that in 1899. This “indifference” to human suffering continues today and is perpetuated by a broken procedure-oriented, insurance-driven system of healthcare that is vastly too expensive for everyone, not just those without insurance. The answer is not so simplistic as providing insurance coverage for everyone (although expanding Medicaid coverage is Texas would have significant positive health and economic benefits for the state).

In the United States, these health inequities extend beyond racial classification. The attainment and maintenance of health is a multifactorial and heavily socioeconomic phenomenon.  Enter COVID-19, the illness caused by the novel coronavirus. Once again, we see higher death rates in vulnerable populations. In the middle of a pandemic, we are not going to solve systemic inequities in healthcare.

But that does not mean we are helpless.

Ironically, the most effective prevention intervention – wearing masks – has become one of the most political, with some rights-obsessed conservatives (who presumably wear seatbelts in their cars) selfishly preferring to risk harming others rather than donning a minimally irritating face covering. Why is it that those shouting “personal rights and responsibility” from the rooftops are the ones rejecting the singularly individual action that can save lives?

In a recent interview, Dr. Francis Collins, director of the National Institutes of Health and former head of the Human Genome Project (and, incidentally, a committed Christian, which should be of some comfort to those who are inclined to conflate religious and political viewpoints), was asked, “As someone who is both an acclaimed scientist and a public Christian, what’s your perspective on the pandemic as a cultural issue?” His reply is both compassionate and pragmatic. “Your chance of spreading the coronavirus to a vulnerable person has nothing to do with what culture you come from or what political party you belong to. Your responsibility is to try to prevent that from happening to vulnerable people around you. But our country’s polarization is so extreme that it even seems to extend into a place like this — where it absolutely doesn’t belong. That is really troubling because it’s putting people at risk who shouldn’t be.” 

In times of great social and political upheaval, we can become despondent and feel there is nothing we as individuals can do to fix anything. (Frankly, we put too much hope in elections.) It just so happens that in the middle of this coronavirus pandemic it is exactly individual action that is going to make all the difference. Whatever your personal ethical or religious motivation, we can all follow the Golden Rule. We can follow the command of Jesus – “Love your neighbor as yourself.”  – who undoubtedly would be wearing a mask right now. Go and do likewise. Do it for the least of these. Wear your masks. Save lives.

Money, Insurance, and Health: An Unfair Relationship

Money doesn't buy happiness, or so they say. But money can buy better health. Add one more difference between the haves and the have nots.

There are many determinants of health. Some behaviors are more under our individual control than others. The Big Three, as I like to call them – smoking, diet, and exercise – would, at first glance, seem to be entirely personal choices. That would be untrue.

Social and economic factors are a major determinant of health. These factors include education level, employment, income, family and social support, and community safety. Each of these factors is correlated with financial well-being. In fact, these social and economic factors as a whole are more important even than individual health behaviors, such as tobacco use, diet and exercise, alcohol and drug use, and sexual activity, since health behaviors also correlate strongly with educational level, employment, income, etc. In other words, we cannot address health behaviors in isolation; we must simultaneously address education, jobs, social services, and community safety if we are to improve health.

Another significant determinant of health – the one that gets the most national attention – is access to and quality of healthcare. In the United States, that access is governed primarily by insurance coverage. Every country rations healthcare; in the United States, we just happen to ration it by separating the insured from the uninsured, and that is very much along economic lines. A privileged few are wealthy enough to be able to pay out of pocket for whatever care they need, but they rarely need to. They have insurance. Good insurance. They can afford to pay their deductible, however high it may be. The working poor, however, have some income but little or no savings and often no health insurance coverage at all. They are the ones who get hit with the entire, undiscounted bill for their care. Bankruptcy is an all-too-common result.

Our healthcare system does make some patchwork provision for the truly indigent, but no one should kid themselves that charity care is in any way equivalent – either in breadth of coverage or ease of use – to what we want for ourselves. Even those with insurance are burdened with astronomical deductibles and copays that most simply can’t afford. These persistent financial burdens can force patients to choose less expensive procedures or to go without care altogether.

And then there is Obamacare.

Implementation of the Affordable Care Act, aka Obamacare, started in 2010, when 16% of the US population – more than 40 million people – were uninsured. Healthcare provided since the advent of Obamacare is, as promised, both more affordable and more available. The percentage of people without health insurance has been cut in half.

The dirty little secret is that many healthcare providers don’t take Obamacare plans, funneling patients into inadequate primary care networks and forcing them to drive long distances for more specialized care. In other words, even under Obamacare we continue to ration care with money-related barriers. No question, Obamacare is far from perfect, but it is still better than nothing.

Ray Perryman, considered by many to be the Texas economist par excellence, issued a report in April 2019 titled Economic Benefits of Expanding Health Insurance Coverage in Texas. In this report, Dr. Perryman states, "Health care needs do not simply go away because individuals do not have insurance coverage. Instead, medical issues tend to escalate and lead to higher costs and worse outcomes. Texas would gain over $110 billion in new Federal health spending during the first 10 years." For the callous who are only interested in the economic benefit accrued to the state’s coffers, this report delivers that in spades.

Guess what, though? According to the Perryman Group report, expanding health insurance coverage in Texas also would result in enhanced “health and wellbeing of individuals directly affected by receiving coverage” as well as “reductions in the numbers of uninsured, fewer emergency room visits, improved health outcomes, enhanced employment and productivity, and other desirable developments.” That is a win-win, my friends.

