Tuesday, December 21, 2010

Physican Educators Should Avoid PhRMA Contacts

(Note: this post is slightly modified from my post at www.npalliance.net/blog.)

Evidence has suggested that physicians are influenced by contacts with PhRMA--via drug reps, conferences, advertising purported to be educational, etc.  As I've previously noted, I think this is a strong reason why physicians should avoid industry contact/influence.

Recently, ProPublica launched their Dollars for Docs reporting series.  This series of stories (and a searchable database) intends to bring light to the relationship between PhRMA and physicians.  It's a very revealing (and fairly unpleasant) overview of how tight these connections are and how much influence industry wields on and through physicians.

A recent article describes how poorly medical schools perform in keeping medical school faculty from joining industry speakers bureaus.  High-ranking faculty at medical schools participate in these activities and give industry-sponsored talks, even though school policies officially forbid that.  In many cases, the physicians' excuses were lacking.  A major failing appears to be that medical schools' policies rely upon voluntary reporting and the honor system.  Considering that some speakers can make over $100,000 yearly through their speaking activities, it is clear that voluntary reporting is insufficient and significant penalties may be required if faculty violates their school's policies.

Considering that companies are seeking to exert more control over what speakers say, it is increasingly evident that PhRMA and other industry-sponsored talks are NOT educational endeavors--no matter how much participants might believe and no matter how much industry insists that they are.

Physicians who speak on behalf of industry are both targets of companies' advertising efforts and a key part of those companies' advertising campaigns.  Continuing this activity is questionable at best.  For our physician educators, who influence other physicians and who teach and mentor future physicians, this is unacceptable.

Sunday, November 28, 2010

Repealing the PPACA Could Harm Vulnerable Communities

I have already posted some observations that, in my opinion, the calls to repeal the Patient Protection and Affordable Care Act (PPACA) are politically motivated, and that the public does not agree with the call for wholesale repeal.  I thought it would be interesting to look at how the proposed repeal could impact vulnerable communities, as outlined in this article.

The article notes that African-Americans are more likely to live under the poverty line (26%) and are uninsured a higher rate than the overall U.S population (21%, as opposed to 14-15% overall).  Those calling for repealing the PPACA have not put forward any measures that would address this lack of access to health insurance, they have not proposed any process to address the lack of primary care physicians working in medically-underserved communities, and have no plan to promote preventive care--all of which are addressed in the PPACA.  In essence, the call for repealing the PPACA would entrench the status quo that already results in significant health care disparities in minority and poor communities.

As an aside, I think it is interesting that the call for repeal embodied in the Republican "Pledge to America" states it will ensure that insurance companies cannot refuse care to those with pre-existing conditions.  This is interesting because the Republicans oppose the main mechanism for reaching this goal (the individual mandate that everyone would need to purchase health insurance) and because this requirement would involved significant government regulation (something the Republicans claim to oppose).

As it stands, then, the Republicans aim to repeal the PPACA's reforms that actually protect patients and that could improve access to care for marginalized communities while having no mechanism in place to fix the problems that already exist--even as evidence increases that the public does not support the call for repeal

I think the Republican's insistence in pushing for this unpopular proposal for repeal will end up changing nothing and serving as nothing more than an opportunity for political grandstanding.  As a result, the House will waste time engaging in showmanship when they could be working to effect fixes in the bill that would strengthen it and that could address areas of concern.  In that case, we all lose.

AMA Guidelines on Physicians and Social Media

Just posted about the newly-released AMA guidelines addressing physician use of social media.  I'm not sure that these guidelines will help very much right now, but I hope they might lead to further discussion heading forward.

Sunday, November 7, 2010

How Popular Is Repealing Health Care Reform?

Now that the fallout from this week's elections are evident, we are already hearing calls from the new Republican majority in the House that they will start actively pushing for repeal of the Patient Protection and Affordable Care Act (PPACA).  This made me wonder: how popular is the notion of repeal among the American public?

The Kaiser Family Foundation published a poll recently that seeks to answer that question.  My reading of the situation is that the polling is fairly hard to interpret, with somewhere between 26% and 51% reporting they would like to see the law repealed.  However, the highest %s that are in favor of repeal were reported when the only choice was repeal/don't repeal.  If the poll offered additional questions, including making small changes, or giving the law a chance to work and adjusting as things move forward, the % supporting straight-out repeal was much lower.

Finally, one poll asked respondents which of the reforms enacted by the PPACA they would like to see repealed.  When analyzed at this level of detail, more than 50% supported keeping 6 of the 8 reforms discussed.  Only 2/8 reforms had 50% in favor of repealing them: the individual mandate that everyone must purchase health insurance (51% favored repeal), and the new taxes and fees on "cadillac" (high cost) health insurance plans.  The reforms that more than 50% wanted to keep included allowing children stay on parents' plans up to age 26, eliminating lifetime benefit caps, making insurance available to people with major preexisting conditions, improving the Medicare part D drug benefit for seniors, and setting up health insurance exchanges to make health insurance available for those who cannot afford it now.

Sounds as though most Americans who disapprove of the PPACA overall still like many of its key reforms, and prefer that the law be adapted/modified, not repealed.  I hope the new Republican House majority is paying attention.

Friday, October 22, 2010

Busy Saving The World

(tongue firmly in cheek)

I realize that it has been some time since I posted to the blog.  Lots of reasons, lots of excuses (including my contributions at smhcop.wordpress.com), but a big reason has been my participation with Una Vida Sana! (UVS).  This project enrolls medical, pharmacy and nursing students to provide outreach screening services to the Hispanic community in Richmond.  The screening also involves medical interpreter students (to help interpret for the students and providers) and lay health workers (promotoras) from the CrossOver Ministry (who help with peer-to-peer health education for the community).  The UVS outreach includes measuring height and weight to calculate a body mass index (BMI; helps assess overweight/obesity), waist circumference, smoking status, blood pressure, blood sugar and cholesterol measurements.  This allows the team to assess patients' current health status and risk of future health concerns related to cardio-metabolic disease: high blood pressure, high cholesterol, diabetes, etc.  The most recent screening event for UVS was as part of the City of Richmond's Imagine Festival, and took place last weekend (October 16, 2010).

In the last 10 years, Richmond's Hispanic community has nearly doubled, and my perception is that much of the increase is made up of young families that are establishing themselves in the community.  In many cases, the adults are young (20s and 30s) and currently in good health, but run a significant risk of health problems in the future and may not realize the importance and value of screening for asymptomatic medical conditions.  My fear is that these conditions could progress, and the incidence of asymptomatic disease could increase in the community until patients develop symptoms and start presenting to emergency departments and other safety net providers with symptoms or complications related to their illnesses. 

Our early events last Fall and Spring suggested that we were working with a community at risk of future illness but without true illness at this point.  The most recent UVS event supports this: a number had elevated blood pressures or elevated blood sugar, and a smaller number had a significant risk of heart disease in the near future.  Past events showed similar results: a lot of "soft" outcomes (elevated blood pressures or sugars, but no official diagnosis) but not a lot of established cardio-metabolic disease yet.

We plan to hold more events during this academic year: December is planned as the next screening this semester, and we expect to hold three or four other events during the Spring semester in order to more clearly determine the community's current health status.  My hope is that we might find that the community is at risk of serious illness but has not yet developed the illnesses themselves.  If that is the case, there might be an opportunity to work with the community's members to emphasize and effect lifestyle changes. 

At the same time, while providing these screening services to the community, our health professions students learn to provide team-based care while working across disciplines and with patients of different cultures.  We think this experience will allow to learn from each other, and might encourage them to consider careers working with under-served and multicultural communities in the future.

I doubt I'll be saving the world on my watch, though that's no reason not to try.  But maybe some of these students might...and our patients and our communities will benefit for their efforts.

Tuesday, September 21, 2010

Health Care Reform's Six Month Mark

As we mark six months since the Patient Protection and Affordable Care Act (the health care reform law derided by its opponents as "Obamacare") I think is is reasonable to review the problems the law was intended to fix as well as honestly assessing support for the law's reforms. 

