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NPR’s “All Things Considered” recently reviewed several scary events from 2010 (“The year in fear: fright or fallacy?”). Reporter Jon Hamilton spoke with Dr. David Ropiek, Director of Risk Communication at the Harvard Center for Risk, about what made these events (Toyota’s acceleration problems, the Deepwater Horizon oil spill and the use of chemical dispersants, etc.) particularly frightening. Dr. Ropiek said that people tend to make decisions, and react positively or negatively, based on very simplistic (and usually unconscious) criteria, rather than on careful critical analysis of the relative benefits of one course of action over another, with the most important criterion being “is there immediate danger?” The reason he gave was that our basic neurobiology was unchanged over human history while our culture and society was remarkably more complex than when quick decisions were mostly about achieving immediate results (fight or flee). “We use a risk-perception system that evolved in simpler times, when the risks were bad guys with clubs, and the dark, and wolves. It's quick. But quick isn't necessarily the best for the complicated stuff we face in modern society.” Thus, for example, even though the evidence would show that the human and environmental danger of the oil spill was in the oil much more than any risk from chemical dispersants, “Just the word chemicals in your listeners' minds is currently setting off a little organ in their brain called the amygdala, which is the 24/7 radar in our brain that says - is there danger in that data?”; that is, our fears are triggered by the word (chemicals) which we have come to associate with danger.
Similarly, people can grasp the specific, and feel the pain, for an individual more easily than for a large, amorphous population. Thus, the outpouring of concern for “Baby Jessica” falling down a well in 1987, or for the child dying of leukemia, is much stronger than that for thousands of people, especially those in other countries, dying of war, disease, or even more abstract, structural violence. It is not just the one versus the many; it is the suddenness of it. We feel for the trapped Chilean miners, or the victims of a bombing; Ropiek says “… a chronic risk doesn’t ring our alarm bells the way a catastrophic, all-at-once one does. Because it concentrates the mind to see a bunch of the tribe all whacked at once.” So a particularly gory battle or atrocity is horrifying, but when there are chronic, repeated bombings and battles (as in Iraq or Afghanistan), even though they lead to much more death, we feel less.
We can see a murderer as a bad person, but it is harder to identify the members of the “grifter class” (coined by Matt Taibbi, “Griftopia”[1] ) who are responsible for the financial system that has visited so much evil on all of us. When people hear about something they know little or nothing about, especially if it is very complex and hard to understand, they often deal with it by putting a “frame” around it, tying it to something that seems similar enough (at least in one dimension) that they feel they can hang their hat on the analogy and judge it. For example, “chemicals=bad” in the example above is such a frame; so is dealing with universal health insurance by framing it as “socialized medicine”=”socialism”=”bad”. Unfortunately, the world is far more complex than this, and more unfortunately unscrupulous politicians and opinion-makers (my frame = “selfish evil people”) take advantage of this to obscure complexity and buy into often nonsensical self contradictions (taxes=bad, deficits=bad; let’s not have either!)
When it comes to health and medicine, the same issues come into play. People perceive immediate distress with acute problems (e.g., cough, fever, and most especially pain!) and know how much they would appreciate relief. The impact of conditions that do not cause appreciable symptoms right now but will cause really bad outcomes (death, morbidity, poor quality of life) if untreated in the future, are much harder to get people to make high priorities. The doctor sees untreated hypertension in terms of a future outcome (stroke, kidney failure), but this is more difficult for the patient. Even when s/he believes and understands it intellectually, it is much less likely that the treatment of a largely asymptomatic condition will rise to the top of life’s many more urgent priorities (food, clothing, housing, childcare, work) than if it were, say, pain.
The problem is even greater for public health, as I discussed in Public Health and Changing People's Minds (Saturday, May 15, 2010) where populations are huge, timelines are long and risk is relative. Public health addresses risks for populations, not me, or my family; translating population risk into individual prior probability is fairly difficult. For most people, even the concept of risk – that a given event will not definitely have or definitely not have a particular result, but will be somewhere on the continuum between them – is something they are not accustomed to thinking about, although they use it all the time (deciding whether to cross on a red light, for example). Consciously comparing the relative risk of different actions is very difficult, especially when the results have very different timelines. A definite immediate benefit (have that tasty fried or sweet food; throw a wrapper out the window, get a big gas-guzzler, have unprotected sex) has a lot more weight than the possibility of a bad long-term outcome (besides, next time, in the future, I’m going to go on a diet, give up smoking, use condoms). Dr. Ropiek notes that because events that cause “a bunch of the tribe to be all whacked at once” happens relatively rarely, “…we tend to downplay chronic risks like car accidents, diabetes, heart disease and the flu.” Sometimes public health officials can create that fear and mobilize the attention of the populace, as with concern about the swine flu of 1976, but that is also an example of how, when predicted risk of bad outcomes doesn’t happen, it reinforces the tendency to downplay those chronic risks.
In making decisions about medical care, this sort of perception can cut either way, depending on how a person looks at it based on personal and familial experience, cultural beliefs, and the way they “frame” medical interventions, as well as how urgent or important a solution is. Some people do not trust doctors or medicines, based on these criteria, and prefer to not take medicines or advice, even when an analysis of the relative risk shows the treatment to be definitely beneficial. Others have unrealistic expectations of what medicine can do (fueled, of course, by both doctors and direct-to-consumer drug advertising), and are angry when the doctor cannot cure their viral illness, make their back pain disappear, or compensate for all of the other parts of life that are bad and make them happy. At times of serious illness, where both treatment and non-treatment have real risks, or at end of life when people are not ready to accept that it is the end of life, even a professional evaluation of relative risk/benefit is difficult, so it is hardly surprising that people return to simpler methods of decision making (will I be able to live another day? Will it end my/his/her pain?).
Hamilton ends the interview segment with: “So Ropiek says we need to acquire a new fear - the fear of getting risk wrong.” I wish us luck on that.
[1] Taibbi, M. Griftopia: Bubble Machines, Vampire Squids, and the Long Con That Is Breaking America. Random House. New York. 2010
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Showing posts with label Medicine. Show all posts
Showing posts with label Medicine. Show all posts
Saturday, January 15, 2011
Saturday, December 18, 2010
ACA, ACOs, and Meaningful Competition
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Criticisms of the new health law, the Affordable Care Act (ACA), have come from all sides. While many of them are justified, they also miss many of the law’s positives. It doesn’t assure the reliable, cost-controlled security of a real universal health insurance program, but it will lead to coverage of tens of millions of more Americans, and will eliminate the ability of insurance companies to engage in health risk underwriting, the practice that allows them to deny coverage to those with pre-existing conditions. These are points that the President made in his recent interview on Jon Stewart’s Daily Show. "Individual mandates", i.e., forcing everyone to buy insurance, while it is a touchstone for the right and is the issue found unconstitutional by a Virginia federal judge (and which will probably go to the Supreme Court), was the price that insurance companies demanded for assuring coverage for everyone. As I have often written, you have to have all the healthy people in if you are going to cover the sick; there are many more healthy, but all of us can become sick.
Apparently, a lot of people understand this. A recent poll by Marist College and McClatchy newspapers shows a majority (51%, but still a majority) of Americans want to continue (16%) or increase (35%) the benefits of ACA, with 44% going the other direction. “Among groups with pluralities who want to expand it: women, minorities, people younger than 45, Democrats, liberals, Northeasterners and those making less than $50,000 a year. Lining up against the law, 11 percent want to amend it to rein it in; 33 percent want to repeal it. Among groups with pluralities favoring repeal: men, whites, those older than 45, those making more than $50,000 annually, conservatives, Republicans and tea party supporters.” OK, these are the “usual suspects”, except that it amazing and saddening to me that older people who are receiving Medicare can be opposed to expanding benefits to others. Maybe they are just ignorant of Medicare and the current law (as reflected in “Keep the government’s hands off my Medicare!”); this is also sad, but would explain what would otherwise be an enormously, almost immoral, selfishness. Yes, more educated Medicare recipients are concerned that the benefits for that program will be scaled back (and there are unquestionably threats to do so!) but this does not justify opposition to extending those benefits to the rest of the country.
A new set of problems is described by Robert Pear in the New York Times, on Sunday, November 21, 2010, “As health law spurs mergers, risks are seen”. The focus of his article is the planned “accountable care organization” (ACO), a relationship between one or more hospitals (or “health systems”), doctors, nursing homes, and home health care agencies. The idea behind creating ACOs is that, by coordination of care and sharing of information, people’s health can be improved and money can be saved. There is a lot of sense to this approach. If a patient is discharged from a hospital to home, or to a nursing home, and there is more sharing of information with the home health agency, or nursing home, or the primary care doctor who will be responsible for care when they leave the hospital, there is greater likelihood that there will not be lapses in the patient’s care. Similarly, if the person’s health deteriorates to the point of needing to be re-admitted, it would be best if 1) all that could have been done in the non-hospital setting to possibly prevent that from happening was done, and 2) all the information about what was done was transmitted to the hospital.
The organizations most cited by health reformers as having been successful in controlling costs and improving quality are those that are already “integrated”, where the system that owns the hospital(s) also employs the physicians and controls the nursing homes and home health care agencies, or else has very close and dependent financial relationships with them, such as Intermountain Health Care, Geisinger Health System, and Kaiser-Permanente. Information – and money, including money saved by having fewer expensive readmissions, is shared among the various participants. So ACA creates financial incentives for others to create such relationships, the ACOs. The issue raised in Pear’s article are that many forms that these ACOs might take run the risk of violating existing laws that are in place to prevent kickbacks, monopolistic practice, and other forms of corruption. For example, it is illegal for a health system for offering contingency payments a physician who is not an employee – such as for admitting patients to the hospital, keeping stays shorter, etc. This makes sense too.
So we have two conflicting things that “make sense”: greater collaboration and aligned incentives can create greater efficiency and save money, but they can also lead to oligopoly and corrupt relationships. Monopoly is more efficient, but creates the opportunity for exploitation. Modern business practices, based on the work of people such as W. Edwards Deming[1], emphasize the importance of long-term relationships with suppliers so that they can learn and better meet your needs over time, something there would be no incentive to do if doing so cost them money, and you were likely to pull your business the next year because someone else bid lower. Governments usually have policies requiring contracts given to the lowest bidder, but there is a danger that the work will be of lower quality.
Much of the criticism of ACA from the “right” has been about lack of “choice”, but as we look at implementation of the health care law, we need to be careful that ideology does not trump actual health outcomes. Two recent studies show the risks of the “law of unintended consequences” of policies that encourage consumer choice and a market approach to health coverage. In “Health care use and decision making among lower income families in high-deductible health plans”[2], Kullgren and colleagues demonstrate that, in fact, as might be anticipated, poor people who choose to spend less out-of-pocket money by enrolling in such high-deductible plans pay the price later in not accessing health care and having poorer outcomes. Millet, et al, in “Unhealthy competition: consequences of health plan choice in California Medicaid”[3], show that, perhaps less intuitively, Medicaid (Medi-Cal) patients in California counties where they have a choice of plans are less likely to be enrolled all year than where they do not have such choice, and “Potential benefits of health plan choice may be undermined by transaction costs of delayed enrollment, which may increase the probability of hospitalization for ambulatory care-sensitive conditions.”
Ideally, a single-payer, Medicare-for-all, system eliminates the risks that people will not enroll or have gaps in enrollment, that there will be people left out, that people will, for understandable and reasonable short-term financial reasons, make choices that can have long-term adverse effects on their health, and that there will be different standards for quality of care for people with different insurance. But even that does not address the system of provision of care. The ACA law seeks to encourage communication and efficiency, but critics see danger in merger and oligopoly, which could limit options for consumers and in itself create risks to health care access and quality.
What could the solution be? One might be to have cooperative relationships with open-source access to information. Thus, your health information would not be in the control of a given hospital, health care system, or doctor, but rather be controlled by you, and made available to whichever provider – hospital, doctor, nursing home, etc. -- that you chose to provide your care. The information would not be in proprietary electronic medical record format, but rather in an interoperable format that could be utilized by any provider. Incentives could exist globally, not simply within a single organization, to produce the highest quality care rather than the highest profit margin. This would be an excellent example of real competition.
[1] See Mary Walton, The Deming Management Method, Berkeley Publishing Group, New York (originally published Dodd Mead, NY, 1986).
[2] Kullgren JT et al., “Health care use and decision making among lower income families in high-deductible health plans”, Archives of Internal Medicine, 2010;170(21):1918-25. (Hyperlink is to abstract as full text not available free on line.)
[3] Millet C, Chattopadhyay A, Bindman AB, “Unhealthy competition: consequences of health plan choice in California Medicaid”, American Journal of Public Health Nov2010;100(11):2235-40. (Hyperlink is to abstract as full text not available free on line.)
.
Criticisms of the new health law, the Affordable Care Act (ACA), have come from all sides. While many of them are justified, they also miss many of the law’s positives. It doesn’t assure the reliable, cost-controlled security of a real universal health insurance program, but it will lead to coverage of tens of millions of more Americans, and will eliminate the ability of insurance companies to engage in health risk underwriting, the practice that allows them to deny coverage to those with pre-existing conditions. These are points that the President made in his recent interview on Jon Stewart’s Daily Show. "Individual mandates", i.e., forcing everyone to buy insurance, while it is a touchstone for the right and is the issue found unconstitutional by a Virginia federal judge (and which will probably go to the Supreme Court), was the price that insurance companies demanded for assuring coverage for everyone. As I have often written, you have to have all the healthy people in if you are going to cover the sick; there are many more healthy, but all of us can become sick.
Apparently, a lot of people understand this. A recent poll by Marist College and McClatchy newspapers shows a majority (51%, but still a majority) of Americans want to continue (16%) or increase (35%) the benefits of ACA, with 44% going the other direction. “Among groups with pluralities who want to expand it: women, minorities, people younger than 45, Democrats, liberals, Northeasterners and those making less than $50,000 a year. Lining up against the law, 11 percent want to amend it to rein it in; 33 percent want to repeal it. Among groups with pluralities favoring repeal: men, whites, those older than 45, those making more than $50,000 annually, conservatives, Republicans and tea party supporters.” OK, these are the “usual suspects”, except that it amazing and saddening to me that older people who are receiving Medicare can be opposed to expanding benefits to others. Maybe they are just ignorant of Medicare and the current law (as reflected in “Keep the government’s hands off my Medicare!”); this is also sad, but would explain what would otherwise be an enormously, almost immoral, selfishness. Yes, more educated Medicare recipients are concerned that the benefits for that program will be scaled back (and there are unquestionably threats to do so!) but this does not justify opposition to extending those benefits to the rest of the country.
A new set of problems is described by Robert Pear in the New York Times, on Sunday, November 21, 2010, “As health law spurs mergers, risks are seen”. The focus of his article is the planned “accountable care organization” (ACO), a relationship between one or more hospitals (or “health systems”), doctors, nursing homes, and home health care agencies. The idea behind creating ACOs is that, by coordination of care and sharing of information, people’s health can be improved and money can be saved. There is a lot of sense to this approach. If a patient is discharged from a hospital to home, or to a nursing home, and there is more sharing of information with the home health agency, or nursing home, or the primary care doctor who will be responsible for care when they leave the hospital, there is greater likelihood that there will not be lapses in the patient’s care. Similarly, if the person’s health deteriorates to the point of needing to be re-admitted, it would be best if 1) all that could have been done in the non-hospital setting to possibly prevent that from happening was done, and 2) all the information about what was done was transmitted to the hospital.
The organizations most cited by health reformers as having been successful in controlling costs and improving quality are those that are already “integrated”, where the system that owns the hospital(s) also employs the physicians and controls the nursing homes and home health care agencies, or else has very close and dependent financial relationships with them, such as Intermountain Health Care, Geisinger Health System, and Kaiser-Permanente. Information – and money, including money saved by having fewer expensive readmissions, is shared among the various participants. So ACA creates financial incentives for others to create such relationships, the ACOs. The issue raised in Pear’s article are that many forms that these ACOs might take run the risk of violating existing laws that are in place to prevent kickbacks, monopolistic practice, and other forms of corruption. For example, it is illegal for a health system for offering contingency payments a physician who is not an employee – such as for admitting patients to the hospital, keeping stays shorter, etc. This makes sense too.
