Life in Underserved Medicine

Please support Medicaid expansion in Virginia

noreply@blogger.com (Mark Ryan) — Sun, 03 Feb 2013 21:55:00 +0000

I am writing to ask Virginia's General Assembly to expand Medicaid in Virginia.

As a family physician in Richmond, working with some of the Commonwealth's poorest and most-marginalized citizens, I believe that the expansion of Medicaid coverage up to 133% of the Federal Poverty Level (as called for in the Affordable Care Act) is critical to the health of our citizens, and to the state's economy.

I would like to provide a few examples as to why this expansion is so important:

Medicaid expansion in other states has been associated with reduced mortality: http://www.nejm.org/doi/full/10.1056/NEJMsa1202099
In Oregon, access to Medicaid was associated with improved healthcare outcomes (though at the cost of increased costs early on--presumably as patients took advantage of newly available coverage): http://www.nejm.org/doi/full/10.1056/NEJMp1108222
Medicaid expansion will cost Virginia less, both in the short and the long term: http://www.thecommonwealthinstitute.org/2013/02/01/revised-medicaid-expansion-still-saves-money-in-virginias-budget/ and http://www.timesdispatch.com/news/state-regional/government-politics/medicaid-expansion-would-save-initially-va-official-says/article_e379990f-75b1-5fc0-9931-241fa922c4fb.html
Finally, it is critical to note that the ACA reduces funding to hospitals that treat a disproportionate share of uninsured patients. These so-called DISH funds are being eliminated under the ACA because the cost of caring for these patients was expected to be covered by the law's Medicaid expansion. At this point, there is no mechanism in place to account for reduction in DISH funds under the ACA. This combination of events not only puts hospitals at significant risk, but also threatens to increase all commercial insurance costs to all Virginians--individuals and employers as hospitals face shortfalls from the increase in uncompensated care and passes those costs along to all insured Virginians. It is also worth noting that, at least at VCU, DISH funds help cover not just in-hospital care but also the VCC program that provides community-based primary care for uninsured patients, meaning that these patients will lose access to preventive and primary care services.

Given that it is very difficult for adults to currently qualify for Medicaid in Virginia, many receive care through volunteer services and through free clinics. These programs do excellent work, but I believe many are already running at or near capacity and would struggle to take on additional patients should the safety net unravel any further. The ACA's health insurance marketplaces (exchanges) do not benefit anyone under 100% FPL, meaning that a failure to expand Medicaid ensures our poorest citizens will left out of our current system.

Expanding Medicaid in Virginia holds the potential to provide better patient outcomes, and to save money. Failing to expand Medicaid access threatens a financial crisis to healthcare providers, hospitals, and anyone who is insured--and I have not heard of ANY action in the General Assembly or from the Governor that would address this potential crisis.

I believe the way forward is clear: expand Medicaid as called for in the ACA.

Sincerely,

Mark Ryan, MD, FAAFP

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If you are a Virginia voter, you can click here to find your state Senator and Delegate.

Why physician groups support the Affordable Care Act

noreply@blogger.com (Mark Ryan) — Sun, 04 Nov 2012 23:10:00 +0000

(Originally posted on the National Physicians Alliance blog November 4, 2012)

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Physicians must care about our patients. In every decision we make and each action we take, the health and wellness of our patients and our communities must be at the center of what we do. The Affordable Care Act (ACA) will make your healthcare better.

Our organization--the National Physicians Alliance (NPA)--was formed in 2005 and is committed to advancing the core values of the medical profession: service, integrity, and advocacy. The organization has key guiding principles that focus on putting our patients health and wellness above all other concerns. NPA's advocacy has emphasized the need to ensure patient protection and to repair the broken covenant that our nation's healthcare system must benefit all Americans. Our commitment and our obligation to care for our patients is limited by many factors: insurance company policies that restrict the care we can provide, health disparities that persist despite individual efforts to address them, and a lack of insurance that limits access to health insurance and healthcare.

As a result of NPA's determination to ensure equitable and affordable healthcare for all Americans, the organization has worked to secure the passage of the ACA and to advocate for its full implementation. In keeping with NPA's guiding principles, our support of the ACA has been focused on the benefits the law provides to patients as well as its protection of the doctor-patient relationship we hold as a sacred responsibility as professionals.

How does the ACA protect patients?

The ACA provides important benefits for ALL Americans: The ACA provides multiple benefits for the middle class. Considering the major role that healthcare costs play in personal bankruptcies (PDF), it is clear that ensuring the affordability of healthcare provides a crucial protection for middle class Americans. Affordable insurance--made more so by government support to help lower income families and changes in insurance enrollment that are predicted to reduce the cost for all--will allow most Americans to see the health benefits of having health insurance (PDF). Adult children will now be able to stay on parents' insurance policies until they are 26 years old, thereby enhancing their ability to access health insurance while in school and starting out in the workforce. Coupled with reforms that will remove limits on annual and lifetime coverage benefits for patients, Americans will be better protected as they look to move into the middle class and secure a better future for themselves and their families. In addition, preventive care services including vaccines, pap smears, colonoscopies, and other necessary services will be made available to Americans without requiring co-pays, making them more available than ever before.

The ACA promotes fairness and equality in medical care: The ACA reverses one of the most egregious facts of healthcare insurance in the US: the fact that a person's gender was the basis for charging women more for health insurance than men. This difference exists only because a woman was a woman, and is not due to specific coverage (PDF) such as for pregnancy or maternity care. The ACA will also target national healthcare inequalities by strengthening the nation's community health centers, increasing the number of physicians working in medically underserved areas by increasing National Health Service Corps scholarships. Finally, the ACA begins to address our national need for more primary care physicians and move towards a healthcare workforce that is accessible to all.

The ACA protects patients from insurance company abuses: Thanks to the ACA, insurance companies will have less control over patients' healthcare. Insurers will be required to offer insurance to everyone regardless of whether or not they have a preexisting medical condition--a benefit that has already gone into effect for children and is planned to go into effect for adults in 2014. The ACA prevents insurance companies from setting arbitrary limits to patients' lifetime health insurance benefits, and as of 2014 will eliminate annual limits to care. Insurance companies are required to spend 80-85% of members' premiums on providing benefits to those members, as opposed to using that money for administrative costs or executive salaries. The ACA bans the practice of rescissions, in which insurance companies would seek reasons to retroactively cancel members' insurance coverage once those members became ill and most needed the protection. The ACA provides greater governmental scrutiny of unreasonable insurance rate hikes, helping insure that Americans are not being harmed by insurers willfully increasing policy costs without reason or justification. Finally, by establishing health insurance marketplaces (or exchanges), the ACA will require all insurers to show the purchasers of their products--our patients--that the companies are effective and responsive to their customers' needs or they will risk patients finding coverage elsewhere. This should increase transparency and provide greater benefits to patients who will be able to vote with their feet and leave ineffective companies to look for better options.

The NPA is not the only physician organization to support the ACA. The law is also supported by the American Medical Association, the American Academy of Pediatrics, the American Academy of Family Physicians, the American College of Physicians, the American Congress of Obstetricians and Gynecologists, the Association of American Medical Colleges, and the American Osteopathic Association.

