Recently, I have been exchanging e-mails with a colleague on an organizational mailing list (and probably annoying members of said list--sorry!). This is a reply to a graphic that was e-mailed to me. I think it is really interesting in the use of language: check out the two halves of the graphic and tell me if you can guess which side is favored. Here's my reply:
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The graphic you sent is interesting--but I think it shows the difficulty in figuring out the best choices and the strengths and weakness of the various options.
The image on the left, the "Consumer-Centered System" highlights as a strength what I think is the greatest risk in the system: Consumers decide what health plan suits them best. I readily admit that many consumers could make this decision--but many, many would struggle to choose a reliable and beneficial plan without significant assistance. We've seen w/ the current subprime mortgage market that people can get themselves in terrible trouble by making bad decisions--many misled, some dishonest. However, when these decisions add up and the system collapses, you risk having a situation where you have exactly what we have now: many uninsured, many who pay for plans they can't get out of, many whose plans do not live up to benefits promised or perceived.
Interestingly, this graphic doesn't even account for any sort of government subsidy or tax break to help individuals fund their purchase. You would assume that patients would try to find the most affordable plan, but would they reliably recognize the limits on coverage that would almost certainly be present. The graphic also takes out any sort of employer-provided health care (it notes that families and individuals would choose their plans); so all the cost falls directly on families? Are employers supposed to pass the savings along to employees to allow them to buy insurance? It seems that this set-up would be riskier than the flawed system in place.
The graphic also doesn't address the issues of cost-shifting where the highest-need and highest-use patients would still likely be covered on government plans which still would not be able to recover costs by insuring healthier, lower-utilization patients.
I guess I just don't see how that model would address the issues of the unerserved or the issue of costs. In the long run, wouldn't we just end up pretty much where we are?
At the same time, the "Government-Driven System" graphic shows all the fears incumbent in any public insurance option: "politicians, bureaucrats in control at top", private plans can't compete, etc. My current understanding of legislation including HR 3200 doesn't fit with that.
This second graphic also seems to indicate that government-mandated "essential benefits" are a bad thing. If we're going to have a marketplace (which is the model in HR 3200 and other proposals) that include a public plan, patients will have hundreds or thousands of plans to choose among. We've seen the challenges of choosing Part D options: how can patients reliably and easily choose between the hundreds of benefits that would be part of each and every plan. Is it bad to require all plans to have some essential features? Maybe things like periodic health maintenance visits (Paps, Mammos, lipids, colon CA screens etc)? Maybe some sort of catastrophic coverage (or an easy way to add this to a basic-level plan). Maybe coverage for some essential level of generic meds at least--how long can we depend on Wal-Mart, Target, etc? If/when their generic plans stop making $ by bringing shoppers in to the store, those plans are at great risk. To me this is
a little bit like requiring seatbelts, brakes, etc on cars: aren't there some things that are SO essential that they MUST be included?
Medicaid and Medicare are terrible payers--we all know this. But is this in part b/c they can't meet their budgets b/c of the cost-shifting referred to above (covering so many patients w/ high utilization and so few that are healthy low-users)? Could/would the payments be better if the budgets were healthier? Wouldn't enrolling more healthy people in a public plan move toward that direction? Couldn't US businesses be more productive if they COULD find a plan with low premiums? So far, private plans have failed terribly at this. Would a public option be better?
To me, the fundamental questions involve fairness. To me this means universal coverage that is portable and affordable and that provides meaningful benefits. I haven't seen it from the private plans and I haven't seen it from Medicare/Medicaid. But this is a chance to make a difference, to provide care for all and to reduce the costs associated w/ healthcare in the US. Maybe even get better outcomes for the $ (which we do very poorly compared to other industrialized democracies).
Other countries are successful with this--public plan w/ private plans co-existing in a market, with varying levels of government control and requirements. Can't we find a system that will work to cover everyone, while still providing physicians w/ a good environment to practice? I think we need both, and I think we need to make sure we're looking at physician issues: malpractice reform, payment re-structuring, supporting EHR implementation, etc. If we don't have docs, we won't have healthcare. But I really feel that the efforts at the federal level can work and I'm troubled that so much energy is being devoted to breaking them down without any great sense of a sustainable, viable alternative.
