Friday, July 6, 2018

Physician frustration and "burnout": A wider breadth of practice helps!

Physician burnout is a topic that is much-discussed in the medical community. It’s not a very good term; most people have stressed, sad, or overworked days or weeks, but it is the one that we seem to be stuck with. It is true that many physicians are often not happy, feel overworked and stressed and unable to spend enough time with their families. Most important, perhaps, they feel that this leaves them unable to do as good a job caring for their patients as they would like to. The main factors are workload, both in terms of the number of people that they have to see in a day, and ever-increasing “administrative” work. A big part of this is charting on an Electronic Health Record (EHR). While this modern method of charting allows quick retrieval of much important information and makes it possible to maximize billing, it is very time consuming.

Primary care doctors, such as family physicians, have among the highest rates of “burnout”, exceeding 30% in some studies and rising to nearly half in younger physicians . A recent study by Young, Burge, and colleagues showed that family doctors spend more time entering data into EHRs than they do face-to-face with patients! Patients are justifiably upset when their doctor spends more time looking at the computer screen than they do looking at them, and it is bad for the physician-patient relationship. However, the charting still has to be done, so those doctors who are not spending time on the EHR during the encounter are staying late to do it after office hours or doing it from home on evenings and weekends, which also contributes to frustration. Studies also show that a higher percentage of female physicians report experiencing “burnout”, likely because in many or most families it is still the woman who bears the burden of household and family responsibilities, even when she has a full-time and demanding job such as a physician.

There are a variety of reasons why family and other primary care physicians are particularly vulnerable to burnout. Reimbursement per visit is lower than for most other specialties, which means there is less money to hire people or buy systems to make things more efficient. Since most physicians are employed, primarily by large hospital systems, rather than in private practice, the system drives the work, not the doctor. Of course, the logic for paying primary care physicians less is, well, non-existent, but there are many non-logical justifications, most of them based upon the tradition of “subspecialist have always made more money” and are self-serving.

One conceit is that the work of subspecialists is “harder” or “more complex” and thus justifies greater reimbursement. This is not always, or even usually, true. As I have previously discussed on this blog (e.g., Can you be "too strong" for family medicine?, March 19, 2013), the work of a family doctor is particularly complex. For each patient, the family physician takes care of, or co-manages, all of a patient’s medical – and psychological and social – issues, as opposed to just one, as subspecialists do. In terms of the day’s schedule, a family doctor sees a wide variety of patients: a person with a new acute illness can be followed by one with several chronic diseases, then a well-child, then a sports injury, then a pregnant woman, etc. I have documented this in an “AAFP One-Pager” published in the American Family Physician in December, 2014.[1]

But, because subspecialists get higher reimbursement, their employers are happier and likely to spend more money supporting them. Some (ignorant but not rare) health system administrators wonder why a family doctor cannot see more patient in a given time, like, say, orthopedic surgeons do. The orthopedist sees someone referred for a specific problem, after x-rays or more extensive (and expensive) tests like MRIs have been done, often after the patient has been seen by another professional such as a physician’s assistant, does a quick exam of the particular area and decides if surgery is needed or not, and has someone else arrange it. It is, of course, the surgery, not the clinic visit, that earns the surgeon money. The family doctor is, as noted above, addressing all of a patient’s chronic and acute medical problems, as well as the social and psychological problems, and often has to fill out forms such as disability, FMLA, etc. even when another doctor (say, that orthopedist) is doing the procedure, because those subspecialists are “too busy” (ie., earning, directly for themselves or for the health system and then indirectly for themselves, too much money per unit of time).

It is, thus, unsurprising that those specialties that are the highest-paid (e.g., orthopedic surgery) and especially those with the highest income-to-work ratios (e.g, radiology, dermatology, anesthesiology) have little difficulty recruiting new doctors, while the lower-paid specialties, like family medicine, have much more. After all, the indebtedness from medical school –typically hundreds of thousands of dollars (which usually requires annual payments of far more than the average American’s total salary) is the same whatever specialty you enter. The higher revenue generated by subspecialists allows them – or the hospital systems that employ them -- to pay for non-physicians to do a variety of tasks, both clinical (nurse specialists and physician’s assistants) and documentation (scribes, coders, etc.) The American Academy of Family Physicians (AAFP) suggests that the root cause of family physician burnout is inadequate team-based care, but the fact is that the members of those teams have to be paid, and the greater the physician reimbursement the more team members there can be.