The reasons all of these physician groups support the ACA is simple. As physicians, the law's reforms allow us to provide better care for our patients--without being limited by insurance regulations or lack of access to health insurance. The ACA removes important barriers to care, and lets us get back to the core focus of our profession: the covenant to do whatever we can to improve our patients' health and wellness.

Partnering with communities: why and how?

noreply@blogger.com (Mark Ryan) — Sun, 28 Oct 2012 18:46:00 +0000

To enhance the impact medicine can have in addressing healthcare disparities, it is often necessary to work outside of the clinical space. One-on-one clinical care is critically important for the individual, but can only address the individual's need at that point in time. Although this is the core of medicine--the doctor/patient relationship--it is not sufficient to address broader issues.

I believe that physicians' roles in leadership and community focus require us to look beyond the clinic to bring necessary change. At the minimum, I believe that physicians need to be advocates for necessary change: at the organizational and/or at the political level, we must be pushing for policies that will improve the health of our communities.

At the same time, it can often very valuable to develop partnerships in the community itself. However one defines community, the community's members will have a strong sense of the community's strengths, needs, and challenges. However, in many cases forming a productive and effective relationship with underserved communities can be challenging. Many times, these communities may feel isolated and marginalized. In some cases, they may actively distrust medical institutions based on past experiences.

Every community is unique, and effective community partnerships will all differ in some way. However, there are some general themes that can guide the process in developing community partnerships:

Demonstrate genuine commitment
Have a long time horizon--things will move slower than you would prefer
Assess the communities needs and values, and respect them
Expect challenges and strife: pre-empt them if you can, address them when needed
Understand that all decisions carry political consequences
Good intentions are dangerous things: consider the ethics of your intervention
Identify and engage the community's leadership (official and unofficial)
Inspiration and interest on our part can help generate an idea, but need community guidance for any intervention
Listen, think, talk...then act
Tolerate of uncertainty
Know that communities are heterogeneous, even if there are not any apparent differences on the surface
Align incentives: look for space where your interests/motivations/rewards align with the community's

By approaching a community guided by these principles, the resulting partnerships will be more robust, more beneficial, and more respectful.

If it is a problem, why don't you have a solution?

noreply@blogger.com (Mark Ryan) — Wed, 18 Jul 2012 13:48:00 +0000

First published on the OccupyHealthcare blog, July 18 2012.

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Just about three weeks ago, the Supreme Court ruled that the Patient Protection and Affordable Care Act (ACA) was constitutional in its requirement that all Americans have health insurance. However, the court also decided that the ACA's expansion of Medicaid eligibility and coverage could not be forced upon the states. States could opt to expand Medicaid as the law required, but those states that choose not to expand would not face the loss of their current Medicaid funding. Already, a number of Governors have declared their opposition to this Medicaid expansion.

The ACA's expansion of Medicaid is an important part of the law's efforts to expand coverage and healthcare access to most Americans. The law would require the expansion of Medicaid to cover individuals up to 133% of the Federal poverty level. The Federal government will pay 100% of this expansion for the first three years, a level of support that gradually lowers to 90% over the next five years. It is expected that, as designed, the ACA's Medicaid expansion would provide coverage to 17 million Americans. The law's new health insurance exchanges, that facilitate individuals' purchase of health insurance and provides subsidies for those with incomes between 133% and 400% Federal poverty level, would account for the rest of the ACA's increase in health insurance coverage.

Late last week, the Republican Governors Association (RGA) sent the Obama Administration a letter outlining their concerns about the proposed Medicaid expansion and the ACA's health insurance exchanges. The letter, signed by Virginia Governor Bob McDonnell, has one particularly notable passage:

The reason this passage struck me is because of its chutzpah. The RGA's own members are those who will make the decisions for their states as to whether or not the state will expand Medicaid coverage. However, if the state chooses not to, it is somehow the fault of the Administration for not having come up with an alternative plan. The letter purports to show concern for those low-income Americans who would have been covered by the Medicaid expansion (if not for the Governors' decisions to reject it), and expects the federal government to provide a means of coverage for these low-income individuals.

Of course, the ACA does provide a means for low-income people to access health insurance: it expands Medicaid. The RGA's letter is absurd, essentially saying: "If we reject the remedy you have developed to cover low-income Americans, you must come up with an alternative." This is even more striking if one reviews the underlying reasons why the states might reject the Medicaid expansion: they claim it is a violation of states' rights. If the states are worried about expansion of federal power, how is asking the Federal government for an answer to a state's own rate of uninsured individuals in any way logical? If anything, the states should be fixing this problem themselves if they were following their argument to its logical conclusion. Instead of asking for Federal help, the states should have already addressed this issue.

The states that have already rejected the ACA's Medicaid expansion include Texas and Florida. Both states are among those with the highest rates of uninsured.

Mississippi is second on this list, and is also considering rejecting the Medicaid expansion. The states whose residents would gain the most in terms of access to health insurance are those who are fighting this increase in access. These three states also have Republican governors, who have not come up with a better plan to improve access to insurance as of yet. If Republican governors truly thought that low-income Americans' access to health insurance was a problem, they have had ample time to come up with a solution...and they have not done so.

Medicaid coverage improves health outcomes, with the trade-off of an initial cost increase (possibly as those who have been insured finally access care). With the Federal government covering 100% of the initial expansion, they (not the states) would be paying for these up-front costs. Given that Medicaid is more cost-effective than private insurers (point 7 on this list), expanding access to health insurance via a program that is both cost-effective and beneficial is a smart move. Meanwhile, we know that being uninsured is bad for one's health.

Thanks to the ACA, we now have the tools to expand health insurance--and health care--to 30 million more Americans. Those who decry the law's reforms have, for the most part, failed to act in their own states and have failed to present a viable alternative. If the ACA's opponents thought the issues of heath insurance and access to health care were a problem, they would have acted long ago. It is time for them to stop obstructing this important step forward to improve Americans' health.

The healthcare aftermath of June 28, 2012: What we protected, what is missing, and what we still need to do

noreply@blogger.com (Mark Ryan) — Fri, 29 Jun 2012 11:59:00 +0000

(Originally posted on the OccupyHealthcare blog June 28, 2012)

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Yesterday, the Supreme Court upheld the constitutionality of the Patient Protection and Affordable Care Act (PPACA). After nearly 2 1/2 years of partisan misinformation, the Court has established the law's legitimacy.

This is an enormous step forward. The PPACA incorporates many patient protections that will reduce the profit-centered influence of for-profit insurance companies on American's healthcare. Once the law is fully implemented in 2014, insurers will no longer be able to deny insurance coverage to any American even if they have pre-exisiting medical illnesses and will no longer be able to place yearly or lifetime limits on members' benefits. Insurance companies will be required to spend 80-85% of the money members pay in premiums on providing benefits to members as opposed to salaries and administrative costs. Young adults will be able to stay on parents' insurance plans until they turn 26--meaning that they can keep necessary insurance coverage as they finish their educations or start their careers. Federal subsidies will make insurance affordable for Americans who are not offered insurance through their jobs and cannot afford to purchase it on their own. Private insurers have called the shots for too long, and restricted access to necessary care for Americans who could not afford it or who were already ill. These days are now coming to an end.

