Friday, December 23, 2011

A bad month for Virginia's Republican leadership, a good month for the PPACA

(This was originally posted on the National Physicians Alliance Virginia Local Action Network blog site December 18, 2011)

Ever since the Patient Protection and Affordable Care Act (PPACA) healthcare reform law was under debate, Virginia has been at the forefront of its opponents.  In March 2010, before the PPACA was passed and signed into law, Virginia passed a law that would make it illegal for the government to require Virginians to have health insurance.  After the PPACA was signed into law, Virginia Attorney General Ken Cuccinelli sued to overturn the law on the grounds that it violated the United States' Constitution's "commerce cause".  Cuccinelli has continued to be vocal in his opposition to the PPACA's reforms, including writing a legal article earlier this year attacking the law's legal foundation.

At the same time that Cuccinelli has taken an ideologically pure approach to attacking the PPACA, Governor Bob McDonnell has taken a more practical approach to the law.  Although McDonnell has opposed the PPACA's reforms from the moment it was signed into law--and he still opposes the law--he chose to set up a Virginia health reform council to discuss how the law's reforms would affect Virginia as well as to review other options to reform health care in Virginia.

Given their political positions (and possible future plans regarding elected office), this has been a difficult Fall for Cuccinelli and McDonald.  First, in September the 4th Circuit Court of Appeals denied Virginia's lawsuit against the PPACA, stating that the state lacked standing to sue until 2014 at the earliest.  Then, November provided two major political blows to Virginia's state leadership: first, when the United States Supreme Court chose to hear legal challenges to the PPACA, it did not include Virginia's legal challenge among the cases it will review.

Then, at the end of the month, the Health Reform Initiative Advisory Council McDonnell appointed filed its report on how Virginia could respond to the PPACA.  Per the ThinkProgress blog, the report indicated that, "[R]oughly half of the uninsured in Virginia will gain coverage, a little more than 520,000 people, and that 420,000 of them will gain Medicaid coverage. A little over 100,000 Virginians would gain private coverage, and more than 60 percent of them will be in group as opposed to non-group markets…[A]lmost 400,000 of those who gain coverage are in households with incomes less than two times the federal poverty level, though 70,000 of the formerly uninsured earn more than three times poverty today." [emphasis in original blog article]  ThinkProgress also reports that the PPACA is expected to reduce the burden of uninsured medical care by approximately 50%.  McDonnell has not yet indicated whether he will recommend formation of a Virginia-run health insurance exchange, but the commission's report suggests that Virginia should run this exchange/marketplace in order to maintain maximum flexibility.

These two developments make November a month that Virginia's Republican leadership would prefer to forget.  On the one hand, the Supreme Court has let stand the Appeals Court decision that Virginia lacks standing to sue to overturn the PPACA.  On the other hand, the Governor's own health care reform commission has found that the state--and it's citizens--stand to benefit notably from the healthcare reform law, and that the state should move forward to enact it.

These same developments support the positions held by the PPACA's supporters: the first being that the the law is constitutional and that the state cannot exempt Virginia from following federal law, and the second being that he law will have tangible and meaningful benefits for Virginians.

This does not end the fight over the law and its constitutionality, and it does not mean that Virginia's General Assembly (now controlled by Republicans in both houses) will work to enact a healthcare exchange.  However, the law's supporters in Virginia can take heart in these recent events as we work to spread the word about the law's benefits--both for Virginia, and for the nation.

Thursday, December 22, 2011

An unbalanced, unfair system--a case study (N=1)

(This post was originally published on the Occupy Healthcare website, December 22, 2011)


About six weeks ago, while in clinic, I developed pain in my stomach--specifically, in my right upper quadrant, just below the ribs.  I had experienced this a few times before, but this time it seemed more persistent than usual.  Following the rule that physicians make the worst patients, I kept working through it until my nurse told me I looked poorly, and made me see my own primary care doc.  This led to an ultrasound that afternoon, a diagnosis of gallstones with mild acute cholecystitis (inflammation of the gallbladder).  I was in the surgeon's office the next week, and in the OR a week after that.  Fortunately, I had an uncomplicated laparoscopic surgery, and was home within 24 hours.

Things are fine now.  I was back at work within a few days, and was fortunate to have received prompt and effective care.  However, I realize that my experiences are not typical.  I am a physician, and my primary care physician is one of my partners: I was seen the same day because I was part of the "family" of docs with whom I work.  The ultrasound was arranged two hours after my doc saw me.  My surgery was scheduled so quickly in part because someone else's elective procedure was bumped to make room for me.  If I had been an average person calling my primary care doc for belly pain (or presenting to the ER with the same complaints) I doubt this process would have been this efficient.  I was fortunate to have privilege on my side: the privilege of being a healthcare professional, in his own system, knowledgeable about how to make the system work to my advantage.

This highlights the fact that our system is not fair.  Why should I get these special considerations?  Obviously, the easy answer is that I work in the health system where I received my care: much of what happened could be considered a form of professional courtesy where I was extended opportunities not available to patients not employed by the system.  But at the heart of health care, shouldn't this sort of care be available to everyone?  Why should it be so difficult for an average, non-medical person to be treated in just this way?  Some systems (likely some of the top systems in the nation) work to make easy and prompt access available to all comers, but they are the exception to the rule.

We need to fix our system to make sure that meaningful, necessary, and prompt access will be available to all, whenever they need it.  The system needs to be truly patient-centered.

Over the course of the next few weeks, I began to get my explanation of benefits (EOB) forms from my insurance.  These EOB forms highlight how much the hospital charged, what my insurance wrote off (or "discounted"), and what I needed to pay.  I am unable to list the costs here due to our system's insurance contracts, concerns about anti-competitive activities, etc. This is unfortunate, because they expose another area where our system is unfair and unbalanced: if you are uninsured, you will be expected to pay more than if you are insured.  This is because insurance companies negotiate with hospitals on their patients' behalf, and reduce the costs for which patients are responsible.  If you are uninsured, and if you don't know how to seek financial assistance, you pay the full (non-discounted cost) of your medical services.  That cost is usually set high enough to ensure your healthcare provider will get the maximum payment possible from the uninsured face the full burden of this increased cost.

It is not unusual for insurance companies to negotiate deep discounts for medical services.  Discounts of up to 40% are not uncommon.  This means that if a hospital charges $1,000 for a given procedure, the insurance company will only be required to pay $600 of this--because they have negotiated a discount.  This $600 will then be shared by the insurance company and the patient, who might have a required co-pay or deductible.  If you are uninsured, you do not have access to this discount and you are responsible for the full $1,000.  The $1,000 price will be set because this is the level the hospital needs to set in order to recover all available payment.  Different hospitals and healthcare systems will have mechanisms for patient assistance, but this programs exist at the decision of the system, and levels of assistance will vary greatly.