So we have two conflicting things that “make sense”: greater collaboration and aligned incentives can create greater efficiency and save money, but they can also lead to oligopoly and corrupt relationships. Monopoly is more efficient, but creates the opportunity for exploitation. Modern business practices, based on the work of people such as W. Edwards Deming[1], emphasize the importance of long-term relationships with suppliers so that they can learn and better meet your needs over time, something there would be no incentive to do if doing so cost them money, and you were likely to pull your business the next year because someone else bid lower. Governments usually have policies requiring contracts given to the lowest bidder, but there is a danger that the work will be of lower quality.
Much of the criticism of ACA from the “right” has been about lack of “choice”, but as we look at implementation of the health care law, we need to be careful that ideology does not trump actual health outcomes. Two recent studies show the risks of the “law of unintended consequences” of policies that encourage consumer choice and a market approach to health coverage. In “Health care use and decision making among lower income families in high-deductible health plans”[2], Kullgren and colleagues demonstrate that, in fact, as might be anticipated, poor people who choose to spend less out-of-pocket money by enrolling in such high-deductible plans pay the price later in not accessing health care and having poorer outcomes. Millet, et al, in “Unhealthy competition: consequences of health plan choice in California Medicaid”[3], show that, perhaps less intuitively, Medicaid (Medi-Cal) patients in California counties where they have a choice of plans are less likely to be enrolled all year than where they do not have such choice, and “Potential benefits of health plan choice may be undermined by transaction costs of delayed enrollment, which may increase the probability of hospitalization for ambulatory care-sensitive conditions.”
Ideally, a single-payer, Medicare-for-all, system eliminates the risks that people will not enroll or have gaps in enrollment, that there will be people left out, that people will, for understandable and reasonable short-term financial reasons, make choices that can have long-term adverse effects on their health, and that there will be different standards for quality of care for people with different insurance. But even that does not address the system of provision of care. The ACA law seeks to encourage communication and efficiency, but critics see danger in merger and oligopoly, which could limit options for consumers and in itself create risks to health care access and quality.
What could the solution be? One might be to have cooperative relationships with open-source access to information. Thus, your health information would not be in the control of a given hospital, health care system, or doctor, but rather be controlled by you, and made available to whichever provider – hospital, doctor, nursing home, etc. -- that you chose to provide your care. The information would not be in proprietary electronic medical record format, but rather in an interoperable format that could be utilized by any provider. Incentives could exist globally, not simply within a single organization, to produce the highest quality care rather than the highest profit margin. This would be an excellent example of real competition.
[1] See Mary Walton, The Deming Management Method, Berkeley Publishing Group, New York (originally published Dodd Mead, NY, 1986).
[2] Kullgren JT et al., “Health care use and decision making among lower income families in high-deductible health plans”, Archives of Internal Medicine, 2010;170(21):1918-25. (Hyperlink is to abstract as full text not available free on line.)
[3] Millet C, Chattopadhyay A, Bindman AB, “Unhealthy competition: consequences of health plan choice in California Medicaid”, American Journal of Public Health Nov2010;100(11):2235-40. (Hyperlink is to abstract as full text not available free on line.)
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Sunday, December 12, 2010
Tax Breaks for the "Masters of the Universe" or for the rest of us?
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The fact is that the wealthiest are doing great and everyone else is being penalized. This cannot be justified by any reasonable economics, voodoo, trickle-down, Friedmanesque or anything else. The elite have a Congress that they have bought and paid for, as discussed in his November 28, 2010 column, Still the Best Congress Money Can Buy, by the NY Times’ Frank Rich. He refers us to recent Times articles documenting the recent enormous corporate profits (“Corporate Profits were the highest on record last quarter” by Catherine Rampell, November 23, 2010) and profligate spending by the Wall St. “masters of the universe”[1] (With a Swagger, Wallets Out, Wall Street Dares to Celebrate, November 23, 2010, by Suzanne Craig and Kevin Roose), while the Times’ editorial page reminds us that while they grow wealthier regular people, who still can’t get jobs, also can’t even get their unemployment benefits extended (The Unemployed Held Hostage, Again, November 28, 2010).
Our health system has long been terrible, in lack of equitable access for many while there have been enormous profits for the insurance and pharmaceutical industries, in excessive interventions and procedures for the well-insured masquerading as the “best health care system in the world”, quantity masquerading as quality even for those who have had health coverage. As developing countries such as India seek to develop their own health systems, the US is notable as a model for what should not be done (see the interview with Nobel-prize winning economist Joseph Stiglitz in the Times of India 'The US model of private health insurers is inefficient, expensive' (thanks to Don McCanne in his wonderful Quote of the Day). The ACA was a first step to fixing it, but scarcely a final one. It is time to stop talking about how to inflict more economic pain on the bulk of Americans, unemployed and working, until we stop giving the store away to the elite.
Surowiecki notes that “seniors think of Medicare as an “entitlement”—something that they have a right to because they paid for it”. Why not? Even though he notes that today they “get far more out of Medicare than they ever put in,” he adds, appropriately, that “There’s nothing wrong with this: the U.S. is rich enough so that the elderly shouldn’t have to worry about having health insurance; before Medicare, roughly half of them didn’t have it”. He’s right on that. And we all should have it – Medicare for all, coverage for all of us. After 45 years of it working for seniors, it is time for it to be an entitlement for everyone. Something, finally, for the 99% who are not the “masters of the universe”. Sounds good to me.
[1] A phrase coined by Tom Wolfe to refer to Wall St titans in his 1987 book The Bonfire of the Vanities, Farrar Straus and Giroux.
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In an Associated Press story from November 28, 2010, “Tax break for employer health plans a target again” (it was widely picked up; here I’ve given the link to the Pensacola News-Journal), Ricardo Alonso-Zaldivar writes about the resurgence of interest in eliminating the employer tax break for contributions to employee health plans. This proposal, put forward from time to time, has been given new prominence by the recommendations of Erskine Bowles and Alan Simpson, the. not dumb and dumber but right-and-righter co-chairs of the President’s task force on deficit reduction, which they have morphed into a task force on cutting taxes. For Bowles and Simpson, it is one of only a number of proposals they make that would take away middle-class tax benefits, and not even the least popular: that honor would almost certainly go to the elimination of the mortgage interest deduction.
The employer’s ability to deduct contributions to their employees’ health insurance goes back to the post-World War II era, when there was tremendous competition for workers (imagine that!) and wage and price controls made it impossible for businesses to compete on the basis of pay, so fringe benefits – specifically health insurance – became a real perk. The unions liked it because they could bargain for this benefit for their members. The losers, of course, were all of us, who did not get a national health insurance program. And for many years this benefit has been a real advantage to being employed by a company with a collective bargaining agreement, and clearly unions will strongly oppose any effort to make it more difficult for them to achieve this benefit.
Meanwhile, some Medicare recipients, concerned about maintaining one of the few benefits the elderly still have, have come out against much of the health reform bill. Many of the most vocal opponents are the wealthy elderly, but unfortunately many middle- and working-class seniors are in this group. This is the subject of James Surowiecki’s piece “Greedy Geezers?” in the New Yorker, Nov 22, 2010, as noted by Tallgrass Activist David Kingsley. While the title might be offensive, many of his points are well taken: “There’s a colossal irony here: the very people who currently enjoy the benefits of a subsidized, government-run insurance system are intent on keeping others from getting the same treatment.” One example of what seniors can see as real cutbacks to their benefits are the cuts to the Medicare Advantage program. Medicare Advantage (also known as Medicare Part “C”) is a program that basically takes your Medicare payment, and an additional payment from you, and enrolls you in an HMO that provides you benefits beyond that which traditional Medicare offers (such as glasses, hearing aids, a better drug benefit, especially before Part “D” was enacted). It was created by the Reagan administration as a way to, at least in part, privatize Medicare, and was accompanied by higher payments from the federal government to these insurers than was spent on traditional Medicare beneficiaries. This was a corrupt program that ACA was right to eliminate, but because those seniors enrolled in it were getting a benefit, they receive a cut. Of course, the cut (appropriately) is much greater to the insurance company, which was getting most of the benefit (the extra benefits received by the enrollees were worth much less than the insurance companies were being paid).
What a great example of divide and conquer! Bowles-and-Simpson’s (now they are one, ostensible bipartisanship aside) proposals, while they were supposed to be about deficit reduction, are all about decreasing taxes. And especially decreasing taxes on the wealthiest Americans and corporations, a strategy that has been demonstrated by the last decade to be extraordinarily beneficial to – the wealthiest Americans and corporations. Trickle down economics, decried by George HW Bush as “voodoo economics” during the 1980 election, are no less so now, although to call them that insults voodoo. Interviewed on NPR’s “All Things Considered”, Bowles-and-Simpson are asked about the criticism of their proposals by economist and NY Times columnist Paul Krugman, who says it is about redistributing wealth upward. While Simpson says Krugman has “lost his marbles”, he doesn’t address Krugman’s criticisms.
The employer’s ability to deduct contributions to their employees’ health insurance goes back to the post-World War II era, when there was tremendous competition for workers (imagine that!) and wage and price controls made it impossible for businesses to compete on the basis of pay, so fringe benefits – specifically health insurance – became a real perk. The unions liked it because they could bargain for this benefit for their members. The losers, of course, were all of us, who did not get a national health insurance program. And for many years this benefit has been a real advantage to being employed by a company with a collective bargaining agreement, and clearly unions will strongly oppose any effort to make it more difficult for them to achieve this benefit.
Meanwhile, some Medicare recipients, concerned about maintaining one of the few benefits the elderly still have, have come out against much of the health reform bill. Many of the most vocal opponents are the wealthy elderly, but unfortunately many middle- and working-class seniors are in this group. This is the subject of James Surowiecki’s piece “Greedy Geezers?” in the New Yorker, Nov 22, 2010, as noted by Tallgrass Activist David Kingsley. While the title might be offensive, many of his points are well taken: “There’s a colossal irony here: the very people who currently enjoy the benefits of a subsidized, government-run insurance system are intent on keeping others from getting the same treatment.” One example of what seniors can see as real cutbacks to their benefits are the cuts to the Medicare Advantage program. Medicare Advantage (also known as Medicare Part “C”) is a program that basically takes your Medicare payment, and an additional payment from you, and enrolls you in an HMO that provides you benefits beyond that which traditional Medicare offers (such as glasses, hearing aids, a better drug benefit, especially before Part “D” was enacted). It was created by the Reagan administration as a way to, at least in part, privatize Medicare, and was accompanied by higher payments from the federal government to these insurers than was spent on traditional Medicare beneficiaries. This was a corrupt program that ACA was right to eliminate, but because those seniors enrolled in it were getting a benefit, they receive a cut. Of course, the cut (appropriately) is much greater to the insurance company, which was getting most of the benefit (the extra benefits received by the enrollees were worth much less than the insurance companies were being paid).
What a great example of divide and conquer! Bowles-and-Simpson’s (now they are one, ostensible bipartisanship aside) proposals, while they were supposed to be about deficit reduction, are all about decreasing taxes. And especially decreasing taxes on the wealthiest Americans and corporations, a strategy that has been demonstrated by the last decade to be extraordinarily beneficial to – the wealthiest Americans and corporations. Trickle down economics, decried by George HW Bush as “voodoo economics” during the 1980 election, are no less so now, although to call them that insults voodoo. Interviewed on NPR’s “All Things Considered”, Bowles-and-Simpson are asked about the criticism of their proposals by economist and NY Times columnist Paul Krugman, who says it is about redistributing wealth upward. While Simpson says Krugman has “lost his marbles”, he doesn’t address Krugman’s criticisms.
The fact is that the wealthiest are doing great and everyone else is being penalized. This cannot be justified by any reasonable economics, voodoo, trickle-down, Friedmanesque or anything else. The elite have a Congress that they have bought and paid for, as discussed in his November 28, 2010 column, Still the Best Congress Money Can Buy, by the NY Times’ Frank Rich. He refers us to recent Times articles documenting the recent enormous corporate profits (“Corporate Profits were the highest on record last quarter” by Catherine Rampell, November 23, 2010) and profligate spending by the Wall St. “masters of the universe”[1] (With a Swagger, Wallets Out, Wall Street Dares to Celebrate, November 23, 2010, by Suzanne Craig and Kevin Roose), while the Times’ editorial page reminds us that while they grow wealthier regular people, who still can’t get jobs, also can’t even get their unemployment benefits extended (The Unemployed Held Hostage, Again, November 28, 2010).
Our health system has long been terrible, in lack of equitable access for many while there have been enormous profits for the insurance and pharmaceutical industries, in excessive interventions and procedures for the well-insured masquerading as the “best health care system in the world”, quantity masquerading as quality even for those who have had health coverage. As developing countries such as India seek to develop their own health systems, the US is notable as a model for what should not be done (see the interview with Nobel-prize winning economist Joseph Stiglitz in the Times of India 'The US model of private health insurers is inefficient, expensive' (thanks to Don McCanne in his wonderful Quote of the Day). The ACA was a first step to fixing it, but scarcely a final one. It is time to stop talking about how to inflict more economic pain on the bulk of Americans, unemployed and working, until we stop giving the store away to the elite.
Surowiecki notes that “seniors think of Medicare as an “entitlement”—something that they have a right to because they paid for it”. Why not? Even though he notes that today they “get far more out of Medicare than they ever put in,” he adds, appropriately, that “There’s nothing wrong with this: the U.S. is rich enough so that the elderly shouldn’t have to worry about having health insurance; before Medicare, roughly half of them didn’t have it”. He’s right on that. And we all should have it – Medicare for all, coverage for all of us. After 45 years of it working for seniors, it is time for it to be an entitlement for everyone. Something, finally, for the 99% who are not the “masters of the universe”. Sounds good to me.
[1] A phrase coined by Tom Wolfe to refer to Wall St titans in his 1987 book The Bonfire of the Vanities, Farrar Straus and Giroux.
.
Tuesday, November 23, 2010
Lung Cancer Screening: Benefits, Costs, and Opportunity Costs for the Public Health
.
In a rather unusual action, the National Cancer Institute (NCI), a division of the National Institutes of Health (NIH), issued a press release on November 4, 2010 announcing preliminary findings from a research study that, at that time had yet to be published (it since has been). This bulletin, Lung cancer trial results show mortality benefit with low-dose CT, announces that a large, multi-center, randomized controlled trial (RCT), called, the National Lung Screening Trial (NLST), has found that regular screening of current and former heavy smokers with low-dose chest computed tomography (CT) scanning aged 55-74, compared to screening by regular chest x-ray, led to 20% fewer deaths from lung cancer. It is unusual in that it is there is no associated published study in a journal describing these results (the statement says that it is being “prepared for publication in a peer-reviewed journal within the next few months”); the only concurrently published article is a description of the methods of the NLST study, with discussion of previous screening studies for lung cancer, is the “National lung screening trial: overview and study design” published in the November issue of Radiology and made available November 2, 2010.
The study comparing these two screening tests – x-ray and CT – appears very strong. Because it is randomized, there is no significant difference between the pre-existing characteristics of those assigned to CT versus chest x-ray screening, and because the end point is death, it largely eliminates one of the most important confounding issues in prior studies called “lead time bias”. This means that if a more sensitive test identifies cancer earlier in its course, the time between diagnosis and death will be longer even if the death itself is not forestalled. (E.g., you have cancer and one test finds it at 55 and you die at 60; another test could find it at 50 and you die at 60; finding the cancer earlier didn’t make you live longer.) It is also a very large study (53,000 people) and well designed in many other ways, so that a 20% reduction in death is important. There is an excellent FAQ for this study, including graphics of lead-time and length-time bias, at the NCI website
So is there any problem? Will lung cancer, the biggest killer among cancers, become like breast cancer, where a screening test can find the cancer earlier, lead to earlier and effective treatment, and decrease mortality? Not exactly. In addition to a 20% reduction in mortality being far less than the reduction in breast cancer mortality from mammography, lung cancer is not breast cancer; we know the cause of the vast majority of cases: smoking. The authors, and the NCI, emphasize that such screening, even if widely adopted, is no substitute for stopping smoking or increasing efforts to get people to stop smoking. The real question is what is the benefit of spending huge amounts of money (while there is no statement of cost of screening in either the NCI brief or the Radiology article, estimates are as much as $12 billion a year -- 30 million screened at $400 per CT screening with interpretation, including follow-up exams -- to screen people who smoke, or smoked, heavily for cancer in pursuit of a significant, but relatively small, reduction in mortality? Moreover, there is no estimate of the potential risk of repeated CT scans (even low-dose, such as studied) and the degree to which the existence of a screening test might decrease the interest of smokers in stopping. (If this seems perverse, it is almost certain to happen; it happens every time news of a possible preventive intervention is announced: some people decide there is no need to stop their risky behavior.) Thus, to save 1 in 300 lives (about 100,000 of the 30 million screened, or 0.039% of the US population), not even considering quality of life (generally low for long-term smokers with cancer who have other conditions such as chronic lung disease), will cost about $40 per every person in the US per year.
