Tuesday, January 27, 2009

Social Justice: Economic Stimulus and Bailout

As the Congress considers President Obama's economic stimulus package, it is distressing, if not surprising, to hear Republican leaders such as Mitch McConnell of Kentucky decry that there is too much going to spending and not enough to tax cuts. Has he, have they, learned nothing? Trickle down doesn't work. Tax cuts for the wealthy don't work to stimulate the economy (though I suppose they are good for the wealthy!) Tax cuts for lower income people, endorsed by the President, are not likely to be enough to get them out of the hole that they are in. The first $350B in "bailout" funds was not spent where it was needed -- to help working people pay or re-negotiate their mortgages, prevent bankruptcy from medical bills, and tide them through being laid off. Rather, it was given to banks and other financial institutions who hoarded it, gave it away to themselves, and paid dividends to shareholders, but didn't loan money to consumers. McConnell and friends are either stupid, crazy or evil. In any case, no matter what they say, it would be a terrible mistake for the President to let them in any way derail the plans to "bail out" the rest of us. The remainder of the financial bailout needs to go to help regular folks stay in their homes. The huge economic stimulus package needs to be passed, and to focus on how regular folks can get jobs, housing, health care, and other necessities. Spend in ways targeted to fix the problems, and tax rebates are not the way to do so.

The "no tax / balanced budget" fixation has led most states, unlike the federal government unable to print money, to be in a desperate situation. Not learning from Joseph in Egypt, who saved some of the crop from the seven years of plenty to tide people through the seven years of drought, they have in most states had two modes: tax cuts in times of plenty and budget cuts in times of shortfall. Now that most of them have the biggest shortfalls ever, the budget cuts will go way past the fat into the muscle and bone stripping the ability of many states to provide the most basic services.

Friday, January 23, 2009

President Obama rescinds Global Gag Rule

Sometimes there is really something to celebrate. As one of the first official acts of his administration, along with announcing the planned closure of the detention center at Guantanamo Bay, President Obama has rescinded the "global gag rule" (see posting of January 11, 2009). This evil and invidious rule, which limited crucial reproductive health funding to agencies and governments all over the world, is now history!

Congratulations and thank you, President Obama!

Thursday, January 22, 2009

The "Neurontin Legacy"

The January 8, 2009 issue of the New England Journal of Medicine includes an article by Landefeld and Steinman called “The Neurontin legacy – marketing through misinformation and manipulation”[1] that should be required reading for every physician, medical student, and hospital or health facility administrator, not to mention students of, and those involved in implementing, health policy. Neurontin, the brand name for the drug gabapentin, was approved by the FDA only for adjunctive (meaning “in addition to first-line drugs”) treatment of epilepsy, but was heavily (and illegally) marketed by the manufacturer (Parke-Davis, a division of Warner-Lambert, purchased by Pfizer in 2000) for a variety of other indications including first-line treatment of epilepsy and, more importantly, pain relief, especially “neuropathic” pain – pain that arises from problems in the nerves themselves, commonly in people with diabetes.

The article notes that in May, 2004, “Warner-Lambert agreed to plead guilty and to pay more than $430 million to resolve criminal charges and civil liabilities. A class-action suit was filed the next day in federal court on behalf of private parties who had paid for illegally marketed Neurontin.” This is an extraordinary settlement, and quite appropriate given the fantastic series of marketing “tactics” that “…included education, publications, and research whose promotional intent was disguised, in addition to more transparent activities, such as advertising and sales visits.” It is illegal to market for non-FDA-approved indications, but Parke-Davis did it both incredibly aggressively and effectively, with Neurontin’s sales rising from $98 million in 1995 to nearly $3 billion in 2004. The company commissioned “research” to show the drug’s effectiveness, suppressed publication of studies that showed it had no effect on neuropathic pain, and in the words of epidemiologist Kay Dickersin, who performed a “recently unsealed 318-page analysis of research sponsored by Parke-Davis…concluded that available documents demonstrate ‘a remarkable assemblage of evidence of reporting biases that amount to outright deception of the biomedical community, and suppression of the scientific truth…’” It is worthy of note that the exposure of the Neurontin affair was the result of the efforts, almost worthy of being called heroism, of a young biologist who named David Franklin who worked for Parke-Davis.

