Wednesday, August 31, 2011

Steps toward a solution: Time to put Single Payer back "on the table"

During the health reform debate, one option we were assured was never seriously “on the table” was “single payer”, or Medicare for All. President Obama, who as a senator had indicated his support for this solution, backed away from it as fast as he could. In this he was undoubtedly encouraged by his many advisors, who have also encouraged bank bailouts, “compromise” on the debt ceiling, etc. (see June 18, 2009,“No Single Payer”: Sebelius – making policy for the powerful).  This is not to say that there were not supporters of single payer within government; there were and are. HR 676, “The Improved and Expanded Medicare for All” act, principally sponsored by Rep. John Conyers of Michigan, had nearly 100 co-sponsors in the House. Sen. Bernard Sanders of Vermont introduced a single-payer bill  in the Senate. Vermont, in fact, has become the first state to move toward a form of single payer on a statewide basis.

As anyone who has been reading this blog for any amount of time knows, I am a strong advocate of single payer. (A few of the many MSJ references: April 28, 2011 Perception and reality of economic inequality; July 22, 2010, Improving quality and access still requires coverage for all;  April 10, 2009, Does the nation need a clear policy on a right to basic health care?).

My reasons for support of single payer are several:
  1. It covers everyone. No one is left out. There is no complex system of “these people get coverage this way, those people get coverage that way, and those people (too bad) are left out altogether.”
  2. It provides a uniform benefit package. Everyone can get the care that they need, without concern about whether they are covered. In our current system, even many people who are insured have inadequate coverage. In addition, to the extent that the society decides to limit access to unproven or detrimental (see #5 below) or even “too expensive” care, no one gets it.
  3. It saves money. Off the top, it saves the profit being taken out of the system by insurance companies and other for-profit businesses. It saves even more money by eliminating all that being spent by those companies to deny care claims and by providers of care to try to get paid (see A Modest Proposal: Bribe the Insurance Companies, August 23, 2009).
  4. It puts us all in it together. This is a core method of ensuring social justice. The more educated and empowered among us will work to make sure that they get good care, and this benefits everyone.
  5. It provides the basis for ensuring quality, by having a degree of control over what gets reimbursed, and therefore what gets done. It may not ensure quality by itself, but it is almost a necessary component.
In 1964, President Johnson signed the Medicare Bill in Independence, MO, giving cards #1 and #2 to former President Harry Truman, who had fought for national health insurance in the late 1940s and lost, and his wife Bess.Forty-seven years later, Medicare has proven its importance in providing a single-payer program for seniors. It is the largest payer in the country, and the rates that it pays for services determine those paid by other insurers. While expanding Medicare to everyone should be the centerpiece of health policy, it has instead become the target of proposals to cut coverage to those who already receive it, particularly from the right. This has led to a lot of bad ideas from politicians such as Rep. Paul Ryan and Sen. Joseph Lieberman (see Medicare: We need to expand it, not cut it!, July 1, 2011).

The “poster child” for a single payer system is Canada, which has had it since the early 1970s. Based on the principle of social solidarity, not often apparent in the US, the Canadian federal government set the criteria for the program (which is also called “Medicare”) and the individual provinces set the specific terms and fund it. There is local (provincial) autonomy within the boundaries established by the federal government (see December 14, 2009, Tommy Douglas and the Canadian Health System;  May 27, 2010, Universal Coverage and Primary Care: The US needs both). Several recent articles have addressed the degree to which changes in the primary care system to create “medical homes” in Ontario, Canada’s largest province, have enhanced the quality of patient care, access of patients, lowered cost, and increased the income of primary care physicians (see Rosser et al, “Progress of Ontario's Family Health Team model: a patient-centered medical home” [1]). It is critical to note that this Family Health Team program was really only possible on such a scale because Ontario, like the rest of the country, has a single-payer system.