How do we evaluate cost-benefit? In the current political environment, the popular theme is “don’t spend public money”, but there is always the implicit caveat “except if it benefits me” – and in this country we have over 300 million “me’s”. Dr. Robert Bowman, who has previously contributed to this blog, describes for us the potential alternative uses of not only the ongoing cost of screening, but even the cost of the study itself:
· The $250 million for this one study involving CT screening for lung cancer is about what the United States spent for all Agency for Healthcare Research and Quality (AHRQ) health care cost, quality, and outcomes research in 2008. (AHRQ is the main government agency looking at these issues, including “outcomes”, particularly important as I have previously discussed; it is obviously funded at a lot less than the $30 billion for NIH.)
· $250 million is the entire sum that the Health Resources and Services Administration (HRSA, the government agency that funds workforce research, training programs in primary care, dentistry, physicians assistants, pipeline programs, etc.) could scrape together to address emergent needs for primary care workforce this year.
· $250 million, if used to train family doctors at about $30,000 cost per Standard Primary Care provider, would produce 8333 Standard primary care years of workforce in family medicine graduates, or about 333 FM physicians serving their entire careers and improving cost, quality, and access where it is most needed.[1]
And the $12 billion?
· The $12 billion a year spent on CT screening for 30 million current or former smokers could graduate 16,000 family physicians a year.
· $12 billion a year, expended each year for the 30 years required to actually build any workforce (i.e., a generation), if applied to family medicine would supply the entire nation enough primary care for all locations and populations in need of primary care. Sufficient primary care for over 90% of Americans in all needed locations would begin 30 years after reaching 16,000 annual graduates and would be maintained with continued funding of 16,000 annual graduates. (Indeed, compared to less-efficient spending on training programs, such as internal medicine, that yield far fewer primary care years per dollar spent, this $12 billion is actually is a savings of a few billion dollars!)
"The US continues to fail, time after time, in the most basic choices regarding care for Americans most in need of care. The US can focus on the health care needed for nearly all people nearly all of the years of their lives in nearly all locations or the US can continue to spend its $7000 per person ($2.5 trillion) on the health care needs for only some of its people for a only a few years of their lives, with health care delivery services concentrated in only a limited number of locations (4% of the land area).
There is little point to research about rural workforce, health access, or primary care until the nation makes a decision to quit sending health care spending to locations with top concentrations for the care of Americans already with the most care."
Any economist – or wise investor or businessperson – can tell you about “opportunity cost”. This means “if you spend money on one thing, you can’t spend it on something else.” Therefore, the benefit of what you spend money on needs to be looked at not only for its intrinsic value (“will spending $12 billion a year on lung cancer screening with CT save lives?”) or against a very limited range of options (“Is it more cost effective than screening with chest x-rays?”) but weighed against reasonable alternative strategies to improving the health of people – all people.
Dr. Bowman gives strong arguments for the benefit of investing in primary care workforce development, and particularly in family medicine. Maybe there are other strategies for most improving the health of most of our people. But looking at new scientific advances in isolation is clearly a flawed approach.
[1] For a detailed description both of this measure – standard primary care (SPC) years – and the reasons that Family Medicine, as opposed to other physician and non-physician primary care training (internal medicine, pediatrics, physician’s assistants, nurse practitioners) is the most efficient producer of SPC years, see Ten Biggest Myths Regarding Primary Care in the Future, January 15, 2009.
.
In a rather unusual action, the National Cancer Institute (NCI), a division of the National Institutes of Health (NIH), issued a press release on November 4, 2010 announcing preliminary findings from a research study that, at that time had yet to be published (it since has been). This bulletin, Lung cancer trial results show mortality benefit with low-dose CT, announces that a large, multi-center, randomized controlled trial (RCT), called, the National Lung Screening Trial (NLST), has found that regular screening of current and former heavy smokers with low-dose chest computed tomography (CT) scanning aged 55-74, compared to screening by regular chest x-ray, led to 20% fewer deaths from lung cancer. It is unusual in that it is there is no associated published study in a journal describing these results (the statement says that it is being “prepared for publication in a peer-reviewed journal within the next few months”); the only concurrently published article is a description of the methods of the NLST study, with discussion of previous screening studies for lung cancer, is the “National lung screening trial: overview and study design” published in the November issue of Radiology and made available November 2, 2010.
The study comparing these two screening tests – x-ray and CT – appears very strong. Because it is randomized, there is no significant difference between the pre-existing characteristics of those assigned to CT versus chest x-ray screening, and because the end point is death, it largely eliminates one of the most important confounding issues in prior studies called “lead time bias”. This means that if a more sensitive test identifies cancer earlier in its course, the time between diagnosis and death will be longer even if the death itself is not forestalled. (E.g., you have cancer and one test finds it at 55 and you die at 60; another test could find it at 50 and you die at 60; finding the cancer earlier didn’t make you live longer.) It is also a very large study (53,000 people) and well designed in many other ways, so that a 20% reduction in death is important. There is an excellent FAQ for this study, including graphics of lead-time and length-time bias, at the NCI website
So is there any problem? Will lung cancer, the biggest killer among cancers, become like breast cancer, where a screening test can find the cancer earlier, lead to earlier and effective treatment, and decrease mortality? Not exactly. In addition to a 20% reduction in mortality being far less than the reduction in breast cancer mortality from mammography, lung cancer is not breast cancer; we know the cause of the vast majority of cases: smoking. The authors, and the NCI, emphasize that such screening, even if widely adopted, is no substitute for stopping smoking or increasing efforts to get people to stop smoking. The real question is what is the benefit of spending huge amounts of money (while there is no statement of cost of screening in either the NCI brief or the Radiology article, estimates are as much as $12 billion a year -- 30 million screened at $400 per CT screening with interpretation, including follow-up exams -- to screen people who smoke, or smoked, heavily for cancer in pursuit of a significant, but relatively small, reduction in mortality? Moreover, there is no estimate of the potential risk of repeated CT scans (even low-dose, such as studied) and the degree to which the existence of a screening test might decrease the interest of smokers in stopping. (If this seems perverse, it is almost certain to happen; it happens every time news of a possible preventive intervention is announced: some people decide there is no need to stop their risky behavior.) Thus, to save 1 in 300 lives (about 100,000 of the 30 million screened, or 0.039% of the US population), not even considering quality of life (generally low for long-term smokers with cancer who have other conditions such as chronic lung disease), will cost about $40 per every person in the US per year.
How do we evaluate cost-benefit? In the current political environment, the popular theme is “don’t spend public money”, but there is always the implicit caveat “except if it benefits me” – and in this country we have over 300 million “me’s”. Dr. Robert Bowman, who has previously contributed to this blog, describes for us the potential alternative uses of not only the ongoing cost of screening, but even the cost of the study itself:
· The $250 million for this one study involving CT screening for lung cancer is about what the United States spent for all Agency for Healthcare Research and Quality (AHRQ) health care cost, quality, and outcomes research in 2008. (AHRQ is the main government agency looking at these issues, including “outcomes”, particularly important as I have previously discussed; it is obviously funded at a lot less than the $30 billion for NIH.)
· $250 million is the entire sum that the Health Resources and Services Administration (HRSA, the government agency that funds workforce research, training programs in primary care, dentistry, physicians assistants, pipeline programs, etc.) could scrape together to address emergent needs for primary care workforce this year.
· $250 million, if used to train family doctors at about $30,000 cost per Standard Primary Care provider, would produce 8333 Standard primary care years of workforce in family medicine graduates, or about 333 FM physicians serving their entire careers and improving cost, quality, and access where it is most needed.[1]
And the $12 billion?
· The $12 billion a year spent on CT screening for 30 million current or former smokers could graduate 16,000 family physicians a year.
· $12 billion a year, expended each year for the 30 years required to actually build any workforce (i.e., a generation), if applied to family medicine would supply the entire nation enough primary care for all locations and populations in need of primary care. Sufficient primary care for over 90% of Americans in all needed locations would begin 30 years after reaching 16,000 annual graduates and would be maintained with continued funding of 16,000 annual graduates. (Indeed, compared to less-efficient spending on training programs, such as internal medicine, that yield far fewer primary care years per dollar spent, this $12 billion is actually is a savings of a few billion dollars!)
Or, if we are concerned about lung cancer, using this for tobacco control campaigns, both the "stop smoking" kind and the legislating non-smoking venues, cities and states.
Dr. Bowman continues:"The US continues to fail, time after time, in the most basic choices regarding care for Americans most in need of care. The US can focus on the health care needed for nearly all people nearly all of the years of their lives in nearly all locations or the US can continue to spend its $7000 per person ($2.5 trillion) on the health care needs for only some of its people for a only a few years of their lives, with health care delivery services concentrated in only a limited number of locations (4% of the land area).
There is little point to research about rural workforce, health access, or primary care until the nation makes a decision to quit sending health care spending to locations with top concentrations for the care of Americans already with the most care."
Any economist – or wise investor or businessperson – can tell you about “opportunity cost”. This means “if you spend money on one thing, you can’t spend it on something else.” Therefore, the benefit of what you spend money on needs to be looked at not only for its intrinsic value (“will spending $12 billion a year on lung cancer screening with CT save lives?”) or against a very limited range of options (“Is it more cost effective than screening with chest x-rays?”) but weighed against reasonable alternative strategies to improving the health of people – all people.
Dr. Bowman gives strong arguments for the benefit of investing in primary care workforce development, and particularly in family medicine. Maybe there are other strategies for most improving the health of most of our people. But looking at new scientific advances in isolation is clearly a flawed approach.
[1] For a detailed description both of this measure – standard primary care (SPC) years – and the reasons that Family Medicine, as opposed to other physician and non-physician primary care training (internal medicine, pediatrics, physician’s assistants, nurse practitioners) is the most efficient producer of SPC years, see Ten Biggest Myths Regarding Primary Care in the Future, January 15, 2009.
.
Wednesday, November 17, 2010
Disparities in physician income are related to disparities in health
.
A major focus of public health, about which I have written several times, is addressing the disparities in health arising from modifiable conditions (such as inequality of opportunity, income, and racial and ethnic differences). While it is common for those with privilege – wealth, health, opportunity – to believe that they have these privileges because they are “deserving”, i.e., because of their hard work, education, etc., such an outlook minimizes the critically important fact that there are lots of people who work just as hard and have very little. The “illegal immigrant”, working 3 minimum (or sub-minimum) wage jobs to try to just keep his or her family fed and housed, is not only not lazy, but working a lot harder than many of us who are able to enjoy weekends off, play golf, watch the kids’ sporting events.
So it is clearly not hard work alone. It is very much influenced by where you start, and what your opportunities have been. These are the social determinants of health (e.g., Social Determinants, Personal Responsibility, and Health System Outcomes, September 12, 2010) and the capability that people have of acting in healthful ways (Capability: understanding why people may not adopt healthful behaviors, September 24, 2010). It is common for people who have a lot to minimize, rather than to emphasize, the degree to which their position at the start of the race has affected their current position. Attacks on those who would seek to redress some of the most egregious inequities are still couched in terms of “economic class warfare” by those who have already won the war. Those with privilege are very concerned about change that would leave them with less of a leg up; they may give lip service to Horatio Alger heroes, but are more likely to wish to follow the model of George W. Bush. “If you’ve spent your entire life with the wind at your back,” a wise sage once noted (and I do not know to whom to attribute it), “a calm day seems unfair”. In terms of health, the connections are very clear. It is good for your health to be born rich. The Horatio Alger hero, pulled up by their own bootstraps, has worse health outcomes than the child born to privilege.
Health disparities, then, are real and important. But why should we – should anyone – be concerned about the disparities in physician income? After all, even the more “poorly” paid specialists, in primary care, make far more than the average American. Yes, they have worked hard to get into and through medical school and residency training, but, just as noted above, so have a lot of other people who will never make nearly as much. The problem is that, if the presence of a larger number/percent of primary care physicians is associated with improvements in the health of the population, and if the presence of wide disparities in income significantly influence students to choose higher paid specialties instead, then these disparities in health status are likely to continue and the overall health of the American people is likely to suffer. There is good data on both counts. Many of the posts in this blog have addressed the first, the positive influence of primary care on the health of the population (e.g., Lower Costs in Grand Junction: More Primary Care, Less High Tech, October 18, 2010; Primary Care, IMGs, and the Health of the People, August 14, 2010; and many others) and on health disparities[1]. I have also addressed the other point, the decrease in the number of students choosing primary care careers (e.g., Primary care specialty choice: student characteristics, July 12, 2010; Primary Care’s Image: A Problem?, November 17, 2009, and others).
A study published in the Archives of Internal Medicine by Leigh, et. al, “Physician wages across specialties”[2], is the most recent effort to quantify the differences. They utilized the large Community Tracking Study (CTS) of physicians from 2004-2005 to gather information on physician income. They grouped the physician responses into 4 broad categories (surgical, internal medicine and pediatric subspecialties [IMPSS], primary care, and other) and again into 41 specific specialties. They went beyond previous studies to calculate gross personal income on an hourly basis (thus controlling for hours worked per week) and did further adjustments to control for other variables, principally sex and age. They used a statistical manipulation to estimate incomes above the maximum set for the CTS (for some reason set at $400,000, much lower than many subspecialists make).
The outcomes were not surprising in comparison to previously reported data. In the 4 broad-group comparisons, primary care physicians averaged about $60/hr compared to IMPSS at $85, other medical at $88, and surgical at $92. In the single specialty comparisons, General Surgery was taken as a reference being actually near the middle ($86/hr), with the top incomes in neurosurgery ($132), radiation oncology ($126), and medical oncology ($114). At the bottom were family practice, general practice, general internal medicine, geriatric medicine, internal medicine/pediatrics, and “other” pediatric subspecialties (whichever those may have been) with a range of $50-$58.
There are several reasons to think that differences are, in fact, greater than those reported. There was only a 53% response rate to the CTS, and so we do not know if non-respondents made more, less or the same as respondents. “Hospital-based” specialties, specifically anesthesiology and radiology, which are among the highest-paid, were excluded. Other high-end specialties, such as cardiovascular surgery or transplant surgery, do not appear as specific specialties, and may have their incomes hidden when grouped with “thoracic surgery” or “other surgical specialties”. There are many sources of income for many physicians, including a variety of expenses that can be paid by practices and which would presumably be greater for higher income practices. Many highly-paid specialties are paid by hospitals directly (such as anesthesiology and radiology) or through “physician service agreements”. The correction used by the authors of the study for incomes over $400,000 could have been inadequate; certainly anecdotal experience in many locations would suggest that considering $400,000 as a reasonable top end for the highest paid physicians would understate that by at least half.
Nonetheless, the income differences, even in 2004-05, were impressive. Given the debt load that medical students (particularly those, obviously, from the less wealthy families) graduate with, the significant attraction to higher pay is clear.
The Wall St Journal, in two recent articles (“Secrets of the system”) published October 26, 2010, looked at the Relative Value Update Committee (RUC), a group of 29 physicians convened by the AMA from different specialty organizations that make recommendations to Medicare on how to pay physicians for their, well, relative value. One, “Physician panel prescribes the fees paid by Medicare” by Anna Wilde Matthews and Tom McGinty, describes how this group meets to divide up a pie that Medicare seeks to keep constant. In the other, “Dividing the Medicare pie pits doctor against doctor”, Matthews discusses the contentiousness that happened when primary care physicians (greatly outnumbered) challenged their surgical colleagues to get a higher portion of the money (that is, to revalue activities done by primary care physicians relative to surgical specialists).
In the same issue of Archives of Internal Medicine that Leigh’s article appeared in, Federman and colleagues[3] surveyed physicians about whether they thought reimbursements were inequitable or not; 78.4% agreed that they are, with not that much difference between generalists and subspecialists. However, when the idea of shifting payments from subspecialists to generalists was raised, there was a marked difference; 66.5% of generalists supported this, while only 16.6% of surgeons did; overall 41.6% were supportive and 46.4% were opposed. That is, for most specialists, paying generalists more is ok, but paying themselves less is not.
