ObamaCare: What's in it for you?

A while back, Teej and I were discussing the Affordable Care Act (ACA) and what it could mean for him. I'm not sure my explanation of how it works at a practical level was particularly clear or useful. But this medium is a little more conducive to presenting complex concepts. So I'm going to try to lay it out here and illustrate in concrete terms what it means, using real live (not hypothetical) newly available numbers to go with it. This will all be from the perspective of an unmarried guy in his '20s, as that seems to be the readership, though the only thing that really changes for different household sizes is the particular numbers.

One disclaimer before we begin: this post is about the new insurance marketplaces being set up as we speak, and most people will not be buying through those marketplaces. If your income is lower than the thresholds we're going to talk about below, you'll be eligible for Medicaid--though the exchange website will still probably be your first stop on the way to getting coverage. The politics and policy of the Medicaid expansion are a topic for another post (or series of posts!). And if you get insurance through work, this won't apply to you. This is really about what happens to people who have to buy insurance on their own.

Enter The Exchange Marketplace

CBO's February 2013 estimates

By way of introduction to all this, it's important to remember the basic change that's happening later this year and why. Most people with private health insurance have it through their jobs in the form of employer-sponsored insurance, the red piece of the pie to the right. While the ACA does affect those people a bit (mostly in the form of some new benefits and consumer protections), the insurance reform provisions of the law are primarily aimed elsewhere: at the individual market, the place where people who need to get insurance on their own shop for it.

In most states, people shopping in the individual market have far fewer consumer protections available to them than do people with employer-sponsored insurance. The insurance policies themselves are skimpier, premiums are more volatile, and "pre-existing condition" is a much deadlier phrase. And since those folks are buying insurance on their own (hence the name "individual market"), they lack the "strength in numbers" advantages that people in employer-sponsored group coverage enjoy. Only about 5% of the population currently gets health insurance through the individual market but expansions in private health insurance coverage will swell the ranks of the individual marketeers. But beyond people simply not being able to afford coverage or being turned away for pre-existing conditions, the individual market doesn't act much like a market:

One of the great challenges in buying health insurance has been a highly fragmented market. Individuals and group purchasers lack a reliable means for seeing their choices in one place and in a manner that allows them to compare what the plans cover, which providers are in various plans’ practice networks, how cost-sharing might differ, and how numerous competing plans might compare on key measures of quality performance. Nor has there been an active, consumer-oriented system for assuring that insurance plans that are offered in the individual and small group markets provide comparable coverage, cover the benefits that are considered essential to any health insurance plan, have accessible provider networks, and are accountable for specific measures of health care quality.

That's from an excellent and relatively succinct overview of what problems health insurance exchanges--recently re-branded by HHS as Health Insurance Marketplaces--are being created to correct and how they're going to do it. The short, short version is that they're creating competitive, transparent, consumer-friendly marketplaces where the playing field is level between you and the insurance companies.



Starting in October of this year, people will be able to start shopping for insurance through them. While they were originally envisioned as being primarily state-designed and state-operated, political intransigence has led to HHS having to step up and run federally-facilitated exchanges in 33 states. But that's a story for another time. Let's get into what's going to be sold in these marketplaces.

Tiers of a Clown

While factors like your gender and
medical history won't raise your premiums,
smoking will.

Since part of what makes a market a market is offering consumers intelligible and meaningful choices, exchanges will have a way of organizing health insurance plan options to allow more apples-to-apples comparisons between them. Plans will be grouped into four tiers, named after metals:

Platinum

Gold

Silver

Bronze

The tiers represent varying levels of generosity across the plans. Note that this does not mean a platinum plan is offering more benefits than a bronze plan. All plans are required to offer a set of essential health benefits, a fairly comprehensive set of services across ten categories of coverage. Plans can offer more but they can't offer less.

The metal level instead refers to the health plan's actuarial value, a measure of what proportion of the costs for those benefits it can expect to cover for a given population. A bronze plan, for instance, will have roughly a 60% actuarial value, meaning that it will pay 60% of the costs of those benefits and enrollees will pay for the remainder of the costs through deductibles and coinsurance when they go to get care. These plans are the skimpiest metal plan, not in the sense that they cover fewer benefits but in the sense that they require you to pay for a larger proportion of them if you need to use those benefits. The tradeoff is that the monthly premiums will be lower.

Silver plans have a 70% actuarial value, gold 80%, and platinum 90%. As you climb the metal ladder, the monthly premiums increase but so does the generosity of the plan; if you need to use covered medical services, swankier metal plans will pick up more of the tab. Silver plans, as we'll see, are sort of the default option but shoppers in the exchanges can choose a plan from any metal tier they like.

