Life in Underserved Medicine

Expanding Health Insurance Coverage Should Reduce Costs

2012-02-26T13:40:00.002-05:00

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

--------------------

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

2012-02-14T07:58:00.000-05:00

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

2012-02-11T12:43:00.002-05:00

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

--------------------

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

2012-02-02T06:00:00.000-05:00

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

--------------------

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

2012-01-22T22:29:00.000-05:00

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

--------------------

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

2011-12-23T05:00:00.000-05:00

(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)

2011-12-22T10:10:00.000-05:00

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

--------------------

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

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

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

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

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

2011-12-18T17:05:00.000-05:00

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

--------------------

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

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

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

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

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

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

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

I think this information leads to two important conclusions:

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!

2011-11-17T08:14:00.001-05:00

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

2011-11-13T12:12:00.001-05:00

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

2011-10-18T01:14:00.003-04:00

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

2011-09-19T15:48:00.000-04:00

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

--------------------

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

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

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

To help us understand the message we must communicate, please review this article that dispassionately and clearly describes the changes that will result from the law. I'll list the 10 points below, but the article will provide more context and background information:

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.

What Does the 11th Circuit Decision Mean?

2011-08-15T21:59:00.000-04:00

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

--------------------

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

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

The Incidental Economist writes in this excellent post that:

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

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

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

Virginia Organizing's Annual Grassroots Gathering

2011-08-14T21:35:00.001-04:00

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

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

2011-07-24T21:25:00.000-04:00

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

--------------------

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

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

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

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

A Reminder why Vaccines Matter

2011-07-17T16:53:00.000-04:00

Created by: Medical Coding Career Guide

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

2011-07-12T10:40:00.000-04:00

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

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

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

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

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

So, we know that we need to produce more physicians overall and that we have a critical and urgen need to produce more primary care physicians. We cannot expect states to step up...and we do not want industry to pay for GME training...and we cannot expect residents to pay tuition for their training. Fortunately, there are other options, but we need to act:

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

Ben Miller has written how much GME funding matters to our current healthcare system. If GME funding for family medicine programs is cut, then the likely response will be to reduce the numbers of GME slots for family medicine training. This will perpetuate--and, over time, worsen--the current crisis in our nation's primary care workforce. We would be producing fewer primary care physicians than we do now...and what we do now is already grossly insufficient. Instead, medical students will find GME training slots in subspecialty care, and we will train more high-tech subspecialists. This will increase fragmentation of care, and will increase healthcare costs (and reduce efficiencies) over time.

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

Another reason to preserve Medicare funding: we NEED more doctors

2011-07-10T22:32:00.001-04:00

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

--------------------

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

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

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

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

I mentioned earlier that the AAMC is calling for an increase in residency training slots. Now the Accreditation Council for Graduate Medical Education (ACGME) is calling attention to the terrible results cutting Medicare funding for residency graduate medical education (GME) could have: (pdf)

Institutions with only one GME program--often primary care, often in community settings, often involved in direct patient care, and often rural--would risk losing their programs if they cannot find other ways to fund them.
Institutions with more than one program may opt to redistribute GME training slots away from primary care and toward income-generating programs and more procedure-focused such as specialized surgery, cardiology, etc.
Institutions seeking to find new funding for GME slots may look to the pharmaceutical and medical device industries to help make ends meet. Given the harm that can result from such industry connections, it might be argued that training in this environment would not produce the best physicians.
Residents and others in GME programs may be charged tuition (instead of being paid) for furthering their education, which may worsen the pull away from the very primary care specialties we desperately need.
Residents' learning environments, work hours, and supervision could be impacted, as expected GME funding to make training safer and more effective would no longer be forthcoming.
The increased pressures on residents--financial, workload, etc--could result in more residents choosing not to complete their training.

We already face a crisis in our physician workforce, and we will face enormous problems providing health care if Medicare funding is reduced as part of a political deal. But put the two together: an urgent need to train more physicians, and cuts in the very training programs we need...and the potential long-term damage is even more frightening. The potential harm is even more alarming when you consider the current need to increase our primary care workforce, and the fact that these GME cuts stand to disproportionately harm those GME programs.

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

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

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

2011-06-12T19:27:00.000-04:00

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

--------------------

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

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

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

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

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

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

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

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

2011-05-15T16:49:00.000-04:00

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

-------------------

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

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

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

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

How the Medical Industrial Complex Influences Physicians

2011-05-15T15:08:00.000-04:00

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

--------------------

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

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

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

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

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

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

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

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

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

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

How Do I Define Family Medicine?

2011-04-30T16:04:00.001-04:00

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

There are various definitions out there already:

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

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

Here are what I think are the key features that define family physicians:

Take undifferentiated symptoms and patient complaints, and determine and appropriate and cost-effective evaluation.
Do this for any patient, regardless of age, gender, complaint or affected body part.
Develop long-term therapeutic relationships with patients and emphasize continuity and coordination of care.
Work with patients' diagnoses, treatments, and ongoing health needs while trying to understand their family and community settings.

These core principles help describe the scope of practice, the importance of continuity of care, and the importance of the bio-psycho-social model that define family medicine.

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

How Will Virginia Benefit From Healthcare Reform?

2011-04-16T01:28:00.000-04:00

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

--------------------

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

In a report titled "Economic Effects of Health Care Reform On Virginia", the center reports that:

Reform will have "significant positive employment effects for Virginia" with over 27,000 jobs created by 2019. Most of these of these jobs will be in the healthcare field.
Healthcare reform will create a $3.3 billion increase in the state's GDP between 2010 and 2019.
The report suggests that the PPACA's potential to reduce health care costs extends its benefits to Virginia beyond the direct impacts noted above. The report indicates that if health care costs can be controlled and these savings are passed along to employers then the employment benefits could nearly double.

If improving access to healthcare to our fellow Virginians isn't enough of a reason to support the PPACA, maybe these economic benefits will help. People are more important than numbers, but sometimes numbers matter. By either measure (access to care or economics), the reforms in the PPACA will benefit Virginia and Virginia's residents.

How Much Proof Do We Need To Support Healthcare Reform?

2011-04-16T00:39:00.001-04:00

(Originally posted on the National Physicians Alliance blog April 16, 2011)

--------------------

Just over year after the Patient Protection and Affordable Care Act (PPACA) was passed, surveys show that many Americans are still unsure of what the law will mean for them. A recent Kaiser Family Foundation poll (pdf) showed that 52% of respondents feel that they lack sufficient information to assess the PPACA's impact--a proportion similar to that seen after the law was passed last year. At the same time, there is increasing understanding that our current health care system is dysfunctional and needs to be reformed: the Commonwealth Fund recently found that 72% of Americans believe that the current system needs fundamental change or major reform. To support this, poll respondents noted "difficulties accessing care, poor care coordination, and struggles with the costs and administrative hassles of health insurance."

In this context, it is revealing to review an earlier Commonwealth Fund publication titled "Help on the Horizon: How the Recession Has Left Millions of Workers Without Health Insurance, and How Health Reform Will Bring Relief." This report found the following:

Millions of Americans lost their jobs and health benefits in the last 2 years: nearly 60% of those who had health benefits through their job lost those benefits, and only 14% kept their coverage through COBRA.
There are few affordable options for health insurance for workers who lost their jobs and benefits: 60% of Americans who sought coverage in the individual market reported great difficulties finding affordable coverage, and 35% were excluded from coverage or faced higher costs due to a preexisting health condition.
The number of adults who have spent time without health insurance has increased in recent years: 52 million people reported being uninsured during at least part of the previous year in 2010 (up from 38 million in 2001). People were more likely to have gone without insurance if they reported low or moderate incomes, if they were members of a minority group, or if they were young adults.
People are spending large proportions of their income on healthcare costs: nearly 1/3 of respondents reported spending at least 10% of their income on healthcare costs, up from 1/5 in 2001.
More and more Americans report facing significant medical debt: 40% reported financial problems related to the costs of their health care.
Americans are foregoing needed care because of costs, and are less likely to get preventive care: 40% reported skipping needed care (avoiding doctors' visits, prescriptions, tests, etc) due to costs, and rates of recommended preventive care were notably lower among uninsured individuals.

Clearly, the system we have had is broken, and the current recession has only made things work. Unemployed Americans lack the necessary leverage to get affordable and comprehensive coverage, resulting in deferred care, financial hardship, and presumably increased risk of illness and harm over time. The 72% in the Commonwealth Fund noted above clearly have a reason to feel our system needs to be changed.

Fortunately, that change is already underway. The PPACA will address these issues once it is fully in effect in 2014. In 2014, the PPACA will provide for nearly universal coverage for American citizens by expanding Medicaid eligibility, subsidizing private health plans with more robust patient protections, and spurring new options for health insurance through the state health care exchanges. Once fully in effect, the PPACA will also prevent insurers from charging more or denying care for individuals with preexisting health problems. The early reforms already in effect allow young adults to stay on parents' insurance until they turn 26, eliminates lifetime caps on benefits, and requires health insurance plans to provide preventive care without requiring patient copays.

The better the existing healthcare system's problems are defined, and the more information we gather about those affected and harmed as a result, the more clear the need for reform is. As this need becomes increasingly clear, it is also increasingly clear that the PPACA's major reforms are targeted at addressing the current system's most crucial problems.

We need to stop trying to justify the PPACA by finding more and more proof reform is needed--we have that proof. We also need to stop trying to prove the PPACA is the answer--we have that proof. What we need to do is to continue working to ensure that all Americans understand the law's benefits and how it will help them. We already have all the proof we need.

Happy 1st birthday, ACA!

2011-04-03T22:45:00.000-04:00

March 23rd marked the first anniversary of the passage of the Patient Protection and Affordable Care Act (PPACA). The PPACA has already expanded coverage to young adults and those unable to afford health insurance to the high costs of individual premiums due to preexisting conditions. Health insurance companies will need to reform their business practices, including ending the policy of revoking care if a policyholder is diagnosed with a serious illness (so-called rescissions) and requiring that 80-85% of premiums paid by policyholders be used to provide care and benefits (instead of paying executives' salaries, etc).

On March 22nd, I was able to participate in an event sponsored by Virginia Organizing to discuss the benefits of the PPACA. Please take a look at my post on the National Physicians Alliance Virginia Network's page for more detail.

And join me in celebrating a very important birthday.

The Cold, Hard Facts About Tort Reform

2011-03-29T20:35:00.002-04:00

Many physicians look for tort reform and would love to see it as part of any future health reform. I admit that it would be nice to not have to worry about lawsuits when I'm working with patients. However, I don't know that tort reform would save much money.

The CBO estimated comprehensive malpractice reform would save the government $54 billion over 10 yrs. However, the government pays $636 billion each year for healthcare costs.

One trillion is 1,000 billions; that means that $54 billion over 10 yrs / $6.36 trillion ($6,360 billion) over 10 yrs: I'm bad at math, but I get a 0.85% savings in healthcare costs from tort reform. Would that really make any drop in the bucket?

I think that if we were to have some ability to ensure that if we practice good medicine we would be protected in case of a bad outcome (such as some sort of safe harbor that if evidence-based guidelines are followed a physician would be protected from suit), this could impact practice patterns. So would reform that allowed physicians to actually spend the necessary time with patients to form long-term relationships, to discuss treatment options and truly engage in shared decision-making, and to allow for follow-up and adjustments to treatment plans when needed. This sort of reform--that put patient care above procedures, volume, etc--would likely make an even greater impact on patient care and (I think) have a bigger impact on practice patterns.

I learned in medical school that if a patient likes you, they are less likely to sue you. And if you actually sit and talk to a patient--and listen to them--they are more likely to like you. And you're much likely to provide better care, and the care the patient needed.

More information on the ¡Una Vida Sana! project

2011-03-20T22:07:00.000-04:00

As a result of working with Spanish-speaking patients who lack access to preventive care and of meeting health professions students interested in working with Spanish-speaking communities, I helped establish ¡Una Vida Sana! The program allows for multi-disciplinary learning while providing necessary medical screenings.

This slide presentation goes over the project in more detail, and provides some background. As the program develops, we hope to have some additional information (and some research results) as a result.

Una vida sana

View more presentations from RichmondDoc

International Medical Service

2011-03-16T01:19:00.000-04:00

As part of my desire to work with marginalized communities, I have been involved in a number of international medical service projects. In 2010, I presented to the Virginia Academy of Family Physicians on the topic of how physicians can get involved in international medical work.

The slides of this presentation are below, and I am happy to provide further detail in the comments.

International and Global Health Service

View more presentations from RichmondDoc.

What we are celebrating, and what we are still fighting for

2011-03-15T11:16:00.000-04:00

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

--------------------

Next week marks the first anniversary of the passage of the Patient Protection and Accountable Care Act (PPACA). This is a good time to remind ourselves what reforms were enacted in the PPACA.

