I apologize. I am eating pie right now and it is great.

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So I feel like I tacked a little too far into ungrateful snark in these last posts. All complaints and no solutions and that’s not what it’s about. What I’m trying to get across is that I believe people are infinitely capable, and we are smart enough and strong enough and have enough will power to address our problems.

So, a day late, here is what I am thankful for:

First: of course, family and friends. We are alive, we are relatively healthy, and we rest easy knowing that if we get sick there will be EMTs, nurses, doctors, therapists, drugs, imaging, and people that maintain a hospital to care for us. Thank you to these people for being on call/nights/weekends/holidays. Also for epidurals ’cause we are having babies at an incredible pace.

Second: a nation of people willing to confront ugliness. It might not seem like we’re special, and the work is never done, but calling out rapists and racists and autocracy and corruption is a thing Americans do well. And we’ve got a government that, while it spies and it lies and it unauthorized murders, does not (successfully) repress criticism for these actions. Hat tip to our citizenry.

Third: artists, writers, and musicians. There is significant Venn diagram overlap with these folks and the folks confronting the ugliness. You’re not doing it for the money you amazing humans. Also there have been at least two life changing albums made in the past year and I’m thankful that music still changes my life even at my ripe old age.

And pie.

Now everyone feels bad about the pies.

(Image from CDC)

Happy day after Thanksgiving. Now that we’re all in regret mode, diabetes! This is a slow-motion public health train wreck, amiright? And it’s another marker of race disparity in health… but I’ll save that for another day.

Diagnostic for diabetesHemoglobin A1C>=6.5 OR 8 hour fasting plasma glucose of >= 126 mg/dl OR oral glucose tolerance test of >= 200 mg/dl OR random plasma glucose of >=200 mg/dl.

Super user-friendly.

So diabetes is a clear medical diagnosis to make, but telling someone with a fasting blood sugar of 120 that they do not have diabetes is the wrong message. You either have HIV or you don’t. Diabetes is a disease on a continuum. Even with moderately high sugars the vessels of the fingers and toes and heart are getting damaged. The delicate vasculature of kidneys and eyes is getting all junked up, and pancreas… oh poor pancreas you will never be the same.

So it would make sense to do some intensive nutrition education for people that fall into that pre-diabetic category, you know, maybe keep them from become full-blown diabetic? As it stands, Medicare does not reimburse (pay for) nutrition consults until you have the official diagnosis of diabetes. So we are giving nutrition education to people in the hospital after they have had their toes amputated, between debridements of wounds that won’t heal, and in dialysis while they wait for a kidney transplant. These are miserable, life-limiting procedures. All of which are way pricier than some front-end nutrition education. And the cost of diabetes has increased 41% over the past 5 years.

My mom falls into the pre-diabetes category. I write little lists and send texts and talk to her on the phone about how she is managing a blood sugar that is next door neighbors with diabetes. Based on my very limited knowledge of nutrition (nursing schools could really fortify this part of our education), here are some of tips I’ve given her: First, 5 a day, lots of fiber, and minimal processed foods. Look for added sugar in all all foods, especially processed. If a product is labeled low or non fat, you can assume that they replaced that fat with sugar. Check the label. Also, exercise helps your cells metabolize sugar, bringing down your blood sugar. Even if you don’t lose pounds. What else can I do? I’m genuinely asking.

Think globally, outrage locally.

One of the volunteers at our tiny county’s only food bank/emergency assistance provider/shelter is always wearing a t-shirt that says IF YOU AREN’T OUTRAGED YOU AREN’T PAYING ATTENTION. He’s one of the gentlest guys I know–a middle aged black man living in rural poverty who relies on the food bank and is its most faithful volunteer. I used to give his son a lot of (unsanctioned by my employer) rides back when I was working in our nearby town. Also soft-spoken and kind. And tall and broad and one of those kids whose stupid luck ends him up in the wrong place sometimes. I worry.

But that t-shirt, oh man it makes me like that guy.

So here’s something I wasn’t paying attention to before one of my nursing colleges (Michael Swanberg, a member of ACT UP, certified nurse midwife, and enchanting human being) brought it to light. This data is pulled from the Thomas Jefferson Health District’s community health assessment, 2012. Page 54. The image quality is terrible but the dark blue is TJHD black infant mortality, teal is TJHD white infant mortality.

infant mortality image

An examination of infant mortality stratified by race demonstrates the same phenomenon in Virginia and TJHD as in the nation — African-American babies die more frequently than white babies. In 2007-2011, the rolling average IMR in TJHD was 4.5 infant deaths per 1,000 live births among white infants, lower than the Virginia (5.4) and U.S. rates; it was 17.3 among African-American infants, which was higher than the Virginia (13.8) and the U.S. rates (Figure 109).