The WSJ‘s Matthews quotes an email from Jonathan Blum, deputy administrator for the Centers for Medicare and Medicaid Services (CMS) saying that the Medicare agency is moving to “improve Medicare's physician systems to correct historical biases against primary-care professionals." That needs to happen. The changes need to be dramatic. And they need to happen soon.
[1] Shi L, Macinko J, Starfield B, Xu J, Regan J, Politzer R and Wulu J, “Primary care, infant mortality, and low birthweight in the states of the USA”,J Epidemiol Community Health 2004;58;374-380
[2] Leigh JP, Tancredi D, Jerant A, Kravitz RL, “Physican wages across specialties: informing the physician reimbursement debate, Arch Int Med 25Oct2010; 170(19):1728-34.
[3] Federman AD, Woodward M, Keyhani S, “Physicians’ opinions about reforming reimbursement: results of a national survey”, Arch Int Med, 25Oct2010;170(19):1735-42.
.
A major focus of public health, about which I have written several times, is addressing the disparities in health arising from modifiable conditions (such as inequality of opportunity, income, and racial and ethnic differences). While it is common for those with privilege – wealth, health, opportunity – to believe that they have these privileges because they are “deserving”, i.e., because of their hard work, education, etc., such an outlook minimizes the critically important fact that there are lots of people who work just as hard and have very little. The “illegal immigrant”, working 3 minimum (or sub-minimum) wage jobs to try to just keep his or her family fed and housed, is not only not lazy, but working a lot harder than many of us who are able to enjoy weekends off, play golf, watch the kids’ sporting events.
So it is clearly not hard work alone. It is very much influenced by where you start, and what your opportunities have been. These are the social determinants of health (e.g., Social Determinants, Personal Responsibility, and Health System Outcomes, September 12, 2010) and the capability that people have of acting in healthful ways (Capability: understanding why people may not adopt healthful behaviors, September 24, 2010). It is common for people who have a lot to minimize, rather than to emphasize, the degree to which their position at the start of the race has affected their current position. Attacks on those who would seek to redress some of the most egregious inequities are still couched in terms of “economic class warfare” by those who have already won the war. Those with privilege are very concerned about change that would leave them with less of a leg up; they may give lip service to Horatio Alger heroes, but are more likely to wish to follow the model of George W. Bush. “If you’ve spent your entire life with the wind at your back,” a wise sage once noted (and I do not know to whom to attribute it), “a calm day seems unfair”. In terms of health, the connections are very clear. It is good for your health to be born rich. The Horatio Alger hero, pulled up by their own bootstraps, has worse health outcomes than the child born to privilege.
Health disparities, then, are real and important. But why should we – should anyone – be concerned about the disparities in physician income? After all, even the more “poorly” paid specialists, in primary care, make far more than the average American. Yes, they have worked hard to get into and through medical school and residency training, but, just as noted above, so have a lot of other people who will never make nearly as much. The problem is that, if the presence of a larger number/percent of primary care physicians is associated with improvements in the health of the population, and if the presence of wide disparities in income significantly influence students to choose higher paid specialties instead, then these disparities in health status are likely to continue and the overall health of the American people is likely to suffer. There is good data on both counts. Many of the posts in this blog have addressed the first, the positive influence of primary care on the health of the population (e.g., Lower Costs in Grand Junction: More Primary Care, Less High Tech, October 18, 2010; Primary Care, IMGs, and the Health of the People, August 14, 2010; and many others) and on health disparities[1]. I have also addressed the other point, the decrease in the number of students choosing primary care careers (e.g., Primary care specialty choice: student characteristics, July 12, 2010; Primary Care’s Image: A Problem?, November 17, 2009, and others).
A study published in the Archives of Internal Medicine by Leigh, et. al, “Physician wages across specialties”[2], is the most recent effort to quantify the differences. They utilized the large Community Tracking Study (CTS) of physicians from 2004-2005 to gather information on physician income. They grouped the physician responses into 4 broad categories (surgical, internal medicine and pediatric subspecialties [IMPSS], primary care, and other) and again into 41 specific specialties. They went beyond previous studies to calculate gross personal income on an hourly basis (thus controlling for hours worked per week) and did further adjustments to control for other variables, principally sex and age. They used a statistical manipulation to estimate incomes above the maximum set for the CTS (for some reason set at $400,000, much lower than many subspecialists make).
The outcomes were not surprising in comparison to previously reported data. In the 4 broad-group comparisons, primary care physicians averaged about $60/hr compared to IMPSS at $85, other medical at $88, and surgical at $92. In the single specialty comparisons, General Surgery was taken as a reference being actually near the middle ($86/hr), with the top incomes in neurosurgery ($132), radiation oncology ($126), and medical oncology ($114). At the bottom were family practice, general practice, general internal medicine, geriatric medicine, internal medicine/pediatrics, and “other” pediatric subspecialties (whichever those may have been) with a range of $50-$58.
There are several reasons to think that differences are, in fact, greater than those reported. There was only a 53% response rate to the CTS, and so we do not know if non-respondents made more, less or the same as respondents. “Hospital-based” specialties, specifically anesthesiology and radiology, which are among the highest-paid, were excluded. Other high-end specialties, such as cardiovascular surgery or transplant surgery, do not appear as specific specialties, and may have their incomes hidden when grouped with “thoracic surgery” or “other surgical specialties”. There are many sources of income for many physicians, including a variety of expenses that can be paid by practices and which would presumably be greater for higher income practices. Many highly-paid specialties are paid by hospitals directly (such as anesthesiology and radiology) or through “physician service agreements”. The correction used by the authors of the study for incomes over $400,000 could have been inadequate; certainly anecdotal experience in many locations would suggest that considering $400,000 as a reasonable top end for the highest paid physicians would understate that by at least half.
Nonetheless, the income differences, even in 2004-05, were impressive. Given the debt load that medical students (particularly those, obviously, from the less wealthy families) graduate with, the significant attraction to higher pay is clear.
The Wall St Journal, in two recent articles (“Secrets of the system”) published October 26, 2010, looked at the Relative Value Update Committee (RUC), a group of 29 physicians convened by the AMA from different specialty organizations that make recommendations to Medicare on how to pay physicians for their, well, relative value. One, “Physician panel prescribes the fees paid by Medicare” by Anna Wilde Matthews and Tom McGinty, describes how this group meets to divide up a pie that Medicare seeks to keep constant. In the other, “Dividing the Medicare pie pits doctor against doctor”, Matthews discusses the contentiousness that happened when primary care physicians (greatly outnumbered) challenged their surgical colleagues to get a higher portion of the money (that is, to revalue activities done by primary care physicians relative to surgical specialists).
In the same issue of Archives of Internal Medicine that Leigh’s article appeared in, Federman and colleagues[3] surveyed physicians about whether they thought reimbursements were inequitable or not; 78.4% agreed that they are, with not that much difference between generalists and subspecialists. However, when the idea of shifting payments from subspecialists to generalists was raised, there was a marked difference; 66.5% of generalists supported this, while only 16.6% of surgeons did; overall 41.6% were supportive and 46.4% were opposed. That is, for most specialists, paying generalists more is ok, but paying themselves less is not.
The WSJ‘s Matthews quotes an email from Jonathan Blum, deputy administrator for the Centers for Medicare and Medicaid Services (CMS) saying that the Medicare agency is moving to “improve Medicare's physician systems to correct historical biases against primary-care professionals." That needs to happen. The changes need to be dramatic. And they need to happen soon.
[1] Shi L, Macinko J, Starfield B, Xu J, Regan J, Politzer R and Wulu J, “Primary care, infant mortality, and low birthweight in the states of the USA”,J Epidemiol Community Health 2004;58;374-380
[2] Leigh JP, Tancredi D, Jerant A, Kravitz RL, “Physican wages across specialties: informing the physician reimbursement debate, Arch Int Med 25Oct2010; 170(19):1728-34.
[3] Federman AD, Woodward M, Keyhani S, “Physicians’ opinions about reforming reimbursement: results of a national survey”, Arch Int Med, 25Oct2010;170(19):1735-42.
.
Thursday, November 11, 2010
Hospital Readmissions: Who pays, who decides, and for whom?
.
I recently attended a Forum on health reform put on by the Sunflower Foundation of Topeka, Kansas in Lawrence. The keynote speaker, John McDonough, PhD, gave an excellent rundown of the contents of the ACA health reform law. Prior to that a panel of experts from state government, that included Sandy Praeger (a Republican), Kansas Insurance Commissioner and former chair of the National Association of Insurance Commissioners (NAIC). She made it clear that the requirement that large insurers spend 85%, and small ones 80%, of their premiums on actually providing health care (infamously known as the “medical loss ratio” in insurance circles) will be taken seriously, and that insurance commissioners in NAIC, which is the group charged with making the recommendations on this issue to HHS, will not blithely allow insurers to load lots of costs not obviously related to patient care (like marketing and paying the folks that deny your claims) into this bucket. Other participants included Andy Allison, head of the Kansas Health Policy Authority, a governmental agency that, in addition to doing health policy runs the state Medicaid program, and several people from area foundations and consumer advocacy groups. One might have thought, listening to the discussion, questions from the audience (largely health advocates and professionals), and the responses to them, that Kansans are not only thoughtful but caring, worried about the health of their neighbors and fellow citizens, and hoping that health reform will really bring about positive change.
So, all the rest of you non-Kansans, keep this in mind when you see who we elect to statewide office, to our legislature, and to Congress. They don’t represent everyone in this state. Maybe their positions don’t even represent their own beliefs but rather crass political calculations. Or, perhaps, financial calculations; looking at where the big contributions are coming from, and serving the interests of those donors.
As panelists discussed what they saw as important parts of ACA, I was struck by the comment of one person, representing a consumer group, that a big way that ACA would save money would be in Medicare not paying for hospital re-admissions. (Actually, the term, in Section 3025 of the ACA, Public Law 111-148, p. 290, the term is “excessive” readmissions.) The assumption here is that the re-admission was a result of inadequate care on the previous admission, premature discharge (motivated, presumably, by the length of stay guidelines that are widely in use by organizations such as, say, Medicare!), etc. This is an attractive idea; after all, if you bring your car in to be fixed, and it breaks down shortly thereafter, should you pay for the second visit to the mechanic? (She didn’t say that; it is my metaphor.)
But, of course, only if it for the same problem, right? Not if the first hospitalization was for a broken leg, and the second for heart failure. After all, if your car had its brakes fixed and the transmission goes 2 weeks later, it is not the mechanic’s fault. Unless, maybe the second hospitalization was for a complication of the first, like say a blood clot in the lung. Especially if the patient was not given proper clot prophylaxis the first time. But what if they were given that prophylaxis and the clot happened anyway? It is not always so simple.
It is not always so simple even when the re-admission is for the same problem. People with advanced chronic diseases have advanced chronic diseases. They can be treated as outpatients, but will frequently decompensate, and require hospitalization. Remember Red, Blue, and Purple: The Math of Health Care Spending (October 20, 2009)? This is one of the main groups comprising the 5% of people who use 50% of the health care dollars; even when they are brought into the hospital and “tuned up” (yes, this automotive phrase is in fact used), even, or especially, when they have spent time in intensive care, they get sick and require hospitalization again. Their body is dying, but modern medical care can do remarkable things to forestall that death, to patch folks up, to send them back home, or to a nursing home -- for a while, until their body resumes its inevitable decline; the closer a person in this condition is to dying, the more frequent the readmissions. To continue the automotive metaphor, it is one thing to bring in a 3 year old car for new brakes and have them begin to fail 2 weeks later and bring it back; it is quite another when the car is 15 years old, has multi-system failure and won’t run, but the great mechanic can patch it up so you can drive it off – when it fails again in 2 weeks, is this the mechanic’s fault?
It is obviously unreasonable to say that you won’t pay the mechanic the second time, or for Medicare or other health insurance to not pay the hospital and doctors for the work they do on the re-admission. It might be reasonable to decide that the person, like the car, is not salvageable beyond the very short term and should not be readmitted, but this is a decision that can’t be made by the treating doctors and hospital, and it is unreasonable to not pay them when the patient returns because they did such a good job of keeping him/her alive the last time. When are these readmissions “excessive”?
So who should make the decision? Ideally, the patient, in consultation with family members or others s/he trusts, maybe even his/her doctor. This is, after all, the idea behind what we call “Advance Directives” such as Living Wills and Durable Powers of Attorney for Health Care. But not everyone has them, not everyone has even discussed their preferences with their family or their doctor, not to mention put their decisions down on paper so that those responsible for making decisions when s/he cannot have both something to guide them and, indeed, something that requires them to do it. Doctors are not paid to have these extensive discussions with people, although many of them do it anyway; the component of ACA that was going to reimburse for these discussions was struck after being maligned as (wrongly) being “death panels” that would “decide to kill your grandmother”.
But who should decide? If an elderly person is demented, cannot communicate, is in kidney failure and heart failure and has been admitted several times, including to intensive care, and kept alive by medical technology, who should decide if they will be readmitted from the nursing home when they get worse? Often the nursing home just sends them. If there is family, they are the ones who currently make these decisions, provided that they can agree. What if the patient cannot swallow without choking, but the family doesn’t want him/her to “starve” – should this person get a big central IV to give basic nutrition, or have a surgical procedure to feed directly into the stomach? The family does not pay, Medicare does. What would you decide? You would never do this to your parent or want it for yourself? Are you willing to be on the “death panel” that overrules the family? What about the similarly demented and sick person who has been admitted to the intensive care unit 3 times in the last year, amazingly “survived” to discharge, and finally, after several later readmissions, finally does die. And the daughter wants to sue because “somebody” must have done “something” wrong? Should we not pay the hospital? Should we tell the ambulance not to pick her up? Will you be the one to tell the daughter that the fact that she has obviously unresolved issues, and that she should have accepted during the first 6-week ICU stay that her mother was going to die soon?
I hope you will be. I hope you will be out there, helping support the healthcare professionals to make the right decisions, not because Medicare is paying but because they are right. And help us to figure out what the right decisions are. While all of us feel differently about those close to us than about strangers, "save money on them, spend it on me!" is not a reasonable, or moral, strategy.
.
I recently attended a Forum on health reform put on by the Sunflower Foundation of Topeka, Kansas in Lawrence. The keynote speaker, John McDonough, PhD, gave an excellent rundown of the contents of the ACA health reform law. Prior to that a panel of experts from state government, that included Sandy Praeger (a Republican), Kansas Insurance Commissioner and former chair of the National Association of Insurance Commissioners (NAIC). She made it clear that the requirement that large insurers spend 85%, and small ones 80%, of their premiums on actually providing health care (infamously known as the “medical loss ratio” in insurance circles) will be taken seriously, and that insurance commissioners in NAIC, which is the group charged with making the recommendations on this issue to HHS, will not blithely allow insurers to load lots of costs not obviously related to patient care (like marketing and paying the folks that deny your claims) into this bucket. Other participants included Andy Allison, head of the Kansas Health Policy Authority, a governmental agency that, in addition to doing health policy runs the state Medicaid program, and several people from area foundations and consumer advocacy groups. One might have thought, listening to the discussion, questions from the audience (largely health advocates and professionals), and the responses to them, that Kansans are not only thoughtful but caring, worried about the health of their neighbors and fellow citizens, and hoping that health reform will really bring about positive change.
So, all the rest of you non-Kansans, keep this in mind when you see who we elect to statewide office, to our legislature, and to Congress. They don’t represent everyone in this state. Maybe their positions don’t even represent their own beliefs but rather crass political calculations. Or, perhaps, financial calculations; looking at where the big contributions are coming from, and serving the interests of those donors.
As panelists discussed what they saw as important parts of ACA, I was struck by the comment of one person, representing a consumer group, that a big way that ACA would save money would be in Medicare not paying for hospital re-admissions. (Actually, the term, in Section 3025 of the ACA, Public Law 111-148, p. 290, the term is “excessive” readmissions.) The assumption here is that the re-admission was a result of inadequate care on the previous admission, premature discharge (motivated, presumably, by the length of stay guidelines that are widely in use by organizations such as, say, Medicare!), etc. This is an attractive idea; after all, if you bring your car in to be fixed, and it breaks down shortly thereafter, should you pay for the second visit to the mechanic? (She didn’t say that; it is my metaphor.)