The importance of increasing, or at least not decreasing, the income of primary care physicians relative to other specialist, has been addressed in several other posts. What about all physicians, as a group? The AMA and other physician groups were, after all, largely responsible for the defeat of Truman’s national health insurance program and were major opponents of the US Medicare and Medicaid programs. Surveys by Physicians for a National Health Program (PNHP, see especially “Single Payer National Health Insurance”) have shown increasing support for single payer among the physician community, with universal health coverage being supported by a majority of US doctors in 20 (Support for national health insurance among US physicians: 5 years later[2]).

A new study may help to persuade physicians that single-payer systems are actually in their financial interest. Writing in August 2011 in Health Affairs, Morra and colleagues report that “US Physician Practices Versus Canadians: Spending Nearly Four Times As Much Money Interacting With Payers[3] (hyperlink to abstract). The title basically says it all. While both Canadian and US physicians spent time (translated into money!) interacting with insurers, the single payer in Canada and hundreds of payers in the US, about patient benefits and payment, the staff of US physicians spent 10 times the amount of time in such activities as did their Canadian counterparts. The authors estimate the cost to US physicians at $82,975 per physician per year, nearly 4 times the $22,205 cost to Ontario physicians. In addition, these costs fall disproportionately highly on small physician practices, which are more likely to be primary care. They conclude that “If US physicians had administrative costs similar to those of Ontario physicians, the total savings would be approximately $27.6 billion per year.”

From a financial point of view, we have an apparent dilemma in the US. The cost of Medicare is very high and creates financial threats to the economy. The reimbursement from Medicare to providers is often too low to make them a desirable payer. But there is a solution. It involves getting control over costs. First, do not pay for harmful or questionable interventions, do not pay major markups to generate excessive profit for private companies, and use the large scale of government purchasing to get good prices for drugs, unlike the boondoggle of Medicare Part D, the prescription drug program in which Medicare pays retail prices to pharmaceutical companies.

The solution is also to emphasize more primary care and prevention (October 18, 2010 Lower Costs in Grand Junction: More Primary Care, Less High Tech). The next steps will be harder, for they will involve making difficult decisions about the cost/benefit ratios of different types of care, particularly as the availability of new, expensive, high-tech interventions provide allure, if not always results.

The way not to do this is for policies restricting access for a part of the population (working and poor people) to be made by another part of the population (big businesses, politicians, and lobbyists) who will not be affected by those decisions. A single-payer system in which we are all covered by the same benefits does not automatically save money, but at least makes it possible.

[1]; Rosser WW et al, “Progress of Ontario's Family Health Team model: a patient-centered medical home”, Ann Fam Med. 2011 Mar-Apr;9(2):165-71.
[2]Carroll A, Ackerman R “Support for national health insurance among US physicians: 5 years laterAnn Int Med 1Apr2008;148(7):566-7.
[3] Morra D, et al, “US Physician Practices Versus Canadians: Spending Nearly Four Times As Much Money Interacting With Payers”, Health Affairs August 2011 vol. 30 no. 8 1443-1450.

Thursday, August 25, 2011

What is the ethical role for physicians in the "business" of health care?

Health care is a complex business. “Business” in the sense of “a human endeavor”, but also as “an organization seeking to make a profit.” Over the last several decades we have seen increases in the portion of health care delivery services that are formally organized as “for profit”. Hospitals, especially, have undergone such changes, joining the ranks of long-term care facilities, pharmaceutical companies, device makers, home health agencies, and insurance companies that have always been primarily “for profit”. Indeed, most physician practices, whether solo, small-group, or large group, are for-profit, organized into “professional” or “limited liability” corporations.

“For profit”, however, means that these organizations pay taxes, but because an organization is “not-for-profit” does not mean it behaves significantly differently. Not-for-profits are granted this status because a significant part of their activity is providing a public good, and their income-over-expenses (profit, which we can call “margin” to be less confusing) is not owned by shareholders but is rather intended to be re-invested to further enhance that public good. But not-for-profit hospitals generally follow very similar business practices to for-profit. They have to “compete for market share”. While they may have a mission, they often cite the mantra “no margin, no mission” as they invest in high-margin product lines (heart disease, cancer, neurosurgery) to attract more paying customers. Rather than, say, spending that money providing their wonderful care for free or at great discounts to the poor and uninsured. Or expanding their provision of high-need but low-margin services (primary care, obstetrics, pediatrics, psychiatry). The salaries paid to management of not-for-profit hospitals and professional personnel are often as high as those paid by for-profits (who, after all, have to maximize profit to please their shareholders, so want to keep costs, largely salaries, down).

