Wednesday, April 28, 2010

Primary Care and Rural Areas

"The primary care physician and health reform”,[1] by Robert H. Brook and Roy T. Young of the RAND Corporation, appears In the April 21, 2010 issue of JAMA. Rather than review the various components of the new Patient Protection and Affordable Care Act (PPACA), as I have recently on this blog, they focus on the need to increase the number of medical students entering primary care, an issue I have also previously addressed. It is a good piece and worth reading, but contains this interesting paragraph:

One approach to this situation is to do nothing. As a result, the number of primary care physicians in practice will continue to decline. Patients who want a primary care physician will probably need to pay some kind of retainer and enroll in a concierge-type practice. Those who cannot afford this luxury will have to endure a medical care system that is even more fragmented than it is today.”

Clearly, they do not endorse this as a desirable plan, and go on to suggest that the alternative is to find a way to get 50% of American medical student graduates beginning with those entering June 2010 to enter family medicine, general internal medicine or general pediatrics (which raises the question of: Why not those who are already in medical school?) They emphasize both the importance of closing the salary gap (which we have heard many times) and redefining the role of the primary care physician, something we hear less about. The basis for this is contained in an earlier paragraph:

The scope of practice for primary care physicians is contracting…the 200 000 physicians who identified themselves as office-based primary care clinicians… manage most of the care for diabetes, hypertension, and obesity; address acute problems such as viral or bacterial infections; and provide general examinations. On the other hand, a large proportion of the visits for conditions that could be managed by primary care physicians such as rheumatoid arthritis, epilepsy, depression, angina pectoris, and other chronic conditions are diagnosed and managed over time by specialists. The role of primary care physicians in the hospital has also narrowed, driven by the emergence of hospitalists and the trend to move a substantial portion of medical care to outpatient facilities.”

Taken together, the two paragraphs that I have quoted contain the implicit assumption that “the patient” we are discussing lives in a major metropolitan area with a large number of physicians, especially subspecialty physicians. However, at least 20% of Americans live in rural areas where this is not true, and many others live in underserved (read: poor) urban and suburban areas. While 23% of family physicians practice in rural areas, they are the only primary care specialty (and we can include here nurse practitioners and physicians assistants) that distribute themselves in this way; NPs and PAs, as well as general pediatricians and what remains of general internists cluster overwhelmingly in urban areas and their suburbs. When the only doctors in town, and for a long way around, are family physicians, they are going to manage the rheumatoid arthritis, epilepsy, depression, angina, etc. And they are most unlikely to charge concierge fees for their patients to be able to access them. However, rural areas remain underserved because 23% of family doctors, while parallel to the percent of rural people, is still too low a percent of all doctors.

I do not mean to be critical of Brook and Young; their commentary is good and makes excellent points, not the least of which is that even people living in urban and suburban areas want to have, and deserve, primary care physicians: “Virtually everyone would like to have a primary care physician—a trusted physician who provides comprehensive, continuous care.” I also commend their clear statement that most of the chronic conditions cared for by specialists – in metropolitan areas, where there are specialists – can be perfectly well taken care of by primary care physicians in either urban or rural settings. I mean only to point out that even the most thoughtful and well-meaning commentators can miss the special and critical needs of rural people, and make assumptions that do not apply to inhabitants of those areas.

The irony is that while insurers, including Medicare, pay higher rates to subspecialists for caring for conditions that generalists could care for, as Brook and Young point out, generalists are reduced to spending more of their time doing procedures, which are more highly reimbursed, in order to make ends meet. This takes away from the time that they can spend with patients being the “trusted physician who provides comprehensive, continuous care”. Producing enough primary care physicians to provide this care to the 80% of people in urban and suburban areas, as well as to usually be the only physicians in rural communities is going to be a big challenge. The only way this is going to happen is to bring the vast difference in income expectations for students dramatically down, and fast.

