Wednesday, January 27, 2010

Health is more than Medical Care

Bob Herbert’s column in the New York Times, January 23, 2010, “They still don’t get it”, is one of many recent pieces that articulately criticize the administration for pursuing policies that benefit the wealthy and the elite, and ignore the absolutely justifiable anger of the majority of American people. That anger is being stoked and ridden by the Republicans, as it was by Obama in 2008, because they are out of power. There is no question that, if the Repubs were in power, they would be even worse, and cater even more to that elite (ref: see administration of GW Bush, 2001-09.) One of the issues that Herbert takes on is health reform: “While the nation was suffering through the worst economy since the Depression, the Democrats wasted a year squabbling like unruly toddlers over health insurance legislation.” Herbert is not opposed to health reform, but rather the outrageous way that this sausage has been made: “No one in his or her right mind could have believed that a workable, efficient, cost-effective system could come out of the monstrously ugly plan that finally emerged from the Senate after long months of shady alliances, disgraceful back-room deals, outlandish payoffs and abject capitulation to the insurance companies and giant pharmaceutical outfits. The public interest? Forget about it.”

With the election of the 41st Republican senator – under Senate rules, 41 votes constitutes a majority in terms of blocking legislation – we have heard many opinions on what should happen with health reform. The Republicans and the right-wing, who, despite their opportunist populism stand firmly in the grasp of “insurance companies and giant pharmaceutical outfits” are predictably calling health reform “dead” and reveling in the possibility that the system won’t change at all. This, of course, is a disaster; the folks who voted for Scott Brown in Massachusetts because they were convinced by demagogues that they would lose their current health benefits will continue to lose them anyway, not because of health reform legislation but because that’s where it was headed – higher cost, lower benefits. Some progressives, including Paul Krugman (“Do the right thing”, January 22, 2010), and physician-writer Atul Gawande (in his Democracy Now! Interview with Amy Goodman on January 5, 2010), call for passage of the current plan because it will, in fact, benefit a lot of people. Krugman says the House should just pass Senate bill to avoid any further votes in the Senate, which might lose. There is a lot to be said for this position. Others, including those I respect most from Physicians for a National Health Program, call for scrapping this whole bill and passing a single-payer Medicare for All program, which is absolutely the right answer, but not going to happen. (Nonetheless, I will, and I urge everyone, to write their representatives every day demanding it!)

While I support single-payer health insurance as the necessary pre-condition for improving health care for the American people, it is also clear that the process of self-interest politics in the formation of the Senate and House bills (in which the self-interest of the most wealthy and powerful is the biggest influence) has moved the discussion so much to medical care insurance coverage and access that we lose sight of the ultimate goal, greater health. In an excellent “Perspective” in the New England Journal of Medicine, January 14, 2010, “Ranking 37th – measuring the performance of the US health care system”, Chistopher J.L. Murray and Julio Frenk review the 2000 World Health Organization rankings of health status in different countries in the world. They remind us that “It is hard to ignore that in 2006, the United States was number 1 in terms of health care spending per capita but ranked 39th for infant mortality, 43rd for adult female mortality, 42nd for adult male mortality, and 36th for life expectancy,” and that the probability of death for men 15-60 has dropped dramatically more slowly since 1974 in the US than in many other countries.

Murray and Frenk also remind us of “the vast number of preventable deaths associated with smoking (465,000 per year), hypertension (395,000), obesity (216,000), physical inactivity (191,000), high blood glucose levels (190,000), high levels of low-density lipoprotein cholesterol (113,000), and other dietary risk factors”. We may not see these numbers every day, but health professionals and policy people know (or should know) them. We have certainly seen calls from many sectors, from this blog to the President, for a realignment of funding priorities from expensive procedures to prevention, from high-tech subspecialty care to primary care, from huge expenses at the end of life to strategies that will extend healthy life, and these numbers emphasize how important those changes are.

But those changes only address health care, and more usually medical care. This can be a diversion, from other, maybe more important, policies that truly will promote health. Even if we can produce more primary care physicians (and other providers), even if we offer “pay-for-performance” type incentives for physicians to do “quality care”, even if we actually pay as much for spending an hour counseling and working with a person to stop smoking, change their diet, and exercise, as we do for a cardiac catheterization or colonoscopy, the problems listed by Murray and Frenk require behavioral change on the part of people. Doctors can help, by counseling, by prescribing drugs for the conditions (e.g., hypertension, diabetes) that may be drug-susceptible, but people themselves are going to have to be the ones who change their diets, exercise more, stop smoking, take those medications.

Please note that I am not one of those who wants to place the blame on individuals, and excuse physicians and other health professionals from their own responsibilities (“I told them to lose weight, to stop smoking, to exercise! They didn’t do it! They are not compliant!”). It is important, however, to look at these problems from a larger social perspective. In the paragraph above I purposely used the word “people”, not, as is popular, “individuals”. Because while individuals, if they are highly motivated enough (and this is helped by having higher income and education and social class) can change these behaviors -- and have, in many cases, such as the dramatic reduction in the prevalence of smoking, these are really societal issues. This sort of behavioral change is hard to do – stopping an addiction like nicotine is harder than heroin, but is nothing compared to changing your diet from foods that taste good (and yes, while to some degree poor food choices come from habit and culture, the fact is that sugar and fat taste good!) to those that are more healthful, to limiting intake of excess calories. And exercise is hard, not only when you are already fat, out of shape and a smoker, but when you are working 2 or 3 jobs, live in a neighborhood that is unsafe, and have to try to fit in taking care of your children.