So what is reasonable profit in health care, for companies that are for-profit? Should there be any? Does competition with for-profits distort the behavior of non-profits or would they act in the same ways if they had to compete only with other non-profits? Is competition good or bad? And what about doctors? Do they behave differently in their practice if they are salaried or have an incentive to make profit? Is this a good thing or a bad thing? So many questions!

In their commentary “Physician stewardship of health care in an era of finite resources” (JAMA 27Jul2011; 306(4):430-1), David B. Reuben and Christine K. Cassel address some of these issues. They start by noting that “Although there are varying opinions about the quality of health care in the United States, there is consensus that it costs too much.” I would guess that this is probably true, but may be as far as it goes. I suspect that each individual player or industry dependent upon health care dollars is unlikely to think it is their part that costs too much. It’s those other guys!

Reuben and Cassel focus on physicians. Not on how much physicians earn (salary or profit), but how they choose to spend health care dollars, because “Health care costs are directly related to decisions made in clinical practice”.  They go on to say that “These decisions are difficult to influence because they are made in the context of individuals who are often sick and vulnerable, with little understanding of the potential benefits and risks of diagnostic and therapeutic options. Patients seek help from physicians and physicians chose careers to provide this help, or at least the hope of it. Because of this relationship, it is futile to expect that changing physicians' behavior through evidence and shared decision making alone will solve the problem of high health care costs. Alternative approaches will be necessary.”

Cassel, the President and CEO of the American Board of Internal Medicine (ABIM, the organization that certifies internists; not to be confused with the American College of Physicians, ACP, the internal medicine professional organization), is both a geriatrician and a medical ethicist. I have heard her discuss physician stewardship in individual cases, arguing that the use of resources ordered by an individual physician for an individual patient should not be based on issues other than the benefit and risk for that patient, since the physician and patient have no control over what money “saved” might be used for. (My patient and I cannot decide to not do expensive interventions and instead use the money for housing the homeless or feeding the hungry – unless s/he is that rare person paying all the costs out of pocket --  all we can decide is whether to do those interventions or not.) Savings have to be looked at on a more global level, with a shared understanding of what those “saved” dollars will be used for.

The contribution that Reuben and Cassel make in this piece is to provide something of a taxonomy of physician stewardship, examining the various levels at which it can occur beyond that of individual patient decisions. These include the “highest” level, of national and state policy where spending decisions (initially, one presumes, via Medicare and Medicaid) should be based on evidence of benefit and consistency with national policy objectives (such as, I imagine, Healthy People 2020). The second level is that of payers (insurers) who would choose to pay for interventions that are shown to be beneficial (and presumably cost effective) rather than those that are ineffective or marginal. They suggest that rather than charging high deductibles and co-pays for services that are known to be beneficial and cost-effective, they simply do not pay for those that are not. This makes sense; why should insurers pay even a significant portion of procedures that are of little or no benefit while excluding such things as hearing aids that are of great benefit and (relatively) inexpensive?

The third level that they address is the practice level, where groups of physicians can use evidence to guide their group decision making and decrease inappropriate variation in physician practice. An example of this would be the use of a limited drug formulary emphasizing generic medications (this could also occur at the insurer level). Finally, there is the individual patient level; while making cost-effective decisions at this level can be more complex, it can certainly be done. While it is certainly unfair to ask a sick person to decide upon the choice of having, or not having, a medical intervention that they can scarcely understand so that saved dollars may possibly benefit some unnamed person more, it is quite a different thing to educate people about the impact of their health decisions, especially before they become critically ill. Advance directives, such as living wills, are one method, but there are many others.