So: if I were uninsured, I would be required to pay more than any insurance company pays...and my increased liability would be the result of other peoples' insurance companies negotiating discounts for their patients.

This is crazy.  Why do we have healthcare systems that charge so much?  Because they feel they need to in order to be able to accommodate insurance companies' demands for discounted services and still turn a profit--if systems charged the actual cost of the procedure, then they would take a "discount" on that amount and end up losing money.  Why do insurance companies expect/demand discounts?  Because it helps justify their existence: if that "discount" were the actual price people were charged, there might be less need for insurance.  Why was my co-pay a small fraction of the total charges?  Because I am fortunate to have really good insurance coverage.

Presumably people who lack health insurance lack it for a reason.  Most people who are uninsured are not doing so because they like to live on the edge or save money, but rather because they cannot afford it.  What rationale is there, then, to charge them 40% more than those who are insured?
If you have ever wondered whether healthcare costs are really that bad and whether they can bankrupt people, here is your answer.  This is a one-person survey (N=1, to use a medical inside joke), so I can't claim these costs are representative of others' experiences.  But, here in Richmond, if I was uninsured and did not have enough in savings to cover the bill, then I would be scrambling to find a way to pay this sudden medical debt.

It is unfair and unjust that people are exposed to back-breaking medical costs for illnesses that are beyond their control.  We can argue about the individual responsibility patients have for diabetes or high blood pressure, though I would suggest it is less than many claim.  But how much individual responsibility is present if someone has gallstones?  Appendicitis?  Retinal detachment?  Breast cancer?  Why does our system penalize the uninsured if they have the bad luck to actually get sick?

Our healthcare system is unfair and unbalanced.  Too many lack meaningful access and struggle to afford the care they can get, while a few have easy access and much lower costs.  We need to fix this broken and dysfunctional system.

Sunday, December 18, 2011

How does the public *really* feel about healthcare reform?

(This post was originally posted on the National Physicians Alliance blog December 18, 2011)


Opponents of the Patient Protection and Affordable Care Act (PPACA) are fond of pointing out how much the public opposes the law.  Now, these voices calling for the law's repeal--with the most prominent voices coming from Republicans (including all the current presidential candidates)--usually overlook one important fact: a substantial portion of opposition to the law come from those who feel the law did not go far enough.  Seems like a fairly convenient lapse.

Having said that, I would like to review the current state of the public support for the law's reforms with the help of the most recent Kaiser Family Foundation tracking poll (pdf).  The overall public view of the law still trends unfavorable, but this seems to reflect in large part the public's unhappiness with the current state of politics in Washington, DC.  The chart on page 3 shows that half the poll's respondents would like the law expanded (32%) or kept in place (18%).  Only 24% would like the law repealed, and only 15% favor repeal and replacement with a Republican alternative.  This suggests that Republican alternatives to the PPACA have not gained traction, and that although many Americans prefer stronger reforms there is a willingness to work with the law as it stands. 

The chart on page 4 shows some reason for the public's confused approach to the law (unfavorable overall view, but support to keep the PPACA in place or strengthen the law): the public is still very confused about the law's reforms, but in terms of what is included in the law, and what isn't.  More than half of those polled believe the law includes a public option (it doesn't), while only slightly more than one-third are aware of the law's reforms to the medical loss ratio (requiring insurance companies to spend money paid in premiums on providing care, as opposed to executive pay, administrative costs, etc) or the law's requirement that screening tests such as mammograms and colonoscopies be provided without any patient co-pays.  This lack of understanding is no thanks to the Republican leadership in Washington or conservative pundits, who are so opposed to the law that they are willing to distort and misinform Americans about the law in their efforts to demonize it.

The reasons for the public's opposition to repeal/replace efforts are likely the law's actual reforms: as shown on page 5, the individual elements of the PPACA's reforms remain broadly popular across the political spectrum.  Republicans polled supported major elements of the PPACA, including closing the Medicare Part D donut hole, providing tax credits to small businesses who provide health insurance for their employees, providing subsidy assistance for individuals unable to afford insurance on their own, providing preventive care without any co-pays or patient cost-sharing, and guaranteeing coverage despite preexisting medical conditions.  In fact, of all the reforms Kaiser polled on, only the individual mandate was viewed unfavorably by the public. 

I suspect that the fact that the individual mandate has been the focus of so much discussion around the PPACA also helps explain why the public is ambivalent about the law: if bulk of the media attention is on the only reform viewed unfavorably, then it is natural that the law will be seen unfavorably.  It would be interesting to see what would happen if politicians and media discussed the law's other (positively-viewed) reforms: would this move public opinion more firmly in favor of the PPACA?  The charts on page 6 reinforce this suspicion: few Americans report hearing  any positive coverage.  Much of the negative coverage appears to come from Congressional and Republican Presidential candidates' debates, reinforcing the perception that the law's political opponents are choosing to attack it as opposed to assessing it fairly.

On page 7, the top chart shows that most Americans see that the greatest benefit from the PPACA's reforms will accrue to low-income Americans, those with preexisting conditions, and those who lack insurance.  This is a good thing, as these are the individuals who have been marginalized by our current system and who are most in need of help.

So: more Americans support the law or wish it were strengthened than support repealing/replacing it, the PPACA's reforms are broadly popular, the law's benefits will largely impact those most in need, and the law's opponents and the media are not discussing the law's reforms and benefits honestly.

I think this information leads to two important conclusions:
  1. The law is a net positive, its reforms are popular, and we need to continue discussing its benefits, protections and reforms and ensure that all Americans understand how it will protect us.
  2. We cannot rely on the media or political leaders to make this information available.  We must continue to be resources to our peers, our patients, and our communities.  We must do this, because otherwise we risk losing these important reforms.

Thursday, November 17, 2011

Answer the call to save graduate medical education...again!

Once again, Congress is considering steep cuts to graduate medical education (GME) programs in the interest of balancing the budget.  This is a classic short term answer: cutting funding to graduate medical education will reduce the number of physicians being trained in the US at a crucial time when we will need more physicians to provide care to our nations' citizens.

I have written about this issue before, and unfortunately find the need to do so again.

Cutting GME programs now might make the short-term budget outlook seem a bit more favorable...but at tremendous downstream costs.  This recent study shows the potential harm: "A 50 percent funding cut would result in the elimination of 3,037 core medical specialty positions." 

This is no time to cut GME funding...especially in the name of a convenient political goal.

Please, take action.  There are twooptions listed below--choose the one that is most comfortable for you, and help save graduate medical education.