The PPACA also addresses key needs in our healthcare system. It will strengthen our primary care workforce and our community health centers. It will encourage research that is both patient-centered and evidence-based, to help patients and physicians make informed decisions about the best approaches to individuals' care. The PPACA also makes preventive care available for all without co-pays, allowing healthcare providers to detect and treat (or even prevent) chronic disease before they cause permanent harm. The law will increase Medicaid access and will strengthen Medicare. Finally, the PPACA includes programs to explore new ways of providing (and paying for) healthcare services that are more effective, more coordinated, and less expensive.

All of these are critical patient protections and healthcare system reforms. The protections will allow us to make sure that healthcare is available with less interference on the part of insurance companies and reforms the most egregious insurance company practices. The reforms will allow us to start to move our healthcare system away from one providers are paid more for doing more care and towards a system that provides better care. These are significant steps, and reforms that the Supreme Court has now endorsed and guaranteed so long as the Affordable Care Act is in effect.

However, the law is an incomplete step forward. It still leaves a number of Americans lacking health insurance, and explicitly prevents many immigrants from accessing care. The PPACA supports private, for-profit insurance companies with public money in the form of subsidies to help low-income Americans pay for insurance. There were still be fragmented care as patients will still move between private and public insurances or between private insurers. There is little in the law to address the high and increasing costs of pharmaceuticals and medical devices. By building upon the flawed structure of individual private insurance companies, the PPACA cannot offer the savings inherent in single-payer systems where administrative costs are lowered, coverage and access are assured to all. The political environment in Washington, DC would not allow for such a significant move as a single-payer system. In fact, the law barely survived in its current form. This does not mean that we should rest on our laurels: even with the PPACA's reforms there will be much more work to do.

We must monitor how the PPACA is enacted, and we must avoid its reforms being co-opted or weakened by special interests and the law's stubborn opponents. Where the law does not meet its intended results, we must revise it to ensure that it will. We must identify those who do not benefit from the law as written and work to find ways to extend the law's benefits to all. We must continue to speak about the law's benefits and make sure that our friends, families, and colleagues understand how very important this law is.

We must be vigilant heading forward. Although the PPACA is constitutional, congressional opponents can continue their attempts to repeal and defund the law. Rest assured that, if they are able to, they will do just that. The House is already planning a repeal vote on July 11. Under the PPACA, the economic and human costs of allowing millions of Americans to go without health care are finally being addressed. We cannot afford to take any steps backwards: there is still a long road ahead.

Global Health and Underserved Communities: Challenges and Rewards

noreply@blogger.com (Mark Ryan) — Mon, 25 Jun 2012 14:54:00 +0000

From May 29 to June 9, I traveled on a medical relief trip to the Dominican Republic. Below is the text of an e-mail I sent the team, which I include here because I believe it states my position on the challenges and rewards that one can attain for working with underserved communities in the US and overseas.

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I wanted to send this note to thank everyone for their hard work and for making the trip successful. For those new to global health projects such as this, I realize it is a difficult adjustment to make: the long hours, the constant work, the uncertainty around schedules and plans, and the constant feel that we should, somehow, be doing more than we are. The recognition that the need is greater than our ability to respond to it, and how we can come to terms with that without necessarily accepting it, and how we can use our resources and skills to do our part in helping the patients we work with.

This is a heavy task: in healthcare, we all would like to think that we can make big differences through our profession, when the humbling truth is that often the best we can do is to be a small part of a larger process. I believe we are obligated to help our patients to the extend of their needs and to the best of our abilities, but this means that there will always be someone who we could not reach, or for whom our skills were not sufficient.

This is not a comfortable place to be, whether in the US or overseas. I think working in developing nations makes this gap between resources and needs more evident, but as you continue your training in Richmond you will start to notice more and more examples of the mismatch between what people need and what we can offer.

The best approach to help as many people as possible is to determine where you can have an impact, and to work as a team to get the most out of what we have. We chose to put a lot of focus on diabetes and high blood pressure because, as medical and pharmacy professionals, this is where our greatest skill set lies. However, our summer clinical work fits into the larger picture of our ongoing community development work in the Dominican Republic: work that aims to address sanitation, flooding, and other broad social determinants of health. The fact that our ongoing commitment to the community leverages our skills and matches them to with community development project allows us to address health on many more levels than if these two initiatives were separate. We may have only done a small part, but it is a small part of a greater whole.

At the same time, our part was not especially small. In the community, we provided healthcare to nearly 500 people: people who would have lacked care if we were not present. For some, this involved treating blood pressure and other chronic illness. For some, this involved parasite medications and vitamins to enhance nutrition. For some this involved coming to get medications to use if problems such as back pain or stomach pain developed in the future. However, I was taught that the role of a healer is to "cure sometimes, relieve often, comfort always" and, as with that as a guiding principle, I believe that there is value in doing our best to care for everyone regardless of the objective severity of their illness.

It would have been impossible to have seen the over 600 patients (when both clinical sites are added up) without teamwork, collaboration, and a unified sense of mission. Despite the challenges noted above, you responded brilliantly. Whether working registration, vitals, pharmacy or seeing patient, everyone willingly stepped forward to do what needed to be done to make sure that we met our commitments to our patients and to each other.

For all of this, I thank each and every one of you for being part of this exceptional team. I look forward to working with some (many? all?) of you again in the future.

#MedRead (part 3): Non-fiction books: Health policy, healthcare reform, and healthcare redesign

noreply@blogger.com (Mark Ryan) — Sun, 24 Jun 2012 18:48:00 +0000

Recently, I made a request on Twitter for suggestions for books that medical students should read. These suggestions could be books of any sort: fiction, non-fiction, clinically-focused, etc. I was hoping to get suggestions for books that made a meaningful impact on people. I'll be posting the lists in a series of blog posts.

In each case, I've linked the book title to its Powells.com listing...mainly because I didn't want to link to larger sites such as Amazon. In practice, I would strongly advise looking for these books at the library (to test them out--use this site to find the books at a library near you) or at your local independent bookstore (such as Chop Suey Books, in Richmond). Remember that if you're local bookseller doesn't carry these titles, they can probably order them for you--and they'll keep your money local.

Alternately, if you wish to support the authors directly, feel free to see if you can purchase the book you are interested in from the author's own website.

This is the third installment, focused on health policy, healthcare reform, and healthcare redesign. The first installment is here, and the second is here.