The Robert Wood Johnson Foundation and the Urban Institute recently released a report (pdf) analyzing how the PPACA increases access to health insurance in the United States. The study used the current (2011) baseline information regarding health insurance coverage, and then modeled the changes that would result if the PPACA was enacted all at once (instead of over the next few years). This allows a more direct comparison of how the law's reforms affect health insurance coverage. Some of the findings:

The percentage of uninsured non-elderly adults would drop by 10.3%, from 18.9% to 8.7%, meaning that more than 27.6 million more Americans would have health insurance under the PPACA. This increase in insurance coverage would be most dramatic in states where people have less access to employer-sponsored insurance and are less likely to meet Medicaid eligibility requirements. This indicates that the PPACA's reforms benefit patients who lack other opportunities to obtain health insurance.
Group health insurance exchanges would cover 8.9% of Americans. The exchanges will have the greatest impact in states with limited access to employer-sponsored insurance and limited access to Medicaid. Therefore, the health insurance exchanges provide an option for insurance coverage in areas where options would otherwise be limited.
Nationally, just over 30% of those covered in the insurance exchanges would have income >400% of the federal poverty level (FPL). These individuals will not receive any government subsidies for their insurance, but would find the exchanges an attractive alternative to purchasing expensive individual insurance in the current marketplace.
The majority of cost-sharing and premium subsidies to help lower income individuals purchase insurance would help people under 200% of FPL. 63% of premium subsidies and 91% of cost-sharing subsidies would go to individuals under 200% FPL, meaning that these subsidies would increase health insurance access to those who are currently lacking it.
Medicaid expansion will enroll just under 5 million people currently eligible for coverage, but who are not receiving it, and 12.2 million people will be newly eligible for Medicaid coverage. The majority of new enrollees will be non-parent adults. These new enrollees will on average have lower health care costs than those adults already receiving Medicaid, many of whom have multiple co-moribd conditions. New enrollees will make up approximately 20% of patients receiving Medicaid, but will only account for 15% of medical costs.

From this analysis, then, it is clear that the PPACA's reforms stand to meet one of the law's major goals: to reduce the number of uninsured Americans. The fact that this law is needed is evident when you look deeper into the numbers: the majority of those who will receive coverage through group health insurance exchanges and through the Medicaid expansion are adults who would be unable to obtain health insurance through other means as a result of low incomes, lack of employer-sponsored insurance, and current Medicaid eligibility standards. These are individuals the pre-PPACA insurance market left out.

Despite the positive benefits of the PPACA's reforms, it continues to be the target of much partisan opposition. Much of this opposition claims that this bill amounts to a government take-over of health care. However, as evident in this study most newly insured Americans will be insured through the group health insurance exchanges where private health insurance companies will sell their products. Although federal subsidies will support people purchasing plans in these exchanges, the coverage will be provided by commercial companies.

The PPACA has already led to significant reforms in its first year, including eliminating lifetime caps and yearly limits on benefits, allowing adult children to stay on parents' insurance plans until age 26, eliminating rescissions, requiring no-cost preventive care, and regulating how much of your premium dollars must be spent on paying for benefits. Once fully enacted, the PPACA will expand access to health insurance to more than 27 million uninsured Americans.

Meanwhile, according to a recent Robert Wood Johnson Foundation report (pdf) there are still approximately 18.5 million adults who will lack insurance coverage despite the PPACA's reforms. Approximately 37% of these are individuals who will qualify for Medicaid but will not be enrolled, nearly 23% will have access to affordable health insurance options, and 24% will be undocumented immigrants. Despite the important reforms embodied in the PPACA, we will need to continue to ensure that those who qualify for insurance are able to take advantage of them and we must review options to insure undocumented individuals have access to needed care.

These needed reforms are worth celebrating, and worth fighting for.

The Individual Mandate is Necessary, and it is Constitutional

2011-03-05T20:26:00.000-05:00

(originally posted on the National Physicians Alliance blog March 5, 2011)

--------------------

Many of the reforms embodied in the Patient Protection and Accountable Care Act (PPACA) are widely popular, even among those who favor repealing the law (PDF; see the chart on the top of page 3). The major reform of the PPACA that is unpopular is the individual mandate. The requirement that everyone purchase health insurance or face a fine is consistently the least popular part of the law, despite the fact that many supporters of the bill feel that it is a necessary step to ensure the law’s health insurance reforms.

The individual mandate has also been the recent focus of the efforts to attack the PPACA in the courts. The law’s opponents, including Virginia’s Attorney General, feel that the mandate to purchase health insurance is unconstitutional. As of now, the courts have been divided on whether this is the case, and whether the mandate can be struck down in isolation or whether the PPACA as a whole would be invalidated if the individual mandate is found unconstitutional. Recently, the New England Journal of Medicine published two articles I think are relevant.

The first article asks the question of whether Congress actually has the right to regulate economic inactivity. The constitutional arguments both for and against the individual mandate focus on the Constitution’s Commerce Clause, in which Congress is given authority to regulate interstate commerce. The argument made in support of the mandate is that everyone will have need for health care at some point, as a nation we have chosen to provide health care largely through private insurance, and the cost of this insurance is increased due to the care provided to uninsured patients. Therefore: if everyone is paying more because many Americans lack health insurance coverage, then mandating health insurance is a segment of interstate commerce. In essence, in this case, choosing not to purchase health insurance (inactivity) is in fact an active choice that ends up costing everyone. Through their article, the authors believe that Judge Vinson’s recent ruling against the mandate is flawed and opposes Supreme Court precedent.

The second article analyzes the individual mandate in more detail, and considers alternatives if it were found unconstitutional when it finally reaches the Supreme Court. The article concludes that although other options exist, it is not clear if they would be more politically viable than the mandate, and replacing the mandate with the listed alternatives would notably reduce the law’s benefits and would destabilize insurance pools that would be unable to turn away patients for pre-exisiting conditions and would be unable to limit lifetime benefits.

The PPACA includes many reforms that the American people support, and those reforms require that all Americans participate in the health insurance system. The lack of participation, by choice or due to inability to pay, costs everyone. The individual mandate, as unpopular as it is, is a key step to ensuring the law’s benefits and its inclusion in the PPACA is within Congress’s mandate to regulate commerce.

Physicians should separate themselves from the pharmaceutical industry

2011-02-19T22:17:00.000-05:00

(originally posted at the National Physicians Alliance blog February 19, 2011)

--------------------

One of the National Physicians Alliance’s guiding principles states: “We place the best interests of our patients above all others and avoid conflicts of interest and financial entanglements. The health of our patients is our first concern.” One of the most evident examples of fulfilling this commitment is the Unbranded Doctor campaign, which aims to remove pharmaceutical company (PhRMA) influence from physicians’ practices.

There are arguments made that not all PhRMA influence is harmful. Some argue that medication samples provide benefits and allow patients to save money. Others–often physicians–claim that speaking on behalf of PhRMA allows them to discuss the benefits of certain medications and treatments (even though deeper investigation indicates that employing physicians as speakers may simply provide another avenue for PhRMA to change phycisians’ prescribing patterns). However, there is research that physicians can be influenced by PhRMA and other industry contacts, and that this influence might not be noted by the physicians themselves. Now, there is a more direct reason for physicians to avoid PhRMA payments: they undercut patients’ trust.

ProPublica and Consumer Reports carried out a survey investigating patients’ perspectives regarding physicians who accept PhRMA payments. The survey indicates that patients are largely unaware of the nature of physician/PhRMA contacts, and 74% of survey respondents disapprove of physicians taking payments for promoting medications to other physicians. Furthermore, 95% of respondents noted that their physicians had not disclosed any PhRMA payments, and 70% thought that physicians should disclose that information (a legal requirement coming soon thanks to the Physician Payments Sunshine Act provisions included in the Patient Protection and Affordable Care Act). Finally, the survey shows that a majority (51%) of respondents felt that payments as low as $500 could influence a physician’s judgment.

As professionals, physicians are held to high standards. These include the obligation to ensure that our recommendations for treatment are free of bias and in each patient’s best interest. Research indicates that PhRMA and industry contacts introduce bias into physicians’ decisions that may not benefit patients, leading one to wonder whether any level of PhRMA or other industry contact is ethical.

Physicians’ decisions to work with or take money from PhRMA is largely unregulated (except by voluntarily codes of conduct) and largely outside the public’s view. In theory, physicians can continue taking PhRMA payments as long as we like. However, we should hold ourselves to a higher standard. We know our patients do.

Why this matters for Virginia

2011-02-14T13:03:00.000-05:00

(Originally posted on the National Physicians Alliance blog February 14, 2011)

--------------------

Since you found this page, I presume you know something about National Physicians Alliance (NPA)'s efforts at the national level to improve access to health care, to reduce the influence of PhRMA and industry on medical care, and to further the causes of fairness and justice in our health care system.

In Virginia, these efforts will be even more important. Our current political leadership did not support the passage of the Patient Protection and Affordable Care Act (ACA; aka "health care reform"). Our current Attorney General, Ken Cuccinelli, takes great pride in the fact that he has sued the federal government to overturn the ACA's individual mandate--a step that will undercut many of the popular insurance company reforms the ACA instituted and that would drastically reduce the law's effectiveness. Meanwhile, in 2010 Virginia’s General Assembly passed a law that aims to exempt Virginians from the ACA’s individual mandate.

It is clear that Virginia, through our state government, will be a battleground state in the current legal challenges to the ACA. It is perhaps fitting, in this 150th anniversary of the start of the Civil War, that we Virginians find ourselves discussing the ideas of states’ rights versus the authority of the federal government. Once again, it will likely be a long and drawn-out struggle, but one that will have a tremendous impact on our nation’s future.

If you would like to work with NPA on these important issues, please join NPA nationally, and please join the local Virginia network focused on addressing these issues in the Commonwealth. Please contact Becky Martin from the NPA (becky.martin@npalliance.net) to let her know of your interest, and welcome to the team!

What does the public really think about healthcare reform?

2011-02-14T12:23:00.001-05:00

(originally published on the National Physicians Alliance blog on February 14, 2011)

--------------------

The debate surrounding the Patient Protection and Affordable Care Act (PPACA) has been marked by misinformation and dishonest rhetoric by those who opposed the law’s passage and who now oppose its implementation. Over the last 6 weeks we have heard much about how much the public supposedly opposes the law, and how anxious the public is to repeal the law wholesale. This is another example of exaggeration, as evidenced in this article. The article indicates that if given only an up-or-down option, more Americans would vote to repeal than to keep it. However, if the polls include additional options, the true public feeling is evident. In one poll, approximately ¼ of those who favor repealing the PPACA do so because they do not feel the law went far enough in its reforms. Another poll shows that approximately 1/3 of Americans would repeal the law, 1/3 would like to expand it, and about 20% would prefer to keep it the same. These results are very different from the current House of Representative’s leadership’s claims that their vote to repeal the law was based on the public’s opposition to the PPACA.

The above article also indicates that the House’s plan to attack the PPACA by de-funding the law is unpopular. In a Kaiser Family Foundation poll, 62% opposed de-funding the law. With that information, it is good to see the PPACA’s reforms being implemented despite its opponents’ rhetoric. Starting on January 1st, provisions providing a boost in Medicare reimbursement for some primary care physicians and general surgeons and a requirement that health insurance plans spend at least 80% of patient premiums on providing care have gone into effect.

As the public and physicians continue to see benefits from the PPACA, the law will become increasingly popular and accepted. In the meantime, it would be nice if the law’s opponents would tone down the exaggerated rhetoric. Both supporters and opponents of the PPACA agree that the law needs adjustments—we should be working together to strengthen the law and ensure access to health care for all.

How would the House replace the healthcare reform they repealed?

2011-02-05T23:06:00.001-05:00

(Originally posted on the National Physicians Alliance blog January 23, 2011)

--------------------

Somewhat lost in the fuss around the House of Representative's actions to repeal the Patient Protection and Accountable Care Act (PPACA) was the fact that the House's Republican leadership actually submitted its own proposal for reforming health care. Last year, now-Speaker John Boehner sponsored an amendment to H.R. 3962 (the "Affordable Healthcare for America Act"). This is currently the only legislation the GOP has submitted to take the place of the PPACA, and therefore it is important to see what this alternative offers.

Fortunately, the Congressional Budget Office (CBO) has completed a preliminary review of the Speaker's proposal. As it currently stands, the supposed replacement for the PPACA will make minimal changes in the current state of the United States health care system. The proposal would reduce insurance premiums in the large group market by 0-3%, and by 5-8% in the individual insurance. The proposed legislation would also reduce the number of non-elderly Americans who lack insurance by 3 million people between 2010-2019 (leaving 52 million non-elderly Americans uninsured).

To do this, the proposal would reform insurance markets by allowing insurers to sell products across state lines. This would allow the state with the most lenient requirements to essentially dictate the market, as the cheapest plans with the fewest benefits would appeal to employers and others attempting to reduce costs. The plan would also reform health spending accounts and work to enact malpractice tort reform.

Nowhere in the plan is there any indication of reforming insurance company practices of denying care on the basis of preexisting conditions, or of ending the policy of rescinding health coverage once an individual starts making use of the coverage they purchased. Nor does the law continue such popular provisions of the PPACA as closing the Medicare Part D "doughnut hole" or allowing parents to include adult children on their insurance until age 26. These are provisions that have broad popular support, and that the Republican-controlled House took away when they voted to repeal the PPACA.
As it stands, the proposed replacement for the PPACA would be laughable if it weren't so sad. The proposed legislation would undercut numerous patient protections from insurance company misconduct while doing nothing to increase access to health care and making minimal changes in the cost of obtaining health insurance coverage.

It's a good thing that the PPACA is still law, and will remain law, despite the House's symbolic vote for repeal. The alternative would be a disaster.

