Tuesday, December 30, 2008
Community Health Centers originated in the Great Society program of the Johnson years. Contrary to false claims that the War on Poverty didn’t work, it did; while poverty surely was not eliminated, its impact was reduced. Of course, the funding for the programs suffered with the expansion of the Vietnam war, and the Reagan administration decimated most of the programs. (Poverty rates in the US dropped from about 20% in the early 1960s to less than 10% in the early 1970s, to rise again through the 80s and 90s.) Known as “330 clinics” because they were established under Title 330 of the Public Health Service Act, and currently know as Federally Qualified Health Centers (FQHCs), these Community Health Centers (and their “cousins”, the Title 329 Migrant Health Centers) provide sliding scale fee-for-service care to the urban and rural underserved. These terms are clearly and simply explained in a University of North Dakota publication. In exchange for meeting a variety of service and reporting requirements, including management by a Board that is at least 51% consumers (clinic clients), these clinics get enhanced reimbursement from Medicare and Medicaid at rates far higher than ordinary doctors or clinics. They also get “grant funds” intended to help them care for the uninsured who are not eligible for one of these federal (Medicare) or federal-state match (Medicaid) programs. (There is also a class of clinics called FQHC-“look alikes” that have to meet the same criteria and get the same Medicare and Medicaid reimbursement, but do not get the cash grant.) Of course, these are the funds that are grossly insufficient for most clinics; the needs of the number of working poor who do not have health insurance and do not qualify for Medicaid, which is the fastest growing portion of our population, far exceed the funding.
According to the Times article, “As governor of Texas, Mr. Bush came to admire the missionary zeal and cost-efficiency of the not-for-profit community health centers.” This is admirable, and I am certainly glad that this admiration has resulted in his expansion of the program. But there remain issues to be addressed, hopefully, by the incoming administration, related to this admiration. First, as we and the article have noted, is the need for additional funding so that these centers, as zealous and cost-efficient as they may be, can begin to meet the health care needs that exist. Second, there need to be programs – unquestionably tied to increased reimbursement – to encourage more young physicians to enter primary care so that there are physicians to staff these clinics. The Bush administration has been less concerned about this issue, continuing to oppose funding for Title VII of the Public Health Service act that funds training of primary care doctors, as well as other programs including physician’s assistant training.
Another issue concerns our expectation that those caring for the poor should sacrifice, be volunteers, be less well paid, than those caring for the insured or more affluent, who we expect to earn as much as possible. The Times article notes that CHCs often start their primary care doctors at $120,000 a year. While there is some regional variation, and it is difficult to get sympathy from people who are losing their jobs for someone “only” making $120,000 a year, this is a salary that is far lower than even primary care doctors make in practices serving the insured, and an amount significantly lowered by the medical school debt accumulated by many of the same committed doctors who wish to work in such settings. And this is “good”, that is, these are at least living-wage jobs for physicians; in many settings that do not have CHCs or publically-funded (usually county or city) clinics, those caring for the poor are actually much closer to being “volunteers”. In my town, the Missouri side of the Kansas City area has a (inadequately) county-supported hospital and two large FQHCs. The Kansas side has neither public hospital or public clinic or its own FQHC. Wyandotte, the poor county, has a high rate of uninsured people and has two one-doctor branches of the Missouri FQHC, 3 volunteer-doctor clinics, and a clinic that works because all the staff including the physicians earn $12/hour. And depends on grants. Johnson County, one of the richest in the nation, has just over 1/3 the uninsurance rate of Wyandotte, but with over 3 times the population, has more uninsured, and poor, people in total. And it has 2 volunteer clinics, with a half-time medical director. So, for the nearly ¾ million people in these two counties there are about 3-4 jobs that pay anything close to a reasonable wage for physicians; in these circumstances it would not matter if a lot more graduating physicians wanted to serve the underserved; the jobs are not there. Johnson County, in particular, with a high income population and a smaller percentage of poor and uninsured, deserves censure for not having a publically funded clinic system, not to mention hospital.
A two-class health system is not desirable, but it is better than when the lower “class” can get no care at all. Those working in CHCs, public clinics, and public hospitals, chronically underfunded, rightly bemoan their inability to truly meet the health needs of their patients, but there are many places where even that level of care is simply not available. CHCs may be excellent models for health care delivery for all people, but while we laud and honor those who work in volunteer clinics and public hospitals, we cannot consider this the solution. Martin Luther King, Jr., said “Philanthropy is commendable, but it must not cause the philanthropist to overlook the circumstances of economic injustice which make philanthropy necessary.” (More pithy, Jonathan Kozol: “Charity is not a good substitute for justice.”) We must never stop struggling against this injustice.
If we ever achieve a national health system, where financial barriers are eliminated and hospitals and physicians are paid the same for the care of a homeless person as a millionaire, we will be much closer. Sure, some hospitals and doctors will still try to avoid caring for the homeless and poor but then, at least, without the financial disincentive, we can correctly identify them as what they are (? how about “scum”?) Until then, we depend on volunteerism and sacrifice to try – very incompletely – to meet the health needs of our most needy. Tudor Hart’s inverse care law again validated.
 US Census Bureau, Historic Poverty Tables, http://www.census.gov/hhes/www/poverty/histpov/hstpov2.html
 Health Professional Shortage Areas (HPSAs) and Medically Underserved Areas (MUAs) http://ruralhealth.und.edu/pdf/hpsa.pdf
 Freeman J, Kruse J “Title VII: Our Loss, Their Pain” Annals of Family Medicine 4:465-466 (2006).
Thursday, December 25, 2008
It will also require a more rational and systematic allocation of resources, based on NEED rather than the opportunity for every individual provider or hospital to maximize its income. Current incentives are perverse, because they do the latter but do not do the former, whatever advocates of a “market-based” approach would say. It doesn’t work, if by “work” one means, as I do, meet the health needs of our people in a high-quality, comprehensive, rational, systematic, and cost-effective manner.