Changing these health parameters is not going to happen solely from everyone having health insurance and access to medical care, paying physicians for “quality”, or increasing the number of primary care providers, or completely changing the premises of medical care reimbursement. It is going to require major societal change. Some has begun to happen – public smoking bans in many cities and states, calorie labels on fast foods in some cities, removal of high calorie snack and drink machines from some schools. But what it needs is not only for these actions to be universal, it will require much more. Stricter regulation of advertising of junk food to children, higher taxes on it, and less availability. The messages for eating healthful food need to be louder and more frequent than the messages to do the opposite. We have to ban insidious campaigns like “drink wisely” (i.e., "do drink"). And have strict limits on access to firearms. And we have to rebuild our communities to encourage not only purposeful exercise (“going to the gym”) but activity as a part of daily life: walking instead of driving to school, shopping, work.

Of course, for all of these changes, there will be powerful lobbies against it –even the easy ones (smoking bans, labeling) not to mention the generations it will take to significantly modify our built environment. And if you thought that the opposition to meaningful health care insurance reform was powerful, you ain’t seen nothing yet!

Thursday, January 21, 2010

Harvard Medical School limits outside income: a good start

Partners Health Care, the physicians group comprising the clinical faculty of the Harvard Medical School at Massachusetts General Hospital and Brigham and Women’s Hospital, has recently set “strict” limits on the compensation that about “two dozen senior officials” (including department chairs, vice presidents and others) can receive from serving on the corporate boards of biotechnology and pharmaceutical companies, according to Duff Wilson in the New York Times, January 3, 2010 , Harvard Teaching Hospitals Cap Outside Pay. These physicians will also be prohibited from receiving any speaking fees from drug companies. The article indicates that many medical schools have put limits on such outside income, but that Harvard’s are the strictest yet. And consequential, because Harvard has so many leaders who sit on such boards. Apparently, the ban on speaking fees was decided first by the policy committee, and then the board income was limited so as not to limit outside income for junior faculty (who may speak for drug companies) but not senior leaders (who are more likely to be on the boards). There is no indication of limits on the participation of anyone on boards of other types of corporations, although biotechnology and pharmaceutical, along with medical device companies, are the most likely to create a conflict of interest.

Many do not see these restrictions as enough. The chair of the Partners’ policy committee, that wrote the rules, distinguished cardiologist Eugene Braunwald, is quoted as saying “We’re the first to go in this deep, and we’re still into it only up to our knees.” Former New England Journal of Medicine editor and Harvard professor emeritus Arnold Relman definitely thinks that they are too weak: “I think that’s a gross conflict for an official of an academic medical center to be on the board of a pharmaceutical company...It’s happening more and more around the country…If it isn’t stopped, I think the academic institutions are going to lose the confidence of the country and the government and they will no longer deserve the tax exemption or anything else. They will be part of industry itself.” Regular people may not see the restrictions, to $5,000 a day (based on $500 an hour for a 10-hour day of actual work on the board) as too severe, but they are not moving in the world of corporate boards. Dennis Ausiello MD, chair of medicine at Mass General, has received over $200,000 since 2006 from sitting on the board of the pharmaceutical giant Pfizer. “I certainly think I should be compensated fairly and symmetrically with my fellow board members,” he says. However, he will abide by the rules. “I’m not there to make money… if my institutions rule otherwise [i.e., against being compensated as are his fellow board members], as they have, I will continue to serve on the board.”

Clearly, Ausiello has a different perspective than Relman, because he believes that he makes a positive contribution being on the board: “I’m very proud of my board work,” while Relman thinks the very presence of medical school faculty on boards is corrupting its mission. Interestingly, both the committees seeking to restrict the participation and corporate pay experts agree that paying board members based on corporate performance and profit ties them to the profitability of the corporation. The Times notes that “Thomas Donaldson, a professor of business ethics at the Wharton School of the University of Pennsylvania…who advises large companies on corporate governance, said dual roles in a hospital and at a drug maker were ‘dicey at best’ because a director’s duty is to look out for the corporation’s financial interests.” He said: “It strikes me as a breath of fresh air in a room that’s getting progressively more stale. I hope this will set a standard for others — hospitals, medical schools.” The Harvard rules specifically prohibit this, believing that pay for work (@ $500/hr) at least has the chance of allowing its faculty to maintain some scientific integrity.

