What does it mean to be a physician?

When I graduated college and entered medical school, I had a strong vision of what it meant to be a physician. To me, being a doctor was a service career. It was not a way to make money, but a way to make a difference. This vision was strengthened and fine-tuned over the course of my medical school training as I interacted with mentors who shared this understanding of a medical career. Physicians must be capable of providing medical care to their patients, but the role should be much greater than that: community service, leadership, education, and professionalism are intrinsic to my definition of what it means to be a physician.

When I learned about National Physicians Alliance in 2009, I was thrilled. Although I was already a member of my specialty organizations, I had not found an organization that fully embraced my (and NPA's) vision of medicine. Other organizations may have included some these elements in their definitions, but I had not seen another organization focus so precisely on these areas:

• Ensuring safe, accessible, affordable healthcare for all.
• Focusing on integrity and trust in medicine, and avoiding and eliminating conflicts of interest in medicine (including interactions with medical device manufacturers and pharmaceutical companies).
• Emphasizing evidence-based medicine and good stewardship of our patients' and our nations' resources.
• Encourage civic engagement as part of medical practice.

A career in medicine is a vocation, and a trust, and physicians must focus on the big picture if we are to give our patients and our communities proper care. We need to be active advocates to address social determinants of health, and we need to be leaders in targeting large-scale problems that impact our nations' health.

I believe that there is a role for trade groups (specialty organizations) in medicine. However, my membership in NPA speaks to a different set of interests and beliefs: it is more expansive and more inclusive, and more energizing. I am proud to be on the organization's Board of Directors.

I hope you will join me in supporting NPA. Physicians: please consider becoming a supporting member of NPA. Everyone else: please consider making a tax-deductible organization to support this organization's great work.

Please support Medicaid expansion in Virginia

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

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

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

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

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

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

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

Sincerely,

Mark Ryan, MD, FAAFP

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