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Thanks for reading.
Wednesday, July 22, 2009
Sunday, July 19, 2009
Why We Need Government Involvement In Healthcare Reform
Another blog post that actually started as a reply to an e-mail. I do not want to print the initial e-mail, as it was not intended for general release and I'm going to refer to the writer as Dr. X. This e-mail was sent to a mailing list with other physicians, which explains what might seem as cryptic references to a mailing list.
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I am by no means a health policy expert, but I have some concerns about Dr. X's position that patients would be better off with a high-deductible catastrophic-illness insurance policy coupled with an HSA. I think this model of providing health care threatens to leave far too many patients without adequate coverage.
I have spend my career to date (not the longest career on this mailing list, but still...) working in underserved and marginalized communities. I have seen patients defer or delay care b/c they could not afford their insurance co-pays. This includes the 20% co-pays required by some private insurance plans as well as the $40 required by a university health system's patient assistance program. How would patients in these positions realistically be able to save enough to fund their HSAs to cover the potentially thousands of dollars required by a high-deductible plan? Is there proof that a drop in medical resource utilization when patients switch to an HSA is b/c patients are being more careful w/ their care (as Dr. X contends in her e-mail)? Or are people deferring needed care b/c they cannot pay the costs?
I also question whether the increased use of medical resources when patients are enrolled in public plans is simply a matter of "if you pay for it, we will do it". I suspect that in many cases, patients have put off important care because they were uninsured (or underinsured), only to try and catch up once they can afford to thanks to some sort of coverage. How many of us have had patients ask us to try and work with them in terms of their care and try to delay optional things until they have Medicare? And then we have to decide whether our recommendations are urgent and must be addressed despite the financial burden--or maybe we can wait a little while. How many of us have had patients show up after qualifying for Medicare or some other insurance and be faced with the challenge of not only controlling out-of-control chronic illnesses but also struggle to catch up with long-neglected health maintenance?
I am not proposing that there be a government committee of some sort to dictate care and I, personally, do not feel that the programs to show relative benefits of treatment would be used to promote valuable care and not to deny care. I may be optimistic on this, but remember that many of our current meds were approved based on their benefit vs. placebo (and not vs. other active therapies) and that many of our specialty-endorsed evidence-based practice guidelines are not always followed.
I suppose that I just feel that there can be a role for the government in controlling costs. If a public health insurance plan is included in the legislation and is unsuccessful, then the private plans will prove their superiority. Considering, though, that the administrative overhead for the for-profit insurance plans can be 6-8x that of the current public plans I think the private plans will have some work to do. We also have to address the fact that the public plans disproportionately insure those patients who will have the highest utilization (such as the elderly and the disabled) while private plans do not carry this burden. This means that, currently, private plans tend to have a favorable patient mix with more relatively healthy people than the public plans. If public plans were able to enroll these healthier, lower-utilization patients, I would suggest that premiums and costs could be lowered. Using the larger purchasing power of such plans, some costs (such as medications) could be lowered drastically.
Finally, we do need to keep an eye on ourselves. I DO NOT think that doctors are the problem, and I do not want to be accused or thought of as saying that this whole messed-up system is our fault. But we can do better. In a recent New Yorker article, Atul Gawande shows how physician practice styles can impact care (http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande). Granted--much of this is the result of the inefficient health care system we currently are discussing. But, if we cannot honestly review and address issues of our practices that will inflate costs, then any reform of ANY kind is facing a steep uphill climb from the beginning.
Finally, we need to continue to work on reform that will address the primary care workforce shortfall. Someone once compared universal health insurance (with guaranteed access for all) without increasing the primary care workforce to giving everyone in town free bus tickets--but only having one bus. The issues of medical student debt, reimbursement for primary care physicians, and changing the model of primary care to allow for the complicated care-coordination and health-promotion roles played by primary care physicians need to be addressed in any health care reform.
*************************
Thanks for reading. Let me know what thoughts or comments you might have.
*************************
I am by no means a health policy expert, but I have some concerns about Dr. X's position that patients would be better off with a high-deductible catastrophic-illness insurance policy coupled with an HSA. I think this model of providing health care threatens to leave far too many patients without adequate coverage.
