I am pretty into reducing, reusing and, of course, recycling. I can't bear throwing away a piece of paper that has writing on only one side of it- I keep it in an incredibly large "scrap paper bin" and try, in vain, to write as many notes and checklists as possible. (I feel like I have saved at least half a tree in my lifetime due to this incredibly inefficient, drawer-cluttering process). I am a huge proponent of reusable shopping totes and washable lunch bags; and I force this practice on others. I take short showers every 1-2 days. Although my boyfriend thinks this is more out of laziness and bad hygiene, I'd like to think the few liters saved per month could be the very ones putting out a brush fire in California. I eat gluten-free, not by choice, but I think that it might have fewer additives and pesticides, so that has got to count for something. All in all, I consider the carbon foot-printing of my personal life pretty respectable.
In my professional life, however, I am creating a shocking amount of poorly-disposed-of waste. And I am not really sure what to do about it. I see possibilities for reducing and recycling everywhere (reusing is not such good idea in the hospital setting). Here is an example from the Labor and Delivery unit at a particular hospital. Immediately before a Cesarean Section begins, the circulating nurse pours the contents of three plastic liter bottles of sterile fluid into basins. These clean bottles, having touched only a nurses gloved hands, are then usually thrown in the medical waste bin. In this OR, there were apparently issues with (highly educated) health care practitioners mistakenly throwing bodily-fluid-saturated OR waste into the regular trashbags. Complaints were made by the Environmental Services staff regarding this misdisposed waste, and the decision was made to remove all regular (white) trashbags from the OR so that all OR waste would be disposed of in red (Regulated Medical Waste) trashbags. According to the NY Department of Health, RMW must be autoclaved, which may cost a hospital 10-20 times more than the disposal of non-regulated waste. For the life of me, I can not imagine who would approve this egregious waste of the hospital's money. Before each case, a tech must construct the operating table, which entails the opening of anywhere from 20-50 packages (all individually wrapped for sterility). This may be done minutes or hours before the patient enters the Operating Room. All the sterile wrappings are, by default, thrown in the medical waste. At the start of the operation, in this particular OR, there is usually already a full red trashbag of perfectly clean wrappings.
I have been unable to locate a reliable source of statistics about medical waste, but the Internet consensus is that US hospitals generate 2 million tons of medical waste annually. Certainly, any piece of material saturated with blood should be disposed of in the hazardous waste bags, for the protection of the people who handle the garbage. However, in the above example, empty bottles could be recycled the in the same way as empty bottles of drinking water. Trash generated before the surgery begins, having never touched the patient, can be safely disposed of in the same way as office trash. Some education, common sense and conscientiousness on the part of health care professionals could probably save a hospital a substantial amount of money. And maybe- just maybe- a portion of the savings would trickle down to make American health insurance more affordable?
Friday, July 25, 2008
Wednesday, July 16, 2008
Young Adults
Very few of the people that I know have a Primary Care Doctor. In New York City, there is a large demographic of young adults who are "trying their luck" in the big city for a few years after college. Most of my friends have jobs that provide health insurance, but there are many young adults who remain uninsured for various reasons. If the young adults are unemployed, sporadically employed or health insurance is not available to them for some other reason, interim health insurance is available, at a hefty price. (Interesting fact: I thought COBRA was a type of insurance, but it is an acronym for the Consolidated Omnibus Budget Reconciliation Act, which states that health insurance must provide a group rate insurance to people who fit certain criteria, one of the criteria being recent college graduation). Paying insurance when you are not sick and do not anticipate becoming sick is a fairly responsible thing to do. I venture to guess that when money is tight and it comes down to health insurance or beer, many fearless, healthy young adults are going to forgo the insurance. The group I find more interesting, however, is the group of young adults who dutifully pay for their health insurance but never bother to find a primary care doctor. I, unfortunatley, fall into the category, as do most of the people I know. In our defense, we are in a new city where we do not know any Doctors, and neither, apparently, do any of our friends. We no longer have our mothers to nag us to make an appointment or drag us to the yearly physical. Furthermore, we are very healthy, active people; far too active, in fact, to schedule a doctors appointment, much less go to an appointment on a weekday.