What is clearly unethical and unacceptable is for physicians to encourage patients, sick or well, to undergo a diagnostic or therapeutic intervention because the physician stands to gain financially from doing it. Unfortunately, this happens. Sometimes it is done consciously, but often it is because the physician who does the procedure (and will happen, coincidentally, to benefit financially from doing it) truly believes it is of benefit. To not believe it would, in fact, be cognitive dissonance. Although there are increasing numbers of procedures being called into question for everyone, there are far more that are of benefit to some people but not to others. It is the ability of physicians to distinguish between these people and present recommendations honestly and free of financial bias that will make the biggest difference. The fact that there are still many physician-owned for-profit hospital and “surgi-centers” in which the doctors benefit financially not only as the providers but as owners of the facility from more procedures being done argues that we have a long way to go. (See also my commentary in an earlier post,  Greed, corruption and medical procedures: ignoring or suppressing the evidence?, August 12, 2011.)

The greed of human beings is not going to be wished away, whether they are physicians or lay corporate executives; whether of for-profit or not-for-profit companies. The taxonomy of Reuben and Cassel is useful for thinking about these issues, but it is only comprehensive – and thoughtful and balanced – regulation that can be sufficient impetus to make these changes happen.

Thursday, August 18, 2011

"Health in All" policies to eliminate health disparities are a real answer

At the recent American Academy of Family Physicians (AAFP) sponsored National Conference of Family Medicine Residents and Students (NCFMRS) held in Kansas City (hey, it can be an advantage to live in the Capital of Family Medicine!), I had the pleasure of hearing Dr. Steven Woolf’s presentation “Health Disparities and the Role of the Family Physician”. I have previously cited (eg, Economics and Disease Prevention, February 13, 2009) the work of Dr. Woolf, a professor in the Department of Family Medicine at the Virginia Commonwealth University (VCU) College of Medicine. He is one of the most distinguished health services researchers in the country, and a clear and articulate speaker.

His presentation, appropriately for residents and students, began with a description of the role of the family physician in the care of both individual patients and the communities in which they practice. He noted the major health toll exacted by “personal health behaviors”, headed by tobacco (accounting for 400,000 deaths per year) and including diet/activity (300,000), alcohol (100,000), microbial agents (90,000), toxic agents (60,000), firearms (35,000), sexual behaviors (30,000), motor vehicles (25,000), and illicit use of drugs (20,000, presumably not counting licit use of prescribed drugs). Note that, of these, only microbes are in the usual “traditional” area of medicine. His point was that to truly improve health the practitioner needs to go outside the hospital or office to the community, where these causes of ill health are located. “Health in All” policies include transportation, land use, built environment, taxes, housing, agriculture, environmental justice, etc. As an example he notes that 2.3 million (2.2%) of continental US households are more than a mile from a supermarket and do not have access to a vehicle. While Russell Shorto’s “Opinionator” piece in the NY Times July 31, 2011,The Dutch way: bicycles and fresh bread” points out that one advantage of using bicycles as much as the Dutch do is that you can’t carry more than a day’s worth of groceries so that the bread can be fresh and preservative-free, this is not the way of things in the US; poor access to healthful food is a big contributor to poor health.
Woolf then went on to demonstrate the familiar (but maybe not to residents and students) data on the remarkable health disparities that exist in the US, particularly by race, socioeconomic status, and educational level (although also by geography, language, and other characteristics). For example, the attached table shows a 24-29% disparity between the age-adjusted mortality rates of white and black males over the period from 1991-2000. The other table shows that the health status of college graduates is much better than that of people with some college, which in turn is much better than HS graduates who have been health than those who have not graduated from HS. These disparities are truly remarkable and should be intolerable. Woolf notes that while most of our current research is focused on finding treatments that are effective, we would save far more lives if we were to focus, instead, on equity by eliminating the health disparities gap.

In a “thought experiment” that he published with colleagues in the American Journal of Public Health in 2007, “Giving everyone the health of the educated: an examination of whether social change would save more lives than medical advances”[1], Woolf demonstrates that even if we attribute all reduction in mortality over to medical advances (nowhere near true; most are due to the types of societal change generally characterized as “public health”, such as clean water, sanitation, and cleaner air), eliminating the disparities that exist on the basis of educational level would dwarf that change, as shown in this table. 