The issue can be complicated for insiders. Deborah Powell MD, former dean of the medical school at the University of Minnesota and an advocate for policies that encourage restraint, herself accepted a paid position on the board of Pepsico. Many believe that her subsequent firing was due, in part, to negative publicity from this action. (U of M medical school reorganizes; dean out by summer, Tim Post, Minnesota Public Radio, January 29, 2009). The American Academy of Family Physicians (AAFP) has recently developed a “corporate partnership” with Coca-Cola that has received a great deal of criticism both within and outside the family medicine community – criticism that has not resulted in the AAFP ending the relationship. Which is a greater conflict of interest for physicians and medical school faculty members – alliances with companies, such as Coke and Pepsi, whose products are clearly detrimental to health, or sitting on the boards of corporations that make medical and pharmaceutical products? I leave the call to you; to me they are both rotten. Corporations want them to get the imprimatur of science and health that these relationships provide. Organizations like AAFP want them for the money. Presumably the individuals on the faculty of Harvard and other medical schools also like the money, but also may, like Drs. Ausiello and Powell, think that they can make significant positive contributions to health through their roles on the boards. And, if these people are full-time employees at their main job, who should get the money that it engenders? Harvard is, as noted, limiting the income, but is allowing corporations to use the rest of the money that the board member would have gotten paid as a charitable donation to any charity not linked to Harvard, Partners, or the hospitals. That deals with the money issue, but still leaves the questions about the ethics of participation, even for free, that are raised by Dr. Relman and others.

Interestingly, the Times article cites the Partners’ decision as, in part, due to the fact that “Harvard, in particular, has come under scrutiny from Senator Charles E. Grassley of Iowa, a leader of Congressional inquiries into the influence of money in medicine.” I say “interestingly” because Grassley, the Finance Committee's ranking Republican, received more than $2 million from the health and insurance sectors since 2003 (Industry Cash Flowed To Drafters of Reform, Washington Post, July 21, 2009). Of course, like the medical school faculty who believe that they are doing important work and are not influenced by the pay (which Sen. Grassley doubts), Grassley himself says the campaign contributions have no effect on his positions (Grassley: Campaign Contributions Hold No Sway, Press Center from the Des Moines Register, August 31, 2009). Double standard? Of course. Ironically, Grassley uses his investigations into the policies of places like Harvard as evidence that he is not “bought” by those interests!

Harvard is taking the right first steps and those principles should guide other medical schools in the future to take even stronger action. And the same should be done for contributions to members of Congress.

Saturday, January 16, 2010

Cancer Care and Hospital Advertising

The December 19, 2009 issue of the New York Times contains an article entitled Cancer Center Ads Use Emotion More Than Fact. The piece, by Natasha Singer, documents the extensive use of advertising by hospitals to attract cancer patients, and decries the appeal to people’s emotions at a time of great vulnerability, after they have received a cancer diagnosis. These appeals contain testimonials from people who were “cured” or had a good outcome (or at least think, at the time of the testimonials, that they had a good outcome), and imply – sometimes frankly state – that their cancer care is better than their competitors’. Those competitors may be other hospitals in the same metropolitan area, or, in the case of centers that have received special National Cancer Institute (NCI) “cancer center” designation, or in the case of the “top” centers (e.g., MD Anderson in Houston, Dana-Farber in Boston, in New York ) each other.

The issue is that this advertising does not have to be based on fact. This is not to say that the actual people in the testimonials are lying, but that there is no requirement for data on statistical outcomes from these hospitals before they produce their advertising. The individual patient may have had a good outcome, but has no way of knowing if the outcome would have been as good (or better) somewhere else. The article documents assertions of superlatives, such as a doctor having the “highest cure rates” and “lowest risk”, which a reasonable person might infer was based on data comparing that doctor’s, or that hospital’s, results to others. However it turns out that they are based on anecdotes, something that would be completely unacceptable in the reporting of scientific results. One expert noted that “There seems to be a disconnect between the business end of the cancer treatment industrial complex and the physicians on the front lines treating patients,” a dramatic understatement. “This isn’t retail advertising,” said the president of a Manhattan agency that developed ads for Mount Sinai hospital, “This is reputation advertising. There is a very big difference.”

Why hospitals want to advertise their cancer care (or their care for any other profitable “service line” such as, the article notes, cardiovascular disease or cosmetic surgery) is obvious – to make money. Though most of them are “not-for-profit”, all that means is that the “profits” don’t go to shareholders, but they can certainly be used by the hospital for expansion or creations of new and better service lines. And higher salaries and bonuses for executives (and physicians). Does it improve people’s health? Well, to a certain degree competition between hospitals does; like competition in any industry it operates against complacency, against “doing what we’ve always done”, against being satisfied with less than “the best”, because if it is possible to do better, there is the chance that your competitor will do better, and take away your business. It is also reasonable to advertise, so that people know how well you are doing. However, when the advertising is not based on real outcomes data, but purports to be, that is, it indicates – possibly not knowingly untruthfully but without evidence to back it up – that is at best misleading, and possibly unethical.

From a health perspective, a community needs a certain capacity for care of cancer patients – or any patients. That community may be a part of a city, or a city, or a metropolitan area, or in the case of rarer cancers, a region or even the nation. Excess capacity is extremely costly – if hospital A gets most of the cancer “business” in town, so hospital B chooses to invest heavily in building a new cancer-treatment facility (including, by the way, with public funds, since because they are not-for-profit, donations are philanthropy and tax-deductible), we now have excess capacity in the community, and a great deal of extra cost. To the extent that this represents a competition that results in better care, as discussed above, it may be a good thing – but the hospitals should have to document that there is actually better care provided, something almost never done. And, if it is going to spend a lot of money to create excess capacity in the community, the hospital should have to use the traditional method of raising capital and not be able to use tax-deductible contributions for this purpose (but, of course, they do).