But, of course, only if it for the same problem, right? Not if the first hospitalization was for a broken leg, and the second for heart failure. After all, if your car had its brakes fixed and the transmission goes 2 weeks later, it is not the mechanic’s fault. Unless, maybe the second hospitalization was for a complication of the first, like say a blood clot in the lung. Especially if the patient was not given proper clot prophylaxis the first time. But what if they were given that prophylaxis and the clot happened anyway? It is not always so simple.
It is not always so simple even when the re-admission is for the same problem. People with advanced chronic diseases have advanced chronic diseases. They can be treated as outpatients, but will frequently decompensate, and require hospitalization. Remember Red, Blue, and Purple: The Math of Health Care Spending (October 20, 2009)? This is one of the main groups comprising the 5% of people who use 50% of the health care dollars; even when they are brought into the hospital and “tuned up” (yes, this automotive phrase is in fact used), even, or especially, when they have spent time in intensive care, they get sick and require hospitalization again. Their body is dying, but modern medical care can do remarkable things to forestall that death, to patch folks up, to send them back home, or to a nursing home -- for a while, until their body resumes its inevitable decline; the closer a person in this condition is to dying, the more frequent the readmissions. To continue the automotive metaphor, it is one thing to bring in a 3 year old car for new brakes and have them begin to fail 2 weeks later and bring it back; it is quite another when the car is 15 years old, has multi-system failure and won’t run, but the great mechanic can patch it up so you can drive it off – when it fails again in 2 weeks, is this the mechanic’s fault?
It is obviously unreasonable to say that you won’t pay the mechanic the second time, or for Medicare or other health insurance to not pay the hospital and doctors for the work they do on the re-admission. It might be reasonable to decide that the person, like the car, is not salvageable beyond the very short term and should not be readmitted, but this is a decision that can’t be made by the treating doctors and hospital, and it is unreasonable to not pay them when the patient returns because they did such a good job of keeping him/her alive the last time. When are these readmissions “excessive”?
So who should make the decision? Ideally, the patient, in consultation with family members or others s/he trusts, maybe even his/her doctor. This is, after all, the idea behind what we call “Advance Directives” such as Living Wills and Durable Powers of Attorney for Health Care. But not everyone has them, not everyone has even discussed their preferences with their family or their doctor, not to mention put their decisions down on paper so that those responsible for making decisions when s/he cannot have both something to guide them and, indeed, something that requires them to do it. Doctors are not paid to have these extensive discussions with people, although many of them do it anyway; the component of ACA that was going to reimburse for these discussions was struck after being maligned as (wrongly) being “death panels” that would “decide to kill your grandmother”.
But who should decide? If an elderly person is demented, cannot communicate, is in kidney failure and heart failure and has been admitted several times, including to intensive care, and kept alive by medical technology, who should decide if they will be readmitted from the nursing home when they get worse? Often the nursing home just sends them. If there is family, they are the ones who currently make these decisions, provided that they can agree. What if the patient cannot swallow without choking, but the family doesn’t want him/her to “starve” – should this person get a big central IV to give basic nutrition, or have a surgical procedure to feed directly into the stomach? The family does not pay, Medicare does. What would you decide? You would never do this to your parent or want it for yourself? Are you willing to be on the “death panel” that overrules the family? What about the similarly demented and sick person who has been admitted to the intensive care unit 3 times in the last year, amazingly “survived” to discharge, and finally, after several later readmissions, finally does die. And the daughter wants to sue because “somebody” must have done “something” wrong? Should we not pay the hospital? Should we tell the ambulance not to pick her up? Will you be the one to tell the daughter that the fact that she has obviously unresolved issues, and that she should have accepted during the first 6-week ICU stay that her mother was going to die soon?
I hope you will be. I hope you will be out there, helping support the healthcare professionals to make the right decisions, not because Medicare is paying but because they are right. And help us to figure out what the right decisions are. While all of us feel differently about those close to us than about strangers, "save money on them, spend it on me!" is not a reasonable, or moral, strategy.
.
Monday, October 18, 2010
Lower Costs in Grand Junction: More Primary Care, Less High Tech
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Grand Junction, Colorado, and particularly the medical care system in Grand Junction, Colorado, has been getting a great deal of publicity since the health care debate began, because it is a community with lower health-care costs, combined with high health status, compared to much of the country. While well-known to health policy analysts for many years, and particularly featured in the analyses of the Dartmouth Atlas of Health Care, it gained greatest fame when Dr. Atul Gawande published “The Cost Conundrum” in the New Yorker in June, 2009. While the focus of the article was the exceedingly high per capita cost for Medicare in the border town of McAllen, Texas, including how unfavorably those costs compared to the other border town of El Paso, Grand Junction was prominently cited as a community in which Medicare costs, and all health care costs, were exceptionally low. This little town on the western slopes of the Rocky Mountains has become a potential model for those who believe health care costs can be controlled while maintaining or increasing quality, and a bugbear for those (mostly those profiting from medical care, or funded by corporations that so profit) who fear limits on medical costs.
The most recent, and brief and pithy, article, “Low-cost lessons from Grand Junction, Colorado”[1] comes from Thomas Bodenheimer and David West in the October 7, 2010 issue of the New England Journal of Medicine. They cite the statistics on health care and costs in Grand Junction and Mesa County from the Dartmouth Atlas: “…average per capita Medicare spending in Grand Junction was $6,599 in 2007 — 24% lower than the national average and 60% below high-cost Miami”, while maintaining high quality, including high performance on preventive metrics. They note that “…data on mortality and morbidity from the Robert Wood Johnson Foundation and the University of Wisconsin's County Health Rankings database show that the population of Grand Junction's Mesa County is far less healthy than those of some U.S. counties with high Medicare costs (www.countyhealthrankings.org), although it is number one in Colorado in the quality of clinical care provided. One would expect less-healthy communities to have higher costs.”
Bodenheimer and West cite 7 characteristics of the Grand Junction medical system that they believe are responsible for this situation and might be replicable (if “generally not without political battles”):
“These are leadership by the primary care community; a payment system involving risk sharing by physicians; equalization of physician payment for the care of Medicare, Medicaid, and privately insured patients; regionalization of services into an orderly system of primary, secondary, and tertiary care; limits on the supply of expensive resources, including specialists, beds, and equipment; payment of primary care physicians for hospital visits; and robust end-of-life care.”
The payment system is based upon the Rocky Mountain HMO, begun in the 1970s and involving most of the providers in the western slope. This HMO gained the attention of scholars years ago, and was described in a case study by Wellever and Moscovice in the Journal of Rural Health in 1998.[2] One of the key parts of the “Rocky” is that it contracts with both Medicare (via a Medicare Advantage program) and Colorado Medicaid, so that providers, who are largely independent in solo or small groups, are paid more or less a single rate, regardless of the insurance (Medicaid, Medicare, or contracted with Rocky via an employer). This makes costs and reimbursement much more predictable and allows physicians to provide the appropriate care for patients, without trying to figure out what their insurance will pay for. It provides the physicians with the security that would, in fact, characterize a single-payer system.
The other critical component is not only leadership by primary care (and predominantly family) physicians, but an appropriate balance between primary care doctors and specialists, and a limitation on the expansion of procedural services that may not be necessary. The key quotation from Bodenheimer and West here is “Because only one hospital can offer interventional cardiac procedures, there isn't room for many cardiologists in Grand Junction; with such limits on facilities and workforce, the rates of such procedures remain low. The same applies to other types of expensive procedures.”
This is entirely the opposite of what happens in most communities, in which competing hospitals seek to add more facilities and hire or contract with more subspecialist physicians in order to increase the income of both physicians and the hospital. As I have discussed in the past (e.g., Cancer Care and Hospital Advertising, January 16, 2010; Doctors, their Patients, and Health Reform, August 6, 2009) and as the Dartmouth Atlas makes clear, the number of expensive services provided to patients is very different in different parts of the country, and demand is very “elastic”; that is, it is often determined not by need but by the availability of physicians and facilities. That is, supply drives demand, rather than vice versa. Hospitals in other communities compete for doctors and patients (insured patients, let us be clear!) so that they can have a bigger “market share”. This “business” rather than health, approach, can be insidious, destructive, and expensive enough, with overbuilding resulting in overcapacity. More serious, however, as Kelly reminds us,[3] than seeking a bigger market share is the complementary business practice of expanding the market – finding new “customers” for your product – in this case, high cost procedures.
Do I know if the number of interventional cardiac procedures (or any other procedures) done in Grand Junction is the “right number”, or if the system that exists there and limits them means that too few are done? No, of course not. We can look at data cited by Bodenheimer and West that suggest that it is not far off, that health status is not decreasing, and that preventive services on discharge are higher than average. But I do know that there is a “right number” and that it is determined by the health status of the patient population and the risk/benefit ratio from doing procedures, not by the driver of “more is better”. Arguable for other consumer goods (e.g., cars, music, toothpaste), the idea of “expanding the market” for expensive medical procedures – widening the field of those who are “eligible” so that we can have “more business” and make more money, is outrageous and immoral, as well as ridiculously expensive. This is true for procedures which are highly advertised and of little or no medical value as well as for procedures that can be important and lifesaving when utilized appropriately in the right patients. The money not spent on unnecessary high-tech procedures can provide more primary care to more people, and improve health outcomes.
Grand Junction, Colorado may not have all the answers to our health care system, any more than Canada or Britain or Switzerland do. But it is doing a lot of things right, it is saving money, and it is improving the health of the community, and that’s a lot more than most areas in the US are doing.
[1]Bodenheimer T, West D, “Low-cost lessons from Grand Junction, Colorado”, NEJM 7Oct2010;363(15):1391-3
[2] Wellever A, Moscovice I, “Rocky Mountain HMO”, J Rural Health. 1998 Summer;14(3):211-23
[3] Kelly PJ, Personal communication.
Grand Junction, Colorado, and particularly the medical care system in Grand Junction, Colorado, has been getting a great deal of publicity since the health care debate began, because it is a community with lower health-care costs, combined with high health status, compared to much of the country. While well-known to health policy analysts for many years, and particularly featured in the analyses of the Dartmouth Atlas of Health Care, it gained greatest fame when Dr. Atul Gawande published “The Cost Conundrum” in the New Yorker in June, 2009. While the focus of the article was the exceedingly high per capita cost for Medicare in the border town of McAllen, Texas, including how unfavorably those costs compared to the other border town of El Paso, Grand Junction was prominently cited as a community in which Medicare costs, and all health care costs, were exceptionally low. This little town on the western slopes of the Rocky Mountains has become a potential model for those who believe health care costs can be controlled while maintaining or increasing quality, and a bugbear for those (mostly those profiting from medical care, or funded by corporations that so profit) who fear limits on medical costs.
The most recent, and brief and pithy, article, “Low-cost lessons from Grand Junction, Colorado”[1] comes from Thomas Bodenheimer and David West in the October 7, 2010 issue of the New England Journal of Medicine. They cite the statistics on health care and costs in Grand Junction and Mesa County from the Dartmouth Atlas: “…average per capita Medicare spending in Grand Junction was $6,599 in 2007 — 24% lower than the national average and 60% below high-cost Miami”, while maintaining high quality, including high performance on preventive metrics. They note that “…data on mortality and morbidity from the Robert Wood Johnson Foundation and the University of Wisconsin's County Health Rankings database show that the population of Grand Junction's Mesa County is far less healthy than those of some U.S. counties with high Medicare costs (www.countyhealthrankings.org), although it is number one in Colorado in the quality of clinical care provided. One would expect less-healthy communities to have higher costs.”
Bodenheimer and West cite 7 characteristics of the Grand Junction medical system that they believe are responsible for this situation and might be replicable (if “generally not without political battles”):
“These are leadership by the primary care community; a payment system involving risk sharing by physicians; equalization of physician payment for the care of Medicare, Medicaid, and privately insured patients; regionalization of services into an orderly system of primary, secondary, and tertiary care; limits on the supply of expensive resources, including specialists, beds, and equipment; payment of primary care physicians for hospital visits; and robust end-of-life care.”
The payment system is based upon the Rocky Mountain HMO, begun in the 1970s and involving most of the providers in the western slope. This HMO gained the attention of scholars years ago, and was described in a case study by Wellever and Moscovice in the Journal of Rural Health in 1998.[2] One of the key parts of the “Rocky” is that it contracts with both Medicare (via a Medicare Advantage program) and Colorado Medicaid, so that providers, who are largely independent in solo or small groups, are paid more or less a single rate, regardless of the insurance (Medicaid, Medicare, or contracted with Rocky via an employer). This makes costs and reimbursement much more predictable and allows physicians to provide the appropriate care for patients, without trying to figure out what their insurance will pay for. It provides the physicians with the security that would, in fact, characterize a single-payer system.
The other critical component is not only leadership by primary care (and predominantly family) physicians, but an appropriate balance between primary care doctors and specialists, and a limitation on the expansion of procedural services that may not be necessary. The key quotation from Bodenheimer and West here is “Because only one hospital can offer interventional cardiac procedures, there isn't room for many cardiologists in Grand Junction; with such limits on facilities and workforce, the rates of such procedures remain low. The same applies to other types of expensive procedures.”
This is entirely the opposite of what happens in most communities, in which competing hospitals seek to add more facilities and hire or contract with more subspecialist physicians in order to increase the income of both physicians and the hospital. As I have discussed in the past (e.g., Cancer Care and Hospital Advertising, January 16, 2010; Doctors, their Patients, and Health Reform, August 6, 2009) and as the Dartmouth Atlas makes clear, the number of expensive services provided to patients is very different in different parts of the country, and demand is very “elastic”; that is, it is often determined not by need but by the availability of physicians and facilities. That is, supply drives demand, rather than vice versa. Hospitals in other communities compete for doctors and patients (insured patients, let us be clear!) so that they can have a bigger “market share”. This “business” rather than health, approach, can be insidious, destructive, and expensive enough, with overbuilding resulting in overcapacity. More serious, however, as Kelly reminds us,[3] than seeking a bigger market share is the complementary business practice of expanding the market – finding new “customers” for your product – in this case, high cost procedures.
Do I know if the number of interventional cardiac procedures (or any other procedures) done in Grand Junction is the “right number”, or if the system that exists there and limits them means that too few are done? No, of course not. We can look at data cited by Bodenheimer and West that suggest that it is not far off, that health status is not decreasing, and that preventive services on discharge are higher than average. But I do know that there is a “right number” and that it is determined by the health status of the patient population and the risk/benefit ratio from doing procedures, not by the driver of “more is better”. Arguable for other consumer goods (e.g., cars, music, toothpaste), the idea of “expanding the market” for expensive medical procedures – widening the field of those who are “eligible” so that we can have “more business” and make more money, is outrageous and immoral, as well as ridiculously expensive. This is true for procedures which are highly advertised and of little or no medical value as well as for procedures that can be important and lifesaving when utilized appropriately in the right patients. The money not spent on unnecessary high-tech procedures can provide more primary care to more people, and improve health outcomes.
Grand Junction, Colorado may not have all the answers to our health care system, any more than Canada or Britain or Switzerland do. But it is doing a lot of things right, it is saving money, and it is improving the health of the community, and that’s a lot more than most areas in the US are doing.
[1]Bodenheimer T, West D, “Low-cost lessons from Grand Junction, Colorado”, NEJM 7Oct2010;363(15):1391-3
[2] Wellever A, Moscovice I, “Rocky Mountain HMO”, J Rural Health. 1998 Summer;14(3):211-23
[3] Kelly PJ, Personal communication.
Wednesday, October 13, 2010
"Top Doctors": Who are they -- and who are they not necessarily?
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I have written about the US News and World Report ratings of “Best Medical Schools” (Rankings of Medical Schools: Do they tell us anything?, Sept 25, 2009; A New Way of Ranking Medical Schools: Social Mission, June 20, 2010). Another popular concept is identifying “Best Doctors”. Seems like every local magazine (“Your City’s Name Here!”) has a list of Top Doctors in various specialties. At another level, the airline magazines have full page ads (www.topdoctors.com) where they list 6 or 7 “top doctors” in a given specialty (orthopedics, plastic surgery, cardiology…never primary care!), usually one in each of several major metropolitan areas. The idea here seems to be to attract the business of well-to-do people who are flying, and may need, say, a rotator cuff repair or a breast augmentation. In addition, if you put a doctor’s name into an internet search engine, most of the “hits” will not be links to her/his office, but rather listings – sometimes accompanied by ratings – on a variety of sites. So what does this mean? Are these listings reliable? Should you go to a “top doctor”?
