Tuesday, May 28, 2019

Growth, Progress, Drugs, and Health Care: All in pursuit of profit


There are times that I worry that I might come across as a Luddite, opposed to new drugs, new technology, progress and change, because I am often critical about how these changes are happening, and also frequently have dampened enthusiasm and expectation for the probability that they will be successful in achieving their stated goals. For the record, I am not against either change or progress, although the definition of “progress” is a loaded one; progress is only good to the extent that it makes people’s lives better. Of course, if it does not it can still be considered “change”, but may well be regress.  Here I exhibit my values: it has to make people’s lives better, and not just those of a few people, but essentially everyone.

I have recently been re-reading John Nichols’ novel “The Magic Journey”, originally published in 1978. While Nichols’ most well-known book is probably “The Milagro Beanfield War”, published in 1974 and made into a film with Ruben Blades in 1988, “The Magic Journey” is his magnum opus. It documents the transformation of Chamisaville, a fictional town that is a thinly-disguised Taos, from a 400-year old subsistence agrarian economy with little cash changing hands, to a “modern” town. A major way this occurs is through the hiring of young people to build things, paying them salaries, allowing them to buy stuff, going into debt, and selling off their families’ land. It is a bit more complex than that, because the “Anglo Axis” controlling this change does far more direct and clearly evil things to move the process along, but the change, the progress (as it were), occurs. It both changes and does not change the life of the people who live there. Yes, they (or many of them) may now have cars and refrigerators and central heating (and the debt that goes with it), but they mostly all still remain poor, and on the edge of desperately poor, often teetering and sometimes falling. Meanwhile, the positive joys of their lives, the music and singing and storytelling and culture fade with each generation, except those that are commercialized for sale to tourists. The Anglo Axis does well, of course, and the one consistency in their decision making is how to make more money and, in order to continue to do so, cement their control and hold on power at every level.

The story of Chamisaville is a story of capitalism – of its triumphs, bringing progress, and its dark, dark side, institutionalizing a continuing oppression and repression. And, in this, it is a microcosm of the US, and much of the world. The health care industry is a big part of that world, and it is run by the same folks for the same reasons. To wit: make as much money as possible, regardless of who (else) gets hurt. And to press forward with the marketing campaign – health is good for you, right? – so that those who control it continue to make money. In capitalism, certainly US capitalism, “progress” is one of the two most commonly used vector words, along with “growth”. Both, the story goes, imply “better”, but this is not always the case.

We know – or should know by now – that “growth” can be terribly bad. With 7 billion people on the planet, most of them in desperate poverty we also have desperate inequality (in India, for example 9 people have as much wealth as the bottom 50% of the population – that’s 600,000,000 people!), we have limited resources. And we spend an enormous percentage of them on war, which continues to compete with the climate crisis generated by our dependence on fossil fuels to see which will be the first to wipe out life on earth, not just our health. The mantra that growth will solve all our problems is not only wrong, it is by now backward.

Yet, in health care, we continue to strive to make progress, and it is not always bad. But one does not have to be a Luddite to note the risks and contradictions. Novartis has just released a new gene therapy, Zolgesma® that treats spinal muscular atrophy, a terrible genetic disease. That is a good thing. But it costs $2.1 million. That is an unbelievable thing. Should it be made available to the children who need it? Yes. Who pays? Not the individuals (unless they are at least multi-millionaires). The insurers? Yes, but then it gets spread to all those with that insurance. The society? Like a national health insurance plan? Sure, but who decides that Novartis should get $2 million for it? This is a big deal. It isn’t that children with this disease should not be treated, but it is the fact that LOTS and LOTS of other people with more prosaic diseases could be treated for that money.

How to allocate resources will always be a difficult decision for health care. More for lower cost services that benefit more people or more for higher cost services than are critical to a few is an ongoing decision made in nations throughout the world because all resources are limited. However, a few things are clear (to me) that should guide these decisions. The benefit of the many should take precedence over the benefit of the few, even if the few are very rich (and I am not saying that the families of SMA children are). This is easy to say, but becomes more difficult when the benefit to the few is great and the benefit to the many is smaller. Or when you are one of the few. Quality of life is important; in the US and some other rich countries, enormous amounts are spent on high-technology care at the end of life. Yes, sometimes it is difficult to know when the end of life will be exactly, but it is often clear that what is being done is protracting existence without quality or hope of improvement. And, in this context, huge profits for the drug manufacturers is not something that should be built into the equation.

It is not only end-of-life care that skews high-technology. Investment in whiz-bang stuff is always, somehow, sexier than providing the care that we already know how to do, already is relatively cost effective, and is not brand new. We need to keep this in mind as we develop, invest in, propagate, and utilize new technologies. Luke Miner’s Op-Ed piece in the New York Times, ”For a longer, healthier life, share your data” argues that the Health Insurance Portability and Accountability Act of 1996 (HIPAA) too extensively restricts data sharing among providers and especially to researchers, who could use this “big data” to identify epidemiologic patterns and link them to genetic profiles within populations, enhancing  both the likelihood of diagnosis and the opportunity to develop treatments. In addition to HIPAA, his big emphasis is on artificial intelligence (AI), and how it could compile and sift through this data to achieve results never before possible. He suggests that, as long as HIPAA prevents sharing this data without your permission, that you give your permission.

This is not necessarily a bad idea, but can never be divorced from the MOST core concept: Who will control that data, and perhaps even more important, who will PROFIT from it. The evidence is absolutely clear: there is nothing so destructive, so evil, so heinous that some people will not do if it makes them enough money. This is lesson #1.

Lesson #2 is that before, or at least while, we invest billions in genetic drugs, personalized medicine, artificial intelligence, high-tech gizmos that will help some people, or maybe (no guarantee!) in some future help a lot of people, we have to be able to disseminate the well-know and cost-effective treatments that we have. Millions die daily from preventable (see: vaccines) or conditions treatable with things we have available to us.

The real magic, the real whiz-bang, the real excitement, will be in ensuring the widest possible implementation of what we already have to care for all the people who need it.

Sunday, May 12, 2019

Requiring TV drug ads to post list prices: a good step from HHS -- but not enough!


"What I say to the companies is if you think the cost of your drug will scare people from buying your drugs, then lower your prices."