Consider hospitals. A rational system would build upon a network of clinics that utilize a community hospital, with several community hospitals feeding into a district referral hospital, and several referral hospitals feeding into a large regional medical center in which the most difficult and complex care can be provided (such as that in use in most industrialized countries, and designed for the US in the old “Dellums bill” for a national healthcare system). Rather, each hospital functions on its own, usually to maximize revenue, although sometimes with other goals such as maximizing research opportunities (usually combined with maximizing revenue) but rarely primarily the health care needs of the population. University academic medical centers, whether state supported or “private” (although these always have large amounts of public money) choose what services they wish to provide; the smallest and local community hospitals are often left only with the opportunity to meet the needs of those left over – or not, if they cannot afford to. Many large academic health centers, such as Johns Hopkins in Baltimore and the University of Chicago, are located in communities of great need, but do little do meet the core needs of their surrounding communities. They frequently indicate that they see themselves as national leaders, coincidentally existing in their neighborhoods, but make these decisions on their own, rather than as part of a rational health system.
The University of Kansas Hospital illustrates some of the contradictions that arise from the perverse incentives in our current health system. The hospital justifiably prides itself on a tremendous “turn-around” in the ten years since the creation of an independent hospital authority (KUHA) made it a “quasi-public” institution no longer under the control of the University, Board of Regents, or State of Kansas. Skilled leadership, with particular financial skills, have led it from losing to earning hundred of millions of dollars, from a building with serious physical plant failings to one which has added new floors, a new heart hospital (“Center for Advanced Heart Care”), a new Cancer Center, and is planning a new Medical Office Building for the physicians’ practice. It has also moved from near the bottom to near the top of the national rankings for quality of care. All good. The skills of the leaders were helped by the freedom from state purchasing and hiring processes (unions, seen by some state universities as a bane in their insistent efforts to protect the living wages of their members, were already not much of a factor in Kansas), allowing it to move much more nimbly. In addition, the fact that the facility, which if not in great shape was at least owned outright, allowed the hospital to take on capital debt for its renovation and expansion. All this is described in a celebratory article in the Business section of the Kansas City Star on Oct. 7, 2008, “KU Hospital's independent path has led to success”, which also quotes hospital leaders as crediting the success in part to not trying to be great in everything, but concentrating on two areas, heart and cancer care.
So far, so good. The hospital has indeed been successful in the current market and reimbursement system. But the concentration on heart and cancer care was not a random decision, and illustrates the problem created by our having the “non-system” of health care described above (and analyzed brilliantly by Bob Ferrer in his classic piece “Within the System of No System” published in JAMA in 2001.) Cancer and heart disease are major health problems in our country, but they are also the most lucrative “product lines”; there is no coincidence that every hospital that can wants to expand these services and increase their “market share” by making their facilities for caring for these conditions more attractive to physicians and patients (note: in this context please read “well-insured patients”) than those of their competitors. They (all hospitals, not just KUH!) are not developing services as arguably important, such as obstetrics, pediatrics (which is in some ways a special case; while general care of children is not a profit center, in most large cities – including Kansas City – it is concentrated in children’s hospitals that are huge recipients of philanthropy), psychiatry, or goodness knows, primary care for the poor. There just is no money in it. So hospitals build excess capacity for caring for the well-reimbursed problems of the well-insured, hoping to lure these patients from other institutions, and quite understandably de-emphasize programs to care for the problems that are poorly reimbursed, or care to the poorly insured. This can provide a challenge for the educational function of academic health centers, which need to train students and residents in all facets of medicine. More important, the problem is that these are, well, health problems. We do not have a system that provides all needed care to all people because the individual institutions are driven by their own individual bottom line.
A study some years ago in Oregon looked at the characteristics of those family medicine residency programs that were closing. They were not those that were inferior in quality or had a more difficult time attracting good students. It turns out that the greatest determinant was whether they were in “one hospital” or “two hospital” towns. In a one hospital town, the hospital knows that everyone will end up there eventually, even the poor; if a family medicine residency can keep their private doctors happy by taking care of the poor and uninsured, and maybe even keep them healthier so they don’t end up in the emergency room in extremis, that is a good investment. In a two-hospital town, there is only one financial goal – all the uninsured should go to the other hospital. Thus, any program, such as a family medicine residency, that might attract the poor, make them feel more welcome, in your hospital than in the other is a negative! How financially understandable, how morally and socially bankrupt!
The competitive market has no place in healthcare because it leads to perverse incentives that lead each institution to look out for its own interest, rather than being based in how the health needs of our people are best met, in terms of medical quality and cost effectiveness, from a system perspective. Even if we develop universal financial access, we will need a rational system of service, and we are long way from having that.
 Ferrer RL, “Within the System of No System”, JAMA.2001; 286: 2513-2514.
Happy Holidays to All!
Sunday, December 21, 2008
“Last week ABC News asked 16 of the banks that have received handouts from the Treasury Department’s $700 billion Troubled Assets Relief Program the same two direct questions: How have you used that money, and how much have you spent on bonuses this year? Most refused to answer.
“Congress can’t get the answers either. Its oversight panel declared in a first report this month that the Treasury is doling out billions ‘without seeking to monitor the use of funds provided to specific institutions.’ The Treasury prefers instead to look at ‘general metrics’, indicating the program’s overall effect on the economy. Well, we know what the ‘general metrics’ tell us already: the effect so far is nil. Perhaps if we were let in on the specifics, we’d start to understand why.”
Let’s get this clear. The American people, who are actually financing this bailout, just as they financed the wealth accumulated by these “titans of banking”, think that they should not get any bonuses. In fact, they don’t even think they should have jobs. We think that the ones who can be convicted of anything should be imprisoned, and the rest should have to give up all their money[*] and be living on unemployment (if their companies were keeping up with the premiums!) in second-hand FEMA trailers, before their companies receive dollar one from the bailout! Can we be clearer?