Given all this, one could reasonably worry that family doctors will no longer be happy doing all the breadth of care that defines the potential of the specialty, such as continuing to deliver babies, or take care of their patients in the hospital, or make home visits. After all, if they are stressed out “just” seeing patients in the clinic, wouldn’t this make it even worse? Take more time? Increase burnout and stress? To me, that would be a bad thing; one of the terrific things about primary care doctors, reasonably defined as “doctors for you” (rather than for a specific condition) is that they can see you, and care for you, in all settings.

Which is why it is gratifying to read the results of a paper just published in the Annals of Family Medicine by Weidner, Phillips, Fang, and Peterson called “Burnout and Scope of Practice in New Family Physicians”. Contrary to what one might fear, it turns out that, at least among younger physicians, having a wider scope of practice – specifically caring for patients in the hospital, delivering babies, and doing home visits – is associated with a lower rate of self-perceived burnout. This is heartening – maybe being able to function at their highest level, care for people in all the settings in which they seek care, provide real continuity, do good medicine is part of the answer. Some of this may be because the breadth of care, the different kinds of problems to care for, the possibility of being there for your patient in whichever venue their care is delivered, the caring for the whole patient, is why people chose family medicine in the first place, rather than a (higher-paid) specialty where you care for only a few diagnoses or do a few procedures over and over again. 

Yes, doctors, even the lower paid specialties, make very good salaries compared to most Americans, and so it is hard for people who have lower-paying jobs, are afraid of losing their jobs, or have no jobs at all to feel too sorry. Yet it is in the interest of their health that their physicians are able to feel satisfaction with their work, most importantly to be able to do the best that they can to take care of a person’s medical needs. Medical care can be made more efficient than it is, especially in eliminating the ridiculous lack of communication between doctors, hospitals, and patients that characterizes our fragmented non-system. All workers feel more satisfaction and do a better job when they have the ability to exercise some discretion and not simply work on an endless assembly line. Medical care especially cannot be reduced to an assembly line, because you are a person, not a widget.

Our medical system needs to cover everyone, communicate within itself effectively, and be flexible enough to meet the needs of all people.

[1] Freeman J, Petterson S, Bazemore A., Accounting for complexity: aligning current payment models with the breadth of care by different specialties. Am Fam Phys 2014 Dec 1; 90(11):790. PMID 25611714

Tuesday, June 26, 2018

Bezos, Buffett, Dimon and Gawande: Better quality in health maybe; a solution, no

A big item of health news in recent weeks is the planned establishment of some sort of health delivery operation by three major corporations personified by their CEOs: Warren Buffett of Berkshire-Hathaway, Jeff Bezos of Amazon, and Jamie Dimon of JP Morgan. We have no details about what it will actually look like, but we are assured that it will be high-quality, efficient, and cost-effective, utilizing the most modern methods of achieving those goals, which our creaky, antiquated, and resistant-to-change health system does not. It will also be non-profit, important given that none of these companies are, but this is the most common model for health care in the US and in itself says very little. As the first concrete step toward its creation, and clue to what it may be, they have appointed Dr. Atul Gawande as its CEO. Presumably he will be instrumental in creating this new venture, and his views on quality and efficiency may provide guidance on what might characterize it.

