Primary Care Shortage makes Times Front Page

On April 27, 2009 the New York Times ran a page 1, right-column piece entitled “Shortage of Doctors Proves Obstacle to Obama Goals” by Robert Pear.[1] This is very interesting in part because this position in the paper is reserved for the most important news of the day; it must have been a slow news day, because this is not news. For example, it has been addressed several times on this blog alone, including most recently in the guest piece by Dr. Patrick Dowling, “The basic law of modern health care” (4/22/09), my own piece “More primary care doctors or just more doctors?” (Apr 3, 2009), “The ten biggest myths regarding primary care in the future” by Dr. Robert Bowman (Jan 15, 2009)and as far back as Dec 11, 2008 (“A quality health system needs more primary care physicians”). So, yes, it is a big problem. However, the comments in Mr. Pear’s articles only sometimes refer to primary care, and sometimes to all doctors, thus confusing the issue. The President says, quite clearly, “We’re not producing enough primary care physicians…The costs of medical education are so high that people feel that they’ve got to specialize.” But Senator Orrin Hatch of Utah is quoted as saying “The work force shortage is reaching crisis proportion,” not clearly about primary care, and Rep. Shelley Berkley includes both: “We don’t have enough doctors in primary care or in any specialty.”

With respect to Rep. Berkley, this last statement is clearly wrong. While, depending upon how we measure it (again see “More primary care doctors or just more doctors?, Apr 3, to see my discussion of Dr. Richard Cooper’s analysis), there may be shortages in some non-primary care specialties, we have plenty of doctors in many others. Probably too many in some. There is an issue of distribution; most doctors are heavily concentrated around major cities and their suburbs and do not “distribute” based upon where the population is located. (Family medicine is the notable exception, as these doctors do distribute to where people are.) It may be politic to say “…or in any specialty” but it does a tremendous disservice to efforts to address the problem. While new medical schools are opening, and others are increasing their class sizes to produce more physicians, there is no evidence that this will increase the number of students choosing family medicine or other primary care specialties. As the article notes (and this blog has described), “Doctors trained in internal medicine have historically been seen as a major source of primary care. But many [correction: most!] of them are now going into subspecialties of internal medicine, like cardiology and oncology.” Even osteopathic medical schools, long high producers of primary care, have been confronting a major movement of their graduates into subspecialty careers.

The economic incentives go the wrong way. According to the Times article, “Senator Max Baucus, a Montana Democrat and chairman of the Finance Committee, said Medicare payments were skewed against primary care doctors...`Primary care doctors are grossly underpaid compared with many specialists’.”
He is proposing an increase in payments to primary care physicians, as is the Medicare Payment Advisory Commission (MedPAC). However, MedPAC feels that “To offset the cost…Congress should reduce payments for other services, an idea that riles many specialists”.

You betcha. “We have no problem with financial incentives for prmary care,” says Dr. Peter J. Mandell of the American Association of Orthopaedic Surgeons, but “We do have a problem with doing it in a budget neutral way”. Because their income will go down. Dr. Mandell states that “If there’s less money for hip and knee replacements, fewer of them will be done for people who need them.” Maybe, but I doubt it. The reimbursement for these procedures could drop a great deal and the surgeons would still be making plenty of money on them, so they will probably not stop doing them.

So there is a great shortage of family physicians and other primary care providers. Something has to be done. One way is to increase the reimbursement of these physicians by Medicare, which will result in other insurers following suit. This can be done in a budget-neutral way, or even in a money-saving way depending upon how much is cut from specialist reimbursement. A way to do this is to only pay for procedures for which there is strong evidence of benefit. Given the current economic situation, the cost of health care, and the enormous incomes of some specialists, it is almost certain that there is no possibility that specialist reimbursement will not decrease, whether or not primary care payments are increased.

Another way to increase the number of students entering primary care is to repay their loans. The Times says that “new doctors typically owe more than $140,000 when they graduate”, and it is frequently much more, even $250,000 for those attending private schools (or public schools as out-of-state students, where the tuition is as high as at private schools) who do not come from wealthy families. This sort of loan repayment is currently done by the National Health Service Corps and the military, but there are not enough positions in the NHSC to supply the nation’s civilian primary care needs. Such programs must be expanded. The Obama administration is continuing the Bush administration’s policy of expanded funding for Community Health Centers, but there are not enough doctors and nurses to fill the positions in primary care.

We need to have a two-pronged effort, to cover everyone in a way that provides quality health care in a cost effective manner (single payer) and incentives for students to enter the specialties of greatest need, primary care and especially family medicine.
Of course, if we continue to hear stuff like Sen. Baucus saying: “Everything BUT single payer is on the table. Single payer if off the table” and Speaker Pelosi: "In our caucus, over and over again, we hear single payer, single payer, single payer. Well, it's not going to be a single payer," we can be pretty sure single payer won’t happen. We’ll get a plan that won’t work and will cost a lot. But maybe we can take heart in Churchill’s optimistic assessment of the American people: “You can always count on Americans to do the right thing—after they’ve tried everything else.”

[1] Pear R, “Shortage of doctors proves obstacle to Obama goals”, NY Times Apr 27 2009.