At this six month mark, the following changes will go into effect: insurance companies will no longer be able to set lifetime limits on your health benefits, and adult children up to age 26 will be able to stay on parents' insurance policies (so long as the coverage is paid for by the family in some way, of course).   For any new insurance plans or plans that change enough that they are no longer considered "grandfathered" (and therefore exempt for now), there are additional benefits: preventive services such as cholesterol checks and breast cancer screenings will be be available without deductibles or co-pays, recommended vaccines will be provided at no-cost, and patients can see obstetricians and pediatricians (when applicable) without needing referrals.  At the same time, small businesses with 25 or fewer full-time employees who earn an average yearly salary of $50,000 will qualify for a tax credit up to 35% of the cost of premiums in order to encourage small businesses to provide health insurance to their employees. 

Insurance companies also face new regulations affecting how they can operate: new policies for children up to age 19 cannot be denied coverage for pre-existing conditions, and the heinous practice of rescissions (canceling coverage once a policy-holder got sick) will be ended except for cases of fraud. 

Medicare benefits will NOT be affected, despite what the plan's opponents claim.  Meanwhile, the law has already started working on reducing the harm imposed by Medicare Part D's "doughnut hole" in providing drug coverage.

Opponents of the law imply that these changes, and the entire law, are deeply unpopular among the public.  This is contradicted by poll indicating that more than 70% of the public support the guaranteed issue of policies for children, tax credits to small businesses and the provision of preventive services without cost-sharing; more than 60% support prohibiting rescissions except in the case of fraud and closing the Medicare Part D "doughnut hole"; and more than 50% support eliminating the lifetime caps on benefits and extending dependent coverage until age 26.  This clearly indicates public support for this law's reforms so long as the public is not manipulated by those decrying it as "Obamacare" while misrepresenting the law's benefits and inventing supposed harms.

Meanwhile, a recent study highlighted the nature of the uninsured in the US.  The number of the uninsured reached 50 million people--approximately 1/6 of the nation's population.  Most of these people are low- or moderate-income and would struggle to pay for a premium without employer contributions.  More than 3/4 of the uninsured are in a working family, and approximately 1/4 of uninsured adults defer care (including preventive care and care for major health problems) because of cost.  When the uninsured access care, they face higher costs than insured people and the bills can escalate rapidly.  These issues are at the heart of why the Affordable Care Act was enacted: providing care to Americans who need it stands to provide significant benefits to those who most need it.

So, six months and and now the real changes begin.  The law will still have opponents, but I hope that we can recognize the falsehoods they put forward.  This law is not a socialist take-over, it is not government-run medicine, and its reforms are not unpopular when the political vitriol is stripped away.  This is a good law, making sensible changes and enacting meaningful reform.  Do not let anyone convince you otherwise.

Saturday, September 11, 2010

APNs, Midwives, And Physicians

This started as a reply to a comment on my previous post.  It got long enough that I made it a separate post.


Regarding the tensions between nursing/midwifery and medicine, there is enough there to discuss that it merits a separate post. In terms of nursing, I'll limit my comments to advanced practice nurses (APNs: nurse practitioners, and the newly-created Doctor of Nursing Practice DNP). This has become a significant issue in Virginia, where APNs  are seeking increasingly autonomous practice

In my mind, the strengths and limits of both models involved the fact that the training for APNs and midwifes comes from the nursing perspective, with a strongly patient-centered, holistic and preventive focus. This is an approach to which I am sympathetic, and it stands in stark contrast to the increasingly impersonal, test-and-technology heavy nature of much current medical practice. For both APNs and midwifes, this approach leads to patient-centered care and an emphasis on wellness. This is a strength.

The counterpoint is that the depth and extent of training for APNs and midwifes is less than that for physicians. The time involved in medical school and a medical residency is far more than that of APNs and midwifes. In my opinion, this leads to increased ability to deal with complicated illnesses, patients with multiple co-morbid diseases, and patients with undifferentiated symptoms.

I think APNs and midwifes have very relevant roles, but I feel that the nature of the training is more applicable to focusing on certain areas or certain conditions, or working with patients who have established diagnoses. For midwives, this area is that of pregnancy, childbirth and postpartum care--although unexpected problems can arise, many of the complications or problems can be anticipated or more easily monitored for because the underlying condition is defined. In the case of APNs, working with acute problems or patients with defined illnesses allows the provider to focus more directly on the anticipated complications or concerns related to these conditions.

I think that midwives and APNs are valuable members of the care team. I also feel, though, that physicians are best qualified to lead the care team. This is my bias (as evidenced by the fact that I chose to pursue my MD), but I believe it is based on the fact that physicians' training is more likely to allow successful evaluation of undifferentiated problems or complicated conditions, or unanticipated complications.

Physicians have a lot to learn from APNs and midwives in terms of the patient-centered, holistic, wellness focus of care. And I think that an experienced midwife or APN is probably more qualified in many areas than many young physicians. But I do not think that APNs and midwives can take the place of physicians.

The Social Contract

Reading through old, saved links I found one that I had overlooked the first time around.  The American Medical Association Journal of Ethics posted on online article discussing the nature of the social contract between physicians and the general society. 

In the article, the authors lay out the fundamental tenets of what this social contract requires in order to be successful.  As with all contracts, there are obligations on each side:

Societal expectations of physicians:
  • The services of the healer
  • Guaranteed competence
  • Altruistic service
  • Morality and integrity
  • Promotion of the public good
  • Transparency
  • Accountability
In return, physicians expect the following out of society:
  • Autonomy
  • Trust
  • Monopoly
  • Status and rewards
  • Self-regulation
  • Functioning health care system
I think that in an ideal situation, these agreements and stipulations make sense.  In essence, society expects to have competent and trusted healers who put patients' well being at the forefront, who will be open and accountable for their actions, and who work toward the greater good.  Meanwhile, physicians expect to be given trust and freedom to work individually within a viable health care system, to regulate themselves, and to be given both tangible and intangible rewards for being the sole providers of designated health care services.  If both sides of the agreement were being lived up to, then this construct would make sense.  But I fear that part of our current health care issues (costs, access, etc) result from each side's reneging on this contract.

As a physician, it is easy (and far more comfortable) to point the finger at society's failings.  Physicians can claim that society has failed to give the promised monopoly, as mid-level providers and physician extenders take larger roles in health care.  We can note that the status and rewards physicians have today are not equal to those given years ago.  And we can point at the dysfunctional health care "system" as a fundamental flaw that harms our ability to provide care.  Physicians can easily claim to be the aggrieved party in this arrangement.

But we must look honestly at our role in the arrangement, and acknowledge that our actions have helped lead to our current situation, and the weakening social contract.  Because we claim autonomy, we often act in our own best interests (and not necessarily from the perspective of enlightened self interest) and make decisions that do not reliably benefit the common good.  In a health care system where volume is rewarded, we do more tests and see more patients--which leads to increased costs for all, and weakens our health care system.  We get upset when we are asked to be transparent about our actions, or when we are held accountable for what we have done.  We are supposed to be altruistic at all times, but our actions are often tinged with at least a hint of self-interest (income, scheduling, etc).

The social contract is a fundamental construct that establishes the rules and roles between professions and society at large.  In the medical realm, though, I fear that both sides have violated its terms.  And I believe that both sides need to take responsibility and work to address this.

Physicians need to recognize the trusted role we have and the sensitive and intimate nature of our work.  We need to be truly altruistic, and work to meet patients' needs (and act in their best interest) at all times.  We need to be open and transparent about what we do, and we need to honestly deal with colleagues who are not competent or who do not meed professional obligations.  And we need to be constantly aware of how our decisions will affect society at large--not just our patients.

Similarly, society needs to ensure that physicians are reimbursed in ways that make it possible to pay off student loans and to make up for the fact that we lose 7 to 10 of our most productive years to complete medical school and post-graduate training.  We need to be given (and we need to earn) the trust to practice without excessive intrusions from insurance companies or from regulators.  And, as a society, we need to ensure that the health care system in place truly allows physicians to provide the care we are expected to.