How To Make The Patient The Center Of Patient-Centered Care

2011-01-23T13:39:00.001-05:00

There is increasing attention being paid to the patient-centered medial home (PCMH) as a way to re-focus medical care on outcomes that matter to patients (such as sick days, hospitalizations, death) and less on surrogate outcomes (such as blood sugar control, cholesterol levels, etc). The PCMH is also expected to allow physicians (especially primary care physicians) to spend more time with patients--time for counseling, care coordination, discussion and education surrounding medical problems, etc. At this point, the National Committee for Quality Assurance (NCQA) is the organization that accredits medical practices as fulfilling the principles of the PCMH. However, a review of their principles shows that in order to qualify as a PMCH a practice must meet a number of expectations, most of which involved new or improved technology (electronic health records, e-prescribing, patient registries and databases, etc). Although there are other expectations, and the technology expectations themselves have understandable reasons for existence, there is no discrete description of what a patient's experience in a PCMH should be like.

This morning, I saw this article from the American Medical Association's Journal of Ethics Virtual Mentor website. It is a few years old, and predates the current push for the PCMH, but is worth noting because the principles listed here are key to truly patient-centered care. If health care providers follow these 10 rules, patients will get better care that is truly focused on their needs--patients will actually be the center of care.

The 10 points are:

Be on time. If you aren’t, apologize. If you know you’ll be late, notify the patient. Doing so tells the patient that you respect his or her time.
Find a way to touch your patient; the simplest way to do this is to shake hands when you enter the exam room. Look the patient in the eye when you shake hands. Maintaining eye contact throughout the visit conveys sincerity and honesty.
Be interested in what your patient is saying—she can tell if you are faking it. Cultivate curiosity about how this patient is different from other patients.
Communicate. Lack of communication is the most common complaint patients have about their physicians. This does not just mean talking—it also means listening. Being an active listener and responding to patients and their families is a vital skill. Effective communication includes explaining tests and diagnoses with patients in plain English.
Learn to appear relaxed and not in a hurry. In situations of illness or crisis an aura of calmness goes a long way. It shows patients that, at the moment, their care is more important to you than the next patient.
Never refer to a patient by a diagnosis. Patients are individuals, not loci or hosts for disease. Do not tolerate others’ use of such terms; such usage reinforces a service-oriented culture and makes the patient-physician relationship less personal.
Convey a sense of warmth. This can’t be done without smiling. Endeavoring sincerely to establish rapport with patients helps put them at ease.
Be mindful of how often you interrupt. Studies have shown that the physician usually interrupts the patient less than 20 seconds into the patient’s side of the dialogue.
The needs of the patient must come first. This means you have to put aside your own prejudices and biases to help the patient. This clinical encounter is for the benefit of the patient—not the physician.
The "platinum rule" of medicine is: treat every patient the way you would want a member of your family treated. A twist on the “golden rule,” it is one of the best ways to be aware of the needs and fears of our patients.

More than just good principles of patient-centered care, these 10 rules are key to effective and successful medical care, period. They allow physicians and patients to develop therapeutic relationships that will address the patient's health care needs.

Ever since medical school, I have carried with me a list of ten key rules on how a physician should practice--something I have previously blogged about. The ten rules listed in this Virtual Mentor article will be companions to those first ten. They will remind me (and the students I teach) of the most important part of patient care: caring for the patient.

Do You Have Any Guns In The Home?

2011-01-18T11:51:00.000-05:00

If this Florida legislator has his way, asking that question could cost up to $5 million and/or 5 years in prison. I presume this is at least in part a result of the recent calls for increased gun control in light of the shootings in Arizona just over a week ago.

The legislator who introduced the bill has built his argument upon his worries that physicians who ask about guns in the home will report this to the insurance company, who could report them to the government, who then could come after your guns. This argument is flawed: most docs who ask about guns do *not* report that to the insurance, and therefore the chain of feared consequences is never even begun.

So: why would physicians ask about guns in the home? A few quick examples:

If there are children at home, a physician could ask about guns in order to discuss safety, accident avoidance and proper gun storage. Evidence is clear that guns are much more likely to kill a family member than an intruder, so asking about gun safety and storage is a necessary part of well-child care.
If someone is suicidal or homicidal, the presence of a gun in the home increases the risk of completing a suicide attempt or severely harming (or killing) another person. If a gun is available, then a mentally ill person has much more probability of hurting themselves or others, and a physician would be ethically and legally bound to approach that person's care more aggressively in order to avoid that harm.
If one person in household is being abused by another, the presence of a gun would increase the potential lethality of the situation. A physician may need to know this information in order to provide the necessary guidance to the victim of abuse in order to see to their safety and protection.

Physicians have legitimate and necessary reasons for asking about the presence of guns in the home. This law, as proposed, would severely undercut doctors' ability to care for their patients and could penalize what most would see as proper medical care, and would place more government controls on what can be discussed in the privacy of the doctor/patient interaction.

Let's hope this bill ends up in the trash pile, where it belongs.

Is There A Right To Health Care?

2011-01-18T11:30:00.001-05:00

As part of an online community, a colleague presented this article to the group in order to further discussion and debate of the issues surrounding health care reform. The article aims to discount claims that there is any sort of right to health care.

Not surprisingly to anyone who reads this blog, I disagree. I'm posting my reply below.

------------------------------

This might not surprise anyone, but I find the article less than compelling. If anything, the author has noted that England's approach to universal health care isn't idea, but he has not shot down the idea of universal health care overall. In other countries (and in certain communities in our country), universal coverage is provided in ways that make health care available to all: there is England's national system, Canada's provincial systems, Switzerland (where everyone has coverage via an individual mandate and tight regulation of insurance company practices and profits--sound familiar?), Germany's combination of private/public coverage, Medicare (which dramatically changed the lives of elderly Americans), the Veteran Administration system (which some argue is among the best systems in America), etc. The one question that can be fairly asked is how universal coverage should be paid for, but there are multiple arguments that the coverage can be provided.

From the standpoint of whether there is a right to health care, I don't think the article's author really, honestly addresses the question. This is a complex question, and one that seems glossed over as the author moves on to attack the means of delivering universal care (as opposed to the perceived right to access care).

A few points:

The rules of medical ethics can be used to argue that access to health care should be available to all: the principles of beneficence, non-maleficence, justice, and autonomy would suggest that a) access to care is good; b) lack of care is bad; c) it is unjust that some have access to care while others do not (often for reasons that are not in their own control); d) one cannot be a fully autonomous individual if one is not healthy.
Religious guidelines can also be used in favor of the right to access: so much as religious faith compels one to help those less fortunate and to provide aid to the ailing, then faith can guide a right to health care. The argument could be made whether such care should be provided in faith-based institutions, charitable organizations, or through government programs, but any faith that concerns itself with caring for the ill and the poor would have a hard time claiming that access to health care is not a right.
Civil institutions can be used to argue for a right to health care: If we are seeking rights to "life, liberty, and pursuit of happiness", it is easy to argue that one cannot have any of the three if one does not have health as a necessary precondition. The connection of health to life and the pursuit of happiness is clear, but is also applies to liberty. How can anyone be an active citizen and take advantage of our cherished liberties if one is not in good health?
Philosophical constructs exist that suggest that as individuals and as societies we should be working for the greatest good for the greatest number. Kant's categorical imperative states that each of us should act in ways that we would like to see become universal law. In this context, the argument I could make is that a)if we all agree that health care is a good thing, then b) we should seek to make health care available. I think the argument could again be made as to the best way to reach that goal, but I think the goal itself can be easily agreed upon.

Regarding the author's question as to why a right to health care didn't exist in 250 BCE or 1750 AD, a quick answer could be this: in those years, medicine had fewer proven benefits and engaged in practices that actively caused harm (bloodletting, laudanum for anxiety, etc), whereas today's medical practice offers a much stronger balance of benefit vs. harm. The argument could be made that increased access to medicine in the 1500s hurt more than it helped--maybe that is why societies did not seek to establish that harm. Of course, in those years one could be enslaved and treated as chattel: maybe our society has advanced and moved forward to a more enlightened place?

Regarding other needs that the author addresses--food, shelter, clothing--many of us feel that there should be mechanisms to assure at least basic needs in all three areas. Even if one does not feel that way, though, I would argue that good health is a necessary precondition for meeting these other three needs. So in that perspective, health (and, by extension, access to health care) is a primary need for all.

I apologize this has run on for a while, and I thank anyone who has read this far. I am not a philosopher, and so I am sure that I haven't been 100% on-target with my statements above--please feel free to point out if I am in error.

The author of the article argues that there is no right to health care because he believes that there is no right to health care. He doesn't back up his claim in any meaningful way, and chooses to attack the *right* to health care by focusing on problems with the *delivery* of health care--two very different arguments.

------------------------------

If anyone who reads this would like to point out flaws in my argument or take a different position, please do. I really do think that engaged, intelligent, civil discussion is an important part of our democratic process. Please comment!

Physican Educators Should Avoid PhRMA Contacts

2010-12-21T23:00:00.001-05:00

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

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

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

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

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

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

Repealing the PPACA Could Harm Vulnerable Communities

2010-11-28T16:16:00.000-05:00

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

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

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

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

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

AMA Guidelines on Physicians and Social Media

2010-11-28T15:45:00.000-05:00

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

How Popular Is Repealing Health Care Reform?

2010-11-07T13:47:00.000-05:00

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

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

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

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

Busy Saving The World

2010-10-22T22:59:00.001-04:00

(tongue firmly in cheek)

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

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

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

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

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

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

Health Care Reform's Six Month Mark

2010-09-21T00:49:00.001-04:00

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

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

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

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

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

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

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

APNs, Midwives, And Physicians

2010-09-11T20:19:00.001-04:00

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

********************

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

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

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

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

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

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

The Social Contract

2010-09-11T18:25:00.000-04:00

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

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

Societal expectations of physicians:

The services of the healer
Guaranteed competence
Altruistic service
Morality and integrity
Promotion of the public good
Transparency
Accountability

In return, physicians expect the following out of society:

Autonomy
Trust
Monopoly
Status and rewards
Self-regulation
Functioning health care system

I think that in an ideal situation, these agreements and stipulations make sense. In essence, society expects to have competent and trusted healers who put patients' well being at the forefront, who will be open and accountable for their actions, and who work toward the greater good. Meanwhile, physicians expect to be given trust and freedom to work individually within a viable health care system, to regulate themselves, and to be given both tangible and intangible rewards for being the sole providers of designated health care services. If both sides of the agreement were being lived up to, then this construct would make sense. But I fear that part of our current health care issues (costs, access, etc) result from each side's reneging on this contract.

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

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

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

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

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

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

How Can We Continue Defending The Status Quo?

2010-09-02T00:01:00.000-04:00

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

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

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

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

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

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

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

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

Join The NPA!

2010-08-26T21:20:00.000-04:00

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

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

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

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

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

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

Oh, By The Way...New Blog!

2010-08-17T23:01:00.000-04:00

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

A Pause, And A (Somewhat) New Beginning

2010-08-17T22:39:00.000-04:00

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

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

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

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

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

Yes, PhRMA Can Be Considered A Bad Player

2010-08-15T18:46:00.000-04:00

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

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

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

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

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

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

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

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

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

Some Further Thoughts On Healthcare Communication and Social Media

2010-08-06T12:10:00.000-04:00

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

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

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

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

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

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

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

It Is A Privilege To Be A Physician

2010-08-05T23:44:00.000-04:00

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

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

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

"What is at stake here may seem a small thing in the face of the enormous health care world you have joined. It is as a nickel to the $2.6 trillion industry. But that small thing is what matters. I will tell you: it is all that matters. All that matters is the person. The person. The individual. The patient. The poet. The lover. The adventurer. The frightened soul. The wondering mind. The learned mind. The Husband. The Wife. The Son. The Daughter.

[...] Those who suffer need you to be something more than a doctor; they need you to be a healer. And, to become a healer, you must do something even more difficult than putting your white coat on. You must take your white coat off. You must recover, embrace, and treasure the memory of your shared, frail humanity--of the dignity in each and every soul. When you take off that white coat in the sacred presence of those for whom you will care--in the sacred presence of people just like you--when you take off that white coat, and, tower not over them, but join those you serve, you become a healer in a world of fear and fragmentation, and "aching" world...that has never needed healing more."

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

2010-07-31T13:47:00.002-04:00

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

********************

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

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

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

The NPA describes the roles of LANs as:

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

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

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

Thanks for your time.

mark

Don't Let The Liars Deceive You

2010-07-26T22:06:00.001-04:00

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

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

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

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

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

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

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

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

Don't let the liars deceive you.

Drug Samples Are Bad Medicine

2010-07-10T13:22:00.000-04:00

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

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

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

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

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

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

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

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

Differences of Opinion (Part 1?)

2010-07-04T12:41:00.000-04:00

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

**********

Dr. L:

For me the real issue is that everyone counts on someone else paying for health care.

Healthcare is not a right. We all have the right to be as healthy as when we were born.

I know I will get tons of replies grilling me for that stance, but so be it.

As an immigrant, I am concerned that in the greatest nation in the world we have so many rights and entitlements, and NOT A SINGLE DUTY. And now we want to add healthcare as a right!

Healthcare is a privilege like driving is a privilege. Could you imagine if driving was a right? I could be as drunk as I wanted and get in a car and crash into anyone regardless of consequences, because it is a right?