There is another problem, which I mentioned briefly above. Hospitals do not heavily (and possibly deceptively) advertise all their services; like other businesses they advertise the profitable services. In general, services (“product lines”) are profitable because the current payment system reimburses for these services far more than the cost of delivering them. Cancer is in this category, because of the enormous markups for providing chemotherapy drugs (this is in addition to the enormous markups charged by the manufacturers). So are cardiovascular procedures, neurosurgical procedures, and of course cosmetic surgery. Hospitals do not heavily advertise the care that they provide (even if it is in fact excellent and better than others’ based on real data) if they don’t make as much, or even lose, money. This includes “regular” medical diseases, as well as very costly special services including much trauma and burn care. Pediatrics is a special case; in general (other than, of course, pediatric cancer care, for the same reasons as adult cancer care, and neonatal intensive care) does not make money, so general hospitals don’t heavily advertise it. “Children’s Hospitals”, however, are often among the greatest recipients of philanthropy in a community, and this is their main source of revenue, so advertising what they do makes sense for them in order to keep their name in front of donors.

We have become used to hearing (including from me) cautions about the greed and influence of the health insurance and the pharmaceutical and device manufacturers on health care, on health legislation and on politicians. These companies are for-profit and interested in their bottom lines, not on the impact that they have on health itself. Much of this is discussed in the New York Times article Health Lobby takes fight to the states on December 29, 2009, but as I have noted, it is the health care industry lobby, not the health lobby. We would have hoped that our communities’ hospitals would see themselves as more interested in our health, but this sort of advertising makes it clear that, non-profit though they may be, they are the health care industry.

Where does this leave us? It leaves us with the need to develop, and publicly report, good measures of outcomes for physicians and hospitals, as called for by many experts, notably Institute for Healthcare Improvement director Don Berwick, MD[1]. Otherwise people will continue to choose hospitals and doctors based on reputation and the quality of their “hotel facilities” rather than on the quality of their care. Pending that, we need to remember to see all health care advertising, including that from doctors and hospitals, as precisely that, advertising, and not confuse those claims with the scientific evidence that we hope will guide our care.

[1] Berwick, D., “Measuring physicians’ quality and performance: adrift on Lake Wobegon”, JAMA Dec9,2009;301:2485-6

Monday, January 11, 2010

Health Workers and the Afghanistan-Pakistan War

This is a guest blog by Seiji Yamada, MD.

President Obama has set our nation on the course of escalation of our war in Afghanistan-Pakistan. What should be the concerns of health workers in this current juncture? As health workers, we should concern ourselves with the health and human rights implications of the war that our nation is conducting. For one, we should care about what happens to the Afghan people, whose life expectancy is 45 years for women and 47 years for men. It is our responsibility as Americans to care about what happens to Afghan people in the course of this war that our nation has been waging since October 2001, particularly when they are injured or killed by our dint of American arms. The effects of war extends to consequences of war, such as the collapse of health services, lack of access to water and food, and damage to infrastructure, economies, and societies. We should keep in mind that Afghanistan is a country that has had ongoing conflict and civil turmoil since 1979.

As noted by Rubenstein and Newbrander, primary care services ensured by the Afghan Ministry of Public Health have improved since 2002:

[T]he number of health facilities has doubled and the number of trained midwives quadrupled. The share of health facilities with at least one female health worker has climbed to 83 percent. The number of children dying in infancy or before age 5 has declined nearly 25 percent, which translates into nearly 100,000 fewer infants and children dying this year, compared with 2002.

These initiatives have strengthened the foundations of a state that can serve its people. Rather than providing or contracting for services directly, USAID, the World Bank and the European Commission have strengthened the capacity of the Ministry of Public Health to develop and implement health policies, oversee programs, manage resources, engage communities and control the delivery of services. In contrast to the corruption obvious elsewhere, the health ministry has shown a level of transparency and accountability that allows U.S. funds to flow directly to the government for the provision of basic health services.[1]

The Ministry of Public Health defined a basic package of health services, including immunization, prenatal and obstetrical care, family planning, and care for childhood illnesses. The Ministry contracts with NGOs (27% of which are international NGOs) to deliver the basic package to a specified geographic area.[2]

In an October 5 CNN joint interview, Robert Gates and Hillary Clinton call for an increase in the proportion of American civilians to military involved in Afghanistan.[3] It is evident that they envision using agencies such as the US Agency for International Development (USAID) essentially as a "force multiplier" or the "hearts and minds" component of their military objectives in Afghanistan. The proposed director of the USAID, Rajiv Shah, a physician, tells the Senate Foreign Relations Committee, “If confirmed, I look forward to working with this Committee and my colleagues at USAID and the State Department to assess USAID’s contribution to counterinsurgency and stabilization operations.”[4]

Rubenstein and Newbrander note that the Washington is planning to divert USAID funding to “quick-impact” projects such as building health facilities or providing medical equipment in direct support of military operations:

Yet there is no evidence that expensive "quick impact" health projects that are not integrated into a larger strategy, or that do not actively engage locals, either contribute to security or wean populations from the enemy.