What is the importance of this scandal? Is it that thousands of people were treated with a drug that was neither FDA approved for the indications for which it was being promoted, and may have been ineffective? Perhaps, although there are many physicians who would continue to argue that, at least in their anecdotal experience, gabapentin is effective for neuropathic pain. Or is it that pharmaceutical companies use aggressive and unethical, bordering upon and sometimes crossing the line into illegal, tactics to promote the use of their products and thus the enormous profits that accrue? Perhaps, but anyone who did not know this has long been deceiving themselves. The pharmaceutical industry has been for many years either the #1 or #1 most profitable industry in the US. The $430 million fine, while significant, is a small part of the profits that Parke-Davis/Warner-Lambert/Pfizer made through the off-label use of the drug. Is it that the court cases involving Neurontin involved the release of enormous numbers of papers (including the Dickersin report mentioned above, as well as internal company documents) that clearly demonstrate the invidious nature of pharmaceutical company promotion? If anyone needed more evidence, it is there. “Promotion,” write Landefeld and Steinman, “was neither discrete, compartmentalized, nor readily apparent; instead, it was intercalated in nearly every aspect of physicians’ professional lives, from the accoutrements of practice to lectures, professional meetings, and publications. Although some pharmaceutical marketing may be less opaque, deceptive and manipulative, evidence indicates that drug promotion can corrupt the science, teaching and practice of medicine.”

If David Franklin is the hero in this episode, the villains, in this particular case and overall in drug marketing, are the pharmaceutical companies who are willing to use any tactics to increase their enormous profits. The victims are clearly the patients who paid more for drugs that may have been ineffective, or no more effective than less expensive drugs (and, from their perspective in their class-action suit, the insurers who paid for these drugs). The facilitators, however, are the physicians who were too willing to take their information (as well as gifts, sometimes small, sometimes large) from pharmaceutical company representatives), rather than more reputable sources, and not pay attention to the principles of conservative prescribing (rule #1: use the drugs that we know are safe and work, be cautious of new “miracle drugs”). They are also certainly medical organizations, the paid physician flaks who gave the talks, and even the medical journals that uncritically published some of the company written studies. They are also, however, sometimes the patients themselves, living in a culture of NEW! BETTER! IMPROVED!, of Technology over All, who frequently beseech their physicians for something new, more effective, especially with regard to pain relief.

We have met the enemy, and it is them. But, in the words of the immortal Pogo (Walt Kelly) it is also us. If they did before (and a frightening number did!) no physician should now have any business trusting pharmaceutical companies to be completely honest, nor believe that they owe use of new drugs to the “nice men and women” who are the drug reps, nor that drug samples (always, only the newest, most expensive drugs, never the old “standbys” or certainly anything available generically) are “free”, nor most of all believe that they are not affected by advertising and gifts. All physicians and students should read not only this piece but the classic “A Social Science Perspective on Gifts to Physicians from Industry”[2] to understand the sublimal efficacy of these tactics. And patients (the medical word for “people”) need to recognize this too, and demand not “new”, but “best”, defined as well-established, effective, and safe.

[1] Landefeld CS and Steinman MA, “The Neurontin legacy – marketing through misinformation and manipulation, NEJM Jan 8, 2009; 360(2):103-05
[2] Dana J, Loewenstein G, “A social science perspective on gifts to physicians from industry”, JAMA July 9, 2003;290(2):252-5.

Monday, January 19, 2009

Martin Luther King, Jr. Day and the Inauguration

In celebration of Martin Luther King, Jr.’s birthday, more than 40 years after his assassination, let us struggle even harder for the values that we share with him. For peace: in Iraq, in Gaza, in Afghanistan, in the Sudan and all the lesser-known conflicts, for an end to hunger, in Zimbabwe and all over the work, an end to oppression, poverty, HIV/AIDs, lack of opportunity, lack of education. Let continue to donate our time and our dollars, but remember his statement that “Philanthropy is commendable, but it must not cause the philanthropist to overlook the circumstances of economic injustice which make philanthropy necessary,” and always continue to fight injustice in all of its forms.

And tomorrow, as Barack Obama, our first African-American President, takes the oath of office, let us hold that as a sign of hope for all of us for the future.

Thursday, January 15, 2009

Ten Biggest Myths Regarding Primary Care in the Future

Introduction: This article is by Robert Bowman, MD, of the AT Still College of Osteopathic Medicine in Mesa, AZ. Dr. Bowman is a long time scholar of primary care and rural health workforce issues. He identifies and comments upon 2 important workforce concepts. The first is “primary care forms” of training, which include 3 physician forms (family medicine, general internal medicine, and general pediatrics), and primary care nurse practitioners and physician’s assistants. The second is the Standard Primary Care (SPC) year, which allows us to look at the success of the different “forms” in terms of how many SPC years they provide per graduate. This takes into account the percentage of graduates who enter primary care, the portion of their practice that is primary care, at what rate they leave primary care for another area, the number of years they practice, and the percent time (part time/full time) they practice. Thus if a form of training has 100% of graduates entering primary care who practice full-time for an average of 35 years with 100% primary care practice, that form would produce 35 SPC years per graduate. If another form had only 50% of its graduates entering primary care, who averaged 50% primary care practice, practiced for an average of 20 years with an average of 75% FTE, that form would produce an average of only 3.75 SPC years per graduate (do the arithmetic: 20 years x 75% FTE x 50% of grads in primary care x 50% of practice is primary care). This is important in comparing projections – one can’t just say, for example “nurse practitioners will take care of our primary care needs” without doing such a calculation.