Obviously hasn’t happened with the Bush administration, and don’t get your hopes up for the incoming administration, not with Citigroup’s Robert Rubin (“I’d do the same all over again”) and his disciples being appointed to Obama’s key financial advisory positions. Sorry, the same people are going to win, and the rest of us are going to keep losing.
[*] For those of you who wonder if we can take all the money they already “earned”, I acknowledge that I am not a legal expert. For those of you who are, here is my question on what seems a parallel set of circumstances: I break into your house and steal the $1000 cash you keep in your sock drawer. For the next week I “put it on the street” in short term, high-interest loans and now have $2000. Then the cops arrest me for my original crime. My question: Do I get to keep the whole $2000, or just the $1000 I “earned”?
Wednesday, December 17, 2008
Taking different types of students into medical school requires a different approach to and understanding of the concept of “qualified”. In the past there has been general consensus that “high scores on exams” was “qualified”, but, as I have noted, these scores only predict performance in the “pre-clinical” (= “courses just like college”) curriculum, not in the clinical; moreover, the students who are most likely to have the characteristics that would lead them to practice in areas of need also have characteristics (such as coming from rural or inner-city high schools, coming from families with lower socioeconomic status) that make their scores lower. The “qualified” student for medical school is one who is likely to make a difference in the health of the American people. These same standards should be applied to the curriculum and reimbursement of physicians – how do they impact on improving the health of the people.
It turns out, unsurprisingly, that medical schools are not the only schools concerned with these issues. The effort to create diverse student bodies in universities and professional schools is widespread. A conference on the “Future of Diversity and Opportunity in Higher Education” was held at Rutgers University Dec 3-5, 2008, co-sponsored by the Center for Institutional and Social Change based at Columbia University. (Website: http://www.groundshift.org/.) Speakers addressed the idea of redefining “merit” to understand context; business has long understood that people hired need to add to the overall value of the organization, often by bringing different backgrounds and complementary skill sets. Lee Bollinger, President of Columbia University and the respondent in the two earlier University of Michigan affirmative suits (Gratz v. Bollinger and Grutter v. Bollinger) notes that those decisions allow selection on characteristics such as socioeconomic deprivation, but also notes that pretending that using socioeconomic characteristics obviates the need for racial and ethnic diversity is wrong. Richard McCormick, President of Rutgers and formerly President of the University of Washington noted the impact of the anti-affirmative action “Initiative 200” in Washington state: in 1998 1/11 freshman was non-Caucasian, but in 1999 it was 1/18. However, by developing new standards, including a required essay on diversity/adversity, within 4 years the ratio was at pre-Initiative rates without explicit use of affirmative action. In a particularly important panel on “Redefining Merit”, Sheila O’Rourke of the University of California at Berkeley spoke to the need to look at the definition of “merit” as not just test scores, but achievement in the context of opportunity. Prof. Lani Guinier from Harvard referred to the work of Malcolm Gladwell, looking at the differences in approach in selecting applicants to modeling schools and to the US Marines. Modeling schools looks for beautiful people in order to enhance their brand; this is selectivity effect. The Marines take people with a basic level of aptitude and skill and make them into Marines. This is treatment effect. The concept of “Democratic Merit” measures people on how they contribute to the mission of the organization or institution, and characteristics should include not only race and gender but socioeconomic status and geography. Much of this work is discussed in the book Prof. Guinier and Prof. Susan Sturm, from Columbia and the Center for Institutional and Social Change, wrote in 2001 “Who’s Qualified?” (Beacon Press, Boston.)
This is a critical concept. It understands how people contribute to the overall mission of a school, workplace or society. It recognizes how such institutions benefit from the difference in background, perspective, and experience of different people – and even how they think. Such a comprehensive perspective has to be of more value than simply performance on a test measuring one slice of knowledge and aptitude. As a simplistic example presented, consider 3 applicants for 2 positions in a company. If the criterion is performance on a 10-question test, and applicants A, B, & C respectively score 7, 6 & 5, should we take A & B? What if A got all 6 of B’s correct answers plus one more, but C’s 5 correct included the 3 both A & B missed? Would not C bring another perspective of value?
Businesses are far ahead of academic institutions in such thinking, even among those attending such a conference. It was from the panel of business leaders responsible for diversity in their companies, that the boldest assertions were made, and I paraphrase: “If there are only 12 top African-American law school graduates, the issue is not whether I can recruit them to my firm, because they will get good jobs somewhere; the issue is growing the number and pool,” and “We want diversity because it is good for our company, and will help it survive in a competitive market, but ultimately even if our company doesn’t survive, it is necessary for the success of our society.” I didn’t hear anything like that from the academics.
We need outcome-based criteria. In medicine, this is not how high the scores of a cohort of students are on exams given after 2 years of “basic science” or even “medical boards” (the USMLE, US Medical Licensing Exam) as long as they are adequate. It is also not whether they “match” in high-status residency programs. It can only be how well they contribute to the improvement of the overall health of our people.
Sunday, December 14, 2008
Given the decrease in interest among medical students in entering primary care careers, the existing health disparities are only likely to increase. I noted that the 20% of the US population that lives in rural areas has only 9% of physicians, but fewer than 3% of medical students are planning practice in rural areas. Even among the decreasing number of students entering primary care training, most come from the urban and suburban areas surrounding what Dr. Robert Bowman calls “major medical centers”, and are used to the life and lifestyle available in those settings. Moreover, even an individual student from a rural area who is otherwise interested in rural primary care practice, may find that the background or work requirements of their spouse or partner precludes a rural location.
The market affects specialty choice by medical students in terms of income; specialties with higher incomes are more in demand by students, increasingly so as medical student debt climbs to $200,000 or more. It is estimated that an anesthesiologist, for example, can (at current reimbursement rates) expect to make $7 million more in his/her career than a family physician, so we’re talking real money. The market is not so good, however, at diffusing physicians. More than for many professions, in medicine, and especially medical subspecialties, supply leads demand. Thus, while the suburbs of a large city may have plenty of X-ologists based on any estimate of need, one more is likely to do just fine financially, generating a comfortable standard of living for his/her family, pride from his/her parents, and maybe even great personal satisfaction; s/he will not, however, have a significant impact on overall population health, or make a dent in the health disparities that exist.