Terrific quote from the not-always-terrific Health and Human Services Secretary, Alex Azar. The Department of HHS will require TV ads for drugs to disclose the list price for the drugs they advertise. Sure, they will be at the end in the small print along with the side effects (‘nausea, vomiting, headache, baldness, serious infections, death, etc.’), and thus far there are no plans to require it in print ads, but it is a big step forward. There is so much evil being done by the Trump Administration that it is nice, every once in a (long) while to be able to point out something that is good. The #Trumpenik himself tweeted something very similar to Azar’s quote.

This has been one effort by the Administration to try and control drug prices by a very indirect route that, tellingly, does not include actually controlling drug prices. It does not even include allowing Medicare (the nation’s biggest drug purchaser) to negotiate drug prices with pharmaceutical manufacturers (that ban was built into the GW Bush era legislation that created the Medicare drug requirement, Medicare “Part D”). Still, it is something and something that is not insignificant. You can tell this from the reaction of the drug manufacturers, represented by PhRMA (the Pharmaceutical Research and Manufacturers of America), which said “We are concerned that the administration's rule requiring list prices in direct-to-consumer television advertising could be confusing for patients and may discourage them from seeking needed medical care." It takes some chutzpah to say such a thing; what PhRMA wants is for patients to demand these drugs (some of which cost upwards of $30,000 a year. Or, for some, a month!) from their doctors, and then the doctors to put pressure on insurers to cover them.

Yes, often the price paid by the insurance company will be much less than the list price that the new regulations will require them to put on their TV ads. But there will still be those, the poorly insured and uninsured, the most needy, who will have to go without, who, even if they are not discouraged from seeking needed medical care will find out that it is not really available to them. While PhRMA is the trade group for the most profitable industry in the US, their objection to posting list prices is mirrored by health providers, especially health systems, who argue that posting their prices from their “chargemaster” is deceptive because insurance companies often (usually) pay less. Yeah, so? Why not charge less and let them pay the charge? This is how it is in most other industries, and in healthcare in most other countries.

The pharmaceutical industry has a well-deserved reputation as an evil cabal, and it is not only the “outliers”. Yes, we have the fantastic extremes of Heather Bresch’s Mylan and its Epi-Pen®, and Martin Shkreli and colchicine, but we also have the “mainstream” pharmaceutical companies who have unconscionably raised their predatory pricing on key life-saving drugs, like insulin. NBC reports a doubling of the price of insulin from 2012-2016, and stories on people who are affected abound. In 2017, the pharmaceutical companies were accused of fixing the price of insulin. They deny it, but their actions belie that denial; in March, Eli Lilly agreed to sell a “generic” version of its Humalog® for half price and ExpressScripts, a pharmacy benefit manager (PBM, read either facilitator or middleman, but however you read it, it is “moneymaker”) said it would offer to cap insulin costs at $25/month. Interesting for a drug whose discoverers refused to patent it because they wanted it freely available to the public. (And, interestingly, insulin still does not require a prescription, although the needles and syringes do…) The NY Times recently reported that “Lawmakers in Both Parties Vow to Rein In Insulin Costs”, but we shall see.

Of course, while its reputation as evil is well-deserved, the pharmaceutical industry is not alone in making rapacious profits from our health needs. The entire “industry” is not about making people healthier, or even curing the sick, but on making money. This includes, of course, insurers, but also health providers, hospitals, health systems, nursing homes, doctors, etc. Ever try to get a price on any health care you need, besides drugs? Ever try to figure out a bill? Two stories from my own life I have written about before but will re-tell here:
Some years ago I had outpatient hernia surgery. I arrived about 6:30am and was back home in my bed by noon. Later I got the bill from the hospital for its charges (not including the doctors’): $10,000. Then my insurance company told me that I would pay $400, they would pay $1,600, and the hospital would write off the other $8,000 as a contractual adjustment.

Of course, if I had been uninsured, I would have not been billed for the $2,000 the hospital actually received, but for the whole $10,000! This is why they don’t want to list their charges. This obfuscation is motivated by insurance companies looking to show what a good deal they provide their customers (look! We saved you $8,000!). Of course, this is baloney; since the hospital was willing to settle for $2,000, that is what they should have charged, everyone.

And price lists? Time for the other story.
I live an hour from the border, and, with Medicare but no dental coverage, I go to Mexico to get my teeth cleaned. It costs $35; a lot less that in the US and is done quickly and thoroughly by a dentist. It costs everyone $35. If you have dental insurance (they take it), it costs $35. But say you need more – a filling, a crown, implants. Not only is it a lot cheaper than in the US but they can tell you exactly how much it is going to cost! A friend had several implants, and this cost thousands (but a fraction of the US cost); the point is they told her exactly what the cost would be up front. This, it turns out, is actually possible!

The article I cited at the beginning, from the Associated Press (and read by me in the Arizona Star, shout-out), quotes
‘Leigh Purvis, a pharma expert with AARP's research division, [who] said disclosure will help dispel a "cloak of darkness" around prices and encourage more informed discussions between patients and their doctors. But she cautioned against expecting too much.
‘"The overall idea of reducing drug prices is something for which there is no silver bullet," said Purvis. "This is just one step, one tool in what will have to be a very big arsenal."’]

She is right. I said it was a good step, worthy of praise, but it will not alone be enough to bring down drug prices. Or the cost of any of the health care we are regularly ripped off for. While the burden will continue, as always, to fall heaviest on those who can least afford it and have the greatest need, it is impacting everyone. Let’s start with letting Medicare negotiate drug prices. Let’s regulate insurance company profits. Let’s make everyone in the health industry post their prices.

Indeed, let’s have a universal, single-payer health system. #MedicareforAll!

___________________________
Breaking News: 

Lawsuit by 44 States Accuses Pharma Giants of 'Multi-Year Conspiracy' to Hike Drug Prices by Over 1,000%


Sunday, May 5, 2019

Whence, and whither, family medicine: will it have role in improving our nation’s health?: Part 3

The 25th J. Jerry Rodos Lecture, presented at the 30th Annual Conference of Primary Care Access, Kauai, April 8, 2019:



Part III: Whither Family Medicine and Our Health?