Dr. Gawande, a Harvard surgeon and senior writer for the New Yorker, has provided us a prolific body of writing in that magazine and in several books, (including the best-seller about issues occurring at the end of life, “Being Mortal”), to help inform us of his views. He has a wide scope of interest in health care and a demonstrated willingness to learn from other industries. Perhaps his most famous article is “The Cost Conundrum”, which appeared in June 2009 and highlighted the wide variation on expenditures by Medicare for similar populations, focusing on the highest cost region, McAllen, TX, and comparing it to a similar population in El Paso, TX, where costs were much lower. Later, in January 2011 “The Hot Spotters” highlighted the work of Dr. Jeff Brenner in Camden, NJ, and others, to use modern geo-mapping techniques to identify the areas with the highest levels of emergency (911) utilization (unshockingly, in Camden, the two highest were a low-income senior citizens housing unit and a long-term care facility) and try to develop methods for addressing their health needs before they became emergencies. In “Big Med”, August 2012, he discusses application of some of the principles that work in restaurants such as the Cheesecake Factory to health care. The principles include enough variety to meet everyone’s needs without expensive unnecessary redundancy; he shows how this applies in orthopedic surgery and how quality is improved and costs saved when every surgeon in a hospital doesn’t use his (or, more rarely among orthopedists, her) favorite implant device and there is some standardization (commented on in this blog on August 24, 2012, Quality and price for everyone: Bigger may be better in some ways, but not all). A very good review of Gawande’s work and probable priorities has been done by the outstanding Dr. Don McCanne in his “Quote of the Day” on June 22, 2018 “Don’t wait for Atul Gawande”, and I will not repeat it here.

Of course, the employees of Berkshire-Hathaway, JP Morgan, and Amazon already have health insurance, so that this new scheme will not reduce the rate of uninsurance. It is possible that it – whatever “it” turns out to be – will allow enrollment from other employers, or possibly even individuals who are currently insured by another mechanism, whether through Medicare, the ACA-sponsored exchanges, or even Medicaid. This will depend in part on what “it” is – mostly an insurance plan, mostly a care delivery system, or a combination of both like many HMOs.

It is possible that this new operation may indeed succeed in achieving, or at least significantly moving toward, the “Triple Aim” of higher quality, greater patient satisfaction, and lower cost. Certainly the third of these is a major focus of businesses that provide health insurance to their workers, and we will grant these people the benefit of the doubt that they also wish to achieve the first two. Some HMOs have had significant success in doing so already, most notably Kaiser Permanente. Other HMOs that were once “consumer cooperatives” (eliminate the middleman and pay less for the same care or the same for more and better care) have almost all been bought by insurance companies, and it is obvious that the “save money” (or really “make more money”) leg of the #TripleAim is of far greater importance to their business model than patient satisfaction or quality. The bar, as has been demonstrated ad infinitum, including in the work of Dr. Gawande as well as other policy analysts from
academia, the foundation world, and journalism, is so low that large improvements in quality can come from things that it is we already know how to do. The major obstacle to this has always been how providers are paid, and this is where the behemoth strength of this new triumvirate may have significant impact.

Unfortunately, though, there is no suggestion that this new operation would do anything to help those currently either frozen out of the system (including poor people in states that have not expanded Medicaid, undocumented people, and those who cannot afford insurance premiums even with ACA support). The average salaries at JP Morgan and Berkshire-Hathaway are high since so many of the employees are high-level finance types, raising the mean and median. However, Amazon is a different story. Jeff Bezos may be the richest person in the world, he did not get there by paying his employees a living wage; the median income for an Amazon employee is $28,446. While they may have health insurance, it would not be surprising if many of Mr. Bezos’ employees qualify for food stamps, and have difficulty making their copays; that median salary is about the poverty level for a family of four, and if it is the median, many workers make less.

It could be argued that is unfair of me to criticize a program – especially one still in the planning stage -- for not achieving what it does not set out to achieve. However, there is nothing wrong – and indeed it is quite correct – to note that it is far from being a health care panacea. By not setting out to ensure access for everyone, it will not solve the basic problem in achieving the Triple Aim. I mean, it’s good to be focusing on quality, cost and patient satisfaction but without a plan to assure that everyone has access to care it can ring a little hollow.

As was observed by Schiff, Bindman, and Brennan more than 20 years ago, and quoted by me before (Medical errors: to err may be human, but we need systems to decrease them, August 10. 2012), denial of care – or lack of access to care for financial, geographic or other reasons -- is the “gravest of all quality defects”.

Sunday, June 10, 2018

Why don't we spend more on public health? It is harder to see the bullets we dodged -- and then there is profit.