In any process of creating a product (and, with apologies, in this sense medical students can be seen as a “product”) the determinants of outcome (in this case which specialties students enter) will be affected by three variables: input variables (who we take into medical school), process variables (what is the curriculum, and the overall experience in medical school), and output variables (what is the practice environment like, especially reimbursement). If the latter is the most important, it is also the one that medical schools have the least control over. Changes certainly need to be made in the process, the experience in medical school, so that students do not hear messages that the more sub-specialized you are the “better” you are – or the ironic dual messages “You’re too smart to be a family doctor,” and “You have to know too much about too many things to be a generalist!”. But medical schools also need to look carefully at who is admitted. We actually know what characteristics are more associated with students entering primary care and underserved practice. These fall into demographic characteristics and individual characteristics.
Demographic characteristics distinguish between populations. The evidence is clear that students who enter primary care and underserved practice are more likely to be from rural areas, under-represented minority groups, and families with lower incomes, as well as to be older. They are also, unsurprisingly, as a group likely to have lower grades, come from “lower status” colleges, and have lower scores on the Medical College Admission Test (MCAT). Thus, using MCAT scores and grades as the main criteria for the selection of medical students will select a cohort of students less likely to practice in the sorts of specialties and areas where there is the most need. I would argue that schools should identify a threshold level of MCAT score above which students rarely if ever fail out of medical school, accept students with scores above that, but not otherwise use it for ranking (i.e., if the cutoff is, say 28, then 32 is not “better” than 30, in terms of making admissions decisions).
There are, of course, individual characteristics as well. Some students from wealthy families, from majority groups, from the suburbs, with high grades, will become primary care physicians and care for the underserved. But, in entering medical school, this cannot be assessed by an essay, or even an interview. The most reliable indicator of future behavior is past behavior; the student who says s/he wants to care for the underserved needs to demonstrate a past history of action; if they have been in the Peace Corps, or VISTA, or Teach for America, or helped start a free clinic or a rape crisis center in college, they are much more likely to actually serve the underserved in the future.
Of course, there is resistance to changing admissions criteria. Many say that it is “lowering standards”. This is only true if one assumes that grades and scores on tests such as the MCAT are the best measure of who will become the best doctor. They are not. In addition to not predicting who will meet society’s needs, they do not even predict performance in the clinical curriculum. (They do better in predicting performance in the pre-clinical, or basic science curriculum, where students mainly sit in class and are assessed by short answer tests measuring recall of facts. Surprise.)
In fact, if we continue to use the same criteria to accept students that we always have, we are likely to continue to produce the same doctors that we always have: smart, competent, and not practicing in the areas of greatest need and thus not likely to reduce health disparities. Paul Bataldan has famously said “Every system is perfectly designed to get the results that it gets,” and we know what the results that we get from our current selection system are. Albert Einstein is credited with saying “The definition of insanity is doing the same thing over and over again and expecting different results.”
Let us not be insane, and do what is needed to be done to meet the health care needs of all of our people.
 Tudor Hart, Julian, “Three decades of the inverse care law”, Br Med J, 2000 Jan 1;320(7226):15-8.
Thursday, December 11, 2008
“Health care reform in Massachusetts has led to a dramatic increase in the number of people with health insurance. But there's an unintended consequence: A sudden demand for primary care doctors has outpaced the supply.”
--NPR’s “All Things Considered”, November 30, 2008 (http://www.npr.org/templates/story/story.php?storyId=97620520)
A national health system will need to cover everyone, as I have discussed, but it must go farther. The goal is not simply to “cover everyone”, but to provide universal access to high-quality, cost-effective health care. To do this, we need the right mix of health professionals, practicing in the right locations, and a payment system that reimburses them for providing the care we want and need. Our population is poorly served in many areas, particularly rural and inner-city areas; our physician workforce now has too few physicians practicing in these areas. Twenty percent of the US population lives in rural areas, while only 9% of physicians practice in those areas, and an even smaller percentage of medical students is planning to practice in these areas. The main specialty needed in rural areas is primary care, particularly family medicine but also general internal medicine.
Having more primary care physicians is important beyond the need to supply doctors to underserved rural and urban areas. A past article (December 5) cited the recent Commonwealth Fund health scorecard, which shows we are on the wrong track, with the US’ scores dropping from 67 to 65 out of 100 from 2006 to 2008; of note is that our worst score is for “efficiency” (53/100), the area where primary care has the greatest impact, although we can also expect primary care to improve our poor performance on “access” and “equity.” The Fund’s scored indicators for “efficiency” include: Potential overuse or waste (duplicate medical tests, tests results or records not available at time of appointment, received imaging study for acute low back pain with no risk factors); ER use for condition that could have been treated by regular doctor (hospital admissions for ambulatory care–sensitive (ACS) conditions); Medicare costs of care and mortality for heart attacks, hip fractures, or colon cancer; Medicare costs of care for chronic diseases: diabetes, heart failure, COPD; Health insurance administration as percent of total national health expenditures.
Virtually all of these conditions are improved by having a greater primary care infrastructure. Extensive work has demonstrated that health systems built around primary care, both in this country and abroad, provide higher quality care at lower cost. When people have a provider who is “their doctor”, not the doctor for a piece of them, or one disease, a doctor who can coordinate, manage, and refer appropriately, who is available to them when they are needed, then people’s health is better and the system is more effective. This data is extensively documented by Baicker and Chandra from Dartmouth, Starfield, Shi and Macinko from Johns Hopkins,  Ferrer, Hambridge and Maly and others.
Baicker and Chandra looked at cost and quality in Medicare patients by state, and found that states with higher Medicare spending had lower-quality care. In addition, states with more primary care doctors had higher quality and lower cost, while those with more specialists had higher cost and lower quality. [Click on the graph to see it more clearly.]