Why not? We all want to go to a good doctor. And isn’t a “top doctor” even better? Of course, if we think about it, we might want to know the basis on which these top doctors are selected; that makes sense. After all, if a site lists the “best cars” and we discover the criteria is which ones are capable of the highest speeds, or hold the largest number of people or cargo, that’s great if what you are looking for is a fast or big car. But if you want, say, a high-mileage car, probably these cars are not the “best”.
Unfortunately, it is very difficult to find out what the criteria are. Even more difficult than finding out how US News ranks medical schools. Some of them are from patient surveys – you are randomly called, or more likely solicited to fill out a survey on what you thought of your doctor. There are problems with this method, although it is nice to know people like their doctors. First, it is not a scientific sample. Maybe people who are happy with their doctors are more likely to fill out such a form. Or (more likely) maybe those who are unhappy with her/him are. Second, people can only evaluate what they can evaluate, and that may or may not be what is important to you. If a doctor listens, shows caring, responds in a collaborative manner – a person can rate that, and maybe that is important to you too (it should be). But maybe you are not interested in collaboration; maybe you just want a doctor who will tell you what to do (probably not if you are reading this site, or reading “top doctor” surveys, but many people are).
Most determinants of physician quality, other than interpersonal skills (and these are very important!) are beyond the ability of patients to assess. Because people really have no way of knowing about many components of the quality of care that they get, much of what they evaluate hospitals (and to a lesser extent, physicians) on is their “hotel services” – are the rooms big? Clean? Well-furnished? Is the food good? More relevant to quality among things people can evaluate are “how are you treated”? Are people attentive? Do they explain things to you? Are your questions answered? (This is, of course, not the same thing as getting whatever you want; receiving medical care is not shopping in a convenience store!) Finally, while a patient can know if they had a good outcome or not, they have no way of knowing if it might have been better – or worse – with a different doctor, or hospital.
If you are, say, having surgery, it might be nice to know how satisfied people are with the surgical results. Or how often people die. It is very hard to get this data, and harder still to control for important causes of variation (we call them “confounders” in research; things that might be associated with both the condition and the outcome). For example, one surgeon might have a very much higher mortality rate than another – until you find out that s/he is operating on the sickest people, the ones who were at highest risk for death, the ones the other surgeons wouldn’t dare to operate on – and that is why a higher percent of his/her patients die; if someone else were operating on the same population, their mortality rates would in all likelihood be much higher.
So what do these ratings mean? Usually not much. One thing that most of the “top doctors”, especially the ones in the airplane magazines, seem to have in common is fancy addresses: Rodeo Drive, Fifth Avenue, North Michigan Avenue. They have their practices in rich neighborhoods and take care of rich people. This may make them the most famous, especially among the folks who the people who write these articles talk to. And, likely, they are among the most financially successful, and thus able to pay to get their names on some of these lists. What it most certainly does not mean is that they are the best doctors, in any of the ways that you might mean it (nicest, best surgical outcomes, best listener, wisest, most highly respected by his/her colleagues, you pick it!). It also doesn’t mean they are not good – or maybe even among the best doctors -- but it is scarcely a guarantee. What they are is doctors who have, for a variety of reasons, chosen to take care of rich people in fancy neighborhoods. The reasons may be ego, a desire for status, a desire for bigger incomes (really a common one) or even a prejudice against or revulsion for poor people.
They are presumed to be the best because they are the ones who take care of rich people, and rich people get the best, right? They have the best cars, and houses, and jewelry, and yachts, and everything else, so they must have the best doctors, right? Wrong. What they have is the doctors who want to take care of rich people. Any medical school has some students who are looking toward such a career, as a prominent rich-people’s doctor, just as others are planning to work in middle class, working class, or poor communities. Or in rural areas. Or in third-world countries. I’ve got news for you – the students in the latter groups are not less smart or less skilled than those in the former group. They probably are more committed and have more developed social values. The densest kid in the class could be on Park Avenue and the smartest practicing in the ghetto, the country, or in Africa.
I don’t know the association of skill as a physician or surgeon and the socioeconomic groups that they care for. I know of both good and not-so-good doctors in all groups. Certainly, every time a celebrity dies of an overdose, we hear of some “Dr. Feelgood” who supplied them with dope, a doctor who was – at least before this adverse publicity – a “top doctor”, a “doctor to the stars” – but not my any measure a good, not to mention “best”, doctor. While elite offices can offer you nicer furniture, less crowded conditions, and more people who look like you (if you are rich), if you are really looking for the “best doctor”, it’s a crapshoot. S/he may be working in the free clinic across town.
So what do you do? Pretty much what you do now. Take recommendations from friends – provided that you think that the friend values the same things as you do in a physician. One who listens. One who is old. One who is young. One who has a nice office or office staff. Maybe one who has – if your friend can tell – helped them to improve their health. Now that would be a good one!
.
I have written about the US News and World Report ratings of “Best Medical Schools” (Rankings of Medical Schools: Do they tell us anything?, Sept 25, 2009; A New Way of Ranking Medical Schools: Social Mission, June 20, 2010). Another popular concept is identifying “Best Doctors”. Seems like every local magazine (“Your City’s Name Here!”) has a list of Top Doctors in various specialties. At another level, the airline magazines have full page ads (www.topdoctors.com) where they list 6 or 7 “top doctors” in a given specialty (orthopedics, plastic surgery, cardiology…never primary care!), usually one in each of several major metropolitan areas. The idea here seems to be to attract the business of well-to-do people who are flying, and may need, say, a rotator cuff repair or a breast augmentation. In addition, if you put a doctor’s name into an internet search engine, most of the “hits” will not be links to her/his office, but rather listings – sometimes accompanied by ratings – on a variety of sites. So what does this mean? Are these listings reliable? Should you go to a “top doctor”?
Why not? We all want to go to a good doctor. And isn’t a “top doctor” even better? Of course, if we think about it, we might want to know the basis on which these top doctors are selected; that makes sense. After all, if a site lists the “best cars” and we discover the criteria is which ones are capable of the highest speeds, or hold the largest number of people or cargo, that’s great if what you are looking for is a fast or big car. But if you want, say, a high-mileage car, probably these cars are not the “best”.
Unfortunately, it is very difficult to find out what the criteria are. Even more difficult than finding out how US News ranks medical schools. Some of them are from patient surveys – you are randomly called, or more likely solicited to fill out a survey on what you thought of your doctor. There are problems with this method, although it is nice to know people like their doctors. First, it is not a scientific sample. Maybe people who are happy with their doctors are more likely to fill out such a form. Or (more likely) maybe those who are unhappy with her/him are. Second, people can only evaluate what they can evaluate, and that may or may not be what is important to you. If a doctor listens, shows caring, responds in a collaborative manner – a person can rate that, and maybe that is important to you too (it should be). But maybe you are not interested in collaboration; maybe you just want a doctor who will tell you what to do (probably not if you are reading this site, or reading “top doctor” surveys, but many people are).
Most determinants of physician quality, other than interpersonal skills (and these are very important!) are beyond the ability of patients to assess. Because people really have no way of knowing about many components of the quality of care that they get, much of what they evaluate hospitals (and to a lesser extent, physicians) on is their “hotel services” – are the rooms big? Clean? Well-furnished? Is the food good? More relevant to quality among things people can evaluate are “how are you treated”? Are people attentive? Do they explain things to you? Are your questions answered? (This is, of course, not the same thing as getting whatever you want; receiving medical care is not shopping in a convenience store!) Finally, while a patient can know if they had a good outcome or not, they have no way of knowing if it might have been better – or worse – with a different doctor, or hospital.
If you are, say, having surgery, it might be nice to know how satisfied people are with the surgical results. Or how often people die. It is very hard to get this data, and harder still to control for important causes of variation (we call them “confounders” in research; things that might be associated with both the condition and the outcome). For example, one surgeon might have a very much higher mortality rate than another – until you find out that s/he is operating on the sickest people, the ones who were at highest risk for death, the ones the other surgeons wouldn’t dare to operate on – and that is why a higher percent of his/her patients die; if someone else were operating on the same population, their mortality rates would in all likelihood be much higher.
So what do these ratings mean? Usually not much. One thing that most of the “top doctors”, especially the ones in the airplane magazines, seem to have in common is fancy addresses: Rodeo Drive, Fifth Avenue, North Michigan Avenue. They have their practices in rich neighborhoods and take care of rich people. This may make them the most famous, especially among the folks who the people who write these articles talk to. And, likely, they are among the most financially successful, and thus able to pay to get their names on some of these lists. What it most certainly does not mean is that they are the best doctors, in any of the ways that you might mean it (nicest, best surgical outcomes, best listener, wisest, most highly respected by his/her colleagues, you pick it!). It also doesn’t mean they are not good – or maybe even among the best doctors -- but it is scarcely a guarantee. What they are is doctors who have, for a variety of reasons, chosen to take care of rich people in fancy neighborhoods. The reasons may be ego, a desire for status, a desire for bigger incomes (really a common one) or even a prejudice against or revulsion for poor people.
They are presumed to be the best because they are the ones who take care of rich people, and rich people get the best, right? They have the best cars, and houses, and jewelry, and yachts, and everything else, so they must have the best doctors, right? Wrong. What they have is the doctors who want to take care of rich people. Any medical school has some students who are looking toward such a career, as a prominent rich-people’s doctor, just as others are planning to work in middle class, working class, or poor communities. Or in rural areas. Or in third-world countries. I’ve got news for you – the students in the latter groups are not less smart or less skilled than those in the former group. They probably are more committed and have more developed social values. The densest kid in the class could be on Park Avenue and the smartest practicing in the ghetto, the country, or in Africa.
I don’t know the association of skill as a physician or surgeon and the socioeconomic groups that they care for. I know of both good and not-so-good doctors in all groups. Certainly, every time a celebrity dies of an overdose, we hear of some “Dr. Feelgood” who supplied them with dope, a doctor who was – at least before this adverse publicity – a “top doctor”, a “doctor to the stars” – but not my any measure a good, not to mention “best”, doctor. While elite offices can offer you nicer furniture, less crowded conditions, and more people who look like you (if you are rich), if you are really looking for the “best doctor”, it’s a crapshoot. S/he may be working in the free clinic across town.
So what do you do? Pretty much what you do now. Take recommendations from friends – provided that you think that the friend values the same things as you do in a physician. One who listens. One who is old. One who is young. One who has a nice office or office staff. Maybe one who has – if your friend can tell – helped them to improve their health. Now that would be a good one!
.
Thursday, October 7, 2010
Primary Care Grants from HRSA: not enough, not wisely done
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In late September, the Health Resources Services Administration (HRSA), a branch of the federal Department of Health and Human Services (HHS) released the funding announcements for its grants support a variety of educational programs for academic year 2010-11. This was long anticipated news by those who had applied for them, since the time period that they cover began in July. The grants cover a wide variety of areas largely involving enhancement of the health professions workforce in primary care, oral health, physician’s assistants programs, minority health, geriatrics, pipeline development, and this year (with ARRA funds) $50 million for equipment. State-by-state funding (very important politically!) can be found here, broken down by state and category here, information on individual grants, by county, can be found here.
Virtually all of the programs supported by HRSA are in important areas that I have written about previously, but I will focus here on those I know best, the “Primary Care Cluster”, part of Title VII. These grants support program innovation in Residency Training, Medical Student (Predoctoral) Education, Faculty Development, and “Academic Administrative Units” (essentially departments of primary care). They have their roots in the development of Family Medicine as a discipline in the 1970s. The feds then, as now, saw primary care (family medicine) as an important need, but one which needed nurturance. Residency programs were being started and needed funding to develop and experiment with different curricula that would be most appropriate to create family doctors. There were no departments of Family Medicine in medical schools, or even academic faculty in the discipline, so the Academic Units grants were created to help support the creation of the former, and the Faculty Development grants the latter. Predoctoral grants helped develop the curriculum for educating medical students in family medicine.
These grants were successful, both in creating programs that trained more family doctors and doctors who went into practice in underserved communities, often through the National Health Service Corps (NHSC), another HRSA program. In addition, another (possibly unanticipated) outcome was that the formal training of family medicine faculty and fellows in educational skills, felt necessary because there were not existing physician educators in this field, created a core cadre of physician medical educators that was far more extensively and formally trained in areas such as teaching skills, curriculum development, implementation, and evaluation, and other education methodologies than faculty in other departments, revealing a large, previously unrecognized need in medical school and residency faculties. In the 1980s, the grants were expanded to a larger pool of primary care programs, primarily General Internal Medicine and General Pediatrics, and later Physician’s Assistants.[1] They became critical supports for innovation in the education of students, residents, and faculty.
While these programs were very successful, reported in numerous articles reporting on general internal medicine[2], general pediatrics, and family medicine (notably in a special issue of Academic Medicine, November 2008) and has been demonstrated to increase the number of physicians practicing in community health centers (Rittenhouse DR, 2008), and have actually enjoyed bipartisan support (after all, both Republican and Democratic legislators have underserved rural and urban areas in their districts), funding has always been threatened. For many years, Presidents of both parties would “zero out” funding for these programs in their budgets, only to have them restored by Congress after significant pressure from their constituents. Even then funding has often been cut; in 2006 there was just enough to fund the existing (usually 3-year) grants and no new ones were funded, and the years since have been marginal.
So there was great anticipation this year, with large (for a small program such as this, compared, say to the NIH funding of biomedical research in the tens of billions) increases from previous desert levels. Much of this was ARRA (stimulus) funding. And the results have been very disappointing. Like much of ARRA, emphasis was placed on projects that would programs that could show quick, tangible results so a good portion went to equipment grants. Some went to specific Congressional earmarks. ARRA funds supporting traditional Title VII Primary Care grants were for 5 years, and were all that was available to General Internal Medicine and General Pediatrics; the relatively small number of programs that were funded thus received relatively large grants. ARRA funds also supported a miniscule number (5) of new Academic Units Grants for Family Medicine. The pot for “regular” funds for grants was smaller than it has been in many other years, and large numbers of faculty development, residency, and medical student education grants that were highly-scored by the peer reviewers did not qualify for funding. The application of ARRA funds made this a particularly crazy year; in the Spring those with existing funding were told that they “might” have to submit new grants, in two weeks, so they wrote them before being told “never mind”. The grant reviews happened late and so funding was late. The staff at HRSA, a highly committed group, must have felt whipsawed by changes in rules from above and urgent questions from potential and current grantees.
So, life is tough. Not all grants get funded. Maybe only a small minority do – talk to those who apply for funds to NIH. And so the money came late – it came (to those who received it.) For grants other than those supporting faculty development fellowships, which would have needed to recruit fellows months before the end the academic year – this is not such a big problem. But with all the talk – justified – about the need to produce more primary care physicians for the US, this is a very small pool of funds to be divided up. Some family medicine leaders have given up on HRSA funding; one writes “Title VII is a dinosaur…it has not effectively funded new ideas for more than a decade…it is no better than a random lottery…” The rigid priority and preferences, good for some reasons, do tend to stifle innovation.
The other issue is the disposition of funds between the 3 primary care specialties, and especially the large 5-year grants to general internal medicine (the leader quoted above continues, “…although it doesn’t seem very random if all the AAU grants went to internal medicine.”) As has been noted on this blog before, the percent of graduates of 3-year IM residencies who enter primary care (general) internal medicine is vanishingly small; most go on to subspecialty fellowships, and most of the rest become hospitalists. The New England Journal of Medicine’s health policy writer, John Iglehart, describes this in the August 5, 2010 issue in an overview of the impact of the ACA law on residency training, “Health reform, primary care and graduate medical education”,[3] in which he indicates 10-20% of internal medicine residency graduates will enter primary care (I think 20% is dreaming; even 10% may be!) From one perspective, perhaps GIM needs a “jumpstart”, but there is little reason to believe HRSA grant funding will change the decisions (largely financial) for most IM graduates. On the other hand, Family Medicine residencies are producing primary care doctors in every study (Iglehart says 91%), so it could reasonably be argued that the funding should go with proven success.
