Puff, puff, fail.

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NPR recently looked at the problem some colleges have when students with medical marijuana prescriptions bring their drugs with them onto campus– because it’s illegal under federal law, colleges which allow it are at risk for losing federal funding.

Nurse: So what we have here is an issue where a single substance is both a prescription medication under state law and an illegal substance under federal law. So. . . houston, we have a problem. Lawyer, what happens when state law and federal law conflict? We know that the feds could pull funding, but what else? I feel like I heard noise from the federal government that enforcing marijuana laws in states where it was legal was not a priority.

Lawyer: Well, basically, it’s still illegal. The state and the feds act in tandem, and the state has said this isn’t a crime, but the feds have said it is, so the state cops can’t arrest you but the DEA still could. Though as I recall, the Obama administration had decided it wasn’t going to prosecute medical marijuana. It hasn’t been all that much of a problem in the more general sense, but this federal funding thing is thorny. 

Nurse: I’ve heard an argument about this which amounts to, “come on, you can’t let these college kids have pot prescriptions, it’s a crock of shit and they’ll just sell it to their buddies.” But, well, first of all, no, there are legitimate medical uses and everyone knows that, and second, state law has already said it’s ok, so the “come on” argument just doesn’t work. 

Lawyer: But state law doesn’t trump federal law. So the feds can still say “come on,” even if the state says it’s okay. In any event, the thing that college kids are getting prescriptions for and selling to their friends isn’t marijuana — it’s aderall. 

Nurse: Imagine this scenario with another drug– something that isn’t illegal under federal law– and it becomes ridiculous. Your student in chronic pain from a car accident can’t have percocet? Your student with ADD can’t have adderall? Your student with cramps can’t have motrin? The college gets to make rules about these things? But when we have this conflict with federal law, this is not longer a patient specific, private issue. Hmmmm.

Lawyer: What I want to know — and this article doesn’t say — is why they think they may lose their funding. Certainly the feds could do that, but have they given any indication whatsoever that they intend to? I also wonder what exactly we’re looking at here in terms of policies. If the college is silent on the matter — i.e., they have a policy that says generally that students are entitled to use drugs for which they have a valid prescription, but are not entitled to use recreational drugs — where is the issue? Do they need pot-specific policies that would draw this kind of scrutiny? Certainly the student would be subject to the same risks he’d be taking if he used the drug anywhere — the feds could always come for him. Why is it on the college, unless they somehow specifically go out of their way to allow it? No one is talking about student health physicians writing these prescriptions. 

In the mean time, it’s a shame if indeed there are students who cannot attend classes because they need the medication, and their colleges are too risk-averse to deal with the situation and give them access to education as needed.

Nurses protesting NATO

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Or, a nurses’ union protesting at the NATO meetings, to be more exact. Lots of news stories covered this story today, so I thought I’d touch on it.

 Perhaps this is puzzling to people who think of nurses as doctors’ handmaidens, bedpan emptiers, and bosses at psych hospitals. Or perhaps it’s troubling to people who feel that nurses should be apolitical, providing compassionate care to everyone without ruffling any feathers or making anyone uncomfortable.

The union members at this particular protest seem to be advocating a “Robin Hood tax” along with a general anti-war message. 

 Whether or not you agree with the politics, I think it’s crucial that our society think of nurses, and that nurses think of themselves, as promoters and protectors of well-being. So, yes, you may see your friendly neighborhood R.N. waving a protest sign for a political cause that affects the well-being of the community– more power to her/him. 

(Just to be clear: I’m not talking about bedside nurses engaging in political actions, or god forbid, discrimination, while in the role of direct caregiver. I hope we all agree that at this level, everyone, regardless of politics, should be treated equally. I am talking about nurses as community members, advocating for causes that they feel are important to the health and well-being of the community. Ok? Ok.)

Nurse Love from the NYT.

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The New York Times is all about nurses today!

In this “Fixes” piece on “The Power of Nursing,” David Bornstein talks about the Nurse Family Partnership (where nurses make home visits to families beginning early in a mother’s pregnancy and continuing until the child is 2) and its great successes in improving health and preventing all kinds of troubles — including criminality later in life for the kiddos. Perhaps the most interesting thing he notes? It doesn’t work if someone who isn’t a nurse makes the same kind of visits.

Lawyer’s favorite part:

What’s special about nurses? For one thing, trust. In public opinion polls, nurses are consistently rated as the most honest and ethical professionals by a large margin.

 

That’s definitely not, er, something people say about lawyers. 

 

DSM-V: What’s at Stake?