So, in the end, is it all about money? Is it about the primacy of profit? We have seen massive consolidation of health systems, all focused upon making money, even if not “for profit”. Doctors as employees, are “pawns in the game” (remember the Dylan song?). PAs and NPs added not because better but because cheaper. FPs are only good because they are cheaper. Do the key principles of family medicine really make a difference? Barbara Starfield said yes, but she is gone and so is the control FPs had of their practices. We are ambulists (some of us hospitalists), few of us deliver babies. How many even care for families?

Perhaps the variety is why we become family doctors. We have variety in our patients, not just limited to one kind of disease or organ system, and we have variety in our day. Well-child, older person with chronic diseases, sports injury, pregnant woman, substance user, minor surgery. Maybe it is this variety that keeps us going, and makes us different from the sub-sub-specialist who needs to know all there is to know about very little. It is challenging because it is more complex, much as that might grate on the specialist; what they do maybe difficult but it is the same thing over and over. A Graham Center one-pager (by me!) looked at complexity in terms of how many different diagnoses, ICD-9 codes, it took to account for 50% of all codes by specialty.  For family medicine, it took 23 codes, for IM 18, for pediatrics 11, for cardiology 6, and for psychiatry 3![i]

We often hear about family physicians being replaced by NPs and PAs, but what about other specialists? Their practices are often more routine, more all-the-same, and in fact easier for NPs or Clinical Nurse Specialists to replace, as we see daily in hospitals. The Clinical Nurse Specialist in Heart Failure knows all there is to know about a narrow practice. But they – both the physicians and non-physicians -- make more money than FPs or FNPs. Is that all it is about?

There are many other challenges that face us, and face other specialists as well. One of the things that my colleagues in other disciplines complain about, and I agree with, is the apparent attrition of critical thinking among many of our trainees. This probably has many intellectual, educational, and social causes, but a big one seems to be the electronic health record (EHR), and the fact that our employers, health systems, have designed them to maximize reimbursement, not truth (is it all about money?). Much of the EHR is about filling in boxes and checking the ones that make our employers the most money. It is about cutting and pasting rather than thinking. The patient had a chest x-ray? Just paste in the whole radiologist report. This creates a huge long note, is a bear to read, is available elsewhere in the record (under, like, ‘radiology reports’, where it was cut-and-pasted from!) and requires no judgement! A simple “normal chest x-ray” (or ‘chest x-ray with interstitial infiltrates, possible pneumonia vs congestive heart failure’) required at least some thinking and judgement. The old “SOAP” note is entirely unbalanced, with not too much in “S” (patient history), bloated “O”s (cut-and-paste) and then – Plan! Almost no “A”, no assessment, no taking the information provided above and reflecting on it and thinking about what it means, or might mean, or might be if it doesn’t mean the first thing. It may be this that is the greatest threat to the role of doctors, any doctors, except as technicians.

But it is not just residents and students and practicing doctors that are being co-opted into a world of rote. Our family medicine leaders – program directors and chairs -- must help contribute to the “needs” of their health system –that is to make as much money as possible. We may, as individuals, care very much for the individuals who are our patients and for good practice, and I think we do, but our institutional role can overwhelm that. For caring for selected populations, mainly those who we get reimbursed for. I remember in the early 1990s, in the days of the Clinton health plan, seeing a version of this cartoon: R. Dolan, MD. “Specializing in the diseases of the insured”.

Our organizational leaders should – and do not always -- guard against the seduction of being part of the “in group”, getting to go to meetings (especially if paid for) being named to policy-making committees and commissions, hobnobbing with other “leaders”. Or maybe I’m wrong, maybe it’s just me, maybe this is really the good part about being a leader, not providing effective advocacy for your faculty, residents, students, and most of all patients? One need not be José Baselga, the former head of Sloan-Kettering who lost his position over graft and lack of disclosure, to lose one’s way – but that is the end of gradual moral and ethical compromise.

Over a decade ago the discipline undertook a major study and marketing program, the Future of Family Medicine. What do you remember from it? I remember that 2/3 of those who thought they had a family doctor really did and 2/3 of those with a family doctor knew it. I remember that when presented with the idea of a doctor who had the characteristics we associate with a family physician – the “Starfield” characteristics of comprehensive, continuous, compassionate, and personal care in the context of family and community – there was terrific resonance among the American people. I remember that specialists valued family physicians almost more than we valued ourselves. But what came of this? Is our health system more oriented to those values and characteristics than it was?

Now we have another project that cost the discipline $20 million, the Family Medicine for America’s Health (FMAHealth) project. Will it change the way the discipline practices and is structured, or will it be more of the same? How many of you have read the reports of the “tactic teams” in the recent February issue of Family Medicine? What do you think? As my friend John Saultz, editor of Family Medicine, notes that if FPs don’t define themselves, their roles, and their scope of practice, others will. It is happening and we as a whole are buying into it.

Is there hope? This is where I always say “a national health system”. I still say it. It is true that a national health system will not solve society’s problems – people will still need homes and food for health. It will not ensure quality of care. It will not mean that family medicine gets its due as the centerpiece of healthcare.

But it provides the context and mechanism for all of these. Most important, and of course this will be the challenge – it will change the focus of the health system from making money to be about delivering health care. It would provide a context for truly measuring quality. It would provide a reason to emphasize critical thinking. It would provide an impetus for health professionals to demand societal changes that will make a difference for people’s health. It would provide a way to make population health really be public health by not excluding anyone.

There will always be those who say we need to compromise, we cannot go too fast; it is something we are commonly hearing now as the campaign for the 2020 Democratic presidential nomination goes forward. But compromise is not always a good thing. Stephen Covey notes it is often lose-lose. We need win-win.

We need completely universal health care. 90% covered won’t do. “99-1/2 just won’t do” (Mavis Staples) because those are real people who are left out. Compromise means real people will not have health care. So the advocates of compromise need to specifically identify who those left out will be. I’m pretty certain they don’t think it will or should be themselves. Unless they are suggesting that we are going to leave them out, leave out the politician, pundit, wealthy, and their friends relatives and neighbors, then the people who need it most should get it most.

In the 1970s the British GP and epidemiologist Julian Tudor Hart put forward the “inverse care law”: the availability of care is inversely proportional to the need for it.[ii]

Let us correct that.

Health care for all!