Quick-impact projects, such as clinic construction or the provision of new medical equipment, are rarely sustainable and seldom based on the community engagement needed for long-term effects. These simplistic and immediate interventions have been known to backfire. One military health analyst has criticized "drive-by" health interventions as "Band-Aid" operations that raise -- and then crush -- local expectations and ultimately lead to greater dissatisfaction and distrust. Moreover, as resources are diverted from the Afghan-led effort to build a system of effective and responsive primary care services, the emergence of a legitimate state will be compromised.[5]

Health workers should resist such attempts to co-opt the humanitarian community. Association with the military gives people the impression that humanitarian workers are furthering military objectives or U.S. foreign policy – threatening the security of aid workers and those that they are trying to assist.[6] Furthermore, health workers should refuse to participate in counterinsurgency.

On October 18, the New York Times Magazine ran a sympathetic story on General Stanley McChrystal’s plans for turning the war around in Afghanistan.[7] Under the rubric of counterinsurgency, the plans are to clear areas of Taliban by force of arms, then maintain control long enough (on the order of years) to reconstruct so-called “civil society.” By this is meant the elimination of corruption, the establishment of good governance, the rebuilding of infrastructure, schools, health care, economic development, the elimination of poppy cultivation, and so on.

In Iraq, McChrystal’s role was as commander of Joint Special Operations, ie.e, overseeing Delta Force and Navy SEALs in covert ops such as the killing the leader of al Qai’da in Iraq, al-Zarqawi, by bomb strike. In Afghanistan, however, McChrystal now upbraids a subordinate European general for bombing a target that might cause harm to civilians. Indeed, limiting the use of artillery and airstrikes reflects a recognition that they alienate the populace. As Vietnam, winning the “hearts and minds” of the Afghan population is the current logic.

But watching these counterinsurgency principles on display in the Frontline episode “Obama’s War”,[8] in which Marines are shown trying to convince villagers in Helmand Province to come shop at a market under U.S. control, it is evident that they are making little headway. Well-meaning though they may be, it is nevertheless painful to watch Marines try to be goodwill ambassadors. As noted by retired Marine John Bernard, who is critical of the rules of engagement that he believes led to the death of his son, Lance Corporal Joshua Bernard on August 14 in Helmand Province, Marines are not trained to be police officers and nation-builders, but rather to “kill people and break things.”[9] Indeed, a July 2006 survey, 3 years into the U.S. invasion of Iraq, estimated 655,000 Iraqi deaths as a consequence of war.[10] Our recent experience in Iraq should make it abundantly evident that the U.S. military is not adept at reconstructing civil society.

Secondly, let us consider unmanned aerial vehicle strikes in the Federally Administered Tribal Areas of Pakistan, the FATA. The CIA is conducting a program targeting Al-Qaeda leaders and enemies of the Pakistani government with missiles launched from unmanned aerial vehicles (UAVs) with names such as Predator and Reaper.[11] In conjunction with the surge of troops in Afghanistan, the Obama administration is stepping up these attacks. Although an unnamed U.S. government official claims that only 20 or so civilians have been killed,[12] Pakistani sources report that of 701 people killed in 60 attacks between January 2008 and April 2009, only 14 were suspected militants.[13] To assassinate Pakistani Taliban leader Baitullah Mehsud on August 5, 2009, sixteen missiles were launched over fourteen months, resulting in between 207 and 321 additional deaths.[14]

Why are such air attacks on civilians not considered war crimes? Air attacks are not as accurate as they are portrayed on TV. They often kill non-combatants, including women and children. Homes and neighborhoods, shelter, water and sanitation, people’s sources of livelihood, are destroyed. In military parlance, this is called merely “collateral damage”, but it is the lives of people and the infrastructure of society. We should also recognize that this bombing from the air turns people against those that they (correctly) hold responsible – the US military.[15] In the wake of the drone attacks on the Pakistani borderland with Afghanistan, an August 2009 Gallup poll revealed that 59% of Pakistanis perceive the U.S. as the biggest threat to Pakistan, compared to 18% who named India and 11% the Taliban.[16] The Pakistani newspaper Dawn reports that Peshawar residents hold the U.S. responsible for bombings that the Pakistani government attributes to the Taliban.[17]

Finally, because we still often resist realizing that we live in an empire, we miss the implications of that fact. I was taken by the title of Seth Jones’ book In the Graveyard of Empires.[18] Jones urges caution in Afghanistan, where attempts at conquest from Alexander the Great to the British and Soviet Empires met ignominious fates. But, a number of chapters into the book, I realized that Jones himself did not think of the U.S. as being an empire. The RAND political scientist has a plan for the U.S. to conduct counterinsurgency more effectively.

Is it incorrect, then, to consider the US an empire? Politically, in some respects, the U.S. remains one nation among many, such as in the UN General Assembly. In the economic realm, it competes with Europe and Asia. In the military realm, however, it reigns supreme. The tendency is thus for the U.S. to “lead with its strength,” choosing to resolve conflicts by military threat or attack.

In the words of Afghan women leading a recent protest against government corruption, "The innocent and oppressed people will be the victims of American air and ground attacks."[19] . As Americans, we are responsible for our nation’s actions around the globe. As health workers, we must uphold the cause of health worldwide. What should be our role be?