The Social Ethic and Covering Everyone: Reinhardt and Himmelstein

Don McCanne, MD, provides a widely-read information service and commentary called “Quote of the Day”. It is distributed by listserve, but is also available through the PNHP website (http://www.pnhp.org/), a link to which is on the left side of this blog. On a couple of occasions, Dr. McCanne has been kind enough to pick up quotes from this blog. Today I would like to call attention to two recent “QOTD”s and to the testimony before Congress that they cover. On April 22, Dr. McCanne noted the testimony of Uwe Reinhardt, PhD, the Princeton University health economist, before the House Committee on Ways and Means, and on April 23, the testimony of David Himmelstein, MD, from the Harvard Medical School and national spokesperson for PNHP, before the House Committee on Education and Labor’s subcommittee on Health, Employment, Labor, and Pensions. Both of these testimonies are required reading, but I wanted to select a few items to feature here.

In his Introduction, Dr. Reinhardt defines the functions of a modern health-care system, which he categorizes as Financing, Pooling Risks, Purchasing, Producing, and Regulating, and he systematically addresses the first three in his testimony. He addresses the “Social Goals of Health Systems” and notes that “Most industrialized nations in the OECD, along with Taiwan, seek to operate their health systems on the Principle of Social Solidarity [which] means to them that health care is to be viewed as a so-called ‘social good’, like elementary and secondary education in the United States….” but that “…Unfortunately the United States never has been able to evolve a widely shared consensus on the distributive social ethic that out to govern the US health system. The bewildering American health system reflects that lack of consensus.” He addresses not only the bewildering health system, but the bewildering and frequently self-contradictory nature of US ideological beliefs:

“the same citizens and politicians who look askance at 'socialized medicine' reserve the purest form of socialized medicine – the VA health system – for the nation’s allegedly much admired veterans. [and, I might add, the military itself!] A foreigner may be forgiven for finding this cognitive dissonance bizarre.

"Similarly, there are many Americans, who believe that government does not have the right to impose on them a mandate to have health insurance, all the while considering it their moral right as Americans to receive even horrendously expensive tertiary health care in case of critical need, even if the recipients have no hope of financing that care with their own resources. Foreigners may be forgiven for shaking their heads at this immature and asocial entitlements mentality, which would be rare in their home countries.”

It would be wonderful if people would “own” the implications of their ideological positions, if, for example, the NRA would say “Yes, 30,000 excess gun deaths per year in the US is bad, but it is a price worth paying for the right to keep and bear arms.” They won’t, and neither will be health ideologues.

Dr. Reinhardt then follows his Introduction with an extensive discussion of the health insurance market and forces governing it, and makes a strong argument for the benefits of a “public option”, such as has previously been advocated by President Obama when he was a candidate.

Dr. Himmelstein’s testimony addresses, in part, the flaws of offering such a “public option”, and makes the case for a single-payer system. He notes research that 75% of those who went into bankruptcy as a result of medical costs (about 50% of all personal bankruptcies) were insured. He points to massive savings of eliminating reimbursement bureaucracy, to the tune of about $120 billion for hospitals and $95 billion for doctors, under a single payer system. However, he notes that:

“Unfortunately, these massive potential savings on bureaucracy can only be achieved through a single payer reform. A health reform plan that includes a public plan option might realize some savings on insurance overhead. However, as long as multiple private plans coexist with the public plan, hospitals and doctors would have to maintain their costly billing and internal cost tracking apparatus. Indeed, my colleagues and I estimate that even if half of all privately insured Americans switched to a public plan with overhead at Medicare’s level, the administrative savings would amount to only 9% of the savings under single payer.”

9%! Why go with a “reform” that leaves over 90% of potential savings on the table?

Himmelstein goes on to note that
“While administrative savings from a reform that includes a Medicare-like public plan option are modest, at least they’re real. In contrast, other widely touted cost control measures are completely illusory. A raft of studies shows that prevention saves lives, but usually costs money. The recently-completed Medicare demonstration project found no cost savings from chronic disease management programs. And the claim that computers will save money is based on pure conjecture. Indeed, in a study of 3000 U.S. hospitals that my colleagues and I have recently completed, the most computerized hospitals had, if anything, slightly higher costs.”

He also addresses the popular (among pundits, not people!) “mandate” method of requiring everyone to buy health insurance, as has been done in Massachusetts. I have previously addressed how the lack of primary care providers makes the “universal” system in Massachusetts untenable (Dec 11) and how forcing everyone to purchase health insurance from them is the preferred “solution” for the insurance industry (Apr 5). Himmelstein clearly demonstrates that this is not a solution:

“My home state of Massachusetts’ recent experience with health reform illustrates the dangers of believing overly optimistic cost control claims. Before its passage, the reform’s backers made many of the same claims for savings that we’re hearing today in Washington. Prevention, disease management, computers, and a health insurance exchange were supposed to make reform affordable. Instead, costs have skyrocketed, rising 23% between 2005 and 2007, and the insurance exchange adds 4% for its own administrative costs on top of the already high overhead charged by private insurers. As a result, one in five Massachusetts residents went without care last year because they couldn’t afford it. Hundreds of thousands remain uninsured, and the state has drained money from safety net hospitals and clinics to kept the reform afloat.”

We can keep it up. We can pretend, incorrectly as Reinhardt notes, that we all want the same thing. We do not. Insurance companies want big profits. Politicians want contributions from insurance companies. We the people want everyone to have access to high quality health care at a cost that is affordable to us all. So far, a single payer system is the one way that has been suggested to do that.