It Saves Lives. It Can Save Money. So Why Aren’t We Spending More on Public Health?”  (New York Times, May 28, 2018). Actually, this is a terrific question. As so often, it is complicated. Let’s start with the benefits that authors Aaron E. Carroll and Austin Frakt describe. First, there are vaccines. They eliminated smallpox and virtually eliminated polio in the United States. They have dramatically reduced the rate of common childhood illnesses including measles, mumps, rubella, chicken pox, and Hemophilus influenza (H. flu) infection. They have the potential for essentially wiping out cervical cancer through immunization against HPV, and liver cancer (as well as many forms of chronic hepatitis and cirrhosis) through vaccines against Hepatitis B.

A huge public health intervention is making our environment safer. This means having good sewage and clean water, and lead-free gasoline and cleaner air. These changes have saved far more lives, and improved health much more, than all of the individual medical care interventions combined. If you have traveled abroad, especially to less developed countries, you know how important these are. Indeed, better sanitation, as well as better surveillance and treatment, have dramatically reduced other infectious diseases that were once terribly feared, notably tuberculosis. And inspection of our food supply, restaurant and otherwise, are another very important part of public health.

The other big public health measure is education. Of course, education can be and is provided to individuals by health professionals as well as populations via public service education, but it is major nationwide public health efforts that have made a big difference. These include the huge decrease in cigarette smoking, and the greater safety of automobiles and their exhausts. Cigarette smoking used to be ubiquitous (see any WW2 movie) and in what would shock young Americans today, widely practiced in restaurants and even college lecture halls. Today that is unimaginable, and smoking in most places is aberrant, with less than 15% of adults currently smoking and most of those trying to quit. Car accidents are still a major cause of death and injury, but deaths from cars are way down. Almost none of this is related to people driving more safely and almost all of it to safer design of cars (think seat belts, air bags, engines that collapse down instead of back in a collision) and roads. Lead poisoning of children is way down in most places in the US thanks to lead being banned from gasoline and paint.

There are still many challenges on the public health front. Reducing the rate of chronic diseases though education around eating huge numbers of empty calories still have a long way to go. The terrible infectious disease epidemic of recent decades, HIV, has been greatly reduced by treatment, but until there is a vaccine, high-risk sexual behaviors persist. The opioid epidemic is killing more and more people, and it is only through societal approaches that this is going to be reduced.

The epidemic of gun death is not abating; many studies and articles in the press have recently discussed the increase in the suicide rate, often prompted by recent high-profile suicides such as those of Kate Spade and Anthony Bourdain (How Suicide Quietly Morphed Into a Public Health Crisis; 5 Takeaways on America’s Increasing Suicide Rate, ). While neither Spade or Bourdain used a gun, guns are the cause of death in at least half of suicides, and suicide far exceeds homicide in terms of numbers of gun deaths. Those who believe it is not the availability of guns that causes deaths from both causes, and other methods could be used to kill oneself or others, are simply wrong. Easy availability of guns, far more effective and efficient at killing oneself or others than any other method, absolutely has been demonstrated to increase both homicide and suicide. Suicide by gun is over 90% effective; by drugs less than 5%. “Successful” suicide rates are far higher in high gun states (e.g., Montana) than in low-gun states (e.g., Massachusetts). Homicides are also more common where guns are at hand. And, in regard to school and other mass shootings, while you can kill someone with a knife or a baseball bat, but it is hard to commit mass murder with them.

So, why do we not spend more on public health? Why do we spend so much more on what is, from a societal point of view, much less effective individual health interventions, and less than 5% of that on public health? One reason, of course, is that when each of us is sick, we (usually) want treatment, as much as possible, especially if there is a chance that it could cure us, or at least ease our suffering. This is understandable, and it is tied to the fact that we have much greater awareness of treatment of something ailing us (curing our infection, relieving our pain) than of not having disease because of the presence of public health practices. As I would tell students, how often do we wake up thankful that we do not have cholera because we have a clean water supply? Indeed, when we find that the water in Flint, MI, is contaminated with lead, we are shocked because we assume our water is safe; when we find an E. coli outbreak from a restaurant, we are shocked because we assume our food is safe.