The Tax Credit

If you're eligible, when you shop for coverage through an exchange a subsidy will be made available to you to help you pay for an insurance plan (and if you're eligible for Medicaid instead, the exchange application process will let you know that and help you in enroll in it). Technically you'll get a refundable, advanceable tax credit. Refundable because its value can actually exceed your total tax burden, in which case the government is giving you money. Advanceable because you don't have to wait until tax time to get it back, it's available upfront when you go to buy insurance--so none of that money actually has to come out of your pocket.

Though HHS is still working the kinks out of their draft of the application process, they've produced a video to show you what the process will be like for a single person:



But how does the tax credit work? Its value will be pegged to the cost of a certain silver plan in your marketplace--the second cheapest silver plan--through a fairly simple formula:

[Value of the federal subsidy] = [Cost of 2nd cheapest silver plan] - [your required contribution]


What that says it that there's some amount of the premium you'll have to pay for the second cheapest silver plan, and then the federal government will pay for the rest of it. Or in picture form:

As we'll see a little more clearly later, this particular insurance plan just serves as the benchmark for calculating the size of the federal subsidy to which you're entitled. You don't have to actually buy that particular silver plan to get the tax credit.

Structuring the subsidy this way helps to retain the incentives and dynamics that should undergird markets. More expensive plans cost consumers more, as they should. Consumers still have incentives to buy less expensive plans (or at least carefully weigh the costs and benefits of buying more expensive plans) and insurers still have an incentive to offer the cheapest plans in the market, because those are the plans that will be most attractive to shoppers--even the subsidized ones.

Show Me the Money!

I mentioned that you have a required contribution to your premium which--along with the price of the second cheapest plan available to you--determines the size of the tax credit you get. If your income is under four times the poverty line, your contribution is limited to a certain percentage of your income. The particular percentage will depend on your income; it increases on a sliding scale, as you can see from this table pulled right from the ACA:

In the case of household income (expressed as a percent of poverty line) within the following income tier:	The initial premium percentage is--	The final premium percentage is--
Up to 133%	2.0%	2.0%
133% up to 150%	3.0%	4.0%
150% up to 200%	4.0%	6.3%
200% up to 250%	6.3%	8.05%
250% up to 300%	8.05%	9.5%
300% up to 400%	9.5%	9.5%

A major part of the "affordable care" bit of the law's title is a reference to this table. The idea is that people buying health insurance in an exchange will have their income protected, i.e. the amount they have to spend on health insurance premiums will be capped at a certain percentage of their income.

So for instance someone at 150% of the poverty line will not be asked to pay more than 4% of his income on health insurance premiums. Meanwhile someone at 250% of the poverty line won't be asked to pay more than 6.3% of his income on premiums.

Now since we're thinking specifically of a single person, we can translate those percentages into dollar amounts. I'm going to base this on the 2013 poverty thresholds, which have the poverty line at $11,490. It might be slightly higher next year when the tax credits and exchanges become available, but that won't change what we find here very much. Here's the table above, recast in terms of the caps on what folks of various incomes pay on their premiums:

In the case of household income within the following income tier:	Maximum monthly premium (low end)	Maximum monthly premium (high end)
Up to $15,282	$25	$25
$15,282 up to $17,235	$38	$57
$17,235 up to $22,980	$57	$121
$22,980 up to $28,725	$121	$193
$28,725 up to $34,470	$193	$273
$34,470 up to $45,960	$273	$364

Remember that those numbers rise smoothly on a sliding scale within each tier. This should give you a rough estimate, based on your income, of the premium you would be asked to pay for the second cheapest silver plan in your area.

Not So Fast!

Seems simple enough, right? You don't even need to know what the actual premium the insurer is charging is going to be because your personal contribution to your premium is spelled out right there in black and white. But it can be as simple or complicated as you like.

This is because of the way the value of your tax credit is calculated. As we saw, the federal government is offering you some fixed sum of money equal to [Cost of 2nd cheapest silver plan] - [your required contribution]. That means if you buy that second cheapest silver plan, all you pay for your premium is your required contribution, as pulled from those tables above.

But you don't have to buy that particular plan. You're well within your rights to buy a more expensive silver plan, or a gold or platinum plan. The government still gives you that fixed amount of money and you have to cover the rest of the cost of the plan. Obviously that means you would end up paying more--maybe a lot more--than the tables above would suggest.

On the other hand, you could also opt for a cheaper plan. That might be the very cheapest silver plan or a bronze-level plan. In that case, you still get the full value of the subsidy, meaning your own required contribution is going to go down.

Let's All Go to Vermont

Let's illustrate with a real example using actual premium values. Right now exchanges are soliciting interest from insurance companies who might participate later this year and they're asking them to submit information on how much they will charge in premiums. Most states (and the federal government) are going to let those numbers trickle in over the next 1-3 months. But one state, Vermont, has finished that process and recently made the numbers public.