I have spend my career to date (not the longest career on this mailing list, but still...) working in underserved and marginalized communities. I have seen patients defer or delay care b/c they could not afford their insurance co-pays. This includes the 20% co-pays required by some private insurance plans as well as the $40 required by a university health system's patient assistance program. How would patients in these positions realistically be able to save enough to fund their HSAs to cover the potentially thousands of dollars required by a high-deductible plan? Is there proof that a drop in medical resource utilization when patients switch to an HSA is b/c patients are being more careful w/ their care (as Dr. X contends in her e-mail)? Or are people deferring needed care b/c they cannot pay the costs?
I also question whether the increased use of medical resources when patients are enrolled in public plans is simply a matter of "if you pay for it, we will do it". I suspect that in many cases, patients have put off important care because they were uninsured (or underinsured), only to try and catch up once they can afford to thanks to some sort of coverage. How many of us have had patients ask us to try and work with them in terms of their care and try to delay optional things until they have Medicare? And then we have to decide whether our recommendations are urgent and must be addressed despite the financial burden--or maybe we can wait a little while. How many of us have had patients show up after qualifying for Medicare or some other insurance and be faced with the challenge of not only controlling out-of-control chronic illnesses but also struggle to catch up with long-neglected health maintenance?
I am not proposing that there be a government committee of some sort to dictate care and I, personally, do not feel that the programs to show relative benefits of treatment would be used to promote valuable care and not to deny care. I may be optimistic on this, but remember that many of our current meds were approved based on their benefit vs. placebo (and not vs. other active therapies) and that many of our specialty-endorsed evidence-based practice guidelines are not always followed.
I suppose that I just feel that there can be a role for the government in controlling costs. If a public health insurance plan is included in the legislation and is unsuccessful, then the private plans will prove their superiority. Considering, though, that the administrative overhead for the for-profit insurance plans can be 6-8x that of the current public plans I think the private plans will have some work to do. We also have to address the fact that the public plans disproportionately insure those patients who will have the highest utilization (such as the elderly and the disabled) while private plans do not carry this burden. This means that, currently, private plans tend to have a favorable patient mix with more relatively healthy people than the public plans. If public plans were able to enroll these healthier, lower-utilization patients, I would suggest that premiums and costs could be lowered. Using the larger purchasing power of such plans, some costs (such as medications) could be lowered drastically.
Finally, we do need to keep an eye on ourselves. I DO NOT think that doctors are the problem, and I do not want to be accused or thought of as saying that this whole messed-up system is our fault. But we can do better. In a recent New Yorker article, Atul Gawande shows how physician practice styles can impact care (http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande). Granted--much of this is the result of the inefficient health care system we currently are discussing. But, if we cannot honestly review and address issues of our practices that will inflate costs, then any reform of ANY kind is facing a steep uphill climb from the beginning.
Finally, we need to continue to work on reform that will address the primary care workforce shortfall. Someone once compared universal health insurance (with guaranteed access for all) without increasing the primary care workforce to giving everyone in town free bus tickets--but only having one bus. The issues of medical student debt, reimbursement for primary care physicians, and changing the model of primary care to allow for the complicated care-coordination and health-promotion roles played by primary care physicians need to be addressed in any health care reform.
*************************
Thanks for reading. Let me know what thoughts or comments you might have.
Sunday, July 12, 2009
Health Care Reform Letter
So, recently the Richmond Times-Dispatch (RTD) printed a letter to the editor which doubted the motivations of the current health care reform efforts in Washington.
I have a letter to the editor in reply, which I am going to send to the newspaper. I don't think they'll actually print it--it's long, and way to liberal for the RTD. So, I'm going to post it here so that I don't feel like I have wasted my entire day.
************************
To the Editor;
I am writing in reply to a letter published July 6, 2009 in the Richmond Times Dispatch regarding the current administration’s health care proposal. In her letter, Ms. Kathy Dean raises a number of questions regarding health care reform legislation that is being considered. I would like a chance to address some of her points. I feel qualified to comment on this issue as I have spent my entire career working in medically underserved communities (urban and rural) where I have seen the harm and the challenges that result from the large number of uninsured and under-insured citizens of our country.