Starfield, Shi and Macinko note that “Evidence of the health-promoting influence of primary care has been accumulating ever since researchers have been able to distinguish primary care from other aspects of the health services delivery system. This evidence shows that primary care helps prevent illness and death, regardless of whether the care is characterized by supply of primary care physicians, a relationship with a source of primary care, or the receipt of important features of primary care.”
They also note that “The evidence also shows that primary care (in contrast to specialty care) is associated with a more equitable distribution of health in populations, a finding that holds in both cross-national and within-national studies. The means by which primary care improves health have been identified, thus suggesting ways to improve overall health and reduce differences in health across major population subgroups.”
They posit six mechanisms why primary care has a beneficial impact on population health:
--Greater access to needed services,
--Better quality of care,
--Greater focus on prevention,
--Early management of health problems,
--The cumulative effect of the main primary care delivery characteristics, and
--The role of primary care in reducing unnecessary and potentially harmful specialist care.
In addition to these strong population health arguments for a primary care infrastructure, there are also the direct benefits to individual patients. People should have a provider who cares for them, the whole person, and understands their health in the context of biology, social situation, psychology and in the context of their family and community. The primary care provider (terrible word, but while it will most often be a doctor it could also be a nurse practitioner) knows the patient over time; the epistemology of the doctor-patient relationship in primary care is longitudinal, rather than acute or episodic. Ferrer and colleagues identify several primary care functions for individuals: “…although not unique to primary care, a strong emphasis on person-focused care projects beyond the patient–physician dyad to support important system goals such as quality of care and efficient use of services. Person-focused care also helps caregivers reach decisions that meet the needs of the patient rather than the health care system. This entails careful consideration of procedures that may be driven by availability rather than benefit; self-perpetuating cascades of diagnostic or therapeutic interventions; and interventions aimed at reducing clinician rather than patient uncertainty.”
The big problem, however, is that we have a shortage of primary care doctors and that problem is getting worse. The number of students entering family medicine residencies has been dropping precipitously. Between 5% and 10% of family medicine residency programs have closed in the last several years, and those that are left are able to fill less than half their positions with American allopathic (MD) graduates. Osteopathic (DO) graduates make up some of the rest, but the bulk are filled by graduates of international medical schools, including US citizens who go to medical school abroad. These students may have even less internal motivation to practice in rural areas than do US graduates, although there is a program that allows foreign nationals on J-1 (student) visas to stay in the US if they practice in an underserved area. General internal medicine, another primary care specialty, has seen even a greater decline. Residents completing a 3-year internal medicine residency may enter primary care (or become a hospitalist; see blog entry December 4, 2008) or may enter subspecialty training, such as cardiology, gastroenterology, or pulmonary medicine. Garibaldi, writing in Academic Medicine (the journal of the Association of American Medical Colleges) in 2005, found that while 54% of internal medicine 3rd-year residents were planning to enter primary care in 1999, in 2005 it was only 27%, and only 19% of 1st-year residents. In a July, 2008 study in JAMA that got a great deal of press coverage, Hauer and colleagues found that only 2% of graduating medical students from 11 US medical schools were planning careers in general medicine. For the US to have the primary care workforce it needs, the factors encouraging medical students to not choose primary care careers will need to be addressed; this is the subject of a future entry.
 “Why not the best? Results from the national scorecare on US health system performance, 2008”, Commonwealth Fund, Jul 2008, http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=692682
 Baicker K, Chandra A, “Medicare spending, the physician workforce, and beneficiaries’ quality of care”, Health Affairs on line, W4-184, 7 Apr 2004.
 Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83:457–502
 Shi L, Starfield B, Kennedy B, et al. ”Income inequality, primary care, and health indicators.” J Fam Pract. 48(4): 275-284, 1999.
 Ferrer RL, Hambridge SJ, Maly RC, “The essential role of generalists in health care systems”, Annals of Internal Medicine 2005;142:691-699.
 Garibaldi, RA, Popkave C, Bylsma W, “Career plans for trainees in internal medicine residency programs”, Acad Med 2005 May;80(5):507-12
 Hauer KE, Durning SJ, Kernan WN et al., “Factors associated with medical students’ career choices regarding internal medicine”. JAMA 2008;300(10):1154-64
Tuesday, December 9, 2008
The article notes that the Institute of Medicine (IOM) report expresses concern about the current 10-year old regulations may not be being enforced: "By most accounts, the current, weaker rules are widely ignored, so it will be imperative to make sure that any revisions are adhered to..." While this raises the obvious question of "how" this will be done, it also raises the issue of where this assertion, "By most accounts..." comes from. I have seen no citations, and know of no programs where these rules are violated in any regular way (of course, there may be a rare intermittent exception). The Accreditation Council for Graduate Medical Education (ACGME) monitors this very closely, and programs violating it have serious sanctions, so I am quite surprised and wonder whether this is really true.
Monday, December 8, 2008
There are reasonable arguments in favor of physicians in academic medical centers having relationships with manufacturers of drugs and devices. The most important is that most of the original research done to develop new drugs and devices is done in such centers by such scientists, usually sponsored in the initial phases by the National Institutes of Health, a federal taxpayer supported agency (contrary to the marketing claims of manufacturers that they support most research and development). When the new compound is promising enough to need industry support for further development and manufacture, it is good that the physicians and scientists involved in development, and the institutions that employ them, get credit and even financial payment. The argument in support of physicians as speakers for drug or device companies (“flaks”) is much less reasonable. There can be no reasonable argument for non-disclosure; indeed, to the extent that such relationships are ethical, there should be no hesitancy on the part of physicians and institutions to disclose. Can’t have it both ways, guys – can’t say it is OK to do, but you would be embarrassed to have your patients and the public and the media know about it.