In medical school, if one is asked a question about the cause of any illness, a safe cop-out answer is "multifactorial".  Almost no disease can be traced to a single cause.  The current failures of our health care system are similarly multifactorial and there is plenty of finger-pointing to go around.  But by refocusing on the social contract, and the agreements (implicit or explicit) necessary for the medical profession to fulfill its role, we might be able to come up with a plan to start making things right.

Thursday, September 2, 2010

How Can We Continue Defending The Status Quo?

One might hope that, in the six months since the Patient Protection and Affordable Care Act (ACA, much derided by opponents as “Obamacare”) was passed and signed into law, opponents of the legislation might have had time to assess the law’s reforms and start focusing on constructive criticism.  After all, even those who supported the push for health care reform feel that the ACA is an imperfect law.  Unfortunately, as shown in a recent opinion piece in the Wall Street Journal, ACA opponents continue to dredge up the same tired and dishonest arguments that argue for continuing the status quo at the cost of patients’ health and wellness.

The writer’s arguments suffer from many flaws and fallacies, and having limited space I have chosen to focus on just a few:

•    Claiming the ACA will interfere with doctor-patient interactions, and that doctors will be beholden to a vaguely defined federal bureaucracy is untrue.  It is likely that physicians and hospitals will need to prove quality care (not just quantity care), but I would hope physicians would be comfortable with this so long as the quality measures are fair and relevant.  At the same time, the writer ignores that fact that for-profit health insurance companies base physician payments on similar measures and that physician decisions are daily affected by limits imposed by health insurance companies.

•    There is no part of the ACA, to my knowledge, that rations care.  Even under Dr. Berwick’s guidance, there is no evidence that there is any intent for rationing care.  Meanwhile, the for-profit insurance companies that control our dysfunctional system ration care every single day.  Apparently, Dr. Scherz either does not experience this or chooses to ignore it.

•    The writer laments that the ACA will reduce the development of new technologies and “miracle drugs”.  He ignores the fact that much of our American health care system’s focus on technology increases costs dramatically while providing little evidence that patient care and wellness is improved and that much of the development of new medications occurs in publicly-funded universities. 

•    Republican senators indeed voted uniformly against the ACA.  However, this has not stopped them from claiming credit for some of the bill’s most popular elements including coverage for preventive care services.  In fact, if you remove the “Obamacare” label from the ACA and ask Americans if they support the individual provisions in the bill, a great majority support all the bill’s provisions and even the majority of self-identified Republicans support nearly all the bill’s reforms.

•    The final point to make is the author’s claim that the United States has the best health care system in the world.  We hear this over and over and over again—despite the lack of any proof.  By most any measures, American health care lags behind nations in terms of quality of care, accessibility of care, and patient-focused outcomes.  In fact, we rank first in only one category: cost.  We pay the most, by far, of any other nation for our health care and we get precious little benefit out of it.

I am proud to be a physician, and I consider it a privilege to care for patients—even when much of my care involves getting the best care out of our broken health care system.  To claim that the status quo is sustainable is to be oblivious to the facts, and to criticize the ACA using such dishonest rhetoric is a disservice to all our patients.

Thursday, August 26, 2010

Join The NPA!

As physicians, we have many opportunities to join organizations of all kinds—trade and professional organizations, fraternal organizations, social groups, etc. And if my schedule is typical of others’, I’m sure you already feel overwhelmed by work obligations, finding time for family and friends and leisure activities. So I am aware that when I ask you to consider joining another organization it is necessary to explain what the organization is, what its mission is, and what makes it different from other areas of organized medicine.

The National Physicians Alliance (NPA; http://npalliance.org/) is a multi-specialty organization that I first learned about early in 2009. I can’t remember how I found them initially, but as I looked over the organization’s website I was struck by its mission and its dedication to re-establishing core values of medicine: service, advocacy and integrity. The NPA’s introductory video (http://npalliance.org/dvd/) struck many chords for me. As a family physician who has spent all my career working with underserved patients, I have been struck by the inequalities and health disparities that currently exist in our health care system. I have been very concerned about working to bring quality health care to those who lack access through “standard” pathways. I was thrilled with the discovery of a group whose care beliefs and mission statement aligned so well with my goals and ideals (http://npalliance.org/content/pages/guiding_principles). The NPA's guiding principles include placing patients' best interests above all else, addressing the bio-psycho-social influences on health and focusing on community wellness as well as individual patient health; and emphasizing professional and collaborative approaches to care. Recently, the NPA has been an active voice in the health care reform debate, and has advocated for separating physicians from PhRMA and industry influence. These are positions not seen often enough or heard loud enough in more traditional medical organizations.

Physicians need to stay engaged in organized medicine. I feel that the VAFP and the AAFP represent me well on many professional fronts: payment and health care delivery reform, advocating for the specialty as a career and as a profession at state and national levels. However, by the nature of many large medical organizations, direct advocacy has been a smaller part of the VAFP and AAFP missions. Personally, this leaves something lacking. As is the case for so many of us, I entered medical school to make a difference. Medicine is a service career, and I feel that physicians must work to care for patients in any way we can. This can range from direct clinical care, formal political activities (such as contacting legislative leaders and key policymakers), teaching medical students and residents all the way to more direct advocacy such as writing letters to the editor, speaking with local media outlets, participating in public events to promote care and wellness for all.

To this end, I have become increasingly involved in the NPA’s efforts to push for better health for patients and a more fair and just health care system that adequately addresses the needs of all Americans, including the marginalized and the underprivileged. I am hoping to find other family physicians in Virginia who share this interest and who are interested in establishing a local action network (LAN) in order to further the NPA's national agenda while also establishing a group to address and act upon issues of local interest and importance. The NPA describes the roles of LANs as:

"The NPA's Local Networks are critical partners in the work of the national organization.  Some Local Networks work on issues championed by NPA on the national level, while others focus on more specific local issues that are consonant with the NPA mission.  This unique model allows NPA to partner with groups of physicians who are interested in our vision and could benefit from the organizational resources of the NPA. Local Networks, in turn, help to enhance the mission of the NPA by focusing on specific issues about which their members feel passionate and by expanding the network of physicians who find their professional home at the NPA."

With this year’s passage of health care reform and the challenges and opportunities inherent in its implementation, these are exciting (and sometimes scary) times to be a physician. Even as our health care system is poised to improve health for all Americans, the final outcome is far from certain. I have found the NPA gives me a voice towards advocacy on behalf of patients that energizes me and that has made me more willing to step forward during these turbulent times. I feel that I am doing the right thing, by my oath to always put patients’ wellness first and by my belief that as physicians our voices need to be heard. I hope that you agree with me, and I hope that you are willing to join me.

Tuesday, August 17, 2010

Oh, By The Way...New Blog!

Since I clearly don't have enough on my plate yet, the collaborative Social Media Healthcare blog is going live, with the first post tonight.  Hopefully it will become a site for discussion, thought, and collaborative discussion.  If you have the time and interest, check it out.

A Pause, And A (Somewhat) New Beginning

As might have become amply evident at this point, this blog is not following the path its name implied.  When I started writing here, way back when, I was hoping to discuss issues surrounding health care in underserved and marginalized communities.  However, with health care reform last year and early this year, as well as many opportunities to comment on issues of the day, my plans have been diverted.

I still hope to discuss issues surrounding underserved communities and health care, but it will evidently be through a broader, health care reform perspective.  I think this is still relevant, considering that health care reform will change the landscape for health care in and for marginalized parts of the US, but I wanted to bring this out in the open in case the blog name/title deceives.

Meanwhile, my professional situation has changed somewhat.  Rather than working full-time in Southside Richmond,  I am now splitting time between that community practice and the family medicine faculty practice at the medical center.  This change will hopefully be a positive move: I'll be more involved in teaching, can start thinking more about research ideas, and can be a resource to students who might have interest in family medicine as a career.  The kicker, though, is that I will not be working as often with underserved or uninsured patients.  The faculty practice usually does not work with the hospital's patient assistance program.  The department has been very generous, and has made it such that any patient I was already seeing who has coverage through the patient assistance program will be able to continue seeing me, but I won't be taking new patients covered through that program.  As a balance, I will be helping staff a medical and pharmacy student teaching clinic at a free clinic on Southside. 