There has been little political appetite to expanding coverage in Texas for fear of “socialized medicine” and an ever-more-intrusive Federal Government. I get it. We can have differences of opinion about whether and how much healthcare is a “right”, how much “responsibility” is required along the way, and the role of government in healthcare. But, leveraging $9.00 in federal resources for every $1.00 in state funding that results in improved health and return on investment is a bet I would make any day of the week.

Our individual and community health depends on many things. Money – or lack thereof – is the most insidious factor. Improving the health of an entire county, as measured by the Robert Wood Johnson County Health Rankings, will require a concerted effort on both the public and private sector fronts and with both large and small scale efforts. Expanding health insurance coverage in Texas via the Affordable Care Act would be an impactful place to start.

Reflections From the May 5th Election

On May 5, 2018, the citizens of Angelina County had the opportunity to participate in what is arguably the bedrock activity of our democracy: a free and fair election. This election was not, some might argue, as significant as one involving state or national representatives. And voter turnout was certainly less than would be expected for those elections. However, approving a $70 million bond issue and electing leaders of multiple educational institutions – with combined budgets of well over $100M and employing nearly 3,000 people – is not insignificant.

The various independent school districts in Angelina County are quite used to running elections. Angelina College, on the other hand, had not had a contested election for 22 years. They pulled it off admirably. But let’s be honest. This set of elections was not perfect. There are things we can do better next time.

One criticism that was leveled at both the LISD bond and Angelina College elections was a lack of transparency. I suppose this allegation is leveled during every election, especially the national ones. Whether or not voters have not only adequate information but honest information about the issues (or people) involved is always in question. With the LISD bond vote, some voiced there was not enough lead time between the announcement of the bond proposition and the actual vote, and not enough information about how that overall decision-making process came about. However, I strongly feel the LISD board, administration, and others did a great job of educating the voters about the needs. You couldn’t live in Lufkin and not be aware that the bond issue was on the ballot. And you certainly couldn’t have had a child at the Middle School in the last 20 years and not been aware of the critical state of that campus.

The transparency criticism of Angelina College was more vague. I did hear it rumored that Angelina College wanted to become a 4-year university (and the implication was that by doing so the needs of the local population would be ignored). Nothing could be further from the truth! Angelina College has amazingly broad educational offerings for students from all walks of life. That is not about to change. But where rumors exist, there is an opportunity for education. 

One recent example may serve as a model for the future. Angelina College welcomed a number of people who came to one of our board meetings (which are always open to the public) when the board toured the Technology Workforce Building. Board members and visitors alike were very impressed with the quality and number of programs offered. This type of “open house” may be a good way to showcase periodically what Angelina College has to offer to our community. 

Another idea brought up during the election during a town hall meeting in North Lufkin was to have town hall-type meetings from time to time as a way to gather community input and to keep the community informed about what is happening at Angelina College. That is not a bad idea.

Angelina College President Dr. Michael Simon has become well known and quite visible in the community and has made inroads and contacts throughout the county. This visibility and approachability – not just of the AC President, but also of the Board – is key to maintaining strong community relationships as well as a vital way to address questions about the direction of the college.

By far, however, the biggest complaint about the election process this year was about lack of publicity, whether TV or newspaper, especially in the days leading up to the election. It seems everyone was looking for last minute information about where to vote. Examples abound of people who voted early in one election but still needed to vote in another, and where do they go? To the LISD Administration building? Slack? Angelina College? To another school district altogether? And early voting in two different locations with different hours of operation was confusing as well. Voters were counting on the local news media to make sense of a very confusing, complicated election. The news media largely failed. 

Yes, this newspaper provided some voter education about the candidates several weeks prior to the election, but the mechanics of the election itself were largely ignored. One article on Tuesday, April 24, 2018 mentioned that early voting was underway, and discussed where early voting for various races was taking place. Beyond that, and especially close to the election, there was nothing. Television coverage was conspicuously absent as well.

That being said, the number of voters participating – nearly 3,000 voted in the LISD bond election and nearly 2,100 in the Angelina College election – shows that off-year, local elections are important to the citizens of Angelina County. Compare that to the Nacogdoches ISD board election, where one candidate won by a vote of 246 to 104.

Going forward, we must not take our democracy for granted, even in the “less significant” or off-year elections. The voters of Angelina County have every right to expect that a free press in a democracy will beat the drum of voter education and voter turnout as loudly as they can. When the next off-year election happens, the news media must step up to their role to educate the public about the complexity and details of multiple different and simultaneous polling locations. Our democracy is too precious to ignore.

The Anti-Vaccination Movement is Fake – and Dangerous – News

Most vaccine-preventable diseases of childhood are at or near record lows. Vaccines prevent the deaths of about 2.5 million children worldwide every year. Yet some highly contagious diseases like measles and whooping cough still pop up where enough people are unvaccinated.

In the United States, compliance with childhood vaccinations remains quite high overall. At least 90 percent of children are getting the recommended vaccinations on time for many diseases – but not all, and not in all locales. Maintaining a high percentage of children vaccinated is important. Herd immunity occurs when a certain threshold percent of a community (such as a school) is vaccinated, reducing the probability that those who are not immune will come into contact with an infectious individual. For highly infectious diseases like measles, 90 to 95 percent of a community needs to be vaccinated to provide herd immunity. That is why vaccinations are required for our schoolchildren.

According to the Texas Department of State Health Services, students are required to have seven vaccinations in order to attend a public or private elementary or secondary school in Texas: Diphtheria/Tetanus/Pertussis (DTaP/DTP/DT/Td/Tdap), Polio, Measles, Mumps, and Rubella (MMR), Hepatitis B, Varicella (chicken pox), Meningococcal (MCV4), and Hepatitis A. Texas law allows physicians to write medical exemptions if they feel the vaccine(s) would be “medically harmful or injurious to the health and well-being of the child or household member.” All well and good.  Texas law also allows – ill-advisedly – “parents/guardians to choose an exemption from immunization requirements for reasons of conscience, including a religious belief.” The “belief” of the anti-vaccination movement is based on lies and is only “religious” in its cult-like following of a dangerous (and discredited) Pied Piper, Andrew Wakefield.