The fastest way, which should begin immediately, is for Medicare to readjust its fee schedule in such a way that proceduralists can do the procedures, subspecialists can care for the rare and unresponsive or conditions in their narrow area, and generalists can care for the complexity of the whole patient, and for all of them equal amounts of work will bring in much more nearly equal amounts of income. This will mean reducing the income of subspecialists and proceduralists as well as increasing the income of family doctors, but it is a much better solution for the population’s health than turning primary care doctors into rare, concierge-type commodities.

[1] Brook RH, Young RT, “The primary care physician and health care reform”, JAMA Apr21,2010;303(15):1535-6

Thursday, April 22, 2010

PPACA, The New Health Reform Law: How will it affect the public's health and primary care?

A great deal remains to be done before any of the parts of the new health reform law, the Patient Protection and Affordable Care Act (PL 111-148), begins to affect people. Regulations have to be written, appropriations (in many cases, where they are not included in the law) need to be made (or not). There are a number of lawsuits pending, including several by states’ attorneys general. While these suits probably have little constitutional basis, nothing is certain when it comes in front of a Supreme Court that has recently declared (in Citizens United) that corporations have the same rights as people, at least in terms of giving money to political campaigns. However, it is a good time to look at this bill – at least parts of the massive 2,600 pages – and consider the impact on health, medicine, and social justice.

I indicated in a guest blog piece on Health Strong, “Why we need health reform”, before the bill became law, that the three key problems that exist, and need to be the touchstones to examine for the new law’s effectiveness, are:
1) Access – does it increase access for the 45+ million uninsured, tens of millions of underinsured, and tens of millions more whose premiums, co-pays and deductibles are becoming more and more prohibitive while the extent of their coverage drops?
2) Cost containment – as medical care costs approach 20% of GDP they threaten to choke off other, key social programs. Is there a viable method for cost control?
3) Health -- medical care, and even health care, are not health (Health is more than Medical Care, Jan 10, 2010). The goal must be to improve people’s health, of which medical care contributes only 15 % at best. In addition to genetics, individual behaviors and the socioeconomic environment are better predictors of health than medical care. At a population level, it is arguably true that improving educational opportunity for all children would provide greater increases in health status than all medical care.

The new health reform law will certainly increase financial access to health care for many people, an estimated 32,000,000. To the extent that this improves actual access will depend upon elimination of other barriers including geographic, transportation, co-pays and deductibles for those who are not fully subsidized, the existence of enough providers (especially in primary care) and the ability of people to get to the place where they can be seen (e.g., many people lose a day’s pay if they go to the doctor). The law will also (provided insurance companies can be prevented from “gaming” the system) prohibit denial of coverage for pre-existing conditions (for children this year; for everyone in 2014) and prevent rescissions – canceling your policy when you get sick.

In addition, as I have previous noted (Primary Care and the Medical Home, Today and Tomorrow, Primary Care and Residency Expansion), there need to be doctors or other providers; in particular there need to be primary care doctors. In rural areas, health care means essentially only primary care, and as has been noted by many of these blog pieces by Robert Bowman (Ten Biggest Myths Regarding Primary Care in the Future, Top Ten Reasons for Future Subspecialist Physicians To Be Concerned) and myself, this means family doctors, because this is the only “form” of primary care that “distributes” to where the population is – 20% of Americans live in rural areas and 23% of family doctors practice in such setting; no other primary care form (physician, NP, PA) come close. However, the need for primary care providers is not only in rural areas; in suburban and urban areas people still need a physician who is “their” doctor, not the doctor for only a piece of their body or a particular condition, someone who can coordinate and manage all their preventive, chronic, and acute care. And there are not, as we have also demonstrated, enough of them. Massachusetts discovered this when its statewide health reform dramatically increased the number of state residents with financial coverage; there were not enough primary care doctors to see all these people. We have also discussed the fact that medical students are not choosing family medicine and other primary care specialties in adequate numbers. (Note that our physician workforce is less than 30% primary care and dropping; to get to 50-60%, the ideal ratio in all international studies, in less than a generation, will require more than 50% entering true primary care training.)