Although I am excited about this, I feel a little conflicted: I have talked the talk about the need for docs to work with patients who lack access to care that I feel self-conscious about walking the walk to a different practice site.  I believe that working with the free clinic and with the largely Spanish-speaking, mostly Medicaid-covered community on Southside will continue to drive me as my mission.  But it will take time to adjust.

This family medicine department is my home department: this is the medical school from which I graduated, and the department is the one with which my residency was affiliated.  I feel very welcome here, and have found many kindred spirits.  So I move on, sort of, but I also settle in.  But I will always keep working to do what I think is right for patients: both those I directly care for, and for what I perceive as the greater good.

Sunday, August 15, 2010

Yes, PhRMA Can Be Considered A Bad Player

Recently, over on www.KevinMD.com one of the site's contributors wrote a post asking if drug companies and the PhRMA industry deserve to be considered bad guys/bad players in health care.  The writer's answer is no, PhRMA and drug companies should no be considered villains.  He notes the profit the companies make, but defends this on the need to make profits off of new products in order to ensure the ongoing supply of new medications and treatments for illnesses.  He contends that without such financial security, pharmaceutical companies will stop pushing the boundaries of drug development and instead will produce a large number of "me-too" drugs that offer little added value to health care.

Unfortunately, the author does not seem to accurately appreciate the true environment in which big PhRMA operates.  Marcia Angell, in her book The Truth about the Drug Companies has already undercut most of this post's author's claims.  Angell points out that much "research and development" (R&D) money spent by PhRMA is spent on turning out nothing but me-too drugs.  Do we really need a 7th or 8th cholesterol pill, or the 6th member of an established class of blood pressure pills?  It's  true that these meds may provide incremental benefits for a small number of people, but they truly offer precious little to our choices of drug therapy.  Even worse, many of these me-too medications are small chemical tweaks of the companies' own medications that are going off-patent (meaning the company will make much less money off of them).  So, we get Nexium as Prilosec goes generic, Pristiq replaces Effexor, Clarinex picks up for Claritin.  There is no convincing evidence that these medication changes benefit health in any way, but they cost much more than the generic versions the are trying to supplant and keep the patent's profits safe for a while longer.  However, all these me-too drugs and second generation patent-extenders have to be treated as new medications, resulting in significant R&D costs that increase medication costs and do not really improve anyone's health (outside of the financial health of the companies and investors).

The writer laments that if we demonize PhRMA we might end up with "Another drug for heartburn that is no better than all the others on the shelf" or "lots of drugs that we don’t really need."  However, somehow he doesn't realize that we are already exactly there--because PhRMA can make money hand over fist under this system.  New meds are compared against placebo (no treatment) instead of being tested against already-established treatments.  So long as the new med is literally better than nothing, then it can be approved and marketed.

Even worse, truly cutting edge research is usually too expensive for PhRMA to pay for on its own.  Instead, this type of research is often government-funded (including NIH funds) and is carried out in universities (including state-funded universities).  Once the research gets close to a point where it can be leveraged into therapy, PhRMA can buy the patent and develop their medication.  Then, they can sell a product developed with public money right back to us with a much higher price tag.  Maybe PhRMA is working on that vaccine against cancer the author mentioned.  I doubt it.  More likely, they're waiting until NIH and/or university-funded research gets close, then they'll swoop in and take the credit and the profit.

We also get lots of lifestyle medications that help symptoms but don't necessarily save lives or improve health very much.  Medications for heartburn (such as Nexium), allergies (Clarinex), erectile dysfunction (Viagra) and various cosmetic uses (such as Vaniqa) are incredibly expensive and cost much money to develop but typically offer minimal benefits in the big picture.

So, no: I don't feel bad about attacking big PhRMA.  I have no worry that they will suddenly cease their "lifesaving" R&D because I think relatively little of what they do qualifies as such.  (I can't tell you how much of PhRMA's R&D is true fundamental research--they haven't released that info in the past.)  Instead, I look at the ridiculous costs for me-too drugs offering little added value.  I look at the fact that new cancer treatments can cost tens of thousands of dollars yearly.  I look at PhRMA's aggressive direct-to-consumer advertising.  And I look at the paucity of genuinely new developments that would stand to benefit the millions of people across the world facing life-threatening infections and chronic diseases that happen in places where people have no money.

The big PhRMA industry is a devil's bargain.  We don't have any other method in the US of getting medications produced and made available because the free market system calls for private industry filling this role.  So that's what we're stuck with, even when pharmaceutical companies are suddenly unable to supply life-saving medications.

I do want to note that I do NOT consider all the people who work for PhRMA to be bad people.  I have very good friends who work in the industry in various capacities.  But I think that PhRMA's role is a flawed one from the very top, and no number of committed and honest and hardworking people can cancel out the fact that the industry as a whole is a bad actor.

So that's the system we have, and those are the limits we face.  But let's be honest and forthright: for the occasional positive impact, big PhRMA costs us an incredible amount of money for precious little return.  In my book--and in this age of new-found awareness of the importance of cost-containment and evidence-based medicine--I feel this is enough to earn PhRMA a bad-guy label.

Friday, August 6, 2010

Some Further Thoughts On Healthcare Communication and Social Media

In an earlier post, I made a brief mention of healthcare communication and social media (HCSM).  Now, ideas for a new blog are slowly starting to come together.  This blog will be an outgrowth of a weekly Twitter conversation regarding HCSM (# HCSM, Sunday nights from 9 to 10 pm on the East Coast) and will be based on the idea of developing ideas brought up during that discussion and try to flesh things out further.  The blog will live at www.SMHCOP.wordpress.com--keep an eye on the site, as we hope to have content developing relatively soon.

I'm cross-posting my first comments for the SMHCOP blog here, because I think HCSM is a topic that will become increasingly relevant.

“Social media” (SocMed) is a phrase with nebulous meaning.  There are various definitions available, but the formulation that is easiest for me to understand is to consider “social media” as a group of web-based applications and services that allow user-generated content to be distributed and/or viewed online.  This would include such sites as Twitter, Facebook, YouTube and blogging sites including Blogger and Wordpress.  At their essence, each of these sites/services (and many, many other sites not mentioned) allows an individual to find a forum for making their opinions and perspectives known to the world at large.  Although the nature of these services differ widely, the common link is anyone (with luck, hard work and expertise) can add to online discussions and express their opinions while also making connections with other users—regardless of where one might be.

The speed at which SocMed is being adopted has accelerated over recent years, and as a result it is becoming a topic of interest in many different areas.  My principle interest is in determining the use of SocMed tools in health care communication.  Physicians and other providers can enhance their online presence (and possibly, their business) by actively engaging in SocMed.  Health care information, treatment recommendations, and public advisories can be distributed widely and to varied audiences through SocMed.  Patients can learn about wellness and illnesses, can join virtual communities and support groups, and can have an influential voice in SocMed in ways that may be difficult in person.  Patient advocates, researchers, and medical educators can all make contacts and exert influence and discuss ideas with new collaborators that would have been hard to identify before SocMed facilitated interactions.

I believe that SocMed’s influence is going to start effecting health care communication and health care practices in the near future.  How doctors and patients interact, how we communicate both personally and professionally is likely to change.  Use of SocMed technology and services may improve patient-oriented outcomes in a number of illnesses.  Novel educational strategies, for patients and for clinicians, will be developed and we will need to determine their appropriate uses.

I think this conversation is still in the early stages.  Significant barriers to use still exist, and conventions of use still need to be established.  How SHOULD doctors interact with patients online?  How do you ensure patient privacy and confidentiality when communicating online?  The conversation can also extend beyond web-based SocMed resources and include furthering e-mail and/or text message conversations.  All of this is still developing, but I believe this is a good time to get involved.  As physicians, if we do not help direct the process, then the process will eventually direct us. 