There is also, unsurprisingly, the issue of the money that to be made. The provision of public health is rarely a big profit center, and it is usually, therefore, done by government – local, state, and federal. Individual health care, however, is a huge money-maker for insurance companies, hospitals, doctors, pharmaceutical and device manufacturers, nursing home companies, and on and on. All that money – over $3.3 TRILLION by recent estimate -- spent on your and other individuals, while it may (or may not) have a salubrious impact on you, is going into someone’s pocket. On the flip side, public health interventions often reduce profit, especially when they are very effective. The struggle against tobacco, which killed more people than any other cause by far, was fought long and hard by the tobacco companies (currently now plying their wares in the less-developed world).Each of the changes to cars that led to the great increases in safety was fought by the industry. Today, we continue to see tremendous opposition to rules that make our environment (air, water) clean and safe; sadly, under the current administration, many of these rules are being rolled back, which will absolutely decrease our society’s health.

I guess I also need to address the people who believe that vaccines are unsafe. They are a major threat, and presumably haven’t seen children dying of measles, of the suffering of chicken pox and mumps, of the morbidity from H. flu infections of the middle ear (my students have never seen it!) or deaths from H. flu epiglottitis. Yes, there can be minor side effects from some vaccines, but the benefit is overwhelming.

Finally, as always finally, it is the poor and disenfranchised who suffer the worst. While sometimes we have the perverse satisfaction of outbreaks of vaccine-preventable diseases in well-to-do communities, anti-vaxxers unconscionably campaign in immigrant/refugee communities telling people to not vaccinate their children. The poor and minority city of Flint suffers a poisoned water supply. The oldest, cheapest houses are likeliest to have peeling lead paint and be located near polluting factories and dumps. Tobacco and junk food manufacturers advertise most heavily in minority neighborhoods. And, of course, the murder rate is highest in poor and minority communities.

Good medical care for individuals is valuable when it is needed, and could be less expensive. Public health measures are even more valuable and cost-effective. We need to increase the money and effort spent upon public health interventions, and certainly not scale them back.

Benjamin Franklin said an ounce of prevention is worth a pound of cure. It’s true, and is a great argument for greater investment in public health.

Saturday, June 2, 2018

The Administration's New Proposal to Address the Determinants of Health

  (a Shakespearean sonnet)

Together, many things affect our health,
Genetics and environment to start,
Where we live and whether we have wealth,
Our personal behaviors play a part.

The Trumpers say they want us to act smart,
Not to smoke, or drink too much, let’s say,
Or overeat (it might affect our heart),
Or else – they’ll take our Medicaid away.

Then we won’t have access to healthcare,
Or treatment options when we do get sick.
Clearly, this is totally unfair,
To solve the problem, it won’t do the trick.

To have a healthier society,
We need real reform, not smug piety.


Saturday, May 26, 2018

Maternal mortality in the US and UK: Why do we tolerate paying so much more for so much worse outcomes?

Last year, ProPublica, in association with NPR, published Why Giving Birth Is Safer in Britain Than in the U.S. In typical journalistic style, it starts by grabbing your attention with a case report of a woman in England who almost died of post-partum hemorrhage, but did not. The lesson is presumably that she did not because the physicians, midwives, and others attending her followed a rigorous set of established protocols for addressing post-partum hemorrhage that are implemented nationally in the UK.

Of course, there is a possibility that this individual woman could have died, or had to undergo more invasive surgical procedures further down the protocol’s algorithm, but the real point is that, overall, the system is working. The evidence is in that the maternal mortality rate (deaths/100,000 women delivering) is 8.9 in Britain, while in the US the rate in 2015 was 25.1, three times that of the UK! What makes this more dramatic is that the disparity has developed only since 1990; until then the maternal mortality rates in the US and UK had been declining in parallel since the 1950s.

