(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.
Sunday, January 22, 2012
Friday, December 23, 2011
A bad month for Virginia's Republican leadership, a good month for the PPACA
(This was originally posted on the National Physicians Alliance Virginia Local Action Network blog site December 18, 2011)
Ever since the Patient Protection and Affordable Care Act (PPACA) healthcare reform law was under debate, Virginia has been at the forefront of its opponents. In March 2010, before the PPACA was passed and signed into law, Virginia passed a law that would make it illegal for the government to require Virginians to have health insurance. After the PPACA was signed into law, Virginia Attorney General Ken Cuccinelli sued to overturn the law on the grounds that it violated the United States' Constitution's "commerce cause". Cuccinelli has continued to be vocal in his opposition to the PPACA's reforms, including writing a legal article earlier this year attacking the law's legal foundation.
At the same time that Cuccinelli has taken an ideologically pure approach to attacking the PPACA, Governor Bob McDonnell has taken a more practical approach to the law. Although McDonnell has opposed the PPACA's reforms from the moment it was signed into law--and he still opposes the law--he chose to set up a Virginia health reform council to discuss how the law's reforms would affect Virginia as well as to review other options to reform health care in Virginia.
Given their political positions (and possible future plans regarding elected office), this has been a difficult Fall for Cuccinelli and McDonald. First, in September the 4th Circuit Court of Appeals denied Virginia's lawsuit against the PPACA, stating that the state lacked standing to sue until 2014 at the earliest. Then, November provided two major political blows to Virginia's state leadership: first, when the United States Supreme Court chose to hear legal challenges to the PPACA, it did not include Virginia's legal challenge among the cases it will review.
Then, at the end of the month, the Health Reform Initiative Advisory Council McDonnell appointed filed its report on how Virginia could respond to the PPACA. Per the ThinkProgress blog, the report indicated that, "[R]oughly half of the uninsured in Virginia will gain coverage, a little more than 520,000 people, and that 420,000 of them will gain Medicaid coverage. A little over 100,000 Virginians would gain private coverage, and more than 60 percent of them will be in group as opposed to non-group markets…[A]lmost 400,000 of those who gain coverage are in households with incomes less than two times the federal poverty level, though 70,000 of the formerly uninsured earn more than three times poverty today." [emphasis in original blog article] ThinkProgress also reports that the PPACA is expected to reduce the burden of uninsured medical care by approximately 50%. McDonnell has not yet indicated whether he will recommend formation of a Virginia-run health insurance exchange, but the commission's report suggests that Virginia should run this exchange/marketplace in order to maintain maximum flexibility.
These two developments make November a month that Virginia's Republican leadership would prefer to forget. On the one hand, the Supreme Court has let stand the Appeals Court decision that Virginia lacks standing to sue to overturn the PPACA. On the other hand, the Governor's own health care reform commission has found that the state--and it's citizens--stand to benefit notably from the healthcare reform law, and that the state should move forward to enact it.
These same developments support the positions held by the PPACA's supporters: the first being that the the law is constitutional and that the state cannot exempt Virginia from following federal law, and the second being that he law will have tangible and meaningful benefits for Virginians.
This does not end the fight over the law and its constitutionality, and it does not mean that Virginia's General Assembly (now controlled by Republicans in both houses) will work to enact a healthcare exchange. However, the law's supporters in Virginia can take heart in these recent events as we work to spread the word about the law's benefits--both for Virginia, and for the nation.
Ever since the Patient Protection and Affordable Care Act (PPACA) healthcare reform law was under debate, Virginia has been at the forefront of its opponents. In March 2010, before the PPACA was passed and signed into law, Virginia passed a law that would make it illegal for the government to require Virginians to have health insurance. After the PPACA was signed into law, Virginia Attorney General Ken Cuccinelli sued to overturn the law on the grounds that it violated the United States' Constitution's "commerce cause". Cuccinelli has continued to be vocal in his opposition to the PPACA's reforms, including writing a legal article earlier this year attacking the law's legal foundation.
At the same time that Cuccinelli has taken an ideologically pure approach to attacking the PPACA, Governor Bob McDonnell has taken a more practical approach to the law. Although McDonnell has opposed the PPACA's reforms from the moment it was signed into law--and he still opposes the law--he chose to set up a Virginia health reform council to discuss how the law's reforms would affect Virginia as well as to review other options to reform health care in Virginia.