  • Myth Number 1: Primary Care has collapsed. Primary care internal medicine has collapsed with lowest production and lowest primary care retention levels. Those associated with internal medicine primary care perceive collapse. But primary care remains. Existing dedicated primary care practitioners continue to deliver primary care despite insufficient support. There are 5 training sources of primary care. Some are remaining steady and some are dropping. The ideal primary care provider would contribute 35 Standard Primary Care (SPC) years: a 35 years career, actively in practice 100% of those years, and 100% remaining in primary care and 100% or top volume of primary care. Among the 5 forms of primary care training, family medicine remains steady in primary care with over 25 Standard Primary Care (SPC) years per graduate. Pediatrics is also steady, but with only 16 SPC years per graduate. The other 3 forms have more graduates who are inactive or part-time, have fewer years in a career, retain a lower percent of graduates in primary care (retention), and have a lower volume of primary care. They thus make limited contributions with fewer SPC years per graduate. Internal medicine, nurse practitioner, and physician assistant forms have declined to less than 4 SPC years per program graduate. Collapse of primary care is found for forms that depart primary care during training, at graduation, and each year after graduation under the assault of poor primary care support. [1]

  • Myth Number 2: Nurse practitioners will take over more primary care duties. Nurse practitioners will continue to supply less than 12% of the primary care supplied by the five primary care training forms using past measures as well as future estimates.[1, 2] Increasing departures to hospital and specialty careers, lowest activity (inactive, part time), lowest volume of primary care, and greatest delays in entering primary care limit nurse practitioner primary care contributions.

  • Myth Number 3: Physician assistants will take over more primary care duties. Less than 30% of new physician assistants enter primary care and active physician assistants will dip below this level in the next 3 years.[3] Physician assistants will continue to supply less than 12% of the primary care supplied by the five training forms. Increasing departures to emergency medicine and subspecialty careers, lower activity (inactive, part time), and lower volume of primary care limit physician assistant primary care contributions.

    Only if physician assistants or nurse practitioners were required to stay in the family practice mode of care would they be able to increase share of primary care, rural primary care, and underserved primary care duties.

  • Myth Number 4: Internal medicine graduates from international medical schools will make significant primary care contributions. Internal medicine residency program graduates from foreign origins and international medical schools will contribute the fewest years of primary care averaging 1.3 SPC years per graduate. The limitations are substantial with lowest primary care retention after graduation, loss of 8 years due to delayed entry into the United States workforce, and losses after graduation including 20% departing the United States for home nations, 8% chronic unemployment, and increasing fractions departing for other nations.[4, 5] Lowest primary care also means lowest rural primary care and underserved primary care. A family practice residency graduate contributes greater than 30 times the rural or underserved primary care per graduate. Changes in the J-1 Visa waiver program and increasing uses of international graduates by the military and teaching hospitals will further limit primary care, rural, and underserved contributions.

  • Myth Number 5: The United States is unable to produce enough primary care. Through policy, medical education efforts, and statewide efforts, the US has been consistently successful. The US was able to quadruple primary care graduates in the 1970s. The US increased primary care production 50% during the span of a few years in the 1990s. Historically Black, osteopathic, and many allopathic public schools have been successful for over 100 years. Primary care contributions are maximized when schools and states focus together on health access in birth to admission preparation, admission preferences, training curricula/faculty/locations, and health policy.[6]

    To sum up: the only way that the United States can fail to produce primary care is to admit the most exclusive students (lowest probability primary care), train in locations with the least health access emphasis (lowest influence), fail to graduate enough family physicians (permanent form), and create a health policy that rewards the most exclusive careers and locations. This, of course, is exactly how US health care is structured.

  • Myth Number 6: Generic expansions of medical school, nurse practitioner, or physician assistant graduates can increase primary care. During the current time period with the worst health access policy in decades, fewer students are choosing primary care and those that can move away from primary care are leaving. Osteopathic (DO) graduates will more than double from 2004 to 2017 but, with the current steady declines in family practice percentages, the end result will be only a gain of 100 more family physicians or a 20% increase despite a 100% increase in graduates. With primary care retention rates dropping steadily at 1 or 2 percentage points each year in the large and growing nurse practitioner and physician assistant pools (over 230,000 combined), new graduates entering the workforce in primary care are not able to keep up with losses of active primary care plus departures from active practice. Only specific expansions of family practitioners that remain in the family practice mode (physicians, nurse practitioners, and physician assistants) can address primary care and health access needs. Retention in the family practice mode is much less likely for NPs and PAs since they can and do depart the family practice mode at any time.