They put together two tables collecting those premium numbers here. (As an aside, you'll notice that there are two tables because one lists prices for Standard Qualified Health Plans (QHPs) and one lists prices for Non-Standard Qualified Health Plans. In putting out feelers to insurance companies to see if they would sell in the exchange, Vermont made clear that participating insurers will have to sell plans with certain standard designs, meaning the plans' deductibles and co-insurance requirements for different services have to be what the state specified. You can see the specifications for the standard plans starting on page 50 of this document. However, in addition to those plans the insurers are allowed to innovate and sell other "non-standard" plans with different designs. Both kinds of plans "count" when figuring out what the cheapest silver plan is.)

Let's look at just silver plans available to a single person shopping in the Vermont exchange. Between the two insurers selling them, Blue Cross Blue Shield of Vermont (BCBSVT) and MVP, there are eight different silver plans you could choose from. The second cheapest one on the market is BCBSVT's non-standard "Blue for You" plan (listed on the second page of that document), weighing in at $413.03 per month.

So now we have the value of the tax credit you have to play with, dear Vermonter. It's going to be $413.03 minus your required monthly contribution. So let's suppose you're making exactly $22,980. Convenient! According to our table, that means that if you buy that Blue for You plan your contribution to the premium will be $121 per month. The government's subsidy to you is $413 - $121 = $292. (For simplicity's sake, let's ignore the 3 cents).

But maybe you don't want to buy the Blue for You silver plan. You're an extravagant type and you want the top of the line: MVP's $614.77 per month platinum plan. You can go buy it and put the government's $292 toward it but that means you're on the hook for paying the other $322.77 every month.

Or maybe you want to go the other way. You're looking to minimize your own premium contribution and so you hone in on the cheapest metal plan on the market: BCBSVT's "Blue for You CDHP" bronze plan. That's $350.08 per month. You still get to put the government's $292 toward that plan, which leaves you on the hook for only about $58 per month. Significantly less than the $121 you'd be paying if you went for the silver plan to which the subsidy's value is pegged. Indeed, for people with lower income than you (who are thus eligible for a larger federal subsidy), they can get their own contribution down to zero for some of the bronze plans. Of course, their own required contribution for the benchmark silver plan is correspondingly smaller than yours and so they don't lose much in paying it and opting for the more generous coverage of a silver plan.

Back to the figure, this time expanded. You can see from the varying total heights of the bars below the difference in total plan costs from plan to plan. The platinum plan on the far right is the most expensive and so it's correspondingly the tallest. It also requires you to pay the most for your premiums, since the federal share of the costs (the tax credit) has a fixed value.

Because the value of the tax credit is pegged to the value of the second cheapest silver plan, its value is the same regardless of which plan you buy.

As this visually (hopefully) makes clear, you can vary your actual monthly contribution to the premium, represented as the red share of the total premium, by choosing cheaper or more expensive insurance plans.

The numbers in this section, of course, are unique to Vermont. The actual premiums and the number of plans to choose from will vary from state to state, although the numbers aren't likely to vary substantially from the Vermont examples we've looked at here.

A word of caution

It's worth noting that there's a special benefit to buying a silver plan. The ACA doesn't just provide subsidies for health insurance premiums, it also provides subsidies for cost-sharing. That means it will help you pay for part of your deductible if you need care, as well as part of your co-pays or co-insurance. However, while the premium tax credit can accompany you to any coverage tier and be applied to any plan, the same is not true of the cost-sharing subsidies: the cost-sharing subsidies are only available if you buy a silver plan. If you buy a bronze plan to get your premium contribution as low as possible, should something happen and you actually need care you'll have a very large deductible (in Vermont's standard bronze plan designs, the deductible is around $2,000) to grapple with and no help in doing so. Something to keep in mind.

Secret Option F

There's one other option in the exchanges I haven't mentioned. This is a plan type that's available only to people under 30 (or people who otherwise don't have access to an affordable plan). It's called a catastrophic plan and is designed specifically to offer less generous coverage than any of the metal tiers. Why is this desirable? It was felt that since young people are less likely to use coverage, they'd be more willing and eager to buy a lower-premium, high-risk "young invincibles" plan than more standard coverage.

However, if you choose the catastrophic option you get no financial assistance. While you can take your federal tax credit and put it toward any plan bronze through platinum, you cannot put it toward a catastrophic plan. The entire premium is on you. And it probably goes without saying that you'll also have no help in paying for the cost-sharing, which by design is sizable in these plans.

Everybody Got That?

Hopefully this was clear enough to give you a sense of what you can expect if you end up buying insurance through an exchange. Comments welcome--if something's unclear or underdeveloped, I'm happy to revise.