Given their political positions (and possible future plans regarding elected office), this has been a difficult Fall for Cuccinelli and McDonald. First, in September the 4th Circuit Court of Appeals denied Virginia's lawsuit against the PPACA, stating that the state lacked standing to sue until 2014 at the earliest. Then, November provided two major political blows to Virginia's state leadership: first, when the United States Supreme Court chose to hear legal challenges to the PPACA, it did not include Virginia's legal challenge among the cases it will review.
Then, at the end of the month, the Health Reform Initiative Advisory Council McDonnell appointed filed its report on how Virginia could respond to the PPACA. Per the ThinkProgress blog, the report indicated that, "[R]oughly half of the uninsured in Virginia will gain coverage, a little more than 520,000 people, and that 420,000 of them will gain Medicaid coverage. A little over 100,000 Virginians would gain private coverage, and more than 60 percent of them will be in group as opposed to non-group markets…[A]lmost 400,000 of those who gain coverage are in households with incomes less than two times the federal poverty level, though 70,000 of the formerly uninsured earn more than three times poverty today." [emphasis in original blog article] ThinkProgress also reports that the PPACA is expected to reduce the burden of uninsured medical care by approximately 50%. McDonnell has not yet indicated whether he will recommend formation of a Virginia-run health insurance exchange, but the commission's report suggests that Virginia should run this exchange/marketplace in order to maintain maximum flexibility.
These two developments make November a month that Virginia's Republican leadership would prefer to forget. On the one hand, the Supreme Court has let stand the Appeals Court decision that Virginia lacks standing to sue to overturn the PPACA. On the other hand, the Governor's own health care reform commission has found that the state--and it's citizens--stand to benefit notably from the healthcare reform law, and that the state should move forward to enact it.
These same developments support the positions held by the PPACA's supporters: the first being that the the law is constitutional and that the state cannot exempt Virginia from following federal law, and the second being that he law will have tangible and meaningful benefits for Virginians.
This does not end the fight over the law and its constitutionality, and it does not mean that Virginia's General Assembly (now controlled by Republicans in both houses) will work to enact a healthcare exchange. However, the law's supporters in Virginia can take heart in these recent events as we work to spread the word about the law's benefits--both for Virginia, and for the nation.
Thursday, December 22, 2011
An unbalanced, unfair system--a case study (N=1)
(This post was originally published on the Occupy Healthcare website, December 22, 2011)
--------------------
About six weeks ago, while in clinic, I developed pain in my stomach--specifically, in my right upper quadrant, just below the ribs. I had experienced this a few times before, but this time it seemed more persistent than usual. Following the rule that physicians make the worst patients, I kept working through it until my nurse told me I looked poorly, and made me see my own primary care doc. This led to an ultrasound that afternoon, a diagnosis of gallstones with mild acute cholecystitis (inflammation of the gallbladder). I was in the surgeon's office the next week, and in the OR a week after that. Fortunately, I had an uncomplicated laparoscopic surgery, and was home within 24 hours.
Things are fine now. I was back at work within a few days, and was fortunate to have received prompt and effective care. However, I realize that my experiences are not typical. I am a physician, and my primary care physician is one of my partners: I was seen the same day because I was part of the "family" of docs with whom I work. The ultrasound was arranged two hours after my doc saw me. My surgery was scheduled so quickly in part because someone else's elective procedure was bumped to make room for me. If I had been an average person calling my primary care doc for belly pain (or presenting to the ER with the same complaints) I doubt this process would have been this efficient. I was fortunate to have privilege on my side: the privilege of being a healthcare professional, in his own system, knowledgeable about how to make the system work to my advantage.
This highlights the fact that our system is not fair. Why should I get these special considerations? Obviously, the easy answer is that I work in the health system where I received my care: much of what happened could be considered a form of professional courtesy where I was extended opportunities not available to patients not employed by the system. But at the heart of health care, shouldn't this sort of care be available to everyone? Why should it be so difficult for an average, non-medical person to be treated in just this way? Some systems (likely some of the top systems in the nation) work to make easy and prompt access available to all comers, but they are the exception to the rule.
We need to fix our system to make sure that meaningful, necessary, and prompt access will be available to all, whenever they need it. The system needs to be truly patient-centered.
Over the course of the next few weeks, I began to get my explanation of benefits (EOB) forms from my insurance. These EOB forms highlight how much the hospital charged, what my insurance wrote off (or "discounted"), and what I needed to pay. I am unable to list the costs here due to our system's insurance contracts, concerns about anti-competitive activities, etc. This is unfortunate, because they expose another area where our system is unfair and unbalanced: if you are uninsured, you will be expected to pay more than if you are insured. This is because insurance companies negotiate with hospitals on their patients' behalf, and reduce the costs for which patients are responsible. If you are uninsured, and if you don't know how to seek financial assistance, you pay the full (non-discounted cost) of your medical services. That cost is usually set high enough to ensure your healthcare provider will get the maximum payment possible from 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.