There is no doubt that the American health care system needs to be reformed. Currently, the United States spends nearly $7,421 per person on healthcare—equal to 16.2% of our nation’s GDP. They are projected to increase to 25% of GDP in 2025. These costs weigh heavily on businesses (employer-based family insurance policies cost employers an average of $12,680 yearly) and families (half of all personal bankruptcies are at least in part due to medical expenses, most of which involved people that had insurance when they first got sick). Despite these high costs, the health care we receive falls well short of desired goals. When assessed across 37 performance indicators, the United States healthcare system scored 65 out of a possible 100 points.
Despite Ms. Dean’s concern about the current legislation enacting “two separate health care systems—one for those with political clout and the rich who can afford to pay taxes on their gold-plated benefits, and one for everyone else”, we already have a healthcare that has dramatic inequalities. Currently, the division is between those who are insured and those who are not. Children who lack health insurance have decreased access to health maintenance services, including vaccinations, well-child check-ups, dental care and prescriptions. Adults who do not have insurance also receive less preventive care and typically suffer worse health outcomes if they get sick. Health inequalities are also notable among those Americans who have insurance: do you have a well-funded employer-supported plan that encourages check-ups and health maintenance, or are you limited to a plan that covers catastrophic illness or hospitalization and includes a sky-high deductible (which you had to choose to keep the cost affordable)? Let us not kid ourselves—the current system is terribly expensive, fails to provide adequate coverage for millions of Americans, and does not achieve its desired goals.
I think Ms. Dean raises some important questions; including whether there will be enough primary care providers to cover the new patients and who will determine the type of care patients receive. The answers to these questions will be determined by the legislation in question. Currently, it is clear that the administration recognizes the need to increase the number of primary care physicians in the United States to ensure that the workforce issue will be addressed. How to meet these needs, though, is still unclear and will not occur in the short-term. Medical students will need to be able to enter primary care careers while still being able to pay their medical school loans (which now average well over $150,000). This will require the current health care payment structure to be adjusted, and primary care physicians will need to be reimbursed for their work in a manner that fairly addresses the challenges of coordinating patient care, ensuring health maintenance, and dealing with needs of patients who present with multiple complicated medical problems. This will not be easy in light of the already-existing challenges to healthcare funding.
In terms of the types of care patients receive, this also has not been determined but as of now there has been no indication that any legislation coming out of Washington will involve rationing. In fact, the administration has made efforts to communicate that patients will be able to choose their physician and the patient/physician team will dictate care. No doubt that there will be some limits or conditions that will be enacted—prior authorizations, medical reviews, etc. However, these limits and conditions already exist in all commercial and government-funded health plans. There has been no indication of any dramatic shift from these models. The government will be funding research to help determine what treatments, medications, and interventions provide the most benefits and are most cost effective. However, there is no sign that the results of this research will dictate care or coverage.
Regarding illegal immigrants, there has been no sign that adults who immigrated here illegally will be covered under any government-provided options. Children who are present illegally may be covered under Medicaid and FAMIS under the Children’s Health Insurance Program (CHIP) legislation already enacted. Considering that this coverage provides for well-child visits and vaccines, which benefit the child while also protecting the community at large against communicable diseases, this coverage was politically viable. Adults are not likely to receive any such consideration, as much as I worry about the strain that will be placed on safety-net providers such as free clinics and emergency rooms once undiagnosed chronic illnesses such as high blood pressure, high cholesterol, and diabetes start to cause complications.
At this point, the public health insurance plan being discussed as part of the healthcare legislation is what appears to be causing the most discomfort among those who oppose the idea. According to polling by Health Care for America Now! (HCAN) the idea of a public health insurance plan is well received by a majority of Americans. This plan would work within the current marketplace to provide an option beyond the commercial insurance plans. This plan will allow for more equitable enrollment of people who are healthy and require relatively few health care interventions and those who require more health care resources. Currently, a disproportionately large number of patients who require more health care are enrolled in public plans (Medicare and Medicaid) while those who are less-frequent users are disproportionately enrolled in private plans. If a public plan enrolled Americans from both the high-use and the low-use groups then the costs of premiums would be lowered and more affordable. This option could also make use of the fact that government-run programs have historically had much lower overhead costs for administration purposes (around 5% or so for public plans) as compared to for-profit commercial plans (nearly 30%). In addition, a public plan could be structured to emphasize health maintenance and health-promotion (including consideration of ideas such as the patient-centered medical home) that will prevent illness while also increasing the appeal of primary care medical careers. The public plan could also emphasize health interventions that work and that are cost-effective, as opposed to promoting new and flashy medications and technologies that have little to no additional benefits but that are dramatically more expensive.