One more thing: if the exchange does its job right, you won't actually have to know any of this. You'll fill out the application and it will figure out what you're eligible for and explain to you what you can and cannot apply it to. You won't need to sit there with a calculator and a set of tables to figure things out.

26

Bones, I don't want to be lectured.

Spock!

Are you not out there?

In an interview with Astrobiology, Lineweaver emphasizes that the "Planet of the Apes" hypothesis is that "such a niche exists - that human beings developed a big brain because there was selection pressure to move into this evolutionary niche. Another way of saying it is that smart organisms are better off and more fit than stupider organisms in all kinds of environments, and therefore we should expect any species anywhere in the universe to get smarter like we consider ourselves to be. 

"Carl Sagan called them "functionally equivalent humans." That's what the SETI program has been based on. There is a big polarization in science between physical scientists like Paul Davies and Carl Sagan and Frank Drake on the one hand, and biologists like Ernst Mayr and George Gaylord Simpson who say that life is so quirky that human beings would never evolve again. If a species goes extinct, it doesn't come back. There may be a niche that opens when a species goes extinct, but the same species or even anything similar to it does not re-evolve into that niche. 

If intelligence is good for every environment, we would see a trend in the encephalization quotient among all organisms as a function of time. The data does not show that. The evidence on Earth points to exactly the opposite conclusion. Earth had independent experiments in evolution thanks to continental drift. New Zealand, Madagascar, India, South America... half a dozen experiments over 10, 20, 50, even 100 million years of independent evolution did not produce anything that was more human-like than when it started. So it's a silly idea to think that species will evolve toward us. 

"If you go to these other continents and ask zoologists, Lineweaver continues, "What do you think is the smartest thing there? Is it trying to become human? Is it any closer today than it was 50 million years ago to building a radio telescope? I think the answer would be no. If that's the answer, then there is no trend toward human-like intelligence, and this whole idea of intelligence being convergent is just an empty claim based on what we want to believe about ourselves."

Blooper alert

While Reihan Salam ponders Should Congress create a national health-care exchange? he makes a glaring factual boo-boo in building the case against state-based exchanges:

While the federal government will cover the entire cost of the subsidies designed to make the insurance plans offered on the exchange affordable, state governments will be free to impose regulations and mandates on insurance plans that could raise their cost. State lawmakers might want to reward medical providers by deeming that various expensive and non-essential medical treatments must be covered by insurance, but state governments will be under no obligation to bear the cost of having done so.

Doesn't anybody fact check anything anymore? States can indeed tack on additional benefit mandates beyond the baseline "essential health benefits" but they most assuredly do have to pay for them. Quoth the law:

(B) States may require additional benefits

(i) In general Subject to the requirements of clause (ii), a State may require that a qualified health plan offered in such State offer benefits in addition to the essential health benefits specified under section 18022 (b) of this title.

(ii) State must assume cost 

A State shall make payments—

(I) to an individual enrolled in a qualified health plan offered in such State; or
(II) on behalf of an individual described in subclause (I)
directly to the qualified health plan in which such individual is enrolled; 

to defray the cost of any additional benefits described in clause (i).

Yes, there's actually a line in the law that says "state[s] must assume cost" in reference to any additional benefits they want to mandate. Salam is disqualified from opining on this for a while.

The Ethics of CPR...and Slow Codes!

In light of recent events, I thought it would be appropriate to discuss some CPR-related material, while at the same time dabbling in medical ethics and the "slow code," which many people aren't aware of, even if they do work in a hospital.

I'd venture to guess that most everyone has heard of cardiopulmonary resuscitation, and most people would know that you perform the procedure when someone's heart has stopped beating.  I'm also fairly certain that a ton of people harbor some misconceptions about CPR, including when to start, when to stop, the traumatic nature of the procedure, and the possibility for saving the patient, among other things.  It's actually a pretty complicated (albeit very imperfect) procedure, wrought with inconsistencies between individuals performing it.  Let's talk about the procedure itself first, then we'll get to the ethics, which is a whole other sack of budding potatoes (shout out to TJ!)

Ok, so your 67-year-old uncle, Billybob, just collapsed on the dining room floor after a delicious meal of said potatoes.  He's definitely not responsive, not moving, and not doing much of anything, really.  However, your aunt Bettybob is active enough for the both of them, screaming at the top of her lungs and doing all sorts of unconscious panicky convulsions near his lifeless body.

What next?  After your "Oh **** (insert favorite explitive)" moment, you check Billybob's pulse, and there isn't one.  That instant, not 10 seconds later, not 20 seconds later, you HAVE to start CPR, and you HAVE to give it your full concentration. Tell Bettybob to call 911, and be confident whatever unintelligible utterances she gives to the dispatcher will summon the appropriate help.