The article cites several reasons for this difference. One, a very important one, is that the UK collects data on maternal mortality nationally and develops guidelines based upon this data which are implemented nationally. In contrast, the US collects data at best by state, or even by hospital, and
There is no federal-level scrutiny of maternal deaths, and only 26 states have an established committee (of varying methodology and rigor) to review them. Nor do all U.S. hospitals routinely examine whether a death could have been avoided. Procedures for treating complications such as preeclampsia, and for responding to emergencies such as hemorrhage, vary from one doctor, hospital and state to the next.
This is true despite the fact that the methods used by the British to collect and analyze this data were developed in the US. While there has been a well-documented 30-year effort to improve quality and to reduce preventable deaths (a category into which most maternal mortality falls) in the US, led by such organizations as the Institute for Healthcare Improvement (IHI) and embraced by such other organizations as the American Hospital Association (AHA), National Center for Quality Assurance (NCQA), the Joint Commission for the Accreditation of Healthcare Organizations (TJC), the National Academy of Medicine, and on and on, no compulsory national approach to this problem has developed. This reflects a common, and often knee-jerk, opposition to centralized approaches to almost everything, even when they have been determined to have an important effect on reducing death. It is actually parallel to efforts within hospitals to standardize care, to require, for example, all surgeries to go through a series of prescribed steps (“timeouts”) before operating, or limiting the number of different devices implanted to those needed by different types of patients rather than by the preference of the individual surgeon (for an interesting discussion, see A. Gawande, “Big Med”, New Yorker, August 13, 2012). That is, it is effective where it has been done, but it is not mandated to be done everywhere and comprehensive national data is not even collected.

Another big part of the successful UK approach to the reduction of maternal mortality has been collecting detail on what happened and why; this goes beyond “there was a death”, or “there was a death from hemorrhage”, or “there was a death from sepsis”, to identifying why it happened, particularly if the reason was something that is relatively easily addressed. Marian Knight, head of MBRRACE-UK, the group that collects the data and makes the guidelines, says
It’s all very well to know a woman died of sepsis, but to know that she died of sepsis because nobody measured her temperature, as they had no thermometers on the postnatal ward, that’s where the instruction Put a thermometer on your postnatal ward might make a difference. It’s not just the what, it’s the why.
Can you believe that there might be post-partum units where there is no thermometer? Apparently it has happened. And having a rule that it must be present is a way of preventing it from happening again.

There are at least three other important dimensions. One is that, as the report states, “These U.S. deaths are not spread equally. Women who are poor, African American or live in a rural area are more likely to die during and after pregnancy.”  This is not a big surprise.  Poor women, minority women, rural women, and uninsured women do much worse, and are much more likely to die from complications of delivery. It is the familiar song in the US, as in so many areas, of health and of every aspect of society. Is it not true in Britain? The article goes on to say
In the U.K., while inequalities persist when it comes to serious complications, according to 2012-2014 data, there is no statistically significant difference in mortality rates between women in the highest and lowest socioeconomic groups. All British women have equal access to public medical services, including free care and prescriptions from pregnancy through the postpartum period.

This also has two components; the greater equity of the quality of healthcare delivered to all segments of the population, a result of having a national health care system, and less disparity in the “social determinants of health”, the actual quality of the lives of people (women, in this case) before they access care. Especially for rural women, some of the problem the lack of an adequate number of health professionals. Over 20 years ago, family medicine residencies in Texas were surveyed and only a small percent of residents were interested in providing rural obstetric care, but no OB/Gyn residents were! This has not improved; while a recent study published by Tong, et al., in Family Medicine (Characteristics of Graduating Family Medicine Residents Who Intend to Practice Maternity Care) found that 22% of FM residents planned to deliver babies, they cite his 2012 study that showed that only 9.1% of FM residency graduates were delivering babies 1-10 years out into practice despite an intention to do so of 24%, comparable to the current study.

Another dimension is that the difference in maternal mortality reflects a greater focus on the health – and life -- of the pregnant woman in Britain, while in the US the focus is more on the health of the fetus and the newborn. This goes far beyond the issue of abortion, although the focus on children rather than women is one that is also characteristic of the anti-choice movement in the US. It is so deeply ingrained in our culture that even many health professionals (including midwives, doctors, and nurses) who see themselves as “pro-choice” and would never want to see a maternal mortality, are still more focused on the fetus and baby. It results in a practice, if not a belief, that considers the woman but a vehicle for producing a child.