But our society spends virtually all of its research dollars on developing new treatments that then are available to only a portion of our population, and have relatively little effect even on those who receive it. Big PhARMA spends $32 Billion/yr. While the National Institutes of Health (NIH), which is part of the Department of Health and Human Services (HHS), spends $28 Billion/yr, primarily on developing new treatments, HHS’ Agency for Health Quality and Research (AHRQ), which looks at systems and utilization, receives only $300 million/yr.

Woolf and colleagues have also developed a great new tool for visually looking at the impact of disparities on health on a state and county level. Called the “County Health Calculator” (, it allows you to pick a state or a county and compare its income level and educational level to that of the entire country (for states) or the entire state (for counties), or one state or county to another. It also presents the “best” and “worst” levels (for state or county), and allows (this is really neat!) you to use a “slider” to move the indicator to find out how changing the educational or income levels up or down would affect mortality. That is, you can see how many more lives would be saved – or lost – if your state (or county) had the income or educational levels of the average, best, or worst state (or county).

The results are truly amazing.  In Kansas, for example, the two suburban Kansas City area counties are almost polar opposites. Johnson County has the highest level of education, measured as % of adults with at least some college, at 78%, and income, measured as % of adults in households that have a “basic income” (defined as at least 2x the poverty level), 86%. Wyandotte County is near the bottom, with a “some college” education level of 39% and a “basic income” level of 56%. (Statewide levels in Kansas are 58% for education and 70% for income.) Using the slider, we discover that if Wyandotte County’s basic income level of 56% were raised to Johnson County’s 86%, 201 or 28% of deaths would be averted per year. If the “some college” education level were to go from the actual 39% to Johnson County’s 78%, it would result in a reduction of 272, or 38%, in the annual death rate!

No drug comes close to this. No treatment of any kind comes close to this. If a new drug were shown to reduce mortality from a disease by 5%, or even 1%, it would get incredible advertising – hundreds of millions of dollars – and huge publicity, in both the scientific and lay press. But the simple fact that so many more deaths could be prevented, so many lives could be improved, by addressing the social determinants of health, is scarcely covered, and hardly funded at all.

We are in thrall to, primarily, the pursuit of corporate profit, but also to a “scientific” perspective that sees new discoveries as the true goal of research rather than “moving the bar” and changing the actual outcomes for actual people. Eliminating health disparities, which improve health and decrease the death rate, will also “bend the cost curve” in ways that only improving access will not. In one of his slides, Woolf presents data from Milstein, et al, in a 2011 Health Affairs article [2] demonstrating that over the next 25 years neither providing coverage nor coverage + access to care, but only both plus “protection” – addressing behavioral and environmental risks – will do so.

There is no contest to the value of a dollar spent on changing social conditions as opposed to finding “more effective” treatments.  There is also no contest in where we actually spend our money. There is something rotten in the state, and it isn’t the state of Denmark.

[1] Woolf S., et al., “Giving everyone the health of the educated: an examination of whether social change would save more lives than medical advances”, Am J Public Health. 2007;97:679–683

[2] Milstein B et al., “Why behavioral and environmental interventions are needed to improve health at lower cost”, Health Affairs 2011;30:823-832

Friday, August 12, 2011

Greed, corruption and medical procedures: ignoring or suppressing the evidence?

One of the challenges for physicians who seek to advocate for patients by championing cost-effective, evidence-based medicine is opposition from the medical community itself. Physicians and other health care providers, as individuals, may practice evidence-free medicine, continuing to do things that have been shown not to work, to cost more than treatments that are equally effective, and sometimes to do harm. Sometimes this comes from ignorance of the evidence, because it may seem to be too hard to keep up. Sometimes it is because practitioners have “always” done it this way”, taught years or decades ago by their teachers. Or they may think that “their” patients are different from the ones who were studied; that “their” practice has shown them what works; that there is an “art” of medicine separate from the science. Maybe they are sometimes right, but usually they are wrong.