It is a shame that Ms. Dean questions whether party affiliation will affect health care, and that she invokes President Obama’s position on abortion to question the motivation and results of these health care reforms. This issue is too serious, will have too many long-term repercussions, and will affect too many people to get caught up in unfounded rumors. There is no call in the current plan for a single-payer national health plan (much to the distress of many who would support it and who can show evidence that such programs improve outcomes and reduce costs)—if the public health insurance plan that is being discussed is not viable, then it will fail in the marketplace. There has been no indication that party affiliation will have anything to do with the coverage one will receive. By developing a health care reform plan that intends to provide affordable coverage to everyone, the current administration is seeking to provide care to the most vulnerable members of our society while also making care available to everyone else: the working poor who represent a large proportion of the uninsured; the self-employed and small businesses who have to choose between paying exorbitant premiums to commercial plans or reduce or eliminate coverage for themselves and their employees; large corporations who face a built-in hurdle compared to other developed nations because American companies have to pay high costs for employee’s health insurance while carmakers in other countries do not have to face this challenge. In short, the current health care reform efforts present a chance to provide meaningful and valuable care for all while still allowing for individual plan choice and reducing costs.
There is no question that our current healthcare system is unsustainable. We pay far too much for much too little, and too many are left uncovered. We need to take full advantage of this opportunity and develop a long-lasting, improved system. This legislation will dictate healthcare in the United States for decades, and it needs to include coverage that would be available to everyone and that will focus on health maintenance, treatments that provide health benefits and are cost-effective, and that will be sustainable long into the future.
*************************
So, that's my perspective. I'm interested in any comments or thoughts, so please feel free to post some if you would like to.
Thanks.
I have a letter to the editor in reply, which I am going to send to the newspaper. I don't think they'll actually print it--it's long, and way to liberal for the RTD. So, I'm going to post it here so that I don't feel like I have wasted my entire day.
************************
To the Editor;
I am writing in reply to a letter published July 6, 2009 in the Richmond Times Dispatch regarding the current administration’s health care proposal. In her letter, Ms. Kathy Dean raises a number of questions regarding health care reform legislation that is being considered. I would like a chance to address some of her points. I feel qualified to comment on this issue as I have spent my entire career working in medically underserved communities (urban and rural) where I have seen the harm and the challenges that result from the large number of uninsured and under-insured citizens of our country.
There is no doubt that the American health care system needs to be reformed. Currently, the United States spends nearly $7,421 per person on healthcare—equal to 16.2% of our nation’s GDP. They are projected to increase to 25% of GDP in 2025. These costs weigh heavily on businesses (employer-based family insurance policies cost employers an average of $12,680 yearly) and families (half of all personal bankruptcies are at least in part due to medical expenses, most of which involved people that had insurance when they first got sick). Despite these high costs, the health care we receive falls well short of desired goals. When assessed across 37 performance indicators, the United States healthcare system scored 65 out of a possible 100 points.
Despite Ms. Dean’s concern about the current legislation enacting “two separate health care systems—one for those with political clout and the rich who can afford to pay taxes on their gold-plated benefits, and one for everyone else”, we already have a healthcare that has dramatic inequalities. Currently, the division is between those who are insured and those who are not. Children who lack health insurance have decreased access to health maintenance services, including vaccinations, well-child check-ups, dental care and prescriptions. Adults who do not have insurance also receive less preventive care and typically suffer worse health outcomes if they get sick. Health inequalities are also notable among those Americans who have insurance: do you have a well-funded employer-supported plan that encourages check-ups and health maintenance, or are you limited to a plan that covers catastrophic illness or hospitalization and includes a sky-high deductible (which you had to choose to keep the cost affordable)? Let us not kid ourselves—the current system is terribly expensive, fails to provide adequate coverage for millions of Americans, and does not achieve its desired goals.