SocMed has the potential to empower patients, make medical care more efficient, and enhance communication in many dimensions of health care.  We should be looking at ways to ensure this will benefit all parties.

Thursday, August 5, 2010

It Is A Privilege To Be A Physician

It is all too easy, these days, to complain about a physicians' lot--especially in primary care.  We are always pressed for time.  Reimbursement is insufficient.  Insurance company billing forms and prior authorizations are ridiculous.  We put in long hours away from friends and families and never seem to get ahead.  In primary care, we see colleagues in other specialties spend less time in the office, keep more friendly hours, and came away with better pay.  There are some days when one feels it would be a better option to be anything but a physician.

Then you read things like this speech by Donald Berwick, who was recently appointed to head the Centers for Medicare & Medicaid Services (CMS).  There are some medically-related writings out there that are inspirational, insightful and help keep things in focus.  Dr. Berwick's speech is one of these writings.

I am not going to say much more, except to urge you to take the time to read the transcript linked above.  It will only take a few moments, and will make a lasting impact.  Whether in the medical field or a patient, this is moving and reminds us of key facts: the focus of health care and health care encounters should be on the patient's wellness, and that we are privileged as physicians to be given the opportunity to work with patients and to help them in their times of need. 

"What is at stake here may seem a small thing in the face of the enormous health care world you have joined.   It is as a nickel to the $2.6 trillion industry.  But that small thing is what matters.  I will tell you: it is all that matters.  All that matters is the person.  The person.  The individual.  The patient.  The poet.  The lover.  The adventurer.  The frightened soul.  The wondering mind.  The learned mind.  The Husband.  The Wife.  The Son.  The Daughter. 
[...] Those who suffer need you to be something more than a doctor; they need you to be a healer.  And, to become a healer, you must do something even more difficult than putting your white coat on.  You must take your white coat off.  You must recover, embrace, and treasure the memory of your shared, frail humanity--of the dignity in each and every soul.  When you take off that white coat in the sacred presence of those for whom you will care--in the sacred presence of people just like you--when you take off that white coat, and, tower not over them, but join those you serve, you become a healer in a world of fear and fragmentation, and "aching" world...that has never needed healing more."

Saturday, July 31, 2010

Do You Believe Physicians Should Be Activists? If So, Read On:

I readily acknowledge that this post might not add to the reach of the e-mails I have already sent out, but I figured I'd put it up in case someone stumbles across it from this source.  Over the last year and a half I have become very interested in the National Physicians Alliance, their advocacy, and the positions they stand for.  So, I'm trying to see if there is any interest in Virginia to set up a local affiliate.  More detail below:


Sorry this e-mail is somewhat impersonal, but I wanted to write you in a more official capacity regarding the opportunity below and to as if you feel that (if you are not interested) whether you know others who would be good contacts.

I am writing to gauge interest in an exciting opportunity.  The National Physicians Alliance (NPA; http://npalliance.org/) is interested in starting local action networks (LANs) in order to further the NPA's national agenda while also establishing a group to address and act upon issues of local interest and importance.  The NPA's guiding principles include placing patients' best interests above all else, addressing the bio-psycho-social influences on health and focusing on community wellness as well as individual patient health; and emphasizing professional and collaborative approaches to care
(http://npalliance.org/content/pages/guiding_principles).  Recently, the NPA has been an active voice in the health care reform debate, and has advocated for separating physicians from PhRMA and industry influence.

Personally, I feel that many of the progressive and patient-focused positions the NPA has taken accurately represent my opinions and beliefs, and I am very interested in the idea of a LAN in Richmond and/or other areas in the Commonwealth.  These LANs could be affiliated within Virginia, or could exist independently of each other but in affiliation with the national NPA.

The NPA describes the roles of LANs as:

"The NPA's Local Networks are critical partners in the work of the national organization.  Some Local Networks work on issues championed by NPA on the national level, while others focus on more specific local issues that are consonant with the NPA mission.  This unique model allows NPA to partner with groups of physicians who are interested in our vision and could benefit from the
organizational resources of the NPA. Local Networks, in turn, help to enhance the mission of the NPA by focusing on specific issues about which their members feel passionate and by expanding the network of physicians who find their professional home at the NPA."

I am more than happy to provide additional information on the NPA, the options regarding LAN development, and hearing other thoughts you might have.  At this point, I am interested in determining who else might be interested in this idea.  If there appears to be enough interest, then I would anticipate that in the next few months we would communicate via e-mail and (probably) teleconferences or conference calls in order to clarify our goals and establish the necessary groundwork.  Once a LAN is established, then the level of activity would be variable.  Presumably the LANs will need formal leadership structures and members interested in being actively involved in the group's activities (writing letters, posting on-line material, participating in gatherings and
get-togethers, etc) but each person's level of activity would depend on their availability and engagement.

I hope to hear from you soon.  Please let me know if I can address any other questions or concerns.

Thanks for your time.


Monday, July 26, 2010

Don't Let The Liars Deceive You

With media attention starting to focus more and more on political primaries and the upcoming November elections, we are going to hear a great deal about health care reform and the Accountable Care Act (ACA).  As to be expected with such a complicated law, it is taking some time to enact all its provisions, and opponents of the law (read: Republicans) are going to try and win political points by opposing the law and calling for its repeal.  (Unless, of course, they try to take credit for it).

I thought it would be a good time to review the popularity of the ACA--the real, honest reforms in the law, as opposed to the nonsense opponents would like you to believe.  This data is from the Kaiser Family Foundation's recent report.  A couple of the more important pieces of information:

There is a majority support for the major reforms in the law, except the individual mandate.  That the individual mandate isn't popular doesn't surprise me at all, but is a necessity to make the law viable.  In enacting the law, the US joins many other countries including Switzerland and the Netherlands in requiring individual insurance.  It should be noted that these countries have successfully managed to cover all of their citizens and have costs no more than 50% of US costs.  There is VERY strong support for health insurance reform, tax credits for employers to better afford providing health insurance for employees, and government subsidies to help pay for premium costs for low-income Americans.

If you separate out respondents' party affiliations, this is what you get:

Self-identified Republican respondents still support the majority of the of the provisions within the law.  Republican candidates and the Tea Party activists will make waves opposing health care reform, but in reality they seem very happy with the reforms the law will enact.

If we could honestly debate this law and its reform, and if individuals were aware of the specific changes and benefits that will result from the law, Republicans would never dream of running on a platform opposing the ACA.  In fact, they might even wish they could REALLY take credit for the law.  If, in honest debate, we stopped calling it "Obamacare" or lying about socialized medicine, etc then we could move forward and make a positive impact for the nation.

Liars only have the advantage if the facts aren't known, and if people accept the falsehoods as truth.  Hopefully, this information will help.  It is clear that these reforms are popular and have broad support.  The net favorable opinion of the law has increased to 48%, and increased awareness of the law's reforms tend to increase positive opinion:

This is a groundbreaking law, that will forever change the way we think of health care in the US.  It is a tremendous step in the right direction.

Don't let the liars deceive you.

Saturday, July 10, 2010

Drug Samples Are Bad Medicine

The AMA's American Medical News recently highlighted results of a study from the Archives of Surgery showing that many doctors still feel kindly towards pharmaceutical/industry reps and feel that drug samples enhance care for patients and that company/physician interactions can be acceptable within limits.

Apparently, I disagree with the majority of my colleagues.  There is research showing that increased physician contacts with industry reps tends to result in physicians making decisions less likely to benefit patients.  Other physicians I have spoken to feel that they have the internal strength to ignore the advertising that reps provide, and that no-one is influenced in their choice of treatments due to a pen or a sandwich.  "Surely," they say, " I am aware of these advertising efforts and will not let myself be influenced by them.  Maybe other, less skilled doctors are possibly influenced, but not me."