A 2017 Washington Post article states, “A leading conspiracy theorist is Andrew Wakefield, author of the 1998 study that needlessly triggered the first fears. (The medical journal BMJ, in a 2011 review of the debacle, described the paper as “fatally flawed both scientifically and ethically.”) Wakefield’s Twitter handle identifies him as a doctor, but his medical license has been revoked. The British native now lives in Austin, where he is active in the state and national anti-vaccine movement.”

The political noise made by these charlatan zealots has been difficult for legislators to ignore. This disturbing movement has been gaining traction especially in certain private schools in Texas. In one such school, the Austin Waldorf School, reportedly more than 40 percent of the school’s 158 students are unvaccinated. This is mindboggling ignorance in a “school” where tuition ranges from $11,450 to $17,147 a year.

Baylor College of Medicine professor Peter J. Hotez, MD, PhD, Founding Dean of the National School of Tropical Medicine and Director of the Texas Children's Hospital Center for Vaccine Development is truly on the front lines of the battle being waged by the anti-vaccination movement. The fact that Dr. Hotez is both a world authority on infectious disease and a parent of an autistic child hasn’t stopped the anti-vaccination movement from attacking him. It does, however, make their attacks even more sad; they have no facts to back up their case, so they just get mean (for example, saying he is in denial that vaccination caused his daughter’s autism).

This insidious – and disproven – idea that vaccines are linked to autism continues to rear its ugly, dangerous head, despite what Dr. Hotez calls “rock-solid proof” to the contrary published in peer-review journals like the New England Journal of Medicine, JAMA (the Journal of the American Medical Association), the British Medical Journal, and by organizations like the Institute of Medicine and the American Academy of Pediatrics. The data that originally was claimed to show a link between vaccines and autism was later found to be falsified. In other words, the anti-vaccine crowd is fueled by conspiracy theories and truly fake news. (Though not known with certainty, it is believed genetics and environmental exposure during early pregnancy may play a role in development of autism.)

The problem with conspiracy theories is that facts don’t matter. Those who try to argue based on facts are automatically considered part of the conspiracy. Unfortunately, President Trump was rumored early in his presidency to favor a proponent of this ‘vaccines cause autism’ theory to chair a new commission on vaccines, lending credence to the lies. Thankfully, those commission efforts appear to have stalled.

Some argue against vaccinations on the basis of parental rights. I’m so sorry, but you do not have the “right” to endanger others’ children. It is a time-honored role of government to provide a safe, healthy environment for its citizens. Just look at the public health disaster in Flint, Michigan, where the government abdicated its responsibility.

Texas needs to stop allowing nonmedical “conscientious” exemptions in our schools. Your “right” to ignorantly and dangerously keep your child from receiving vaccinations stops at the schoolhouse door. California made it tougher for parents to opt out of vaccination compliance and vaccination rates increased. Texas should do the same.

In this New Year and upcoming legislative session, may the Texas Legislature resolve to pass legislation limiting nonmedical exemptions. Here’s hoping they can ignore the cacophony of lies and claims of “rights” of those who try to stop them. Those liars endanger all our children, and that is not a right they should have.

The Demise of Polite Conversation

When did the art of pleasant conversation and open dialogue end? Every national new item – it seems – sparks vitriol that demands an alignment in one political camp or the other, one race or the other, or one sexual orientation or the other. I am afraid we have lost the ability to exchange ideas, to communicate freely, to learn from one another. To celebrate our differences rather than condemn them. Passionate speech and polite speech are not incompatible.

But I am afraid to speak, for fear my words are misinterpreted. I am afraid to write, lest my writing not encourage the thoughtful conversation I intended, but provoke a hateful backlash. Is it no longer possible to have civil discourse?

I am afraid to laugh, for fear my laughter is misconstrued. Can’t I both laugh at Tina Fay’s Saturday Night Live sheet-caking stunt, for example, as well as at Chad Prather’s “Unapologetically Southern” YouTube videos? At political cartoons of both the Wall Street Journal and the New York Times? Or is humor no longer funny, only hateful? Can’t we laugh at ourselves anymore, at our own hypocrisies? We all have them. I’m afraid we no longer recognize that; we are blinded by our self-interest.

I am afraid of social media. Facebook has unfortunately turned into a forum where, other than the annual birthday wish or mundane vacation photo, posts are filled with inflammatory opinions and commentary-as-fact with the self-righteous, ignorant replies that follow. Mob mentality sets in and people post things they would never say to your face. Hurtful – hateful – things.

Free speech is not the same thing as kind speech, uplifting speech, or frankly, intelligent speech. Nor should honest disagreement be labeled hate speech. Unfortunately, much speech today is designed to shut down the conversation by labeling one’s opponent –are they really an opponent? – a bigot, or by declaring they have no moral standing even to join the conversation. That is coercion, intimidation, and bullying no matter which side is doing it. That makes me very afraid.

I am afraid when I see fellow Christians deciding that following politics is more important than following the Ten Commandments. When they opt for strict party affiliation over and above "Thou shalt love thy neighbour as thyself" (Mark 12:31, KJV). And when they decide it is expedient to legislate hate, discrimination, and economic disparity while ignoring inconvenient moral issues like poverty and healthcare. What happened to being Jesus to those around us?