Most of the cost of healthcare is for chronic and preventable diseases and the morbidities that it brings. Most of these issues could be prevented by better choices and better public policy. But I am a doctor, not a policy maker.

I embrace freedom of choice. But why should I pay for the consequences of your freedom to be irresponsible?

I was raised with simple values, one of which is “be responsible for your actions”

The central issue is that there is no Personal Responsibility, and then the masses want someone else to fix the problem.

Dr. S:

OORAH! Well said, Dr. L! We must all admit the truth here!! Health care is a privelege, NOT a right!

Again, I will come out of 'hiding' and say what I think a lot of us here realize probably has to happen. GET THE GOVERNMENT OUT OF HEALTH CARE. It is the only real way for any reform to occur. This whole thing is going to be bad no matter what we do, but it will only get worse if we go toward more government regulation(e.g., single payor system, Obamacare, etc...). At least if people are given back the responsibility for their own health care, then they can realize that they have more choices to make (hopefully healthy choices). Again, thank you for saying this.

Me:

Dr. S:

Just asking: if you end govt roles in health insurance

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

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

Dr. S:

Dear Dr. R,

It depends on how much of the 'government' you get out of health care. Here would be some starting thoughts (and these are rudimentary, by the way):

If we still require public institutions to not turn away anyone for care, then the poor will continue to access these facilities as they do now. This, in my opinion, is the 'myth' of access to care that everyone seems to believe. EVERYONE in this country, including those who are not even citizens, cannot, by law, be denied access to care and at least a screening physical exam in a public facility.

If we eliminate Medicare and Medicaid, then I would hope that we eliminate their pay system as well. In which case, we would then have the potential for a true 'free market,' and I would think that if hospitals, health care providers, etc... didn't have to have as much administrative costs, then we would already be able to offer care at a lower rate (or even at what Medicare and Medicaid reimburse now). Their would be competition for patients that would take the form of price reductions - this already happens with 'elective' procedures, such as LASIK, for example. It would take a little time, but one would logically think that health insurance companies would have to lower their rates or be priced out of the market by individuals being able to get their care for less money than what they pay for their health insurance premiums.

What about health care consortiums? I know of some groups of people agree to pool their money to pay for everyone in the group - I think one is called the Christian Health Care Alliance(?)

If you take a look at history, you will note that the Church set up many hospitals all over the country to take care of the poor. Why not allow them to do this again??

Could we incentivize people to practice good health habits?? For example, could we pay people to lose weight (sort of like the "Biggest Loser" competition?). Could we somehow incentivize people to stop smoking or drinking, or doing drugs? This could be positive incentivization or negative incentivization -- I would even be so bold as to say that if we are going to deny care to anyone, the first group to be denied care would be known alcoholics, known drug addicts, and even smokers. That would certainly make them at least consider changing their behavior.

I once asked one of my attendings during residency who practiced before 1964 (before Medicare and Medicaid) in a major metropolitan area (>300,000 people) how the poor and disadvantaged got care at that time. He said that in the city hospital, there was a "City Ward" where these people were cared for, and the doctors on staff in that community rotated through the service to care for these people. Why can't we do something like this for the poor and disadvantaged?

It's true, we will always have the poor -- but isn't there a way to incentivize people to NOT be poor?? If America is truly the land of opportunity, then this would certainly be possible.

Much of this depends upon the individual person's sense of responsibility, civic duty to his/her country, and living up to our motto of "In God We Trust." Maybe it's time the citizens of this country took these matters into their own hands, instead of giving this responsibility to the government.

It has taken us 46 years to get to this point -- how can we expect to reform it in 46 months, or even 46 days??

This situation is going to be bad either way (whether we have more governmental intervention or less) - I submit to you and to all of my collegues on this list serve that if we get the government out of medicine, it will be bad for a shorter period of time as the market rights itself, than if we allow more government intervention into health care -- my belief is that this new system will probably be really good for about the first 10 years or so, and then it will become corrupted (just like Medicare and Medicaid already have), and then we will be paying higher and higher taxes, and getting essentially NOTHING for it. AND giving up more and more of our freedoms as the price - something one cannot even place a price tag on is freedom.

Stuff that I believe we ALL need to be seriously thinking about right now as this whole mess of "Obamacare" that has been forced upon us by a minority of elitists presumably goes into effect.

Respectfully and in the spirit of compassionate care for our patients as a fellow Family Physician,

Me:

Dear Dr. S;

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

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

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

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

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

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

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

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

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

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

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

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

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

Sincerely,

Dr. S:

Dear Dr. R,

Thanks very much for your thoughtful reply. It is these sorts of conversations that I hope to have on this subject - I truly believe they are meaningful if any sort of reform is to occur. I just have a few minutes here, so I want to reply to a couple of your concerns:

I want to say that anybody that comes into the ER gets a basic medical evaluation because I worked ER for four years, and I WAS the one who did the evaluation - this was in rural ER's where I was the contract doc on call, and there was no mid-level coverage. I also worked in a major city hospital ER as the 'pit boss' overseeing at least one PA - again, everybody got a basic evaluation and at least the emergent care they needed.

I agree that chronic care is very much needed by patients, but in my opinion, there are some of what I would call 'major categories' of patients that come into an ER (and arguably, that come into my office even at the present time): 1 - those who want care, but really don't need it, 2- those who need care, but really don't want it -- or really don't want the care that we deem they need, and 3 - those who need care and want what we can provide. Yes, these are arbitrary distinctions, but my point is that the term 'access to care' is really more complex than I feel we make it out to be.

My question to you (and anybody else that may be reading on this list-serve) regarding allowing so-called 'faith - based' organizations to provide care is: we are already having problems with entrusting the care of our most vulnerable citizens (BTW, how do you define who our most 'vulnerable' citizens are?) to the government -- would we do much worse to let these organizations have a try at it??? If nothing else, these organizations could ease the burden on the public facilities, such that people would then have more of a 'choice' as to where they feel comfortable getting their indigent care. I mean, what about the Shriner hospitals??? With respect to these organizations, it would be implicit that physicians, nurses, support staff, etc... would be donating their time or at least agreeing to take a lower pay scale to care for these patients.

By stating that I would want to incentivize the poor 'not to be poor,' I'm not implying that there are people who hope to be poor (however, the nuns and Mennonites I have met have in effect chosen this lifestyle). These people are often poor because of the choices they have made, or choices that their significant others have made (or not made) -- or quite commonly, because of mental illness.

Just some starting thoughts... more to come.

Respectfully,

Me:

Dr. S;

To continue our previous conversation--

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

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

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

Sincerely,

Dr. S:

Dear Dr.R,

Thanks for the reply. I'm on call, so only have a few minutes, but I want to hone in on a couple of concepts you presented, and hopefully not get on an unproductive tangent...

1. What is the difference between 'triage' and 'discrimination' in the context of healthcare?? I mean, one draws an intellectual (if not philosophical) line when we are determining who is sick, and needs emergent medical care, and those who are not 'ill' and really don't need the care that they think they need... i.e., the alcoholic who is not physically ill enough to need inpatient treatment for DT's, but who desperately needs treatment for his/her anxiety disorder, and frankly doesn't want it??

2. The term "patient-centered" care needs to be 'fleshed out' here -- some of this will depend upon one's (both the patient's and the physician's) 'world view,' but I would maintain that if so-called 'faith - based' orgainizations held as their rule to treat or not treat a certain kind of condition in a certain way that is consistent with their 'mission statement, or bylaws' then they would certainly be free to do so. There are already biases in our current health care system anyway - you could argue this to the moon. It's still a free country (thank God). You are also touching on a huge issue with contraceptive services - I agree that it should be patient - centered, but I am also implying here that this would include adequate education of the patient with respect to ALL available choices, including non-hormonal therapies, and non-abortifacient methods, etc... Again, a potential HUGE tangent, but there are many more than these.

3. I appreciate your further analysis of the 'vulnerable populations' -- my next question would be "vulnerable to what??" Alternative medicine? Alternative beliefs? What about appropriate treatment, and a caring atmosphere that maybe some of them (particularly the children) have not as yet experienced? Just being in our American society and pop culture, these people are already vulnerable to very damaging behaviors being represented in the media - is exposing them to a Catholic (or Protestant, or Jewish) hospital that much more damaging than what probably many of them have already seen?? I'm not sure what the answer in all cases is here, but I trained in a Catholic Hospital, and I certainly felt that the care was of the highest quality and the atmosphere was most certainly a caring one - and certainly at par with the University Hospital, VA Hospital, IHS hospital, and community hospitals in which I had worked as a medical student and in practice.

Anyway, some more thoughts....

Respectfully,

Me:

Dear Dr. S;

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

To address your most recent comments:

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

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

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

**********

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

Salaried Physicians: Effects On Health Care?

2010-06-27T17:58:00.001-04:00

Just saw a couple of New York Times articles, looking at the trend of physicians moving from private practice and into salaried positions. The first is nearly a year old, and discusses the benefits of the trend for many physicians. The benefits for many doctors is the ability to focus on medical care and less on business needs, while health systems (and maybe health care overall) benefit from lower costs that result from less duplication of services, (maybe) fewer tests and visits, and better doctor-to-doctor communication. The second article is more recent, and discusses the continued trend as well as noting that salaried physicians tend to be more politically liberal.

The articles note the benefits to entering a salaried position: stable hours, focusing on medicine vs. business, etc; they also comment on some of the downsides: likely lower salaries when all is said and done, less individual say in practice policies, etc. However, more and more young physicians are concerned about loan burdens and work-life balance, and the stability and reliability offered by a stable salary can be very appealing.

The second article does not discuss the leftward shift in physicians' politics once they become salaried in great detail, and doesn't provide much support to the claim. But it is interesting to consider the future if the proportion of salaried physicians keeps increasing. Is it possible that ideas such as a public option or a single payer system could gain further strength and additional support within medical organizations heading forward?

Upcoming Events

2010-06-27T01:20:00.000-04:00

On July 1st (next Thursday), Virginia's Attorney General Ken Cuccinelli goes to court to defend his lawsuit alleging that the recently enacted Affordable Care Act (ACA) is unconstitutional. As Cuccinelli tries to ensure that millions of Americans remain without true access to medical care and health insurance, activists will gather outside of the federal courthouse to ensure that the law's newly established patient protections and insurance regulations will be preserved.

I have been asked by the Virginia Organizing Project to say a few words regarding the benefit that I see this law will bring to patients in Virginia. I thought I would jot some notes down here, and start organizing my thoughts:

--First, as a physician who cares for a large proportion of uninsured patients, the reforms enacted by the ACA will ensure that patients will be able to secure health insurance and access health care. I have had to work with far too many patients whose medical problems have been uncontrolled--sometimes to the extent of threatening life or limb--because they have not been able to get routine and regular medical care. The ACA will start providing access to insurance to uninsured people as early as this year, with access expanding over the next five years as the health insurance exchange is developed. Also, small businesses start receiving tax credits this year in order to defray the cost of providing employees health insurance. Finally, young adults will be able to stay on parents' policies until they turn 26, thereby ensuring that these young people can extend their education and/or begin their careers without having to worry about securing affordable health insurance at the same time.

--The previous administration enacted a Medicare Part D drug benefit program for seniors, but in order to hide the true cost (which was inflated by the law's requirement that Medicare could NOT negotiate for lower prices from drug manufacturers) the benefit included a "donut"hole. This gap in coverage made seniors 100% responsible for their medication costs after reaching a certain level of expenses during the year, and the gap continued until patients reached a level of out-of-pocket costs deemed to require further assistance. This gap complicates medical care, as seniors' drug costs shoot up during the donut hole and many have significant difficulties managing this sudden increase. The ACA will start to provide some help in the form of $250 rebate checks this year, but the donut whole will start to close and continue closing until it is fully done away with.

--Health insurance reform will ensure that insurers actually have to provide health care to patients who carry their policies. The policy of recissions, where insurers could drop your policy for any reason (even an honest mistake) despite the fact that you had paid up your policy will be eliminated. Pre-existing conditions will be ended. Insurers will be required to keep a certain medical-loss ratio, meaning that they will have to spend 80-85% of policy premiums (YOUR payments to the company) on providing health care--not salaries, bonuses, etc. Preventive service coverage will be expanded, allowing patients to seek screening and health maintenance services and hopefully stop problems before they fully start.

--The ACA provides additional funding to public health, coverage for rural health care services and tax relief for health professionals working in underserved areas. These services play critical roles in some of our nation's most isolated and/or economically marginalized communities and we desperately need to strengthen their ability to continue in these key roles.

These things are all scheduled to begin in 2010 and early 2011. Over the next 7 years the law will see its full effects and I think that the nation, and patients as individuals, will be better off.

And I hope Cuccinelli's windmill-jousting ends next week.

Common Themes

2010-06-07T16:36:00.002-04:00

Currently I am in the Dominican Republic, part of a 12-person medical service trip whose aim is to provide care to marginalized communities in Santo Domingo. We have just finished 4 days of work in Paraiso, just north and west of town, and are taking a day to rest and reorganize prior to shifting our worksite to Los Mina, a neighborhood that merges into a shantytown hugging the banks of one of the city’s rivers.

When here, a few different things always strike me. One is the fact that underserved communities face similar obstacles to care all around the world. There are differences in degree and in quality, but common themes visible anywhere people lack necessary care:

--Inadequate medical workforce: healthcare systems are most efficient and have the best outcomes when primary care is a strong component of the system. In inner city and rural America, as in Paraiso or Los Mina, primary care is notably absent and patients lack access to efficient and available primary care services.