  • Myth Number 7: Nurse practitioners make substantial rural primary care contributions. Rural primary care requires both rural location and primary care contributions. While 20-25% of nurse practitioners are rural, they do not have the primary care component. Nurse practitioners contribute 1 rural Standard Primary Care year per graduate (4 SPC years times 25% rural) in rural workforce whereas family physicians contribute 5 Standard Primary Care years per graduate (25 SPC years x 20%) in rural locations.

  • Myth Number 8: Primary care is not marketable to the American consumer.[2, 7, 8] It is very hard to understand how respected authorities in leadership positions could make such statements. Only a severe lack of awareness explains their comments. Workforce experts, trainers and educators in major medical centers and medical schools, leaders in the Council of Graduate Medical Education and the Association of American Medical Colleges all live in areas with the highest concentrations of people, physicians, and medical schools. These experts have spent their entire lives in locations that employ the fewest primary care physicians and support primary care at the lowest levels. They have tolerated the training of medical students and residents in dysfunctional primary care settings.[9] It is not surprising that primary care does not appear marketable to those clustered in the 3,300 US zip codes which make up 4% of the land area with 75% of physicians and 95% of medical schools. This limited perspective ignores the 38,000 zip codes in which 65% of the American population and 70% of the elderly are cared for by the remaining 23% of total physicians. In these locations, 30 – 100% of the total physicians are primary care physicians.

    The total elimination of health care for millions is unconscionable and this is what is suggested by the statement that primary care is not marketable. The locations that depend upon primary care are also locations that offer better primary care salaries, better primary care support, better practice options to generate more revenue, lower costs of delivering health care, and lower costs of living. Those designing health care for an entire nation must place much more emphasis on care for the 65% of the population left out of the current health care design. All of medicine and medical education will pay dearly for the choices of a few leaders. Current leaders appear to have abandoned Butler’s call to a season of accountability and social responsibility for medical education.[10 ]

  • Myth Number 9: The nation needs more pediatric graduates to meet primary care needs. More pediatric graduates will not meet primary care needs. According to pediatric leadership, pediatric primary care is saturated in the locations where pediatricians choose to locate, at the same time that the United States has fewer children. Even though 15% of white female medical students remain committed to pediatric residency choices, they and other pediatric graduates will compete with all other primary care graduates already delivering pediatric primary care. This is likely to result in more practicing in part time, specialty, hospital, urgent, and emergent pediatric care settings.[11]

  • Myth Number 10: Care for Age 65 and Up Will Be Provided By Geriatric Specialists. Geriatricians are a small fraction of new physicians, they are less likely to be found in locations with concentrations of older Americans, they have limited support, they have lower volume of patients, and they have some of the most complex patients. Older patients move toward locations with lower costs of living and health care and they move away from concentrations of internal medicine physicians, geriatricians, geriatric training programs, stroke centers, and heart attack centers.[12] They move steadily toward locations served predominantly by family physicians.

    National studies confirm patterns of care for the elderly and for all seeking ambulatory care in the United States in 2004. About 62.5% of age 65 and older patients saw a family physician compared to internists for 29%, and somewhat less than 19% seeing a nurse practitioner.[2] This is not what numbers of graduates predict since both internal medicine graduates and nurse practitioner graduates are about twice the number of family practice graduates. In 2004 family physicians led in all but one ambulatory category. In addition to seniors, family physicians were seen by 43.4% of adults seeking care, and 39% seeking women’s health care. The family physician share of 20% was second to pediatricians although family physician percentages increased for children over age 4 and for the 65% of the population beyond concentrations of pediatricians.[2] This is why increased family physicians can address pediatric care needs while more pediatricians cannot.

Myths persist unless they are compared to reality. Primary care must be measured according to a standard and the standard is set by forms of primary care training that produce providers who remain for 35 years of a career, who continue to provide primary care, who remain in the wide range of most needed locations, who continue to serve the populations most in need of care, and who continue to do so whether the current “policy era” is supportive or unsupportive of primary care. For physicians, nurse practitioners, and physician assistants, the standard is set by those that remain in the mode of care known as family practice.