Rod Dreher, in his timely book The Benedict Option, notes that political victory does not vitiate the vice of hypocrisy. The socially liberal churches are just as guilty of blindly aligning with the Democratic Party as the fundamentalists are with the Republican Party. Could it be that Jesus understood this when he said, “Render therefore unto Caesar the things which are Caesar’s; and unto God the things that are God’s” (Matthew 22:21, KJV)?

I am afraid our clumsy, partisan involvement has resulted in a political environment increasingly hostile to the very real – and very Christian – charitable work of the Church. We must redirect our gaze outside our church walls and into our increasingly diverse and desperate communities. Putting our faith to work on the ground speaks volumes and accomplishes so much more than legislating selective moral conformity.
It often takes a crisis – a disaster? – to bring the country together to work for the common good. Perhaps Hurricane Harvey will accomplish that. It appears to be doing so; I just hope it lasts.

Dreher wrote, "The state will not be able to care for all human needs in the future, especially if the current projections of growing economic inequality prove accurate.” Christians need to rediscover an ethic that marries personal responsibility with intentional charity and corporate love and respect. I fear we may have drifted too far to do so.

But I am afraid not to try.

The Crockett Hospital’s Painful Demise

June 30, 2017 was a sad day for Crockett, Texas, our neighbor just 47 miles to the west. Little River Healthcare ended its management affiliation with the Houston County Hospital District that Friday, effectively shuttering the Crockett hospital. Nearly 200 employees are affected by the closure.

The simple sign taped on the front door said, “HOSPITAL CLOSED” and directed people to either call 911 in an emergency or to go to Palestine Regional Medical Center, the closest hospital 39 miles away.*

Though this seemed like a sudden event, in many ways it was a slow death over many years. The 49-bed Crockett hospital – most recently known as Timberlands Healthcare, under the management of Little River Healthcare since April 18, 2016 – had danced with several management partners over the last several years. Little River Healthcare didn’t even last 15 months. 

Prior to Little River Healthcare, CHC (Community Hospital Corporation) was brought in June 1, 2015 to run the Crockett hospital for an interim period after the hospital’s messy divorce from East Texas Medical Center (ETMC) in Tyler. ETMC ran the hospital for 10 years. ETMC claimed to have invested $27 million in facility and technology upgrades in Crockett, but for a hospital in the 21st century, that was a paltry amount when spread out over 10 years. 

So why didn’t Little River Healthcare succeed?

According to published news reports, Little River Healthcare blamed Blue Cross and Blue Shield for not paying $32 million it was owed; BCBS would not comment. Little River stated that when it took over the Crockett hospital, the hospital had been “cash flow negative for a long time,” but that they thought they could turn it around.

It was a helluva lot to turn around. Payroll alone was $1.5 million per month. To keep the hospital running in its current state would have cost $2.7 million per month. The Houston County Hospital District board had already increased property taxes to the max amount and even borrowed money in an attempt to keep the hospital afloat. 

LRH Co-Owner Ryan Downton was quoted as saying, “We came to the conclusion the patient volume just isn’t there in the town anymore.” The problem was not volume; it was reimbursement. You can double or triple the number of patients you see, but if you don’t get paid adequately, you are just digging a deeper hole.

Crockett is a dying town. According to the Census Bureau, its population is around 6,500 and shrinking. 39% of the population is living in poverty. Only half of those 16 years of age and older are employed. A mere 17.2% of the population 25 years and older has a bachelor’s degree or higher (and 22.4% don’t even have a high school diploma). 27.4% of the population under the age of 65 has no health insurance. In today’s medical climate, no hospital can survive with this demographic. No hospital district can squeeze enough taxes and reimbursement out of an uneducated, poverty-stricken, unemployed, and under- or un-insured demographic to keep a hospital afloat.

What happened in Crockett is, unfortunately, not unusual. At least 15 rural hospitals have closed across Texas over the last several years. Dozens of counties in Texas have just a single physician – or none at all.

I grieve for Crockett. My brother and his wife live there. I have had the privilege of treating many dear patients from Crockett over the years. We share a compassionate state representative, Trent Ashby, whose rural upbringing cannot be far from his mind in a situation like this. Trent has said he is “committed to working with all of the involved stakeholders to mitigate the loss of existing jobs and help move forward with a plan to increase access to healthcare in our area of the state.” I don’t doubt it one bit. But to be honest, there’s not much he can do. CHI St. Luke’s Health Memorial Lufkin leadership was over in Crockett even before the closing to assist some with employment, but even they can’t come close to softening the impact of nearly 200 jobs lost.

Ultimately, this falls far too heavily on the shoulders of the local Houston County Hospital District board to find a solution. They can’t pull money out of thin air or tax property any higher. And they certainly can’t get paid for healthcare when no insurance coverage or safety net exists. I hope the hospital district board can reassess and reallocate resources to focus on providing comprehensive primary care and prevention services to the citizens of Houston County, at a minimum. They also need to strengthen relationships with surrounding regional hospitals to provide higher level of care services where needed. 

Those of us outside Houston County need to open our eyes. Without a much deeper, systemic and national change in how we allocate and pay for healthcare in this country, what just happened in Crockett is going to be replicated in more and more communities around the country. Let’s help Crockett, but don’t think it can’t happen to us.

*Will Johnson, Senior Reporter for the Messenger News in Grapeland, and Caleb Beames with KTRE-TV have done an excellent job reporting on the hospital closure, and I am indebted to them for some of the details and quotes in this column.