What does the health reform law do for these issues, particularly in producing primary care doctors and related issues? Here are some of its components, with page numbers in the law in parentheses for anyone who wants to read the law in more detail:
· Primary care physicians (defined in a reasonable way) will received a 10% increase in reimbursement from Medicare for 5 years, as will general surgeons practicing in rural areas.
· The annual threat to all physicians from Medicare cuts will be addressed.
· Medicaid will reimburse primary care physicians at the higher Medicare rate for 2 years (2013-14).

These changes (pp 1413ff) will help primary care providers survive, but are not likely in themselves to reverse the trend of students entering subspecialties. (The American Academy of Family Physicians, AAFP’s, Robert Graham Center (“Does graduate medical education also follow green?”, ref below) estimates that a 35% increase in primary care reimbursement would be needed for students interested in family medicine to feel that they would earn enough to be able to pay off their medical school debts). In addition, residency training is addressed in several ways:
· Unused residency “slots” (positions Medicare would pay for) are to be distributed with a preference for primary care and rural training (pp 1421ff),
· Medicare GME money would pay for training in non-hospital settings, addressing the problem of hospitals wanting to keep residents in-house and thus limiting their training in community settings (pp 1431ff),
· Teaching Health Centers, especially in federally-funded Community Health Centers, would be encouraged with grant money (pp 1457ff).
· Training grants for primary care (“Title VII”) will be re-funded, and there will also be new grants, both with specific funding priorities rewarding schools and residencies that send graduates into underserved and rural areas (pp 1315ff, pp 2343ff), as well as grants to fund Preventive Medicine residencies (pp 2349ff).

Access to care will also be enhanced by large increases in funding for Community Health Centers (CHCs) (pp1479ff) and for loan repayment for doctors who work in underserved areas through the National Health Service Corps (NHSC). It will also provide funding for the creation of Primary Care Extension Services, which I have previously advocated (pp1404ff). The Medical Home concept, which identifies a multi-disciplinary “home” for each patient, requires advanced management techniques like electronic medical records and easy patient access, and pays for prevention and care coordination, is supported through an “Innovations Center” and the law requires payment for these services from insurers (p 2048). Funding is also provided for national and state health care workforce planning. In addition several new programs, including one that creates US Public Health Service “scholars” who will receive tuition and stipends (pp. 1372ff), and a major initiative to train dental therapists to provide basic dental care in areas where there are no dentists or even dental hygienists, are included, as are demonstration projects to reduce fees for underserved people (pp. 2357ff), and training Community Health Workers (pp. 1346ff).

On the downside, more than 23 million people, including all undocumented residents will remain uninsured. Clearly, covering the undocumented is a “hot button” political issue, but not allowing it is a classic example of “head in the sand”; these people are here, they work, they pay taxes – and they get sick and use expensive emergency rooms for care of conditions that could have been treated much earlier and better. The law is also a windfall for both insurance companies (who will get paid at their outrageous rates for all these new customers) and pharmaceutical companies. There are no structural systems for really controlling costs.

In summary, the good parts of the new law are that it is good for primary care practice, probably good for providers in general, expands funding for primary care education, provides more funding for CHCs and the NHSC, creates funding for Medical Homes, Primary Care Extensions, and other innovative programs. More people will be covered, it will prohibit denying coverage for pre-existing conditions and prevent rescissions, and will create restrictions on “medical loss ratio” – that is, insurers will have to pay at least 85% of the premiums they collect on actually paying for health care (imagine that!).

On the negative side, it leaves lots of people uninsured, is very complicated (it phases in over many years and it is still not clear how – or even whether – all the components will be implemented), there is no real mechanism for cost control, and it is good for insurance companies and good for drug companies (a bad thing – e.g., Insurance company greed: To know them is to not trust them). It also creates incredible complexity in coverage, with different members of families likely being eligible for coverage through different programs.