The “Basic Law of Modern Health Care”

Slate recently ran an article in which they noted that the most “radical” health reform (single payer) is also the most fiscally conservative.[1] After showing a graph that indicated health insurance premiums have increased 6 times that of wages between 1999 and 2008. The author, Timothy Noah, notes that “Whatever pay increases the average worker received were wiped out, and then some, by the rapidly growing amounts deducted from his paycheck to cover health insurance. That's assuming he was lucky enough to be among the 59% of the U.S. population that received employment-based health insurance… These calculations don't take into account the rising cost of actually using ever-pricier health coverage. During the same period, deductibles tripled.” Noah goes through a study by the Lewin Group[2] on the cost of care and probable savings from a “public option”, as well as pointing out that the obstacle is in its very savings – the savings will come largely from loss of profit by insurance companies, which will oppose any effort to implement it. Noah concludes “For the true spending hawk, I see no practical alternative to the "socialist" public option.” The New York Times recently had a brief article in which former Democratic house leader Dick Gephardt cautioned that Obama must first enact cost savings reforms in the health care delivery system before anything close to universal or near universal coverage will pass congress.[3]

In a commentary shared with his colleagues in the Association of Departments of Family Medicine (ADFM), Patrick Dowling, MD MPH, Chair of the Department of Family Medicine at UCLA and a leader in health policy, both of these articles are “…tip-toeing around the basic cost problem of the delivery system.” Dr. Dowling goes on:

At some point a person of influence (how about Warren Buffet?) is going to discover The Basic Law of Modern Health Care which is, of course:
“A cost effective high quality health care system for all cannot be achieved without a well trained and numerically adequate primary care physician infrastructure, geographically dispersed according to need, working in concert an addressing biopsychosocial issues with an adequate number of subspecialty consultants dispersed as needed.”

This of course cannot be achieved until one addresses the perverse incentives of how physicians are paid. Since we do not at present have an adequate primary care infrastructure, the situation is only going to get worse as the number of US medical graduates going into Family Medicine or General Internal Medicine continues to slide just as the number of baby boomer patients hit Medicare followed by expanding waist lines and chronic disease, and the huge number of baby boomer doctors retire or expire. Let’s face it: our health care delivery system is basically modeled on the bloated General Motors approach. Providing everyone with a GM truck or car is not going to solve the transportation, energy or global warming issues in this country. As such, even if the political capital existed to pass a single payer in the US today, I would argue it could not be implemented cost effectively because we do not have a sufficient number of primary care physicians, unlike Canada in which 52 % of the physician workforce are family doctors.

We need to get this point across. Perhaps we should rename family medicine as “Honda” or “Costco” because family doctors produce high quality accessible goods at a fair price!

I do not know if it should be called “Honda” or “Costco”, but Slate and Dr. Dowling are absolutely correct in pointing out that the ability of our country to provide cost-effective care depends on two things:
1. Developing a system that controls costs and thus cannot build in outrageous overhead and profits. This is why a universal care system, which we absolutely need, has to have a public “option”, if not (preferably) a completely public single-payer system.
2. Develop the necessary primary care infrastructure to provide high-quality, lower-cost care. This means incentives (or removal of disincentives) for physicans and students to enter primary care.

At the present time, there is a lot of talk, but no action. From Warren Buffett or from our elected leaders, like President Obama. The people support this change, and if the President were to get out front and lead on the issue, the clamor of enthusiasm from the American people would drive the insurance company lobbyists into quick retreat.

[1] Noah T, “Against Consensus: Why the most politically radical health care solution is also the most fiscally conservative,” Slate, April 10, 2009, http://www.slate.com/id/2215825/
[2] Sheils J, Haught R, Staff working paper #4, “The Cost and Coverage Impacts of a Public Plan: Alternative Design Options”, the Lewin Group, Falls Church, VA. http://www.lewin.com/content/publications/LewinCostandCoverageImpactsofPublicPlan-Alternative%20DesignOptions.pdf
[3] “The caucus – Health care cautions, from one who knows”, NY Times, April 13, 2009, www.nytimes.com/2009/04/13/us/politics/13caucus.html

Medical Ethics and Social Justice

In a recent JAMA Commentary[1], Darrell Kirch, MD, President of the Association of American Medical Colleges (AAMC) and his colleague David J. Vernon, speak about the “Ethical foundation of American medicine”. They discuss the 4 traditional components of medical ethics: beneficence (do the right thing, or “provide good care”), nonmaleficence (don’t do the wrong thing, “do no harm”), respect for autonomy, and justice. They note that the first two have been the most emphasized in medical ethics and “are foremost in the minds of physicians”. In general, these two are the most obvious ones individual patients, as well as society, would desire to have done, although they can sometimes be very complex and lead to difficult decisions when the line between “do the right thing” and “don’t do the wrong thing” is not perfectly clear.

The authors briefly address respect for autonomy, noting that this includes physician, as well as patient, autonomy, discussing the fact that physicians have “delegated authority” from society, which confers them privileges in return for their using “…their best informed judgment when caring for individuals who need assistance…”. They express significant concern about the degree of physician autonomy in a market-driven system, where “fiscal independence” and the “right to enhance physician revenues” seem to “…have become as important as autonomous decision making in practice…” The result of this, they fear, is that “…attention to social justice [the fourth tenet of medical ethics] may be decreased.” It is this tenet, social justice, to which they dedicate the remainder of their discussion.