[1] Rubenstein LS, Newbrander W. Undermining Afghan health care. Washington Post, Nov 29, 2009. Accessed Dec. 12, 2009
[2] Loevinsohn B, Sayed GD. Lessons from the health sector in Afghanistan. JAMA 2008;300:724-726.
[3] Gates R, Clinton H. Interview. CNN, Oct 5, 2009. Accessed Dec 12, 2009
[4] Questions for the Record Submitted for the Nomination of Rajiv Shah to be USAID Administrator by Senator John F. Kerry (#1) Senate Foreign Relations Committee. Accessed Dec 12, 2009
[5] Rubenstein & Newbrander.
[6] Bristol N. Military incursions into aid work anger humanitarian groups. Lancet 2006;367:384- 386.
[7] Filkins D. Stanley McChrystal’s Long War. New York Times Magazine, Oct 18, 2009.
[8] Gaviria M, Smith M. Obama’s War. Accessed Nov 2, 2009
[9] Sharp D. Marine’s dad speaks out. Honolulu Advertiser, Oct 18, 2009.
[10] Burnham G, Lafta R, Docey S, Roberts L. Mortality after the 2003 invasion of Iraq: a cross-sectional cluster sample survey. Lancet. 2006; 368: 1421–28.
[11] Mayer J. The predator war. New Yorker, Oct 26, 2009. Accessed Nov 8, 2009
[12] Shane S. C.I.A. to expand use of drones in Pakistan. New York Times. Dec. 4, 2009. Accessed Dec 12, 2009
[13] Ahmad MI. Pakistan creates its own enemy. Le Monde Diplomatique. Nov 2009. Accessed Nov 5, 2009
[14] Mayer J.
[15] Young M, Sprey P. (Interview). Bill Moyers Journal. Accessed Nov 2, 2009.
[16] Ahmad MI.
[17] Bombings, drone attacks fuel anti-US sentiment in Pakistan. Dawn. Dec 7, 2009. Accessed Dec 12, 2009
[18] Jones S. In the graveyard of empires. New York: W.W. Norton, 2009.
[19] Perry T. Afghan women lead protest against government corruption. LA Times. Dec 10, 2009. Accessed Dec 12, 2009,0,320839.story

Thursday, January 7, 2010

Primary Care and Residency Expansion

In discussing some of the things I liked in the bill that passed the Senate (December 23, 2009, Health Reform: The good, the bad, and the bigoted ) one of them was that the proposal to expand by 15,000 the number Medicare-supported residency (or Graduate Medical Education, GME) positions did not get included. The reason was that it did not explicitly require that these positions be used for primary care, which I believe is an essential requirement. I cited the strong arguments made by Shannon Brownlee and David Goodman in their New York Times op-ed of the same date, "Doctors no one needs". Most primary care, and particularly family medicine, groups were also unenthusiastic to opposed.

The Association of American Medical Colleges (AAMC) does not agree, unsurprisingly to those who are familiar with medical education, and was the biggest advocate for that provision. As AAMC President Darrell Kirch wrote in his December 21, 2009 communication “Leader to Leader” (not publicly available on the AAMC website), the news on the Senate bill “…was a great disappointment because we viewed this as a truly historic opportunity to make a positive impact on our future workforce.” In what many in the primary care community saw as a more combative statement, he went on to say “During this process we were deeply concerned that some members of the primary care community spoke out against the amendment, and argued that it would not support the expansion of the primary care workforce. Facing an extremely tight timetable, Senate staff clearly indicated to us that such opposition would discourage the leadership from moving forward on any GME language. The AAMC expressed strong concern that the vocal opposition of the family medicine community threatened to halt progress on GME legislation that did indeed benefit all training programs.”

In a recent letter to Senator Harry Reid, staking out the organization’s positions on what needs to be included (read “benefits academic medicine”) as the Senate and House move to reconcile their health bills in conference, Dr. Kirch writes that the GME expansion is critical, and that the AAMC is “…supporting the inclusion of this workforce expansion as part of provisions to strengthen primary care.” That sounds, good, making nice. However, other parts of the letter indicated that AAMC’s attack on primary care, and particularly family medicine, groups, for not supporting the its agenda of expanding (“benefit[ing] all training programs”) has progressed.

"The AAMC recognizes that primary care is an integral part of health care delivery. Primary care, however, may be provided by many types of physicians and other practitioners. We support defining primary care by the types of services provided and not by a specialty of the physician or other provider.”

What is the problem here? Surely the assertion above is reasonable, that defining primary care by services provided rather than the specialty of the provider makes sense. And the AAMC is saying it is supportive of primary care, and even including goals for more residents in the primary care specialties in the expansion of GME slots. It is a big step for the AAMC to be so supportive, publicly, of primary care, as they have not always been. And, in addition, there are other specialty areas (e.g., general surgery) that are also in great shortage. Indeed, the movement has been to sub-specialization and sub-sub-specialization, so we are seeing fewer physicians who are even generalists in their own sub-specialties (such as cardiology). The goal should definitely not be to increase slots only for primary care, but to target those specialties in which there is a mismatch between the number of doctors being trained and the number needed by the community.

Considering primary care, however, there are several problems with the current AAMC proposal.