From my reading, though, this position is inaccurate.  We are taught and acculturated to return favors, to be nice to those who are nice to us.  Even a small gesture--lunch, some pens, etc--can put us in a dependent position where now we feel like we should give something back to the person who gave us a gift.  We might tend to prescribe that rep's med, just because they stand out from others.  The influence might be subtle: we still wouldn't prescribe meds that the patient didn't need, but if we're going to prescribe a specific type of medicine (for cholesterol, for example), why not use that rep's products.  Doesn't hurt me, and I can justify it for the patient.  So long as the insurance covers it, then everything should be fine. 

A similar situation exists with drug samples.  Reps will bring in samples of their newest and greatest products so that we can get patients started on meds for free and see how they do.  Often, these samples have discount programs allowing patients to continue getting the meds down the road even if they are not usually favored by their insurance.  However, samples are a false economy.  True, the first few weeks (or maybe the first month) is free--but then patients are locked in to this medicine indefinitely (as physicians are loathe to change meds that are working).  At best, this means that patients will have to pay higher co-pays for a name brand med (when a generic might be available), and their insurance picks up a higher cost.  At worst, an uninsured patient ends up becoming dependent on samples or having to pay full-price for a medicine that is terribly expensive.  But as a doctor, samples look great on the surface: I get to give a gift, patients like free things, and we leave happy.  But this ignores the future or system-wide harms that can result.  This is even more inexcusable when you realize that the majority of name-brand meds have generic cousins that work just as well (or maybe better) than the name brands.  However, no-one advertises generic meds and no-one samples generic meds.  Also--if I write for a generic patients have to go buy and pay for them.  This may be a $5 co-pay for insured patients or a $4 co-pay at large pharmacy chains offering inexpensive generics.  This isn't much, but it's more than the $0 the samples would cost.

My final comment to colleagues who DO accept industry rep contacts is to remember that these reps--who come nicely dressed, asking for a moment of your time--are ADVERTISING.  They do not provide education.  They do not provide teaching or guidance.  They bring advertising material that tends to overstate the benefit of their products and journal articles that highlight their products' strengths while at the same time downplaying or dismissing any potential harms.  When Ketek (an antibiotic) was on the market, reports of liver injury began to show up after it had been in use for some time.  When I asked a rep about this, I was assured that it was 2 cases and (theatrical whisper) "One was a drinker."  I never used Ketek much (it was a me-too drug that cost more and offered no benefits to other meds on the market then), and I was glad when the FDA restricted the medication's use...due to reports of liver failure and deaths related to the medication.  The medicine was not pulled off the market by the FDA, but has essentially become a worthless medicine.  If you trust drug or other industry reps to bring you unbiased, honest information, then you're fooling yourself.

In my opinion, physicians must recognize and understand the potential harms that industry contact bring--biased information,  a risk that you will make decisions that do not benefit patients, and patients' perceptions that you are biased toward drug reps due to your contact withe them.  I think individual doctors' offices should develop policies that restrict or forbid industry rep contacts, similar to rules and restrictions in existence in many academic centers.  I think we need to help patients understand that drug samples are NOT good medicine, and that the $4 co-pay to start a generic you will be able to continue taking is worthwhile.  We also probably need to re-evaluate the policy of pharmaceutical companies producing direct-to-consumer ads (or at least be prepared as physicians to point out the inaccuracies in those ads).  We need to ensure that industry reps are abiding by their industry's voluntary restrictions and by familiarizing ourselves with these restrictions so we can call out reps who violate them.  Or we need to simply step away from industry rep contacts--they provide minimal (if any) benefits to us as doctors, to our patients, or to our health care system overall.

Finally, when we access health care as patients, start to pay attention to industry influence in our health care system.  Do you see ads in offices?  Do you get samples?  Do you really feel comfortable with your answers?

(There are some movements trying to remove industry influence from medical practice.  You can learn more about some of these by reading about the National Physician Alliance's Unbranded Doctor campaign and by learning more about "academic detailers"--medical professionals who come to doctors' offices like industry reps do, but who provide information about the value of generic drugs and who encourage doctors to follow evidence-based practice guidlines that focus on generic meds w/ proven benefits.)

Sunday, July 4, 2010

Differences of Opinion (Part 1?)

As a member of the American Academy of Family Physicians, there are a number of listserves I can track.  I'm transcribing an exchange between me and other physicians because I think it's interesting to see how far apart docs are regarding the best way to provide health care to all those who need it and whether or not health care should be a accessible to all.  Dr. L's comments started the discussion which ensued between me and Dr. S.  I don't think either of these physicians are bad people; in fact, I know that one of the two is a dedicated supporter of family medicine and primary care.  It is striking to me, though, how differently we see the world.


Dr. L:

For me the real issue is that everyone counts on someone else paying for health care.
Healthcare is not a right. We all have the right to be as healthy as when we were born.
I know I will get tons of replies grilling me for that stance, but so be it.
As an immigrant, I am concerned that in the greatest nation in the world we have so many rights and entitlements, and NOT A SINGLE DUTY.  And now we want to add healthcare as a right!
Healthcare is a privilege like driving is a privilege. Could you imagine if driving was a right?  I could be as drunk as I wanted and get in a car and crash into anyone regardless of consequences, because it is a right?
Most of the cost of healthcare is for chronic  and preventable diseases and the morbidities that it brings. Most of these issues could be prevented by better choices and better public policy. But I am a doctor, not a policy maker.
I embrace freedom of choice. But why should I pay for the consequences of your freedom to be irresponsible?
I was raised with simple values, one of which is “be responsible for your actions”
The central issue is that there is no Personal Responsibility, and then the masses want someone else to fix the problem.

Dr. S:

OORAH!  Well said, Dr. L!  We must all admit the truth here!! Health care is a privelege, NOT a right! 
Again, I will come out of 'hiding' and say what I think a lot of us here realize probably has to happen. GET THE GOVERNMENT OUT OF HEALTH CARE. It is the only real way for any reform to occur. This whole thing is going to be bad no matter what we do, but it will only get worse if we go toward more government regulation(e.g., single payor system, Obamacare, etc...). At least if people are given back the responsibility for their own health care, then they can realize that they have more choices to make (hopefully healthy choices).  Again, thank you for saying this.


Dr. S:

Just asking: if you end govt roles in health insurance

--how do you propose the poorest in our nation access care?

--how would you prevent private insurers from continuing their regressive policies?

Dr. S:

Dear Dr. R,
It depends on how much of the 'government' you get out of health care. Here would be some starting thoughts (and these are rudimentary, by the way):
If we still require public institutions to not turn away anyone for care, then the poor will continue to access these facilities as they do now. This, in my opinion, is the 'myth' of access to care that everyone seems to believe. EVERYONE in this country, including those who are not even citizens, cannot, by law, be denied access to care and at least a screening physical exam in a public facility. 
If we eliminate Medicare and Medicaid, then I would hope that we eliminate their pay system as well. In which case, we would then have the potential for a true 'free market,' and I would think that if hospitals, health care providers, etc...  didn't have to have as much administrative costs, then we would already be able to offer care at a lower rate (or even at what Medicare and Medicaid reimburse now). Their would be competition for patients that would take the form of price reductions - this already happens with 'elective' procedures, such as LASIK, for example.  It would take a little time, but one would logically think that health insurance companies would have to lower their rates or be priced out of the market by individuals being able to get their care for less money than what they pay for their health insurance premiums. 
What about health care consortiums? I know of some groups of people agree to pool their money to pay for everyone in the group - I think one is called the Christian Health Care Alliance(?) 
If you take a look at history, you will note that the Church set up many hospitals all over the country to take care of the poor. Why not allow them to do this again?? 
Could we incentivize people to practice good health habits?? For example, could we pay people to lose weight (sort of like the "Biggest Loser" competition?).  Could we somehow incentivize people to stop smoking or drinking, or doing drugs?  This could be positive incentivization or negative incentivization -- I would even be so bold as to say that if we are going to deny care to anyone, the first group to be denied care would be known alcoholics, known drug addicts, and even smokers. That would certainly make them at least consider changing their behavior. 
I once asked one of my attendings during residency who practiced before 1964 (before Medicare and Medicaid)  in a major metropolitan area (>300,000 people) how the poor and disadvantaged got care at that time. He said that in the city hospital, there was a "City Ward" where these people were cared for, and the doctors on staff in that community rotated through the service to care for these people. Why can't we do something like this for the poor and disadvantaged?  
It's true, we will always have the poor -- but isn't there a way to incentivize people to NOT be poor?? If America is truly the land of opportunity, then this would certainly be possible. 
Much of this depends upon the individual person's sense of responsibility, civic duty to his/her country, and living up to our motto of  "In God We Trust."  Maybe it's time the citizens of this country took these matters into their own hands, instead of giving this responsibility to the government. 
It has taken us 46 years to get to this point -- how can we expect to reform it in 46 months, or even 46 days?? 
This situation is going to be bad either way (whether we have more governmental intervention or less) - I submit to you and to all of my collegues on this list serve that if we get the government out of medicine, it will be bad for a shorter period of time as the market rights itself, than if we allow more government intervention into health care -- my belief is that this new system will probably be really good for about the first 10 years or so, and then it will become corrupted (just like Medicare and Medicaid already have), and then we will be paying higher and higher taxes, and getting essentially NOTHING for it. AND giving up more and more of our freedoms as the price - something one cannot even place a price tag on is freedom.  
Stuff that I believe we ALL need to be seriously thinking about right now as this whole mess of "Obamacare" that has been forced upon us by a minority of elitists presumably goes into effect.
Respectfully and in the spirit of compassionate care for our patients as a fellow Family Physician,