They cite Rawls’ theory of justice[2] [3], “often referred to as social justice” as a dominant theory of justice. The two components of this theory, which are also core to the content of this blog, are:

· “People should have maximal liberty compatible with the same degree of liberty for everyone” and
· “Deliberate inequalities are unjust unless they work to the advantage of the least well off.”

Wow. What concepts! The first states that your liberty does not allow you to hurt me, and the second that policies of justice must work to the benefit of the least well off. This is, of course, completely opposite to the trends of the last many years in the US, where the intent of policy has been to be to the advantage of the most well off. This concept is applicable far beyond medicine, prominently including legislative / governmental policy, based on the idea that socially (that is, in addition to issues such as providing for the common defense) the role of government should be to help those most, rather than least in need. The presumption is that those who are “most well off”, are, well, most well off, and least in need of help from the rest of society. Similarly, in regard to health care, it is those who have the least resources – to purchase medication, to take time off from work to see a doctor, to have the most dangerous jobs, to have no job, to have inadequate food or housing – who have the greatest need. Yet, in both cases, governmental and medical, we have not followed this precept; governmentally, it is those with the loudest voices and the most money who have the ears, and service from, government (problem: poor people just don’t contribute enough to politicians!); medically, the greatest resources go to those who have the best insurance, often not those with the greatest need.

Kirch and Vernon look at the difficulties that inhibit physician pursuit of the goals of social justice. They note 3 “interrelated” factors:

“Fundamental human behavior. Physicians, like most individuals, seek and compete for opportunities within their current circumstance to create the best life possible for them and their families.” This means that, while they will (hopefully) offer the best care to their individual patients, they may look first to making more money than expanding to Medicare, Medicaid, or self-pay patients. They observe that the flaw here is that “…for each of the physicians who decide they can no longer care for these patients, the responsibility falls to another clinician.” Perhaps, but that clinician may be in the ER when the patient presents with far-advanced disease because no one in the community will see him/her. (Plus I am always leery of phrases like “fundamental human behavior” and “it’s human nature”; like “I’m sure I speak for all of us when I say…”, there are almost always exceptions!)

Medical student debt. This means not only that students have to make a lot of money to pay it back, but that the socioeconomic background of those going to medical school may become even more imbalanced than it already is (they say “…more than 75% of medical students came from families the top 2 quintiles of family income…”). Facing this debt, maybe those from non-wealthy families will seek other careers.

The US culture of “individualism”. “Specifically regarding health care, many other western nations have some form of universal coverage supported by their government and treat health care as a public good.” Right. And so could we. Especially as we not only spend far more money per capita on health care than any of them, but we actually spend more public money (Medicare, Medicaid, federal, state and local employees, military, VA, and the taxes lost because employer contributions to health insurance are tax deductible) per capita than any other country!

They worry that “…the emphasis on individual responsibility may be deepening,…” citing a study by Lee, et.al. that showed that “…the percentage of Americans who agree that the high the income, the more the individual should expect to pay in taxes to cover the cost of care for individuals who are less well off decreased from 66% in 1991 to 51% in 2003 and to 39% in 2006.”[4] However, this is one study, focusing on the highest cost drugs; study after study has shown that a majority of Americans see the need for a universal health care system and are willing to pay more taxes to achieve it.[5] A majority of physicians support national health insurance.[6] Although, I again note, the taxes for most people would be more than offset by not having to pay for health insurance. And the number of people who have no insurance, inadequate insurance (high deductible, low maximum limit, excluded conditions), sporadic insurance, or think they were insured but still find themselves financially ruined by disease treatment costs – and people who know, work with, and are related to them and thus feel their pain – grows every year.

The 4 principles of ethics are all important, but the emphasis on social justice, in this time and place, is critical. Kirch and Vernon conclude:

“Physicians have a responsibility to ask and answer these difficult questions that are properly viewed as not simply involving politics, but rather as speaking to fundamental medical ethics. The answers in turn may well require personal sacrifices (eg, accepting a lower level of income), professional group action (eg, advocating as much for health care system improvements as current advocacy for the preservation of specialty reimbursement levels), and a commitment to work within the political process (that goes beyond lobbying for maintenance of the status quo). These efforts and corresponding sacrifices are necessary first steps toward creating a society in which everyone has access to appropriate health care.”

Amen. I would add that it is also critical that in medicine, and in medical education, that these are not issues relegated only to special courses in “medical ethics” but are rather core values informing all of what we do.
[1] Kirch DG, Vernon DJ, “The ethical foundation of American medicine: in search of social justice”, JAMA 8Apr2009; 301(14):1482-4.
[2] Rawls J. A Theory of Justice. Cambridge, Massachusetts: Belknap Press of Harvard University Press, 1971. Revised edition 1999.
[3] Gillon R. Justice and medical ethics. Fr Med J (Clin Res Ed). 1985;291(6489):201-202 (This is the reference the authors cite for their discussion of Rawls’ theory of justice)
[4] Lee TH, Emanuel EJ, “Tier 4 drugs and the fraying of the social compact”, NEJM 2008;359(4):333-5.
[5] CNN Poll, May 4-6, 2007, http://i.a.cnn.net/cnn/2007/images/05/09/rel6e.pdf, Question #30, accessed 4/15/09
[6] Carroll AE, Ackerman RT, “Support for national health insurance among US physicians: 5 years later”, Ann Int Med 1Apr2008;148(7):565-7.