The Times reports that Guy Chisolm, chair of the Cleveland Clinic’s conflict-of-interest committee, says “῾Disclosure is a minimum,’…The current disclosure simply lists the companies for whom the consulting takes place. He said the group was planning to improve the clinic’s ability to audit the information it received from doctors, because the clinic must now rely on doctors’ self-reporting to find potential conflicts.” and I absolutely agree. When you have scandals such as that of Emory University’s “…Dr. Charles B. Nemeroff, [who] drew criticism in October for failing to disclose at least $1 million in consulting fees from drug makers,” it is clear that self-disclosure is insufficient.
Then there is the question of whether the disclosures will make any difference to patients. “Some experts wonder how useful the industry disclosures actually are to patients when they are told of a doctor’s industry ties before agreeing to take part in a research trial. A patient, they argue, may not know what to make of such information.” Well, that is the doctor’s job. Ethically, it is part of informed consent. It is not only the doctor’s job to be able to not only explain clearly why s/he thinks that this is a good idea (which is obvious); s/he needs to make the counter-arguments him/herself, and direct the patient to places where they can find informed alternate, independent, and even opposed information. This is the responsibility of the academic medical center to enforce. Beyond the direct effect on patients, it is only through such disclosure that the colleagues of a particular physician or scientist will know of these potential conflicts, know that independent information will be needed by patients, and be in a position to exert peer influence and policing in excessive cases.
Finally, the Times quotes Dr. Delos M. Cosgrove, a cardiothoracic surgeon who is the Cleveland Clinic’s chief executive. He “…acknowledges that the environment has changed significantly in recent years as doctors’ industry relationships have come under scrutiny. In fact, he considers some of that scrutiny to be excessive. `You can’t get a coffee mug from a drug company,’ Dr. Cosgrove said.”
While quite a different issue from the big-dollar relationships that the Cleveland Clinic is addressing, and probably worthy of at least another blog entry, the question that comes to mind is: Why would Dr. Cosgrove, who presumably makes a good living and can afford his own coffee mugs, want one from a drug company? Why would any doctor? Why compromise yourself for coffee mugs, pens, sticky pads, calendars, and donuts? While not worth thousands in themselves, these “small” gifts have a big impact. The individual physician may not think much of using a pen with a drug company logo to write a on a note pad with a drug company logo while sitting under a poster or calendar or clock with a drug company logo, but patients notice these things, and understandably might think that the doctor is endorsing these products.
The American Medical Association position is that small gifts are ok, but large gifts are not. Fortunately, many academic medical centers are restricting even small gifts, for both the “appearance of propriety” and for the good reasons noted above. Essentially, gifts to physicians are a form of graft, in that they are given to one person (a physician, a politician) to encourage them to spend money on the company’s product – but not their own money – someone else’s (in the politician’s case, the public’s; in the physician’s case, the patient’s.) Arguing that small amounts of graft are OK is not a position I would care to defend.
Of course, most physicians would argue that their prescribing habits are not affected by gifts, large or small, or dinners. While that always could be true for a particular individual, it is clearly not true for the universe of doctors or the pharmaceutical companies wouldn’t spend so much money doing it! For those who are interested in how what is in one’s financial self-interest is seen, often subconsciously, as “coincidentally” the “fair” or “right” thing, I strongly recommend the article “A Social Science Perspective on Gifts to Physicians From Industry” by Dana and Loewenstein (JAMA.2003; 290: 252-255). While directed to the topic at hand, it is actually very useful in understanding a variety of self-justifying behaviors.
Sunday, December 7, 2008
Friday, December 5, 2008
“The United States today devotes 16 percent of its gross domestic product to medical care, more per capita than any other nation in the world. Yet numerous measures indicate the country lags in overall health: It ranks 29th in infant mortality, 48th in life expectancy and 19th out of 19 industrialized nations in preventable deaths.”
This is not news – health policy experts, scholars such as those from the Dartmouth Atlas project among many others, organizations such as Physicians for a National Health Program, labor unions, churches, and consumer groups have been citing these statistics for many years. In addition to the more horrifying statistic – that 49 million Americans are uninsured, and probably another 30 million have significantly inadequate insurance. These data have been around for a long time, and are getting worse. The Commonwealth Foundation, in its 2008 report issued in July, found that the US health system scored only 65 out of a possible 100 on measures including healthy lives, quality, access, efficiency, and equity, and that we have not improved since their last report, in 2006. In the area of “mortality amenable to medical care” the US ranked 19th out of 19 countries examined, down from 15th in 2006. (We had improved some, but other countries improved more. And we do this while spending twice what other industrialized countries do.) http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=692682nd.org/publications/publications_show.htm?doc_id=692682
What is perhaps news is that the Washington Post and other mainstream media outlets are beginning to cover it seriously. Beginning to have found enough friends and relatives in their own neighborhoods and workplaces who are suffering to realize that it is not just a problem for “them”. Beginning to recognize that the Cassandras on the “fringe” have in fact been exactly correct; we spend too much, we cover too few people and we have poor health outcomes. We do not, in fact, have the best health system in the world. Very far from it.
We may provide the best health care for certain problems that require expensive technology (and “require” is different from “commonly used”, as the article point out.)
But only to those with coverage. Good coverage. Not everyone. And those same people with very good coverage may be getting BAD care because of the perverse incentive that doctors, hospitals, and other health providers are paid for doing more, not keeping you healthy.
The Post article continues with a quote from Peter Orszag, head of the Congressional Budget Office, who was nominated last week to be director of the Office of Management and Budget in the Obama administration. “Even if only a third of that could be invested in critical programs, imagine the possibilities. Given the scale of it, I am puzzled as to why we are not doing more to improve the efficiency of the health system."
Note that “efficiency” is the lowest score that the US received in the 2008 Commonwealth Fund report. Efficiency scores were low because of poor performance on measures of avoidable hospitalizations; inappropriate, wasteful or fragmented care; variation in quality and costs; administrative costs; and information systems. Arguably, these are the areas which are most responsive to a strong primary care infrastructure (see a future blog entry).