I think Ms. Dean raises some important questions; including whether there will be enough primary care providers to cover the new patients and who will determine the type of care patients receive. The answers to these questions will be determined by the legislation in question. Currently, it is clear that the administration recognizes the need to increase the number of primary care physicians in the United States to ensure that the workforce issue will be addressed. How to meet these needs, though, is still unclear and will not occur in the short-term. Medical students will need to be able to enter primary care careers while still being able to pay their medical school loans (which now average well over $150,000). This will require the current health care payment structure to be adjusted, and primary care physicians will need to be reimbursed for their work in a manner that fairly addresses the challenges of coordinating patient care, ensuring health maintenance, and dealing with needs of patients who present with multiple complicated medical problems. This will not be easy in light of the already-existing challenges to healthcare funding.
In terms of the types of care patients receive, this also has not been determined but as of now there has been no indication that any legislation coming out of Washington will involve rationing. In fact, the administration has made efforts to communicate that patients will be able to choose their physician and the patient/physician team will dictate care. No doubt that there will be some limits or conditions that will be enacted—prior authorizations, medical reviews, etc. However, these limits and conditions already exist in all commercial and government-funded health plans. There has been no indication of any dramatic shift from these models. The government will be funding research to help determine what treatments, medications, and interventions provide the most benefits and are most cost effective. However, there is no sign that the results of this research will dictate care or coverage.
Regarding illegal immigrants, there has been no sign that adults who immigrated here illegally will be covered under any government-provided options. Children who are present illegally may be covered under Medicaid and FAMIS under the Children’s Health Insurance Program (CHIP) legislation already enacted. Considering that this coverage provides for well-child visits and vaccines, which benefit the child while also protecting the community at large against communicable diseases, this coverage was politically viable. Adults are not likely to receive any such consideration, as much as I worry about the strain that will be placed on safety-net providers such as free clinics and emergency rooms once undiagnosed chronic illnesses such as high blood pressure, high cholesterol, and diabetes start to cause complications.
At this point, the public health insurance plan being discussed as part of the healthcare legislation is what appears to be causing the most discomfort among those who oppose the idea. According to polling by Health Care for America Now! (HCAN) the idea of a public health insurance plan is well received by a majority of Americans. This plan would work within the current marketplace to provide an option beyond the commercial insurance plans. This plan will allow for more equitable enrollment of people who are healthy and require relatively few health care interventions and those who require more health care resources. Currently, a disproportionately large number of patients who require more health care are enrolled in public plans (Medicare and Medicaid) while those who are less-frequent users are disproportionately enrolled in private plans. If a public plan enrolled Americans from both the high-use and the low-use groups then the costs of premiums would be lowered and more affordable. This option could also make use of the fact that government-run programs have historically had much lower overhead costs for administration purposes (around 5% or so for public plans) as compared to for-profit commercial plans (nearly 30%). In addition, a public plan could be structured to emphasize health maintenance and health-promotion (including consideration of ideas such as the patient-centered medical home) that will prevent illness while also increasing the appeal of primary care medical careers. The public plan could also emphasize health interventions that work and that are cost-effective, as opposed to promoting new and flashy medications and technologies that have little to no additional benefits but that are dramatically more expensive.
It is a shame that Ms. Dean questions whether party affiliation will affect health care, and that she invokes President Obama’s position on abortion to question the motivation and results of these health care reforms. This issue is too serious, will have too many long-term repercussions, and will affect too many people to get caught up in unfounded rumors. There is no call in the current plan for a single-payer national health plan (much to the distress of many who would support it and who can show evidence that such programs improve outcomes and reduce costs)—if the public health insurance plan that is being discussed is not viable, then it will fail in the marketplace. There has been no indication that party affiliation will have anything to do with the coverage one will receive. By developing a health care reform plan that intends to provide affordable coverage to everyone, the current administration is seeking to provide care to the most vulnerable members of our society while also making care available to everyone else: the working poor who represent a large proportion of the uninsured; the self-employed and small businesses who have to choose between paying exorbitant premiums to commercial plans or reduce or eliminate coverage for themselves and their employees; large corporations who face a built-in hurdle compared to other developed nations because American companies have to pay high costs for employee’s health insurance while carmakers in other countries do not have to face this challenge. In short, the current health care reform efforts present a chance to provide meaningful and valuable care for all while still allowing for individual plan choice and reducing costs.