We will see how this plays out, but it would have been (and still remains) a much better idea to simply include everyone into Medicare, creating a single payer for everyone, a simpler and much less costly administrative mechanism, and a real opportunity to control costs. Those, including most (or all) Republicans who are critical of this bill because of the cost are neither advocating (in fact, they desperately oppose) a single-payer system that would really save money, nor even recognizing that continuing the way we were going was about the worst choice. Maybe it is too much to ask them for logical consistency. But those of us who are committed to social justice must continue the struggle. Re-read Dr. Ferrer’s blog piece The Sharp End of Ideology.

· The bill – HR 3590
· MEFS summary
· Community Catalyst summary
· Kaiser Family Foundation summary
· STFM Summary & implementation timeline
· Implementation timeline (AAFP)
· Aaron HJ, Reischauer RS, “The war isn’t over” NEJM, 8Apr10;362(14):1259-61
· Himmelstein DU, Woolhandler S, “Obama’s reform: no cure for what ails us”, BMJ 3April2010, 340:742
· Weida NA, Phillips RL Jr, Bazemore AW. Does graduate medical education also follow green? Arch Intern Med. 2010 Feb 22;170(4):389-90

Friday, April 16, 2010

VISA and colchicine: maybe the banks and Pharma really ARE in it for the money!

This is a guest posting by R. Stephen Griffith, MD, Chair of the Department of Family and Community Medicine at the University of Missouri-Kansas City.

A recent article explains in some detail one of the devious ways the banking industry, and the recently spun-off companies of VISA and MasterCard, make the money it takes to support the executive salaries and bonuses. (“How Visa, Using Card Fees, Dominates a Market”, Andrew Martin, NY Times, Jan 4, 2010)

Each time one of us swipes a debit card at a retail outlet, the retail outlet pays a banking institution a fee. That seems like an honest way to make a living, but the plot thickens. If we punch in the secret code associated with the card, the bank gets a few cents. If instead of using the code we sign the receipt the bank gets a bigger fee. Apparently there is no more expense associated with the latter method, but the fees negotiated by VISA et. al with the retailers provides for the higher fees. The individual banks then receive the fees, which encourages them to “push” more of the VISA’s (or which ever company is offering them the best deal). The credit card companies expand their reach, the banks make more money, and everyone involved in the deal is happy. In fact, the higher the cost per transaction the credit card company can negotiate makes more money for the bank, and so a bidding war develops in which the higher the fee, the more the banks gravitate to that company. The fee can be up to 75 cents per transactions—many multiples of the fee for a swipe and use of the code. This is transparent to the consumer, who willingly signs or puts in his/her code as requested by the retail outlet. Of course, the unwitting consumer eventually pays the extra expense (passed on from the retailer as part of the cost of doing business). Just another way for the banks to make a living.

There are those of us who would suggest that this is “gouging” the customer and there should be some repercussion to the perpetrators. I was among the inflamed and insulted when I read the article. But then this horrible thought crossed my mind: as a well meaning and cost conscious family physician, how many times have I committed the same offense?

The relationship between physicians and Pharma has been a topic of discussion since I was in medical school, although until relatively recently I have seen very little response from the medical community. The representatives of Pharma host our meetings and visit our offices, give us food, pens, pads, tickets to games, sometimes even trips to nice places. Associated with the gifts is also free “education” about why the product about which they are educating the physician is better than generic or “me, too” drugs made by another company. The docs are given samples which they can provide their patients to try the new drug out and “help save money for the patients.” Of course, if the medication works, a prescription for the drug will be given. The extra expense (sometimes an extraordinary amount of extra expense!) of the newer drug is borne by the patient or the patient’s insurance after a co-pay (which results in higher premiums the patient pays.)

So the medical community’s “scam” is we get lots of benefits and the expense of those benefits is borne by someone else—our patients.

To be fair, not all physicians accept gifts from Pharma. And in the last few years or so, the value of the gifts has been more restrained. And a growing number of physicians are refusing to even meet with representatives from Pharma, refusing the samples and the false economy of providing them, refusing the gifts and “education”. Creating distance from Pharma is a good thing—they are as fun to hate as the banking industry. And if you doubt the amount of greed in Pharma, please read this: “An Old Gout Drug Gets New Life and a New Price, Riling Patients”, Jonathan D. Rockoff, Wall St. Journal (and below, as it may not be completely available on the WSJ site.)