Image from CNN

The whole purpose of CPR is to get blood to the patient's brain and, to a much lesser extent, all other vital organs.  That means you have to push hard enough to squeeze the heart ventricles between the sternum and the spine, which requires about 2 inches of sternal depression to accomplish.  This isn't a trivial fact.  Two inches is a big distance, especially for a chest cavity.  The rule is if you think you're pushing hard enough, push harder.  Notice how to hold your hands and where to put them with the above picture.  On top of that, you have to keep a fast rate, of at least 100 beats per minute.  Too slow, and you don't have adequate cardiac output.  Too fast, though, and you don't give the heart enough time to fill before the next beat.  As it turns out, the Bee Gees, despite their girly octaves, made a terrific contribution to medicine with their hit song "Stayin' Alive" (appropriately named, as well!).  Most anyone in the hospital has this song in their head while they're performing compressions, and it gets you a rate around 120-130, which, coupled with excellent, deep compressions, is about as good as you can get for the utility of CPR.  

Memorize that chorus.  It could save your Billybob's life.  

As you can imagine, our Billybob is in for a beating.  Most commonly patients suffer numerous broken ribs, bruises, and the occasional pneumothorax (due to a rib puncturing a lung) during CPR.  In 30 hypothetical minutes, to the Bee Gee's catchy beat (no doubt stuck in your head for the rest of the day, as it should be), a rotating team of 200lb men would pound on his chest 3,600 times.  It isn't pleasant, and I can certainly say I've had the unfortunate experiences of hearing the "snap" of few fragile ribs while performing CPR, especially on the elderly.  Just consider the train wreck equivalent you or someone you care about will be going through when "all resuscitative measures" are taken.  This isn't necessarily a bad thing, just something that isn't often taken into consideration especially when end-of-life decisions are being made in the geriatric population.

Just a few more points, then we'll get to the philosophical/ethical gobbledygook.  So now you're doing CPR on Billybob, pushing really hard on his chest, and you realize you haven't been giving him any breaths.  Its just you and Bettybob, still in her frenzied state, in the house waiting for the EMTs.  Here's another important point, one which has been slightly controversial in the past few years, but one which the American Heart Association has put to rest once and for all in March of 2012.  DON'T GIVE BILLYBOB ANY BREATHS.  I think we're all so put off by the mouth-to-mouth aspect of CPR, that a lot of people might not jump right away to help an unfortunate pulseless soul because they fear swapping spit with this (near) lifeless stranger.  Well fear no longer!  Even if your worst enemy, plagued with a variety of STDs and infected lip rings, manages to lose grasp of his pulse, you can effectively perform superb CPR without inflating his lungs.  Continuous, deep chest compressions are what matter.  The only situations in which you should stop compressions are when you are switching off with someone else, you are delivering a shock through a defibrillator, the patient gets a heartbeat back, or the patient is declared dead.  In our case with Billybob, the only thing we're really trying to do with CPR is to save him time until the medics get there to possibly deliver a shock.

And now the bad news.

Billybob's chances aren't good.  The fact that he lost a pulse puts him in really bad shape, but the fact that you started CPR immediately gives him the best chance he can hope for.  When we talk about successes with CPR, we not only consider if the patient's heart started back up again eventually, but we also account for neurological function.  As an example, if CPR is administered less than 6 minutes after the onset of cardiac arrest, at 10 minutes of CPR time only about 50% of people who survive--we'll get to this in a moment--will have a satisfactory (i.e. awake and communicating) neurologic recovery.  At 30 minutes of CPR in the same patient, that percentage drops to about 2%.  If it takes more than 6 minutes to start CPR, the percentage of survivors with a satisfactory recovery plummets to 20% at 10 minutes of CPR, and is 0% at 15 minutes of CPR.  This is why you generally stop CPR after 30 minutes when resuscitation was started early ( less than 6 minutes), and 15 minutes after CPR was started late ( more than 6 minutes) after the initial arrest.  The reason the percentages are low, even for those with quick initiation of CPR, is because most individuals either do not provide adequate chest compressions or even adequate compressions are not providing necessary blood flow to the selfish brain.  And the final depressing stat about CPR:  The survival rate, at best, meaning the entire procedure is performed wonderfully with perfect chest compressions and the patient has minimal arrest time and relatively quick defibrillation, is about 10%.  This, combined with our previous stats, means that about 5%, at most, will have a satisfactory neurological outcome and survive their ordeal.  It sucks, but not if you or a loved one is the 1 out of 20 with this outcome. If you can administer a shock in the first 3-5 minutes, depending on the study, survival can reach an astonishingly underwhelming 30%, but still amazing compared to later shocks during the process.