1. Bowman RC. Measuring Primary Care: The Standard Primary Care Year. Rural Remote Health. Jul-Sep 2008;8(3).
2. Ferrer RL. Pursuing equity: contact with primary care and specialist clinicians by demographics, insurance, and health status. Ann Fam Med. Nov-Dec 2007;5(6):492-502.
3. American Academy of Physician Assistants. Data and Statistics. http://www.aapa.org/research/index.html. Accessed October 26, 2006, 2006.
4. International Medical Graduate Section of the American Medical Association. Report on International Medical Graduates. Chicago 2007.
5. Quick Views. J-1 Waivers on the Decline. amednews.com. January 22, 2007.
6. Bruce TA, W.R. N. Improving Rural Health. Little Rock, Arkansas: Rose Publishing Company; 1984.
7. Philibert I. An interview with Carl Getto, MD. ACGME Bulletin. 2004;Spring:10-11.
8. Salsberg E. Physician Workforce Policy Guidelines for the U.S. for 2000–2020. Presented to the Council on Graduate Medical Education. Bethesda, MD. September 17–18, 2003.
9. Keirns CC, Bosk CL. Perspective: the unintended consequences of training residents in dysfunctional outpatient settings. Acad Med. May 2008;83(5):498-502.
10. Butler WT. Academic medicine's season of accountability and social responsibility. Acad Med. Feb 1992;67(2):68-73.
11. Committee on Pediatric Workforce. Pediatrician workforce statement. Pediatrics. Jul 2005;116(1):263-269.
12. Perrotta BL, Perrotta AL. Access to state-of-the-art healthcare: a missing dynamic in consumer selection of a retirement community. J Am Osteopath Assoc. Jun 2008;108(6):297-305.

Sunday, January 11, 2009

Mr. Bush’s Legacy: The Global Gag Rule

The New York Times, Jan 3, 2009, has an editorial entitled “Mr. Bush’s Health Care Legacy.” Acknowledging that “This page has criticized the Bush administration’s weak performance on many important health care matters: its failure to address the problem of millions of uninsured Americans or stem the rising costs of health care, its refusal to expand eligibility for the State Children’s Health Insurance Program, its devious maneuvers to cut Medicaid spending, its support of unjustified subsidies for private health plans, to name a few,” the editorial goes on to laud his “achievements in health care”. The editorial names his work on proposing funds (increased by Congress to $50 billion over 5 years) to fight AIDS, tuberculosis and malaria worldwide and his pushing the Medicare drug-benefit program, Medicare Part “D”, despite their disagreement with “many features of the program – the refusal to allow the government to negotiate with manufacturers for lower prices, shortfalls in providing subsidies to low-income Americans, a failure to protect many patients from high out-of-pocket costs.”

I am willing to credit anyone, even George W. Bush, for anything that they do that is good, and I am willing to acknowledge that funding for fighting these terrible diseases and to help older Americans obtain prescription drugs are important. I will not add to the Times’ list of flaws in Medicare Part “D”, though they are very serious and could be expanded upon. I will point out that the current funding for fighting AIDS, TB, and malaria comes with strings attached, but it is also a very good thing. I do, however, want to focus on a particularly vile part of Bush administration policy that has had very destructive effects worldwide, the Global Gag Rule (“Mexico City Policy”) preventing any agency using any of its funds from any source to do – or counsel about – abortion from getting any family planning funds from the US Agency for International Development (USAID).

You may remember an effort by the Bush administration to impose such a "gag rule” domestically, that was thankfully unsuccessful. However, this policy has been in placed for international aid through all Republican presidencies since it was announced at the Mexico City Conference of the United Nations International Conference on Population by Alan Keyes of the Reagan administration in 1984. It was repealed by executive order by President Clinton in 1993, and reinstated by President Bush in 2001. Its effect has been devastating in the developing world, particularly in Africa and Asia, where local organizations have had to decide between losing significant portions of their funding (the International Planned Parenthood Foundation lost 20% of its funding) or not performing critically important family planning services to their clients. The impact of this rule are detailed at the website www.globalgagrule.org. “The Global Gag Rule Impact Project is a collaborative research effort led by Population Action International in partnership with Ipas and Planned Parenthood Federation of America and with assistance in gathering the evidence of impact in the field from EngenderHealth and Pathfinder International. The Project’s objective is to document the consequences of the Global Gag Rule. The Project was initiated soon after the policy was reinstated by President George W. Bush in January 2001. While the missions of the collaborating organizations are diverse, we are united in our belief that policies governing U.S. assistance should be evidence-based and reflect proven public health practices.” Since much of the concern about AIDS revolves around sex, this restriction impacts much of the vaunted AIDS funding also.