--------------------
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.
Sunday, December 18, 2011
How does the public *really* feel about healthcare reform?
(This post was originally posted on the National Physicians Alliance blog December 18, 2011)
--------------------
Opponents of the Patient Protection and Affordable Care Act (PPACA) are fond of pointing out how much the public opposes the law. Now, these voices calling for the law's repeal--with the most prominent voices coming from Republicans (including all the current presidential candidates)--usually overlook one important fact: a substantial portion of opposition to the law come from those who feel the law did not go far enough. Seems like a fairly convenient lapse.
Having said that, I would like to review the current state of the public support for the law's reforms with the help of the most recent Kaiser Family Foundation tracking poll (pdf). The overall public view of the law still trends unfavorable, but this seems to reflect in large part the public's unhappiness with the current state of politics in Washington, DC. The chart on page 3 shows that half the poll's respondents would like the law expanded (32%) or kept in place (18%). Only 24% would like the law repealed, and only 15% favor repeal and replacement with a Republican alternative. This suggests that Republican alternatives to the PPACA have not gained traction, and that although many Americans prefer stronger reforms there is a willingness to work with the law as it stands.
The chart on page 4 shows some reason for the public's confused approach to the law (unfavorable overall view, but support to keep the PPACA in place or strengthen the law): the public is still very confused about the law's reforms, but in terms of what is included in the law, and what isn't. More than half of those polled believe the law includes a public option (it doesn't), while only slightly more than one-third are aware of the law's reforms to the medical loss ratio (requiring insurance companies to spend money paid in premiums on providing care, as opposed to executive pay, administrative costs, etc) or the law's requirement that screening tests such as mammograms and colonoscopies be provided without any patient co-pays. This lack of understanding is no thanks to the Republican leadership in Washington or conservative pundits, who are so opposed to the law that they are willing to distort and misinform Americans about the law in their efforts to demonize it.
The reasons for the public's opposition to repeal/replace efforts are likely the law's actual reforms: as shown on page 5, the individual elements of the PPACA's reforms remain broadly popular across the political spectrum. Republicans polled supported major elements of the PPACA, including closing the Medicare Part D donut hole, providing tax credits to small businesses who provide health insurance for their employees, providing subsidy assistance for individuals unable to afford insurance on their own, providing preventive care without any co-pays or patient cost-sharing, and guaranteeing coverage despite preexisting medical conditions. In fact, of all the reforms Kaiser polled on, only the individual mandate was viewed unfavorably by the public.
I suspect that the fact that the individual mandate has been the focus of so much discussion around the PPACA also helps explain why the public is ambivalent about the law: if bulk of the media attention is on the only reform viewed unfavorably, then it is natural that the law will be seen unfavorably. It would be interesting to see what would happen if politicians and media discussed the law's other (positively-viewed) reforms: would this move public opinion more firmly in favor of the PPACA? The charts on page 6 reinforce this suspicion: few Americans report hearing any positive coverage. Much of the negative coverage appears to come from Congressional and Republican Presidential candidates' debates, reinforcing the perception that the law's political opponents are choosing to attack it as opposed to assessing it fairly.
On page 7, the top chart shows that most Americans see that the greatest benefit from the PPACA's reforms will accrue to low-income Americans, those with preexisting conditions, and those who lack insurance. This is a good thing, as these are the individuals who have been marginalized by our current system and who are most in need of help.
So: more Americans support the law or wish it were strengthened than support repealing/replacing it, the PPACA's reforms are broadly popular, the law's benefits will largely impact those most in need, and the law's opponents and the media are not discussing the law's reforms and benefits honestly.
I think this information leads to two important conclusions:
--------------------
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.
Thursday, November 17, 2011
Answer the call to save graduate medical education...again!
Once again, Congress is considering steep cuts to graduate medical education (GME) programs in the interest of balancing the budget. This is a classic short term answer: cutting funding to graduate medical education will reduce the number of physicians being trained in the US at a crucial time when we will need more physicians to provide care to our nations' citizens.
I have written about this issue before, and unfortunately find the need to do so again.
Cutting GME programs now might make the short-term budget outlook seem a bit more favorable...but at tremendous downstream costs. This recent study shows the potential harm: "A
50 percent funding cut would result in the elimination of 3,037 core medical
specialty positions."
This is no time to cut GME funding...especially in the name of a convenient political goal.