Finally, there is cost, ironically but again unsurprisingly much higher in the US. Much higher. The total cost for a normal vaginal delivery in the US is about $30,000, and about $50,000 for a Caesarean section. In Britain, the cost for a normal vaginal delivery or planned Caesarean is about $2500, or less than 1/10th the cost in the US, perhaps rising to $3400 for complicated cases (such as the one that leads off the article). Thus, the US charges far more, but has much worse outcomes for maternal mortality (as for many other conditions). This is not a side note; it is not just an interesting contradiction that our care costs more but has worse outcomes. And it is not by any means limited to pregnancy care or maternal mortality, but is present in our healthcare system at almost all levels and for most conditions. What ties these two components, cost and quality, tightly and inversely together, is that our “healthcare system” is only secondarily about delivering quality healthcare, and primarily about being a profit-making business.

So, that is the bottom line. The US has three times the maternal mortality rate of the UK despite charging ten times as much for delivery. The reasons are the absence of a national strategy to identify and remedy the causes of maternal mortality and the lack of a national healthcare system to provide the access necessary for women at risk. It causes the suffering and death to disproportionately affect those women who are already at greatest risk: the poor, minority, rural, and uninsured. The root cause is that our healthcare system is composed of poorly interconnected components, most of which are run as businesses to make money.

It is inequitable, and it is irrational from a health perspective if not from a business one. It causes unnecessary death and excessive cost, and seems to not be improving. It is not acceptable. We need to change it.

Friday, May 4, 2018

Health status in the United States and State Health Performance: The Commonwealth Fund report and potential solutions

The Commonwealth Fund has recently issued its 2018 Scorecard on State Health System Performance. This scorecard has data for each state (+ DC, so 51 spots), measuring performance against a variety of metrics evaluating access to health care, quality of care, efficiency in care delivery, health outcomes, and income-based health care disparities. Because the Scorecard has been issued 2013, Commonwealth can compare the current year’s rankings and performance to previous ones, seeing how states get better (or worse) on these individual measures as well as on overall performance.  

There is not much change. The Top 5 in performance remain Hawaii, Massachusetts, Minnesota, Vermont, and Utah, in the same order as last year. The Bottom 5 (47-51) are Arkansas, Florida, Louisiana, Oklahoma, and Mississippi, and are close to the same, the only change being Florida dropping 5 spots to join the group and displacing West Virginia, now at 46. Hawaii at the top and Mississippi at the bottom are not only unchanged, but remain far ahead or behind of their nearest competitor. The top regions are still the Northeast and Upper Midwest, with the West dragged up by Hawaii and Utah but otherwise an average to low average group.

Commonwealth also ranks the states on degree of improvement of their scores in each of 43 different indicators. More indicators improved than went down, which in itself is a good thing, but there are a lot of caveats. For one thing, it doesn’t measure amount of improvement, or how much less a state might have improved compared to others. For example, Oklahoma joins the list of the top 5 states with improvement on the most indicators (17, to rank it #4), and yet dropped two places in the overall ranking, from a dismal 48 to 50th! This is not good. More important, however, were the areas in which indicators fell for many states and for the nation as a whole. This include rising death rates (a really big one!), including a 50% increase in deaths from suicide, alcohol, and drug use since 2005, rising obesity, and gaps in care with a rising disparity between and within states.

Many of the improvements are in areas that have been focal points of public health policy, like decreasing smoking. This is good, but this long-time-coming advance over the tobacco industry’s heavily funded effort to get people to continue to smoke, and young people to take it up, has still not been entirely won. More important, the lessons from the anti-tobacco campaign have not yet transferred to the other well-funded high-profit threats to health, notably sugar and guns, as well as alcohol and pharmaceuticals. Unfortunately, each of these struggles seems to need to rise up almost as if the others hadn’t been joined; activists can and do learn from the previous ones, but so do industries that manufacture unhealthful commodities. These industries replicate the strategies that tobacco used to delay change for so long. The main one, of course, is the liberal application of money to politicians. The same lobbyists who worked for tobacco work for sugar, and guns, and alcohol; the color of their money is still green, and politicians still enjoy receiving it.