[i] Freeman J, Petterson S, Bazemore A, “Accounting for Complexity: Aligning Current Payment Models with the Breadth of Care by Different Specialties”, Am Fam Physician, 2014 Dec 1;90(11):790.
[ii] Hart JT, “The Inverse Care Law”, Lancet. 1971 Feb 27;1(7696):405-12.

Monday, April 22, 2019

Whence, and whither, family medicine: will it have role in improving our nation’s health?: Part 2


The 25th J. Jerry Rodos Lecture, presented at the 30th Annual Conference of Primary Care Access, Kauai, April 8, 2019:


Part II: More whence, and some whither family medicine

Family medicine introduced many great things to medical education. We had non-physician faculty in our departments and residencies, psychologists and educators, unheard of then. We valued education, and realized that just being a good doctor was not the same as being a good teacher, so created faculty development programs, including fellowships, often supported by Title VII grants. Our Board required recertification from the beginning, and no one, not even those who created it, were immune, or “grandfathered in”. Many of these innovations (if not the “no grandfathering”) were adopted later by other specialties, although not always crediting the discipline family medicine. And many specialties have not adopted them yet, still to their shame.

But, in the US, family medicine is still somewhat on the margins. It never completely took over as the centerpiece of the health system, not as in Canada or the UK. Much of the opposition has been regional, especially in the NE, and in cities where there were already plenty of doctors who did not want to give up control – or money (remember that word, money, we’ll be coming back to it). Of course, then, as now, most pundits who comment on medicine – actually, on all things – are, at least relatively, well to do. Poor people often adopt such attitudes as “specialists are better”, because they assume that what the rich have is better (bigger houses, better cars, certainly better doctors), although those of us who went to medical school know that that is not necessarily true. Our classmates who wanted to become elite subspecialists caring for the rich did that, and those who wanted to serve the needy did that, and it had little or nothing to do with class rank or skill. Of course, the obstacle to poor people getting what the rich get is, well, they don’t have, and so their doctors wouldn’t make, enough money!!

The small-town white picket fence practice, of Marcus Welby and many fathers and grandfathers (less commonly mothers or grandmothers) of current FPs, such as many of those portrayed in Fitzhugh Mullan’s book ‘Big Doctoring’,[1]


may be mostly gone, but that model was long the darling of the RRC; those of us working in inner-city training settings often felt that the rules were written for someone else. 

Other issues confront us, sometimes divide us. Should the future of family medicine be about “full scope” practice, including caring for children, delivering babies, hospital work, emergency care, musculoskeletal care? Or should it be limited, specialized even (OB, geriatrics, sports medicine)?  Should we be using the term primary care or family medicine? What about general internal medicine? Pediatrics? GIM has pretty much abandoned the field, since 80% of IM graduates become subspecialists and over half the remainder become hospitalists. Should we just stop saying “primary care” and insist on “family medicine”?

Most of us recoil at the oft-heard-from-medical-students idea that GIM is family medicine without the OB and pediatrics. We think that there is a conceptual basis for our specialty that has to do with caring for the whole person and caring for them in the context of their lives, families and communities. Despite the concerns of the young Josh Freeman, this context is critical. The pediatrician cares about the health of the child she cares for, and likely that of the adult that child will become. The family physician also cares for both, but more concretely than the pediatrician experiences the health issues that adults face that often have at least part of their roots in their childhood experiences. In addition, the family doctor cares for that child’s family, and knows, for example, that the child’s mother is not just “mom” (I hate that usage!) but someone with their own problems, maybe a hard job, maybe not enough money, maybe a troubled relationship, maybe caring for her own parents, maybe with her own health issues. I have often said that if clinical sciences have associated basic sciences (like psychology for psychiatry, and anatomy for surgery) then anthropology is the basic science for family medicine because it examines people in the context of their families and communities.

Family medicine is also comprehensive, per se, by its nature. I was once able to recruit an anthropologist to our department because she wanted to work in that comprehensive context, and public health/preventive medicine didn’t really offer it. Preventive medicine is seen by some as holistic, but it segments just as medical specialties do: I do smoking, you do seat belts, she does bicycle helmets, he does violence. But the family physician has to address them all. We can’t say “wear your seat belt” but ignore “stop smoking”! Or, is that what we want FM to become? Geriatricians and sports medicine and women’s health? Hospitalists and ambulists, nocturnists and weekendists? (By the way, that anthropologist went on to help run the AAFP’s national research network.)

Sometimes the issue of how family physicians practice is formulated as a conflict between lifestyle and scope. Is that true? Maybe. Maybe it is good to not take call, or too much call, or have to round in the hospital or have to get up to deliver a baby in the middle of the night. But it may also be true that for a well-trained family doctor, 8-5 clinic patients can become drudgery. Sometimes teaching helps. And what about the issue of lifestyle vs lifestyle? People want to move to and practice in cool places to live, with a lot going on, stimulating cultural events and good educational systems. But these places may pay less money and cost more to live in. Besides your practice, do you want to be San Francisco poor or Nebraska well-to-do? That old white picket fence family doc may have had no conflict, but now young people do.

There have been lots of changes in the health system in my lifetime. Family medicine was created in the 1960s and grew to adolescence in the 1970s. In the 1980s we had lots of promise; Nixon pushed for HMOs, and in the 1990s we had gatekeepers – and different opinions about whether that was good or bad. Our best resident matches were in the late 1990s; no student wanted to be an anesthesiologist because they were afraid of not getting a job. But now ….

One study showed a student entering an anesthesiology residency can expect to make $7 million more in their lifetime than one entering family medicine. In this country. When I was in Denmark a few years ago I visited a rural family practice. In conversation, the doctor mentioned his daughter was married to an anesthesiologist. Tied to my own country’s norms I joked that at least he wouldn’t have to worry about being supported in his retirement. Oh, he replied, in Denmark family doctors make more than anesthesiologists!
Is it all about money?

We have a health system that fails to focus on the health of the people. We have almost abandoned the concept of public health. Indeed, the currency of the term “population health” is more than a semantic difference. Population health can be narrowly defined to be any population – the population of your practice, say -- and it can and does often leave people out. The people who are hard to care for, or don’t make money for us, or mess up our statistics.  Public health requires us to look at the WHOLE public. Eew! How messy!





