God and Mary and Jesus Are Back…..And Coming to a Hospital Near You

I am referring to the increasing number of US hospital mergers between Catholic missions-driven not-for-profit hospitals and secular hospitals. This hospital merger phenomenon has been happening for years, but is picking up speed in large and small cities—and even rural communities—across the country. Most health policy wonks attribute this uptick in hospital mergers to health care reform measures, which have increased hospital accountability for Medicare and Medicaid expenditures. Hospital systems are under more pressure to perform well, and following basic economic principles, the hospitals want to gain larger and larger market share by gobbling up competitors. It has happened here in Seattle, with Providence Health and Services (Catholic) merging with Swedish Medical Center/Health Services (secular). In this case, Swedish was the smaller fish (pun intended), and is now a division of Providence. Swedish has agreed to stop performing abortions, but is trying to staunch the outcry by funding a new (and not needed) Planned Parenthood office near the hospital. My family doctor is a part of the Swedish Medical System. I’m going  elsewhere in protest.

There are close to 600 Catholic charity hospitals in the US and they are all explicitly Catholic missions. That means they ‘do’ hospital care as an extension of their Catholic faith, as a way to evangelize through the provision of health care.  In their book God Is Back: How the Global Revival of Faith is Changing the World, Micklethwait and Wooldrige point out that in a decidedly Protestant young America, Catholicism had to fight for its market share of the faithful. The Catholic Church did this by developing a private welfare state in the US, complete with hospitals and schools. There are other religiously affiliated hospitals in the US (New York-Presbyterian is perhaps at least historically), but Catholic hospitals account for close to 80% of all such hospitals. In addition, Catholic hospitals are alone in working under special “Religious and Ethical Directives for Health Care Services.” These directives include bans on the provision of contraceptives (including condoms), sterilization, infertility treatments, abortion services, or end-of-life decision-making by patients. These bans fall disproportionately on the backs of poor, uninsured women who rely on charity-care hospitals. When Catholic hospitals merge with secular hospitals, the Catholic hospitals insist on contract clauses whereby the secular hospital has to abide by the Catholic religious/ethical directives.

Catholic leaders take their Religious and Ethical Directives for Health Care Services very seriously, going so far as to excommunicate a nun, nurse Margaret McBride, for being part of a hospital decision to allow an abortion in order to save a mother’s life. This happened in Phoenix, Arizona in 2009 when McBride was an administrator at St. Joseph’s Hospital and Medical Center. It involved a young woman with life-threatening pulmonary hypertension who was 11 weeks pregnant. If she had not had an emergency pregnancy termination, the young woman would have died.

I am all for religious freedom, and I even support—to a point—conscience exclusions for health care providers. But I also believe that the separation of church and state goes both ways—not only protecting the church/religion from the bully-power of the state, but also the state (government and civil society) from the bully-power of the church. Medicare and Medicaid account for over half of the total funding for Catholic hospitals. In addition, they (the Catholic hospitals) enjoy benefits such as tax-exempt status and low-cost financing through government bonds programs. In some cases they even enjoy free use of municipal buildings. Perhaps it is time to re-think those arrangements.

(The statue of Jesus included in this post is Christ the Divine Healer, an 11 foot marble statue in the foyer of the original hospital building at Johns Hopkins (a Quaker). When I went there it was still a ritual for patients, family members and students to touch Jesus’ big toe for luck, blessing, whatever you wanted to call it. It was a well-worn toe….)

More Ways To Be Crazy

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The American Psychiatric Association (APA) is nearing completion of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). This will be its first major revision in 17 years. Work on it had already begun 15 years ago when the DSM-4 was only a few years old. The DSM drives research, treatment, health insurance, and public benefits decisions (disability and special needs school services). So you can imagine just how highly charged and politicized the process is of revising the DSM.

The main decision makers behind the DSM are the APA and the mental health branch of the National Institutes of Health (NIMH). The actual revisions are done by workgroups, who collectively are considered an independent third party review. There are 160 members of the DSM-5 workgroups: 97 (MD) psychiatrists, 47 (PhD) psychologists, 2 (MD) pediatric neurologists, 3 (PhD) epidemiologists and then 1 each from (MD) pediatrics, social work, psychiatric nursing, speech/hearing specialist and a consumer group. The one nurse on the workgroups is Barbara E. Wolfe, ARNP, PhD—a psychiatric nurse practitioner on faculty at Boston College and an expert on eating disorders.

There is a DSM-5 website with information on the background/history of the DSM-5, workgroup members names/affiliations, and updated lists of proposed changes to be included in the DSM-5. The developers of the DSM-5 have already held two open public comment sessions on their website, and the third and final public comment session is slated for April. They report that their work is 90% complete, and that they will finalize the DSM-5 by December 2012 (publication date May 2013).

There’s been a fair amount ofnews coverage of several of the proposed DSM-5 changes, most notably a tightening of the definition of Autism, as well as changes in the definition of Bipolar Disorder. In reading through the updated proposed changes to the DSM, I came across the following items of interest. “Stuttering” is being renamed “Childhood Onset Fluency Disorder.” “Hypochondriasis” is being renamed “Illness Anxiety Disorder.” And under the diagnostic category of “Mood Disorders” (includes Depression), they are adding “Premenstrual Dysphoric Disorder. Proposed new mental conditions (listed as ‘under review’) include Apathy Syndrome, Internet Addiction, Seasonal Affective Disorder, Parental Alienation Disorder, and Male-to-Eunuch Gender Identity Disorder (ouch!). They need an “Overdiagnosis of Mental Disorders Disorder Syndrome,” then everyone including the DSM-5 members will be covered.