The article is about colchicine, a drug for the treatment of acute gout (and a few other things) that has been around for more than a century—long before the advent of the FDA. The FDA has encouraged pharmaceutical companies to study some of the older drugs for true effectiveness, and the company can then apply for a three year patent on the medication. URL Pharma, Inc. did the clinical trials on less than 1,000 patients, and proved that a drug everyone already knew worked, worked. Amazing! They received a three year patent, and now a pill that was $4 per month long before the $4 per month plans existed, is $5 per pill! Since it is usually given twice a day, the drug will now cost patients $10 per day when it formerly cost about a quarter.

Stories like this and the one about banks makes it easy to feel distaste for the banking industry and Pharma. Where is the justice in banking executives making millions and then being bailed out by taxpayers? Where is the justice of Pharma making huge (I would argue inappropriately huge) profits from the ills of our patients? I just wish the profession of medicine (and I) hadn’t played a part.

(From the Wall St. Journal),
An Old Gout Drug Gets New Life and a New Price, Riling Patients
A centuries-old drug used to treat excruciating gout pain had cost just pennies a tablet—until last year. Now, the retail price has skyrocketed to more than $5 and some of the manufacturers have ceased production amid a battle over marketing rights.
The tale of how this common gout drug, colchicine, became the costlier branded drug Colcrys offers a window into the Byzantine world of drug pricing. The price rise is a consequence of a Food and Drug Administration effort to improve the safety of long-used but unapproved drugs, with a trade-off often made between drug affordability and safety.
In July 2009, a Philadelphia drug maker received FDA approval to exclusively market colchicine for gout attacks for three years. The company, URL Pharma Inc., was taking advantage of a push to bring medicines predating the FDA, like colchicine, under the agency's regulatory umbrella. The FDA offers exclusive marketing rights if a drug maker conducts clinical trials.
URL Pharma had commissioned studies that confirmed its colchicine product's safety and efficacy, while demonstrating it should be taken at a lower dose than typical and not used with certain other medicines. The company is marketing its drug as Colcrys—and the retail cost averages $5 per pill, according to DestinationRx, a health-care data provider.
URL is also suing longtime manufacturers of unapproved colchicine, saying the companies are now illegally marketing their products. Some of the companies are fighting the lawsuits. Some themselves have raised prices—including one increase of just under a dollar per tablet to $1.17, according to DestinationRx. The higher price for Colcrys was first reported by Kaiser Health News.
There were 3.5 million prescriptions and $6.4 million in sales in 2008, according to the most recent data available from IMS Health, a drug-data firm.
"It's not a new product. It's been out for hundreds of years. To all of a sudden have to pay $125 or $150 a month, after it only cost $5 or $10 a month, is a real problem," said Stanley Cohen, a Dallas doctor who is the president of the American College of Rheumatology. He met with the FDA to express concern about the price increase.
The chief executive of URL Pharma, Richard Roberts, said that it priced Colcrys in line with other approved, branded drugs used to treat gout pain. To help patients afford Colcrys, Dr. Roberts said, the company is offering to pay a portion of co-pays, and it is providing a three-months' supply to low-income patients for $15.