Interestingly, one of the priority criteria for funding was that “90% of students entering ‘primary care’ specialties (FM, IM, Pediatrics) are in primary care practices 3 years later.” Given the large number entering IM, and the low % at almost all schools entering GIM, this is an extremely high bar, even though it generously uses 3 years rather than the 8 years post-graduation used in the study by Mullan and colleagues cited previously (A New Way of Ranking Medical Schools: Social Mission). The social mission of medical education: ranking the schools[4] used 8-year data to account for such things as a delay for a year or 2 between completing residency and entering a subspecialty fellowship as might occur for a 2-year NHSC commitment or a brief stint as a hospitalist to make money. My school, the University of Kansas, was ranked #5 nationally, mostly for its success in getting graduates into primary care and rural practice, but this was almost entirely due to family medicine; when the HRSA criteria are applied, only 70% of graduates of FM, GIM, and Peds were in primary care in 3 years, reflecting the fact that for KU graduates, as those from most institutions, the retention of internists in primary care is abysmal.
In any case, it is critically important to have significant federal funding for education and training in primary care if we are to meet our nation’s health needs, have physicians for rural areas, and staff our community health centers. The funding needs to be much greater, it needs to be reliable year-to-year, it should have consistent criteria, and it decisions should be made well before the start of the grant period. It is the least that Congress can do.
[1] Funds are also available to support nurse practitioner programs, but through a different stream, targeted to nursing.
[2] (Lipkin M, 2008)
[3] Iglehart JK, Health reform, primary care and graduate medical education, NEJM 5Aug2010;363(6):584-90.
[4] Mullan F et. al., The Social Mission of Medical Education: Ranking the Schools, Annals of Internal Medicine, 15Jun2010;152(12):804-10
.
In late September, the Health Resources Services Administration (HRSA), a branch of the federal Department of Health and Human Services (HHS) released the funding announcements for its grants support a variety of educational programs for academic year 2010-11. This was long anticipated news by those who had applied for them, since the time period that they cover began in July. The grants cover a wide variety of areas largely involving enhancement of the health professions workforce in primary care, oral health, physician’s assistants programs, minority health, geriatrics, pipeline development, and this year (with ARRA funds) $50 million for equipment. State-by-state funding (very important politically!) can be found here, broken down by state and category here, information on individual grants, by county, can be found here.
Virtually all of the programs supported by HRSA are in important areas that I have written about previously, but I will focus here on those I know best, the “Primary Care Cluster”, part of Title VII. These grants support program innovation in Residency Training, Medical Student (Predoctoral) Education, Faculty Development, and “Academic Administrative Units” (essentially departments of primary care). They have their roots in the development of Family Medicine as a discipline in the 1970s. The feds then, as now, saw primary care (family medicine) as an important need, but one which needed nurturance. Residency programs were being started and needed funding to develop and experiment with different curricula that would be most appropriate to create family doctors. There were no departments of Family Medicine in medical schools, or even academic faculty in the discipline, so the Academic Units grants were created to help support the creation of the former, and the Faculty Development grants the latter. Predoctoral grants helped develop the curriculum for educating medical students in family medicine.
These grants were successful, both in creating programs that trained more family doctors and doctors who went into practice in underserved communities, often through the National Health Service Corps (NHSC), another HRSA program. In addition, another (possibly unanticipated) outcome was that the formal training of family medicine faculty and fellows in educational skills, felt necessary because there were not existing physician educators in this field, created a core cadre of physician medical educators that was far more extensively and formally trained in areas such as teaching skills, curriculum development, implementation, and evaluation, and other education methodologies than faculty in other departments, revealing a large, previously unrecognized need in medical school and residency faculties. In the 1980s, the grants were expanded to a larger pool of primary care programs, primarily General Internal Medicine and General Pediatrics, and later Physician’s Assistants.[1] They became critical supports for innovation in the education of students, residents, and faculty.
While these programs were very successful, reported in numerous articles reporting on general internal medicine[2], general pediatrics, and family medicine (notably in a special issue of Academic Medicine, November 2008) and has been demonstrated to increase the number of physicians practicing in community health centers (Rittenhouse DR, 2008), and have actually enjoyed bipartisan support (after all, both Republican and Democratic legislators have underserved rural and urban areas in their districts), funding has always been threatened. For many years, Presidents of both parties would “zero out” funding for these programs in their budgets, only to have them restored by Congress after significant pressure from their constituents. Even then funding has often been cut; in 2006 there was just enough to fund the existing (usually 3-year) grants and no new ones were funded, and the years since have been marginal.
So there was great anticipation this year, with large (for a small program such as this, compared, say to the NIH funding of biomedical research in the tens of billions) increases from previous desert levels. Much of this was ARRA (stimulus) funding. And the results have been very disappointing. Like much of ARRA, emphasis was placed on projects that would programs that could show quick, tangible results so a good portion went to equipment grants. Some went to specific Congressional earmarks. ARRA funds supporting traditional Title VII Primary Care grants were for 5 years, and were all that was available to General Internal Medicine and General Pediatrics; the relatively small number of programs that were funded thus received relatively large grants. ARRA funds also supported a miniscule number (5) of new Academic Units Grants for Family Medicine. The pot for “regular” funds for grants was smaller than it has been in many other years, and large numbers of faculty development, residency, and medical student education grants that were highly-scored by the peer reviewers did not qualify for funding. The application of ARRA funds made this a particularly crazy year; in the Spring those with existing funding were told that they “might” have to submit new grants, in two weeks, so they wrote them before being told “never mind”. The grant reviews happened late and so funding was late. The staff at HRSA, a highly committed group, must have felt whipsawed by changes in rules from above and urgent questions from potential and current grantees.
So, life is tough. Not all grants get funded. Maybe only a small minority do – talk to those who apply for funds to NIH. And so the money came late – it came (to those who received it.) For grants other than those supporting faculty development fellowships, which would have needed to recruit fellows months before the end the academic year – this is not such a big problem. But with all the talk – justified – about the need to produce more primary care physicians for the US, this is a very small pool of funds to be divided up. Some family medicine leaders have given up on HRSA funding; one writes “Title VII is a dinosaur…it has not effectively funded new ideas for more than a decade…it is no better than a random lottery…” The rigid priority and preferences, good for some reasons, do tend to stifle innovation.
The other issue is the disposition of funds between the 3 primary care specialties, and especially the large 5-year grants to general internal medicine (the leader quoted above continues, “…although it doesn’t seem very random if all the AAU grants went to internal medicine.”) As has been noted on this blog before, the percent of graduates of 3-year IM residencies who enter primary care (general) internal medicine is vanishingly small; most go on to subspecialty fellowships, and most of the rest become hospitalists. The New England Journal of Medicine’s health policy writer, John Iglehart, describes this in the August 5, 2010 issue in an overview of the impact of the ACA law on residency training, “Health reform, primary care and graduate medical education”,[3] in which he indicates 10-20% of internal medicine residency graduates will enter primary care (I think 20% is dreaming; even 10% may be!) From one perspective, perhaps GIM needs a “jumpstart”, but there is little reason to believe HRSA grant funding will change the decisions (largely financial) for most IM graduates. On the other hand, Family Medicine residencies are producing primary care doctors in every study (Iglehart says 91%), so it could reasonably be argued that the funding should go with proven success.
Interestingly, one of the priority criteria for funding was that “90% of students entering ‘primary care’ specialties (FM, IM, Pediatrics) are in primary care practices 3 years later.” Given the large number entering IM, and the low % at almost all schools entering GIM, this is an extremely high bar, even though it generously uses 3 years rather than the 8 years post-graduation used in the study by Mullan and colleagues cited previously (A New Way of Ranking Medical Schools: Social Mission). The social mission of medical education: ranking the schools[4] used 8-year data to account for such things as a delay for a year or 2 between completing residency and entering a subspecialty fellowship as might occur for a 2-year NHSC commitment or a brief stint as a hospitalist to make money. My school, the University of Kansas, was ranked #5 nationally, mostly for its success in getting graduates into primary care and rural practice, but this was almost entirely due to family medicine; when the HRSA criteria are applied, only 70% of graduates of FM, GIM, and Peds were in primary care in 3 years, reflecting the fact that for KU graduates, as those from most institutions, the retention of internists in primary care is abysmal.
In any case, it is critically important to have significant federal funding for education and training in primary care if we are to meet our nation’s health needs, have physicians for rural areas, and staff our community health centers. The funding needs to be much greater, it needs to be reliable year-to-year, it should have consistent criteria, and it decisions should be made well before the start of the grant period. It is the least that Congress can do.
[1] Funds are also available to support nurse practitioner programs, but through a different stream, targeted to nursing.
[2] (Lipkin M, 2008)
[3] Iglehart JK, Health reform, primary care and graduate medical education, NEJM 5Aug2010;363(6):584-90.
[4] Mullan F et. al., The Social Mission of Medical Education: Ranking the Schools, Annals of Internal Medicine, 15Jun2010;152(12):804-10
.
Friday, October 1, 2010
The Challenge of Global Health and Primary Care
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I recently attended the 7th American Academy of Family Physicians (AAFP) sponsored Family Medicine Global Health Workshop. Over a period of 3 days, we heard plenary speakers, attended small-group breakout sessions, reviewed a large number of posters, and had an opportunity to talk and share ideas with each other. As one of those in attendance with the least experience in international health (while I have spent some time in Brazil, including a rather short teaching Fulbright, I have never been part of so much as a “medical mission” trip, not to mention spent protracted or recurrent time in providing health care or developing health systems in other countries, either in disaster relief or ongoing care), I felt I had a great deal to learn and I tried hard to absorb as much as possible. The collective experience represented by the attendees was overwhelming. Senior participants had spent decades working in both direct patient care and the creation of clinics as well as in consulting with governments and Ministries of Health on developing health systems based in primary care and family medicine. Some of the participants had returned for years – or for decades – to the same regions, spending months there each year. Family physicians ran or were part of a number of not-for-profit organizations that provided disaster medicine or primary care in countries in need around the world. Others were still residents, or even medical students, who had spent some time in areas of need (most recently, of course, in Haiti) and were planning on making this a central part of their future careers.
There was a breadth of motivations for this work. While many of the participants, and many who work in international health, were inspired by their religious beliefs (and “medical missions” still, in most places including medical schools, is the de facto term for any trip taken by physicians and students even when not sponsored by a religious organization), there were others whose motivation was not, and in particular was social justice. A poster presented by Joanie Baumer, MD, from Fort Worth’s John Peter Smith Hospital Family Medicine Residency (the largest in the country), which has been involved in programs in many countries, surveyed participants on what their main motivations were – and what they perceived those of others to be. Social justice topped the both lists, with “mission” (religious) about 4th, although it was higher in motivations attributed to others.
Plenary sessions from former HHS Secretary and University of Miami President Donna Shalala and others addressed important issues. Fitzhugh Mullan, MD, of George Washington University raised the issue of “brain drain” (see also Primary Care, IMGs, and the Health of the People in this blog, August 14, 2010), in which physicians trained in developing countries, often at public expense, migrated to wealthy Western countries, where they were often welcomed (as in the US) to fill residency and underserved-area-practice positions. While there was some pushback from the (small number) of attendees who had come to the US from other countries, it is hard to argue with Dr. Mullan’s proposition that “the US ought to be able to train enough physicians to care for its population without having to import them from the developing world” (paraphrased). As in so much of policy, there is often a distinction between the individual stories, needs and aspirations of individuals and the overall effect. Cynthia Haq, MD, of the University of Wisconsin, told her own story; one of increasing involvement in international work, from naïve trips to longer stays, to work with WHO and helping other countries develop their health systems, seamlessly intertwined with the story of her own family (“Stepping Stones: Strategies to enrich your life with Global Family Medicine”, posted like many of the other presentations, to the Family Medicine Digital Resource Library, www.fmdrl.org). Steven Spann, MD, of Baylor, presented a superb discussion of ethical issues in doing international work. In a breakout session (and remember, I can only report on those I attended) Gary Morsch, MD, founder of Heart to Heart International, presented the work of that group, which provides opportunities for health professionals to work abroad for shorter periods, a week or two, in settings such as Haiti, in contrast to larger and more famous organizations such as Medecins sans Frontieres, which requires 6-9 month commitments. Dr. Morsch also described H2H’s affiliated group, “Docs Who Care”, which provides locums tenens opportunities in rural parts of the Midwest, both helping those communities with their health needs and the physicians with the opportunity to earn a living in a manner that allows them to spend much of their time doing international work.
Haiti, where the January 2010 earthquake created incredible needs in a nation already living on the edge, with over 300,000 killed outright and hundreds of thousands more severely injured physically, psychologically, and emotionally as well as having every aspect of their lives disrupted or destroyed, was obviously a major focus. Many of the presenters of posters and breakout sessions, and many more of the attendees, had spent some time working in Haiti, in the initial “disaster” phase or the (still disastrous) “primary care” phase. They discussed the good (the people and their resilience, the commitment of the volunteers, the resources pouring in) and the not so good (the historical background of oppression and de-resourcing of Haiti, the lack of coordination between relief agencies, the volunteers who were on occasion self-centered and more often ignorant of the needs and realities of the situation). One of the best sessions I attended was by André Vulcain and Michèle Dodard of the University of Miami Department of Family Medicine. In 1999, they helped to start a family medicine residency program in Haiti’s second city, Cap Haitien, which had graduated 35 family physicians by the time of the quake and is still functioning. Unlike many of the other collaborations described, which are often with private (usually religious) hospitals, this program is sponsored by the Ministry of Health of Haiti and is based in a government hospital. While Dr. Vulcain’s powerpoints are not yet available on FMDRL, Dr. Dodard’s description of the work of the University of Miami’s “Project MediShare”, Rebuilding Haiti’s Healthcare System, is. Rebuilding that system, working with the Haitian government and people, training Haitian health professionals so that they do not need to depend on “mission trips” has also become a key focus of the work of Partners in Health (PIH) (“Zanmi Lasante” in Haitian Kreyol) and many other groups.
One of PIH’s founders, Paul Farmer MD PhD, and his colleagues Vanessa Bradford Kerry MD and Sara Auld MD propose the creation of an “International Service Corps for Health” in an article in a the September 23, 2010 issue of the New England Journal of Medicine.[1] They talk about the work that has been done, particularly that done by academic medical centers, but also address the limitations, especially financial, of these efforts, and suggest that a government-sponsored program, working in collaboration with other US agencies, might be a very effective way of increasing the international reputation of the US as well as helping to meet the staggering needs that exist in the world, such as in Africa, which “…bears 24% of the global disease burden but hosts only 3% of the global health care workforce and is responsible for less than 1% of world health care expenditures.” They describe the enormous impact that the small country of Cuba has had internationally, “…between 1999 and 2004, Cuban foreign-service workers increased doctor visits in resource-poor communities by 36.7 million, provided health promotion outreach for millions of underserved people, and taught 900,000 medical education courses to local personnel.” If carried out reasonably and equitably, an International Health Service Corps (IHSC) might be a major step forward.
There are still great healthcare needs in the US, and very underserved communities (both rural and urban), as detailed in the recent US Census Bureau report “Income, Poverty and Health Insurance Coverage in the United States, 2009”, and it is sometimes distressing to medical educators to observe that many medical students have much greater enthusiasm for “international work” than they they do for helping to meet those domestic needs. However, as Kerry et. al., and the presenters at the AAFP Conference, among others, document, the international needs are staggering.
The interest and commitment of health professionals and students in working internationally, demonstrated not only in the AAFP Global Health Conference but daily in our schools and residency programs, is a wonderful thing. Developing meaningful, useful, and long-term opportunities to serve, such as the existing programs described above and at the conference, or a new “international health service corps”, are very important goals.
[1] Kerry VB, Auld S, Farmer P, “An international service corps for health – an unconventional prescription for diplomacy”, NEJM 2010Sep23;363(13):1199-1201
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I recently attended the 7th American Academy of Family Physicians (AAFP) sponsored Family Medicine Global Health Workshop. Over a period of 3 days, we heard plenary speakers, attended small-group breakout sessions, reviewed a large number of posters, and had an opportunity to talk and share ideas with each other. As one of those in attendance with the least experience in international health (while I have spent some time in Brazil, including a rather short teaching Fulbright, I have never been part of so much as a “medical mission” trip, not to mention spent protracted or recurrent time in providing health care or developing health systems in other countries, either in disaster relief or ongoing care), I felt I had a great deal to learn and I tried hard to absorb as much as possible. The collective experience represented by the attendees was overwhelming. Senior participants had spent decades working in both direct patient care and the creation of clinics as well as in consulting with governments and Ministries of Health on developing health systems based in primary care and family medicine. Some of the participants had returned for years – or for decades – to the same regions, spending months there each year. Family physicians ran or were part of a number of not-for-profit organizations that provided disaster medicine or primary care in countries in need around the world. Others were still residents, or even medical students, who had spent some time in areas of need (most recently, of course, in Haiti) and were planning on making this a central part of their future careers.