Pathologies of Power – Paul Farmer

Landmark: The Inside Story of America's New Health Care Law, and What It Means For Us All – Washington Post Staff

Understanding Health Policy -- Bodenheimer and Grumbach

The Social Transformation of American Medicine – Paul Starr

The Last Well Person: How To Stay Well Despite The Health-Care System – Nortin Hadler

The Truth About the Drug Companies: How They Deceive Us and What to Do about It – Marcia Angell

Selling Sickness: How the World's Biggest Pharmaceutical Companies Are Turning Us All Into Patients – Ray Moynihan

Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer – Shannon Brownlee

Overdosed America: The Broken Promise of American Medicine – John Abramson

Creative Destruction of Medicine: How the Digital Revolution will Create Better Healthcare – Eric Topol

Time To Die : How American Hospitals Shape the End of Life – Sharon Kaufman

Let the Record Show: Medical Malpractice, the Lawsuit Nobody Wins – J. Kelley Avery

AMA Code of Medical Ethics

Money Driven Medicine: The Real Reason Healthcare Costs so Much – Maggie Mahar

Health Care Will Not Reform Itself: A User's Guide to Refocusing and Reforming American Health Care – George C. Halvorson

Through the Patients’ Eyes: Understanding and Promoting Patient-Centered Care – Margaret Gerteis

Caring for the Country: Family Doctors in Small Rural Towns – Howard Rabinowitz

Beliefs and Families: A Model for Healing Illness – Lorraine M. Wright, Wendy Watson, and Janice M. Bell

On the Take: How Medicine's Complicity with Big Business Can Endanger Your Health – Jerome P. Kassirer

The Patient Paradox: Why Sexed Up Medicine Is Bad for Your Health – Margaret Mccartney (A more-detailed description can be found here.)

If you have read these books (or if you recommended them), please use the comments below to provide us with some thoughts on why the book mattered to you.

ACA triggers insurer reforms...but the law is still necessary.

noreply@blogger.com (Mark Ryan) — Tue, 12 Jun 2012 14:17:00 +0000

(First published on the National Physicians Alliance blog, June 12 2012)
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Yesterday, three major insurers announced that they would keep in place major insurance reforms introduced in the Patient Protection and Affordable Care Act (ACA), regardless of how the Supreme Court decides regarding the law's constitutionality.

UnitedHealth, Aetna, and Humana all announced that they would continue allowing children under age 26 to remain on parents' health insurance plans, allow independent appeals of insurance decisions, and cover certain preventive services.

Although this move by these for-profit insurers appears to be a good thing, there are two important considerations to remember. The first is that none of these insurers have agreed to issue insurance plans regardless of pre-existing conditions. If an individual with prior medical problems applies for insurance from these organizations, the insurers can still deny coverage. This would no longer be possible once the ACA is fully implemented. Therefore, the law is still critically important to make sure that all Americans will have access to health insurance coverage.

The second consideration is that the ACA was the catalyst for insurers to change their practices. For-profit insurers have been around for a long time, and had plenty of opportunity to implement these reforms on their own. However, none did until the ACA was passed and signed into law. The provisions that the insurers plan to keep in place are the law's most popular provisions, but they were not established by the insurers in a vacuum. The ACA put these reforms in place, the public realized that they were beneficial, and now the insurers have decided to reform their practices accordingly. If not for the ACA, I deeply doubt we would have seen any sort of insurance reforms of this sort. In fact, when the law was being developed, insurers defended their rights to rescind patients' coverage. The ACA deserves full credit for forcing insurers to enact these important patient protection reforms.

Despite the fact that insurers have belatedly agreed to support these patient protections, the law is still critically important:

Not all insurers have agreed to sustain these important reforms. Blue Cross/Blue Shield, Wellpoint, and Cigna are hedging their bets until the Supreme Court's decision is known and declined to make any commitments in response to yesterday's announcements from UnitedHealth, Aetna and Humana. Considering the size of these insurers, this would place many Americans at risk of losing insurance coverage if the ACA's protections were lost.
The ACA provides subsidies for Americans who cannot afford to pay for private insurance out-of-pocket. These subsidies make health insurance, which is otherwise prohibitively expensive for many Americans, affordable and available. Without the ACA, the insurers could claim to make their coverage available to many in the sense that it is technically available, but could price it at a level that places it out of reach.
One of the major ways that the ACA will expand insurance coverage is by expanding Medicaid. This will provide access to health insurance for millions of low-income Americans, something that these actions by the insurance companies will not affect.
The ACA requires private insurers to spend 80-85% of the money they receive in premium payments on providing health care services (instead of using this money for administrative costs, salaries, etc). This is known as the medical loss ratio (MLR). The ACA's MLR requirements will mean that the money individuals pay to ensure they have insurance coverage will actually be used to provide insurance benefits. None of the insurance companies have pledged to maintain this ratio heading forward should the ACA be overturned.

Although it is good to see insurers pledging to keep important patient-centered reforms in place, it is necessary to put this in context. The insurers are agreeing only to keep in place the ACA's most popular reforms and reform some of their most egregious practices. They are not pledging to make their products less expensive (or more affordable) to the average American, they are not agreeing to offer coverage to all Americans regardless of pre-existing medical conditions, they are not agreeing to follow the ACA's MLR guidelines. Finally, not all insurers have agreed to continue the new practices required by the ACA.

The ACA has forced insurers to make some meaningful changes in how they practice--changes the insurers had given no indication they would enact on their own. This shows the law's power and effectiveness: thanks to the ACA, millions of Americans will have more robust insurance coverage, regardless of the Supreme Court's decision. However, what the private insurers have omitted from their promises to extend the ACA's benefits shows why we still need this important piece of healthcare reform: it is a critical step to ensure affordable and accessible healthcare insurance for all.

The Cost Depends on the Value

noreply@blogger.com (Mark Ryan) — Mon, 30 Apr 2012 01:53:00 +0000

(Initially published April 27, 2012 on the OccupyHealthcare blog.)

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Last week, Medscape released the results of their 2011 survey of physician compensation:

I share this post here to point out the discrepancy in physicians' average salaries based on their specialties. In particular, I would like to highlight that the three lowest-paid specialties are the three primary care specialties: pediatrics, family medicine, and general internal medicine.

This post is not written to argue that physicians must be paid more. I would submit that if physicians cannot live on $150,000 then we might be doing something wrong...and we are unlikely to get much sympathy from the average person.

Rather, my intent is to note how undervalued primary care services are in our current system of healthcare delivery and payment. Primary care physicians--the physicians who provide comprehensive care, who provide preventive care, who coordinate care--are paid less than all other medical specialists. Radiology and anesthesiology make nearly twice what primary care doctors do; dermatology and anesthesiology make nearly 175% of the average primary care physician.

This is not to say that these medical specialists do not have important roles in providing medical care; however, should a physician who views x-rays and imaging studies be valued at twice the level of the physicians who keep our children well, who monitor their development and intervene if necessary, and who ensure children are fully vaccinated? Should a physician who deals with skin problems be paid at nearly twice the level of a physician who can deal with many of the same skin problems...while also addressing patients' diabetes, blood pressure, heart disease, and mental illness?

The cost of any given service or item depends on its value. Precious metals are expensive because we value them greatly. Luxury cars are expensive because they are highly valued in our culture. Primary care physicians in the US are paid less than all other specialists, and cost less per physician than all other specialists...indicating that the primary care specialties are valued less than other medical specialties.

We have previously noted the importance of primary care to a high-functioning, efficient, and effective healthcare system. Despite the key role primary care should be playing, however, the chart above shows that primary care is not valued at a commensurate level.

Unless we value primary care, and redesign our healthcare delivery and payment systems to reflect this, then we will continue to have a healthcare system that under-performs even as healthcare costs continue to increase. The cost depends on the value: so long as we do not value primary care, then costs will rise even as outcomes do not improve.