Yes, many important studies from which evidence-based guidelines are derived do not include all types of patients. For years poor and minority people were the main substrate for research (see “Tuskeegee”). More recently, perhaps in overcompensation, poor and minority people have been left out of research trials, which funders interested in health disparities (including the National Institutes of Health, NIH) are trying to change. But the fact that the patients you take care of were not included in these studies is not sufficient evidence for the results not applying to them. And, importantly, providers caring for exactly the population of patients who were studied are no less likely to ignore the results.

It is good to learn from your teachers. Hey, I’m a teacher. But new evidence emerges, and your patients count on you to be aware of it, to use it, to be on top of the knowledge that they cannot be. Does it take time? Sure. But that is the job. And for doctors that is one of the reasons that they are well-paid. To keep up. But what about one’s own personal experience? Experience is a good guide, in the absence of other evidence, but rarely does one provider have sufficient experience to have stronger evidence than large clinical trials. Moreover, “anecdotal” experience (“I once had a patient who X treatment didn’t work for”, or more likely “I once had a patient where Y treatment worked great”) has its own pitfalls. Mainly, it is usually wrong, even in the context of that individual provider’s practice. We have a tendency to remember the unusual, and to remember that for use in our future practice rather than the usual. I remember, while working in an urgent care center before the advent of “rapid step tests”, I had to  review yesterday’s throat culture results. I would see a positive result and say “Ha! I knew that patient had strep!”, but not consider all the negative tests on patients for whom I may have thought the same thing.  This is why we do large clinical trials. The “art” of medicine is important, especially in areas where there is no, or insufficient, evidence, and in translating that evidence into what the patient should do. The art of medicine is not, however, in ignoring the evidence.

Much more serious, however, is when greed causes physicians refuse to abide by the evidence because it shows that something that they are doing, which makes them money, is not indicated. This too can be subconscious, because if you have been doing a procedure for a long time believing it works, it is hard to suddenly change your mind because of new evidence. It is easy for your subconscious to deny that this resistance has anything to do with your own economic benefit, and is rather the result of your knowing it works. But when large groups of physicians, professional societies, get involved, it is no longer subconscious. It is financial protectionism pure and simple.

A good example of this is the recent opposition to recommendations by the Institute of Medicine (IOM) suggesting how the Food and Drug Administration should make rules governing the use of medical devices. Some manufacturers and physician groups  began to criticize them before they were even published (“Study of medical device rules is attacked, unseen”, Barry Meier, NY Times, July 28, 2011). The failure of many medical devices currently on the market, including artificial joints and defibrillators, was the impetus for this report. The IOM, a group of independent physicians and scholars convened by the National Academy of Sciences, are tasked with making recommendations on a wide variety of medical issues. Many of their most well-known reports focus on quality and patient safety, such as “To Err is Human: building a safer health system”. As Meier reports, a business group representing many of the device manufacturers went for the old “the best defense is a good offense” strategy and attacked the rules before they were promulgated. It is self-serving, but not surprising: “With millions of dollars of product sales at stake, the experts said, it is not surprising that the device industry and others would want to avert what they see as potentially restrictive new rules. Still, the lobbying has taken on a tone akin to Washington infighting over an issue like bank regulation, rather than patient health, they said.” Guess what? With millions of dollars at stake, it is exactly like attacking new bank regulations rather than focusing on patient health!  (For those who are interested, the actual IOM recommendations on medical devices, Medical Devices and the Public’s Health: The FDA 510(k) Clearance Process at 35 Years  is available on line.)

Of greater concern than these actions by the Washington Legal Foundation (additional information available in Wikipedia), a “pro-business group”, representing the self-interest of manufacturers, is the involvement of physicians. WLF’s attorney, Richard Samp, “… said his organization took action after the issue was brought to its attention by a lawyer who works at a firm that represents device makers. Shortly after filing its petition, the legal foundation was contacted by an official of the American Academy of Orthopaedic Surgeons, which represents doctors who perform joint replacements, who congratulated it for ‘taking the bull by the horns,’ Mr. Samp said.”