There is no question that our current healthcare system is unsustainable. We pay far too much for much too little, and too many are left uncovered. We need to take full advantage of this opportunity and develop a long-lasting, improved system. This legislation will dictate healthcare in the United States for decades, and it needs to include coverage that would be available to everyone and that will focus on health maintenance, treatments that provide health benefits and are cost-effective, and that will be sustainable long into the future.
*************************
So, that's my perspective. I'm interested in any comments or thoughts, so please feel free to post some if you would like to.
Thanks.
Saturday, June 27, 2009
More Excitement Than I Ever Wanted
I spent the first 2 weeks of June in the Dominican Republic with an international medical service group from Virginia Commonwealth University School of Medicine. It was a part of a larger program--the Honduras Outreach Medical Brigada Relief Effort (HOMBRE).
This was the first year that the DR was part of HOMBRE. Things went well for the first 1/2 of the trip, but as we were getting ready to transition to another site we were attacked in our hotel. You can read a little more detail at the Dominican Aid Society of Virginia (DASV) website (the "What We Think" section) as I'm really not up to re-writing it.
I believe international medical service trips are valuable and are important. Medical students that participate in international trips are more likely to work in underserved communities and to pursue primary care careers. These events will not dissuade us from returning to the DR, but we will be working to figure out how to try and avoid any similar events down the road.
This was the first year that the DR was part of HOMBRE. Things went well for the first 1/2 of the trip, but as we were getting ready to transition to another site we were attacked in our hotel. You can read a little more detail at the Dominican Aid Society of Virginia (DASV) website (the "What We Think" section) as I'm really not up to re-writing it.
I believe international medical service trips are valuable and are important. Medical students that participate in international trips are more likely to work in underserved communities and to pursue primary care careers. These events will not dissuade us from returning to the DR, but we will be working to figure out how to try and avoid any similar events down the road.
Saturday, May 23, 2009
Back in the city
Just to pick up on the last career-related blog:
In the summer of 2007, I started a new job at a Virginia Commonwealth University (VCU) Health System community health center on the south side of Richmond. It's been nearly 2 years since I have been working there, and it has presented the challenges and rewards so often seen in working in marginalized communities.
The patients we work with have little access to health care elsewhere. Most of our pediatric patients are from Spanish-speaking families who have very few Spanish-speaking doctors to choose from. On the adult side, most of our patients lack insurance and have qualified for patient assistance from the health system (the VCC program). VCC allows these patients to access primary care service, including preventive care and rotuine check ups for chronic illnesses) at little or no cost.
I feel that, by working at this office, I am able to provide a Spanish-speaking option for our pediatric patients and I can expand the services provided to our adult patients. I think this health center, the Hayes E. Willis Health Center of South Richmond, feels a critical role in the community and has a large potential benefit to the health center in a number of different ways. I'll try to discuss that more in the future.
In the meantime, I am preparing to travel to the Dominican Republic in 10 days for a 2 week medical service trip. You can see more about that at www.DominicanAidSociety.com.
(to be continued...)
In the summer of 2007, I started a new job at a Virginia Commonwealth University (VCU) Health System community health center on the south side of Richmond. It's been nearly 2 years since I have been working there, and it has presented the challenges and rewards so often seen in working in marginalized communities.
The patients we work with have little access to health care elsewhere. Most of our pediatric patients are from Spanish-speaking families who have very few Spanish-speaking doctors to choose from. On the adult side, most of our patients lack insurance and have qualified for patient assistance from the health system (the VCC program). VCC allows these patients to access primary care service, including preventive care and rotuine check ups for chronic illnesses) at little or no cost.
I feel that, by working at this office, I am able to provide a Spanish-speaking option for our pediatric patients and I can expand the services provided to our adult patients. I think this health center, the Hayes E. Willis Health Center of South Richmond, feels a critical role in the community and has a large potential benefit to the health center in a number of different ways. I'll try to discuss that more in the future.
In the meantime, I am preparing to travel to the Dominican Republic in 10 days for a 2 week medical service trip. You can see more about that at www.DominicanAidSociety.com.