--Importance of community determinants of health: whether it relates to unsafe neighborhoods in the US that keep our families and children from exercising and being physically active, the absence of sources for healthy foods (too many fast food restaurants and not enough fresh veggies and fruits), or a lack of potable drinking water and prevalence of parasitic stomach infections, individual health is heavily dependent on the broader community’s obstacles and resources.

--Improper healthcare interventions: in the US we tend to have an over-reliance on high tech interventions, whether medications or advanced testing and imaging studies—even if these interventions do not actually improve health. In Paraiso, many patients seek care in more expensive private health care facilities and are prescribed expensive or unaffordable tests and medications. In each case, the cost to the individual and (if insured) to the system is very great even though the actual outcomes are no better for the investment. Alternative options—focusing on preventive care, wellness, and health maintenance would stand to provide a better return on investment but do not have the necessary influence or awareness to change general practice patterns.

--Those who are powerless lack influence: a self-evident statement, but one that needs to be noted. Many of those living in Paraiso and Los Mina are squatters, lack title to their land, and are largely disconnected from the political system. Similarly, minority and poor communities in the US (that make up the majority of our underserved communities) lack political heft and influence. Without this influence, communities are hard-pressed to effect change on their own behalf. Community-identified leaders (whether the official government leadership structure or influential community members) can work to organize the community to try and effect change, but to make change sustainable is very difficult when individuals are just barely making ends meet. By partnering with communities in ways that identify and support their own resources and by providing assistance in ways that empower the community without imposing an outside agenda, it would appear to be possible to start creating structures that can have meaningful and sustainable results.

I suspect more commonalities will become evident as I reflect more on this trip. I know that many of the experiences I have had and skills I have learned in rural and urban underserved communities stateside stand true in the Dominican Republic, and vice versa. I hope that by my direct action, and by teaching students and working with communities, that a greater good can be advanced.

It Will Take Community Action To Improve Health For All

2010-05-23T14:49:00.000-04:00

I've been traveling a lot recently, both a faculty development workshop focusing on working with underserved communities and to the world conference of family doctors (WONCA) conference. As a result, I have a number of ideas bouncing around in my head as to how I can act to improve medical students' willingness and ability to provide care to marginalized communities but also how to work to provide care to all who need it--in the US and abroad. Realizing that my direct impact will never be as great as I might like, it's still necessary to keep trying.

As a result, I'm posting 2 links here that will probably influencing a lot of my thinking over the next few weeks:

--The first link shows the interplay of individual factors that affect health with social and community impacts and broader socioeconomic factors. Each circle/level is acted upon by the levels outside of it, meaning that one can never fully address the health of the individual without also addressing the broader societal factors that lead to poor health outcomes. How can we effectively target diabetes or high blood pressure when patients live in communities with poor access to nutritious foods, regular exercise, good education and jobs that provide for their individual and family health and well-being?

--This second link opens a table describing a new way to conceive of health care, as a social justice issue, not a market based issue. If we agree with this new description of health (which really doesn't seem new at all, but rather a return to essential precepts of health and health care), then it would call for significant changes in our health care system: more primary care, more wellness and preventive care, but also more action on the broader societal determinants of health referenced above.

2 thought-provoking ideas. I hope that they take hold, as I feel our patients, our nation, and our world will be better off if these became our standard-operating procedure.

A Corollary

2010-05-02T22:24:00.000-04:00

A few days ago, I wrote a post about the need to reinvigorate primary care.

This study shows the critical stage of primary care as of 2008--prior to the new health care reform that will expand health care availability. Pretty sad to think that over 1/4 of physicians interviewed would choose non-medical careers if given a chance to do things over.

Letter to the Editor, Virginia Free Press

2010-05-01T00:07:00.000-04:00

Just a quick note that I had a letter published in the Virginia Free Press. No surprise, it's about health care reform. The content probably won't surprise you, either:

***************

With all the noise, hot air and controversy concerning the health care debate over the last year, it is no surprise that folks might not know what the recently passed health care legislation actually includes.

As a physician, I am concerned that many people believe the “sky is falling” scenarios that they are hearing about the health care bill. My primary concern is the health of my patients, and making sure they understand their health care options are of key importance. My job is not helped by the misinformation that abounds concerning the recently passed legislation.

As I tell my patients, in the next six to nine months the health care law will have immediate benefits
that may directly affect their access to health care. The law will allow access to insurance for uninsured patients with pre-existing conditions and will eliminate pre-existing condition restrictions for children. Small business tax credits will be made available for purchase of health insurance. There will be $250 rebates for seniors caught n the Medicare Part D doughnut hole. The bill will immediately end cancellations of coverage and eliminate lifetime limits. Adult children can stay on parents’ insurance plans until they turn 26, making insurance available as they begin their professional careers or extend their education. Insurance plans will be required to provide key preventive and
wellness services. Finally, this bill will strengthen public health and community health centers to improve care to many of the most vulnerable Americans and will start addressing
the looming shortage in primary care physicians to care for the newly insured.

Once you get through the misinformation, it is honestly not a bad six to nine months’ work.

***************

Doctor Or Administrative Assistant?

2010-04-29T22:05:00.001-04:00

It is currently estimated that by 2025 there will be a shortage of nearly 46,000 primary care physicians in the United States. This is of critical importance, considering that 32 million more Americans will receive health insurance coverage under the new Patient Protection and Accountable Care Act (PPACA), and they will need physicians to provide their care.

Primary care (family medicine, general internal medicine and general pediatrics) comprises the specialties that provide preventive and wellness care to avoid future illnesses and that deal with undifferentiated complaints and help determine the best approaches to diagnosis and treatment. It's not that other specialties don't do that to some extend, but it is the foundation of what primary care physicians do. Health care systems that are strong in primary care tend to provide better care for less cost.

It is even more concerning, then, that so few United States medical students are interested in primary care careers. This article in the New England Journal, and this associated commentary from the New York Times, show some of the reasons for this

The article shows that this practice's physicians saw an average of 18 patients per day. This is what most of us went to medical school for: to provide care for patients. Beyond that, though, physicians handled nearly 24 phone calls daily, 20 lab reports, 17 e-mails, 12 refill requests, 11 imaging reports and 14 consultation reports. This is also appropriate (mostly) because these directly affect patient care. (I say mostly because a large portion of the phone calls involve insurance company authorizations, etc).

The problem: administrative and paperwork requirements far outweigh the patient care. For the 18 visits, there were nearly 100 other tasks to be accomplished. An even greater problem: physicians are not paid for those 100 non-patient-care tasks. So, in this practice the non-reimbursed services outweighed the income-generating services by 5:1.

I suspect most physicians did not enter medicine to make a lot of money. There are other better, easier, more lucrative careers IF one is only seeking higher incomes. However, medical practices cannot stay open to provide medical care if they cannot pay the bills.

We desperately need to bring medical students into primary care careers, and there are many ways to do this. However, we also need to fundamentally change the way that health care is provided and reimbursed. Articles like those noted above show some of the challenges; now we need to look for solutions.

We need to return focus on the patient, on the heart of what makes medicine such a challenging and rewarding profession. We need to find ways to de-emphasize these non-clinical tasks OR we need to decide that these tasks are necessary to provide care and we should reimburse for them. Health care delivery models such as the patient-centered medical home (PCMH) would account for this and allow for reimbursement of asynchronous care (care when the patient is not directly in the office).

Whether with the PCMH or another innovative model of care, we must reinvigorate our nation's primary care workforce--both to make the PPACA successful, but also for the better health of all.

Decalogue

2010-04-26T23:53:00.000-04:00

In medical school and residency, all of us are vulnerable to influences that will color how we practice and how we approach patients and medicine for the indefinite future. I tell students that their practice style will be based on things they saw preceptors and teachers do that they choose to emulate, and an active avoidance of things with which the student was uncomfortable.

In school, I read the following comments by G. Gayle Stephens, M.D. Dr. Stephens was one of the early proponents and defenders of Family Medicine when the specialty (then know as Family Practice) was developing out of the previous general practitioner (GP) model. I found these ten points spoke very deeply to me, and I have tried to use them as guideposts along the way. I cannot claim that I was always successful, but I do believe I have done my best.

A Decalogue for Family Practice Residents Entering Practice--G. Gayle Stephens.

Don’t give up the reform ethos. Keep on the side of responsible change in education, practice, and social justice.

Don’t lose faith in the power of relationships and the therapeutic use of self. (Or, don’t hire anybody to save you from spending time with patients.)

Don’t turn your practice into a mere business. It may not be less, and it should be a great deal more.

Learn to distinguish between uncertainty and ignorance; only the latter is remediable and potentially culpable.

Find some way to practice charity; i.e., willingly give a part of your services consistently to those who cannot pay.

Try to see that the groups in which you hold membership are at least as moral as you are.

Humanize and personalize the Microsystems in which you work.

Act at all times as if the patient is fully autonomous; the weaker the patient is, the more vulnerable you are to violating his/her personhood.

Reflect on your professional experiences. Within the bounds of protecting patients’ privacy, think, talk, and write about your clinical stories.

Worry less about patients becoming overly dependent on you than about your becoming undependable.

With the increased stresses likely to result from the Patient Protection and Accountable Care Act (PPACA) and as new systems of health care delivery and payment are tested and enacted, I think this ten points will continue to show the way to be a good physician in difficult times.

Empathy

2010-04-24T22:46:00.001-04:00

If you ask people what they want in a physician, most people will list a few key characteristics. Usually, these will include knowledge and competence, availability, and empathy and compassion.

It's distressing, then, to read that medical students start to lose empathy as early as their first year of medical school. Empathy scores fall off after the first year, and then take another step down at the end of the third year after completing clinical rotations. In the first case, this is apparently due to the stress and hardship of med school. In the second case, the researchers think that this is related to the fact that hospitalized patients are sick, that the work can be hard, and that teaching physicians are rushed and may not provide the mentorship and teaching students were hoping for. The drop after 3rd year might also be impacted by the fact that students care for patients whose illnesses can result at least in part from choices they have made: smoking, substance abuse, obesity, etc.

It is difficult to put in 2 long and hard years of classroom learning to prepare yourself for clinical rotations. It is even harder to adjust to the fact that some of the patients you care for on the wards are there in part because of what they did to themselves. I suspect it is easier to be empathic when caring for a child with cancer or an older patient who broke a hip in a fall then someone shot by a rival gang member or a lifelong smoker with end-stage emphysema.

This is a shame, because most students enter medical school with a strong desire to help others and a wish to make a difference for the better in peoples' lives. Reading medical school applicants' essays reveals a group with great hope, energy and passion to enter a healing profession. To see this energy start to lag within a year is troubling.

Some students fare better than others. Women sustain empathy better than men, and students entering primary care and generalist specialties do better than those who enter Radiology and Surgery. But it is evident that our medical education system has to do better.

There are ways to address these concerns. At VCU School of Medicine, Project Heart matches students with mentors who help work through these issues during the pre-clinical years. The Foundations of Clinical Medicine teaches clinical skills in the M1 and M2 years, but also teaches how to work with patients and how to handle difficult situations. I don't know how VCU School of Medicine compares to other schools, but I am glad that this problem is recognized and is being addressed.

There are other ways to address this, including matching students with mentors who embody the desired qualities, asking students about their emotional or personal reactions to patients being cared for, and addressing non-empathic behaviors that might be demonstrated during patient care (whether student, resident, attending, nurse, colleague, etc).

Medical education has changed a lot in the last 10 years. Gone are the days of 36- or 48-hour on-call shifts, and the system has shifted toward a more humanistic perspective. Addressing medical student burnout and empathy are important next steps.

Do Americans Support Health Care Reform? Rhetoric Versus Reality

2010-04-22T20:13:00.000-04:00

I've made many claims in this blog that the rhetoric used by the opponents of health care reform leads to misconceptions about the bill overall, and that the components of the bill are popular amongst Americans. Today, the Kaiser Family Foundation released a poll that backs up these claims.

This poll looked at public awareness about the bill, and shows that a small plurality of the public support the bill (46% to 40%). This isn't the important point, though. If you shift the question to ask about the specific reforms the bill brings about, public support is very high. In fact, a majority of people polled support all 11 reforms that go into effect this year. Most of the time, this support is by large margins:

So, nearly 2/3 of those polled agree with the reforms coming into play over the next 8 months. I would consider this solid support.

Even more interestingly, take a look at the support when broken down by political affiliation:

So even Republicans support these reforms, except for the future limits in Medicare provider payments.

Just wondering: if the American public overall supports these reforms, and if Republicans support these reforms in large amounts (and independents support them even more strongly), what exactly are the Republicans fighting against? Policies and reforms that both make insurance coverage available to 32 million more Americans and that are also strongly supported by the public at large?

This, to me, is another example of what dishonest rhetoric leads to. Calling the bill "Obamacare", "socialized medecine" or "a government takeover of health care" polarizes the discussion, even though the programs put in place by the bill receive wide support. Health care reform's opponents use fear to galvanize opposition without allowing people to discuss and understand what really will happen when this law is fully in place.

That's because, if Republicans and other health care reform opponents engage in honest discussion, they lose. Even in their own party.