Anyway, I have decided to implement a little survey to some nurses who were hired last summer. I know that they all have insurance, because working at the hospital you must take some kind of insurance unless you can prove that you are otherwise insured. So, after a year living in New York, I would like to see what percentage actually have a primary care doctor. From my experience, I would guess that less than half do. Stay tuned....
Anyway, I have decided to implement a little survey to some nurses who were hired last summer. I know that they all have insurance, because working at the hospital you must take some kind of insurance unless you can prove that you are otherwise insured. So, after a year living in New York, I would like to see what percentage actually have a primary care doctor. From my experience, I would guess that less than half do. Stay tuned....
Sunday, July 13, 2008
Avastin- let the market sort it out
http://www.nytimes.com/2008/07/06/health/06avastin.html?ex=1373169600&en=194376ea36fc6226&ei=5124&partner=permalink&exprod=permalink
I keep thinking about this article that I read in the New York Times last weekend. The article addresses the moral dilemma surrounding Avastin, a widely used cancer drug of astronomical price whose treatment potential has recently been called into question. [If your curious, Avastin works by blocking VEFG (vascular endothelial growth factor), thereby preventing tumors from growing blood vessels]. Avastin, currently used by 100,000 Americans, costs $4,000- $9,000 a month (generating about 3.5 billion dollars a year in revenue for Genentech). In the first clinical trial, Avastin showed no statistically significant prolongation of life in patients with advanced breast cancer. In a second trial, Avastin was shown to add an average of for additional months of life to patients with advanced colon cancer. It was FDA-approved in 2004 and has enjoyed great success, being prescribed on and off-label to patients with many types of cancer. In a recent, larger, study, no statistically significant difference was proven with Avastin.
The article raises important question- how great a disparity between price of treatment and value of treatment will society allow? And who gets to make the decision? The Declaration of Independence tells us that we are all entitled to "Life, Liberty and the Pursuit of Happiness". How far does that entitlement go? Does every person "deserve" every possible treatment, with no economical constraints? Health care is the only sector of our capitalist economy where there is such exorbitant spending with such little accountability. We are in a indisputable health care crisis. Tremendous insurance costs render 47 million Americans uninsured. General Motors is laying off workers by the thousands because it can't afford the health insurance for it's employees and retirees. In light of this, I wonder how Medicare justifies paying for 80% of an off-label treatment that, in the best (colon cancer only) clinical trial, was shown to add only four months of life. (I say Medicare, because that is the insurance quoted in the article, I don't know the reimbursement ranges of private insurances).
Having said this, no one close to me has ever been offered Avastin. Put in that position, who knows how much I would think the hope of four more months would be worth? How can you put a price on someones life? And isn't that what health insurance is for, anyway? To the last question, I answer no. Health insurance, whether self-paid or otherwise acquired, must not become a carte blanche for any possible intervention in the world. There must be a basic, reasonable amount of care paid for by insurance. Resources are limited and finite. Drugs that have not proven valuable (meaning a benefit appropriate for the cost) must be viewed as elective treatments. In the same way that health insurance will pay for the removal of a mole that may be cancerous (and thus detrimental to the health) but not a mole for purely vanity purposes, Avastin must be judged on it's actual, demonstrable benefit. If this benefit is not worth it's cost to the insurance company, the patient must forgo the treatment or find alternate means for affording the treatment. This will force the price of Avastin to adjust to the level that a patient deems worth it. The supply will have to meet the demand in terms of price. Either Genentech will find a way to make Avastin affordable enough to the people who want it, or Avastin will no longer be available.
Of course there must be more clinical trials to discern the efficacy of Avastin. At the same time there must be large financial incentives for the companies to find a more effective and more affordable drug. In the mean time, Genentech stock holders can cross their fingers that insurance companies will continue to pay upwards of $100,000 dollars a year out of a fear that they will look like bad guys if they refuse to pay.