This situation is untenable, and must change. We must demand a healthcare system that values those services and specialties that reduce costs. We must enhance primary care's role in our system in order to improve our system's performance. If we change what type of medical care our system values, then we can truly affect cost.

Setting the Stage for the ACA's Second Anniversary

noreply@blogger.com (Mark Ryan) — Tue, 13 Mar 2012 13:00:00 +0000

(First published on the National Physicians Alliance blog March 13, 2012)

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In one week, the Patient Protection and Affordable Care Act (PPACA, or ACA for short) will attain its second anniversary. In preparation for the media attention this milestone will attract, it is necessary to set the stage regarding the ACA's achievements and popularity.

First, a review of what the reforms already in place as a result of the ACA: this timeline provides a good summary, as does this timeline. A review of these timelines shows that the ACA has already led to the following changes:

Young adults can stay on parents' insurance policies until age 26.
People with preexisting medical conditions who have been uninsured for at least 6 months can access care via Preexisting Condition Insurance Plans.
Insurance companies can no longer rescind patients insurance, and have eliminated lifetime caps on insurance benefits.
Children can no longer be denied medical care due to preexisting medical conditions.
Seniors have received discounts and rebates on their medication costs via Medicare Part D.
Patients can receive many preventive care services without paying co-pays.
Funding has been increased for community health centers and for the National Health Service Corps.
Increased targeting of healthcare fraud.
Insurance companies will be held accountable for unreasonable premium rate increases, and are being required to spend at least 80-85% of the premiums they receive on providing necessary medical services to beneficiaries.

These are among the ACA's reforms that are favored by individuals on both sides of the political spectrum (pdf link). Even before the ACA's major reforms become active in 2014, the law is already improving the status of healthcare in America.

It can be anticipated that there will be a great deal of critical commentary about how the ACA represents a governmental overreach and that Americans resent this supposed power grab. However, in the most recent Kaiser Family Foundation Health Tracking poll (pdf), 35% of Americans would like to see the law expanded, while 19% would like to see the law kept in its current form. When 54% of the nation would like to leave the law as is or expand its reforms, it is hard to argue that most Americans oppose the ACA in the way that the law's opponents would have us believe: they might highlight that 72% of Americans oppose keeping the ACA in its current form, but 1/2 of that number want the law expanded. This underlines the disingenuous nature of the claims made against the ACA: the law's opponents highlight those bits of data that can be presented as supporting their claims, but conveniently omit the details that undercut their claims.

Opponents of the ACA also have chosen not to propose any replacement for the law any time soon, despite the fact that the House of Representatives actually voted to repeal the law in 2011. While the Republican Party delays action, 1/3 of Americans are struggling to pay their medical bills. This statistic illustrates the reasons that the ACA's reforms were so badly needed: Americans cannot easily afford necessary medical care. The law will address this directly as the health benefits exchanges come online in 2014, but the reforms noted above stand to improve this statistic.

We will certainly hear more and more reasons that the ACA was unconstitutional, especially as the Supreme Court will be hearing arguments on the law's constitutionality the week following the law's anniversary. One of the major arguments against the ACA focuses on the law's mandate that individuals purchase health insurance or face paying a penalty. This article nicely encapsulates arguments as to how and why the ACA and its individual mandate are both constitutional and necessary.

This is where we stand: the ACA is already benefiting Americans, many of whom are in favor of the law's reforms or who would have preferred more expansive reforms. The need for reform is clearly evident, and the ACA's opponents have not proposed any meaningful answer to the current crisis in healthcare access and affordability. Despite the law's opponents' fervent claims and beliefs, the law's constitutionality can be supported in a number of ways.

If you support the ACA's healthcare reforms, get ready, be vocal, and stand tall. The week of March 19-23, 2012 promises to be quite active.

Poverty in Richmond, Virginia: We Have Our Work Cut Out For Us

noreply@blogger.com (Mark Ryan) — Sun, 11 Mar 2012 21:13:00 +0000

Today, I attended the first part of a three part series of presentations focused on the nature of poverty in Richmond, Virginia. Today's presentation was focused on a review of the data; the next will discuss the history that led to this situation, and the final presentation will discuss suggested interventions that might address this issue. The nature of poverty in the city is especially notable because concentrated poverty compounds desperation and leads to hopelessness and alienation. The presentations are based on the work of Dr. John Moeser, of the University of Richmond's Bonner Center for Civic Engagement.

The data is focused on the Richmond Planning District. In 2010, the poverty level for a family of 4 was a yearly income under $22,314. In Richmond City, the rate of those living in poverty increased from 22.1% to 25.8% 2009-2010. Poverty rates rose 18.2%-25.8% 2000-2010. Poverty in the city is at an historical high since 1970. Just as important is the fact that the proportion of those living in poverty in surrounding counties increased from 2000 to 2010 by 94% in Henrico and 71% in Chesterfield. 46% of those in poverty in the Richmond area live in the city; 54% of the region's poor now live in the suburbs. This shift in poverty in the Richmond area reflects a national trend of increasing poverty in suburbs.

There is also a significant level of wealth inequity in the region. In Richmond City, the wealthiest census tract has an average income 17x greater than the poorest. Wealthiest census tract in central VA has an average income 21x the poorest. Despite this great difference between the riches and poorest residents in the city, there is very little physical distance: there are only 3 1/2 miles separating the wealthiest census tract in the city (Windsor Farms) and the poorest (Gilpin Court).

Further details regarding who is poor in Richmond is also striking. Currently, 38% of children in Richmond City live in poverty; this is double the rate from 1990. If one looks at poverty by race, it is notable that 48% of the poor are black. However, the % of all whites and Hispanic community living in poverty have increased. In particular, the % Hispanic community living in poverty increased from 8%-23.5% from 1990-2009. [Editorial note: I think this might represent the fact that the Hispanic community has nearly doubled throughout the Richmond metro area in the last 10 years; many of these newly-arrived individuals and families earn annual incomes below the poverty level.]

Most poor whites live in the suburbs (69%) in suburbs; 61% of all black poor live in the city. Asian and Latino poverty is largely suburban. Overall, Hispanic and black poverty are typically higher density, whether in city or in suburbs; while white poverty less concentrated. More than 20% of the population living in poverty in Richmond City is concentrated in south and east Richmond. 5 census tracts in the city have more than 50% of their residents living in poverty; Gilpin Court has 69% of its residents living in below the poverty line. Concentrated poverty in the City of Richmond is largely found east of Chamberlayne Ave, and on both sides Jefferson Davis Highway south of the river. These areas of concentrated poverty align with the locations of public housing developments. There is no concentrated public housing in counties, but concentrated poverty in the city spills over from the city to the older inner ring of suburbs. There are some census tracts in the city where poverty rates declined, and older housing stock is renovated via gentrification. At the same time, there are some census tracts that have increased in the % of their residents living under the poverty line. Overall, "South Richmond is the city's new East End" with increasingly concentrated poverty. This shift appears to be largely related to increased Hispanic poverty.