1. Call the AMA advocacy hotline. 1-800-833-6354 (note you don't need to be an AMA member nor a health professional to use it - anybody can call this!)
2. Provide your zip code.
3. Connect directly (if calling AMA hotline) or write down the names and numbers of your representatives the hotline provides.
4. When connected, read the following:
"As a (future/current/supporter of) health care professional(s) from your Congressional District (for Representatives)/state (for Senators), I strongly urge you and your colleagues to preserve Medicare funding for Graduate Medical Education (GME) and adamantly oppose any GME cuts that might be included in a deficit reduction package. GME payments help support a portion of the costs associated with training physicians under close supervision once they co mplete medical school. They also help the nation’s teaching hospitals cover a portion of the unique costs of caring for highly complex, seriously ill, and critically injured patients who require a level of clinical expertise and technology usually unavailable elsewhere in the community.

It is imperative that Congress preserve Medicare support for residency training programs (GME) so that the next generation physicians can fulfill their aspirations of keeping America healthy. In fact, the Medicare Payment Advisory Commission (MedPAC) has, since June 2010, urged Congress to preserve—and not cut—GME support.

We appreciate the seriousness of our nation's deficit and the work underway by the "Super Committee." However, as our nation faces a physician shortage, along with a record number of new Medicare beneficiaries, it is unwise to reduce support for programs that produce the doctors our seniors will need.

Please urge your colleagues , the Congressional Leadership, the Obama Administration, and the Super Committee to oppose Medicare GME reductions as part of deficit reduction."

5. Tell your friends to do the same.


2. Click on "Take Action"
3. Use a personal email address (not your school/business email) to fill out the form and send your messages.
4. Tell your friends to do the same.

Sunday, November 13, 2011

Why social determinants of health matter, and what we must do

Recently, my friend Carmen Gonzalez wrote a post for the Occupy Healthcare site in which she highlighted the state of healthcare inequities in the United States.  Carmen's post is brief and pointed: our nation has significant differences in healthcare status and outcomes, often as a result of factors that are largely beyond individual control: ethnicity, income, educational attainment, community resources, etc.

These factors are referred to as a group as "social determinants of health (SDOH)", in that they affect individual health but are not the results of individuals' decisions.  For example: the fact that low-income neighborhoods often lack easy access to nutritious foods and safe places to exercise, meaning that those living in those neighborhoods will have greater challenges following our medical advice to exercise and eat well...not because they might not want to, but because these resources are not readily available to them.  The important role of SDOH in impacting health means that any individual's health status is not simply the result of poor personal choices, but rather an interplay of individual risk factors and the social milieu in which one lives.

In the United States, we have the most expensive healthcare system in the world (as % GDP (pdf), and per capita), while performing at a level far below our economic peers:

  • 37th in this WHO analysis (pdf), including lagging behind in infant mortality and adult mortality.
  • In this Commonwealth Fund report, the US scored only 64/100 points due to increased costs, lack of improvement in health outcomes, lack of access to care, and increased health disparities.  This report's findings showed how much improvement in outcomes and costs could result if the US worked to address failings in our healthcare system.  If the US healthcare system was on par with the best-performing systems in the world we could save up to 84,000 premature deaths and nearly $114 billion per year on administrative costs.  
  • Also from the Commonwealth Fund, this report shows that in the US over 1/4 of Americans struggled to pay their medical bills and 42% skipped needed care.  The Commonwealth Fund recently reported on U.S. Census Bureau data showing that out-of-pocket healthcare costs are significant burdens for Americans, and threaten to push millions of Americans into poverty.
In a recent article in Health Affairs, Steven Woolf and Paula Braveman discussed the impacts SDOH have on individual and population health outcomes.  The full text of the article is not yet available publicly, but in the article Woolf and Braveman note:
  • Income correlates directly with health status: higher income, better self-reported health status.  The Health Affairs article reports that "studies of Americans at all income levels reveal inferior health outcomes when compared to Americans and higher income levels."  Woolf et al demonstrated that 25% of deaths in Virginia 1996-2002 could have been avoided if the mortality rates of the five most affluent cities and counties applied statewide, demonstrating the clear impact income has on health.  (reference here)
  • Education notably influences health outcomes, both of individuals and families.  Braveman has noted that children's health depends greatly on parents' educational levels (reference here), while Woolf et al have noted that increasing American's educational levels could have greater impacts on health outcomes than biomedical advances.  (reference here)
  • Education and income levels are associated with behaviors such as smoking and physical exercise, showing the interrelatedness of these issues.  
  • The Health Affairs article also summarizes the ways in which environment influences individuals' habits, both in where people live, where they work, etc.  These influences are reviewed in-depth in this article by Bravemen et al. (pdf)
As a result of the roles SDOH play on individual health, Woolf and Braveman call for a broader approach to improve the health of individuals and (by extension) the performance of healthcare systems.  It is not sufficient to focus on one patient--or even one family--at a time.  Although this individual health care is what most of us think about when we discuss healthcare overall, Woolf and Braveman indicate that it might not be the most important factor in affecting overall health.  Although meaningful, affordable, effective individual access to healthcare is of critical importance, it is not sufficient to bend the curve on system-wide performance or on healthcare costs.  After all, more individual healthcare will mean that the system will be paying for more services, meaning that cost savings will be delayed.  Even if better and more-timely care results in fewer complications and fewer preventable deaths, resulting cost savings will not be evident in the short-term.  Therefore, we must not stop at ensuring individual access to care.

As Woolf and Braveman write in Health Affairs, "[t]he leaders who can best address the root causes of disparities may be the decision makers outside of health care who are in a position to strengthen schools, reduce unemployment, stabilize the economy, and restore neighborhood infrastructure.  Policy makers in these sectors may have greater opportunity than health care leaders to narrow health care disparities." 

So: what can we do to target SDOH and improve the health of individuals and communities? How can we take on this task?  A few proposals include:
  • Work to ensure that affordable and effective healthcare is available to all individuals.  Yes, I have argued that SDOH should be our main targets, but each of us experiences our healthcare as an individual and we must ensure that healthcare at this level is safe, effective, affordable, and available to all Americans.  For now, this might mean supporting the Patient Protection and Affordable Care Act (PPACA) as its policies are reforms are implemented.  For me, it means supporting the PPACA as a valuable first step to reform health care even as we acknowledge its gaps and work to address them.
  • Get in touch with your national elected representatives.  From the White House to Congress, our elected officials purportedly represent our views.  We must ensure that they hear from us, and we must make sure to advocate on behalf of policies that will improve SDOH.  This might include advocating for environment protection, reforming federal education laws, or supporting policies to improve the economy...but we must be heard.  Find your Senators here, your Representative here, and contact the White House here.
  • Remember that many of the policies that affect SDOH are actually determined at the state and local levels.  Find out who your state representatives are by starting here, and then linking to your state.  Remember that your state legislators are likely more accessible than those at the national level.  Keep in touch with them before, during, and after your state's legislative sessions. 
  • Find out where and how you can get involved in your local political process.  Vote in elections for mayors and city council, consider attending school board and city council meetings.  Contact your local representatives and ensure that they hear about the policies and decisions that matter to you, and that can affect SDOH.  
  • Encourage patients and peers to become involved in our political process.  Help them register to vote.  Help identify issues where they can and should be heard.  Partner with local organizations and action groups to be a productive part of dialogue at all levels of government.  Consider joining programs such as RxDemocracy, or National Physicians Alliance -- both organizations operate from the position that in order to be heard, you must be involved in the process.  
SDOH affect health through various pathways, and to address their impact we need to work at a level above that of the individual while not neglecting the individual.  This means that we must become involved in our political process.  We must call for accountability, while also ensuring that our voices are heard...otherwise, only the voices of large financial contributors will have influence.  We must remember that this is our government, and we should call on our representatives to represent US.  We can work to fix the shortcomings in our political systems...but we must also work to enact change within the systems that exist.