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The American Psychiatric Association is scheduled to publish its next edition of the massive manual of psychiatric disorders next year. Some changes were made at their Annual Meeting last week. Allen Frances has expressed some concerns in a New York Times op-ed.

A few reasons why we care what the APA says is a mental disorder:

It can influence what types of medications and treatments insurance companies will cover.

It can influence what doctors decide to do with any given patient.

It can influence how the law treats different kinds of problems. (One reason for throwing out a suit that alleged a video game maker was liable for ruining the life of a gamer who got addicted to playing it? Video game addiction is not a recognized diagnosis.)

It can affect how responsible people are considered for their actions. (And while having a diagnosis doesn’t qualify you for the insanity defense, it can act as a mitigating factor in sentencing.)

Not to mention the softer factors of telling people they have a disease or mental illness — when that’s debatable.

There are plenty more consequences — please chime in in the comments if you have thoughts!

Really, Kansas? Really?

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We could barely bring ourselves to write about this.

The Kansas House has passed what would probably be the most restrictive abortion bill in the country, described here by the Huffington Post.

Lawyer: I think the two most troubling provisions (obviously?) are the ones mandating that doctors tell women certain things, and those authorizing doctors to withhold certain information. 

Nurse: Yeah. . . this seems like it completely undermines the doctor/patient relationship. You can no longer trust that your doctor is telling you what he really thinks is in your best interest. This seems a little. . . facist? I don’t know. The state doctor is going to tell you the state facts about your body now.  True? What do you mean? The state scientist said so. This is coming from the political party that wants the state to intervene less? Um. Ok. I think we really have 3 parties– democrats, fiscal conservatives, and religious right-wing nut-jobs. 

Lawyer: We can look at it both from the perspective of the rights of the patients and the rights of the doctors.  (Let’s not forget that the First Amendment not only prohibits restraining speech — but also compelling speech.)

Nurse: Good one. Plus, I didn’t even get into the fact that, um, the birth control/breast cancer link which is part of this whole argument is not what any informed person would call solid evidence. So there’s another way the state is telling doctors to lie.

Lawyer: It also raises a really thorny question about the relationship between science and law, reminiscent of the debate about teaching creationism. If a legislature deems something fact, that doesn’t make it true — but they do (and properly, I think) have some control over a curriculum. It’s harder to argue that the government has any role in dictating what can happen in the exam room with the door closed.

Nurse: Yep, that was my reaction as well– it’s similar, but worse. Private physicians behind closed doors should not have to tell patients any particular thing. Public schools. . . . more debatable. But, then, how the h-e-double-hockey-sticks are they going to enforce that law? Big brother? 

Lawyer: It’s also just really gross.

Nurse: AMEN, SISTER.

In Nursing News. . .

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In nursing news, Centers for Medicare & Medicaid Services made a lot of changes this week, including expanding the definition of “medical staff,” to allow professionals including advanced-practice nurses to practice to the full extent of their training and scope without arbitrary federal rules about physician oversight– state laws already govern scope of practice.

This is a coup on behalf of patient care, healthcare systems, and nurses! CMS is explicitly recognizing that health care is changing, and moving away from a model which is entirely physician-driven.  We had a pretty long discussion   on the issues surrounding advanced practice nurses a while ago. Is this week’s news indicating that the times, they are a changing’?

If there was an anti-AIDS pill, who would get it?

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Remember our discussion about the implications of knowingly exposing someone to HIV? I think it’s interesting to revisit that analysis in light of the recent news about Truvada, a drug that potentially reduces risk of HIV infection– it appears to be safe and effective, and a panel will make a recommendation to the FDA this week.

It’s an interesting question– of course, we “know how” to prevent HIV without using drugs– i.e., don’t have unprotected sex, don’t share needles, etc– but we also know that the virus spreads anyway for all kinds of reasons. I can think of a few scenarios where a drug would be useful: people who are high-risk and will not or cannot change their sexual practices or drug use (this may be seen as a harm-reduction strategy), or, perhaps more importantly, for people who are routinely sexually coerced (think of women in cultures that do not allow them to refuse). Of course, there are lots of obstacles– it’s expensive, there are side effects, it’s not completely effective, we don’t know the long-term issues– but still, it’s a very exciting idea.

HIV disproportionately affects marginalized groups. Could a drug like Truvada help to change the sense of victimization associated with some HIV infections? Can we avoid a repeat of the original fiasco associated with HIV drugs, their expense, and the witholding of available treatment based on inability to pay?

You need stitches, is this going on your VISA today?

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. . . and while you’re here, you owe us five thousand dollars. The NYT reported twice recently on medical debts and collections issue: here and here.