(to be continued...)
Saturday, March 21, 2009
Continued decline in primary care
The results of this year's National Residency Match Program (NRMP), referred to everywhere as the Match, show a continued struggles to bring medical students into primary care.
The American Academy of Family Physicians reports that fewer medical students chose to enter family medicine this year. This continues the downward trend since 1997 in the number of students choosing family medicine. Last year showed a small increase in the number, but it appears to have been an exception. This is combined with fewer and fewer residency postions offered over the same period.
So--fewer family doctors are being trained every year. Family physicians provide health care to many, many underserved areas in the United States and if the numbers of family physicians being trained continues to drop, one expects that more and more communities will be designated as medically underserved.
To add to the problem, fewer students entered primary care internal medicine and internal medicine/pediatrics programs. Primary care pediatrics has also been struggling to fill offered positions.
So--primary care physicians, who are in short supply now and will continue to be in short supply for some time are not being trained at the levels needed to maintain the workforce. The largest culprit for this seems to be worries around medical school debt: students are less likely to consider primary care if they carry high levels of debt and instead move toward better-compensated specialties. In addition, the current structure of funding medical schools and the structure of medical school educational programs appears to discourage students from considering primary care (especially family medicine) careers.
As primary care continues to be undervalued in our health care system and as primary care physicians continue to be underpaid relative to the critical role they play in the health care system, it is easy to predict further declines in the family medicine/primary care workforce until either major health care reform makes the career option more palatable for medical students or a level is reached where this difficult situation becomes a greater crisis.
The American Academy of Family Physicians reports that fewer medical students chose to enter family medicine this year. This continues the downward trend since 1997 in the number of students choosing family medicine. Last year showed a small increase in the number, but it appears to have been an exception. This is combined with fewer and fewer residency postions offered over the same period.
So--fewer family doctors are being trained every year. Family physicians provide health care to many, many underserved areas in the United States and if the numbers of family physicians being trained continues to drop, one expects that more and more communities will be designated as medically underserved.
To add to the problem, fewer students entered primary care internal medicine and internal medicine/pediatrics programs. Primary care pediatrics has also been struggling to fill offered positions.
So--primary care physicians, who are in short supply now and will continue to be in short supply for some time are not being trained at the levels needed to maintain the workforce. The largest culprit for this seems to be worries around medical school debt: students are less likely to consider primary care if they carry high levels of debt and instead move toward better-compensated specialties. In addition, the current structure of funding medical schools and the structure of medical school educational programs appears to discourage students from considering primary care (especially family medicine) careers.
As primary care continues to be undervalued in our health care system and as primary care physicians continue to be underpaid relative to the critical role they play in the health care system, it is easy to predict further declines in the family medicine/primary care workforce until either major health care reform makes the career option more palatable for medical students or a level is reached where this difficult situation becomes a greater crisis.
Health care reform
Another digression from my oh-so-interesting life story to touch on health policy again. As is obvious to anyone who has any contact with health care (patients, doctors, etc), health care in the United States is in bad shape. Costs are increasing dramatically, but we still rank very poorly in terms of meaningful health care outcomes. 50% of all bankruptcies in the U.S. are due to medical bills and, of these, 3/4 had health insurance at the time they became ill yet STILL became bankrupt. Doctors are frustrated with insurance hassles, employers (who provide health insurance to most Americans) are struggling with the costs, and patients are going without needed care. Meanwhile, the system itself is focused on dealing with illness and is not adequately focused on promoting wellness and providing preventive care.
President Obama has made health care a priority for his administration, and has proposed 8 principles for quality health care:
This is going to be a KEY period in health care, and might determine the face of U.S. health care for the next generation. I intend to post again soon to give some thoughts on the issue.
President Obama has made health care a priority for his administration, and has proposed 8 principles for quality health care:
- Protect families’ financial health.
- Make health coverage affordable.
- Aim for universality.
- Provide portability of coverage.
- Guarantee choice.
- Invest in prevention and wellness.
- Improve patient safety and quality care.
- Maintain long-term fiscal sustainability.
This is going to be a KEY period in health care, and might determine the face of U.S. health care for the next generation. I intend to post again soon to give some thoughts on the issue.
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