[1] Mullan, Fitzhugh. Big Doctoring in America: Profiles in Primary Care. Millbank. 2002.

Saturday, April 13, 2019

Whence, and whither, family medicine: will it have role in improving our nation’s health?: Part 1


This was the 25th J. Jerry Rodos Lecture, presented at the 30th Annual Conference of Primary Care Access, Kauai, April 8, 2019:

Part I: Whence family medicine, and me

The history of family medicine is familiar to those of us attending this conference. Although most of us were not there “at the beginning” in the 1960s, we have heard, frequently at this conference, about the seminal reports, people, and events that led to the founding of our discipline.

The Willard Report, issued in 1966, was commissioned in 1964 by the American Medical Association’s Council on Medical Education and found that medicine needed a new kind of specialist, the family physician, educated to provide comprehensive personal health care within the nation’s complex healthcare system. It defined a family physician as one who “accepts responsibility for the patient’s total health care within the context of his or her environment, including the community.”[1] The COME also commissioned a report on graduate medical education to achieve this goal, and the Millis Report was also issued in 1966. It contained one of the earlier modern definitions of a primary physician, one who “...will serve as the primary medical resource and counselor to an individual or a family”.[2] The 1967 Folsom Report, developed by the private National Commission on Community Health Services and sponsored by the American Public Health Association and the National Health Council, called for “communities of solution”.[3]
 
Following these reports, the AMA hired two early leaders in our field, Drs. Leland Blanchard and Lynn Carmichael to “develop family practice”, and they crossed the country doing just that; Carmichael established the first FP residency at the University of Miami in 1965.[4] By 1969 there were 16 residencies. These early residencies were led by major figures in the history of the discipline, including Gayle Stephens in Wichita and Gene Farley at the University of Rochester, and grew to nearly 500 by 2016.[5]

The choice of the term “family doctor” to replace “general practitioner” was not incidental. The ABFM was founded in 1969, but the AAGP did not change its name to the AAFP until 1971, after at least 3 failed efforts. Obviously, people had always referred to their primary physician as their “family doctor” and for marketing purposes the term “family doctor” evoked positive feelings among the American people.

Like everyone here, I am sure, I can tie this to my personal story. Entering medical school in 1973, I did not come from a medical family, and think my parents had only one physician among their friends. I knew what kind of doctor I wanted to be, but not the right word for it. I didn’t even register GP; I wanted to be a “regular doctor”. You know, the kind you can go to with whatever is wrong and not have to diagnosis yourself first, and they can take care of it. As far as specialties were concerned, I guess I had an idea that pediatricians took care of children and obstetricians delivered babies. And maybe from high school friends who had money as well as acne, I knew that dermatologists took care of skin, but that was probably it. Of internal medicine, which played such a huge part in medical school, I had no concept; if anything I would have probably guessed it had something to do with gynecology, as I remember my mother having gone for annual “internal” exams.

My medical school, Loyola, had no family medicine at that time, but as I approached my scheduling for clerkships I found out that there was a physician, Werner Cryns, who ran a family practice clinic at the school. Trained as a pediatrician, Dr. Cryns had gotten private outside funds to establish this small clinic in a corner of the medical school, and I chose it for my elective. It was also my first clerkship, and from then on, I knew that was what I wanted to do. I did my residency at Cook County Hospital in Chicago, under Dr. Jorge Prieto, only the fourth full class to start in 1976. (Little side story: the hospital had always given out an “intern of the year” award, and in the first full class of FP residents, in 1973, it was won by one of them. Everyone else freaked out because “they rotate with everyone; they’ll always win it”, so there went the hospital-wide award. It became departmental.) I wanted very much to work at this public hospital with all of my socially and politically conscious friends from many of the Chicago medical schools, and was thrilled that they had a program in family medicine.

I had interviewed around the country, though, and found out about different programs, including two others that consciously saw themselves as training doctors for the urban inner city populations, Montefiore and San Francisco General. If I had gone to Montefiore, back in New York where I had lived my entire life before medical school, I likely would have had me a different life, but that cannot be known. I wanted to love SF General, as I loved San Francisco and had been unsuccessfully trying to get to California at least since applying to college, but was actually turned off by its emphasis on family dynamics and behavioral science. As someone who loved his own family but saw very much the negative impact that many families had on their children, I wanted to “keep the family out of family medicine”! Suffice it to say, I was wrong, and long since have understood the importance of the interaction of people, families, and communities, on an individual’s health.

At the 1989 Denver STFM meeting, I heard Gayle Stephens talk about “Family medicine as counterculture” (the talk was later published in Family Medicine[6]), and I admit that I was pretty surprised. I felt I had been part of the counterculture, but that doctors, even family doctors, even Dr. Stephens, were a bunch of old white guys in suits representing the establishment. I have to admit that, even though I have long since become an old white guy, and have been frequently known to wear a suit, the faces of those stern corporate-type authority figures from the 1950s and 1960s still make me anxious and a little bit hostile. (Full family disclosure, my father was a worker, not a suit.) But 1989 was a seminal STFM meeting.

I had already been attending STFM for some years, first in 1982 as a fellow at the University of Arizona, and then starting in 1985, when Dr. Prieto shared the educator award, every year since. If I make it to Toronto that will be 35 in a row. Actually, maybe it was 1988, in Baltimore, that was the seminal year, because that was the year Sen. Orrin Hatch received the Leland Blanchard award from the Foundation, orchestrated by Utah department chair and STFM matriarch F. Marian Bishop. I am sure Dr. Bishop did not anticipate, and surely did not appreciate, the antipathy of much of the younger cohort of STFM members to Sen. Hatch. From her point of the senator had been a big supporter of Title VII and family medicine. From our perspective, he was a virulent opponent of not only abortion rights, but ERA and other key issues affecting women. The only organized group within STFM opposing this was the Group on Women, which gathered signatures on a petition that was presented at the business meeting.

So, the next year, 1989, in Denver, there was a conscious effort to make a change. David Schmidt welcomed us with an upbeat and progressive speech. The Blanchard lecturer was Christine Cassel, then a professor of geriatrics at the University of Chicago and later a lot of other things, including head of the ACP Foundation and seminal in developing the “Choosing Wisely” program, speaking on medical ethics. In addition to Dr. Stephens’ talk on counterculture, Dr. Roger Rosenthal spoke about the need to care for underserved people. Several new groups were organized that year, including the Group on Minority Health, which still exists, and the Group on Universal Health Care, which had a shorter life. I felt really good about STFM and Family Medicine – and still do.