Health Communication And Social Media

2010-04-17T18:54:00.001-04:00

A brief note to mention something really interesting, but still in the works. The last two weeks, I've participated in an online Twitter discussion regarding health care and social media. These conversations tend to be focused on one or two issues, but have started me thinking more about what this medium could provide over time.

I have 2 major questions right now:

1) what do patients want from health care providers on social media? Do they want providers to act as information aggregators, or is the hope that providers will provide direct patient interaction?

2) how can health care providers find good patient-centered resources to follow? I understand that interest and professional groups have accounts, but how many can one follow and really stay on top of things?

I think this is a conversation that is in the early stages and, if to reach maximal benefit, would require major discussions of issues such as online privacy/confidentiality, the HIPAA privacy laws, provider liability, etc.

Not something with any definite answers, but an interesting set of questions.

Next Steps For Health Care

2010-04-17T18:31:00.001-04:00

Now that health care reform has been passed and enacted (no longer a bill, but a law), health care will become available for millions who have lacked access until now.

The next big question, then, is where will these patients go? American Medical News published an article indicating that by 2025 the nation will lack nearly 160,000 physicians that will be necessary to provide care for the nation. 46,000 of this anticipated 160,000 physician shortfall are primary care physicians--the very core of a cost-effective and patient-centered health care system. This issue has already developed in Massachusetts, where state law has extended health care coverage to essentially all of the state's residents. The article notes that 40% of family physicians and 60% of internists in the state have stopped accepting new patients, and the wait for a new-patient appointment with a primary care physician is up to 44 days.

Passing health care reform is a tremendous accomplishment. However, it is necessary to take the next steps to truly reap the benefits. At the heart of the efforts is the need to increase the numbers of medical students choosing primary care careers.

There are innumerable reasons medical students choose specialties other than primary care; probably as many reasons as there are medical students. Lifestyle, income, prestige, etc--all of these play a role. There has been a trend in medical students choosing the better-paid and better-lifestyle ROAD specialties (Radiology, Orthopedics, Anesthesia, Dermatology), while primary care specialties have struggled to attract high quality applicants.

There are many steps to addressing this issue. We need to make primary care more appealing to students, which will require addressing the costs of medical education, the payment structure of a health care system where procedural specialties are paid better than "intellectual" specialties, looking at concerns of physician burnout, etc.

Passing health care reform was a critical step. Now, we have to turn our sights to the next steps to make the promises real.

Non-partisan Assessment of Healthcare Reform

2010-04-04T22:38:00.000-04:00

A week or so ago, I saw a Republican "assessment" of healthcare reform law. Simply reviewing the language makes it clear that you can't really expect an unbiased opinion.

I realize that similar claims could be made towards the Democrats summaries, though.

So, I submit a summary from the non-partisan Kaiser Family Foundation. This provides a thorough overview of the changes the law brings into effect.

So, I hope this further clarifies what is REALLY happening, and not what either side would like us to believe MIGHT happen.

What To Expect

2010-03-26T23:06:00.000-04:00

With all the noise, hot air and nonsense over the last year, it is no surprise that folks might now know what the recently passed healthcare legislation actually includes. A couple of resources that might help: this one summarizes key points of the bill, and this one shows a timeline to implementation.

To give you a sense of what to expect in the next 6 months:
--Access to insurance for uninsured patients with pre-existing conditions.
--Small business tax credits.
--$250 rebates for seniors in the Medicare Part D donut hole (no drug coverage).
--Eliminating pre-existing condition restrictions for children.
--Prohibiting recissions (when insurance companies take back a policy you bought).
--Eliminating lifetime limits.
--Regulating use of annual limits on insurance.

Honestly, not a bad 6-9 months' work.

It Is Accomplished...

2010-03-26T21:42:00.001-04:00

Last night, the House passed the reconciliation bill after the Senate's modifications. With this action, the legislative process for healthcare reform is complete. This bill will be forwarded to the President's desk for signature, and means that healthcare is now law. The House's fixes to the Senate bill include improving the affordability provisions for lower income families, and repealing some of the more egregious special deals put into the bill during Senate negotiations.

Prohibitions against health insurance companies denying care for children due to pre-existing conditions go into effect immediately. Health insurance reforms start to take meaningful effect in 6 months with increasing protections over the next 4 years.

This bill is far from what I might have hoped for. It essentially props up the private insurance market, although it does make the market less predatory towards individuals and more accountable for their actions. This law extends healthcare insurance to 32 million uninsured people once it takes full effect.

Most importantly, this bill addresses the issue of whether healthcare is a right or a privilege. As a nation, we have now moved forward and determined that it is a reasonable and appropriate goal for healthcare to be available for all. This law is an imperfect vehicle for bringing this to pass, but it has been accomplished just the same.

So--after more than a year of effort and a century of hope, the country to move forward.

Now, our work is to help make this bill life up to its intent and anticipated benefit.

And From The Senate Back To the House

2010-03-25T20:26:00.001-04:00

Now that the healthcare reform bill has been passed by the House, the remaining issue is to address the reconciliation package. This package passed the Senate today and has to return to the House for the final vote because of some procedural changes brought about in the Senate. This is apparently expected tonight and, if passed, will bring to a close the legislative process regarding healthcare reform.

Healthcare Reform Passes The House

2010-03-21T23:59:00.000-04:00

Tonight, the House passed the Senate's healthcare reform bill, and then passed the budget reconciliation bill. The Senate's bill, now having been passed by both chambers of Congress, moves to the President for signature into law while the reconciliation package moves back to the Senate for passage.

This is a big day--the first time in over 60 years that presidential and national efforts to expand healthcare coverage has passed out of the Congress. I truly and deeply believe that this legislation will make a substantial difference in peoples' lives. The expanded access to care and the reforms on insurance companies are critical steps.

Did I want more? Yes. Am I happy with the bill? Happy enough.

Every journey of 1,000 miles begins with a single step. This is the first significant milestone on that journey.

The Beginning Of The End

2010-03-21T19:08:00.000-04:00

Debate on passage of healthcare reform has just begun in the House of Representative. Those in favor of the bill have successfully hurdled each of the preceding test votes on this bill, so hopefully the bill will be successfully passed.

It's been a long days, with the same lies and half-truths put forward by the opponents. This should not surprise us, as this has been the Republican's plan since the beginning.

The bill being discussed will expand coverage to over 30 million currently uninsured individuals and will bring meaningful reform to the out-of-control for-profit health insurance companies.

This is a day that matters, and hopefully a day we can celebrate later.

Una Vida Sana!

2010-03-14T23:25:00.001-04:00

Somewhat off the subject, but I wanted to mention that work is moving forward on the Una Vida Sana project. This program is intended to provide health screening services focused on the uninsured, Spanish-speaking community in Richmond. These are individuals that will not be helped by healthcare reform, whatever the final product looks like.

The short description of the project is: "A service learning program to provide cardio-metabolic disease screening and health outreach services to the Spanish-speaking community in Richmond while also providing clinical learning opportunities for medical, pharmacy and nursing students; clinical experience for Spanish-speaking medical interpreters; and health education experiences for lay health promoters."

The group has held 2 events thus far (last September and November) with another event coming up on March 20--next Saturday.

As this project grows and moves forward I plan to blog about it in greater detail.

The Current Health Care Reform Proposal

2010-03-14T23:05:00.001-04:00

I tried to place this info in the preceding post, but for some reason when I did so it threw the rest of the post off-balance. I thought it was worth laying out some details of the current proposal:

--Affordability: Makes it easier for low-income families and middle-class families to purchase insurance; if a family's income is <$55,000, that family would have between 73%-94% costs covered.

--Fine for not purchasing insurance: $2,850 or 2.5% family income.

--Employer responsibility: Senate bill lacked employer mandate; President endorses the Senate approach but increased the fees on employers if ANY employee purchases insurance on the exchange. Employers with fewer than 50 employees are exempt; there is no employer mandate, but there are provisions to make providing insurance more attractive.

--Medicaid/CHIP: coverage extends to 133% federal poverty level (for a family of 3 this would be less than $24,000); there would be a 100% match 2014-2017, 95% 2018-2019, 90% 2020 and beyond for all states. President’s plan removes the “Cornhusker Kickback" that would have provided disproportionate benefits for Nebraska.

--Health insurance exchange in both plans; national in House, state in Senate. The President endorsed state-based exchange for individuals & small businesses must be administered by govt agency or non-profit.

--President proposed a plan without a public option, but develops Health Insurance Rate Authority to provide Federal assistance and oversight to States regarding unreasonable rate increases and other unfair practices. There must be at least two multi-state “qualified” plans in each exchange, at least one non-profit and one w/o abortion coverage.

--President’s plan probably leaves 20 or 21 million uninsured; of those about 7 million would be illegal immigrants (who were not covered in either congressional proposal, either).

--Neither bill includes coverage assistance for undocumented immigrants and (in Senate) cannot buy policies from exchanges.

--Abortion coverage: President’s language would permit a state to prohibit any plan from providing coverage (so it is possible that NO plan on an exchange would provide coverage); plans that offer coverage must create allocation accounts to ensure that no federal $ goes to abortion coverage and plans are not allowed to discriminate against providers who do not provide coverage.

--Phase out Medicare D prescription coverage donut hole. --Both bills provide significant support for increased primary care workforce and President’s bill provides $11 billion for community health centers.

--Physician payment system would move away from the “fee for service” model, move towards accountable care organizations or other models.

--4 Republican ideas are included in compromise legislation: $50 million to reduce state demonstration projects for malpractice reform, improve Medicaid reimbursement to physicians, include health savings accounts in the exchange, and begin random undercover investigations to reduce fraud.

Push For Healthcare Reform

2010-03-14T22:33:00.015-04:00

It appears that we are approaching the defining votes on healthcare reform. From what I understand, the House of Representatives will pass the bill the Senate passed, while the reconciliation process will be used to change some of the Senate's language to be more aligned with what the house passed.

Conservatives need not fear. The public option is, unfortunately, not on the table. It's a shame, because I still feel that a public plan would be a necessary counterbalance to private insurance companies.

There are severe costs to doing nothing. There is evidence indicating that, had health care reform been implemented in the past, US health care spending would be much less than it currently is and would be more in-line with spending in other developed countries. The average family premium was $12,300 in 2008 and is expected to increase to $23,842 in 2020. This sort of cost escalation is unsustainable, either if the family purchases insurance privately or if it is employer purchased. Add this to private company denials of coverage, rescissions, and the like and it is clear that the already horrifying condition of health coverage will only get worse.

The House and Senate bills have a number of areas of agreement already:
--Individual mandate to purchase insurance
--Greatly increased regulation of private insurance companies
--Eliminates preexisting conditions
--Eliminates rescission (companies cannot drop people who are ill)
--Eliminate annual & lifetime caps
--Medical loss ratio of 80-85% (how much of every insurance $ is spent on care)
--Eliminate anti-trust exemption
--Expands coverage for preventive care
--Increased emphasis on primary care
--Increased support for public health
--Incentives for small businesses to provide insurance
--Creation of a health insurance purchasing exchange
--Support for health information technology
--Support for comparative effectiveness research
The President's proposal looks more like the Senate bill, but does have some proposals that reflect the House (and Republican) preferences.

Polling suggests that the country is divided about 50/50 regarding the legislation. Interestingly, if you discuss the policies and changes that are actually included in the legislation, support increases. People are distrustful of the process used to reach the current proposal and are skeptical that it will benefit them. However, if you discuss the specifics of the legislation, people increasingly support the proposals.

The general public is more likely to support legislation that includes the following pieces:
--Stop insurance covers from denying coverage.
--Require insurance companies to spend $ on care, not on insurance company profit.
--Helping small businesses to afford health insurance.
--Fix Medicare drug benefit.
--Help control costs and make good insurance available for all.

The current legislation provides for all the above. Opponents of reform have worked hard and, unfortunately, fairly successfully to criticize the proposal by being less than honest with what is actually contained in the legislation (death panels, anyone?).

This legislation cannot wait, and must be passed ASAP. Too many people die yearly, too many people defer care, and too many people are left behind for us to delay.

(By the way, don't fall for Republican claims that budget reconciliation is an underhanded, devious technique. Worked fine for them in the past on bills that dramatically increased budget deficits. It's just another attempt to pull attention away from what matters.)

If you read this, call your legislators and ask them to vote for health care reform. Now is the time, and this is the opportunity.

A Conservative Failure

2010-03-14T21:32:00.000-04:00

I admit, I look at the world from a certain perspective. As I've mentioned elsewhere (and earlier) in this blog, I approach medicine as a service career. I trust that I could make more money in other careers or, even if I stay in medicine, could make more money working elsewhere. But I don't feel that is my calling. I feel a need to work with patients who need care and who would have trouble accessing care elsewhere.

As a result of this, I look at marginalized and impoverished individuals as being worthy of our help and our care. I feel it is society's responsibility to help those who need help and, because I see the need as being so great, I believe that government and society has a critical role to help. These individuals usually come from communities and families that have become entrenched in poverty. I acknowledge that some people make poor decisions--but so do well-off people. The well-off just have more wiggle room if they make a mistake, and live in a society where tax policies, investment plans, etc are weighted to their benefit. (If you disagree, let me ask you whether mortgage interest deductions or deductible IRA contributions are more likely to benefit the wealthy or the poor)?

