Category: Deborah Cho

A Case Against the “Noncompliant” Patient

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By Deborah Cho

In recent years, providers have attempted to shift how health care is delivered so as to include the patient in the decision-making process.  This concept of shared decision-making was most memorably relayed to me in medical school through a critical lesson during which we were instructed to replace the word “noncompliant” with “non-adherent” when describing patients who were unwilling or unable to stick with treatment regimens.    Noncompliance painted a picture of a paternalistic provider mandating the rules of play, while the patient cowered below as a disobedient subordinate.  It also implied that the patient did something wrong by breaking the rules and that the actions of the patient ought to be modified to fit the rules, rather than the other way around.  On the other hand, non-adherence signified that the patient was a contributing partner in the development of the treatment plan and, further, that he may be justified for not abiding by the terms of his plan.

There were two overarching reasons for the shift to the shared decision-making model: first, that this would produce better overall clinical results and second, that this view shows more respect for patient autonomy.  Providers were learning and accepting that treatment plans prescribed within their vacuums could fail to be affordable, intelligible, or even realistic given a patient’s life circumstances.

So how does this relate to law students and lawyers?

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Tips from a former medical student – Part II

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By Deborah Cho

[See Part I here]

Last week, I wrote the first of a two-part series on tips that may be helpful for law students and lawyers interested in or working in health/medical law.  I continue with Tip #4 here.

4. If you need to learn about a disease, procedure, or drug that you know nothing about, your best starting point is probably Wikipedia.  Google will lead you to some incorrect answers, and diagnose-yourself websites will give you answers that are much too broad to use practically in legal practice.  Once you have familiarized yourself with the general topic on Wikipedia, you can then go back to your search engine of choice for more specific terms and weed out the wrong information.  Starting on PubMed or GoogleScholar probably isn’t the best idea either because most of what you’re reading will be highly technical and the articles you find will likely be about novel uses or instances of whatever you’re searching.  Another fantastic source is UpToDate, an evidence-based Wikipedia-like source for healthcare providers, but many people may not have access to all the information on this site.

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Tips from a former medical student – Part I

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By Deborah Cho

As a student in the Disability Litigation Clinic, one of the many fantastic clinics here at Harvard Law school, I’ve come to appreciate the value of hands-on experience as an essential component of legal education.  One issue that we as students are often faced with, however, is a lack of familiarity with the particular subject matter we are assigned to work with.  Now, I know that topic-specific knowledge typically comes on the job, but I’m starting to see that many of us trying to practice law touching the medical field never really have a chance to learn the basics of the medical world and just how essential that basic knowledge really is.

As a short introduction to this post, I will say that I spent several of my college years volunteering and doing research at various hospitals and clinics, went to medical school for two years, have an M.A. in Bioethics (noting this to add to my hours spent in a hospital), have interned in the health care division in state government, have interned in a health law nonprofit firm, and, as noted above, am enrolled in the Disability Litigation Clinic right now.  All that to say, please take everything I write here with a grain of salt.  I am by no means an expert on this, but have found that this information has helped me throughout my healthcare-related legal experience so far and I hope that this will spark dialogue and interest on this subject.

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Is CVS really doing the right thing?

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By Deborah Cho

As announced earlier this month, CVS has decided to stop selling tobacco products in stores starting October 2014 because it is not in line with its goal of promoting health.  Since this announcement, there have been countless articles and editorials on whether this was a good move by CVS or not.  Those who have said that this is a good (or great) decision generally emphasize that it makes a powerful statement about the harmful health effects of smoking, while others have noted that CVS’s decision is an unwise financial move and is unlikely to actually decrease the rate of smoking in the country.

It was interesting that CVS chose October 1st as the official start date of its new initiative, as if it were signaling that it were a health entity coming into full compliance with the ACA and ready to herd in its customer-patients.  CVS has attempted to adopt the identity as a health provider, with its president hoping it evolves into an alternative to the doctor’s office.  As such, CVS must shed itself of anything that does not mesh properly with its new image.  This, however, inevitably leads to the question of why tobacco products were singled out as “unhealthy” when so many other products that are sold at drugstores like CVS provide just as little health benefit to the American population.

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Capitalizing on Fecal Transplants

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By Deborah Cho

Last summer, the FDA reversed its previous decision that required researchers to file INDs for fecal transplants to treat Clostridium difficile.  This decision came without much official explanation as to the reasoning behind the reversal, but can be understood as a result of the unusually high success rates of fecal transplants in treating the deadly infection and the impracticality of applying IND requirements to the procedure.  As the FDA guidance notes, however, the agency’s “exercise of discretion regarding the IND requirements” affects only the use of fecal transplant to treat C. difficile and does not apply to the treatment of other diseases or conditions.