This is not the first time that orthopedics organizations (which for some reason choose to use the British-style diphthong “orthopaedics” despite being Americans who do not make a practice of using other medical diphthongs such as haemorrhage, oesophagus, anaemia or oedema) have chosen to attack evidence-based rules by political means. When, back in 1995, the Agency for Healthcare Policy and Research (now the Agency for Health Quality and Research, AHRQ) issued evidence based guidelines that recommended that certain popular (and remunerative) surgeries for back pain were not very effective, the orthopedic groups were able to convince Rep. Henry Bonilla (San Antonio) to introduce legislation to de-fund the agency! (“Agency’s report provokes a revolt”, by Neil A. Lewis, NY Times September 14, 1995).That’s playing hardball! However, the procedure, vertebroplasty, was overused, usually didn’t work and often caused harm. Interestingly, mounting evidence of its inutility continues to this day, recently for vertebral fracture in the British Medical Journal[1] [2], the results of which summarized by the editors of Journal Watch General Medicine.[3]

I don’t want to pick especially upon orthopedists (or orthopaedists), although as high-income procedural specialists, they have been involved in more than their share of these issues. Many of the IOM’s recommendations involve procedures done by other specialists, including cardiologists. Indeed, we need to applaud the work of the academic cardiologists who have done the studies that show that many of these procedures that constitute a major source of income for their practicing colleagues (the pâté and vichyssoise if not the bread and butter) are not indicated.

The researchers doing this work are some of the true heroes of medicine. Those who hold on to evidence-free procedures because they make a lot of money from them need to be careful that they do not join the villains.


[3] “The results do not support routine use of vertebroplasty in patients with vertebral compression fractures, including those with recent-onset pain or severe pain at baseline. Strengths of this meta-analysis include its use of individual patient data and the blinding of patients to vertebroplasty or sham procedures. As noted by the authors, lack of blinding overestimates treatment benefit, which casts doubt on the results of a recent nonblinded randomized trial that suggested vertebroplasty is superior to conservative treatment (JW Gen Med Sep 2 2010).

Saturday, August 6, 2011

Cook County Hospital: Health care for the poor or poor health care?

I am a family doctor, and I did my residency training at Cook County Hospital in Chicago in the late 1970s. After a few years in Arizona, I worked as an attending physician there for another 14 years. When I tell people that, I get a lot of responses like “Oh! That must have been something!” They are thinking, I guess, that it was an endless stream of gunshots, a constant flood of the worst that they can imagine in their Emergency Rooms. It wasn’t, at least not all. Don’t get me wrong – the Emergency Room was incredibly busy, there were lots of gunshots and other traumas, and no matter where you worked there was an endless stream of people. But mostly it was doing medicine, family medicine, with people who were usually poor and usually sick and usually in need and usually not able to access care anywhere else.

David Ansell, MD, captures much of the story of “County” in his recent book of the same name.[1] It starts with his arrival as a new intern in 1978. He was part of a group of medical students from Upstate Medical School, the State University of New York medical school in Syracuse, he and 3 others in internal medicine and one in pediatrics. They had decided that they would train as a group, to support each other, and do it in a setting where they would be able to make a difference in the health care of people in need. Cook County was the place they chose, and it was no coincidence. The need was there and there was a “critical mass” of house staff with similar commitment, including me; I had started two years earlier.
The year before I came as an intern, in 1975, the House Staff Association – our union – had gone on strike. The issues were entirely about patient care, and the Hospital and its Governing Commission refused to negotiate over them. It wasn’t that they had something against unions; the County’s employees were almost all unionized and they probably would have talked about wages and traditional issues of working conditions. But when the residents defined “working conditions” as including EKG machines on the wards and nurses available to start IVs, the County wouldn’t consider negotiating. A dozen of these striking residents ended up in Cook County Jail after the politicos at the County Board got an injunction against the strike. (Ironically, one of these became, several years later, the medical director of the hospital in the Jail.)  A year after Ansell got there (and after I left) in 1980, control of the hospital passed from a quasi-independent Health and Hospitals Governing Commission to become directly under the County Board, eliminating any impediment to the Board members using it as it had always been – a jobs program for their supporters.