1. The proposed bill is about expanding residency slots, not about defining the content of a primary care practice. Yes, there are subspecialists who provide comprehensive patient-centered care for their patients. Particularly in pediatrics, but also in adult internal medicine; people who have mainly one serious chronic disease (kidney failure, cancer, heart disease) sometimes receive most of their comprehensive care from nephrologists, oncologists, or cardiologists (more often in pediatrics because having only one chronic disease is the norm in children, but much less common in adults). Many of these subspecialists do not. In identifying practices as providing primary care for, say, increased reimbursement, looking at services provided is quite reasonable. However, in looking at a strategy for creating greater primary care capacity, what makes sense is to expand the residency programs in specialties that are particularly about training physicians to practice primary care, and whose graduates actually do so – family medicine, general pediatrics, and general internal medicine. This is especially true when looking at how we can provide comprehensive primary care to communities, not simply to selected individuals. To say “let’s just train more doctors altogether, and some will probably do some primary care" (radiologists? anesthesiologists? ophthalmologists?) is a nonsense strategy.

2. The significant impact on the health of the population that is related to increased primary care capacity only occurs with more primary care doctors. It does not occur with just more doctors, some of whom might do some primary care. (This is the point of the Brownlee and Goodman piece cited above.) These results have been documented repeatedly, in a variety of geographic areas and populations. Yes, there is also a contribution made by “non-physician” primary care providers including nurse practitioners and physician’s assistants, but they are not the concern of the AAMC, and, moreover, are increasing not practicing primary care. (See “myths” 2 & 3 in Dr. Bowman’s guest blog of January 15, 2009, Ten Biggest Myths Regarding Primary Care in the Future.) I addressed the issue of specialty choice in More Primary Care Doctors or Just More Doctors? (April 3, 2009). Of note, Dr. Richard Cooper, whose positions I criticize in that piece, has more recently been advocating for the needs of poor and minority communities, a good thing. His main point is that the Dartmouth Atlas data on geographic variation do not account for socioeconomic differences (debatable, certainly); however, I have not seen any retraction of his AAMC-type support for “more doctors” rather than more primary care doctors.

3. There are not enough students currently interested in entering primary care to fill currently existing positions. Thus, even if a greater priority were given to family medicine and other primary care residency positions, the new positions would, barring a major change – that would, as discussed in many previous pieces, have to be systemic and involve large, not simply cosmetic, changes in reimbursement – also be unfilled, at least by US graduates. Then, of course, the teaching hospitals and medical schools would use them for other specialties. Indeed, a big reason even more students do not enter the “ROAD” specialties described by Pauline Chen (“Primary Care’s Image Problem”, New York Times November 12, 2009, and discussed in this blog November 17, 2009, as Primary Care’s Image: A Problem?) is the limited number of slots; increasing slots without increasing the attractiveness of primary care as a career option will just increase the mismatch between the proportion of primary care doctors needed by the society and that being produced by medical schools. To the extent that primary care residency positions are filled by international medical graduates, it continues to contribute to the “brain drain”, where third-world countries bear the cost of educating physicians to provide care to first-world citizens.

The only way an increase in the number of GME slots could be beneficial is not only if a majority are targeted at primary care, but are required to be primary care, or they don’t happen. And that only specifically primary care internal medicine residencies count, and that the slots are withdrawn if, after 5 years, more than 25% of graduates have entered subspecialty training.

In greater detail, Patrick Dowling, chair of family medicine at UCLA, comments on the AAMC letter:

Granted these are complex issues but in the end I read this as: ‘give us more of the same—we need more doctors, more funding for academic centers and we need to get reimbursed better!’ I think the AAMC would have much more credibility if they stepped up to the plate and said:

‘The US health care delivery system is terribly flawed and we are a significant part of the problem. We have terrible geographic and specialty maldistribution of physicians, our costs continue to be way out of line compared to any other industrialized country and we have unacceptable racial and ethnic disparities in outcomes of care.

‘Moreover, because the graduates of our medical schools have overwhelming chosen to practice subspecialty medicine in green leafy suburbs we must import international physicians, to staff our inner cities and rural towns in exchange for visas. Although we are fortunate to have someone to send, these docs face overwhelming linguistic and cultural barriers, especially in the provision of care to low income minority populations. And in some instances they represent a “brain drain” in from the donor countries

‘Further, as the baby boomers begin to hit age 65 at the rate of 5,000 per day on Jan 1, 2011, the epidemic of chronic diseases linked to aging will soar. We would propose the following new innovative steps to insure that we have a geographically dispersed physician workforce that delivers cost effect, high quality care with a physician workforce that is optimally balanced by specialty.

‘If you provide $X billion in extra funding for Academic Medical Centers (AMCs), enhanced funding for NIH budgets and thousands of more Medicare funded GME spots we will insure that the number of HPSAs will be reduced by X, that the actual number of USMGs choosing bona fide primary care specialties will increase by Y number which will result in a primary care to specialty ration of A to B, a ratio which works very well in other industrialized democracies.

‘Finally, if we are funded we promise to bend the unacceptable curve of increasing costs so that average yearly increases are less than X% of CPI. If we fail to meet these objectives we agree to decreased funding over the following years of $Z billion.’