Conscientious Objection in Medicine

Julie Cantor, MD JD, has a Commentary in the New England Journal of Medicine, April 9, 2009, titled “Conscientious objection gone awry – restoring selfless professionalism in medicine”,[1] in which she discusses the aggressive content and insidious effect of the “conscious” laws and the more extensive impact of Department of Health and Human Services (DHHS) regulations put into effect in the last months of the Bush administration. Current laws protect providers from being forced to be involved in the performance of abortion or sterilization. If hospitals or other agencies receive federal funds, people cannot be discriminated against for failing to perform, discuss, or refer patients for abortion. “On their face, these laws are quite broad. But the Bush administration’s rule is broader still. It restates existing laws and exploits ambiguities in them”, in ways which will definitely limit patients’ access to health care. “Now everyone connected to health care may opt out of a wide range of activities, from discussions about birth control to referrals for vaccination. As the rule explains, ‘an employee whose task it is to clean the instruments used in a particular procedure would also be considered to assist in the performance of the particular procedure,’ and would therefore be protected. Taken to its logical extreme, the rules could cause health care to grind to a halt.”

Is Dr. Cantor overstating the issue? I don’t think so. The goal of these regulations is to eliminate – by creating as many barriers as possible – abortion, and while they are at it sterilization or anything else that these policy makers and their supporters oppose. It is not really at all to worry about the implications for patient care, or the way that these rules could be interpreted to restrict access to all sorts of care. The rule, Dr. Cantor points out, “…sidesteps courts, which interpret statutory ambiguity and discern congressional intent…” by offering “…sweeping definitions. It defines ‘individual’ as physicians, other health care providers, hospitals, laboratories and insurance companies, as well as ‘employees, volunteers, trainees, contractors and other persons’ who work for an entity that receives DHHS funds”. She also notes that the regulation conflicts with other existing federal law, Title VII of the Civil Rights Act, “…which requires balancing reasonable accommodations for employees who have religious, moral, or ethical objections to certain aspects of their jobs with undue hardship for employers.” The regulation goes MUCH farther, putting the entire responsibility of accommodation on the employer (“ …if an employee objects, for example, to being a scrub nurse during operative treatment for an ectopic pregnancy, subsequently reassigning that employee to a different department may constitute unlawful discrimination….”) But, if we understand that the goal of the regulations is not to protect the employee’s moral objections but to put as many obstacles as possible in the way of anyone doing anything that, while legal, these regulators object to, it is completely understandable.

My remembrance of “conscientious objection” goes back to when there was a military draft and draftees could petition for an exemption based on their religious, ethical or moral objections to killing and war. It was not that easy; long-time members of recognized “peace churches” such as the Quakers had a much easier time making the case than people whose objections were not based in formal religion. And a case had to be made. And the military could reject the petition. In addition, a “mid-range” classification (I-A-O) existed between I-A (draftable) and I-O (conscientious objector), which allowed the individual to be drafted and serve in war, but not be required to kill; many medics came from the I-A-O group. The remarkable difference is that the current “conscientious objector” regulations are both far more sweeping in their “protections” of an individual’s “conscience” and yet require far less investigation – indeed, none – all a person has to do to enjoy all these protections is assert them. Imagine if that had been the case for conscientious objectors in the Vietnam era! Thus, it is clear that the rules are never what the rules say they are about; in the era of the draft it was to get as many young men drafted as possible; in this era it is to block abortions, sterilizations, provision of birth control and other “objectionable” (to someone) procedures as possible.

When these regulations went into place to “protect” pharmacists with such objections from having to dispense emergency (or sometimes any) contraception, access to these legal, and even over-the-counter medications were severely restricted in many communities. There was a “joke” that went around the internet “Did you hear about the Christian Scientist pharmacist? He refused to fill any prescriptions!” Funny? Maybe not. While not their intention, these regulations would actually protect him!

This is all complete and utter nonsense. People should not be forced to perform procedures that they morally or ethically (or religiously) object to; current civil rights law more than adequately protects them. Dr. Cantor suggests that people should not enter fields where their beliefs will prevent them from serving their patients:

“As the gatekeepers to medicine, physicians and other health care providers have an obligation to choose specialties that are not moral minefields for them. Qualms about abortion, sterilization and birth control? Do not practice women’s health. Believe that the human body should be buried intact? Do not become a transplant surgeon. Morally opposed to pain medication because your religious beliefs demand suffering at the end of life? Do not train to be an intensivist. Conscience is a burden that belongs to the individual professional; patients should not have to shoulder it.” If you are a Christian Scientist, then do not become a pharmacist.

”Patients,“ Cantor says, “need information, referrals, and treatment. They need all legal choices presented to them in a way that is true to the evidence, not the randomness of individual morality.” I agree with her, but the fact is that the morality is not random, it is agenda-driven. It is not about protecting the moral beliefs of individuals who are providers, but forcing the choices of others, patients, to conform to those beliefs.

