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

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

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

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

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

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

How the Medical Industrial Complex Influences Physicians

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

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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?

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

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

There are various definitions out there already:

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

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

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

• Help all patients, regardless of age, gender, complaint or social situation.
• Evaluate undifferentiated symptoms and patient complaints about any/many organ systems, and determine a holistic, appropriate and cost-effective treatment plan.
• Develop long-term therapeutic relationships with patients, and emphasize continuity and coordination of care with necessary specialists, counselors, and community resources.
• Manage patients' chronic illnesses, treatments, and ongoing health needs within the context of their family and community settings.

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

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

How Will Virginia Benefit From Healthcare Reform?

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

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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?

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

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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!

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

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.