No More Free (drug) Lunches or Pens

As part of the Affordable Care Act (ACA) health care reform, drug companies will soon be required to report payments and free lunches/dinners/cruises/vacations/gifts to physicians or payments to teaching hospitals. It includes any free ‘educational’ service for physicians or teaching hospitals. This is section 6002 of the ACA and is known as the Physician Payment Sunshine Act (sunshine, as in shedding light on or transparency). As part of the mandatory reporting, individual physicians and hospitals will be named, along with what items of monetary value they received and by which companies. This information will be publically available and easily searchable. Companies will be assessed hefty fines of up to $1 million for failing to report the information. This Sunshine Act was supposed to have already been implemented, but has been delayed while government officials at the Centers for Medicaid and Medicare sift through public comment and iron out final details.

I read through the proposed Physician Payment Sunshine Act (vol 76,no. 243/12-19-11 Federal Register), and found that they define “physician” as a doctor of medicine or osteopathy, dentists, podiatrists, optometrists and licensed chiropractors. Teaching hospitals are defined as hospitals having graduate medical education. And here is their rationale for the Sunshine Act:

“2. Transparency Overview

Collaboration among physicians, teaching hospitals, and industry manufacturers may contribute to the design and delivery of life-saving drugs and devices. However, while some collaboration is beneficial to the continued innovation and improvement of our health care system, payments from manufacturers to physicians and teaching hospitals can also introduce conflicts of interests that may influence research, education, and clinical decision-making in ways that compromise clinical integrity and patient care, and may lead to increased health care costs.” (p. 7)

(The NYT has a recent article on this, as does Kaiser Health News–older but good.)

Several states including Vermont have already implemented similar reporting requirements. Some physicians are complaining that drug companies are now wooing more nurse practitioners as a way around the reporting requirements. I saw that in action at this past fall’s regional nurse practitioner conference. It was overrun by aggressive pharmaceutical reps waiving tons of swag (including the ubiquitous drug pens), as well as signing NPs up for free lunches/dinners/talks, etc.

In the community health clinics where I’ve worked, most all of the family physicians were rabidly anti-drug company marketing and influence. One physician in particular would go on a tirade if she discovered one of her medical residents writing with a drug company pen. They—and everyone else in the building—would get a lecture in the evils of drug company influence on physician prescribing practices and health care costs. So I thought I had long ago purged myself of all drug company free stuff. While preparing to write this blog post I engaged in some late winter housecleaning searching for hidden drug company subliminal influences. I found six drug company pens, four of which were for drugs that have been pulled from the market as unsafe. I threw them all away. On a popular blog lamenting the Sunshine Act, one physician complained that he has to buy pens for the first time since he graduated from medical school in 1986.

The only drug company swag I found that I am keeping is a funky glass sun catcher given to me by a retired pharmacist who lives on my street. It has elemental alchemy symbols for strange things like lead and vinegar and talc—but is really an advertisement for a nasal decongestant hidden in small type at the bottom. See if you can find it on the attached photo—but don’t buy the stuff!

The Race from the Pink

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The Susan G. Komen for the Cure foundation vs. Planned Parenthood political drama this week was fascinating to follow. This, of course, was the news that Komen was withdrawing all grant funding to Planned Parenthood for breast cancer screenings for low-income women. After a groundswell of public outrage over their decision, Komen’s founder and CEO, Nancy G. Brinker made a public announcement upholding their decision and trying to assure people that it wasn’t politically motivated—the subtext that it had nothing to do with the fact that Planned Parenthood services include abortion. Then when her explanation only made the backlash worse, Brinker announced they would reverse their decision and fund Planned Parenthood at least for this year. This drama all happened over the course of four days.

When listening to people’s conversations about this unfolding drama—especially around my nursing-type friends and colleagues—I was surprised at how many of them were surprised that the Komen foundation would do such a thing. The sacred hot pink halo hovering over the Komen foundation has blinded most nurses—as it has blinded most of the general public. It has never been PC to critique the Komen foundation’s stated “race for the cure” of breast cancer. It was also interesting to discover how many people didn’t realize that Nancy G. Brinker is far right leaning politically. She has long been a major Republican donor, and was named Ambassador to Hungary and then Chief of Protocol (e.g.: official ‘party planner’ for visiting dignitaries to the White House) under Bush.

In 2010 the Komen for the Cure foundation pulled in $311,855,544. The top administrators make over $500,000 per year. And although many Race for the Cure pink t-shirt wearing participants think that most of the money they are raising goes to fund breast cancer research, only ~20% goes to research. At least a million dollars a year seem to be spent on legal fees for the Komen foundation to sue anyone using ‘for the cure’ or anything approximating a pink ribbon in their marketing. Breast cancer has become big business—even for the supposed non-profit Komen foundation. Barbara Ehrenreich (of Nickeled and Dimed fame) uses the term “Cancer Industrial Complex” when discussing everything that profits from cancer—and especially from breast cancer. Writing in November 2001 in Harper’s Magazine (“Welcome to Cancerland: A Mammography Leads to a Cult of Pink Kitsch”) Ehrenreich reports that the breast cancer industry is estimated to be a $12-16 billion dollar a year business in the US, between all the breast cancer centers, radiation centers, mammograms, surgeries and drugs (doesn’t include breast cancer research spending).

And then, of course, there are the dismal statistics pointing to the fact that all the increased breast cancer research, increased focus on mammograms, early detection and treatment, really haven’t changed the death rate from breast cancer.  On the Susan G. Komen website—in amongst the flashing hot pink merchandise to buy—is Nancy G. Brinker’s declaration that the Komen foundation has “changed the world.” The world is pinker perhaps.