Despite the peculiarity of this type of treatment, researchers and patients alike seem to have embraced it for its ability to cure more than just life-threatening infections that have few other viable options.  In fact, a physician in Seattle studied the effects of fecal transplants on inflammatory bowel disease.  And, as it goes with many drugs, there even seem to be clinics claiming to use fecal transplants to treat weight loss. 

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How Drug Samples Are Being Used to Fight the Good Fight

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By Deborah Cho

I would highly recommend reading the Stanford Social Innovation Review’s recent article An Rx for Surplus Meds featuring the Dispensary of Hope, a brilliant model of providing prescription medications to those who need but can’t afford them.

In a nutshell, the Dispensary of Hope, a not-for-profit enterprise, collects unused medication samples from participating physicians and pharmacies across the country and redistributes those medications to safety-net health centers.  Those health centers can then prescribe these much-needed medications to patients who are unable to obtain them otherwise.  Since many of those medications would likely sit on shelves until they had to be discarded if they were not donated, this is beneficial to both the physician practices that no longer have to worry about proper drug sample disposal and also to safety-net health centers and their patients.

More specifically, participating physician practices and pharmacies simply fill with medications the boxes that are shipped to them by the organization and then ship the box back to the organization’s headquarters.  The organization’s staff and volunteers there do all the legwork necessary to properly inventory the drugs so that they can be distributed.  This way, time and effort required on the parts of these physician and pharmacy groups is minimal (not to say that their contribution is minimal – the Stanford article states that $14 million of sample donations were expected for 2013).  The organization thus provides a missing link, acting as an intermediary between the donors and the recipients to keep the supply constant and regular.

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Health Insurance & Patient Responsibility, Part II

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By Deborah Cho

In my first post, I introduced the general problem of patients not being fully informed about their health insurance policies and instead relying on providers to correctly apply each patient’s unique policy when making medical decisions.  Though patients are ultimately responsible for abiding by the terms of their individual insurance plans, there may be ways that health care providers can help patients avoid being stuck with unnecessary and unmanageable medical bills.

One solution might be to make giving a general statement about the importance of understanding how your health insurance policy relates to recommended care become standard practice during patient encounters for physicians and other health care providers.  Health care providers can, for example, add something along the lines of “You may wish to check with your insurance plan to see if this is covered” when providing a recommendation for treatment or when providing a referral.  Such practice should not place liability on health care providers to guarantee that patients have an accurate understanding of their insurance coverage.  Instead, insurance coverage and medical debt should be viewed as factors that can directly affect a patient’s health and well-being, thus deserving a few moments of the patient encounter whenever possible (perhaps similar to brief counseling on smoking cessation, which is covered only if appropriate and timely).

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Health Insurance & Patient Responsibility, Part I

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By Deborah Cho

With the implementation of the Affordable Care Act, many consumers can now (or eventually…) head to HealthCare.gov to compare health insurance plans to find one that fits their needs.  Health insurance plans, however, can be complicated and fraught with exceptions and exclusions that consumers learn of only when it is too late and medical bills have already started to pile up.  Consumers are directed to consult member handbooks to learn their plan’s terms and conditions, but these handbooks are often nearly a hundred pages in length and densely packed with information.

Nonetheless, patients are held responsible for understanding and abiding by the terms of their plans, even if those terms are confusing and hard to fully appreciate.  For example, patients are expected to know what types of medical care require prior authorization from their insurance carriers and that they must obtain approval before receiving that care.  If these steps are not taken in the correct order, payment can be denied and the patient may be left to foot the bill for the services.  Similarly, patients must understand that their policies may fully cover only in-network providers and must additionally know who is in-network and who is not.  Because the member handbook and/or benefits document allegedly provide adequate notice, the patient is out of luck if he is not aware of these conditions.

The outcome is similar even when a medical provider or the provider’s staff does something to indicate that the medical care in question is covered by the patient’s insurance plan.  This can be as simple as suggesting a specific procedure to help with the patient’s condition or even merely referring the patient to a particular specialist.  A patient may accept care on the understandable yet incorrect assumption that an action recommended by his treating physician is automatically covered by his insurance plan. Though providers often verify that costly care will be covered by a patient’s insurance in order to ensure proper compensation, the instances when this does not happen can be financially devastating to patients.

So who should be responsible for knowing the ins and outs of these health insurance policies?

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Introducing Student Contributor Deborah Cho

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Deborah Cho is a second-year law student at Harvard Law School interested in social justice and health law.  She graduated from UCLA with a BS in biochemistry and then attended Case Western Reserve University School of Medicine.  After two years of medical school, Deborah’s interest in social justice and inequitable access to health care prompted her to begin considering law school.  She subsequently received her MA in bioethics while doing research on expanded genetic carrier screening at the Center for Genetic Research Ethics and Law at Case Western Reserve University.  At law school, Deborah has interned at the Health Care Division in the Massachusetts Office of the Attorney General and is currently an intern at Health Law Advocates, a public interest law firm. She will also be a student editor of the forthcoming Journal of Law and Biosciences.

Representative Publications

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