In the same way that other activists call on us to "think global, act local", we must "think about social determinants of health, act to care for the individual patient."  The two cannot be separated, and our duty must be to improve outcomes at all levels: we must make our healthcare system more effective, more efficient, and more affordable.  The status quo is unjust and unsustainable.

Tuesday, October 18, 2011

Occupy Healthcare

Why do we need to occupy healthcare?  Why are we here, on this website, calling for change?  We are so often told that America has the best healthcare system in the world.  If that were so, then there would be no need to change anything.  We could continue running things as we currently are, and all would be well…

Except that we do not have the best healthcare system in the world.  And we do need to change our current dysfunctional system. 

When I make this statement, naysayers usually point out that America is the destination of choice for people all over the world who come here for care of their complicated medical problems.  Advanced cancer, for example—the US is apparently the place to be if you need high tech, high-intensity care.  Another argument is that patients come here to jump the line to get hip surgery or heart surgery that would require a much longer wait in their original country…although it is not often that this claim is supported with evidence that the procedure in question could not have waited.

So: I have staked a position, one that is contrary to the common wisdom.  I have made the claim that American healthcare is not the best in the world.  It is now necessary to defend this position:

•    American healthcare is not #1 in the world.  In this World Health Organization (WHO) analysis, the US ranks 37th.  We place just behind Costa Rica.  Other nations that outrank us: Dominica, Chile, Saudi Arabia, Cyprus, Greece, Colombia, and Morocco.  Just below us: Slovenia, Cuba, Brunei, New Zealand.  Essentially every developed nation in the Western Hemisphere performs better than we do.
•    It’s worse than it looks: as this analysis shows, we are 39th in infant mortality, 43rd for adult female mortality, and 42nd for adult male mortality and some of the US’s quality measures have not increased as much as other nations’.
•    We rank last among seven developed Western-style democracies in US healthcare performance (graphic here).  We ranked 7th out of seven in efficiency, equity and “long, healthy, productive lives” 6th in quality care, and tied for 6th in access.  This last category (access) is ironic, given that many of the arguments against reforming the US healthcare system focus on the potential loss of patients’ access to their physician; it appears this access is not as robust as we might believe.
•    Our healthcare spending per capita is 50% greater than the next highest nation’s, and our healthcare spending in the US is increasing faster than most other nations’, and the % of national GDP spent on healthcare in the US is the highest in the world (reference here).
•    According to this just-released report from the Commonwealth Fund, the US scored 64 out of 100 points and lagged behind other developed nations.  You can see the short version of the report here.

Americans pay much more per person, to support a health care system that does not function very well at all, that provides inadequate and unequal care for far too many people (pdf), and that leaves nearly 50 million Americans without health insurance. (pdf)  These are all indicators of a system with significant, fundamental dysfunction.

How can we tolerate this?  How long do we continue paying for a system that is not meeting our needs, and that is costing us more and more?  How long can we continue draining resources on a system that is unequal and that does not meet its intended goals?

Every system is perfectly designed to produce the results that it is producing.  If we continue doing the same things, we will continue getting the same results…only at ever-greater cost.  Even with the passage of the Patient Protection and Affordable Care Act (PPACA), the fundamental structure of our system will not change, and we will still need to find ways to make our healthcare system more effective, equitable and efficient.

We cannot continue the status quo.  We must occupy healthcare, and we must fight for reform that will make a true difference for our nation and improve our fellow citizens’ health.

Monday, September 19, 2011

The Message We Must Communicate

(Originally posted on the National Physicians Alliance blog September 19, 2011)


Despite the Patient Protection and Affordable Care Act (PPACA) being just about 1 1/2 years old, there are still many Americans who do not understand what the law means. Ironically, this includes a large number of uninsured Americans, who stand to benefit significantly from the law.

Some have argued that this lack of understanding results from poor messaging on the part of the Obama administration in that they have failed to communicate what the law's reforms will mean to the average person.  Others have argued that the law's benefits will be increasingly understood (and valued) as its benefits become apparent.  This has been the case in Massachusetts: as the Massachusetts law's benefits were realized, public support for the reform has increased (pdf).  The increased popularity of the Massachusetts health reform law may bode well for the PPACA, given the laws' similarities.  Indeed, there is an argument to be made that as the PPACA benefits individuals, it will be harder for politicians to repeal the law and do away with its reforms.

In that light, it is absolutely necessary for us to promote the PPACA's benefits.  We must let people know what the PPACA really does to benefit individuals and the nation as a whole.  While I think that the law will gain support with time, many reforms do not take full effect until 2014--after the next Presidential election--at which time the law may find itself politically vulnerable.  We must make sure we communicate the law's benefits whenever we can, even while we let it develop its own momentum.

To help us understand the message we must communicate, please review this article that dispassionately and clearly describes the changes that will result from the law.  I'll list the 10 points below, but the article will provide more context and background information:
  1. The PPACA will provide new insurance coverage to 32 million Americans.
  2. The individual mandate is not a "mandate"--it is a penalty for those who choose not to sign up for insurance, but it doesn't actually require anyone to sign up.
  3. The PPACA is projected to lower the national deficit.
  4. The law will lower Medicare spending.
  5. Under the PPACA, Medicaid coverage will be expanded (and, as an aside, physician reimbursement will increase).
  6. More than 500,000 young adults (under age 26) have already gained access to health insurance.
  7. The PPACA targets Medicare and Medicaid fraud and abuse.
  8. Maybe as a result of the targeting of fraud and abuse, Medicare spending increases have already started to slow.
  9. The PPACA will allow Americans to take better control of our own health by requiring restaurants to provide nutrition information for their food.
  10. The PPACA will directly target health care inequalities between races/ethnicities.
The gains embodied in the PPACA are already benefiting millions of Americans, including seniors enrolled in Medicare Part D who are getting more help with their medication costs and those Americans seeking preventive care without worrying about co-pays.  This law is too important to wait for its benefits to reach enough people that public support increases.  We must help it gain that momentum, and do our parts to communicate the PPACA's benefits and its real benefit to Americans.