Let’s get right to the crux of the matter: abortion. Despite the proclamations of the virulent anti-abortion movement, it is not about life. While many anti-abortion activists are consistent in their pro-life views, opposing war and capital punishment, most are not. And do not support the living, are not advocating for financial support for the food, clothing and education of the born. The issue is about choice, or more properly, self-determination. No one is “pro” abortion. But people on the “pro-choice” side believe that the decision belongs to the individual, always a “her”, with the counsel of those she trusts and whose opinions she values: family, friends, clergy, physicians, etc. It is perfectly possible to be “anti-abortion”, to never have one for oneself and to do one’s best to talk those one cares about and can influence out of having one, but still believe the decision is ultimately that of the pregnant woman. The “anti-choice” side believes that the decision should be theirs, not the woman’s. And that is what this is all about. How can “we” (in this case, the Bush administration) develop policies that force everyone to do what we believe to be right, whether on abortion, sterilization, stem cells, gay rights, or even having sex for other than procreation within marriage?

Yes, the Obama administration needs to repeal these regulations, post-haste and completely. And yes, the Congress needs to change the actual statutes to be consistent and first protect patients, not providers. And yes, people should choose professions and specialties where they can meet the needs of all patients who come to them, not just those who share their beliefs. And yes, laws protecting health care providers from providing services that they see as morally objectionable should never protect them from not giving patients full information and referral for those services. And yes, we need “truth in advertising laws” so that clinics whose goal is to prevent abortion by withholding information and delaying cannot be advertised as “Crisis Pregnancy Centers” but as “No abortion – Keep your Pregnancy! Centers”. And yes, we need to strip the hypocrisy of these regulations and all these efforts, and to end anti-scientific bias.

But most of all, we need to focus on the health care of the patients. On making sure they are fully informed about issues, have resources to further explain them, helping in making informed decisions, and supported in the decisions they make.

[1] Cantor J, “Conscientious objection gone awry – restoring selfless professionalism in medicine”, NEJM 2009Apr9;360(15):1484-5.

Does the nation need a clear policy on a right to basic health care?

At a recent conference, I was asked to be a “thought provocateur” (!!) on the topic “The nation needs a clear policy on the basic right to health care".

This is an interesting question, since my first reaction is: “Of course, we need a clear policy on the basic right to health care! I mean, I have a pretty clear idea of what that policy should be, but certainly even those who would disagree with me would agree that we need a policy!”

But, on reflection, I don’t know that they do. I think that a great deal of the perseverance of our “non-system” of health care has been a result of a consensus among our leaders to NOT talk about this issue, to NOT grapple with it, to not have to take a position one way or another on whether health care is a basic right.

This is because, if one does take a position, there are implications, and things that we would then have to do.

If health care is a basic right, then we need to provide it to everyone. We can no longer diddle around with partial fixes, tinkering around the edges, covering (maybe) children but not their parents, covering people who are poor – as long as they are children and their mothers and are really poor and not working – but not those who are poor, or nearly-poor, depending on which state you are in. Or, for that matter, working-class, or, in increasing numbers, middle class.
But the problem is most people in power, including most politicians including the President, don’t want to have to take a position against health care being a basic right. It sounds, well, mean. There aren’t many people, except, well, mean people (and maybe some reactionary ideologues), who are willing to defend this position.

So we have shows such as “Sick Around America”, the Frontline “sequel” to T.R. Reid’s “Sick Around the World” (which Reid disassociated himself from). It interviewed insurance company executives who said “sure we can insure everyone”. If we make it mandatory and can make a profit everyone. Hmm. The cost would be ridiculous. And the option of single payer was never mentioned. There is a lot more that has to be decided if we agree that health care is a basic right, like how to provide it, how to pay for it, and what will be and will not be covered. I mean, sure, other countries seem to have solved that problem, and we could model a system on one or more of theirs, but where’s the fun in that?

And if we agree that health care is not a basic right, we solve that problem, but we have other ones – like all these uninsured, and underinsured people.

• And folks not getting preventive care but rather incredibly expensive curative care.
• And companies like our automobile companies going bankrupt in some part because of the cost of health insurance.
• And, oh yeah, people dying in the streets.

For the record, I do believe that we need a policy on health care as a basic right, and my belief is that it should be. Perhaps the most important reason is social justice; we all share in the public good. This is what virtually every other nation of the first world has long realized. When T.R. Reid asked the leaders of the countries he visited for “Sick Around the World” how many of their citizens went bankrupt as a result of health care debts, they all said none. The most dramatic response was from the President of the Swiss Confederation, a conservative who had originally opposed the Swiss program in the early 90s. “No one,” he boomed in his French-accented English, “why, it would be a national scandal!”

The health of our society depends upon the health of all of us.

• When people crowd our emergency rooms, not with minor illnesses, but with serious illnesses that could have been prevented with earlier treatment, that is a scandal.
  
• When parents cannot afford their own health care and their illnesses threaten their ability to keep providing for their children, that is a scandal.
  
• When people stay in jobs they hate, or forego the opportunity to start a new business, because they rightfully fear being uninsured, that is a scandal.
  
• When our friends and neighbors, parents and children, only take partial doses of their medicine because it is a choice between that and not eating, that is a scandal.
  
• When a hard-working man with chest pain can see the billboards advertising the superb heart care available at our local hospitals and know they are not meant for him because he is uninsured, that is a scandal.

When we are all in it together, we all have an interest in making the system be as good as it can be. The efforts of those of us who are more educated, more financially able, more vocal, more empowered will ensure that the needs of those who are less able to lobby for themselves are also met.

Just as our nation cannot survive half-slave and half-free, or with only half of adults having the vote, we cannot survive with only some of us having access to health care.