I met lots of people through family medicine – at STFM and the Program Directors’ meeting (later AFMRD), and this meeting, who were inspirational, like Frank Dornfest, the South African who was at the time program director in Santa Rosa -- the program our own Rick Flinders has written a history of -- and Gene Farley, who I met when I was a fellow at Arizona and he was chair at Colorado – an inspiration for his whole life. And some who were not old white men – Jorge Prieto, Denise Rodgers, and Carlos Moreno, and Janet Townsend, and others like David Swee and John Frey, white men who were not yet old! And the folks I worked with at Cook County – Pat Dowling, Janice Benson, and Crystal Cash, and many others. And, of course, many of those I have met or gotten to know better at this conference.

Part II: Whither family medicine, and American medicine, will be forthcoming

[1] https://cchs.ua.edu/the-willard-report-2/
[2] https://www.nap.edu/read/9153/chapter/4#10
[3] http://www.annfammed.org/content/10/3/250.full
[4] https://www.aafpfoundation.org/foundation/chfm/collections/exhibits/carmichael.html
[5] https://www.stfm.org/FamilyMedicine/Vol49Issue4/Carek275
[6] “Family medicine as counterculture”, Family Medicine, 21(2):103-109, Mar-Apr 1989

Sunday, March 31, 2019

Medicare for All: Still a great idea!


My last several posts have all had “Medicare for All” in the title. This makes one more. Maybe I am in a rut, or maybe it is simply the most important issue confronting health care in the US. Certainly there has been a lot written about it; just a review of very recent articles in the New York Times includes a wide variety. Conservative columnist David Brooks informs us that there is “no plausible route” to get to it, and we are told by Reed Abelson and Margot Sanger-Katz that there is “no precedent” for abolishing private insurance. The angst of the Democratic Party leadership in dealing with this newly-resurgent demand from its base is also discussed at length, with the Associated Press letting us know that it is a “divisive issue for Dems”. Robert Pear tells us about Nancy Pelosi’s plan to “expand health coverage” while being sure to not cover everyone. Of course, President Trump, not to be outdone (nobody outdoes the #Trumpenik!) has now announced his own plan, to completely gut and get rid of the Affordable Care Act and its expanded coverage. This is seen as a great gift to Pelosi, who needed something coming from way to her right, and now can “pivot hard” to fight to preserve ACA from the GOP rather than fighting with her own party’s progressives.

Of course, the Trump plan – get rid of Obamacare and then, well, don’t really have a plan after that, but it will be great – makes even a lot of Republicans nervous. Gail Collins has a particularly good time pointing this out, noting that
Republicans in Congress began desperately leaking the news that they had tried to talk their alleged leader out of the idea. The Democrats were almost swooning with joy. Really, Trump could not have made them happier if he’d announced that he planned to unveil a new tax cut called Help for The Greedy Rich.’
She also observes that the President has now moved from “who knew health care was so complicated?” to “I now understand health care especially very well”. Of course, he doesn’t – in fact, he understands it much less well than most policy makers, which isn’t very well at all, but he does understand how to both appeal to his base and please the wealthy folks who control the Republican Party, and indeed much of the Democratic Party.

It is frequently pointed out that many of the people who were most helped by the ACA, in particular its provisions that allow individuals to buy insurance at community rating, prevent discrimination against those with pre-existing conditions, and expanded Medicaid, are those in Trump’s base, and that eliminating the program and leaving another 20 million people without insurance might backfire. Paul Krugman’s column “The Republicans really hate health care” is accurate, and makes this point; for example, that West Virginia was promised better health care and more coal jobs. It has gotten only a few coal jobs, but 140,000 people stand to lose health care coverage if ACA is repealed. It remains to be seen if this will translate into folks voting against him and his minions, but I wouldn’t hold my breath. Although, even the Wall St. Journal has had an op-ed by Robert Pollin advocating for Medicare for All.
So what is it with the Democrats? The concerns that are expressed by many centrist, leadership Democrats about Medicare for All, or Universal Health Care of any kind seem to be in three broad areas: 1) Is it a good thing to cover everyone? 2) What will be the price Americans pay for universal health care? 3) Is this a politically feasible possibility? It is important to recognize that the fact that these questions are being asked at all, and that there is a significant portion of the Democratic congressional delegation who support Medicare for All, and that there is huge support among the American people, is YUGE. It is a testimony to how important health care is to us, to the fact that most of us are not buying the GOP line, and to the success that Sen. Sanders had and continues to have in raising the issue and continuing to focus on it.
First, is it a good thing to cover everyone? Answer: Yes. Everyone needs access to health care, and those who need it the most are often those who are left out of current, past, and future schemes for coverage – mainly poor, or near poor, people. It might be ok to leave some people out if those advocating it, advocating incrementalism, would suggest that the appropriate people to be left of were themselves and people like themselves, or the wealthiest, who can afford to pay their own way. But no, it is always the most vulnerable. And, anyway, there is great advantage to everyone being in the same system; the wealthy and powerful will ensure that the system works for them, and if everyone is in it together, it is more likely to work for everyone. The Times has a recent article about  Sen. Sanders saying “No to incrementalism”, which for some reason makes it sound like a bad thing. It is not. Certainly not if you and your family are being the ones left out by incrementalism!
Second, what will be the price? It will cost a lot to cover everyone. The numbers that even the sponsors of HR 1384, the Improved and Expanded Medicare for All bill whose primary sponsor is Rep. Pramila Jayapal of Washington, have put forward are very large. The thing is, though, the numbers that we spend NOW, by insurers and the federal and local governments (via Medicare and Medicaid and covering all their employees), and out of our own pockets in premiums, deductibles, and co-pays are far larger! And, of course, all this money buys us neither adequate health care for lots of people who are underinsured or have insurers denying claims, or good health outcomes. The US has for decades trailed the developed world in almost all measures of population health outcomes, and led only (by far) on money spent, both in total and per capita. Much of this money can be characterized as “waste” in the sense that it does not deliver health care to anyone, but is spent on high administrative overheads and profits for insurers and providers and drug manufacturers.
Third, is it politically feasible? This is an issue with lots of components. One highlighted by several articles in the media, such as the above-mentioned ‘Abolish private insurance: no precedent’ in the Times, are the jobs that will be lost in the insurance industry. And, although it doesn’t say it, in the offices of hospital providers who have armies of workers to fight with the insurance workers about payment. An expensive zero-sum game, except it is the people who pay. Sure, these are real job losses, but when has it been right to continue a bloated, non-productive industry that screws the whole country to protect jobs? I think never, but this is just a smokescreen for protecting profits. And HR 1384 actually contains funding for job retraining. The bigger issue for Democrats is money, money from big donors, as described in another NY Times article, ‘Even Liberal Democrats Can’t Quit Wealthy Donors and Their Big Checks’, although Sanders and Warren are the exceptions. In essence, “politically feasible” is always the one put forward by those who do not want big change to try to head it.
But there is great momentum from, you know, regular people, now. We have to keep it up and demand it from our legislators and candidates, and that will make it feasible.