What I Would Like to See in Healthcare Reform (Part 2)

Last month, I wrote about the bloated, incredibly inefficient federal bureaucracy that eats up hundreds of billions of dollars annually in administrative costs. I mentioned that Obamacare was not, in my opinion, true healthcare reform and did not address these inefficiencies; rather, it simply added people to the rolls of a broken system.

In this column, I am not intending to argue for or against Obamacare or whether we “repeal and replace” or go with “Obamacare Lite”, whatever that might be. I am simply pointing out areas where I see daily a burden for both patients and providers. My dream would be for simplification of much of the process of valuing, coding, and billing for healthcare services. Whether any of these thoughts are achievable or affordable, I don’t know.

Let’s start with that dreaded hospital bill. Medical billing is indecipherable. Even patients with advanced degrees can spend hours trying to interpret the bill they receive for a hospital stay. And that bill is obscenely higher than what either the hospital or the providers are going to get paid. What’s ironic is that bill often has no correlation with the actual cost of the care received or the value that the federal government (or the insurance company) places on that care. We must simplify how we charge for medical care and how hospitals and providers get paid. Unfortunately, the only patients who get stuck with the full, inflated bill are those without insurance – the ones who can least afford to pay it. That is unethical.

The overall cost of care (and your bill) is determined by coding every aspect of care, from the Kleenex and bedpan to the heart valve. For every cancer patient I treat, there are dozens of separate codes submitted for reimbursement covering all different aspects of planning, designing, QA’ing, and delivering treatment. I have no doubt that much of that could be combined into, say, a fixed reimbursement for treating prostate cancer. The problem is, when the government wants to bundle procedures together, they do it to cut overall reimbursement immensely. We still do the work; we deserve to get paid. Why can’t we work out a way to simplify, cut administrative costs, and make it a win-win both for the providers and the payors?

Along the same lines, consider a simple office visit to the doctor. The complexity required to determine whether I get paid a level 2 or level 3 office visit – which reimburse only $25 and $50 – is outrageous. These so-called Evaluation and Management (E&M) codes – and there are many of them – are based on four different possible levels of complexity of three aspects of the patient encounter: history, examination, and medical decision-making. Take history, for example. The proper level of complexity is determined by the presence or absence of documentation for four sub-elements: chief complaint, history of present illness, review of systems, and past, family, and/or social history. Do you see where I am going with this? Documentation of these encounters (consultations, follow up office visits) often takes longer than the encounter itself! And, any "error" in billing is considered fraud and abuse. It is common to hear patients complain that their doctor never looked at them, but was always looking at the computer screen. We need to simplify coding and put physicians back face-to-face with their patients.

Then there is the ever-increasing burden of deductibles and co-pays. We have such a mishmash of healthcare plans, each with their own deductibles and co-pays, that it is virtually impossible to keep it all straight. At the beginning of every year, doctors’ offices and hospitals cringe. Did a patient change insurance plans, or did their insurance lapse? What about the deductible for the new year? What about co-pays? More than half of Americans have less than $1,000 in savings. Deductibles for individuals enrolled in the lowest-priced Obamacare health plans will average more than $6,000 in 2017. Can the majority of Americans afford that? Certainly not! This is an unfair burden both on patients and on providers, who end up providing that care for free. Why? Most of it gets written off, but only after we spend a lot of personnel time and effort proving we try to bill for what we can’t collect in order to avoid the appearance of fraud and abuse. Those patients who are forced to pay may rack up credit card debt, get sent to a collection agency, and/or go bankrupt. Some go without the care they need rather than add to their debt. I truly believe co-pays and deductibles are a vestige of a bygone era. I would like to see the dollars saved by decreasing the administrative burden of healthcare go to actually paying hospitals and providers what they deserve and earn, and do away with co-pays and deductibles. There should be one price for a procedure or encounter, and that cost should be paid 100% by insurance.

What about insurance companies? In the best of circumstances, they pay fairly and quickly. But too often they can and do delay patient care and prevent patients from getting the care they need in a timely manner, if at all. They do this through a process called precertification or prior authorization (read: denial). And sometimes when they do give prior authorization, they still deny payment. This ought to be illegal. But it happens without recourse because the state insurance regulations are written in favor of the insurance companies. We need to loosen the precertification grip on the practice of medicine, and we need to be able to hold insurance companies accountable to their agreements. A preauthorization is a contract to pay.

The two hospitals in Lufkin (Woodland Heights Medical Center and CHI St. Luke’s Health Memorial) have spent tens of millions of dollars on electronic health records, not to mention what individual and group physician practices have spent, all mandated by the federal government. To what end? This was supposed to be about “quality”, but that emperor had no clothes. There is precious little improvement in communication between providers and hospitals than before electronic health records. The various doctor’s offices use a number of different vendors, and each hospital uses their own separate vendor. None of them share information with each other. I dream of a truly universal electronic health record language with seamless interconnectivity between offices and hospitals, but I sure don’t want to live through the incredible expense, time and effort it would take to get there. But I do dream.

Finally, let’s talk about rights. I have never felt that free or universal healthcare was a “right”. Hear me out. No one has a "right" to healthcare without some responsibility. That responsibility may be in purchasing insurance, but that is not the only way to contribute. The most glaring, but not the only, example is smoking. Half of long-term smokers will die of a smoking-related illness. If you smoke, the rest of us are burdened with some (or all) of your healthcare costs. On average, a pack of cigarettes in the US costs a smoker $5.51, while the combined medical costs and productivity losses attributable to each pack are approximately $18.05, according to researchers. This is where consumption taxes are attractive, but only if the tax truly goes to help offset the cost of healthcare. How we balance rights and responsibilities in healthcare is a good subject for a doctoral dissertation.