Eileen Wood, vice president of pharmacy and health-quality programs at CDPHP, an insurer in New York state, said insurers will have to absorb much of the added expense. URL's contribution was "not any new therapeutic tool, not new science; they just added cost," she said.
Nancy Sparks Morrison, a retired schoolteacher who suffers from familial Mediterranean fever, an inflammatory disorder that's treated with colchicine, said she is buying colchicine from Canada because she can't afford Colcrys. Ms. Morrison said she plans to get help from URL Pharma to pay for Colcrys because the company has just expanded its assistance program. "I'm retired on Social Security, and I have a small pension," said Ms. Morrison, 71 years old, who lives outside Charleston, W.Va.
The price increase is an unintended consequence of the FDA's nearly four-year-old initiative to regulate unapproved drugs. These medicines were sold before the FDA was established, and therefore weren't required to undergo approval. After decades of use, the medicines are considered safe by doctors, but haven't been proven to satisfy the agency's standards. Colchicine's use has been traced back to the sixth century, according to the FDA.
Seventy drugs that were grandfathered have been approved since the FDA began its initiative, most notably pain reliever Vicodin, from Amneal Pharmaceuticals LLC, the FDA said.
The FDA had hoped a significant price increase wouldn't follow Colcrys's approval and regrets the increase, said Janet Woodcock, director of the agency's Center for Drug Evaluation and Research. Dr. Woodcock encouraged more competition, saying another company could seek approval for colchicine's regular use in gout, rather than the acute use that URL Pharma received approval for.
There had been no standard for dosage before FDA approval. Colchicine's excessive use can cause side-effects, such as severe diarrhea that is potentially fatal. The FDA said it receives reports of five deaths a year, on average, involving patients who took colchicine tablets.
"We took bad guidance, even guesswork, and made this evidence-based medicine," Dr. Roberts said.
Closely held URL Pharma, which is owned by a hedge fund, a private investor and employees, is a longtime seller of generic drugs, including colchicine. When the FDA launched its push, the company began searching for those with safety risks whose patients could benefit from clinical testing, Dr. Roberts said.
URL Pharma said its 17 clinical trials of colchicine involved a total of 988 patients. The trials showed that gout patients need take two tablets after an attack and one more an hour later, the FDA said. Trials also demonstrated side-effects from use with certain other medicines, including some antibiotics and antihypertensive medicines. Those are now flagged on the label of Colcrys.
After obtaining FDA approval of Colcrys, URL Pharma went to federal court to sue manufacturers of colchicine, including Excellium Pharmaceutical Inc., Vision Pharma LLC,
Watson Pharmaceuticals Inc. and West-Ward Pharmaceutical Corp., saying they have been illegally marketing their colchicine products since Colcrys's approval. A fifth company, Qualitest Pharmaceuticals, settled and stopped production. The four companies are fighting the lawsuits.
"You have this product out for at least a hundred years and all of a sudden it's no good?" said Lou Dretchen, who oversees sales and marketing at Excellium of Fairfield, N.J. Mr. Dretchen said the small, closely held generic drug maker stopped colchicine production after URL Pharma sued. The other companies declined to comment.