Please, take action. There are twooptions listed below--choose the one that is most comfortable for you, and help save graduate medical education.
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
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.
Sunday, November 13, 2011
Why social determinants of health matter, and what we must do
Recently, my friend Carmen Gonzalez wrote a post for the Occupy Healthcare site in which she highlighted the state of healthcare inequities in the United States. Carmen's post is brief and pointed: our nation has significant differences in healthcare status and outcomes, often as a result of factors that are largely beyond individual control: ethnicity, income, educational attainment, community resources, etc.
These factors are referred to as a group as "social determinants of health (SDOH)", in that they affect individual health but are not the results of individuals' decisions. For example: the fact that low-income neighborhoods often lack easy access to nutritious foods and safe places to exercise, meaning that those living in those neighborhoods will have greater challenges following our medical advice to exercise and eat well...not because they might not want to, but because these resources are not readily available to them. The important role of SDOH in impacting health means that any individual's health status is not simply the result of poor personal choices, but rather an interplay of individual risk factors and the social milieu in which one lives.
In the United States, we have the most expensive healthcare system in the world (as % GDP (pdf), and per capita), while performing at a level far below our economic peers:
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:
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.
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.
- 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 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.
In the same way that other activists call on us to "think global, act local", we must "think about social determinants of health, act to care for the individual patient." The two cannot be separated, and our duty must be to improve outcomes at all levels: we must make our healthcare system more effective, more efficient, and more affordable. The status quo is unjust and unsustainable.
Tuesday, October 18, 2011
Occupy Healthcare
Why do we need to occupy healthcare? Why are we here, on this website, calling for change? We are so often told that America has the best healthcare system in the world. If that were so, then there would be no need to change anything. We could continue running things as we currently are, and all would be well…
Except that we do not have the best healthcare system in the world. And we do need to change our current dysfunctional system.
When I make this statement, naysayers usually point out that America is the destination of choice for people all over the world who come here for care of their complicated medical problems. Advanced cancer, for example—the US is apparently the place to be if you need high tech, high-intensity care. Another argument is that patients come here to jump the line to get hip surgery or heart surgery that would require a much longer wait in their original country…although it is not often that this claim is supported with evidence that the procedure in question could not have waited.
So: I have staked a position, one that is contrary to the common wisdom. I have made the claim that American healthcare is not the best in the world. It is now necessary to defend this position:
• American healthcare is not #1 in the world. In this World Health Organization (WHO) analysis, the US ranks 37th. We place just behind Costa Rica. Other nations that outrank us: Dominica, Chile, Saudi Arabia, Cyprus, Greece, Colombia, and Morocco. Just below us: Slovenia, Cuba, Brunei, New Zealand. Essentially every developed nation in the Western Hemisphere performs better than we do.
• It’s worse than it looks: as this analysis shows, we are 39th in infant mortality, 43rd for adult female mortality, and 42nd for adult male mortality and some of the US’s quality measures have not increased as much as other nations’.
• We rank last among seven developed Western-style democracies in US healthcare performance (graphic here). We ranked 7th out of seven in efficiency, equity and “long, healthy, productive lives” 6th in quality care, and tied for 6th in access. This last category (access) is ironic, given that many of the arguments against reforming the US healthcare system focus on the potential loss of patients’ access to their physician; it appears this access is not as robust as we might believe.
• Our healthcare spending per capita is 50% greater than the next highest nation’s, and our healthcare spending in the US is increasing faster than most other nations’, and the % of national GDP spent on healthcare in the US is the highest in the world (reference here).
• According to this just-released report from the Commonwealth Fund, the US scored 64 out of 100 points and lagged behind other developed nations. You can see the short version of the report here.
Americans pay much more per person, to support a health care system that does not function very well at all, that provides inadequate and unequal care for far too many people (pdf), and that leaves nearly 50 million Americans without health insurance. (pdf) These are all indicators of a system with significant, fundamental dysfunction.
How can we tolerate this? How long do we continue paying for a system that is not meeting our needs, and that is costing us more and more? How long can we continue draining resources on a system that is unequal and that does not meet its intended goals?
Every system is perfectly designed to produce the results that it is producing. If we continue doing the same things, we will continue getting the same results…only at ever-greater cost. Even with the passage of the Patient Protection and Affordable Care Act (PPACA), the fundamental structure of our system will not change, and we will still need to find ways to make our healthcare system more effective, equitable and efficient.
We cannot continue the status quo. We must occupy healthcare, and we must fight for reform that will make a true difference for our nation and improve our fellow citizens’ health.
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.
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