As well all hear about and read about proposed healthcare changes over the next year or two, look for what they are really trying to change, and ask yourself, are they really improving the system, or are they just trying to squeeze more people under a broken umbrella? Can they do both? Let’s hope they try.

Support Raising the Smoking Age to 21

The 85th Texas Legislative Session is in full swing. On Wednesday, February 15, a bill was filed in the House by Representative (and physician) John Zerwas (R) to raise the smoking age in Texas to 21 (so-called Tobacco 21, or T21 for short). A companion bill has been filed in the Senate. This is truly a bipartisan effort and is a great idea. For decades now, the legal drinking age has been 21. Tobacco kills far more people than alcohol, and almost all long-term smokers start smoking before they reach the age of 21.

Deep East Texas contains the lowest ranked counties in Texas for health outcomes, and part of that is due to our higher smoking rates. Nearly 90 percent of adults who smoke started smoking before the age of 18 and nearly 100 percent started by age 26. 18- and 19-year-old smokers are a major supplier of cigarettes for younger kids, who rely on friends and classmates to buy them. Raising the smoking age to 21 can help decrease our smoking rates as well as save tax dollars on future healthcare spending related to tobacco use.

Speaking of tax dollars, annual Texas health care expenditures directly caused by tobacco use amount to a whopping $8.85 billion, and we taxpayers bear part of that cost. The State Medicaid program’s total health spend as a result of tobacco use is $1.96 billion. No, we can’t save all of that, unfortunately, unless no one smokes. However, Jeffrey Fellows, PhD, in a Center for Health research report wrote, “Increasing the smoking age to 21 [in Texas] would result in 30,500 fewer smokers after three years, and lead to $185 million in reduced healthcare expenditures and productivity costs over five years. Lower cigarette excise tax revenue of $3.4 million would reduce the 5-year net savings; however the state would still generate a net financial savings of just under $182 million.”

It isn’t just about dollars; it’s about lives, too.

The Institute of Medicine predicts that smoking prevalence would decline by 12 percent if the national minimum age of sale was raised to 21. One of their models also predicted that raising the national minimum age of sale to 21 would result in approximately 223,000 fewer premature deaths, 50,000 fewer deaths from lung cancer, and 4.2 million fewer years of life lost for those individuals born between 2000 and 2019. Smoking kills.

In case you wonder if the tobacco companies think this will work, here’s a quote from a 1986 Philip Morris report (one of the largest suppliers of tobacco products worldwide): “Raising the legal minimum age for cigarette purchaser to 21 could gut our key young adult market (17-20) where we sell about 25 billion cigarettes and enjoy a 70 percent market share.” To the tobacco industry, it is always and only about market share and profit.

Raising the smoking age to 21 isn’t the only answer to our smoking and poor health epidemic. Many cities and even entire states have gone smoke-free. Texas needs to. Dietary and exercise components of good health also need to be emphasized. But if we can lessen the number of the next generation who start to smoke simply by increasing the smoking age of to 21, why wouldn’t we? That’s right… there is no good answer. For a healthier Texas and Angelina County, support Tobacco 21.

What I Would Like to See in Healthcare Reform (Part 1)

I often tell people that if all I had to do was take care of patients, life would be grand. It is the countless hours of dealing with the administrative aspects of healthcare that have practically ruined the practice of medicine for many physicians. You should care; it takes away from our time with you.

TheHill.com, noted that physicians and their staff spent over 15 hours per week complying with quality reporting requirements and that for every hour a physician spends with patients, an additional two hours are consumed completing administrative tasks related to the visit. This meaningless (to physicians, anyway) work has costs in both time and money, leads to burnout, and is increasingly mentioned as the reason for early retirement. I, for one, found myself daydreaming in a committee meeting the other day and I calculated that it was 3361 days until my 65th birthday. That's 9 years, 2 months, and 15 days. No, am not planning to retire early, but sometimes I sure wish I could. Healthcare needs reform.

The average person thought Obamacare WAS healthcare reform. In reality, Obamacare did nothing to actually improve the healthcare system; it simply added more people to the rolls. Don't get me wrong. Having more people insured is not a bad thing. But we need more than just additional enrollees in a broken system.

After Trump was elected, there was an initial, overly optimistic assumption that Obamacare was on its last leg. Recent infighting among policy makers suggests Obamacare may be more like the proverbial cat with nine lives. I only hope true reform is part of whatever "replacement" or "repair" Congress and the President come up with.

In particular, let's hope some of that reform will significantly scale back a bloated, paranoid bureaucracy that sucks hundreds of billions of dollars out of healthcare that could go to those who actually care for patients. And, perhaps, some could go back into the taxpayers' pockets.

Back in 2012, Berkshire Hathaway CEO Warren Buffett called healthcare "the tapeworm of the American economy". To be more accurate, the federal government is healthcare's tapeworm. In an online article in Medical Economics last year, Ryan Gamlin, who studies what drives inefficiency, waste, and harm in U.S. healthcare, found that "as countries spend a larger percentage of their healthcare dollars on administration (as opposed to public health, or providing patient care, for example), things get worse for patients and healthcare providers. High administrative expenditures seem to be associated with negative experiences of providing and receiving healthcare." That is a nice way of saying there's a ton of money wasted going to paper pushers.

