My 3rd Capital TransPride, Washington, DC USA

Capital TransPride 2015 55384The transgender pride flag is a symbol of transgender pride and diversity, and transgender rights (View this photo on Flickr.com)

As the subject line says. And as we predicted, the venues for Washington, DC’s Capital TransPride would get bigger and the rooms would get more full. We didn’t predict how big, though – 500% increase from last year.

The World: Learning to Love Better

New data from the Human Rights Campaign (@HRC) shows that of 2016 likely voters, 22 % of people know someone who is transgender, up from 17 % one year ago. This parallels the trajectory of acceptance of lesbian, gay, and bisexual individuals, with a higher slope on the curve.

U.S. Medicare has reversed its coverage stance (see: Just Read: Medicare bids farewell to the 20th Century in covering transgender person care, and maybe pokes fun at itself, too… | Ted Eytan, MD), as has the Federal Employee Health Benefits Program, to name just a few.

I connected with more people who are receiving health care and I could see the difference immediately. This cohort will be this year’s ambassadors of total health, which will create another – trajectories …

…at a faster pace

In the last year, some of my establishment medical colleagues have mentioned that they feel things are changing too fast. When it comes to achieving life goals through optimal health, change can never really happen fast enough.

Why be a doctor if you aren’t going to help people achieve their life goals? Fortunately, I am one, I am going to, and all of my colleagues will learn to as well 🙂 – many of them already are, and in my eyes, they are the best doctors in the world.

Kaiser Permanente Platinum Sponsor Capital TransPride CTP15 Washington DC USA 55222

Kaiser Permanente Platinum Sponsor Capital TransPride CTP15 Washington DC USA 55222 (View on Flickr.com)

With more allies

In the meantime, proud once again to be part of the medical profession, the health care system here in support (Kaiser Permanente Mid-Atlantic States @KPMidAtlantic is a platinum sponsor of Capital TransPride).

Capital TransPride also hosted the first ever workshop on how to be a successful ally – another packed room, with people from multiple states (!) present.

I was also joined by a talented photographer with a really good camera this year, because diversity looks beautiful. Enjoy their photos as well.

While making history

DC People and Places 54033

Reeves Municipal Center in 2015 Washington, DC, now safe and comfortable host to the future (View on Flickr.com)

The Reeves Municipal Center was built in 1986 by Washington, DC Mayor Marion Barry: “…. meant to bring government services closer to a struggling neighborhood and to revitalize a corner still recovering from the 1968 race riots. (Washington Post)”. There’s a sort of photographic homage to 1986’s Washington, DC contained within (you can see the photo here).

1986’s or even 1995’s Washington, DC was not friendly to people who are transgender, until 20 years ago this year. Then the City violated its own human rights act in allowing a transgender woman, Tyra Hunter, to die, with negligence and malpractice, after a car accident.

Now, 20 years after that, the City is the most protective of transgender (and all of LGBTQ) people in the United States, and its municipal buildings are hosting their celebration, sponsored by municipal entities (The DC Library, first year @DCPL) complete with gender neutral bathrooms.

Who knew if Marion Barry would have predicted this outcome, it happened nonetheless. Trajectories …

My photos are below. Enjoy, questions and comments welcome as usual.

Just Read: Medicare bids farewell to the 20th Century in covering transgender person care, and maybe pokes fun at itself, too…

even assuming the NCD’s exclusion of coverage at the time the NCD was adopted was reasonable, that coverage exclusion is no longer reasonable.

In english, this means that Medicare’s former determination in 1981, 33 years ago, that gender confirmation surgery should not be covered, is now history. Medicare entered the 21st century only 14 years too late. With glass-half-full, that’s 3 years faster than the length of time it takes for science to make it into practice 🙂

Definitively stated: Gender confirmation surgery is safe, effective, backed by science

There is an excellent review of the literature within which puts to rest any notion that gender confirmation surgery is experimental (it isn’t), that there isn’t evidence to support its use (there is, plenty), that it isn’t safe (it is).

The experts cited note that the surgical procedures used in gender confirmation have been validated (and are covered) in other medical conditions, such as Mayer-Rokitansky-Kuster-Hauser syndrome, or MRKH, in which women are born with a complete or partial absence of a vagina, cervix and uterus.

With regard to safety, 1985 appears to be the turning point year, where surgical technique improved to the point that compliation rates and hostpital stay requirements went down significantly.

The decision also points out something that wasn’t called out in 1981, which is the lack of safety in a situation where treatment is not offered:

…(Gender Dysphoria) ..if left untreated, can result in clinically significant psychological distress, dysfunction, debilitating depression and, for some people without access to appropriate medical care and treatment, suicidality and death”

By the way, all of these symptoms of no treatment, leading up to and including death, are covered in health insurance plans even if the medically necessary care is not. In other words, as stated by the American Medical Association, coverage for this care is probably preventive.

