Author: P Hasselbacher

Our Vanishing Right to Patient Privacy.

On March 20, I submitted the following letter to the Courier-Journal. Others have offered similar views and I gather that my contribution was not accepted. Since I buy my ink by the gigabyte, I have the opportunity to publish the letter anyway! Here it is.

Bullying not allowed in school.
Kentucky education Commissioner Wayne Lewis has demanded that 10 different school districts in the eastern half of the state send him records and documents for teachers who did not show up to work this legislative session. Enough teachers did so, that at least some schools had to close. The demand specifically includes doctor’s notes confirming illness. The first thought of the physician in me is that federal patient privacy law (HIPAA) prohibits the sharing of patient information except to other health professionals or entities sharing in medical care of a given patient. These protections are quite strict. Specific permission from a patient is
required to discuss matters even with a family member, or to even to disclose whether an individual is a patient or not. A note from a doctor– even without a diagnosis– conveys information simply by virtue of the physician’s practice. A note from an obstetrician might suggest a pregnancy. An individual may not wish to disclose that they are seeing a cardiologist, psychiatrist, or any other specialty that might announce a pre-existing condition. Even if Kentucky law or regulation allows Frankfort or a school district to demand a doctor’s note, it is not clear to me why federal law would not supersede state law. I will leave that to legal experts.

Given the obvious animus of the Bevin administration towards Jefferson County and its public-school system in general, and towards teachers and the teacher’s union specifically; a reasonable person might conclude that Commissioner Lewis’s demands represent an attempt to intimidate teachers for standing up for what they believe is right for their schools. The Commissioner’s more recent promise not to punish anybody if there are no further work stoppages converts a veiled threat into an operative one. Commissioner Lewis reasonably suggests that students can ill-afford to miss even one day of school when avoidable. How can one disagree? I would ask, however, what would be the response of the public if Commissioner Lewis asked for the names and the medical records of students who skipped school in order to protest for the need of gun control following the aftermath of school shootings here in Kentucky and elsewhere? I am confident that our public would be outraged! We should be outraged today. Teachers did not make the decision to travel to Frankfurt lightly. They deserve public support– indeed public protection against what is in my opinion, and that of others, an attempt to bully teachers into submission.

Peter Hasselbacher, MD
Louisville, KY
March 25, 2019

Kentucky’s Hepatitis-A Epidemic: Could We Have Done Better?

A society is only as healthy as the sickest individual within it.

Summary:
Kentucky is in the middle of, and hopefully emerging from a major epidemic of Viral Hepatitis-A (Hep-A).  Hepatitis-B and Hepatitis-C, are caused by different viruses and commonly result in more serious chronic liver disease.  Classically, the spread of Hep-A is attributed to contamination and ingestion of food or water by the feces of infected persons or related poor hygiene practices.  Nonetheless, illicit drug use appears to be the major risk factor  in Kentucky’s current outbreak.  Hep-A is rarely fatal to otherwise healthy people but can cause debilitating symptoms. It can be fatal however, especially to individuals with preexisting liver disease such as alcoholic hepatitis or other forms of viral hepatitis. It is not clear when the first cases of the current outbreak began to emerge, but in the 21 months between Aug 1, 2017 and Feb 23, 2019; some 4229 presumed or suspected cases of Hep-A have been reported, including 2036 hospitalizations and 43 deaths. This can be compared to only 9 reported cases in all of 2016! Our current outbreak is the most severe in the nation. Concern has been expressed that, compared to the aggressive and successful response by the Board of Health of Jefferson County, that the best advice from experienced state public health experts within Kentucky’s Public Health Department in Frankfort was ignored allowing the statewide epidemic to expand and be prolonged. My independent analysis of available data supports this criticism. In my opinion, the appointment of an inexperienced public health commissioner by the Bevin administration– probably for political and ideological reasons– likely played a significant role in what occurred. Kentucky remains in the middle of upsurges of Hepatitis B and C. All three varieties of viral hepatitis have roots in poverty, substance abuse, exclusion from healthcare systems, despair, and other non-medical fellow-travelers that will be difficult to fix. It is therefore important that the current responses to the Hepatitis-A epidemic be independently reviewed so that we may be better prepared for the next time– which will surely come. Continue reading “Kentucky’s Hepatitis-A Epidemic: Could We Have Done Better?”

Mandatory Posting of Hospital Charges: Rest In Peace.

I thought that before I signed the death certificate of the Posting Standard Charges Project, that I would place a mirror beneath its nostrils just to make sure it was ready to put in the ground. I was planning to add this confirmatory step as an addendum or comment to my first article, but it was clear that additional details and discussion would be necessary. My first pronouncement was based on a bedside-look at the several chargemaster databases. What did the local hospitals choose to disclose; what must they have intentionally omitted; how easy was it to find anything; and was the information useful to compare different hospitals? I did not even have to feel for a pulse to know the answers. Out of fairness and a desire not to bury the patient alive (but with certainty that my initial diagnosis was correct) I applied a more definitive diagnostic test that might been a valid real-world trial for me had these posted standard charges been available last Fall.

As I pulled away from my cardiac pit stop at Rhode Island Hospital, it was suggested I schedule a cardiac echo stress test back home to evaluate the size and function of my heart. Using all of my wisdom and experience as a physician and Professor, I did what everybody else does– find a cardiologist who would see me as a new patient and do what they suggest! The stress test was normal. I could not have hoped for a better result nor more competent and attentive care. The question for our present exercise is: If posted standard charges were available– and I had time to look at them– what I have found? [Spoiler alert! The effort would have been a waste of time, if not misleading.] Continue reading “Mandatory Posting of Hospital Charges: Rest In Peace.”

Federally Mandated Postings of Standard Charges by Louisville Hospitals Are Unusable for Their Intended Purpose.

(But will reveal the the unacceptable and unjust absurdity of how we pay for medical services.)

Reporter Gilbert Corsey of WDRB was, to my knowledge, first on the block locally to take public look at the implementation of a newly enforced federal law requiring hospitals to publish their Standard Charges online. Originally part of the Affordable Care Act (a.k.a. Obamacared) as turned into regulation last year,, the stated purpose was to allow the public to compare the cost of services and choose wisely among hospitals before they incur responsibility for payment. An overlying expectation (?dream) was to improve quality and decrease costs. Hospitals bitterly protested implementation of this law.

Mr. Corsey’s reporting verified the expectation that charges amoung neighboring hospitals can vary greatly. For example, an uncomplicated birth at one Louisville hospital was priced twice as high as another, and an injection of a drug used for prostatic cancer varied threefold. Corsey’s report also concluded that the published lists are confusing and difficult to decipher. I agree. I will go further and argue these lists are essentially worthless for their intended consumer purpose – surely knowingly so. Their value however for unintentionally making the policy point that, like pricing for pharmaceuticals, hospital pricing and billing exists in a logic-free, Alice-in Wonderland zone to the detriment of the public. Allow me to explain. Continue reading “Federally Mandated Postings of Standard Charges by Louisville Hospitals Are Unusable for Their Intended Purpose.”