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.