As can be seen by the attached chart, however, it is clear that the problem isn’t that we don’t have enough administrators. Perhaps the answer is more along the lines of “corporate – especially insurance company – profit”.
Thursday, December 4, 2008
The complexity of caring for hospitalized patients, combined with the desire of many primary care doctors to limit their practice to the ambulatory setting, has led in recent years to the development of a new specialty, the “hospitalist”. Hospitalists are usually graduates of internal medicine residencies or family medicine residencies (or for children, pediatrics residencies) who choose to limit their practice to the hospital. Their practice structure tends to follow that of emergency physicians – they are either employed directly by the hospital, or by a group which contracts with the hospital for services. This system is particularly attractive to an efficiency-and-business oriented culture (the one hospital and health systems administrators are usually trained in). The primary care doctors can work all day seeing patients in the clinic, without being distracted by hospital visits, and the hospitalized patients can be cared for by people who are specialists in this field, and of course, it would seem, provide better care. In fact, this is the way care is structured in most European countries, where the general practitioners do not admit to the hospital, and specialists (usually called “internists” since in those countries virtually all primary care is done by general/family physicians) provide the hospital care.
Interestingly, the studies that have been done of quality of care by hospitalists, comparing them to doctors-who-take-care-of-their-own-patients-in-the-hospital are quite mixed, and do not reliably demonstrate higher quality. In one recent study, by the measures of care for cardiac disease used, the hospitalists had slightly better quality than the general internists and about the same as the family physicians. By the measure most dear to the heart of hospital administrators, costs follow the same pattern – none. Hospitalists are not reliably more or less cost-effective. And of course there are great differences in hospitalists and hospitalist groups – studies done of a cohort of hospitalists who have been doing that work for 10 years may not be valid when applied to a recent internal medicine residency graduate who is taking a year off before doing a cardiology or gastroenterology fellowship.
But there are other concerns. For the patient. The hospitalist is by definition not the primary care doctor, who has known you for a long time (and will be the one caring for you after discharge!). S/he meets you only in the hospital, and doesn’t really know what you were like “before”. S/he can see if you are getting better, but really doesn’t have the perspective that your primary doctor does who knew you before the episode that led you to be hospitalized. And, of course, hospitalists work shifts and “blocks”, so if you are going to be admitted to the care of the hospitalists, it works best if you can arrange to be admitted on Monday and discharged before Friday, so you will probably have (vacations aside, and nights aside – we are now finding hospitals hiring nocturnists!!) only one hospitalist. Should you, however, choose to come in Thursday and stay past the weekend, you will probably have several hospitalists doing your care even over the short stay. Besides the nocturnists! And none of them knew you before, and each of them has to learn you anew, and probably sees things just a little bit differently than the one who “had” you before.
About a year ago my sister, in California, had an abdominal problem eventually requiring surgery and had the non-surgical care provided by hospitalists (unfortunately, her problem had the bad judgment to require admission late in the week). After the surgery, she had some serious non-surgical complications, which we won’t get into here. The (newest) hospitalist indicated one day that she was a lot “better”. Perhaps, said my other sister who had flown in to be with her, she is better than yesterday, but this is no where near normal for her! The poor hospitalist, who had only met her the day before, had no basis for determining what was “normal” for her. Her “regular” doctor would have, but her regular doctor was not caring for her in the hospital. Lucky she had family there.
I think, in general, people are ok with seeing their doctor’s partner or a nurse-practitioner who works with them when they are coming to the office for a sore throat or blood pressure check and their doctor is not available. But it precisely when you are in the hospital, when you are sick and vulnerable and scared, that it is important that you see someone who knows you, who knows how you were last week and last month and will be responsible for caring for you when you leave. That may not be the surgeon who operates on your cancer, or the oncologist who prescribes the chemotherapy or the radiation oncologist who prescribes the radiotherapy, or the nephrologist who manages the kidney failure you got from the treatments – but it is the doctor who cares for you, as a person. Who recognizes you as a person, and is there to interpret all the confusing things that are happening.
Familiarity, caring, continuity of care, are wonderful things for you when you are sick, even if they seems to be costly or inefficient to those counting the beans.
Wednesday, December 3, 2008
To the regular person reading these recommendations, they would at first seem quite reasonable, indeed a “gimme”. If the pre-Libby Zion work hours of some residents were horrific, the fact that the current ones are better does not make them good; even the new recommendations, that still allow residents to work to 80-hours a week, may seem excessive. Maybe, but there are other things to think about.
Let us look at who residents are. They are medical school graduates, MDs or DOs, who are now in training in a particular specialty. They spend a minimum of 3 years (for family medicine, internal medicine, pediatrics, and other specialties) to 5 years (for general surgery) or even 7 years (for cardiovascular surgery) in such training. For most residents, most of training is in the hospital; indeed the very term “residents” derives from when they lived in the hospital; the alternative “house staff” still implies that they are based there. For some residencies, however, mainly family medicine, practice in the outpatient continuity setting is the core focus of residency training. While other specialties (general internal medicine, general pediatrics) are also primary care, the residency programs in these specialties still emphasize hospital care, with usually one half-day weekly in outpatient clinics. Family medicine residents do in-hospital rotations, but, particularly in the last two years of residency, they are expected to develop and follow a panel of patients, and typically see their clinic patients 3-5 half-days per week. This means that they have to be available during the day on a regular schedule to see patients who expect them to be there. Unlike hospital medicine, or emergency medicine, this sort of practice doesn’t work very well with shifts. Such residents also have hospital duties but it is rare that they work more than 80 hours a week. Most programs have adopted systems like “night float” – where one doctor works the night shift for a week or two.