For anyone who believes (as I do) that the social determinants of health matter, then this information is striking and relevant. Improving communities' and individuals' health will require more than disease-focused outreach and prevention programs. We will need to refocus on affecting and influencing public policy in such a way as to take health, education, income, etc. into account whenever policy decisions are made. This is less immediate, and perhaps less gratifying, then working one-on-one with patients...but it is equally (or, perhaps, even more) important work. Physicians need to involve ourselves in discussions about policy changes and we need to hold our elected leaders accountable for making decisions that will improve the health status of all people--both by improving healthcare, and by including healthcare considerations when discussion all policy issues.

#MedRead (part 2) Non-fiction books: Patient narratives, culture, society, and science

noreply@blogger.com (Mark Ryan) — Sun, 11 Mar 2012 12:30:00 +0000

This is the second in a series of blog posts that will list books recommended for medical students as a result my asking for suggestions on Facebook and Twitter. This second installment (the first installment can be read here) focuses on society, patient narratives, science, and culture.

In each case, I've linked the book title to its Powells.com listing...mainly because I didn't want to link to larger sites such as Amazon. In practice, I would strongly advise looking for these books at the library (to test them out--use this site to find the books at a library near you) or at your local independent bookstore (such as Chop Suey Books, in Richmond). Remember that if you're local bookseller doesn't carry these titles, they can probably order them for you--and they'll keep your money local.

Alternately, if you wish to support the authors directly, feel free to see if you can purchase the book you are interested in from the author's own website.

Grand Pursuit: The Story of Economic Genius – Sylvia Nasar

The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures – Anne Fadiman

And the Band Played On: Politics, People, and the AIDS Epidemic – Randy Shilts

A Question of Intent: A Great American Battle with a Deadly Industry – David Kessler

Medicine and Human Welfare – Henry Sigerist

Guerrilla Warfare – Ernesto Guevara

28 Stories of AIDS in Africa – Stephanie Nolen

The Year of Magical Thinking – Joan Didion

Autobiography of a Face – Lucy Grealy

Nickle and Dimed – Barbara Ehrenreich

Wretched of the Earth – Frantz Fanon

Pedagogy of the Oppressed – Paulo Friere

Anything by Emily Martin: A good start might be Bipolar Expeditions: Mania and Depression in American Culture

Immortal Life of Henrietta Lacks – Rebecca Skloot

The Match: "Savior Siblings" and one Family's Battle to Heal Their Daughter – Beth Whitehouse

Medial Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present – Harriet Washington

The Ghost Map: The Story of London’s Most Terrifying Epidemic—and how it Changed Science, Cities, and the Modern World – Steven Johnson

Mountains Beyond Mountains – Tracy Kidder

Treatment Kind and Fair: Letters to a Young Doctor – Perry Klass

As Nature Made Him: The Boy who was Raised as a Girl – John Colapinto

Anything by Richard Feynman: What Do You Care What Other People Think? Further Adventures of Curious Character seems a good start.

A Whole New Life: An Illness and a Healing – Reynolds Price

Mama Might Be Better Off Dead: The Failure of Health Care in Urban America – Laurie Kaye Abraham

Let Us Now Praise Famous Men – James Agee and Walker Evans

Broke, USA: From Pawnshops to Poverty, Inc – How the Working Poor Became Big Business – Gary Rivlin

Barefoot Heart: Stories of a Migrant Child – Elva Treviño Hart

Still Alice – Lisa Genova

Half the Sky: Turning Oppression into Opportunity for Women Worldwide – Nicholas Kristof and Sheryl WuDunn

If you have read these books (or if you recommended them), please use the comments below to provide us with some thoughts on why the book mattered to you.

#MedRead (part 1) Non-fiction books: Physician Narratives, Medical Practice, and Illnesses

noreply@blogger.com (Mark Ryan) — Mon, 05 Mar 2012 01:18:00 +0000

Recently, I made a request on Twitter for suggestions for books that medical students should read. These suggestions could be books of any sort: fiction, non-fiction, clinically-focused, etc. I was hoping to get suggestions for books that made a meaningful impact on people. I'll be posting the lists in a series of blog posts.

In each case, I've linked the book title to its Powells.com listing...mainly because I didn't want to link to larger sites such as Amazon. In practice, I would strongly advise looking for these books at the library (to test them out--use this site to find the books at a library near you) or at your local independent bookstore (such as Chop Suey Books, in Richmond). Remember that if you're local bookseller doesn't carry these titles, they can probably order them for you--and they'll keep your money local.

Alternately, if you wish to support the authors directly, feel free to see if you can purchase the book you are interested in from the author's own website.

The first group includes books that focus on medical practice, physicians' narratives, and the medical aspects of disease:

Every Patient Tells a Story: Medical Mysteries and the Art of Diagnosis – Lisa Sanders

How Doctors Think – Jerome Groopman

The Man Who Mistook his Wife for a Hat – Oliver Sacks

How We Die: Reflections on Life's Final Chapter – Sherwin Nuland

The Case of Doctor Sachs – Martin Winckler

House Calls – Thomas Stern, MD

Anything by Atul Gawande: Complications, Better, and The Checklist Manifesto.

White Coat, Clenched Fist – Fitzhugh Mullan

My Own Country – Abraham Verghese

Of Spirits and Madness – Paul Linde

A Fortunate Man – John Berger

The Coming Plague – Laurie Garrett

Betrayal of Trust – Laurie Garrett

Medicine in Translation: Journeys with my Patients – Danielle Ofri

Not All of Us are Saints: A Doctor’s Journey with the Poor – David Hilfiker

Travels – Michael Crichton

The Motorcycle Diaries – Ernesto Che Guevara

The Great Influenza – John Barry

Final Exam: A Surgeon's Reflection on Mortality – Pauline Chen

The Youngest Science: Notes of a Medicine-Watcher – Lewis Thomas

Aequanimitas – Sir William Osler

White Coat, Black Hat: Adventures on the Dark Side of Medicine – Carl Elliott

The Emperor of All Maladies: A Biography of Cance – Siddhartha Mukherjee

The Demon Under the Microscope: From Battlefield Hospitals to Nazi Labs, One Doctor's Heroic Search for the World's First Miracle Drug – Thomas Hager

Blind Man's Marathon – Steven Hatch

If you have read these books (or if you recommended them), please use the comments below to provide us with some thoughts on why the book mattered to you.

Expanding Health Insurance Coverage Should Reduce Costs

noreply@blogger.com (Mark Ryan) — Sun, 26 Feb 2012 18:40:00 +0000

(This post was initially published at on the National Physicians Alliance blog, February 26 2012)

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Without significant changes, healthcare spending in the United States (already one of the highest rates in the world per capita) will continue to increase at an unsustainable rate (PDF). One of the most important goals of the Patient Protection and Affordable Care Act (PPACA) is to control the costs of medical care. Various analyses have discussed the PPACA's potential to reduce healthcare utilization and costs, including this analysis of the law's cost containment features (PDF) and this review of how the PPACA could bend the healthcare cost curve.