The counterpoint claimed by conservatives is that the public sphere, and public money, should not be used to help the poor and underprivileged. They claim that private citizens, churches and charities can provide the necessary help. In their vision, marginalized people are helped by kindhearted individuals and organizations with a mission to do just that.

So how do they explain Glenn Beck's recent nonsense? (It's an MSNBC link, b/c I can't bear to find the original clips on Fox.) Here is an individual beloved by many conservatives and who acts as a mouthpiece of the conservative movement calling on his fans and listeners to abandon and run away from any church that supports social justice and economic justice.

So, apparently there is a part of the conservative movement that believes not only that public money should not assist the poor, but faith communities shouldn't either. So where does that leave the poor? Apparently up the proverbial creek without a paddle. Couple this with the fact that the charitable organizations that do so much to help the less fortunate are badly hurt by the economy at the same time that their services are needed (link here) and you have to ask yourself: exactly what to conservatives want the poor do to?

Last time I checked, Jesus preached social and economic justice and called on followers to care for (and about) the poor. It takes precious little bible study to see this--the Beatitudes in the Sermon on the Mount make an easy starting point.

So, Beck is wrong in calling on people to abandon churches that promote social and economic justice. And he shows a critical flaw in conservative thought (if you can call him a conservative thinker--I think his current comments show that the jury is still out on that). If the poor are supposed to rely on churches and charities when those churches and charities are already strapped, and if "leaders" of the movement are calling on parishioners to leave their churches, then again: what are the poor supposed to do?

I readily acknowledge that there are may Christians who will disavow Beck's comments, and that many churches and secular charities will continue to do strong work to benefit the underprivileged. That doesn't change the basic fact that conservatives' answers to these questions are woefully inadequate.

And this is why we need to sustain a viable and meaningful public safety net.

Some Thoughts On Working In Southside

2010-03-06T15:19:00.001-05:00

I work at an outpatient practice in Southside Richmond. My pediatric patients are essentially 100% Medicaid/FAMIS (Virginia's state children's health insurance program --SCHIP) and nearly 90-95% Spanish-speaking. On the adult side, probably 70% of my patients are uninsured and receive assistance from our health system's patient assistance program; another 15% or so have Medicare coverage, and the other 15% are mostly Medicaid. I've been working here for over 2 1/2 years, and have developed some thoughts about working in this setting:

--Medicaid is very poorly responsive to its patients' needs: many children are covered for 1 year after they are born, but have to reapply for coverage. Many of the letters that are sent out are in English (to Spanish-speaking families), or are hard to understand. There is no evidence of any proactive approach to avoid this, so we get a number of kids that fall through the cracks at their first birthday. Similarly, many patients are unaware that their insurance coverage includes transportation to and from doctors' visits. Our Spanish-speaking patients do not receive full value from their insurance coverage.

--It is nearly impossible to get Medicaid as an adult in Virginia. You could be destitute, living in a box near a highway, and have no employment but you still do not qualify for Medicaid assistance.

--Even $4 prescriptions are expensive. Patients receiving our health system's assistance can get prescriptions for $4 for 30 days. I have been asked more often than I imagined to identify which of the prescriptions is the most important one because they cannot afford all $4.

--Our health system provides a full scope of referrals, but doesn't really accommodate the need very well. Already I have some appointments scheduled for patients in February 2011. I am glad to have the referrals (on paper) but I wonder if we couldn't find a way to make them more meaningfully useful.

--If you are approved for Disability income, don't expect much. Disability pays most of our patients who qualify somewhere around $700-900 a month. This really isn't enough to do much of anything. People who accuse the poor of spending all their money on big-screen TVs and fancy stereos can probably find a few people who validate their claims, but for the most part these people have no idea what they are talking about.

--There are levels of poverty in our very city that would not be out of place when I work in international settings. As a nation, state and city we should be embarrassed and appalled by this.

--It is much less expensive and resource-intensive to fix problems before they develop than to play catch-up later. Many of the adult patients I care for present with multiple uncontrolled medical problems and it takes a great deal of time, effort and resources to get things under control. It would be much more efficient if these problems could have been detected, controlled or prevented long before. That, of course, would require having meaningful access to health care even if one was unable to purchase private health insurance. This is why healthcare reform is so critical--it would open access to health care for everyone.

Oh, Virginia...

2010-03-06T15:06:00.000-05:00

Virginia's General Assembly session is drawing to a close, and the state's budget woes are currently the focus of legislators and advocacy groups. There are many arguments and discussions about how best to address the state's budget shortfall.

At this point, budget proposals include cutting K-12 education, cutting Medicaid reimbursement, cutting public health departments, and cutting programs promoting child health and wellness.

I cannot understand this plan, and I cannot see any value in it. How is cutting childhood education and health services and cutting public health departments actually supposed to help anything? If there ever was a "penny wise, pound foolish" plan, this is it. I cannot understand how sick, undereducated children are supposed to be in anyone's best interest.

It gets even more frustrating when you consider the current budget environment. The cuts to Medicaid and K-12 education total approximately $1 billion. Virginia spends $950 million every year paying for car tax relief, thanks to this guy's foolish campaign pledge. My opinion: we have a certain amount of choice in the kind of car we buy, and so we can control to a great extend the amount of personal property tax we pay. If the car tax "relief" was repealed, this would free up approximately $950 million dollars.

So: if people who buy more expensive cars are held responsible for doing so and are expected/required to pay the full amount of the personal property tax on those more-expensive vehicles, we could pretty much balance out the cuts to education and Medicaid. This would not address the issues of funding the local departments of public health and would not address CHIP funding, but it would at least be a start.

The local newspaper's web site has a widget allowing you to adjust income and spending to see how you could balance the budget. If you use this tool, increasing the personal income tax by 1% and raising the cigarette tax by $0.30, you end up with a $300 million surplus. This seems to be a reasonable proposal, but our current governor has absolutely ruled out any tax increases--a position supported by the Republican-controlled House of Delegates.

When did we decide as a society that it would be just to balance the budget on the backs of Virginia's poor and marginalized? This might be a rhetorical question, except that this seems to be the arc of American history.

Just to add insult to injury, Virginia's new Governor removed protections that would prevent state government from discriminating in employment on the basis of sexual orientation. Now, our Republican Attorney General is calling for all public colleges and universities to repeal their policies protecting individuals against discrimination on the basis of sexual orientation.

The Republican party in Virginia: carrying the Commonwealth backwards on the backs of the poor. Not the most attractive slogan, but it certainly reflects the way I feel right now.

Belated Analysis

2010-02-19T20:11:00.000-05:00

I realized that I never came back around to comment on the Twitter feed I typed up a couple of weeks ago. Just a brief comment:

I think that healthcare reform--critical and necessary as it is--will be focusing on primary care. Healthcare is more efficient and has better outcomes when primary care is the focus, not just a component of the healthcare system. However you feel about the current legislation in Washington, all players appear to agree that primary care will be the focus.

One of the knocks against family medicine and other primary care specialists is that we don't get paid enough for the paperwork and long hours and insurance hassles we have to face. The patient-centered medical home model, long endorsed by the AAFP, would remedy this and I think will be a component of restructuring the current broken system.

Making family medicine and other primary care careers more appealing to medical (and pre-medical students) will help bring qualified applicants into the fields. This change in the workforce will benefit patients and the system overall. This will involve restructuring and adjusting payment structures, and will probably end up with some unattractive doctor-vs-doctor arguments as those who currently hold the larger pieces of the pie are asked (or required) to give up a portion.

I think the AAFP has positioned the specialty well to make progress under healthcare reform. I hope that Congress can complete its work and allow the rest of us to get on with ours.

Listserve Exchange

2010-02-19T19:59:00.006-05:00

As part of the American Academy of Family Physicians, I'm signed up to a handful of listserves. This message came across on one of them:

"I thought I had been purged from this listserve after I dropped my AAFP membership, but this discussion reminds me of why I quit the AAFP: it is a political organization with a leftist tilt that is happy to be used as a shill for the current administration's goals. The AAFP does not help me advance my career as a DOCTOR OF MEDICINE. I feel trapped in a "specialty" that, in spite of my years of training and experience, is the lowest paid of any and is very limiting in terms of career options. I could not do a fellowship in any medical subspecialty because the residency I completed is not regarded as equal to an internal medicine residency. A graduate of a 3 year internal medicine program could later decide to become a rheumatologist, an endocrinologist, a cardiologist, a gastroenterologist, a neurologist, etc, etc, but a family doctor probably would not be a candidate for a fellowship in any of those specialties. A family doctor is regarded as easily replaceable by a nurse practitioner, except that nurse practitioners probably have a wider choice of specialties and practice settings. Heck, a nurse can become an anesthetist and make more money than I can as a family doctor, but could I become an anesthetist? IMO, the AAFP should be focused on improving the training of and practice opportunities for its members, instead of being the ultimate politically correct machine."

Another person followed directly with an "Agreed" message endorsing the first.

It probably goes without saying, but I don't agree with them at all. I sent back the following reply (I've deleted the e-mail addresses involved):

"I can't make out the names of our 2 colleagues who just posted, so I'll frame my reply to your e-mails:

Dr.s X and Y:

I sympathize with your frustration re: the state of our current health care system, and agree that our specialty is undervalued (and we are underpaid relative to our interventionalist colleagues). I believe that the AAFP (and the state AFP chapters) are working to address these issues by addressing scope of practice issues and pushing for increased reimbursement and recognition of the specialty. Healthcare reform currently underway--whether you agree with the central proposals or no--recognizes the need for primary care and I believe that it will put family medicine in a strong position. The patient-centered medical home model promises to allow us to provide the type of care most of us wanted to (patient centered, focused and wellness and disease prevention), and has increasing support as a means to rebuild the system. The AAFP has been a strong proponent for this model.

Unlike you, I feel that our specialty allows us to do a large number of things that other physicians cannot: I can see a newborn, take care of a geriatric patient, work on heart failure, deal with sports injuries, inject a shoulder, diagnose a rash, and provide comprehensive caring for ALL of patients. None of our colleagues can claim the same.

As an organization, the AAFP focuses on the big picture, a holistic assessment of health. As such, political and social issues will impact our Academy to perhaps a greater extent than others. The Congress of Delegates and the NCSC allow all members to speak via their representatives and make their opinions known. If you do not like a policy or a position, there are mechanisms to address that.

You have chosen to step back from the organization because you do not think its values are yours, and because you do not perceive that it provides return for your membership. Many of us feel otherwise. I feel that the AAFP leadership has worked hard to position the specialty favorably during the health care debate. I feel that the Academy has a valid role in addressing social issues that affect health. If I felt otherwise, I could speak to my AFP and determine how to work on resolutions to address or change those positions.

This listserve might not be the ideal venue to discuss issues such as climate change. But, this issue could be brought up for discussion and debate as a resolution later. If the membership agrees that it is not an issue that merits a position statement, then the representatives will make that known.

If you stepped down from the AAFP, so be it. Your call, and your $. I hope you will still benefit from the actions of the AAFP in the future which (I believe) will result in a stronger specialty. I continue to encourage the medical students I work with to consider family medicine--many of us are still energized by our patients and, while upset and frustrated by the current healthcare system and reimbursement concerns, will continue to work to improve conditions for all."

I fell privileged to be in a position to help patients. I'm sorry that some of my colleagues don't.

Twitter Transcription

2010-01-30T10:47:00.000-05:00

American Academy of Family Physicians president speaking re: healthcare reform at this conference; will try live tweeting during the talk.

A lot of half-truths, misperceptions have become incredibly partisan and media is not doing a good job of explaining what is really there.

AAFP has been working on healthcare refrom (HCR) for over a decade--not a partisan issue.

AAFP priorities: expand coverage (for ALL Americans--regardless of legal status), workforce issues, insurance market reform, tort reform.

Cannot expand coverage w/o expanding workforce: more primary care providers--increase income, more med student interest, residency support.

Need to get students and residents interested. Income plays a role (subspecialists make 2-3x primary care), but type of practice matters.

Patient-centered medical home is the kind of practice students want, and is at the forefront of AAFP priorities.

Insurance market reform is critical: insurance fighting care, denying care.

Tort reform is also AAFP priority, but is not priority at the national legislative level (this administration, nor the last one).

Tort reform is a state issue.

Workforce issues: MD payment needs to change; support primary care pay, care coordination fee, performance improvement are starting points.

Center for Medicare Services (CMS) has proposed regulatory changes to increase primary care payments for 2010 b/c primary care is underpaid.

Primary care bonus will come out of other peoples' budgets (over-valued services)--if Family Medicine gains, someone else loses.

Student interest: loan repayment/forgiveness, value of Family Medicine (FM) in medical school setting, ensure enough residency slots.

Most societies w/ "healthy" healthcare systems are 50/50 primary care / subspecialists; not the case in the US.

Over the last 9 yrs, employer-provided healthcare insurance is dropping--large employers (over 50 workers) not much change.

Employers w/ 3-9 workders: nearly 10% drop in providing insurance benefits; nearly 10% drop in employers w/ 10-24 workers. Too expensive.

In most states, the two largest health plans account for over 50-69% of cpverage. No real competition in many cases.

Cost of healthcare is rising in unsustainable way. 10% population accounts for 80% of costs but quality does not reflect the cost.

We spend a ton on healthcare, but patients do not receive much of the recommended care. 10th life expectancy and 27th infant mortality.