 Nurse: For me, this is just one more symptom of the overall huge problem of the way our health insurance and healthcare systems (fail to) work. I was especially surprised that FICO said it doesn’t consider medical debt any differently from other debts– so debt you incur for being irresponsible is the same as debt you incur for being genuinely unlucky. You got sick and couldn’t pay? Your credit score takes the same bump it does if you overspent your credit card at Saks.

Lawyer: I don’t know much about how FICO operates, but there are lots of shades, too. I mean, student loan debt is different from credit card debt is different from your cell phone plan is different from healthcare. 

 I suppose one could argue that their job isn’t to measure how “responsible” you are, so much as how responsive you are in paying debts that you do have, no matter why you have them. 

But one of the real problems seems to be that people get caught in this crazy maze of not knowing who’s actually responsible for what, or wanting to dispute certain things, and having that process damage their credit (rather than straight up unpaid bills — which is also a problem, but a different one.)

 Nurse: It sounds like the bill under discussion here is reasonable– removing these medical credit black marks more quickly– but I don’t know, do you think there would be unintended consequences? I don’t buy the “quality of data” decline that the credit agency advocates are pushing.

 Lawyer: I agree that it seems like a reasonable bill. And the “quality of data” thing sounds like a crock to me, too, especially given the high rates these stories are reporting of things being either straight up errors or being matters of genuine dispute. I think other possible solutions involve including that info in the reports, but separating it out and clearly identifying it as a specific type of problem, so that users of the score (e.g. lenders) can evaluate whether they find it relevant or not. Or doing what they do with credit cards — forbidding them to report it to credit agencies in certain types of dispute situations, pending some reasonable resolution of the dispute. 

 Nurse: Of course, this doesn’t even get into the fact that, as the article points out, billing errors are rampant. That goes back to my original point that the system is so far broken, what can we do? You can’t get a doctor or hospital to quote your a price for treatment, so how are you supposed to really evaluate if you’ve been billed correctly? Have you ever tried to use an insurance company phone tree? Have you ever tried to do any of this while you or a family member was ill?

Lawyer: A classmate in the business school here was recently overbilled for a procedure, and it took her (a Stanford MBA student) a huge amount of time and effort to get it sorted out — she also says she just barely caught the error. I hate to imagine how difficult it would be for someone who doesn’t have any background or training in dealing with such things. Where do we lay the blame? Maybe the problem is with hospitals sending things into collection too quickly, without addressing/resolving disputes with patients first. (See above proposal about not reporting to credit agencies during a dispute resolution process.)

Nurse: On the bedside debt collectors: dude, not cool. Hospitals may employ debt collection agencies, and they often do, which is ok, but allowing them into patient care areas? This is slimy, having debt collectors posing as hospital employees, or having them demand payment before treatment in the ER. Isn’t that illegal, lawyer? EMTALA?

 Lawyer: I don’t know much about EMTALA (that’s the Emergency Medical Treatment and Active Labor Act) — I think it forbids refusing care based on inability to pay, but I’m not sure it forbids demanding payment in advance where possible. I could see a problem arising if the hospital didn’t make it clear to the patient that they would receive emergency treatment even if they couldn’t pay. (In other words, if they mislead the patient, and the patient leaves without care, that could be trouble.)

It certainly sounds like some of these practices are some kind of possible fraud or misrepresentation. And it probably violates state law in a lot of places that have good consumer protection laws.

Nurse: Yes, my concern is that it may seem to patients that they are or will be refused care if they can’t pay, even if that’s not really the case– it’s essentially intimidation on the threat of not receiving care. Patients, you are entitled to evaluation and stabilization in and ER, whether or not you can pay, and whether or not you owe anyone money. They can ask you for payment, but they must evaluate and treat you, payment or not.  Also not cool: You should not need to fear that seeking treatment in an ER will lead to your harassment for current or previous bills.

Lawyer: Very good point. 

Nurse: Yes, hospitals provide uncompensated care. No, they can’t fix it this way. Unless they care more about money than about care– in which case, they should go work for Goldman Sachs, am I right?

Lawyer: Maybe it’s kind of a desperation play? Because heaven forbid we should work to reduce the cost of care. That would probably do more to keep the doors open.

Nurse: Yeah, I mean, they try that, but it’s a big, messy problem. True, you can’t provide any care at all if you are entirely broke– but there is a line, and this practice crosses it.

Lawyer: Where do you think that line is? Is it okay to just talk about payment before providing care (assuming the person isn’t actively dying at the moment?)

What about people who actually legitimately incur costs that they can’t pay — when can the hospital start pursuing them for payment? 