Helen Adamopoulos, writing in Becker's Hospital Review in 2014, noted that US hospital administrative costs account for more than 25% of hospital spending, more than double that of Canada, for example, where hospitals receive global, lump-sum budgets. In contrast, US hospitals must bill per patient or DRG (diagnosis-related group), requiring additional clerical and management workers and specialized IT systems. They also have to negotiate payment rates with multiple payers with differing billing procedures and documentation requirements, driving up administrative spending. Not to mention all the personnel, time, and IT required to satisfy CMS’s (the Centers for Medicare & Medicaid Services) monstrous appetite for "quality" and "safety" data, with the ever-present threat of fraud and abuse hanging over every unintentional misstep.

What should be a simple process of billing for services provided is a minefield. And anyone who has ever tried to understand a hospital bill knows it is an impossible task. Aliya Jiwani, writing in BMC Health Services Research, notes that billing and insurance-related (BIR) administrative costs in 2012 were estimated to be $471 billion and that fully 80% of this spending, which provides little to no added value to the healthcare system, could be saved with a simplified financing system. Jiwani predicted that greater use of deductibles under Obamacare will likely further increase administrative costs, stating, "Empirical evidence from similar reform in Massachusetts is not encouraging: exchanges added 4% to health plan costs, and the reform sharply increased administrative staffing compared with other states."

A CNBC report of a Health Affairs study tagged the extra administrative costs of Obamacare at more than a quarter of a trillion dollars, an average of $1,375 per newly insured person, per year, from 2012 through 2022. The Health Affairs blog authors reported, " The overhead cost equals a whopping 22.5 percent of the total estimated $2.76 trillion in all federal government spending for the Affordable Care Act programs during that time."

What do I wish we could be different in our healthcare system? In March, I will discuss some specific changes that would reduce the administrative burden on healthcare providers and, in many ways, return us to a simpler, more direct, and frankly better transaction of healthcare.

History and Medicine in Angelina County

I recently came into possession of Angelina County Medical Society meeting minutes dating back 80 years, from 1936 to 1954. These archives were kept by Dr. W. D. Thames. A walk down medical memory lane with these records is remarkable. Some facts are simply mundane. For example, dues in 1936 were $10.50 per member - $488 in today’s dollar. That makes our current County Medical Society dues of $100 seem like a bargain.

More fascinating to me is that even though the practice of medicine has changed profoundly over the last 80 years, little of the economics and politics of being a physician has changed. For example, charity care issues were documented back in 1937. We struggle with that today. The physician-patient relationship – what today would be assessed by patient satisfaction scores – was the topic of lectures in 1938.

The broad legislative issues on the table today are hardly different than those in 1938 when a Legislative Committee was appointed. Scope of practice issues with optometrists and chiropractors were discussed way back in 1941. In 1953, Dr. Arnett “encouraged members of our society to join the American Association of Physicians and surgeons, which is a political organization of doctors. Its purpose is to stop socialized medicine.” (What would they say now?)

Some issues from the past seem frankly quaint today. In 1952, Dr. Arnett was to appoint a committee to investigate a physician who took out an ad in the Lufkin Daily News, apparently quite the no-no at the time. The next month’s minutes document how that physician “apologized and said it wouldn’t happen again”. The Society even had a secret ballot to vote whether he was guilty or not guilty of advertising. He was acquitted on a 9 to 2 vote.

Admirably, the Angelina County Medical Society minutes also contain notable evidence of community involvement and civic leadership. In January, 1940, the Society was holding joint meetings with city and county officials and the Chamber of Commerce directors to discuss a federal aid program for the building of a county hospital. It was these very discussions that spurred local industry leaders to join together to build a new hospital. The legend we pass down is that in 1941, Arthur Temple, Sr., President of Southern Pine Lumber Company, W.C. Trout, President of Lufkin Foundry & Machine Company, E.L. Kurth, President of Southland Paper Mills, and Col. Cal C. Chambers, President of Texas Foundries, along with ten other businesses and industries, joined resources, refused federal funds, and raised one million dollars to build the non-profit Memorial Hospital (now CHI St. Luke’s Health Memorial). But we have forgotten the groundwork was laid the previous year by the healthcare community, the city and county leaders, and the Chamber of Commerce, all working together. Such cooperation and leadership can still take place today.

Another more poignant event occurred in February, 1954. Then President Dr. Gail Medford “read a letter from the Negro Chamber of Commerce wanting help from the Angelina County Medical Society in their plan to improve sanitary conditions in the colored community. Drs. Taylor and Spivey, City and County health officers, were appointed to work with the colored organization.” We cringe now, thinking about Jim Crow segregation and disparities in neighborhood services and conditions. But do we recognize similar disparities in healthcare today? Are we addressing the needs of the indigent, uninsured and underserved populations among us? Is the medical community as approachable today as it apparently was in the segregated 1950s?

Technology has revolutionized healthcare over the last eighty years. But technology cannot replace the heart. Let us not forget our calling, our oath, and our love for the patient. The practice of medicine should never be just a job. It is a profession.

I invite everyone to the Salute to Healthcare banquet on Thursday, November 10, 2016. Help us recognize and honor those in our community who set the standard in healthcare and who are true to the calling – the profession – of medicine. Call the Chamber at 634-6644 for ticket information.

The Significance of an Ethical Foundation

Last month, I wrote about the role of the hospital Ethics Committee and commented that open and honest communication between healthcare professionals, patients and family solves most ethical dilemmas. That assumes we are speaking the same ethical language and have a common ethical foundation, both in medicine and in society at large. In our increasingly pluralistic society, that is no longer a safe assumption. The recent Orlando attack on a gay nightclub showed us that people can do terrible things when ostensibly motivated by a perverse ethic or belief system.