Since there are many who support this rule because they are opposed to abortion, it is critical that the data supplied by those at www.globalgagrule.org and others, such as that of physician Isaiah Ndong, on the blog RH Reality Check (http://www.rhrealitycheck.org/blog/2008/12/22/the-time-lift-global-gag-rule-is-now) are so important. These rules restrict information, about sex, safe sex, contraception, and, yes abortion. The result of the restriction of such information is that there is just as much (perhaps more) sex, more unsafe sex, less contraception – and no less, perhaps more, abortion. But the abortions are more unsafe, especially in countries in which, often influenced by the US, it is illegal. This is true not only in the Third World, but in the US and Europe – restricting access to abortion, and making it illegal does not make women have fewer abortions, it makes them have less safe abortions, and makes more of them die. This may not be what abortion opponents want to happen, but it is what does happen. And when funds are stripped for educational programs, again in the US as well as in the Third World, young people do not have less sex, but they have less-safe sex, and are more likely to contract and transmit STIs, including HIV. And they have more abortions.

The USAID funds available for HIV/AIDS, lauded by the Times, are also tied to “abstinence only” educational programs, similar to those supported domestically by the Bush administration. These programs, which hope to decrease STIs including HIV, and unwanted pregnancy (and thus, presumably, abortion) by teaching ONLY abstinence, are abysmal failures in every venue. Teaching abstinence as one, perhaps the best, method of not getting pregnant or sick, is a good idea; teaching only abstinence is cynical and disastrous. Other wishful-thinking-with-terrible-results ideas include “virginity pledges”; another study was just published describing its failure (from the abstract, bold mine): “Five years after the pledge, 82% of pledgers denied having ever pledged. Pledgers and matched nonpledgers did not differ in premarital sex, sexually transmitted diseases, and anal and oral sex variables. Pledgers had 0.1 fewer past-year partners but did not differ in lifetime sexual partners and age of first sex. Fewer pledgers than matched nonpledgers used birth control and condoms in the past year and birth control at last sex.” [i] A recent publication in the US demonstrates that People – including young people – will have sex, and will get pregnant, and will often seek abortions. There are only two things that have ever helped to decrease this are 1) comprehensive and accurate sex education, which at best empowers young people to only have sex when they want to and are ready, or at least provides them with the information to protect themselves, and 2) freely available safe abortion, so women do not die of septic abortion.

Finally, the ultimate irony. The factor most associated with economic and social development in a country is the educational level of its women. In many third-world countries women struggle against enormous barriers to achieve education. Unfortunately, it is often costly and often the only avenue open to earning money is prostitution. So our policies, rather than encouraging and supporting education of girls and women, make it likely that, should they get pregnant, they will either have to end their education, or risk their life having an unsafe abortion, or get HIV. Or all of them.

We can do better. We must do better.
[i] Rosenbaum JE, “Patient teenagers? A comparison of the sexual behavior of virginity pledgers and matched nonpledgers”, Pediatrics. 2009 Jan;123(1):e110-20.

Thursday, January 8, 2009

Sanjay Gupta for Surgeon General?

I feel compelled to post this message from Physicians for a National Health Program.
Goodness gracious! A health reporter? With the recycling of so many questionable-to-bad Clintonites, why not take the best -- David Satcher?

"The report this week that President-elect Obama is considering Dr. Sanjay Gupta, CNN's chief medical correspondent, for the position of U.S. surgeon general is deeply troubling.
Among our concerns are these:
He has very little background in public health, preventive medicine or administration.
He has openly opposed progressive health reform, going so far as to cite false information to denigrate single payer (e.g. in his error-laden attack on Michael Moore's film "Sicko") and parroting the health insurance lobby's distortions of single payer.
As a media figure, he has been disturbingly cozy with Big Pharma. He co-hosts Turner Private Networks' monthly show "Accent Health," which airs in doctors' offices around the country and which serves as a major conduit for targeted ads from the drug companies. Another example: In 2003, despite mounting evidence to the contrary, he publicly downplayed concerns about the dangers of Vioxx. It was removed from the market a year later by its manufacturer, Merck.
In the 2008 election campaign, his reporting on John McCain's health proposals was misleading and implicitly positive, giving undeserved credence to McCain's claims that buying private health insurance on the open market is a financially viable option for most Americans.
We urge you to write to President-elect Obama and express your opposition to Gupta's possible nomination, and to urge Obama to nominate a more acceptable candidate for this critically important post. You can do so by clicking here: http://salsa.democracyinaction.org/dia/track.jsp?v=2&c=VQcr%2B9YPm7HVdjzAicv%2FgKcrNJ24hBg4."