The point of all this is that everyone, no matter what their education level or walk of life, could be in the position to save someone's life through proper administration of prompt CPR and good compressions, to the tune of a Bee Gees classic.  If you don't like the Bee Gees, learn the damn song anyway.

I now suggest you grab a beer (I'm sure as hell going to), listen to "Stayin' Alive" again, and put on the good ol' thinkin' caps in preparation for the second half of the longest blog entry I've ever written in my life.

The Ethics of CPR...and other things

At the beginning of the post, I linked to a trending news story in which (in very concise neanderthal-like sentences):  Old lady (87) in old lady living facility goes kerplat.  "Nurse" lady in said facility calls 911.  "Nurse" lady proceeds to tell 911 lady that it is the institution's policy to NOT perform CPR on their residents.  911 lady flips out.  No one else does CPR until the medics arrive like 7 minutes later.  Old lady dies.

This opens a whole kettle of worms, which are in turn infected with parasitic worms, in turn infected with more...well, you get the idea.  Point is, we have a shitload of worms and a nasty kettle that no one is going to eat from ever again.  Let me just preface this by saying that, if I were in "nurse" lady's shoes, and the old lady didn't have some kind of DNR order or advance directive that I was aware of, I would have done CPR on the old lady.  And I think the reason that this story is getting into the news in the first place is because it strikes a dissonant chord with the majority of people's morality eardrums.  It's great news to in fact see that humanity still has perky morality ears, but I think we have to look deeper into why this whole thing bothers us so much...or maybe it doesn't bother you at all, in which case we'd want to look into that too.

For me, this story is bothersome on a few levels.  First and foremost, the "nurse" lady says she is a nurse.  If anyone is going to do CPR for the old lady in this situation, it's her.  Knowing what we know now about CPR stats and outcomes, CPR has to be started immediately if there is to be any hope of recovery.  The old lady, undoubtedly, was starting with a worse projected outcome simply due to her age and whatever other comorbidities she had.  It's even more important, then, to start prompt CPR in this situation if we really want to have a chance of bringing her back from the purported "white light."

What really confuses me in this instance is the conflict between calling 911 and the refusal of care on "nurse" lady's part.  Her intent behind the 911 call was to obtain life-saving care for the old lady (at least I presume that's why you call 911 in this situation), but there was no attempt for bridging care from a medical professional between arrest time and EMT arrival.  If you're trying to save the old lady's life, then you call 911 and do everything you can to save her life.  If you're not attempting to save the old lady's life, as if she had a DNR, then you call the coroner.  You don't, however, half-ass resuscitation efforts when you commit to them, where quick action with CPR is the best (and really only) available treatment option at that point.  I don't claim to know the facility's policies on medical treatment for their residents other than what was said on the 911 transcript.  I have a hunch that their "rule" about not giving residents medical treatment was just stating that they don't dispense medications, provide nursing staff, etc. on the premises, and had nothing to do with whether emergency treatment was offered if needed.  Otherwise everyone in the facility would have to possess a DNR, much like a hospice facility.  So I think this case represents more of a lapse of judgment and moral compass from one or a few individuals involved in the early stages of the old lady's care.

But is CPR always necessarily started after every heart stops?  Of course not.  Let's put aside the cases where advanced directives and DNRs govern that no attempts at resuscitation be performed, and instead look at those cases where the patient has either expressed a desire for life-saving measures or has not made their desires known.  The first case appears easy; we would assume that anyone who wants CPR in the event their heart stops would get it, and for the vast majority this is absolutely true.  We'll save the exceptions (gasp!) for later.  The second case, where the patient has not voiced his or her desires, becomes a little more tricky.  Luckily, the American Heart Association again provides some guidance.  They recommend that resuscitation be performed on all patients unless:

1. The patient has a valid DNAR order.
2. The patient has signs of irreversible death: rigor mortis, decapitation, or dependent lividity.
3. No physiological benefit can be expected because the vital functions have deteriorated despite maximal therapy for such conditions as progressive septic or cardiogenic shock.
4. Withholding attempts to resuscitate in the delivery room is appropriate for newly born infants with —Confirmed gestation <23 weeks or birthweight <400 g —Anencephaly —Confirmed trisomy 13 or 18

So here we have only four instances where CPR can be withheld.  The first describes a DNR (DNAR = Do Not Attempt Resuscitation) situation.  The last describes newborns with devastating conditions.  The second is simply stating that you don't attempt to bring a cold, dead body back to life.   Also, if you are going to do CPR, make sure your patient's head is still attached to their body.  The third instance is where we will spend our time, as there is much room for interpretation.