Saturday, March 2, 2019

Medicare for All, Compromise, and who gets left out


As the movement for Medicare for All gains steam, with the new bill, HR-1384, being introduced by Rep. Pramila Jayapal (D-WA) and 100 co-sponsors (video available on PNHP Facebook page), the attacks have, unsurprisingly, started coming. They are hard and soft, overt and subtle. The overt attacks on it from Republicans who call it “socialism” are probably the least important. They, and the folks for whom socialism is a buzzword that has them throwing up their hands in horror, were never going to support it or any effort to have universal health insurance, and are probably not going to support any less-extensive compromise. On the other hand, they could learn something by reading about the experiences of people in the all-the-other-industrialized-countries-in-the-world who have some form of universal health care. For example, the recent piece in the Washington Post by an American studying in Taiwan,  uninsured in either country, whose abdominal pain nonetheless led him to go to the ER at 3am. He was seen and given treatment in 20 minutes, had lab tests and imaging studies, was diagnosed with a stomach virus and given 2 medications, and sent off. Total cost: $80. (March 1, 2019)

The real threat, unsubtle and incredibly well-funded, is from the insurance and hospital corporations (and “non-profit” health systems) who are responsible for about 30% of all dollars spent on health care in the US being for administrative costs (including their huge profits) and not actually health care. They are a major cause of the high cost of health care in the US, and stand to lose the most if Medicare for All is implemented, because it will be funded in large part by taking that money away from them. Thus, they are highly motivated to attack any such attempt, organized to do so, and are already doing it, as clearly presented in Health Care and Insurance Industries Mobilize to Kill ‘Medicare for All’, NY Times February 23, 2019. This will ultimately be the real fight, incredibly wealthy companies that would lose a lot of money will do almost anything to keep it, even though it will prevent a change in the current crazy, costly, poor-result non-system that we currently have, that would benefit the health of all the rest of us.

The more subtle attacks, or perhaps “criticisms”, are from other Democrats and ostensibly liberal media, like the Times. Senator Bernie Sanders (I-VT) sponsors a single-payer Medicare for All bill in the Senate, S-1804, and many of the current candidates for the Democratic presidential nomination are co-sponsors, including Sens. Elizabeth Warren (D-MA), Kamala Harris (D-CA), Cory Booker (D-NJ), and Kirsten Gillibrand (D-NY), and Rep. Tulsi Gabbard (D-HI) is a cosponsor of HR-1384. Sen. Amy Klobuchar (D-MN) and Rep. Julian Castro (D-TX) are not. S-1804 is not quite as good or comprehensive as HR-1384 (the even-better successor to the old HR-676), but this is not the reason almost all of them (except, of course, Sen. Sanders) have stepped back a little from, or danced around, their position on a single-payer program in various interviews with the press. They worry it might go too far, and while want support from single-payer fans, they fear alienating others, or believe that Medicare for All cannot happen, and talk about compromise. Several senators have introduced another bill that would allow people over 50 to buy into Medicare ('Medicare for More', but only if they pay). The Times, however, is getting more supportive; in their February 16, 2019 editorial ‘How Much Will Americans Sacrifice for Good Health Care?’, they move to focusing on the cost and practicality, and no longer say single payer or Medicare for All is not a good thing.

Of course, other leaders of the Democratic Party do not even pretend to support Medicare for All, and cling to the falsehood that the Affordable Care Act (ACA) would be enough if the GOP had not let many of its components expire, and GOP governors had not refused to institute expanded Medicaid in so many states. The classic rendition of this song was performed by House Speaker Nancy Pelosi (D-CA), in an interview in a recent Rolling Stone. Dr. Don McCanne, in his great Quote of the Day, correctly says of Pelosi’s comments:
‘Perhaps most disappointing have been the responses of those who would prefer to continue to support the Affordable Care Act and add a public option - a Medicare buy-in for some…."All I want is the goal of every American having access to health care. You don’t get there by dismantling the Affordable Care Act." Further she says, "When they say Medicare for All, people have to understand this: Medicare for All is not as good a benefit as the Affordable Care Act." Has she been practicing composing Trumpisms? The Jayapal Medicare for All Act is vastly superior to ACA - absolutely no contest.’

“Compromise” is often touted as a good thing, and sometimes it is. Maybe it means you and your partner take turns deciding what movie to see or what to have for dinner. But often compromise is, as noted by business guru Stephen Covey, it is a “lose-lose”, where everyone gives up something they want. If we can find something that is “win-win”, it is of course better. Medicare for All might actually be a “win-lose”, a win for the American people (comprehensive health care for less money) but a loss of enormous profit for the big health and insurance corporations (no tears here).

The most obvious flaw in the logic of the mainstream Democrats is harping on the cost. Yes, it will cost a lot, but the average American family will pay less than they are now in premiums, deductibles and co-payments. The big saving would be in the elimination of the money being made by insurance companies, drug companies, and health systems, and apparently Speaker Pelosi is not ready to cut off their access to the trough. Already, the government pays almost 60% of all health costs (Medicare, Medicaid, coverage for government employees, tax breaks for employer contributions to health insurance, etc.) This means that, in our country, the government already pays more per capita than in most countries that cover everyone. Yes, HR-1384 would expand the benefits of Medicare (‘Improved and Expanded Medicare for All’) to be basically everything with no copays or deductibles, and this would be costly, but those of us who can afford it pay for them anyway, and those who cannot currently do without.