Monday, August 15, 2011

What Does the 11th Circuit Decision Mean?

(Originally posted on the National Physicians Alliance blog, August 15, 2011)


Last Friday, the 11th Circuit Court of Appeals struck down the individual mandate included in the Patient Protection and Affordable Care Act (PPACA). Conservative opponents of the law have claimed this as a blow for liberty, while the PPACA's liberal supporters believe this ruling will be overturned. At the end of the day, though--and all politics aside--what does this decision actually mean?

Timothy Jost, writing in the Health Affairs Blog, points out the decision's limited impact in this post. First of all, it is important to note that the decision does not actually rule the entire law unconstitutional. This opposes other courts' decisions stating that without the individual mandate, the rest of the law was also void; that the individual mandate was not severable from the the rest of the law. The 11th Circuit's decision states that the rest of the law can stand, even without the mandate. Politically, this would be a difficult position (health insurance companies might not be so willing to move forward on eliminating preexisting conditions and such without the increase in customers the mandate would bring) and the law will be harder to fund, but the law fundamentally is sound. So, this is not a finding against the PPACA itself. At best, opponents of the law can point to the fact that one piece of it was struck down by the court. The decision also lets stand the proposed expansion of Medicaid, something the plaintiffs wanted the appeals court to invalidated.

The Incidental Economist writes in this excellent post that:

"The most you can say is 'two judges decided the individual mandate is unconstitutional under the Commerce Clause, but would have been constitutional if it had been more explicitly designed as a tax. The rest of health care reform is constitutional.'"

This in-depth analysis of the decision notes that the individual mandate was eliminated because of the fear that if purchasing health insurance was required, then the government could force Americans to buy any other product. (As an aside: I think this argument is fatuous: so long as we have mandated care--at least ER care--and our care is paid for by insurance, then requiring all Americans to pay for their own care by buying insurance is clearly different from purchasing any other product out there.) Further in the Court's decision, there are many examples of what would have been constitutional...including a carrot-and-stick approach to encourage coverage, strengthening penalties on those without coverage etc. This does not seem to be a vigorous rejection of the individual mandate.

At the end of the day, the 11th Circuit's opinion really just means that the Supreme Court will essentially have no choice but to hear the inevitable appeal: with divided circuit decisions, and with the fact that the government will be filing the appeal, a hearing in front of the Supreme Court seems inevitable. Now, it is just a matter of when.

Sunday, August 14, 2011

Virginia Organizing's Annual Grassroots Gathering

Yesterday, I attended Virginia Organizing (on Twitter at @VAOrganizing)'s Grassroots Gathering.  I live-tweeted the workshop I attended, focused on working with the media and messaging, and comments from Wendell Potter regarding the importance of healthcare reform.  You can read through the transcript below.

Sunday, July 24, 2011

Do physicians need *more* contact with PhRMA and medical device makers?

(Originally posted on the National Physicians Alliance blog, July 24, 2011)


I suppose I should not be surprised, but there is a new organization that opposes the current movement to separate physicians from pharmaceutical (PhRMA) and medical device industry money.  While many of us feel that these medical industries have too much influence on physicians, the Association of Clinical Researchers and Educators (ACRE) apparently feels that these worries are exaggerated and that industry money is necessary to promote medical device and medication  innovation.  In its recent meeting, ACRE positioned itself as doing important and necessary work that would not have been done without industry funding and engaged a patient panel (including at least one celebrity) to support their position. Reviewing ACRE's website, the group takes issue with what they call the "anti-industry movement" and calls on lawmakers to find new ways to enhance researcher and physician ties with industry.

Interestingly, I could not find any information on ACRE's website describing who funds the group.  This creates doubts in the group's authenticity.  This blog post provides some additional background on ACRE, and describes the positions taken in the past by one of the group's leaders.

According to the ProPublica Dollars for Docs database, it appears that ACRE's leadership has received over $125,000 as personal payment for services provided to PhRMA and medical device makers.  This number does not include any research support they might have received from industry.  Is it possible that this financial support could affect these physicians' perspectives on this issue?

In the meantime, keep an eye on the Physician Payment Sunshine Act (pdf) that was passed as part of the Patient Protection and Affordable Care Act (PPACA) passed last year.  This law will require disclosure of any physician gifts greater than $100 in a year and will make public any payments (including research support) provided to physicians from PhRMA and medical device makers.  It will be interesting how this disclosure affects physician/industry connections, and what actions organizations such as ACRE might take to delay or weaken the law.

Tuesday, July 12, 2011

#SaveGME to Save Primary Care...and Reform GME to Save our Healthcare System

As I wrote in my last post, graduate medical education (GME) funding is threatened by proposed cuts to Medicare funding.  This is because Medicare provides money to training hospital to pay for GME positions and, if Medicare funding is cut, then training hospitals will review the perceived value of these GME positions.  It is possible, or even likely, that this would result in drastic and harmful changes to GME training--and primary care training programs would likely be the hardest hit.  The Accreditation Council for Graduate Medical Education (ACGME) has listed possible outcomes if Medicare funding for GME is reduced (pdf).  These include closing residency programs (especially in those hospitals that have only one program) and re-purposing those GME slots to more profitable or more prestigious positions, seeking industry support (from PhRMA or medical device makers) to pay for programs, increasing the debt burden on students interested in primary care, etc.

This is absurd.  If these changes were to take place, then we would be threatening our nation's health care system for decades to come.  We already are facing a shortfall of nearly 33,000 primary care doctors in the next few years (pdf).  How would reducing GME funding to primary care training improve this situation?  We already know that students' debt burden can discourage them from pursuing primary care careers.  How would increasing this debt burden improve this situation?  There is increasing understanding that PhRMA and other industry contacts influence how physicians practice.  How would making GME dependent on industry funding improve this situation?

The answers, obviously, is that reducing federal funding for GME will not solve anything.  Instead, it will reduce the number of new physicians--and, more importantly, the number of primary care and family physicians--at the very moment we urgently need to be training MORE physicians.  In his Dr. Synonymous blog, Pat Jonas demonstrates just how bad the situation is, and how bad it could get.

The fact that the proposed Medicare cuts would disproportionately impact primary care and family medicine programs will cause much deeper and longer lasting harms than might be suspected: Barbara Starfield's work has shown that INCREASED primary care IMPROVES outcomes while DECREASING costs in health care systems.  This is exactly what we are supposedly aiming for.  Meanwhile, evidence continues to mount showing that increased use of subspecialty reduces care coordination and would stand to increase costs.  So, as we look to decrease funding to GME and as training programs cut or cancel family medicine and primary care training slots in favor of subspeciality positions, we will reduce our system's ability to provide coordinate, safe, and cost-effective care while increasing the costs and fragmentation of care.