Dear Dr. S;

I agree with some of your points.  Providing incentives for people to follow healthy lifestyles can be beneficial, but must be carefully structured to make sure that the opportunities are open to all.  People living in poor or underprivileged neighborhoods may not have valid access to safe places to exercise, healthy foods, etc.  This is a society-level issue, and one that must be accounted for if we intend to incentivize healthy choices.

Incentivizing people not to be poor sounds nice.  Haven't yet met someone who hoped to remain poor.  If/when you have an idea how to do that, please let me know.  I work in communities where structural poverty is a fact of life and no simple answers will work.  Again, making changes to this are a major society-level challenge that will be very difficult to enact. 

If we thought health care reform was a tough fight, imagine what will happen if we try to enact reform to encourage the healthy living programs and the economic empowerment programs that would be necessary to effect the changes you propose.

In terms of your contention that all Americans are entitled to access to some sort of medical evaluation (I presume you mean the ER); you have to admit that that is irrelevant.  Just because an ER can't turn me away doesn't mean I will get the care I truly need (and we know I won't get the chronic care I need), that I'll be able to afford the care, that medical costs will be managed in some responsible way, or that having this "access" provides any benefit to anyone (unless I am truly facing a life-threatening emergency).

Unlike you, I have great qualms about entrusting the health of our most vulnerable citizens to faith-based organizations.  I do not argue that faith-based or church-based hospitals have provided a great deal of valuable care, but they do so only within the confines of their religious missions.  If an uninsured woman presents to a Catholic hospital requesting help with contraception, she will have no access and she will have to find other options.  In Virginia she could go to the public health department, but (under your structure) this sort of government program would be de-emphasized.  Do you not have concerns about what would happened if a patient of one faith was forced to access care in another faith's hospital?  Although in many cases belief might not affect care, there will be cases where this would be an issue.  What if a Christian Science health care center opened focusing on healthy living but not using medications or medical technology? Would we, as physicians, feel this is the best option?  What about treating illnesses that have social elements (HIV, STDs, etc)?  Would faith-based systems be able to exclude those conditions?  If not, how would we prevent it?  Govt regulations?

Health care consortia are also very concerning to me.  Would these consortia be allowed to set rules as to who they will pay for, and for what procedures?  If so, how would this be controlled/regulated?  Should we simply trust to their better natures?

The free market rules do not really apply to health care.  Free markets, to my understanding, really only work when both sides of a transaction are free to walk away from the deal or to argue or negotiate for better options.  This is not the case in medicine.  True, for some purely elective care this might work.  But what about acute care?  Urgent interventions?  Trauma?  Should we expect to negotiate the prices of a CABG, maybe 3 vessels for the price of 2?  The current free-market portion of our health care system has brought us pre-existing conditions and rescission.  How would you propose this be stopped?  Also, what about communities where there is no health care competition (such as 1 hospital, 1 pulmonologist, 1 endoscopist, etc)?

Unless we think we'd be able to drop the costs of health care interventions to levels easily affordable by even the poorest in our nation, then patients will require health insurance.  Without significant oversight and regulation (such as that incorporated into the Accountable Care Act), private insurers will fall back in their recessive ways.  Remember, Blue Cross/Blue Shield started as non-profit insurers, and then morphed into Anthem and then WellPoint courtesy of the free market.  Do you feel this has really benefited patients?

You speak about the corruption of Medicare and Medicaid.  Do you really believe that private payers do not have their own motives and their own "corruption"?  Private companies are only answerable to shareholders and board members.  Is this really better than having (at least on paper) a public accountability?

Virgina, to my knowledge, has no public hospitals.  Your idea of forming a "city ward" in a city hospital would require establishing an entirely new govt hospital.  Is this really what you propose?  If so, how is this really better than current govt programs?  Will we provide a govt outpatient clinic, too, in order to provide the follow-up car?  Or are these hospitalized patients (with some bill of some sort due as a result of their inpatient stay) supposed to negotiate with private providers and shop around for the best price for their post-hospital visit?  Or will the same city hospital provide the outpatient care in the same rotating system?  And how would you get the providers for the city hospital?  If the city hospital is added to the private hospitals in a given community, why would providers choose to provide care (unless they did so out of humanistic ideals)?  Would the humanistic volunteers be sufficient?  If providers were required to provide care at a public hospital as a condition of practice or licensure, would we prefer this to choosing whether or not to accept Medicare/Medicaid?

I am not a huge fan of the current Accountable Care Act, largely b/c it underwrites a dysfunctional private insurance system without enough recourse to universal access to true, meaningful, evidence-based, chronic disease care and preventive care.  But, this was what the political climate allowed.  Under this law's conditions, insurance company abuses are directly addressed and all citizens will have access to insurance coverage that will allow access to needed services.  Indeed this insurance is required by the law's individual mandate, and the costs of the coverage is subsidized for those who cannot afford it.  (And individual mandates are necessary to ensure that costs are truly shared across everyone, and not shifted towards the public programs or shifted onto those who have private health insurance).  Small business tax credits will help extend the employer-based system we currently have.  I'm not saying this is the best system, but these reforms seek to improve the system we have.

Asking people to live up to their civic duty and their personal responsibility is fair, but as a nation we must make sure that the potential benefits of doing so are really available to all.  I challenge those who support this position to explain how to make sure this is really the case.

I know that all of us will continue to provide the best care to our patients, and to do right by the person we are working with.  It is when we try to determine the national policy that best allows this that we tend to separate in our opinions.  Still, I am glad that we are able to have a free and open discussion about this.