However, it can be argued that the key cost savings feature of the PPACA is also the law's defining reform: the PPACA is expected to extend health insurance coverage to nearly 32 million currently uninsured Americans. It can be argued that this expansion of coverage was the underlying crisis that drove the passage of this law, but whether or not expanding healthcare insurance access would reduce costs was unclear.

Now, a new study looks at the impact of extending healthcare access to individuals who previously lacked this access. In November 2000, Virginia Commonwealth University (VCU) Medical Center launched a community-based coordinate care program in response to the health center's role as a principle safety net provider in Richmond, Virginia. Individuals under 200% of the federal poverty level who lacked any other coverage options were eligible for this program. Once enrolled in the program, patients were assigned to a community-based primary care office and these primary care providers received a management fee and fee-for-service reimbursement that were equal to roughly 110% of Virginia's Medicaid fee schedule. This structure would be comparable to enrolling patients in programs that enhance primary care access through either private insurance or public insurance programs such as Medicaid--the two major approaches that the PPACA will take to expanding coverage.

Since this program was implemented, VCU Medical Center has seen a significant change in their system's usage of high-cost services. Primary care visits increased over the period when patients were enrolled in the program, while emergency department visits and inpatient admissions decreased during the same period. This suggests that increased access to primary care services reduces the need for higher-cost emergency department and inpatient interventions. The program also saw inpatient costs fall each year, and total average costs per year per employee fell nearly 50% (from $8,899 to $4,569).

The study's authors conclude that "previously uninsured people may have fewer emergency department visits and lower costs after receiving coverage, but that it may take several years of coverage for substantive health care savings to occur." The authors also noted that there were larger cost savings were achieved in patients with more chronic conditions. This conclusion aligns with prior research including this study, this study, and this article from Dr. Barbara Starfield (PDF).
This new article highlights two important considerations. First: in the program this article describes, increasing individuals' access to health care reduces the overall costs of care. This has significant implications for national healthcare spending trends. Second: as the US population increases its theoretical access to healthcare services, there will need to be primary care physicians available to care for them. The PPACA includes plans to address this workforce need, but other healthcare system reforms (including payment reforms and graduate medical education training) will need to be enacted to meet its full potential.

As the PPACA approaches its second anniversary, and as it moves closer to full implementation in 2014, there is increasing evidence that the reforms embodied in the law will begin bending the cost curve of medical care. This is of critical importance, especially as the political debate in Washington, DC focuses on budgets and deficits. We must support and fully implement the PPACA to help address the nation's fiscal security, as well as providing better and more effective care for our patients.

Interdisciplinary Service Learning: Una Vida Sana! and Richmond's Hispanic Community

noreply@blogger.com (Mark Ryan) — Tue, 14 Feb 2012 12:58:00 +0000

In 2009, I helped start a new interdisciplinary service learning program named "Una Vida Sana!" (A Healthy Life). This program targets cardio-metabolic disease screenings (diabetes, high blood pressure, and high cholesterol) within Richmond's Hispanic Community.

We have now started analyzing some of the data from student participation and our patient data. We reported on the early data analysis at the recent Society of Teachers of Family Medicine (STFM) Conference on Medical Student Education two weeks ago. Below is the presentation from that conference (apologies that the formatting is a little off after the upload):

Una Vida Sana! STFM Pre-Doc

View more PowerPoint from RichmondDoc

Where I'm Coming From

noreply@blogger.com (Mark Ryan) — Sat, 11 Feb 2012 17:43:00 +0000

(This article originally appeared on Progress Notes on February 9, 2012.)

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When I entered medical school in Richmond, Virginia, I was certain I wanted to be in primary care but I was not yet sure what specialty. Once I had decided to work in a medically underserved community I chose family medicine because in a rural site, where resources are limited, there is added value in the breadth and scope of family medicine training. I would be able to see all patients, regardless of age, gender, or initial symptoms. This training served me well when I took my first job after residency, in the small town of Keysville, Virginia. In Keysville, I worked for four years providing care to patients in town and in the surrounding counties.

While in Keysville, I helped launch an international medical service and community development in the Dominican Republic in partnership with the College of William and Mary in Williamsburg, Virginia. Working with this project in close partnership with the community of Paraíso, just outside the capital city of Santo Domingo, I have become more aware of the concept of community-oriented primary care. At its heart is the idea that primary care is most effective and most responsive when it is provided in the context of the community. Interventions and care should take into account—and make use of—community resources in order to have the greatest effect. There is little value in a doctor’s recommendation that a patient does not have the resources to follow.

After four years in Keysville, I returned to Richmond to provide care to the Hispanic community and to work more with medical students. Through our department’s International/Inner City/Rural Preceptorship (I₂CRP) program, I further developed my understanding of community-oriented primary care and of the importance of social determinants of health – the wide-ranging community and environmental factors that affect health, such as local schools and education, environment and pollution, access to affordable and nutritious foods, and safe public space for exercise. Robust evidence supports social determinants and the need to address them if we wish to improve health (and, perhaps, reduce costs).

Knowing this, I have noticed my perspective changing both on my specialty and on my medical practice. It is increasingly clear that social determinants wield tremendous influence on individual health and that to be effective in primary care we must advocate for change that targets social determinants, but change that is focused on communities’ needs as the community itself identifies them. For example, diet might be difficult to address in a community where the cheapest food is calorie-dense fast food. Exercise might be impractical if patients work late hours and lack safe places to exercise. I believe that we must both keep social determinants in mind as we work with patients and push for reforms that will address (and improve) them.

One-on-one primary care provides notable benefits for the individual, but there is great value in advocating for socially responsible change that will benefit the community at large and, as a result, benefit the individuals we care for. It is not appropriate or sufficient for those outside a community to define what a community’s priorities should be. These priorities should be mutually agreed-upon with the community and should target its key needs.

It is with this combination of motivations and interests that I practice and teach day-to-day. At the heart of all medical care is the one-on-one care provided for the individual patient. This is the core of what we do and what we believe as clinicians, and this relationship and responsibility still carry critical importance. However, we must provide this care with an understanding of the social determinants of health. We must recognize the limits of some of our standard recommendations. Finally, we must begin to connect with our communities. Much of medical education occurs in the sheltered and protected environment of tertiary care centers and classrooms. Students must begin to learn how to look outside of that environment, work with and understand communities, and help build coalitions and partnerships that stand to improve conditions within the communities we serve but to do so on the communities’ own terms.

This is an exciting and challenging time to be in primary care. With our national workforce shortage in primary care, we are both in high demand and heavily worked. For these reasons, we need to train medical students with broad vision, individual focus, and community orientation to provide the medical care that our community and our nation need. I hope to be a part of this solution. It is an important step in making our medical care more efficient and more effective.

On The Shoulders Of Giants

noreply@blogger.com (Mark Ryan) — Thu, 02 Feb 2012 11:00:00 +0000

(This was originally posted on the Occupy Healthcare blog, February 2, 2012)

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Dr. Barbara Starfield died in 2011. For many people, her name will not stand out. For those of us looking to improve our healthcare system, however, her work is of critical importance.