We need to do this for all of us, for, after all, ultimately, we are our brother’s and sister’s keepers.

"Sick Around America": A little bit sickening

Last week I watched “Sick Around America”[1], the PBS show Frontline. I was greatly looking forward to it as the follow-up to the outstanding show “Sick Around the World” that T.R. Reid, a former international correspondent for the Washington Post and Atlantic did last year. “Sick Around the World”[2] had Reid traveling to 5 countries to look at the way that they delivered health care. Carefully chosen to display a variety of approaches to providing health care to everyone, he visited three long-standing systems, the UK (National Health Service), Canada (single-payer), and Germany (a mixed public-private system), and two rather newer ones, Switzerland (early 90s) and Taiwan (early 2000s). In each country, he probed the people he interviewed, usually health ministers, sometimes prime ministers, and health scholars about the strengths and weaknesses of their programs, but in all he received the message that there was a sense of social responsibility and social justice. In each country he asked how many of their citizens went bankrupt as a result of health care debts, and they all said none. The most dramatic response was from the President of the Swiss Confederation, a conservative who had originally opposed the Swiss program in the early 90s. “No one,” he boomed in his French-accented English, “why, it would be a national scandal!”

The lesson from “Sick Around the World” was that there are many approaches to covering everyone, but that there must be an agreement and consensus to do so, a decision every (other) industrialized country has made. I paraphrase his ending: “For the US veteran in the VA system, healthcare is much like in the UK; for the retiree on Medicare it is like in Taiwan; for the employee with insurance, the US experience is much like in Germany; and, for the 40 million uninsured in the US, it is just another third-world country.” So I looked forward to see what Reid would show us in the US in “Sick Around America”.

The first thing that was apparent was the absence of T.R. Reid, which seemed very strange. The show was ok, I guess, following the trials of some people who had difficulty receiving health care (or not); kind of a watered-down version of parts of Michael Moore's Sicko! without the funny or the punch. There were some good points made, particularly around pre-existing conditions and medical underwriting; for example, when the chairman of one of the health insurance companies noted he had to keep his job because, since he had had cardiac surgery, he would not be able to get insurance on the individual market.

The difficulty and cost of getting insurance in that market was one of the big emphases of the program. The other, surprising, thing was how positively the health insurance companies, and their representatives such as Karen Ignagni of America’s Health Insurance Plans (AHIP), the trade group, are portrayed. The clear message was that our health insurance companies could cover everyone, without problems with exclusions for pre-existing conditions, if only everyone were required to be “in”. The message was that health insurance had to be mandated. The incredible cost of doing this while maintaining insurance company profits was never addressed. Nor was single-payer, the only reasonable alternative that would cover everyone and not cost a great deal more, precisely because it would eliminate the huge profits of the insurance companies.

Indeed, this was the message of “Sick Around the World”; in Switzerland, a country with a grand capitalist tradition and many insurance and drug companies, it turns out that the insurance companies, even before the new system was put in place, were not-for-profit. So how come Reid did not make sure this was pointed out? It turns out, amazingly, that the producers of Frontline dramatically changed the program to make the political point that they wanted to – this nonsense plan to require everyone to have health insurance which would be so amazingly costly that it would never work, and exclude any reference to single payer. And so Reid withdrew from the project. Excellent coverage of this by Russell Mokhiber of Counterpunch, including text of the exchange by the “moderator” and Ignagni[3]. Really disappointing of Frontline. Another effort of the “haves” to exclude a discussion of something that will meet the needs of all of us.

[1] http://www.pbs.org/wgbh/pages/frontline/sickaroundamerica/
[2] http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/
[3] http://www.counterpunch.org/mokhiber04022009.html

More Primary Care Doctors or Just More Doctors?

In a Health Affairs “Web exclusive”, Dr. Richard Cooper of the Wharton School at the University of Pennsylvania has two studies, “States with More Physicians Have Better-Quality Health Care,”[1] and “States With More Health Care Spending Have Better-Quality Health Care: Lessons About Medicare”[2], which have generated a great deal of discussion; in this article I will address the first of these.

Cooper’s study purports to refute a previous study published by Katherine Baicker and Amitabh Chandra previously cited on this blog, “Medicare Spending, The Physician Workforce, And Beneficiaries’ Quality Of Care”[3], a widely quoted study that demonstrated that when states were ranked by either quality of care indicators or by Medicare spending, there was a large difference between those with higher numbers of specialists (costs up, quality down) and generalists (quality up, cost down). Cooper, a long-time advocate of increasing physician production -- but not with an emphasis on primary care or generalists (believing that market demand is an effective way of determining physician workforce) -- argues that increasing numbers of physicians increases quality of care, regardless of whether they are family physician/general practitioners (FP/GP) or specialists, and identifies what he sees as flaws with the statistical assumptions and analysis in the original Baicker and Chandra article. Cooper looks at regions, and notes that the South has low numbers of both specialists and generalists and low quality, the Northeast has high numbers of specialist and low numbers of generalists and pretty high quality, but that the Upper Midwest, Northwest, and Northern New England states, with high quality and high levels of FP/GPs are what creates this result (seeming as if more FP/GPs improve quality). He believes that this is because these states are relatively wealthy, have relatively low numbers of poor and minorities, and perhaps more progressive social policies demonstrated, for example, by the lower rates of incarceration. Some of these are good points; places that have a lot of resources, both in terms of money and social capital, do well; it does not address the issues of the incredibly higher cost of medical care in the Southern New England and Mid-Atlantic states compared to the three areas above, which are very probably the result of the high level of specialists compared to generalists. Cooper does not address cost at all.