In that third instance we're basically seeing that the AHA allows for the withholding of CPR based on a description of futility, and in fact their paper defines both qualitative (quality of life) futility and quantitative futility, the latter associated with factors such as arrest time, initial heart rhythm, comorbidities, and an ultimate "calculation" of chance of survival.  AHA recommendation is to take quantitative futility into account when withholding CPR, due to the wide physician-patient disagreement in terms of quality of life assessments.  This is all well-and-good, but we really don't have a way to give a great "calculation" for such an imperfect science, at least not yet.  As they point out in the paper, at what % chance of survival do we withhold resuscitation?  Do we have to wait until there is an absolutely 0% chance of survival?  Is the cutoff 1%, 5%?  In the end, a lot of this quantitative junk gets turned into a qualitative decision anyway, as we really don't have a good idea how to use the calculations we derive.  Basically if the doctor thinks CPR will be futile, that maximum treatment has been administered to no avail, resuscitation does not have to be started.

You're in for a treat now.  Get ready to have your mind fucked and your moral senses irked.  We're going to talk about slow codes.

During a regular Code Blue in a hospital, in which life-saving treatment is likely necessary, organized (and sometimes disorganized) chaos ensues.  Nurses are usually the first on the scene and the first to pull the code alarm.  The operator overhead pages a code blue with the location, and anyone on the code team usually gets a page or a call on their hospital phone to the same effect.  These are the times you see doctors running down the halls, because, as we've discussed, prompt resuscitation is key for improving the odds of survival.  Advanced Care Life Support (ACLS) is initiated, if required, and usually about 10-15 people gather in the patient's room, including nurses, physicians, med students, and sometimes a designated team to provide chest compressions.  This all happens within seconds of the original code being called.

Let's back up for a second and talk about an elderly patient named Mr. Z.  He's a grouchy old man, but he's also very sick.  He's had heart surgery in the past to repair a valve and unblock some coronary arteries, and he had a partial bowel resection for colonic perforation 6 months ago.  Since then, his health has declined, and he had a number of enteric fistulae develop (small openings in the skin tunneling down to the bowel, constantly leaking bowel contents), and he has required increasing amounts of oxygen.  Heart failure is creeping up, and he has not really gotten out of bed since his operation half a year ago.  He's currently the patient with the longest stay in the hospital.  Numerous attempts have been made to inform him of his ill-fated situation, but he insists that all resuscitative efforts be made in the event his heart stops, and his distant, ill-informed daughter agrees.  If his heart actually does stop, it is very likely that Mr. Z would not survive resuscitation due to his comorbidities.

So what if Mr. Z's heart stops beating?  On the one hand, he aggressively stated that he wanted all attempts at resuscitation.  On the other, the man is extremely sick, and the CPR probably wouldn't help much, if at all.  There's no 100% guarantee that it wouldn't work, however, and we may be able to bring the man back to life, albeit at best in the same condition he's in now, probably worse due to all the trauma induced from the procedure itself.  So, pretend for a minute that you're the attending surgeon coming on the general surgery service for the week.  You have to tell your residents what you want done if Mr. Z's heart poops ou in the middle of the night.  What will it be?  Resuscitation or no resuscitation?

Before you answer the question in your own mind, there is one more option.  Hardly discussed outside of the hospital setting, your third option is to perform a slow code on Mr. Z.  At this point in the discussion, all ethicists familiar with this topic start to get sweaty palms and their anal sphincters start puckering.  A slow code is an attempt to clear up a situation like Mr. Z's, to provide him with the requested resuscitation while at the same time allowing nature to take its course, so to speak.  Here's how it works:

When Mr. Z collapses on the floor or wherever, a Code Blue is called just as any other code.  The decision to perform a slow code lies with the physicians, and often times the nurses will be performing their duties as they would during any other code.  However, when the residents and attending physician get their pages about the code, everyone will take their time getting to the room, in hopes that Mr. Z peacefully passes before they start running the code in the room.  Instead of seconds, sometimes it will take the physicians a few minutes to get to the room.  Once there, CPR is continued, but compressions are not as deep, not as frequent, and the goal is to not cause trauma to the chest.  CPR is also not maintained as long as it would be in a full code.  Pretty much no one is brought back from slow codes, as the half-assed effort does not truly circulate any blood to the individual's brain.   It's an elaborate show, good enough to say a code was run but not quite satisfactory to win a tug-of-war game with death.  Of important note, no mention of the words "slow code" or similar jargon appear anywhere on the patient's chart.  It also stirs some pretty strong feelings in a vast array of fields, including ethics, nursing, sociology, anthropology, and law.  It really pulls on some moral heartstrings (ha!), and causes everyone involved to spend some time in reflection about their own values and the field of medicine as a whole.

So now you have three options for Mr. Z:  Full resuscitation, no resuscitation, and a slow code.  Remember, you're in charge of a life here, so choose carefully!