Sunday, April 11, 2010

Doctors and Health Reform: How should a physician's politics affect their patient care?

President Obama’s health reform bill (officially the "Patient Protection and Affordable Care Act, PL 111-48) has finally passed, but the furor over it has not died down, with Republican’s harnessing their electoral future to continued opposition. To the new law, certainly, but more significantly to anything that might actually begin to address the health care needs of the American people, to cover the uninsured, to protect those with pre-existing conditions, to provide a basis for cost control, or to improve people’s health. Opponents of the plan talk incessantly about its cost, but offer no alternative. The question for the President is whether enough of the benefits of the bill will kick in and have a positive effect on people soon enough to overcome the negative bluster.

Among the groups still trying to figure out the impact of the new law on them are health care providers, including hospitals and physicians. While physicians, as a group, tend to support the Republican party, especially on the single issue of malpractice (with the trial lawyers being, conversely, big Democratic contributors), most major medical organizations have come out in favor of health reform, and in general have endorsed proposals that go significantly beyond those of the new law. Even the AMA, which opposed every national health insurance plan including Medicare, has acknowledged the need for health reform. The two largest physician specialty organizations, the American College of Physicians (ACP – internists) and the American Academy of Family Physicians (AAFP) have endorsed universal health care. Where do they stand now?

On a recent morning news show discussing the impact of health reform on doctors, one of the regular hosts asked about malpractice, saying that “every time I go to my doctor, he talks to me about the malpractice issue”, so apparently many doctors feel fine about lobbying their patients. I don’t know any of the details; after all this patient is a newsman, and may bring up the question of health policy issues, so perhaps this is not something that doctor talks with all his/her patients about. But we recently learned of a Florida urologist who posted a sign saying “If you voted for Obama seek urologic care elsewhere. Changes to your healthcare begin right now. Not in four years.” (Urologist Posts His Politics on His Florida Office Door, Damien Cave, New York Times, April 2, 2010). Predictably, and probably correctly, the criticism focused upon whether such a sign was inappropriate, whether it was wrong to refuse to treat people because you didn’t like their politics (although the doctor, Jack Cassell, “…told the Orlando Sentinel that he has not refused to treat any patient for his or her political views and does not quiz patients about their politics, but he also does not plan to take the sign down.”)

More interesting, to me, is the question of whether the financial self-interest of doctors should be of concern to their patients, and how much that should count for in making policy. Clearly, when reimbursement is so low that the cost of running the practice is more than the revenue coming in (more likely to be the case for, say, family physicians than, say, urologists), a medical practice run as a business cannot survive. It is even true that the business needs to not only not lose money, but to make enough for the physicians to have a reasonable income. But if a physician is making, compared to most people, a very large amount of money (and I have no idea whether this is true of Dr. Cassell), is it reasonable for him/her to expect people to be compassionate if it drops to only a large amount? Should Americans be concerned if a subspecialist’s take-home pay drops from, say, $450,000 to $350,000? I know the doctor would be, but what about everyone else?

I find most interesting is how the expression of this sentiment, whether Dr. Cassell continues to treat Obama supporters or not, gets to the heart of the real issues in the health care debate. To the extent that a doctor can choose which patients to treat, or whether a patient can choose which doctor to visit, maybe this could work out. But it postulates medical care as a commodity to be sold, and that its purchase depends on a patient having sufficient money, or insurance, to buy it. It absolutely does not see medical care as a right that all people should have equal access to based on their medical need. For many of those who use a high proportion of medical care (perhaps especially urologic care) that insurance is provided by Medicare, a government-run, tax dollar supported entitlement program. Health reform as passed into law currently expands the pool of people who will have insurance coverage, and thus be able to pay the doctor. It is a far cry from Medicare-for-all, which I support, and which all people who support the current Medicare-for-some that currently exists, and are not entirely selfish, should support. If Dr. Cassell can survive as a urologist in Florida without taking those socialist Medicare dollars I would be surprised; if he is willing to take them, he should be supportive of Medicare-for-all.

Maybe he is. Maybe everyone has misinterpreted him. Maybe that is why he is so upset about the new law – that it doesn’t cover everyone fairly. If so, more power to him. If he is already refusing Medicare, at least he is logically consistent. However, if he takes Medicare but is opposed to even so mild a plan as the new health care law for expanding coverage to others, then he is just out for his own self interest.

The real issue remains: is access to medically-necessary health care a right, as it is considered in every other first-world country, or is it a commodity to be carefully husbanded by those who have it and sold to those who can meet the price? The real concern is not Dr. Cassell’s medical ethics, but his (and others’) worldview.

Monday, April 5, 2010

Primary Care and the Medical Home, Today and Tomorrow

March 18, 2010 was “match day”, the day that the seniors at US allopathic medical schools, along with many from osteopathic (DO) schools and thousands of graduates of non-US schools (including many who are Americans) “open their envelopes” and find out where they will be doing their post-graduate residency training. Most have already chosen their specialty and are waiting only to find out with which program they have “matched”. This year, for the first time in many years, the number of US medical students matching in family medicine has risen from the prior year. Not by much – there were, according to the American Academy of Family Physicians (AAFP) report, 75 (2.1%) more positions offered, and 2,404 (91.4%) of the 2,630 positions offered were filled on match day, the highest percentage in history. 1,184 of these are US grads, which was 101 more than last year and the highest number since 2004. This is good because, as I have often indicated, we need more primary care physicians and family medicine is the only specialty where virtually all graduates practice primary care. However, more sobering, it also notes, “The majority of positions offered and filled in the NRMP, however, continue to be in nonprimary care subspecialties.”