There are a number of ways that this crisis could be addressed.  One of the easier answers would be to ask states to help support community-based family medicine and primary care training programs.  The problem is that states continue to face major budget shortfalls of their own, and most are in no position to help.  In Virginia, the state has actually been CUTTING the budget line item that supports community-based family medicine training programs...and the programs narrowly avoided more cuts in the last fiscal year.

So, we know that we need to produce more physicians overall and that we have a critical and urgen need to produce more primary care physicians.  We cannot expect states to step up...and we do not want industry to pay for GME training...and we cannot expect residents to pay tuition for their training.  Fortunately, there are other options, but we need to act:
  1. Call on Congress and the White House to remove Medicare cuts from current budget discussions.  Although the current GME funding mechanisms are flawed, they are better than the alternatives.  Click here to find your Representative, click here to find your Senators, and click here to contact the White House.  Insist that Medicare funding be preserved as is, and that cuts to Medicare not used to make a political point.
  2. If you are a member of the American Medical Association, push to get this organization to support preserving funding for primary care slots as a priority--not just preserving GME funding overall.  We don't need more dermatologists or radiologists right now.  We need more primary care internists and pediatricians...but mostly we need more family physicians.  The AMA has not stood by primary care in the past (as evidenced by the recent outcry against the AMA's RUC), but this is a time when the AMA's support for family medicine training needs to be clear, loud, and aggressive.  Dr. Kevin Bernstein, on the Future of Family Medicine blog, makes the case as to why we need to save family medicine GME training.
  3. Once the threatened cuts are avoided, we need to change the way that community-based GME slots are funded.  We need to separate GME funding from hospitals, and provide funding directly to those institutions and residency programs providing accredited GME.  This funding should be separated from Medicare, so that our current situation does not recur.  Dr. Mike Sevilla makes this case on his Family Medicine Rocks blog--and points out how GME cuts would harm community physicians...and the communities and patients they care for.
  4. We need to rethink how we fund GME overall.  We know we have a national shortage of primary care physicians, and that there is no shortage of a number of other procedure-based subspecialties.  Why, then, are we still funding programs that a) do not meet a national need and b) make money on their own?  If a hospital can bill for their cardiology fellow's cardiac catheterizations, and the fellows increase the number of catheterizations their facility can perform, does the hospital really need GME funds?  No doubt they like those funds, but do they need them?  In a time when we are required to make difficult decisions and reduce the costs associated with health care, one option could be to put money where it will have the most value.  Increased funding for primary care--including robust loan repayment or loan forgiveness programs and enhanced GME funding--could improve care, reduce care fragmentation and reduce costs by addressing our primary care workforce imbalance.
Ben Miller has written how much GME funding matters to our current healthcare system.   If GME funding for family medicine programs is cut, then the likely response will be to reduce the numbers of GME slots for family medicine training.  This will perpetuate--and, over time, worsen--the current crisis in our nation's primary care workforce.  We would be producing fewer primary care physicians than we do now...and what we do now is already grossly insufficient.  Instead, medical students will find GME training slots in subspecialty care, and we will train more high-tech subspecialists.  This will increase fragmentation of care, and will increase healthcare costs (and reduce efficiencies) over time.

If we do not save GME funding for primary care, we will weaken our healthcare system's foundations...and these foundations will continue to weaken as we move forward.  Eventually, when the foundation is riddled with enough holes, then the system will collapse.  We could sit and wait until that happens...but we must not.  We must address this issue now, to prevent short-term harms, and we can rework the system to make it sustainable heading forward.  Otherwise, we will find ourselves picking up the pieces after our healthcare system--already the most expensive among developed nations, while producing lackluster results--after it finally fails.

Sunday, July 10, 2011

Another reason to preserve Medicare funding: we *NEED* more doctors

(Originally posted on the National Physicians Alliance blog, July 10, 2011)


If the Patient Protection and Affordable Care Act (PPACA) remains the law of the land after its inevitable Supreme Court review, then an estimated 34 million Americans will gain access to health insurance.  Once they have access, they will seek to establish medical care: perhaps to get a physical, to get care for chronic diseases, or to help figure out a symptom or problem.

However, when those newly-insured would-be patients go and seek to establish care with a physician, they will find a major roadblock: the Association of American Medical Colleges (AAMC) is predicting that between this increase in the insured population and the continued increase of Medicare-eligible Americans, the United States will find itself short nearly 63,000 physicians.  Nearly one-half of this shortage (33,000) is expected to be in primary care specialties. (PDF)  In its report, the AAMC calls for increase in residency training slots to address this coming crisis.

At the same time, part of the current budget debate includes making significant restrictions to Medicare funding as a way to try and balance the books.  As I noted before, Rep. Paul Ryan has proposed a budget that would drastically change how Medicare is run, and some in Congress are calling for Medicare cuts as part of any deal to increase the national debt ceiling (and prevent defaulting on our national debt).

As difficult as these two issues are separately, there is a connection: Medicare funding pays for majority of physicians' post-medical school training.  In other words, medical school graduates who continue their training to specialize in most fields--primary care or subspecialty--will be paid for from Medicare funds.  So: any cuts to Medicare will reduce our nation's ability to train new physicians, at the very time when we desperately need to train new physicians.

I mentioned earlier that the AAMC is calling for an increase in residency training slots.  Now the Accreditation Council for Graduate Medical Education (ACGME) is calling attention to the terrible results cutting Medicare funding for residency graduate medical education (GME) could have: (pdf)
  • Institutions with only one GME program--often primary care, often in community settings, often involved in direct patient care, and often rural--would risk losing their programs if they cannot find other ways to fund them.
  • Institutions with more than one program may opt to redistribute GME training slots away from primary care and toward income-generating programs and more procedure-focused such as specialized surgery, cardiology, etc.
  • Institutions seeking to find new funding for GME slots may look to the pharmaceutical and medical device industries to help make ends meet.  Given the harm that can result from such industry connections, it might be argued that training in this environment would not produce the best physicians.
  • Residents and others in GME programs may be charged tuition (instead of being paid) for furthering their education, which may worsen the pull away from the very primary care specialties we desperately need.
  • Residents' learning environments, work hours, and supervision could be impacted, as expected GME funding to make training safer and more effective would no longer be forthcoming.
  • The increased pressures on residents--financial, workload, etc--could result in more residents choosing not to complete their training.
We already face a crisis in our physician workforce, and we will face enormous problems providing health care if Medicare funding is reduced as part of a political deal.  But put the two together: an urgent need to train more physicians, and cuts in the very training programs we need...and the potential long-term damage is even more frightening. The potential harm is even more alarming when you consider the current need to increase our  primary care workforce, and the fact that these GME cuts stand to disproportionately harm those GME programs.