But there is another flaw. All of the folks advocating for less-than-universal-coverage, Medicare-for-More, buy-in to Medicaid for folks not poor enough to qualify now, let’s-not-let-the-perfect-be-the-enemy-of-the-good, are missing something. What they are missing is those people who are not covered or covered with poor insurance that won’t meet their needs if they are sick. All the compromise politicians and pundits seem to forget that these are real people, not just numbers (yes, if fully implemented the ACA covers 90%, but is that enough?). As I wrote in my very first blog post (“Universal Health Coverage”, November 28, 2008), ‘When was the last time, even in private but certainly in public, you ever heard someone say “I’m really suffering without health coverage, but don’t worry about including me and my family in your health reform plan. We don’t want to let the perfect be the enemy of the good.”?’ Those advocating for less than universal coverage need to get out there and tell us who it is that they don’t think needs good health coverage, who can be left out. You? Your Uncle George or Aunt Minnie? Your neighbor? Who are the Americans who they are advocating leaving out?

I can tell you one thing. It won’t be them or their families.

Wednesday, February 13, 2019

Medicare for All, or "Eat well, take your medications, and good luck!"


I have often written about the need for a universal national health insurance plan in the US, even more frequently recently. This is in part because the rise in costs and cuts in health coverage for Americans, including especially those who are in states that did not expand Medicaid as part of the ACA, have continued to erode our health coverage and increase our cost. It is also in hope that the Democrats in Congress will not abandon a real “Medicare for All” program in favor of a non-solution such as “Medicare for More” or almost anything that maintains for-profit insurance companies.

A Nurse Practitioner friend writes:
Many patients I see are very complex and, I think, not NP (Nurse Practitioner) appropriate but no one else is there for them because they are uninsured. And they tell stories of meeting with cardiologists who talk about several interventions and then when the MD finds out no insurance just says to them, “Well, be sure to eat well and take your medications and good luck”. 
And every day I see the effects of having so many people without insurance. I see the ones who ended up in the ED because of preventable problems. Yesterday I saw a 33 year old mother of two who had hypothyroidism, no insurance, ended up with severe cardiomyopathy [heart muscle disease] and heart failure all for lack of thyroid medication due to lack of care due to lack of insurance -- and she works in an MD office doing billing to keep our health care system going for those with insurance!!!

This situation is neither rare nor new. It happens to that particular NP every day. NPs in many states work under “collaborative agreements” with sponsoring physicians, and in others have independent practice privileges. When the patients are too complex for them, “their” doctors may be unwilling to take them, if they are uninsured. In addition, in many cases, the NPs (or PAs) practice in remote sites – sometimes very remote. But, the reality is that even if the physician is willing to see them, even if the patient is seen initially by a physician and not an NP, ultimately there is a similar outcome for those people without insurance or with poor-quality insurance. This scenario happens all providers, physicians included, except those who refuse to care for poor, uninsured, and poorly insured people.

It is essential that everyone who cares for, or about, people realize this, including the politicians who make the decisions and the pundits who opine about such things. They may be well insured, and likely most of the people that they know personally are (although every day that number grows smaller and the financial and health exposure of those who thought they were well insured grows larger), but many, many people are not. Whatever sticker shock insured middle class people have when they get sick or need medication (see the graph on the cost of Humalog ®, the most common insulin for people who need that drug to stay alive, vs inflation), it is much worse every step you go down the ladder of income into poverty, down the levels from “good” to “fair” to “poor” to “no” insurance.

It is also critical to remember that any reform plan that does not cover 100% of everyone will leave people like the woman described above out, and the stories that physicians and other health providers have to tell about how their patients cannot get the care they need will keep coming. For a plan to not only be “good”, but to be affordable, every single person in the US needs to be IN. It is most affordable if it goes all the way, putting everyone in one plan (Improved and Expanded Medicare for All), because that would eliminate the massive profits of the insurance companies that have administrative overheads of over 30% (compared to Medicare’s 1-3%) and would tightly regulate the profits (and whatever your favorite expression is for money made over costs for “non-profits”) of providers. Other plans that are seen as compromises are, like so many “compromises”, lose-lose. By dealing in the insurance companies and their profits so they won’t oppose the change (as ACA did) we build in this cost to our system, siphoning off at least 1/3 of the dollars ostensibly spent on health care to overhead!

One of the most widely supported bad ideas is continuing Medicare Advantage, also known as Medicare Part C. Basically, the insurance company that sponsors such a plan takes the money you’d get for regular Medicare (Parts A and B) and you kick in an additional payment, and you are covered, as in an HMO, for a variety of other services that traditional Medicare does not. It sounds like a good deal, and it generally is for the recipient with all the plusses (extra services at usually lower cost) and minuses (limited choice of providers, limit to geographic coverage area) of an HMO. At first, it seems to be a win-win, for patients and the insurance companies represented by America’s Health Insurance Plans (AHIP). AHIP has garnered letters of support just recently from 302 House members and 66 Senators, of both parties. The problem is that the insurers get extra money that traditional Medicare doesn’t, costing the public a lot (and sometimes involving fraud). Continuing Medicare Advantage not only gives some people better coverage, and makes a single Medicare for All again financially challenged, it costs the government more and makes insurers richer.

A real Medicare for All – not a bunch of different plans, some of which cost more money and spend a lot of that on insurance company profit -- is not an unrealistic pipe dream. What is actually unrealistic is keeping the current system (or, better, non-system) we have, or some minor modification of it, and expecting that it will lead to better health for more people and lower cost. That won’t happen, and the idea meets Einstein’s definition of insanity: doing the same thing over and over and expecting different results. High costs – proportionately higher for low-income people – and poor health outcomes – also higher for low-income people – are baked into that system.

Or, we can not do a comprehensive include-everyone program. We can stay with what we have, or some “part way compromise”. Read the story above again. Memorize it. Because, if we don’t have a universal health plan like every other developed country, it will continue to repeat thousands and thousands of times a day, in every city, state, and rural area in the USA.

If not, be sure to eat well and take your medications and good luck!

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