Ansell does an excellent job of documenting the challenges facing the hospital in those years, even while telling enough “horror” or “gross out” stories to keep readers and reviewers interested. Abigail Zuger, MD, gives it a pretty good review in the New York Times (“Their zeal changed lives, if not the system”) although she doesn’t like his writing as well as that of Fitzhugh Mullan (“White Coat, Clenched Fist”[2]) or others. On the other hand, my father liked  his writing style a lot.

Rush University Medical CenterAnsell’s story goes beyond the years of his residency, for he became an attending physician at County. He worked there for many years (when I got to know him best), before leaving to become Chair of Medicine at Mount Sinai Hospital in Chicago and then to his current position as Medical Director of Rush University Hospital, back across the street from where he started. He traces the long saga of the hospital. On the downside, political machinations and exploitation of the hospital and the people it served, and, on the up side, the improvements in patient care and hospital quality. For example, when I started the Emergency Room had 2 attendings who worked day shift, and the senior doctor in the ER at night might be a 2nd-year medical resident; 10 years later it was a well-staffed ER with many attending physicians and an ER residency program. There still was and continues to be a very long wait.
The later part of the book describes the regular turmoil creates by politics at County as well as the efforts of Ansell and others to provide the best possible care to their patients, individually and as a group. County physician staff were, for the most part, incredibly dedicated both to the care of their own patients. They did whatever they could to make the hospital a good, or at least, better place for health care for the entire population that depended – and still depends -- on it. Even when that meant going head to head with the County Board and their hand-picked administrators. And that, of course, is the story.

Cook County to ban smoking on all hospital grounds
Was – is – Cook County Hospital (now reconstituted in a new building as John H. Stroger, Jr., Hospital) a “hell-hole”, where patients received substandard care from inadequately trained physicians, in physical disastrous conditions? Or was it the only place in town where the poor, largely minority, people of Chicago could come and receive care after being overtly or covertly turned away from other sources of care? Both, certainly, although the former is much much less true than it was 30 years ago; the latter is a little less true. Not every patient who came to County was personally turned away somewhere else, of course. It was known in the community and in their family that this was the place people could go and get care, and amazingly often, get respect from doctors like Ansell.

From a lot of the doctors and other staff. Yes, some of the staff was callous, but unlike at many university teaching hospitals, the medical staff were usually concerned more about the future of the patients than about their careers; unlike in many community hospitals, they cared for everyone, not just those from a certain background, socioeconomic status or degree of “social acceptability”, or at least ability to pay.

Do I have criticisms of Ansell’s book? Sure; everyone has their own experience, and while David and I overlapped for much of our careers, and certainly, I hope, in our social concerns, I do find some things missing. Reading County one might think that all of the “good guys” and all of the good programs were in Internal Medicine. Certainly many of them were, from Quentin Young, MD, the Internal Medicine Department Chair for many of those years and still a dedicated health activist, to the plethora of committed physicians he describes and many others. But the physicians in department family medicine also played a major role.

Family medicine at Cook County? Under the leadership of Jorge Prieto, MD, Family Medicine was the pioneer for getting County doctors out of the “hulk squatting in faded splendor” on Harrison St. into the community. Dr. Prieto only agreed to take the chair of the department if the hospital agreed to set up a clinic in the Latino community. The South Lawndale Health Center, where I trained, is still there, although expanded into much bigger quarters and known as the Jorge Prieto Health Center. An entire network of community clinics was set up (and later largely dismantled), an effort led by Family Medicine. For many years, training at Cook County in Family Medicine defined urban family medicine, along with a few other programs such as Montefiore in the Bronx and San Francisco General. That is another story. David Ansell has written his book about County, and it stands on its own.

Cook County Hospital, then and now (as Stroger), is a publicly funded hospital that cares for the neediest people in the city. Is it often second class care? Maybe, but that is a step above no care, which is the reality for many people in cities and counties and states without publicly funded health care.

[1] Ansell, DA. County: Life, death and politics at Chicago’s public hospital. Academy Chicago. 2011.
[2] Mullan, F. White Coat, Clenched Fist: The Political Education of an American Physician, Macmillan, 1976.

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