Check my math but that means that African-American neonates in our health district are nearly four times more likely to die than their white counterparts. Brand new no-jackass-on-earth-can-say-their-deaths-were-deserved babies. Are you feeling the outrage? The black neighborhoods in Charlottesville are literally in the shadow of the towers of an academic health center. Tell me how this can be.

Open Access. For journals. For everything.

The journals that publish those papers are, in many cases, for-profit institutions — and they prefer charging for access.

via The Gates Foundation pushes to make more academic research free and open to the public – Vox.

The (TAXPAYER FUNDED) National Institutes of Health, which spends about $30 billion yearly on medical research, began in 2008 requiring that research studies it funds be made open access a minimum of one year after publication. The Gates Foundation now requires that publication of the research it funds be openly accessible by the public starting now and for, like, ever–meaning that publishing in big brand name subscription-only journals might be off the table. This puts pressure on those journals to provide open access. HOORAY! Science evolves!

At the moment clinical research is the area of study least likely area to be open access. The community hospital I work at provides its clinicians no scholarly resources. My school bestie and I our putting our thesis where our mouth is by choosing to study and promote access to clinical resources for staff nurses…despite being told by every adviser we have that it’s a bad idea. We may (probably will) go down in flames, but sometimes the amount of push-back you get is proportional to how right you are.

Ethical problems crop up in establishments that sustain themselves by limiting access. Closed institutions embolden those with access to manipulate those without, provide a nice incubated broth for corruption, weaken the rigor of their founding principles, and encourage opacity to protect against anything that might devalue access.

Am I talking about academia? The journal Nature? Fraternities?

If you opt for open access and promote a culture of transparency you’ll get two things: 1.) Diffusion of knowledge making fertile ground for creativity and innovation, 2.) Confronted with the fact that there’s a lot of bad wood underneath the veneer. Which is the first step in getting that rotten stuff out of there.

How Obamacare Lowers Your Property Taxes – Forbes

How Obamacare Lowers Your Property Taxes – Forbes.

Key point:

A snapshot of this trend can be seen in Cook County, Illinois, where the public hospital system has seen a decrease in patients who cannot pay their bills thanks to the law’s expanded Medicaid health insurance for poor Americans.

Long and short–Medicaid expansion offers insurance to people in poverty, which is a means to provide payment to public hospitals and health systems that are mandated to give care regardless of an individual’s ability to pay.

Here’s the AHA reports on uncompensated care through 2012 for those who want numbers (before Medicaid/marketplace).

PS- I love working for a public health system because it is the closest thing I’ve seen to fulfillment of that phrase under Lady Liberty’s feet. That’s corny as hell, right?

A seat at the table. Psst this is a feminist issue.

I spent all day yesterday and half of today at the hospital, then the other half of today writing a paper about my profession, then came home and watched this 26 min documentary about the future of nursing. I am so thoroughly in brainwashed/in love (that’s the same thing, right?).

I’m on board with all of this nurses are the answer messaging. But the very last line hits a sour note:

“Wake up public, you vote us most trusted profession but we need your support to be all that we need to be.”

THUMBS DOWN. Don’t spend twenty minutes talking about how we are natural fixers of problems then lob the biggest one we have, our fractured image, into the lap of the public.

Wake up faculty. Teach young nurses that it is absolutely their professional obligation to speak up for their patients. Not just in the hospital. Take that noise to the press, the internet, the state house.

Wake up nurses. That trust we get from the public is sacred. Earn it by being conscientious, whip-smart, and brave. And be public about it.

Price Tags On Health Care? Only In Massachusetts | Kaiser Health News

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Let us be doubly thankful to Massachusetts.

Anyone with private health insurance in the state can now go to his or her health insurer’s website and find the price of everything from an office visit to an MRI to a Cesarean section. For the first time, health care prices are public.

via Price Tags On Health Care? Only In Massachusetts | Kaiser Health News.

If you have health insurance you’re likely used to making two types of price-based decisions when it comes to care:

1.) Primary care problem: How much sinus infection misery warrants a $35 copay to my doc? Answer (for me) 3-4 days.

2.) Emergent care problem: How much money am I willing to pay to have my burst appendix removed? Answer: ALL OF THE MONEY WHAT IS MONEY PAIN MEDS STAT.

But, for expensive and not especially time sensitive diagnostics and procedures transparency in pricing is so pleasingly sensible. The article makes the point that health care is not a commodity to be bought on price alone and I totally agree, but up ’til now we’ve had no way to collect data connecting price and quality. This is a step in the right direction.

Pro tip on buying your health care based on price–If you are buying on the exchanges/marketplace please do not make the Travelocity sort by cheapest yup I’ll take that one mistake. That is how you end up with a $10,000 deductible and 40% coinsurance on everything. You will not be happy. As I was not happy when I picked a hotel in Richmond that way. Hourly rates. Somehow under I95. Feral tomcats.