I keep thinking about this article that I read in the New York Times last weekend. The article addresses the moral dilemma surrounding Avastin, a widely used cancer drug of astronomical price whose treatment potential has recently been called into question. [If your curious, Avastin works by blocking VEFG (vascular endothelial growth factor), thereby preventing tumors from growing blood vessels]. Avastin, currently used by 100,000 Americans, costs $4,000- $9,000 a month (generating about 3.5 billion dollars a year in revenue for Genentech). In the first clinical trial, Avastin showed no statistically significant prolongation of life in patients with advanced breast cancer. In a second trial, Avastin was shown to add an average of for additional months of life to patients with advanced colon cancer. It was FDA-approved in 2004 and has enjoyed great success, being prescribed on and off-label to patients with many types of cancer. In a recent, larger, study, no statistically significant difference was proven with Avastin.
The article raises important question- how great a disparity between price of treatment and value of treatment will society allow? And who gets to make the decision? The Declaration of Independence tells us that we are all entitled to "Life, Liberty and the Pursuit of Happiness". How far does that entitlement go? Does every person "deserve" every possible treatment, with no economical constraints? Health care is the only sector of our capitalist economy where there is such exorbitant spending with such little accountability. We are in a indisputable health care crisis. Tremendous insurance costs render 47 million Americans uninsured. General Motors is laying off workers by the thousands because it can't afford the health insurance for it's employees and retirees. In light of this, I wonder how Medicare justifies paying for 80% of an off-label treatment that, in the best (colon cancer only) clinical trial, was shown to add only four months of life. (I say Medicare, because that is the insurance quoted in the article, I don't know the reimbursement ranges of private insurances).
Having said this, no one close to me has ever been offered Avastin. Put in that position, who knows how much I would think the hope of four more months would be worth? How can you put a price on someones life? And isn't that what health insurance is for, anyway? To the last question, I answer no. Health insurance, whether self-paid or otherwise acquired, must not become a carte blanche for any possible intervention in the world. There must be a basic, reasonable amount of care paid for by insurance. Resources are limited and finite. Drugs that have not proven valuable (meaning a benefit appropriate for the cost) must be viewed as elective treatments. In the same way that health insurance will pay for the removal of a mole that may be cancerous (and thus detrimental to the health) but not a mole for purely vanity purposes, Avastin must be judged on it's actual, demonstrable benefit. If this benefit is not worth it's cost to the insurance company, the patient must forgo the treatment or find alternate means for affording the treatment. This will force the price of Avastin to adjust to the level that a patient deems worth it. The supply will have to meet the demand in terms of price. Either Genentech will find a way to make Avastin affordable enough to the people who want it, or Avastin will no longer be available.
Of course there must be more clinical trials to discern the efficacy of Avastin. At the same time there must be large financial incentives for the companies to find a more effective and more affordable drug. In the mean time, Genentech stock holders can cross their fingers that insurance companies will continue to pay upwards of $100,000 dollars a year out of a fear that they will look like bad guys if they refuse to pay.
"So what do you do?"
My job seems to be the only thing I am able to talk about. While I never considered myself a particularly skillful listener, I always thought that I had the necessary social intelligence to let other people have their chance to talk. Since I started my new job, I seem to have lost that social intelligence. Sometimes I feel like I have verbal seizures. I often repeat in my head, don't talk about your job, don't talk about your job, people are only pretending that they care, they really don't want to hear about how the loss of skin turgor coupled with decreased vasculature (due to decreased myocardial contractility, decreased blood volume [secondary to decreased thirst mechanism and subsequent dehydration]) makes the placement of a 18-gauge IVs in 80-year-olds really difficult. And then I "come to" and realize i've been blabbering on about false positive d-dimers and how they lead to expensive, lengthy and pointless CT scans and MRIs in obviously healthy, hypochondria-ridden young girls. Advice to other nurses (and myself): this is not what people want to hear when they meet you for a drink. They either want to hear about the really cool trauma that you saw (note: withhold details about punctured organs and "disgusting" bodily fluid) or they want you to just smile and say "Very exciting, just like Grey's Anatomy, and, yes, there are a plethora of Dr McDreamys that I would love to set you up with. How is your (finance) job?"
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