While it is true that many politicians from both major parties have been recipients of such largesse, the retreat from reality-based policy that is the hallmark of both the Trump administration and the Republican Party in Congress has major impact on the causes of illness and will continue to do so into the future. One good example of the latter is the aggressive retreat from environmental regulation, personified by EPA administrator Scott Pruitt, rolling back auto-pollution emissions standards (a decision currently being challenged by a coalition of states led by California). Another is the firm resistance to common-sense regulation of guns, which result in over 30,000 US deaths a year, a tiny fraction of which are from foreign terrorists. Limitations on semi-automatic weapons and high-capacity magazines, waiting periods and background checks, absolutely would decrease the number of these deaths (the majority, by the way, are suicides), but are blocked by legislators feeding from the gun-industry funded NRA trough.

Not only politicians are recipients of graft; a recent New York Times exposé provides evidence of pharmaceutical companies using ostensible “speaker’s fees” to actual provide kickback payments to physicians who are big prescribers of their drugs. The article emphasizes payments to doctors who practice pain medicine and are in a position to prescribe large amounts of the opioids manufactured by these companies. Sadly, this is almost as unsurprising as the graft going to politicians to compromise our health. What we should be is outraged about it, and working to combat it. Certainly the politicians do not seem to be. In the conclusion to her “controversial” speech at the White House Correspondents’ Dinner Michelle Wolf noted that: “Flint still doesn’t have clean drinking water.” It is harsh, it is true, and it is almost as bad as the news that the government of Michigan will no longer be providing free bottled water, even though the tap water is still unsafe.

Flint, of course, is a majority minority and overwhelmingly poor city. It has long been clear that its struggles with lead-poisoned water is not coincidental with the makeup of its population, and it not a coincidence that it is in Michigan. The Commonwealth Report illustrates a wide divide between those states that have better and those that have worse health status. Largely, the map is geographic with northern states better and southern states worse, but there is a tongue of northern states in the worse group, heading up from Kentucky and West Virginia into Indiana, Ohio, and on up to Michigan. What these states have in common with most of those in the south is control by Republicans who in most cases have not, in most cases, expanded Medicaid for their citizens. Expansion of Medicaid was a central part of the Affordable Care Act, but a Supreme Court left the decision on whether to do so optional for the states; those that have not done so have worse population health status. This is exacerbated by changes in federal policy that have increasingly made access to health care worse and more expensive in most states, with the impact felt most in states that have elected Republican government and that voted for President Trump.

In another blog post, First Look at Health Insurance Coverage in 2018 Finds ACA Gains Beginning to Reverse, the Commonwealth Fund notes that*:
·        About 4 million working-age people have lost insurance coverage since 2016
·        The uninsured rates among lower-income adults rose from 20.9 percent in 2016 to 25.7 percent in March 2018
·        The uninsured rate among working-age adults increased to 15.5 percent
·        The uninsured rate among adults in states that did not expand Medicaid rose to 21.9 percent
·        The uninsured rate increased among adults age 35 and older
·        The uninsured rate among adults who identify as Republicans is higher compared to 2016
·        The uninsured rate remains highest in southern states
·        Five percent of insured adults plan to drop insurance because of the individual mandate repeal

This is also not good news. Much of the problem is because employer health insurance costs (much of it passed on to workers) have been rising as Medicare and Medicaid control costs. A Washington Monthly article (excerpted by the great Don McCanne in his Quote of the Day) calls for price controls, noting that much of the cost (in lower wages) that workers bear for higher health insurance is not obvious to them, and they would thus have sticker shock from a Medicare for All program. Dr. McCanne notes that a current California bill, AB 3087, calls for price controls, and is supported by unions but opposed by industry and the California Medical Association so it has little chance of passage, suggesting that this solution is not more palatable to the powerful. He calls for well-thought out Medicare for All program, saying:
Now would it be that difficult to let people know about the hidden costs of health care that they are already paying? Do people really prefer being kept in the dark by an opaque financing system rather than being enlightened by the transparency of financing through an equitable tax system, especially if the amount being spent is somewhat less for all but the wealthiest of us?

I do not think so. It is time to do something to change a status quo that is unacceptable for the health of so many as well as unaffordable. It is time to do the right thing.

*Also summarized by Dr. McCanne

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