One of the more interesting things in the IOM panel report was its emphasis on “hand-offs”, where the doctors “going off” share the patients’ status and condition with those relieving them. From the NY Times:
“The panel paid particular attention to the so-called patient handoff, the point at which a resident briefs the next doctor about a patient’s history and needs as he or she is ending a work shift. The handoff is a risky time for patients, because rushed and fatigued doctors often inadequately brief incoming staff members, said Dr. Sandeep Jauhar, director of the heart failure program at Long Island Jewish Medical Center and a reviewer of the report.
Dr. Jauhar, who recently wrote about his medical training in the book ‘Intern: A Doctor’s Initiation,’ recalls a time during his own residency when a fellow doctor-in-training rushed a patient briefing without giving him basic facts about the patient’s serious condition.
‘When the nurse asked, “What do you want to do, doctor?” I didn’t have a clue,’ Dr. Jauhar said. ‘I didn’t have his case; I didn’t know what tests had been done. Each time you hand off a patient there is a possibility of error.’’’
There are a lot of issues being confused here. I don’t know when Dr. Jauhar did his residency (the “internship” is the first year of residency) but it looks like it was before the current hours rules were implemented. And it looks like he got poor “sign-out” or “hand-off”, for which there is no excuse. The big problem is that in putting the phrase “Each time you hand off a patient there is a possibility of error” in the context of these recommendations to reduce resident work hours, the implication is that somehow reducing work hours would reduce the frequency of hand-offs, which is entirely the opposite of what is true. The more that work hours are reduced, the more frequently the care of patients has to be “handed off” from one doctor to another. If there are risks inherent in these transfers of care, they will only be exacerbated by have more limited shift hours.
Patients want, and expect, the doctors caring for them to be awake, alert, and on top of their game. They should. However, they also want doctors who know them, know their “case” (what a horrific term for a person suffering an illness), know what has been done and what needs to be done. They should want that too. Ideally, the major decisions are made during the day by the patient’s primary doctor, who has not been up all night. But sometimes stuff happens, especially to sick people in the hospital, when it was not planned, and then there needs to be adequate information available to the responsible physician in house, including access to the ‘attending’ physician caring for that patient. (Note that there is no worry about post-residency physicians being awakened in the night.) Careful planning needs to happens. Schedules have to be designed to maximize learning for the resident, limitations on their hours, and also keep the care of the patient at the top of the list. None of these issues are as simple as they first seem.
Tomorrow, we will discuss another threat to continuity: Hospitalists.
Follow-up on not letting “the perfect be the enemy of the good” (November 28). Robert Ferrer, MD, MPH points out: “The other thing one might say about "don't let the perfect be the enemy of the good" is that it is a dishonest formulation. In most human endeavors, perfection is understood as rarely attainable. Consider the 800 SAT, the perfect game in baseball, the flawless scientific study. "Perfect" lies at the extreme right end of the bell curve of performance. Not so for universal health care, where, somehow, the vast majority of nations have managed to attain "the perfect." Only in an N of 1 scenario, where the U.S. is considered in isolation, can universal coverage qualify as exceptional performance.”
Monday, December 1, 2008
“Back in the 1980s,” the Times editorial notes, “private plans — known as health maintenance organizations — were seen as a savior for Medicare. They could provide the same or better services as traditional fee-for-service Medicare, but because of managed care they could do it at a lower cost. Over the years Congress brought other, less managed private plans into Medicare, and in 2003 the Republican-dominated Congress substantially increased government payments to private plans.” That is, the anti-government, the private-sector-is-always better ideology of the Republican party (surprise!) has led to the creation of Medicare Advantage plans that are more popular with consumers because they get extra benefits, but bill the taxpayer for both these added benefits and extra profit for the insurance company.
Insurance company profit is the key concept here. Many people have less-than-positive memories of managed-care companies, or Health Maintenance Organizations. Rather than thinking of HMOs as being able to “…provide the same or better services as traditional fee-for-service Medicare, but…at a lower cost,” people mostly remember restrictions on access to care, including limited access to specialists. What people did not, and often do not recognize, is that the problem was not the structure of managed care but it was the vehicle used by private, for-profit corporations, usually insurance companies, to expand their control over the healthcare delivery system.
Historically, HMOs, way before they were called HMOs, were consumer-owned cooperatives much like farmers’ cooperatives. By cutting out the middleman (the insurance company) these groups, such as HIP in NYC, Ross-Loos in LA, Group Health in Seattle, were able to provide their members the same coverage for less money or more coverage for the same money. They were perceived, particularly by groups such as the AMA, as socialized medicine.
But then, with the support of the Reagan administration, insurance companies saw that if they owned the HMOs, they could increase their profits. In the old (and now current) fee-for-service system, where money is made by providing more care, the health risk to the patient is receiving unnecessary (and perhaps risky) service, and the cost is higher. Under the prepaid model of HMOs, the less care that is provided, the greater the profit to the owner. When the “owners” were the patients in the era of consumer cooperatives, this was unlikely to happen; when the owners are for-profit insurance companies, the ratcheting down of services provided, reducing the percentage of the premiums actually spent on medical care for patients, was a given.
So let me be clear. The problem absolutely is not capitated care, HMOs, or even “managed care”, which have many positive characteristics to recommend them. The problem absolutely is the control of the health care delivery system by for-profit corporations. Whether doing it through the mechanism of managed care, or in the current fee-for-service systems by restrictions on services, high copays, and high deductibles, such for-profit companies will always seek to maximize their profit by collecting as much money as possible and delivering as little care to patients as possible. Indeed, the insurance company term for the amount of money they collect in premiums that is actually spent on beneficiaries’ health care is termed, amazingly, the “medical loss ratio”! No wonder our per capita “health” costs are so much greater than in any other country – many of those dollars being spent not only on overhead but on corporate profit.
We can’t afford it, and we shouldn’t have to pay for it. The Times is correct in its opposition to excess payments to the Medicare Advantage plans but misses the greater point that corporate profit does not belong in health care delivery. Medicare, whose overhead is less than 3%, is a great example of cost-effective management of a payment system.
We need a universal care, single payer program so that the health system can focus on providing high-quality, necessary care for all the people of the United States.