“If I was in the US Congress,”
Dr. Dowling concludes, “I would tell the AAMC that rather than stuffing their pockets it is time to put some skin in the game and actually become the leaders in the science of health care delivery and solve these problems.”

Hear, hear.

Sunday, January 3, 2010

The business of America...or is America a business?

The business of America,” President Calvin Coolidge said, “is business.” His only famous quotation (after all, the guy’s nickname was “Silent Cal”), it is almost a mantra guiding the actions of Presidents, and Congresses, and state legislatures, since. It can be seen almost as a tautology, recognizing that successful businesses are essential to the economic success of the entire country, and the world. Pursued to perversion, with governments not just facilitating the success of business but doing anything businesses want, with no respect for the balance between business success and negative impact, however, it can have terrible results for society -- for many people, or, as in the recent implosion of the economy, for all people. Completely abandoning all regulation of financial derivatives, the housing market, etc., was predictably a bad idea. But, of course, those predictions were not heeded.

And are not being heeded. On the heels of the enormous public bailouts, absent any requirements that the financial industry actually do anything to help Americans (like, say, lend them money), we continue to see further deregulation. The Supreme Court will soon decide on whether to permit corporations, not just the individuals who own and work for them, to contribute to political campaigns. Many folks think that the conservative majority will say “yes”, based on the legal fiction that corporations are people, and therefore have First Amendment rights to freedom of speech.

Of course, corporations are not people, and the “founding fathers” who wrote both the Constitution and Bill of Rights had absolutely no intention of considering them as such. Indeed, given their experiences, most were quite suspicious of – often hostile to – corporations, which is why the Constitution provides for state control of them. This was because, as stated in an interesting discussion by Jan Edwards on the “Third World Traveler” website, “State governance was closer to the people and would enable them to keep an eye on corporations. In the eighteenth century, corporations had very few of the powers that we now associate with them. They did not have limited liability. They did not have an unlimited life span. They were chartered for a limited period of time, say 10 or 20 years, and for a specific public purpose, such as building a bridge. Often a charter would require that, after a certain amount of time, the bridge or road be turned over to the state or the town in which it was built. Corporations were viewed differently in early America. They were required to serve the public good.” Things, however, have changed, and this is apparently an area in which the “strict constructionists” on the Court are a little less strict.

Would this make a big difference? Well, perhaps conceptually it would, but corporations are already able to use their money to have great influence over policy. This includes the donations to candidates by the people associated with them, but more often and in greater amounts to the soft-money PACs to which they contribute. On the health care front, the New York Times recently ran an article (December 29, 2009) unfortunately titled Health Lobby takes fight to the states (I say unfortunately because, as the article makes clear, it is the lobby for the health care industry, not lobbyists for our health!) that looks at efforts in state legislatures to not participate in any health reforms that eventually pass Congress. The rationale for opposing the changes that would prevent insurance companies from denying coverage to people because of pre-existing conditions, and at least potentially extend coverage to the majority of the uninsured, is, according to author David Kirkpatrick, is based “on the grounds that it tramples individual liberty”. This is eerily reminiscent of the first point in Andy Borowitz’ December 17 piece, Senate Unveils CompromiseCare: “Under CompromiseCare (TM), people with no coverage will be allowed to keep their current plan”. Except that was intending satire; I don’t think that the 42 Florida Republican legislators pushing this plan meant to be self-satirical (but, hey, who knows?)

More interesting, and bringing this back to the influence of corporations on policy, Kirkpatrick notes that those 42 co-sponsors “…were almost all recipients of outsized campaign contributions from major health care interests, a total of about $765,000 in 2008, according to a new study by the National Institute on Money in State Politics, a nonpartisan group based in Helena, Mont.” Amazing. The suggestion is that these wealthy corporations are buying votes. A reader might conclude that these legislators, and so many others, are corrupt scuzzbuckets. But it is, probably, coincidental.

Maybe. After all, in our current political culture it takes money to get elected, money to get the word out on your positions, money to get the word out smearing your opponent, to buy radio and TV time. And it is a known fact that very rich people and corporations give much more money to politicians than poor and working people. So why would we think that they wouldn’t have an influence on the votes of these legislators, or those in Congress? Whether it is a matter the legislators “paying their donors back”, or simply of those donors funding the election of candidates who really believe in the issues important to them -- such as corporate personhood, or that trying to ensure that people get health care coverage tramples on their individual liberty. Or maybe those candidates just care more about that individual corporation than are about those cheap poor people who don’t make campaign contributions. OK, they’re corrupt scuzzbuckets.

I don’t know why, at my age and my at least moderate knowledge of history, I continue to be amazed by this. After all, one of the most corrupt Presidential administrations was that of Warren G. Harding, whose vice-president (and successor) was ol’ Silent Cal himself. I think there are a lot of Americans who actually think that their elected officials should work on their behalf, not on that of a monied corporate elite; they were responsible for the election of Barack Obama to the Presidency. Perhaps they thought that was enough, and now they could go back to watching TV, or playing on line at Facebook and Foursquare.

But they have to stay involved, because the powerful have the resources to keep coming back. If the people can defeat them once, they will try again. If the folks who voted for Obama do not keep working, inertia will lead to control staying with those who can afford to buy politicians. We cannot allow our country to be sold to the highest bidder

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