The ACGME is calling for attention and for action, as is the AAMC.  All of us--physicians, patients, families, friends, constituents--need to be doing the same.

Call your representatives in Congress, or write them, or e-mail them.  Use this link for the House, and this link for the Senate.  The message must be clear: Medicare cuts are unacceptable.  They will deprive our nation's citizens of the care they need now, and they imperil healthcare access for all of us--for decades to come.

Sunday, June 12, 2011

Rep. Ryan's Budget Plan Increases Support for the PPACA

(Originally posted on the National Physicians Alliance blog, June 12, 2011)


Recently, the Patient Protection and Affordable Care Act (PPACA) health care reform law received increased support from a surprising source: from the Republican Party.

As you know, Republican Representative Paul Ryan submitted a budget proposal that included major changes to Medicare.  In short, Rep. Ryan's plan would change Medicare from its current structure to a voucher-based plan in which the government would provide subsidies for the cost for seniors to purchase private health insurance.  Although this is similar to the mechanism the PPACA will use to provide access to health insurance for most Americans (providing subsidies to allow those who cannot afford to by insurance on their own), it is a major change from Medicare's current structure.

Rep. Ryan's plan to change Medicare is widely unpopular.  74% of seniors oppose it, as do 54% of conservatives.  But Rep. Ryan's plan has had another outcome he likely did not intend: it has increased public support for the PPACA.

In a recent poll (PDF), the Herndon Alliance found that when respondents heard about Rep. Ryan's plan the rate of support for the PPACA rose 3%, from 42% to 45%.  I realize 3% is not a large number, but considering how evenly split public opinion has been on the PPACA I believe this number is interesting.  In this case, once people understood the extreme nature of what the House Republicans are aiming to do in "reforming" Medicare, the reasonable and common-sense reforms embodied in the PPACA become more appealing. The poll also found that voters were concerned that Rep. Ryan's proposal would reverse the PPACA reforms that would prevent insurance companies from denying care due to preexisting conditions. Finally, significant majorities of those polled opposed the impact Ryan's budget would have on Medicare (54% oppose the Ryan plan) and Medicaid (63% were very concerned about the impact on nursing home residents).

The poll results included more indications that the supposed public opposition to the PPACA's reforms is overblown: only 42% of respondents want the law repealed, only 39% want the PPACA defunded, and of the 58% of Americans who do not support the law fully 10% of them would have wanted the law to go farther than it did.  Only 43% of the public felt that the PPACA went to far while 47% felt the reforms were appropriate or should have gone further.

Once again, we another poll reveals that a plurality of Americans oppose repealing or defunding the PPACA and that many feel the law should be given a chance or should have been extended.  Once the public hears about the destructive ideas the PPACA's opponents and congressional Republicans would put in its place, the more the public supports the PPACA.

This is why we need to stay active and vocal, and need to continue speaking up in defense of the PPACA and its goal of fair access to care for all: because the alternatives would be disastrous.

Sunday, May 15, 2011

Last Week's Hearing on Virginia's Health Care Lawsuits

(Originally posted on the National Physicians Alliance Virginia Local Network page, May 15, 2011)


Last week, two Virginia lawsuts against the Patient Protection and Accountable Care Act (PPACA) were heard in the United States Court of Appeals for the Fourth Circuit.  The 3-judge panel heard appeals for two different cases: one case brought forward by Liberty University (in which the PPACA was upheld), and one case brought forward by Virginia's Attorney General Ken Cuccinelli (in which the PPACA was found unconstitutional).  This is the next step on what will be the PPACA's inevitable review by the United States Supreme Court.  Last Tuesday's hearing begins a string of appeal hearings across the United States.

As of right now, it does not sound as though the hearings went very well for AG Cuccinelli.  Kaiser Health News summarized much of the news coverage of the hearing, and most analysis indicated that the panel appeared inclined to uphold the PPACA.  Some of the news reports indicate that the panel might even determine that the Commonwealth of Virginia has no standing to sue the Federal government regarding the PPACA.  Despite this apparently unfavorable early response from the court, AG Cuccinelli is making no indication of changing his approach even though the panel seemed to reject his claim that not buying insurance was inactivity (as opposed to activity) and therefore could not be regulated.

Obviously, every single person (unless incredibly lucky) will need to access health care during our lives, so this is a necessity and not a commodity.  So long as healthcare expensive (which it is) and largely paid for by for-profit insurance companies (which it is), people will need to have access to health insurance.  And as long as we require Emergency Departments to provide treatment for everyone, regardless of their insurance status (which we do), then it is fair to ask everyone to pay into the system that will pay for their care when they need it.  Currently, it is estimated that $1,000 of each family's health insurance policy costs result from cost-shifting for uncompensated care.  It is reasonable to expect all of us to pay our share, and to help those who seek insurance but cannot afford it.

A decision from the 3-judge panel is expected in the next few months; whatever happens, another appeal will follow.

How the Medical Industrial Complex Influences Physicians

(Originally posted on the National Physicians Alliance blog, May 15, 2011)


One of the National Physicians Alliance (NPA)'s key issues is that of integrity and trust in medicine, and the greatest focus in this area has been that of physicians' conflicts of interest with the pharmaceutical (PhRMA) and medical device industry.

There is an already-developing literature showing that increased physician contact with industry impacts the decisions that physicians make and the nature of the care that we provide.  Articles have advised that physicians should refuse to see pharmaceutical sales reps as the evidence suggests that increased contact with PhRMA results in medical decisions that do not necessarily benefit our patients.  Other articles have indicated that PhRMA contact changes physicians' prescribing patterns; that physician/PhRMA contact affects prescribing and professional behavior; that PhRMA funding affects research decisions, seems to affect the way research results are reported, may affect the content of continuing education (CME) programs, affects medication sales and formulary decisions, and negatively effects physicians' prescribing decisions in that physicians exposed to advertising tend to use newer medications inappropriately (or excessively), and that physicians tend to underestimate the effect advertising has on their practice (link here); that even unintended or unrecognized bias may affect patients' trust in physicians; etc.

As the evidence continues to build, PhRMA has developed a voluntary code of conduct (pdf) that is intended to guide its members' interactions with health care providers.  This code of conduct addresses such issues as gifts and meals PhRMA reps can provide to physicians, the way in which industry interacts with corporate consultants and speakers, and how industry will support CME programs.  The American Academy of Family Physician's summary of this updated code of conduct can be read here.  The end result of this update appears to limit the risk of bias and influence as industry sales reps interact with health care providers.