The Association of American Medical Colleges (AAMC)’s “Reporter” for March, 2010, contains an article by Scott Harris (written before the current match results were in), “Primary care in medical education: the problems, the solutions”. He notes that
Primary care is generally defined as family medicine, internal medicine, and pediatrics, although it is the adult-oriented specialties for which the problem exists most pointedly, physician workforce experts say. In the 2009 Main Residency Match, 3,703 U.S. allopathic senior students matched to an internal or family medicine residency program, compared with 4,617 in 2000 and 5,020 in 1996. According to AAMC data, all primary care practitioners entering general practice after residency are down from 8,162 in 2000 to an estimated low of 6,757 in 2007. The Council on Graduate Medical Education (COGME) claims that all primary care physicians currently comprise 35 percent of practicing physicians, but that number is rapidly declining because of increased retirements and fewer new doctors to replace them. Recent COGME studies show that fewer than 20 percent of all U.S. medical students are choosing primary care specialties.”
This formulation recognizes the problem of most of the graduates entering internal medicine specialty training ending up as subspecialists. If we are currently at 30-35% primary care, 20% of new students won’t get us to the 50% we need. In fact, even if 50% of graduates enter primary care specialties, it will be a generation before that number is achieved.

Harris’ main focus, however, is on the “hidden curriculum” in medical schools, the influences outside the formal curriculum from teachers and peers that encourages students to enter non-primary care specialties. He quotes students and faculty members who identify the problem. One is David Deci, a family physician at the University of Wisconsin, who says "Modern medicine is enthralled with high-tech measures. We're all drawn to bells and whistles. The contribution that can be made through a long-term relationship with a patient needs to be shown as well. When you're working with an elderly patient with multiple conditions and diseases, and you manage to keep him out of the hospital for two years, you've made a great contribution. But it's harder to demonstrate that than it is to show the value of removing a tumor with gamma knife surgery." Another is Jeffrey Borkan, chair of Family Medicine at Brown and (now) past-president of the Association of Departments of Family Medicine (ADFM), who notes “Medical education is all about context. There can be an inherent bias because of who the trainers are and where the education happens. U.S. academic medical centers and medical schools tend to be in urban areas and have a predominance of specialist and subspecialist physicians, providing care in tertiary and quaternary hospital settings. Primary care and primary care physicians and educators can be underrepresented in these settings, even though present in the broader community and country." Most distressing is the student (planning to enter radiology) who tells of a family medicine program director discouraging him from entering the field. Harris’ article also has descriptions of programs at a number of medical schools, including new ones and those that have been around a long time, who have programs and plans for changing or modifying this “hidden curriculum”. How well they will work, however, especially against the financial pressure of greater reimbursement for narrower specialties, remains to be seen.

There are some hopeful trends on the horizon. The new health reform bill promises some increased reimbursement and other support for family medicine. At a recent private meeting with the President, a family medicine chair was told that Mr. Obama understood that family medicine was the crucial specialty for providing care for the American people. The ADFM and other primary care organizations are working with the Patient-Centered Primary Care Collaborative (PCPCC), a network of employers such as IBM, health insurers, providers and drug manufacturers who recognize that health systems built around primary care keep people healthier and save them money. Of course, the “save them money” part may be the most important part for many of the corporations. It is an important venture, although the family physicians in the collaborative will have to remain on guard that the health of people remains the most important focus. Merck’s slogan, for instance, may be “Where patients come first”, but the reality of their practice has been much more “Where profits come first” – $6 billion in one recent year, despite the Vioxx recall; some details can be found at

I certainly hope that all these efforts work. Goodness knows, we need them. And I hope that the many medical schools who are not on board, whose focus has never been primary care, who feel their main missions are biomedical research and quarternary care rather than training the doctors our country needs, will rethink their curricula – formal and hidden – as well.

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