There is dramatic regional variation in the quality of care provided. FL has high costs, but quality is not very high.

Where primary care is lacking and subspecialists increase: higher cost with lower quality. This is the case in much of the US.

Having a regular source of primary care associated with: lower ER use, fewer hospital admissions, fewer tests/procedures, less illness...

...lower per-person costs, improved quality of care, higher patient satisfaction.

Too much care: # needed to treat vs. # needed to harm is hard to teach; need comparative effectiveness research.

New technologies and treatments need to show safety, but also IMPROVED outcomes that are meaningful to patients.

Delay in care worsens acute and chronic problems: care is more costly. Delay due to lack of insurance and lack of providers/physicians.

Major components of legislation: insurance mkt reform, increased coverage (Medicaid, etc), individual mandate, shared responsibility.

Senate is still the driver re: legislation. Dems concerned that walking away from healthcare will result in electoral backlash/angry voters.

Will voters be more angry if reform fails or if reform is passed? Congress trying to figure this out, and how to proceed.

Comprehensive reform still needed. Breaking into pieces will not lower the GDP costs and will not make much difference for the avg. voter.

House/Senate differences to resolve: excise tax, abortion funding restrictions, employer penalties if no insurance, insurance exchange setup, ...

...funding the legislation, concessions in public option is dropped (such as repeat of the antitrust exemption for health insurance cos).

Still a lot of politics: only 34% public "mostly" approves bill, 37% approve his handling of health care; Brown vs. Coakely (re: cloture).

HR 3962: increased Medicaid payment rates to Medicare rates, residency reforms & slot redistribution to primary care, primary care bonus.

Primary care bonus is 5%, but really a 25% bonus would likely be needed to improve medical student interest b/c of high student loan debt.

Senate bill HR 3590: increased premiums w/ more coverage from insurance company plans; 57% purchasers would pay 56-59% LESS over time.

Senate bill: 94% legal residents covered, tax on "Cadillac plans" (though being negotiated b/c of labor concerns), primary care bonus...

...Dept of Health and Human Services authorized to adjust mis-valued services, pilots such as patient-centered medical home (PCMH).

Senate bill needed improvement; AAFP did NOT send a letter of support for the Senate bill (though AAFP publicly supported House bill).

House vs. Senate: similar emphasis on preventive/primary care, workforce issues, insurance exchanges and regulation...

...but different provisions re: insurance affordability, access to care and employer obligations.

Suspect that, as things move forward, the final product might look more like the Senate bill.

Sustainable Growth Rate (SGR): facing a 21% payment reduction in Medicare payment; reform passed the House but failed the Senate.

SGR cuts come up every year, and every year are deferred b/c of the risk physicians will leave Medicare. No fix so far--just yearly holds.

As a result, $209 billion behind over the next 10 yrs. AMA pushing Congress to completely fix the SGR issue TOTALLY this year.

AAFP disagrees: if we call the bluff and Congress decides to push through the 21% cut, primary care will likely suffer the most.

Not clear when Congress will address the 21% cut. There is not much time, the budget is tight, and the 21% cut is looming.

One of the big losers in CMS pay changes to improve primary care payments is Cardiology, who have tried suing and pushing Congress to change.

As a result, Cardiology has lost a fair amount of political capital and the CMS payment rule is likely going to go through.

(There is likely to be a question and answer session later this morning; I'll note any relevant information.)

An Experiment

2010-01-30T08:26:00.002-05:00

I'm at a conference this morning, and the American Academy of Family Physicians President Lori Heim is going to be speaking about Health Care reform. I'm going to try and live tweet during the talk. We'll see how it goes--check out my Twitter feed and see what happens.

I plan to blog about it later on in case you miss the experiment.

Another Glancing Brush With Fame

2010-01-23T11:20:00.002-05:00

I was featured in an article in the Virginia Commonwealth University Student newspaper, the Commonwealth Times. We did a Q&A regarding my work in underserved settings, but at home and abroad.

Haiti

2010-01-18T23:23:00.000-05:00

Since the earthquake last week in Haiti, I have felt terribly conflicted about how to respond. We returned from the Dominican Republic last Saturday, just a few days before the earthquake. Had we been in the DR at the time of the disaster, we might have been in a position to have responded directly. Having just returned to the U.S., though, I found myself considering all the "practical" reasons that I could not turn around and fly right back. Family, patient schedules, work obligations, etc--many, many reasons which are valid, but which pale in relation to the scale of the disaster faced in Haiti.

So, I have no good idea how to respond. I was let of the hook--for now--when the medical relief teams in Haiti called for physician volunteers with trauma, surgery, orthopedics or emergency room experience. I lack skills in those areas, and so I could justify that I currently was not needed. Could I find another option, such as to work in the DR as diaster victims came over the border? Probably, but stateside obligations again make it easier to justify not traveling.

I feel like I am copping out: if pressed, I know I could probably do more. This would take a significant effort to get the time off work, to readjust my schedule, and to use vacation time to make the trip.

What have I done, then? I did put my name in as a volunteer willing to work after the emergency/acute reponse is over. I do not know if/when I would even be called to assist, but at least if I am called my skills and abilities will be better up to the task. I have also contributed to relief organizations already at work in Haiti.

Is that enough? Probably not. Is it enough for me to feel as though I am at least contributing somewhat? For now, yes. I have deferred the issues of how to work around time away from the office until later, but this gives me time to figure out how to handle that should I be asked to volunteer.

For now: all of us should try and help in whatever capacity we are able to. Look at the Partners in Health Stand With Haiti website to see if you can help directly. Donate to Doctors Without Borders--USA, who have already established hospital outposts to care for the injured and sick. Support the American Red Cross. All of these organizations--and many others--are already carrying out critically important work in Haiti.

Individually, we might not be able to do much. However, when unified, our smaller efforts grow into something much larger and much more significant--and we can make a difference.

Richmond Times Dispatch Article

2009-12-31T16:10:00.000-05:00

If you found this blog, it's possible you got here through a link from the Richmond Times Dispatch article that discussed my work in international medicine and in medical service projets. In case you got to this blog without seeing the newspaper article first, here is the link in case you're interested.

Senate Action On Healthcare Reform

2009-12-27T22:57:00.000-05:00

Early on December 24, the Senate voted to approve the healthcare reform package that had been under discussion. The process moves forward to conference committee before returning to each chamber for a final vote on the final bill.

Neither bill is perfect. I like a lot of what is included in the House bill, but the abortion limits bother me. The senate is much more conservative and leaves a lot more people without coverage, but is probably going to contribute much to the final product.

So, neither option is perfect. But both are much, much better than what we have now.

Two thoughts on this passage from the same website: this one is short and to the point, while this one is longer and more direct.

I'm getting ready to travel later this week on another medical service trip. As time allows, though, I'll try to give a little more thought and comment to the Senate bill.

This is further than reform has over gotten before...

Words To Live By

2009-12-12T23:06:00.001-05:00

I suppose by now, if you read any other posts on this blog, that you might now where I stand politically. I believe that each of us, and our society as a whole, has a responsibility to care for the most vulnerable and marginalized members of our society. I try to live this ethic as much as possible, and I try to give of my time and skills to those who could benefit from them.

I also believe that we need to look beyond our borders to care for poor and marginalized peoples in other nations. Poverty and need exist in our country and cannot be denied and should not be accepted. At the same time, the poverty and need found in developed nations often exceeds the worst cases found in our nation.

When President Obama spoke at the Nobel Prize acceptance ceremony, his speech expressed many ideas that I feel are key aspects of being human: caring for others, striving to improve the conditions of the neediest in our society and our world, and always keeping those goals in mind as guiding forces in our lives. The speech is well worth reading.

Some of the parts of the speech that resonated most deeply for me:

**********

"[T]rue peace is not just freedom from fear, but freedom from want.

It is undoubtedly true that development rarely takes root without security; it is also true that security does not exist where human beings do not have access to enough food, or clean water, or the medicine and shelter they need to survive. It does not exist where children can't aspire to a decent education or a job that supports a family. The absence of hope can rot a society from within."

**********

"[T]he one rule that lies at the heart of every major religion is that we do unto others as we would have them do unto us.

Adhering to this law of love has always been the core struggle of human nature. For we are fallible. We make mistakes, and fall victim to the temptations of pride, and power, and sometimes evil. Even those of us with the best of intentions will at times fail to right the wrongs before us.

But we do not have to think that human nature is perfect for us to still believe that the human condition can be perfected. We do not have to live in an idealized world to still reach for those ideals that will make it a better place. The non-violence practiced by men like Gandhi and King may not have been practical or possible in every circumstance, but the love that they preached -- their fundamental faith in human progress -- that must always be the North Star that guides us on our journey."

**********

"As Dr. King said at this occasion so many years ago, 'I refuse to accept despair as the final response to the ambiguities of history. I refuse to accept the idea that the 'isness' of man's present condition makes him morally incapable of reaching up for the eternal 'oughtness' that forever confronts him.'

Let us reach for the world that ought to be -- that spark of the divine that still stirs within each of our souls."

**********

I'm sure that the President's detractors will find many ways to cut down his comments and minimize their importance. I hope that we can look past the naysayers and embrace his word and his vision as key elements of our own.

Witnessing History

2009-11-15T21:29:00.002-05:00

By coincidence, the Virginia Academy of Family Physicians (VAFP) Board of Directors' (BOD) meeting on November 7 was the same day that the United States House of Representatives (HOR) was due to debate and vote upon H.R. 3962—Affordable Health Care for America Act. This act has been at the center of much of the political debate all summer, and includes significant overhauls of our health care system as well as providing for the establishment of a public health care insurance plan. As we were waiting to enter the Capitol for a tour, we saw a long line of people waiting to enter the HOR gallery to witness the debate on this important piece of legislation.

Following the tour of the Capitol, my wife Janet and I came back to the hotel to meet up with other members of the BOD. While we were mingling, Jan Ragland (the current VAFP President) mentioned that Sterling Ransome (one of the VAPF’s previous Presidents) had received tickets to visit the HOR gallery and we could check with him if we were interested. We deferred, considering that it was already after 7:30 pm and we didn’t want to head back over and wait in line. However, when Sterling showed up and offered the tickets directly, we figured that we really should go and sit in on some of the debate.

When we walked back to the Capitol, we realized that the lines were gone and we were able to proceed directly to the gallery. There we saw the introduction of the Stupak Amendment (which extended the Hyde Amendment restricting federal funding of abortion to the insurance plans purchased on the health insurance exchanges proposed by H.R. 3962) as well as the introduction of House Minority Leader John Boehner’s substitute amendment that would replace the proposed legislation with new legislation put forward by the GOP. As expected, the debate on this was energetic and long, and after being in the gallery for nearly 2 hours Janet and I decided to look for a cup of coffee.

It took a little while to find an open restaurant where we could get coffee and a snack, and we decided that we would head back to the Capitol. I didn’t expect there to be a vote of any consequences for some time—I expected something to happen in the early hours of the morning, but we felt that this was a historic moment (whichever side won) and we wanted to see how long we could last.

As we approached the HOR visitor’s entrance, it was clear that something was happening. People were streaming across the plaza outside of the Capitol, which was now filled with cars where it had previously been empty. We hurried through the security stations and into the line waiting to reach the gallery. As luck would have it, the Capitol security was in the process of moving current gallery occupants out to make room for new visitors and we were able to move forward right away and were soon seated in the gallery.

The floor of the HOR, which previously had only 30 or 40 people scattered in the seats, was packed and standing-room-only. Janet and I realized that the vote was underway on Boehner’s substitution amendment, which was voted down 258-176. Suddenly we realized that this was THE vote—that H.R. 3962 was going to be voted on directly.
Before the bill itself came to a vote, Minority Whip Eric Cantor (of Virginia’s 7th Congressional district) rose with a motion to recommit the bill to committee with instructions to add language regarding tort reform. This motion was voted down 247-187, and the bill itself came to a vote.

In the gallery, I was sure that the bill would pass without difficulty. After all, the two previous votes showed less than 190 votes that would likely also be votes against the bill. As the clock started counting down the time to vote, however, it became evident that the vote was closely matched. The “nays” reached 187, then 190, then 200 as the “yeas” stayed just 3 or 4 votes ahead. Each side increased little by little until, with approximately 3 or 4 minutes left in the vote, the “yeas” reached 218—the number needed to ensure a majority in the 435-member chamber. A loud cheer went up from the Democratic side of the HOR, and from many in the galleries—even as security sought to enforce the no-clapping rule for visitors. The final minutes of the vote expired, with the final count being 220-215 for passage. Whatever your perspective on the debate, it was dramatic and terribly important moment.

I support the bill, and after the vote Janet and I walked over to our Congressman’s office to see if we could thank him for his vote in favor of the bill. Bobby Scott’s office was open, and his aides mentioned that he was due back in a few minutes and if we would like we could wait and meet him. We waited—after all, what were a few more moments when it was already after midnight—and were able to speak with Rep. Scott for a few moments and thank him for his work in support of this bill.
When I went to college, Government was the other major I was considering other than Biology. It was a great chance to see the process at work—ugly and convoluted as it can be—and an opportunity to walk in and meet our representative. Health care reform has a long road ahead of it and, whatever side of the argument you find yourself on, I urge each of us to become active and engaged in the process. If we choose not to, rest assured that someone else will be speaking their mind to our representatives.