Tuesday, January 6, 2009

Enthoven: Consumer Choice Health Plan -- Again

An Op-Ed in the New York Times of December 28, 2008 by Alain Enthoven, Professor of Management at Stanford, brought back memories of his “Consumer Choice Health Plan” published in the New England Journal of Medicine in 1978[1] and brought back in 1989.[2] In this current piece, Prof. Enthoven cites a plethora of problems with the health system that are not likely to be addressed by the current Obama health plan. These include having ”…a health care system that regularly rewards waste and punishes efficiency…”, that we are weak on and do not reimburse for preventive services, and a fragmented, unintegrated system of care. He also notes the cost to the federal budget of more than $1 trillion, citing not only the direct costs (Medicare, Medicaid, federal employee benefits, military, VA) but ”…the cost of excluding employer health contributions from workers’ taxable incomes”. Woolhandler and Himmelstein have demonstrated in a number of studies (extensive references) that this amount, plus the amount spent by states and local governments, is not only nearly 60% of US healthcare spending, but exceeds the amounts spent per capita by all other countries. (Thus, they note, we are paying for a national health system, but not getting it!)[3]

Unfortunately, Enthoven’s solution is to bring back out his same plan. There is nothing wrong with having the same ideas in 2008 as in 1978 and 1989 – single payer, for example, was a good idea at those times and remains so. The problem is that the Consumer Choice Health Plan was a bad idea then and remains so. It advocates efficiency, large group practices, physicians working for salary instead of fee-for-service, preventive care and cost-conscious behavior. However, it seeks to achieve it by a complex system based, essentially, on making patients pay for a larger percent of their health insurance premiums, which will incent them to insist on cost-effective, efficient practices. This concept is heavily based on the idea that it is the doctors’ fault that the system is bad. In talking about the “85 percent of doctors [who] work in small, fee-for-service practices, he is willing to admit that “Many of these doctors are very good and hard-working.” Not even “most”. But they are also “…unable and unwilling to be held accountable for the quality and cost of the care they deliver.” Unable perhaps; the system does not encourage this, and frequently does not make it possible, but “unwilling”? Based on what? Moreover, employees have been having their health benefits cut back dramatically over the last several years, bearing larger and larger percentages of the cost and this has not resulted in increased competition, increased efficiency, or increased quality. Mostly it has resulted in fewer people being able to afford, and thus having, insurance.

I agree that we need a health system in the US that encourages and rewards quality care, that increases communication and sharing of information, that fosters the development and implementation of system-based practices. But there is no reason to think that Prof. Enthoven’s plan will result in such a system, much less is a good way to get there. It does not address the issue of the uninsured, the fastest-growing part of our population. He makes it seem that most employees have generous health plans, while the fact is that they don’t, and even those who have – notably employees of large car manufacturers such as GM and of state governments (he cites Wisconsin and California) are having great cuts to their benefits.

As noted by Schiff, et. al. in 1994[4], lack of access is the greatest quality deficit, and Enthoven’s plan does not even begin to address this. We need a comprehensive health insurance plan, preferably a single-payer plan such as an expanded Medicare-for-all as called for in HR 676, so that everyone is covered and can get access to the health care that they need. Only then do plans to increase quality, efficiency, and cost-effectiveness make sense. Otherwise such consumer directed health plans are, in Woolhandler and Himmelstein’s words “except for the healthy and wealthy, unwise”.[5] My in my Christmas Day (Dec 25) post I discussed a funding situation that makes hospitals and other health care institutions pursue some (profitable) “product lines” and not others demonstrates this insanity. Why should the diseases some people have be “profitable” and some “unprofitable” resulting in inadequate or unavailable care? Why should care for some people be profitable or unprofitable?The only solution is to develop a system where everyone is covered, where access to care is based upon health needs, where the payment system doesn’t perversely encourage treatment rather than prevention, or intervention rather than waiting, or high-cost drugs rather than low-cost, or care for some conditions rather than others of equal or greater health risk/benefit.
[1] Enthoven AC, Consumer-Choice health plan. A national-health-insurance proposal based on regulated competition in the private sector (two parts), NEJM 1978 Mar 23;298(12):650-658 and 1978 Mar 30;298(13):709-720
[2] Enthoven A, Kronick R, A consumer-choice health plan for the 1990s. Universal health insurance in a system designed to promote quality and economy (two parts), NEJM 1989 Jan 5;320(1):29-37 and 1989 Jan12;320(2):94-101
[3] Woolhandler S, Himmelstein DU, “Paying for national health insurance – and not getting it.” Health Aff (Millwood) 2002 Jul-Aug;21(4):88-98.
[4] Schiff GD, Bindman AB, Brennan TA “A better-quality alternative. Single payer national health system reform. JAMA 1994 Sep 14;272(10)803-8.
[5] Woolhandler S, Himmelstein DU, “Consumer directed healthcare: except for the healthy and wealthy it’s unwise”, J Gen Int Med 2007 Jun;22(6):879-881.