Baicker and Chandra respond to this article in the same web issue of Health Affairs,[4] particularly addressing both Cooper’s misinterpretation of their data, and (in their assessment) poor use of statistics in his own study. (I will not try to summarize these issues, which involve the use of correlation, weighting and regression analysis; those of you who are expert enough in statistics can read the article.) They conclude that, properly analyzed, Cooper’s data (as opposed to his conclusions) supports their conclusions in the original 2004 study that higher numbers of FP/GP doctors improve quality measures and higher numbers of specialists do not. They take issue with his title and main theme, ““Quality is better in states with more physicians, both specialists and family physicians”, saying “A more careful statement would be, ‘Quality is better in states with more family physicians, but no significant association was found for specialists.’” They state, in pointing out that correlation shows direction but not in magnitude:

“The numbers of specialists and generalists per capita may have identical correlations with quality, but they have very different size effects on quality. Cooper’s own exhibits suggest that this is the case—and that generalists have a dramatically bigger effect on quality than specialists do....you would have to add roughly ten specialists per capita to move up ten spots in the quality ranking, but you would only have to add one generalist per capita to move up the same ten spots. And, apparently, even the small effect of additional specialists on quality is statistically insignificant.”

Philip Musgrove, deputy editor of Health Affairs, who wrote the Introduction to Cooper’s article, makes this point in the most recent issue of Health Affairs, which contains a series of letters relating to these articles (including letters by both Cooper and Baicker and Chandra). In responding to a letter by John Frey (see below) that asserts that Cooper’s viewpoint is supported by Musgrove, the latter endorses the analysis of Baicker and Chandra, writing “Cooper’s analysis actually agrees with theirs [Baicker and Chandra’s], since his own results show that the presence of more specialists has a much smaller (about a tenth as large) effect on quality than the presence of GPs has.” [5] Of note, Cooper’s response contains no such acknowledgement.

The letter from Dr. Frey, a leading family physician and academic who is Professor and Chair Emeritus in the Department of Family Medicine at the University of Wisconsin, suggests that:

“To test Richard Cooper’s hypothesis that it is simply more doctors, not the mix of specialty/generalists, that makes a difference in access, quality, and cost, why not close down all generalist training programs (which are well on their way toward that goal anyway, with the choices made by U.S. medical students) and see what happens? Managing complex multiple comorbidities, managing urgent and unorganized health complaints, or providing primary and secondary preventive care to large populations of chronically ill patients would be done by an increasing cadre of subspecialty providers.”[6]

Implicit in Frey’s suggestion is that they (the subspecialists, sometimes, to distinguish them from generalists, called “partialists”) would not, and perhaps could not, do so. I absolutely agree. While I do not urge the adoption of such a plan (and I’m sure Dr. Frey really does not either) any more than I advocate closing volunteer safety net clinics to stop “bailing out” government and society from the consequences of their failure to act to meet the basic health needs of all our people, I have no question but that the results would be exactly what Dr. Frey implies. And I have no doubt that the subspecialists would overwhelmingly agree. The “Joint Principles of the Patient Centered Medical Home” developed collaboratively by the American Academy of Family Physicians (AAFP), the American College of Physicians (ACP, representing internal medicine doctors), the American Academy of Pediatrics (AAP), and the American Osteopathic Association (AOA) and endorsed by the Patient Centered Primary Care Collaborative (PCPCC)[7], an industry-led coalition, never specify that these services must be provided by an identified primary care doctor, but it is very unlikely that there are many subspecialists who would choose to have to provide all these services.

However, Frey is correct about the fact that medical students are voting with their feet and running from primary care. Unquestionably, while there are many reasons that medical students might choose one specialty or another, the major issue in the dramatic change away from primary care in recent years ere is expected income combined with medical debt. As I have previously noted, much of this income differential is not “market” driven but simply reimbursement driven. If nothing is done to change the circumstances that have produced this movement, Frey’s ironic suggestion might become de facto true, and we will all suffer for it. Unfortunately, the work of scholars and policy people such as Cooper, advocating simply increase in the number of physicians without attention to the composition of the physicians workforce, may hasten rather than slow, this disastrous outcome.

[1] Cooper RA, “States with More Physicians Have Better-Quality Health Care,” Health Affairs 28, no. 1 (2009): w91–w102
[2] Cooper RA, “States With More Health Care Spending Have Better-Quality Health Care: Lessons About Medicare”, Health Affairs 28, no. 1 (2009): w103–w115
[3] Baicker K & Chandra A, “Medicare Spending, The Physician Workforce, And Beneficiaries’ Quality Of Care”, Health Affairs, 7 Apr 2004;W4.184
[4] Baicker K & Chandra A, “Cooper’s analysis is incorrect”, Health Affairs 28, no. 1 (2009): w116–w118
[5] Musgrove P, “Primary/specialty care: an author responds”, Health Affairs Mar-Apr 2009;28(2):594-5.
[6] Frey JJ, “Test the primary/specialty care hypothesis”, letter, Health Affairs Mar-Apr 2009;28(2):594.
[7] “Joint Principles of the Patient Centered Medical Home”, February 2007, http://www.pcpcc.net/node/14