Laughter is good medicine – do I detect a little humor in here?

I assume there are many ways to wipe away a 33 year legacy. You can do it with solemnity but you don’t want to appear too solemn because then the legacy won’t be sufficiently wiped. I suppose you can inject some humor into it as well, and that’s what I spy in this paragraph on page 18:

the 1981 report (and the NCD) cited an alleged “lack of well controlled, long term studies of the safety and effectiveness of the surgical procedures and attendant therapies for transsexualism” as a ground for finding the procedures “experimental.”

…and then goes on to say that the same report cited studies that ran in length from 3 months to 13 years and

If these studies do not qualify as acceptable long-term studies, the basis for such a conclusion is not adequately explained in the NCD record.

This is unmistakeable medical speak for “you have got to be kidding.”

What else can I say except, I enjoyed it :). In reality though, a subtle poke at the past helps a new generation of medical professionals tease apart data and bias, which are clearly and transparently wrapped up together in the previous coverage decision. Which is now vaporized.

Health plans are changing their coverage decisions in response

A careful review performed by my digital librarian (Google) shows the impact. Check out the difference in this coverage decision from a large commercial health plan in California, from 2012 to 2014. You can see the edits that move this medically necessary care into the same domain as all other medically necessary care. Check it out.

“Use this page to view details for national coverage determination (ncd) for transsexual surgery (140.3)” – this is the “heritage” coverage determination, which was invalidated on May 25, 2014. (see original)

Fit for the museums of the future…

In addition to saving the coverage decisions above, I’ve also clipped the 1981 National Coverage Decision for posterity. One day it will hang on a museum wall (Perhaps this one? @LGBTMuseum ) where people will stare at it in disbelief.

This saga reminds me of a quote I will never forget by one of my medical school professors, Andrew Weil, MD (yes, that Andrew Weil), who once said, “We’ll look back at what we did to people with cancer in 20 years and be aghast.” Maybe that’s the quote that will be printed on the wall above these heritage pieces as well, and I am so happy to be in medicine on the other side of those 20 years. I only wish we didn’t have to wait so long.

seattle gay marriage 5

Congrats, sorry it took so long

Welcome to the present, Medicare, we’re glad to have you!

Photo Friday: The right answer is to involve patients in every decision

Ted (me), Mark Scrimshire ( @ekivemark ), Kait Roe ( @kaitbr ), at the Kaiser Permanente Center for Total Health ( @kptotalhealth ), for the Care Innovations Pre-summit. Photograph taken by Jason Bhan, MD ( @gomedivo ), jackets by Regina Holliday ( @ReginaHolliday ).

DC Care Innovations Summit Viewing Party at KP Center for Total Health

Care Innovations Summit Viewing Party at KP Center for Total… – Eventbrite. Washington, DC is at it again!

I’ve been spending this week gearing up for the Care Innovations Summit in Washington, DC, which will be on January 26, 2012, as well as a pre-event happening the day before. From what I have seen so far, I can say that passion for innovation will be filling the DC sky this week.

As luck/serendipity would have it, the actual summit is “checked in full,” however, Kaiser Permanente is hosting a viewing party with live link to the Summit at the Center for Total Health. That’s where I’ll be.

Hashtag is #cisummit , feel free to register at the link above before it fills and we’ll see you there.

Are you integrating Intensive Behavioral Therapy for Obesity into your medical practice?

I recently posted about the “CMS Proposed Decision Memo for Intensive Behavioral Therapy for Obesity (coverage by Medicare)” and received this query. I don’t know the answer, so I’m posting it here to see about the wisdom/experience of the crowd. Please add what you know/what you’re doing in the comments!

(we are) trying to learn more about this is being done in the real world, post ACA.  We’re just trying to learn the nuts and bolts to help providers get reimbursed for this service so that they will be encouraged to actually provide this counseling.

Incidentally, the final CMS Decision Memo for Intensive Behavioral Therapy for Obesity (CAG-00423N) – is now posted, feel free to look to it for reference, it discusses guidelines for coverage, along with the science behind the effectiveness for Intensive Behavioral Therapy for obesity (and there is documented effectiveness).

Medicare To Cover Obesity Counseling Without Cost Sharing

Medicare To Cover Obesity Counseling Without Cost Sharing – Kaiser Health News.

Since I’ve mentioned this to more than a few people recently, I’m writing a post about it.

This is significant for two reasons:

  1. For changing the way health care is paid for, from procedures to counseling, which talking AND listening.
  2. For changing the way we think about obesity treatment, from thinking about it as untreatable (which is a myth), to thinking about it as treatable (which the science supports)
#1 has potential implications above for other things in health care that have been underemphasized (by they way they are reimbursed) such as advanced care planning (think “Engage with Grace“). It’s worth checking out to see what the parallels are.