Choose a better fate.

Cholera Gave a British Doctor the Idea for IVs – The Atlantic

via Cholera Gave a British Doctor the Idea for IVs – The Atlantic.

WOO IV therapy! That’s my bread and butter! Hydration, volume expansion, insulin drips, antibiotics, everything you could want while unconscious. Plus just like in early days, it’s always there for a last ditch attempt. Coding? FLUIDS!

Also, science was much drunker before IRBs and we owe dogs so much apology and gratitude.

In 1656, Sir Christopher Wren wanted to see what would happen if he took a quill and a pig’s bladder and used it to send intoxicants—beer and wine and opium—directly into a dog’s blood. (The dog was intoxicated.)

Whooping cough outbreak at Grand Traverse Academy nearly doubles to 161 probable cases

Image NIAID

Whooping cough outbreak at Grand Traverse Academy nearly doubles to 161 probable cases | MLive.com.

Herd immunity/community immunity: when enough people are immune to a disease, that disease will not spread through the population. As a result those who are not or cannot be vaccinated (pregnant women, infants, immunocompromised) are protected from the disease as well.

Infants are eligible to receive their first pertussis immunizations at 2 months. Pertussis/whooping cough in the first three months of life is frequently severe and often fatal. Pertussis is a respiratory disease that in early stages has the same symptoms of a cold. Babies are most likely to get the disease from a parent or a sibling. (American Academy of Pediatrics)

I’m not going to ruin my night by getting on the soap box because it’s Saturday and ACA open enrollment is not a total disaster so far and I was just destroying at Jeopardy, but y’all are picking up what I’m putting down, right?

Heath Insurance 101, for those who have.

For my nursing school people, basic health insurance components/jargon demystified. Also, I wrote you a vocab list and a little story, too. <3

Premium: monthly cost (often split between individual and employer OR fed gov’t subsidy (ACA Healthcare Marketplace, Medicare) OR state gov’t (Medicaid).

Copay: Set amount of $ you have to pay to see a doc/receive a service.

Coinsurince: % of bill you owe.

Deductible: $ you pay before insurance kicks in (depending on plan, you may have to meet a deductible before insurance will cover anything, or before your insurance will cover specific services, or you may not have a deductible at all).

Out of pocket max: The most $ you’ll have to pay in 1 year (insurance agrees to cover all expenses after it’s met).

Formulary: list of Rx drugs covered by your insurance usually split into “tiers” that determine how much you pay. Tier 1=generics, cheapies, 2=expensive generics, brand names, 3=expensive brand names, 4=specialty or brand new (crazy expensive).

Provider network: “In network”=hospitals, health systems, and doctors your insurance has bargained with for lower prices. HMO/EPO insurance will not pay anything towards care out-of-network. PPO pays much less for out-of-network.

Referral: Required by some insurance plans, a referral comes from your primary care doctor and recommends that you see a specialist.

Re-enrollment: period of time when you must sign up for a new insurance plan or verify that you are sticking with your current plan. Happens yearly, often in late November.

STORYTIME
You’re biking in the school arboretum which you weren’t even supposed be doing in the first place and you fall and break your arm. But, intelligent child that you are you’ve remembered to sign up for health insurance and pay your $200 a month premium so this injury won’t sink your financial battleship. You go to the ED at an in-network hospital and pay a $100 copay at registration. You have x-rays and get a soft cast and the doc gives you 2 Percocet and an Rx for some Percocet for the road. You fill your Rx at the pharmacy and lucky you Percocet comes in generic and is on tier 1 of the formulary so you’re only out $7 for the pills. Man you sleep like a baby. Your health insurance plan doesn’t require a referral from your primary care doc so first thing in the morning you go to the orthopedist and pay your $35 specialist copay as you register. The doc examines your arm, puts on a hard cast and says see ya in 6 weeks.

Four weeks later you’re scratching your arm with a coat hanger and the bills are rolling in. You have a $200 deductible for physicians’ services, diagnostics, or treatments, so you have to pay the full $200 bill for the Emergency Services Physician’s Group (this pays your ED doc for his time). That satisfies your deductible. Bills from the hospital system arrive and you pay a 20% coinsurance on the x-rays, the soft cast, and the meds they gave you in the hospital. Next comes the bill from the private practice orthopedist who bless his heart is also in-network. You pay 20% coinsurance on the amount he charged for setting and casting your arm.

You’ve paid about $500 towards your out-of-pocket maximum for the year. If you’re going to have a catastrophic injury or illness, it would be cheapest for you to do it now and not wait for re-enrollment to come around!