Nurse: I think if they could tell you what it will cost, and make it clear that your will receive treatment no matter what, it might be ok. But it’s pretty near impossible to find out what a medical treatment is going to cost you before you get it. Just try sometime. You’ll be told, “well, it depends. . . .” There have been lots of studies comparing costs of treatments lately and it’s just wild. 

I would not want to work as a nurse in this environment– and I think my duty as a patient advocate would be to treat and protect these patients upfront. After they are treated, on their way out, fine, but not on my watch.

 Lawyer: Luckily, a lot of times when debt is sold, it’s done sloppily, so collection agencies sometimes sue for collection and it turns out they don’t have clear enough records to actually state any kind of legal claim to the debt. (Though this happens more with consumer debt than with medical debt, which is, perhaps obviously, more closely tied to the person who incurred it.) 

I don’t know how that interacts with the credit agencies.

 For now, I’m gonna put my money on state law for eliminating these abuses. But fingers crossed on the federal laws about credit scores, too!

You only get one brain. . .

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This week, with the suicide of Junior Seau, we have another sad turn of events concerning head injuries in professional football. . .

Lawyer: Seriously. How many more of these is it going to take before people (TV networks?) start taking this really, really seriously? Yes, better helmets, small rule changes, okay, but human brains are not designed for this kind of repeated trauma. All in the name of lazy sundays and something to do while you drink your bud light and eat your wings.

I have lots of sports soap boxes to get on. But my big 2 are college sports and the dangers of pro football.

Nurse: Um. . . Nurse is about to take an uncharacteristically non-liberal standpoint on something. I might get on the college sports soapbox with you, and I will definitely talk about risks to high-school athletes, but I think I will allow the NFL . . . at least, if we are taking legally. (And yes, I know that the two former are related to the latter, but forgive me!) I mean, people are free to play for the NFL or not, and they are paid an enormous amount of money to do it (and I would consider that an incentive, but not coercion).

Lawyer: But the problem is that they (a) have known about these risks for a long time and done little to mitigate them (or possibly even actively concealed them) and (b) have actively encouraged (albeit not directly) behavior that makes the game more dangerous than it has to be. (see Bountygate.)

Nurse: The NFL is an organization with rules– and I agree that it has a responsibility (perhaps a moral one) to try to protect its players from harm. And clearly repeated head trauma is bad for you. But I have a hard time generating the level of outrage over this issue that I do over a lot of other stuff. Does it suck that this happens to guys? Yes. Is it a major public health concern? Honestly. . . not really.

Lawyer: I think it is in a way, though, because lots and lots of little boys (and a few little girls) watch this stuff on TV and form dreams. And habits. So it goes beyond the, I don’t know, 1500 guys in the NFL.

Nurse: Would everyone in the NFL drop out tomorrow if they were given a full, in-depth presentation on the dangers of head trauma? Doubt it.

Lawyer: But the point isn’t that people shouldn’t play football. It’s that it can be played in a less dangerous manner, with less glorification of injury and much more attention to the dangers of head injury. Players should come out of the game. They should miss games. And it shouldn’t be their call, because the culture is such that you can’t make that kind of call and succeed.

A few weeks ago, someone had written to the NYT’s Ethicist column about watching football, and whether it was ethical, given the injury thing.

She concluded that perhaps it isn’t.

Nurse: They know they can get hurt. They do it anyway. Boxers break their noses. Dancers get eating disorders. Skiiers tear their ACL’s. So, should the NFL do what it can to lessen the risks? Absolutely. Should we ban pro football? Nah.

Lawyer: Agreed. We shouldn’t ban it. But we need to have a big shift in the culture.(And a lot less HGH. Or something.)
Is it ever going to change? Can it? Can small changes to the rules actually get us anywhere in the age of bounties set for injuring opponents?

Nurse: Besides, I like wings. . .

Lawyer: You got me there.

On Lawyer’s iPod

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Ok, I’m about 6 months behind on Radiolab episodes. But on my morning run I listened to Patient Zero, a typically fascinating hour of exploration of tracing diseases back to their origins.

We got Typhoid Mary. And an in-depth look at where AIDS came from (patient zero, chimp zero, and monkey zero.)

Buried in there are some fascinating legal issues, which I hope we can discuss in depth in the future.

But just consider…

When can the government imprison an innocent, but contagious, person? Does it matter if she definitely knows she is infecting people but refuses to take precautions?

Can you go to jail for giving someone AIDS? If you do it on purpose?

Should the government be able to trace your phone records to try to piece together patterns about the spread of disease? (imagine agents showing up to ask questions at the home of someone who has just made a bunch of calls to a health provider…)

Definitely worth a listen!