Dr. S:

Dear Dr. R,
Thanks very much for your thoughtful reply. It is these sorts of conversations that I hope to have on this subject - I truly believe they are meaningful if any sort of reform is to occur. I just have a few minutes here, so I want to reply to a couple of your concerns:
I want to say that anybody that comes into the ER gets a basic medical evaluation because I worked ER for four years, and I WAS the one who did the evaluation - this was in rural ER's where I was the contract doc on call, and there was no mid-level coverage.  I also worked in a major city hospital ER as the 'pit boss' overseeing at least one PA - again, everybody got a basic evaluation and at least the emergent care they needed.
I agree that chronic care is very much needed by patients, but in my opinion, there are some of what I would call 'major categories' of patients that come into an ER (and arguably, that come into my office even at the present time): 1 - those who want care, but really don't need it, 2- those who need care, but really don't want it -- or really don't want the care that we deem they need, and 3 - those who need care and want what we can provide. Yes, these are arbitrary distinctions, but my point is that the term 'access to care' is really more complex than I feel we make it out to be.
My question to you (and anybody else that may be reading on this list-serve) regarding allowing so-called 'faith - based' organizations to provide care is:  we are already having problems with entrusting the care of our most vulnerable citizens (BTW, how do you define who our most 'vulnerable' citizens are?) to the government  -- would we do much worse to let these organizations have a try at it??? If nothing else, these organizations could ease the burden on the public facilities, such that people would then have more of a 'choice' as to where they feel comfortable getting their indigent care.  I mean, what about the Shriner hospitals??? With respect to these organizations, it would be implicit that physicians, nurses, support staff, etc... would be donating their time or at least agreeing to take a lower pay scale to care for these patients. 
By stating that I would want to incentivize the poor 'not to be poor,' I'm not implying that there are people who hope to be poor (however, the nuns and Mennonites I have met have in effect chosen this lifestyle). These people are often poor because of the choices they have made, or choices that their significant others have made (or not made) -- or quite commonly, because of mental illness.
Just some starting thoughts... more to come.


Dr. S;

To continue our previous conversation--

I agree that "access to care" is a fairly general term, but this is the way all of us look at our health insurance.  Can I see the doctor I want to see?  Can I get in to a physician if I don't feel well?  Can I get the tests my doctor recommends, and the medications he prescribes?  As you know, your 3 categories of patients exist in all communities--insured, well-off, poor, Medicaid, etc.  It would be more cost effective (and maybe easier to support) if we agreed to provide health care for those who *really* need it (those having an MI, appendicitis, pneumonia, etc).  But as we know, we really can't discriminate well as to who is SICK and who isn't when people first present.  Why shouldn't it be possible for all of us (poor, wealthy, in-between) to be able to get care when needed?  I suspect that the ER screening exam isn't free, so even this "guaranteed" care is not really (affordably, sustainably) available for many in the US.

I also realize that "vulnerable populations" is a vague phrase.  Insert your choice: poor, disabled, chronically ill, economically marginalized, etc.  In some conceptions of reforming health care that emphasize the free market, none of these population categories are accounted for.  We are all supposed to sink or swim in the market of free competition.  I foresee a lot of sinking.

Regarding enrolling faith-based organizations in providing health care, my main issue is how you would ensure that these organizations provide PATIENT-centered care, regardless of the organization's agenda.  As I noted earlier, Catholic health systems (at least in the Richmond, VA area) do not support or provide any contraceptive procedures, medications, etc.  Other denominations and faiths would likely have other restrictions.  How would this be avoided if these organizations are to be the new safety net once gov't services are gone?  The Shriner's programs are wonderful, but are not really in the same category.  Shriner's Hospitals provide orthopedic, burn, SCI and cleft lip and palate care for children; areas where any denomination or faith would be on the same page as being a good thing.  Also, the Shriners are a fraternal organization, not a religious organization.  Maybe a Rotary Club hospital or a Lions Club vision hospital would be more comparable to the Shriners.  Finally--we have already seen private faith-based charitable organizations try to opt-out of federal laws requiring equal and fair hiring.  A few years ago, the Salvation Army asked to be exempted from federal laws requiring fair hiring (they didn't want to hire gay or lesbian employees) but wanted to keep receiving federal funds under the Bush administration's faith-based initiatives.  Faith-based hospitals or clinical systems might seek similar exemptions to avoid providing services inconsistent with their beliefs. 


Dr. S:

Dear Dr.R,
Thanks for the reply. I'm on call, so only have a few minutes, but I want to hone in on a couple of concepts you presented, and hopefully not get on an unproductive tangent...
1. What is the difference between 'triage' and 'discrimination' in the context of healthcare?? I mean, one draws an intellectual (if not philosophical) line when we are determining who is sick, and needs emergent medical care, and those who are not 'ill' and really don't need the care that they think they need... i.e., the alcoholic who is not physically ill enough to need inpatient treatment for DT's, but who desperately needs treatment for his/her anxiety disorder, and frankly doesn't want it??
2. The term "patient-centered" care needs to be 'fleshed out' here -- some of this will depend upon one's (both the patient's and the physician's)  'world view,' but I would maintain that if so-called 'faith - based' orgainizations held as their rule to treat or not treat a certain kind of condition in a certain way that is consistent with their 'mission statement, or bylaws' then they would certainly be free to do so. There are already biases in our current health care system anyway - you could argue this to the moon. It's still a free country (thank God).  You are also touching on a huge issue with contraceptive services - I agree that it should be patient - centered, but I am also implying here that this would include adequate education of the patient with respect to ALL available choices, including non-hormonal therapies, and non-abortifacient methods, etc... Again, a potential HUGE tangent, but there are many more than these.
3. I appreciate your further analysis of the 'vulnerable populations' -- my next question would be "vulnerable to what??" Alternative medicine? Alternative beliefs? What about appropriate treatment, and a caring atmosphere that maybe some of them (particularly the children) have not as yet experienced? Just being in our American society and pop culture, these people are already vulnerable to very damaging behaviors being represented in the media - is exposing them to a Catholic (or Protestant, or Jewish) hospital that much more damaging than what probably many of them have already seen?? I'm not sure what the answer in all cases is here, but I trained in a Catholic Hospital, and I certainly felt that the care was of the highest quality and the atmosphere was most certainly a caring one - and certainly at par with the University Hospital, VA Hospital, IHS hospital, and community hospitals in which I had worked as a medical student and in practice. 
Anyway, some more thoughts....


Dear Dr. S;

Happy 4th of July!  I hope you have a quiet, enjoyable day.

To address your most recent comments:

--To me the issue between "discrimination" and "triage" in health care is an apple/oranges proposition.  I think we would all agree that "triage" is a process by which we decide who is ill and needs care, and who will benefit from our care.  In the ER, this would come down to determining who needs care urgently and who can be put lower on the list of priorities.  Of course, as you point out, the ER has to provide care regardless of what the triage process determines.  I would argue "discrimination" is a different issue altogether.  In the context of accessing health care, discrimination would involve keeping those who desire access from gaining access to the system for purpose of evaluation, diagnosis and treatment.  I agree that many people who seek care do not (in our estimation) really need it. But how often are somatic complaints part of a psychiatric issue?  How often are chronic problems found when addressing acute issues?  Do not acute visits allow us opportunities to address chronic problems (such as addressing smoking in the context of a URI visit)?  Why should 85% of us have such opportunities and 15% of us (the uninsured) be denied?  Ideally, our health care system should allow all of us to access at least screening services, but also have affordable and *real* access to care if needed.

--I agree that faith-based health care systems can be very valuable to many, and particularly to patients who share a similar world view.  However, in your suggestion, these faith-based systems would largely take the place of of government-provided care.  This will lock patients in to faith-based systems--with which they may not agree.  Would you agree, for example, if an Islamic health care system set up a health care center providing care to the indigent/uninsured but required that men and women be kept fully separate and only be cared for by providers of the same gender?  I realize this is an extreme example (implying, as it does, that Islamic-oriented health care centers would be organized on conservative principles).  Should non-Catholic patients be required to access care in Catholic systems and accept the restrictions the Catholic Church places on providers?  I feel it is better to ensure that patients could access providers of their choice, something that Medicare and Medicaid already allow to a large extent (though I realize many providers do not participate in these programs), and that the Accountable Care Act will promote through allowing affordable health care coverage.  If patients have health insurance, they can find providers that share their "world view" to the extent that such providers are present.

--By "vulnerable populations", I would further clarify with the phrase "economically vulnerable"--patients who do not have the income or resources to freely pay for care on their own and who currently need to access it by means of government programs (or avoid accessing care at all).  I would also include communities that typically have been on the short end of health disparities.  These 2 descriptors will often overlap and, to me, any reform we implement needs to look at hair we can create a more just and fair system for these groups.


This discussion has been going on for about a week now, and I'm going to take the author's prerogative to post it as an "in-progress" conversation.  If/when Dr. S re-posts, I will post the further discussion that might ensue.