Friday, January 2, 2009

Student Debt, Resident Hours, and Primary Care Redux

HAPPY NEW YEAR! May 2009 be a big improvement!

The December 18, 2008 issue of the New England Journal of Medicine includes Perspectives on 3 topics that have been previously addressed on this blog: Medical student debt (Dec 14), resident duty-hours (Dec 3, 9), and the future of primary care (Dec 11).

The piece on “Medical Student Debt – Is there a Limit?” by Robert Steinbrook presents data on the extraordinary rise in tuition, and debt, among medical students, most surprisingly in the public medical schools. “For the current academic year, tuition, fees, and health insurance at private medical schools range from $15,278 (for Texas residents) or $28,378 (for non-residents) at Baylor University to $51,969 at Tufts University in Massachusetts and $52,236 at Temple University (for nonresidents of Pennsylvania – state residents are charged at $43,232.” While tuition rates at private medical schools are generally higher than at public, the non-resident tuition at public schools is about the same as that of the privates, and the rate of rise (percent change) in the last 10 years at public schools has far exceeded that at private schools (100% vs 50% increase). Indebtedness ranged from an average (high is different) of $80,000 to $163,000 at public schools, and $70,000 to $182,000 at private schools. Some schools give significant tuition scholarships, but others are more challenged: Stanford’s endowment allows it to give a far larger number of scholarships relative to loans than does, say Drexel. More important, the article points out that the high debt burden may discourage lower-income students from applying to medical school, and to enter specialties with higher income potentials. “It is not surprising that a recent analysis showed a ‘strong direct correlation’ between higher mean salary in a specialty, such as orthopedic surgery or radiology, and the percentage of residency positions filled by US graduates.” The piece says that there is no easy solution, and probably there is not. But most countries have very low medical school tuitions, but require national service of their graduates.

Revisiting Duty Hour Limits – IOM Recommendations for patient safety and resident education” by John Iglehart, discusses that topic in a balanced way. It points out the acknowledgment in the IOM report that “Although some might propose further reductions in total duty hours, the report notes, ‘evidence suggests it is an indirect and inefficient approach given the moderate correlation that exists between resident duty hours and sleep time.’” Igelhart also notes that “the 2003 limits on duty hours have resulted in an increase in handoffs of patient care between physicians – transitions associated with increased risks to patient safety.” I have discussed this at length, but I did note that this article includes a table with a recommendation I had missed – that internal and external moonlight be counted against the 80-hour per week limits. I have no difficulty with that conceptually, as it makes perfect sense – what is the point of limiting work hours in the residency if residents can moonlight for extra money in an unrestricted fashion? – but I wonder about the legal ability of program directors to restrict the moonlighting activities of their residents in their off hours.

The Future of Primary Care – the Community Responds” involves a followup to a series of opinion pieces and a roundtable discussion with Drs. Thomas Bodenheimer, Barbara Starfield, Katharine Treadway, Allan Goroll, and Thomas H. Lee that appeared in the November 13, 2008 issue. The comments, and responses from the roundtable participants, are salient and generally useful. Several writers noted the role of physician assistants, and one (Paul Lombardo) states that “Patients, and the U.S. health care system as a whole, would be better served if the content of and level of primary care education were better matched to the needs of patients. The physician assistant (PA) model of medical education, with its emphasis on physician-physician assistant teams, needs to be expanded.”

These are all thorny, and not unrelated, issues. What is the relationship between resident work hours and physician’s assistants? Well, someone has to do the work. Since residents, even with the 80-hour restriction, work twice as many hours as do physician’s assistants, for about half the salary, and have a greater scope of practice, it would be incredibly expensive for hospitals to replace resident labor with that of physician’s assistants, not to mention physicians. As hospitals complain about the “cost” of resident education, this needs to be kept in mind; they are much better at accounting the cost than the benefit. Even if a hospital closes its residencies because it assesses the costs are greater than the benefit, this usually includes the fact that the residents care for many medically indigent patients, and you can be sure that the hospitals are planning to no longer care for them at all, not to pay someone else to do it. This, of course, again decreases access for the most needy.

I have repeatedly said that the nucleus of a solution is a comprehensive national health program, which includes a single-payer and a system that is tasked with ensuring the health and access to quality health care of all Americans. With such a system, addressing issues such as resident work hours, medical student debt, and the composition of the physician (and NP and physician assistant) workforce could be feasible; without it, they all remain insoluble because they all depend upon each other.

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