Ethics, at its core, is simply a set of moral principles or values which guide an individual’s – or a religion’s or a government’s – actions. In the United States, that governing set of principles has been rooted, sometimes more and, regretfully, sometimes less, in a Judeo-Christian ethic based on the inherent (and, according to the Declaration of Independence, Creator-endowed) equal value of every individual. In medical ethics, the two related guiding principles date much further back, to Hippocrates around 400 BC: the sanctity of human life and the concept of “first do no harm”.

Modern medical ethics rests on four major pillars: Autonomy (the patient decides), Beneficence (does it help), Non-maleficence (don’t harm), and Justice (is it fair or impartial). In other words, do our medical recommendations and interventions respect the rights of the individual patient, are they helpful, do they not do harm, and are they fairly and equally available. It is a tall order to keep these broad principles in mind, especially when trying to balance competing interests with limited resources.

American history in general – and medicine in particular – has tended to elevate Autonomy over and above her sister principles. We are a pioneering, individualistic “I did it my way” society. The winds appear to be changing, both in healthcare (with the move toward universal healthcare) and in political discourse. The traditional emphasis on the individual’s responsibility in his or her own pursuit of happiness is taking a back seat to the notion that it is the government’s role somehow to guarantee equal outcomes, seemingly regardless of effort, for all. For example, we just completed a groundbreaking primary season where an avowed socialist garnered significant support on a platform of income redistribution.

Amidst this sea change of process, of roles and responsibilities, can we agree on a common ethic to guide us?

I firmly believe that regardless of who we elect and within whatever system of healthcare delivery we end up with, a Judeo-Christian emphasis on the inherent, God-given value of each and every individual (whether black or white, gay or straight, handicapped or not, born or unborn) is uniquely protective of both the individual and society as a whole. Mass shootings and terrorist acts demonstrate that our moral ethic (or lack thereof) determines our behavior. To paraphrase a Dostoevsky character in The Brothers Karamazov: If God does not exist, all things are permissible. A disturbing corollary appears to be: If my moral ethic condones and encourages killing lots of people, why not do it?

Motivational speaker Zig Ziglar once said, “Since belief determines behavior, doesn't it make sense that we should be teaching ethical, moral values in every home and in every school in America?” Whose values? All belief systems are not equal. Governments and terrorist organizations which do not value the individual, inherent worth and equality of “all Men” – to again reference the Declaration of Independence – are not going to treat their (or our!) citizens equally. In fact, they may kill them (and us).

If I had to choose one word to describe the ethical principle I pursue in life and in healthcare, it is love. Not hate, not selfishness. Not religious dogmatism. And not a “love” of government, cult or fanaticism that discriminates or (God forbid!) kills others in the name of some god or political whim. It is the pure Christian commandment to “Love your neighbor as yourself.”

Is this idealistic? Absolutely. Is it achievable? No, to be honest. But that doesn’t mean I stop working tirelessly, incessantly toward that goal. Our country should do the same.

Let's Not Get Trumped

I am ashamed. I wrote that phrase recently on a Facebook post of two Finnish friends who are looking across the ocean with a combination of disgust and disbelief at the Trump phenomenon. Consider my vow to avoid public political commentary this year broken.

The first president I ever voted for was Ronald Reagan in 1980. I have voted Republican ever since. But I will not vote for Trump if he is the Republican nominee. Don’t worry… I’m not voting Bernie Sanders, either. The socialist movement in the Democratic Party is just as disaffected and radical as the Trump wing of the Republican Party… and just as dangerous to our American way of life. We are not Finland. But with Sanders, you know what you get. With Trump, all bets are off.

Trump's campaign speeches are bullying and belittling, full of empty rhetoric and supportive of (indeed, encouraging) violence. I don't care how angry you are at the “establishment”; there is no place in American politics for Trump’s inflammatory, derogatory speech. Yes, he has a right to say those things. But shame on each and every American who jumps into the pig sty with him, eggs him on, and actually votes for him! Regrettably, all of us on the sidelines have been stained by Trump’s mud.

To my fellow Christians in particular, Trump – in his campaign rhetoric, at least – displays no evidence of being a Christian, which he claims to be. There, I said it. Forgive me if you think I am being judgmental, but I simply don’t see the fruit. This is not about waffling on various social issues on which well-meaning Christians can and do disagree. Consistently, his public demeanor is far from “Love God”, much less “Love thy neighbor as thyself.” If Trump loved anything as much as himself, we’d all be better off.

I don’t get how so many people – Christians in particular – are following like lemmings in the wake of a reality show Pied Piper – one who plays an enticing (but fundamentally deadly) tune. It is ironic that Jerry Springer, who long ago helped set the nasty reality TV tone that is emblematic of Trump’s campaign, can’t believe we would elect Trump as president.

I get that Trump is tapping into popular themes like immigration and "making America great again" – whatever that means – but the reality TV emperor has no policy clothes. In effect, Trump supporters are saying they want an angry president who doesn't know what he is doing. That is both startling and dangerous. Anger does not lead to sound foreign policy.

Trump's narcissism, lack of a verbal editor and foul speech suggest a personality disorder at a minimum. More worrisome, they expose a disturbing lack of compassion and respect for the innate value of other human beings. Add in a questionable moral compass and I truly fear the international fallout with his impulsive finger on the nuclear trigger. He’s just plain scary.

Ultimately, this column is not really about Trump. It is about me. By what ethic do I live my life and cast my vote? Do I believe that might makes right? Does the end justify the means? God forbid!

What about you?

If the Republican Party implodes (or if the Democrat Party nominates a Socialist), I do not blame the "establishment". I blame voters on both sides of the aisle who can't tell the difference between a slot machine and a voting booth. They just blindly pull the red or blue lever hoping for a jackpot. If only they could see, with that approach we are all going to lose.