Dr. Starfield is best known for her work emphasizing the importance and the value of primary care. Primary care (usually focused on family medicine, but including general pediatrics and internal medicine) is the segment of our health care system that focuses on long-term relationships, addressing medical problems from a whole-person perspective, and addressing undifferentiated problems and illnesses. Dr. Starfield wrote in the New England Journal of Medicine that "[i]mportant functions of primary care include serving as the first point of contact for all new health needs and problems; delivering long-term, person-focused care; comprehensively meeting all health needs except those whose rarity renders it impossible for a generalist to maintain competence in them; and coordinating care that must be received elsewhere." This as a concise definition as I have seen for the role of primary care.

In the same article, Dr. Starfield notes that "[r]obust evidence shows that patient care delivered with a primary care orientation is associated with more effective, equitable, and efficient health services. Countries more oriented to primary care have residents in better health at lower costs. Health is better in U.S. regions that have more primary care physicians, whereas several aspects of health are worse in areas with the greatest supply of specialists. People report better health when their regular source of care performs primary care functions well. In addition to features promoting effectiveness and efficiency, there are fewer disparities in health across population subgroups in primary care–oriented health systems"

The article noted above goes on to summarize the evidence that backs up her claim, and I will not post all that evidence here. Similarly, Dr. Starfield authored many, many other articles that provide additional insight on the key roles of primary care in an efficient and effective health care system. I encourage you to review some: if you have taken the time to find this site and read this post, then I presume you have an interest in these ideas. Dr. Starfield's work is a good place to start.

I would like to make myself look smart, and recite all the ways in which our healthcare system fails us on a daily basis. And I would like to pretend that I came up with these ideas on how to fix the system on my own. But, as with so much of life, these ideas are not mine. I try to contribute what I can, but I am building on the work of those who came before--physicians and scholars such as Dr. Starfield. So I would like to present her suggestions (from this interview) as to how we can reform our healthcare system to make it stronger and to improve our nation's health:

"For health care reform to be successful, the system must focus on providing more primary care to more people. We know exactly what we mean when we say primary care. It is not just having a family physician or internist. It is providing services that achieve four functions. First of all, care has to be accessible, and we know that our care is not very accessible compared to countries that do much better than we do on health.

Second, care has to be person-focused over time. Now, instead of focusing care on meeting peoples' needs, professionals define the needs -- usually in terms of having a specific disease -- and then forget about the people while dealing with the disease. We know from evidence that if you don't deal with people's problems, people are much less likely to get better. We are focusing on diseases that are professionally defined needs. We are not focusing on people-defined needs. Unless we address people-defined needs, we are not going to get good health outcomes.

The third characteristic is comprehensiveness. Instead of referring so much unnecessarily to (sub)specialists, we have to reserve (sub)specialist care for things that (sub)specialists are really needed for -- the less common and complicated things -- and take much better and more care of most health needs within a primary care setting.

The fourth characteristic is coordination. People have to go elsewhere for (sub)specialized services every now and then and that is good care, not bad care. When they do go, the care they receive elsewhere has to be coordinated with their ongoing care.

We know exactly what primary care is, we know exactly why systems organized around it do a better job. It is not a secret, it is not rocket science, but we don't do it."

Accessible care, person-focused care, comprehensive care and coordinated care. Simple concepts, and core ideas, that have been lost in our hospital-focused and specialist-heavy system. This is how we change healthcare: identify the beliefs and practices that matter and that work...and then start finding ways to make our system honor and be accountable to them. We don't do it, but we should...and we must.

Shining a Needed Light on PhRMA/Physician Interactions

noreply@blogger.com (Mark Ryan) — Mon, 23 Jan 2012 03:29:00 +0000

(This post was initially published on the National Physicians Alliance blog, January 22 2012)

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Recently, National Public Radio's program "On the Media" discussed the Physician Payment Sunshine Act. This legislation (PDF; a useful overview is available here--also a PDF) was part of the Patient Protection and Affordable Care at and requires that pharmaceutical companies (PhRMA) disclose how much they pay physicians in compensation for being consultants, on speaker's bureaus, etc. The rules that were released in December 2011 go even further than many expected: PhRMA and medical device makers will need to disclose how much they pay physicians for speaking at formal CME events.

There are many physicians who will claim that these talks are educational--whether at CME, or at industry-sponsored events. They will also claim that they only speak on behalf of medications and/or companies they believe in. However, ProPublica's excellent Dollars for Docs investigative series has detailed ways in which PhRMA and other industry actively seek to control physician's presentations and often target the speaking physician as much as their audience. However, there are rising concerns that these relationships might not only raise costs, but could lead to harm or promote care that might not be in patients' best interests.

If physicians and industry are proud of these relationships, then they should be wiling to open their books for patients' review. If we are receiving medical advice and care from professionals, we should be able to know if their interests might be skewed based on their relationships with industry. The Sunshine Act will help accomplish this: patients will be able to review who pays their physicians, and can make their own decisions as to whether this has any impact on care. In return, putting this information out in the open will encourage physicians to be transparent and encourage us to provide evidence-based care that is patient-centered.

Until the Sunshine Act's database is available online, I recommend using ProPublica's searchable database to see if your physicians are getting paid by PhRMA and medical device manufacturers. What you find might be revealing...and your physician's response if you ask them about payments might be surprising. I readily admit that not all these connections are necessarily bad...but in that case there should be even less need to hide them.

NPA has a strong position about conflicts of interest in medicine, which led to our Unbranded Doctor campaign. Patients deserve unbiased medical care, and physicians should be held to that standard. We are willing to do our part.

Join us.

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

noreply@blogger.com (Mark Ryan) — Fri, 23 Dec 2011 10:00:00 +0000

(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.

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

noreply@blogger.com (Mark Ryan) — Thu, 22 Dec 2011 15:10:00 +0000

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

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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 insurers...so 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.

How does the public really feel about healthcare reform?

noreply@blogger.com (Mark Ryan) — Sun, 18 Dec 2011 22:05:00 +0000

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

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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:

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.
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.

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

noreply@blogger.com (Mark Ryan) — Thu, 17 Nov 2011 13:14:00 +0000

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.

BY PHONE:

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!) or http://www.congress.org/congressorg/directory/congdir.tt

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.

BY EMAIL:

1. Visit http://www.capwiz.com/aamc/home

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.

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

noreply@blogger.com (Mark Ryan) — Sun, 13 Nov 2011 17:12:00 +0000

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.

Occupy Healthcare

noreply@blogger.com (Mark Ryan) — Tue, 18 Oct 2011 05:14:00 +0000

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.

The Message We Must Communicate

noreply@blogger.com (Mark Ryan) — Mon, 19 Sep 2011 19:48:00 +0000

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

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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:

The PPACA will provide new insurance coverage to 32 million Americans.
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.
The PPACA is projected to lower the national deficit.
The law will lower Medicare spending.
Under the PPACA, Medicaid coverage will be expanded (and, as an aside, physician reimbursement will increase).
More than 500,000 young adults (under age 26) have already gained access to health insurance.
The PPACA targets Medicare and Medicaid fraud and abuse.
Maybe as a result of the targeting of fraud and abuse, Medicare spending increases have already started to slow.
The PPACA will allow Americans to take better control of our own health by requiring restaurants to provide nutrition information for their food.
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.