In response, it appears that PhRMA and medical device companies are starting to look elsewhere to exert influence.  As public scrutiny of industry/physician relationships increase, industry appears to be exerting influence at higher level.  ProPublica recently reported on the nature of industry relationships with medical societies.  This influence is of great importance, both because influencing professional medical societies can lead to downstream influence of that society's members, and because these societies are often involved in writing and/or endorsing practice guidelines that influence the way thousands of physicians practice.  For example, ProPublica has reported that nearly 1/2 of the money the Heart Rhythm Society collected in 2010 came from makers of medical devices and cardiac medications.  As a result, at one of the Society's recent meetings, industry ads were seen on the carpet, on the bus used to transport attendees, and in attendees hotel rooms.  In addition, ProPublica found that 12 of 18 of the Society's directors have received money from industry sources, and this does not appear to be something limited to this one organization.  The article continues to describe the ways in which professional societies and industry have worked together to influence is frightening and very much worth reading.

In a related article, ProPublica has reported that the Society for Cardiac Angiography and Interventions received 57% of its revenues in 2009 from the medical device industry.  This took place even as over 50% of patients who received stents did so before receiving optimal maximal therapy, which is counter to the recommended course of care of maximizing medical treatment before using stents to treat coronary artery disease.  The United States Senate's Finance Committee has released a report indicating that the professional societies that represent interventional Cardiology have done little to address this issue of over-treatment.

The professional societies usually defend their interactions with PhRMA and medical device makers by arguing that the industry funding makes educational programs less expensive, that the funding can be used to provide training programs for physicians, and that without disseminating this information physicians will be unable to keep up with new developments in their fields.

I would counter by arguing that, as physicians, it is our professional obligation to keep up on new developments without depending on industry-funded "education".  We need to recognize that any information that is affected by industry funding is likely to demonstrate some level of influence, and we need to seek sources of information that do not use any industry money.  If this involves paying more money for subscriptions, memberships, etc, then so be it.  If we are reading a journal or attending a conference that includes industry ads or exhibits, we can choose to ignore them and pass them by.  Our professional societies need to work harder to remove industry influence from any educational events they sponsor: make funding and conflicts of interest transparent, move any industry exhibits to an area that does not require conference attendees to pass through them in order to get to the conference rooms or any academic exhibits, and continue to search for other funding mechanisms that can reduce industry's influence.

Unfortunately, it appears that the medical profession is not yet at the point where we are willing to take on this increased responsibility.  In a recent study, physicians noted their concern that industry support can bias medical education, but that less than 1/2 of those who responded would be willing to pay more to remove industry influence and only 15% felt it was necessary to eliminate commercial support for CME. So: we acknowledge the risk of influence, and yet decline to do anything to reduce it.

We should be better than this.  We should be asking our professional societies to disclose exactly how much of their funding comes from industry and how that funding is used.  We need to push those who organize CME events to reduce the opportunities for industry influence, and to make any financial conflicts of interest public--both at the level of the event and for each of the event's speakers.  We can discuss these issues with patients, and encourage patients to ask their physicians if they take industry money...or encourage patients to find out for themselves by using this resource. We can join the NPA's Unbranded Doctor campaign, and/or take the No Free Lunch pledge.

We must do better.  Our patients' health and wellness depends on it.

Saturday, April 30, 2011

How Do I Define Family Medicine?

(Edited 3/16/12, much for the better, with deep thanks to Emily Lu)


While at the STFM meeting this weekend, some of us discussed how best to define family medicine.  This is increasingly important, as there is a dire need for more primary care physicians over the coming years and Family Medicine must make up a significant part of that increased workforce.

There are various definitions out there already:

  • American Academy of Family Physicians: "Family medicine is the medical specialty which provides continuing, comprehensive health care for the individual and family. It is a specialty in breadth that integrates the biological, clinical and behavioral sciences. The scope of family medicine encompasses all ages, both sexes, each organ system and every disease entity."
  • WONCA Europe has a long definition (pdf here) which is comprehensive but not very accessible.
  • Kevin Bernstein (@MDStudent31 on Twitter) wrote a blog post in which he notes that family medicine is very difficult to define.

I would argue that the first two definitions are insufficient.  The first, although accurate, is a mouthful of jargon that does not really resonate.  The second is 9 pages long--and that's the short version.  I also accept Kevin's thoughts that the nature of family medicine is that the scope of training and scope of practice is very broad and individual providers' practices differ significantly from one to another.  Having said that, I think there is value in trying to define what family medicine is and what role family physicians play (and should play) in health care.

Here are what I think are the key features that define family physicians:
  • Help all patients, regardless of age, gender, complaint or social situation.
  • Evaluate undifferentiated symptoms and patient complaints about any/many organ systems, and determine a holistic, appropriate and cost-effective treatment plan.
  • Develop long-term therapeutic relationships with patients, and emphasize continuity and coordination of care with necessary specialists, counselors, and community resources.
  • Manage patients' chronic illnesses, treatments, and ongoing health needs within the context of their family and community settings.
These core principles help describe the scope of practice, the importance of continuity of care, the importance of community-oriented primary care, and the importance of the bio-psycho-social model that define family medicine.

So: that's my current try at the definition.  I would love to discuss further in the comments below.

Saturday, April 16, 2011

How Will Virginia Benefit From Healthcare Reform?

(Originally posted on the National Physicians Alliance Virginia Local Network page, April 16, 2010)


The Kaiser Family Foundation has developed a resource to show the current status of health care coverage and access in each of the 50 states.  The overall site is here; the page detailing Virginia's information is here.  This data shows that Virginia has an overall lower % of uninsured non-elderly adults, slightly higher % of residents receiving health care insurance through their employer, and slightly lower % of publicly-insured residents compared to the nation overall.  This might lead one to ask how much Virginia stands to gain from the Patient Protection and Affordable Care Act (PPACA).  Fortunately, the University of Virginia (UVA)'s Weldon Cooper Center for Public Service has tried to answer this question.

In a report titled "Economic Effects of Health Care Reform On Virginia", the center reports that:
  • Reform will have "significant positive employment effects for Virginia" with over 27,000 jobs created by 2019.  Most of these of these jobs will be in the healthcare field.
  • Healthcare reform will create a $3.3 billion increase in the state's GDP between 2010 and 2019.
  • The report suggests that the PPACA's potential to reduce health care costs extends its benefits to Virginia beyond the direct impacts noted above.  The report indicates that if health care costs can be controlled and these savings are passed along to employers then the employment benefits could nearly double.
If improving access to healthcare to our fellow Virginians isn't enough of a reason to support the PPACA, maybe these economic benefits will help.  People are more important than numbers, but sometimes numbers matter.  By either measure (access to care or economics), the reforms in the PPACA will benefit Virginia and Virginia's residents.