I have to admit that I'm very uncomfortable with the idea of slow codes.  They're deceitful, and they parallel the case of the  "nurse" lady not providing CPR to the old lady at the living facility, where a half-assed resuscitation was attempted as well.  But I'm not convinced that they are entirely evil either, and though I would hope that I am never in the situation of making a decision about running a slow code, I can't say that it would be absent from my repertoire of options.  It's a slippery slope, I wholeheartedly agree.

My last bit of advice for nurses, medical students, and anyone else who finds themselves with a coding patient on their hands without a physician in the room, regardless of a discussion about slow coding the patient was brought up, is to perform a code aligned with the patient's wishes.  If his or her wishes aren't known, I would still give every ounce of my effort into appropriate resuscitation, and wait for a physician to make the final call about the course of the code.  Mr. Z's case resembles that of a patient encountered on my surgical service, and though the patient never coded, the decision was made by the attending to perform a slow code if the situation presented itself.  As an aside, nursing got wind of the plan, and made a formal statement saying that they would not be participating in a slow code if physicians were not present, which, as I mentioned, I find to be perfectly appropriate.

I have much more that I would like to discuss on all of the topics I've covered in this novel of a post, but I'll save everyone's eyes and possibly put up a few smaller posts in the coming weeks.  I'd love to hear other opinions on the "nurse" lady and her actions, as well as the morality of slow codes, as I'm trying to master my moral compass on the matter as we speak.

Meaningful research and the "antibiotic apocalypse"

I wanted to share a recent article at BBC news that caught my eye, especially considering a conversation Mike, Jim, and I had just the other day regarding the argument that any kind of public health service in the U.S. would hurt medical research, which is currently funded in large part by American pharmaceutical companies.  It seems to me, at least, that the general assumption behind that argument is that nobody else in the world is making real, significant contributions to medical discovery and that if the U.S. offers a public option, which could hinder pharmaceutical profits, then research will suffer.

The BBC news article discusses a new project examining life from isolated areas of deep oceanic trenches for fresh ideas on antibiotics.  The two things I wanted to sort of highlight from the article are: 1) the research is being led by scientists from Aberdeen University in Scotland, a country that coincidentally has a public health service; and 2) the last sentence of this quote - the bold font is mine:

"Project leader Marcel Jaspars, professor of chemistry at the University of Aberdeen, said: "If nothing's done to combat this problem, we're going to be back to a 'pre-antibiotic era' in around 10 or 20 years, where bugs and infections that are currently quite simple to treat could be fatal."
He said there had not been a "completely new" antibiotic registered since 2003 - "partially because of a lack of interest by drugs companies as antibiotics are not particularly profitable"."

It's cherry-picking, I know, but I wanted to share because we were just talking about the idea.  Money is absolutely important when it comes to research. But maybe the approach and general philosophy behind research can and should sometimes be of greater importance than who can dump the most money into a problem (and the foreseeable profit that can be made from a discovery).

The Incredible Shrinking Medicare Tab

Every year in January the Congressional Budget Office releases its Budget and Economic Outlook for the next decade (they also produce an abbreviated update to the year's outlook in the late summer, as they did last August). Just this week they released this year's: The Budget and Economic Outlook: Fiscal Years 2013 to 2023.

In these documents the CBO, among other things, projects how much the federal government is going to be spending on Medicare in each year. What's fascinating is that if you look at each of these documents, every time they release a new one their projections for Medicare spending each year shrink. Click on this, a simple compilation of their Medicare spending projections (in billions of dollars) going back to the January 2010 report (i.e. the last budget outlook before health reform became law):

What the CBO is doing here is just acknowledging what's already known: Medicare spending growth right now (particularly on a per capita basis) has slowed to a crawl. A turn of events that is, to borrow a phrase from HHS, "unprecedented in the history of the Medicare program." What's amusing is that it continues to surprise the CBO and they have to keep revising their already-revised-downward projections even more. But as they say in this week's report:

In recent years, health care spending has grown much more slowly both nationally and for federal programs than historical rates would have indicated. (For example, in 2012, federal spending for Medicare and Medicaid was about 5 percent below the amount that CBO had projected in March 2010.) In response to that slowdown, over the past several years, CBO has made a series of downward technical adjustments to its projections of spending for Medicaid and Medicare. From the March 2010 baseline to the current baseline, such technical revisions have lowered estimates of federal spending for the two programs in 2020 by about $200 billion—by $126 billion for Medicare and by $78 billion for Medicaid, or by roughly 15 percent for each program.

This doesn't mean Medicare doesn't still face big challenges: even if it sustained last year's per capita growth rate of just a bit more than 0% (a big if and a major challenge), the Baby Boomers are going to continue aging into the program. That means total spending is going to swell, even if per capita costs remain at historic lows. But it's worth remembering sometimes that things are not always quite as grim as they seem.