There was a breadth of motivations for this work. While many of the participants, and many who work in international health, were inspired by their religious beliefs (and “medical missions” still, in most places including medical schools, is the de facto term for any trip taken by physicians and students even when not sponsored by a religious organization), there were others whose motivation was not, and in particular was social justice. A poster presented by Joanie Baumer, MD, from Fort Worth’s John Peter Smith Hospital Family Medicine Residency (the largest in the country), which has been involved in programs in many countries, surveyed participants on what their main motivations were – and what they perceived those of others to be. Social justice topped the both lists, with “mission” (religious) about 4th, although it was higher in motivations attributed to others.
Plenary sessions from former HHS Secretary and University of Miami President Donna Shalala and others addressed important issues. Fitzhugh Mullan, MD, of George Washington University raised the issue of “brain drain” (see also Primary Care, IMGs, and the Health of the People in this blog, August 14, 2010), in which physicians trained in developing countries, often at public expense, migrated to wealthy Western countries, where they were often welcomed (as in the US) to fill residency and underserved-area-practice positions. While there was some pushback from the (small number) of attendees who had come to the US from other countries, it is hard to argue with Dr. Mullan’s proposition that “the US ought to be able to train enough physicians to care for its population without having to import them from the developing world” (paraphrased). As in so much of policy, there is often a distinction between the individual stories, needs and aspirations of individuals and the overall effect. Cynthia Haq, MD, of the University of Wisconsin, told her own story; one of increasing involvement in international work, from naïve trips to longer stays, to work with WHO and helping other countries develop their health systems, seamlessly intertwined with the story of her own family (“Stepping Stones: Strategies to enrich your life with Global Family Medicine”, posted like many of the other presentations, to the Family Medicine Digital Resource Library, www.fmdrl.org). Steven Spann, MD, of Baylor, presented a superb discussion of ethical issues in doing international work. In a breakout session (and remember, I can only report on those I attended) Gary Morsch, MD, founder of Heart to Heart International, presented the work of that group, which provides opportunities for health professionals to work abroad for shorter periods, a week or two, in settings such as Haiti, in contrast to larger and more famous organizations such as Medecins sans Frontieres, which requires 6-9 month commitments. Dr. Morsch also described H2H’s affiliated group, “Docs Who Care”, which provides locums tenens opportunities in rural parts of the Midwest, both helping those communities with their health needs and the physicians with the opportunity to earn a living in a manner that allows them to spend much of their time doing international work.
Haiti, where the January 2010 earthquake created incredible needs in a nation already living on the edge, with over 300,000 killed outright and hundreds of thousands more severely injured physically, psychologically, and emotionally as well as having every aspect of their lives disrupted or destroyed, was obviously a major focus. Many of the presenters of posters and breakout sessions, and many more of the attendees, had spent some time working in Haiti, in the initial “disaster” phase or the (still disastrous) “primary care” phase. They discussed the good (the people and their resilience, the commitment of the volunteers, the resources pouring in) and the not so good (the historical background of oppression and de-resourcing of Haiti, the lack of coordination between relief agencies, the volunteers who were on occasion self-centered and more often ignorant of the needs and realities of the situation). One of the best sessions I attended was by André Vulcain and Michèle Dodard of the University of Miami Department of Family Medicine. In 1999, they helped to start a family medicine residency program in Haiti’s second city, Cap Haitien, which had graduated 35 family physicians by the time of the quake and is still functioning. Unlike many of the other collaborations described, which are often with private (usually religious) hospitals, this program is sponsored by the Ministry of Health of Haiti and is based in a government hospital. While Dr. Vulcain’s powerpoints are not yet available on FMDRL, Dr. Dodard’s description of the work of the University of Miami’s “Project MediShare”, Rebuilding Haiti’s Healthcare System, is. Rebuilding that system, working with the Haitian government and people, training Haitian health professionals so that they do not need to depend on “mission trips” has also become a key focus of the work of Partners in Health (PIH) (“Zanmi Lasante” in Haitian Kreyol) and many other groups.
One of PIH’s founders, Paul Farmer MD PhD, and his colleagues Vanessa Bradford Kerry MD and Sara Auld MD propose the creation of an “International Service Corps for Health” in an article in a the September 23, 2010 issue of the New England Journal of Medicine.[1] They talk about the work that has been done, particularly that done by academic medical centers, but also address the limitations, especially financial, of these efforts, and suggest that a government-sponsored program, working in collaboration with other US agencies, might be a very effective way of increasing the international reputation of the US as well as helping to meet the staggering needs that exist in the world, such as in Africa, which “…bears 24% of the global disease burden but hosts only 3% of the global health care workforce and is responsible for less than 1% of world health care expenditures.” They describe the enormous impact that the small country of Cuba has had internationally, “…between 1999 and 2004, Cuban foreign-service workers increased doctor visits in resource-poor communities by 36.7 million, provided health promotion outreach for millions of underserved people, and taught 900,000 medical education courses to local personnel.” If carried out reasonably and equitably, an International Health Service Corps (IHSC) might be a major step forward.
There are still great healthcare needs in the US, and very underserved communities (both rural and urban), as detailed in the recent US Census Bureau report “Income, Poverty and Health Insurance Coverage in the United States, 2009”, and it is sometimes distressing to medical educators to observe that many medical students have much greater enthusiasm for “international work” than they they do for helping to meet those domestic needs. However, as Kerry et. al., and the presenters at the AAFP Conference, among others, document, the international needs are staggering.
The interest and commitment of health professionals and students in working internationally, demonstrated not only in the AAFP Global Health Conference but daily in our schools and residency programs, is a wonderful thing. Developing meaningful, useful, and long-term opportunities to serve, such as the existing programs described above and at the conference, or a new “international health service corps”, are very important goals.
[1] Kerry VB, Auld S, Farmer P, “An international service corps for health – an unconventional prescription for diplomacy”, NEJM 2010Sep23;363(13):1199-1201
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Friday, September 24, 2010
Capability: understanding why people may not adopt healthful behaviors
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In Social Determinants, Personal Responsibility, and Health System Outcomes, I discussed the limitations of the potentially attractive (at least to the empowered) concept of “personal responsibility”. In its more malignant form, personal “accountability” as put forward by John Mackey of Whole Foods, there is the implicit – sometimes explicit – suggestion that people might be denied care if they had not personally taken on the behaviors that might have helped prevent the condition. Of course, which behaviors, for which conditions, and how much remains unspecified. Aerobic exercise 60 minutes daily? Or would 30 minutes 3 times a week qualify? No sweets, or cookies only on Sunday? How many? I am reminded (well, I’m old) of former North Carolina senator Jesse Helms who was against funding the treatment of AIDS as it came from inappropriate and immoral behavior (MSM sex and IV drugs were, I think, what he had in mind). Of course, he strongly supported both tobacco and funding the treatment of heart disease (such as he, a heavy smoker, had).
Of course, I’m sure that, today, smoking is on John Mackey’s “no-no” list, but it is the concept of “your bad habits are worse than my bad habits” that is emblematic of the “different from me is bad” phenomenon that ebbs and flows in world history, and has become increasing common both in this country and around the world. The Tea Party movement is one domestic example; at the “Values Conference” recently held in Washington, Christine O’Donnell, the newly-elected Republican candidate for Senate in Delaware, wowed the crowd with the line "We're not trying to take back our country. We ARE our country." Except, of course, for those who are not part of “we”. Me, for example. And those other ‘others’: those who believe in brotherhood, caring, and diversity.
But surely John Mackey is not embracing racism or prejudice? Classism, maybe; certainly discrimination against those who don’t adopt the health behaviors that he endorses. One might ask: why don’t they? And, if one does, we can get a good answer from a wonderful article that appeared in the recent Annals of Family Medicine, “Capability and clinical success”, by RL Ferrer and AV Carrasco (disclosure: Dr. Ferrer has previously been a guest-author on this blog.) Going beyond the “social determinants of health”, which is a relatively passive model in that it mainly just describes them, Drs. Ferrer and Carrasco discuss the concept of “capability” of health behaviors. They draw upon the work of Nobel Prize-winning economist Amartya Sen, who introduced this concept, and that of Jennifer Prah Ruger of Yale, who has developed its use in health (e.g., “Health capability: conceptualization and operationalization” in the January, 2010 issue of the American Journal of Public Health). The concept of “capability” goes beyond simply evaluating people’s behaviors, and looks at opportunity to perform those behaviors, which is not equally available to all:
“What distinguishes the capability framework from other approaches to evaluation is its emphasis on opportunity as well as achievement. Turning raw capacity (e.g., the ability to walk) into action (walking for 60 minutes a day) to achieve a goal (being physically fit) requires that there be real opportunities to do so. Examining the set of potential opportunities that are viable for a given person (a capability set) helps to define what goals are attainable. For instance, a capability set for physical activity would encompass the various modes and durations of physical activity that are realistically achievable given a person’s constraints of time, money, support from others, physical abilities, and what is locally available.”
Capability is influenced by individual, social, psychological and environmental factors, as well as by income. Money – or lack of it – is a major component, but not the only one, because other features can mitigate or exacerbate financial issues. The concept of “social capital” developed by Robert Putnam (“Bowling Alone”[1]) and others is one formulation of this. In his book Heat Wave[2], Eric Klinenberg describes how the deaths in the 1995 Chicago heat wave, while associated with age, illness, poverty and availability of air-conditioning, were also associated with the availability of social supports. He notes the differential death rates in two adjacent low-income communities. In one, the decimation of the commercial sector and fear of crime had people locked in hot apartments, while in the other neighbors checked on the old, sick, and poor, and merchants on the vibrant shopping street allowed them access to their air-conditioned stores. “A capability perspective,” write Ferrer and Carrasco, “implies that poverty should not be defined primarily by income but by scarce opportunity to pursue valued activities and goals. Strong external supports create opportunities that enable people with limited income to pursue their goals for healthy living. Capability is thus a key mediator of the relationship between socioeconomic position and outcomes.”
What Ferrer and Carrasco add to the discussion is the clinical component, discussing how the clinical relationship can take account of capability, and how the clinician can play a role in enhancing the health of patients through understanding and acting to help ameliorate its impact on those who have little. They suggest an example of a series of questions (their Table 2) that a clinician can ask in order to assess an individual’s capability of adopting different healthful behaviors. They also provide suggestions for how the clinician or practice can access help through social service agencies, public health departments, programs of connectors or promotores, and grass-roots agencies. Clinicians may be able to assist in helping people gain access to wholesome food or places to exercise, and to groups that would support their activities.
Of course, in some cases, maybe often, these programs will not already exist. In that case, it could become the role of the clinician or the practice, or even better the health system (or, to use the terms of the new ACA law (PL 111-148), the 'Accountable Care Organization') to help develop such programs in the interest of promoting the health of its patients. Indeed, we should and must if we are interested in promoting health and not just casting blame.
[1] Putnam, Robert D., 2000, Bowling Alone: The Collapse and Revival of American Community, Simon & Schuster, New York, NY
[2] Klinenberg, Eric., 2002, Heat Wave: A Social Autopsy of a Disaster in Chicago, University of Chicago Press, Chicago.
.
In Social Determinants, Personal Responsibility, and Health System Outcomes, I discussed the limitations of the potentially attractive (at least to the empowered) concept of “personal responsibility”. In its more malignant form, personal “accountability” as put forward by John Mackey of Whole Foods, there is the implicit – sometimes explicit – suggestion that people might be denied care if they had not personally taken on the behaviors that might have helped prevent the condition. Of course, which behaviors, for which conditions, and how much remains unspecified. Aerobic exercise 60 minutes daily? Or would 30 minutes 3 times a week qualify? No sweets, or cookies only on Sunday? How many? I am reminded (well, I’m old) of former North Carolina senator Jesse Helms who was against funding the treatment of AIDS as it came from inappropriate and immoral behavior (MSM sex and IV drugs were, I think, what he had in mind). Of course, he strongly supported both tobacco and funding the treatment of heart disease (such as he, a heavy smoker, had).
Of course, I’m sure that, today, smoking is on John Mackey’s “no-no” list, but it is the concept of “your bad habits are worse than my bad habits” that is emblematic of the “different from me is bad” phenomenon that ebbs and flows in world history, and has become increasing common both in this country and around the world. The Tea Party movement is one domestic example; at the “Values Conference” recently held in Washington, Christine O’Donnell, the newly-elected Republican candidate for Senate in Delaware, wowed the crowd with the line "We're not trying to take back our country. We ARE our country." Except, of course, for those who are not part of “we”. Me, for example. And those other ‘others’: those who believe in brotherhood, caring, and diversity.
But surely John Mackey is not embracing racism or prejudice? Classism, maybe; certainly discrimination against those who don’t adopt the health behaviors that he endorses. One might ask: why don’t they? And, if one does, we can get a good answer from a wonderful article that appeared in the recent Annals of Family Medicine, “Capability and clinical success”, by RL Ferrer and AV Carrasco (disclosure: Dr. Ferrer has previously been a guest-author on this blog.) Going beyond the “social determinants of health”, which is a relatively passive model in that it mainly just describes them, Drs. Ferrer and Carrasco discuss the concept of “capability” of health behaviors. They draw upon the work of Nobel Prize-winning economist Amartya Sen, who introduced this concept, and that of Jennifer Prah Ruger of Yale, who has developed its use in health (e.g., “Health capability: conceptualization and operationalization” in the January, 2010 issue of the American Journal of Public Health). The concept of “capability” goes beyond simply evaluating people’s behaviors, and looks at opportunity to perform those behaviors, which is not equally available to all:
“What distinguishes the capability framework from other approaches to evaluation is its emphasis on opportunity as well as achievement. Turning raw capacity (e.g., the ability to walk) into action (walking for 60 minutes a day) to achieve a goal (being physically fit) requires that there be real opportunities to do so. Examining the set of potential opportunities that are viable for a given person (a capability set) helps to define what goals are attainable. For instance, a capability set for physical activity would encompass the various modes and durations of physical activity that are realistically achievable given a person’s constraints of time, money, support from others, physical abilities, and what is locally available.”
Capability is influenced by individual, social, psychological and environmental factors, as well as by income. Money – or lack of it – is a major component, but not the only one, because other features can mitigate or exacerbate financial issues. The concept of “social capital” developed by Robert Putnam (“Bowling Alone”[1]) and others is one formulation of this. In his book Heat Wave[2], Eric Klinenberg describes how the deaths in the 1995 Chicago heat wave, while associated with age, illness, poverty and availability of air-conditioning, were also associated with the availability of social supports. He notes the differential death rates in two adjacent low-income communities. In one, the decimation of the commercial sector and fear of crime had people locked in hot apartments, while in the other neighbors checked on the old, sick, and poor, and merchants on the vibrant shopping street allowed them access to their air-conditioned stores. “A capability perspective,” write Ferrer and Carrasco, “implies that poverty should not be defined primarily by income but by scarce opportunity to pursue valued activities and goals. Strong external supports create opportunities that enable people with limited income to pursue their goals for healthy living. Capability is thus a key mediator of the relationship between socioeconomic position and outcomes.”
What Ferrer and Carrasco add to the discussion is the clinical component, discussing how the clinical relationship can take account of capability, and how the clinician can play a role in enhancing the health of patients through understanding and acting to help ameliorate its impact on those who have little. They suggest an example of a series of questions (their Table 2) that a clinician can ask in order to assess an individual’s capability of adopting different healthful behaviors. They also provide suggestions for how the clinician or practice can access help through social service agencies, public health departments, programs of connectors or promotores, and grass-roots agencies. Clinicians may be able to assist in helping people gain access to wholesome food or places to exercise, and to groups that would support their activities.
Of course, in some cases, maybe often, these programs will not already exist. In that case, it could become the role of the clinician or the practice, or even better the health system (or, to use the terms of the new ACA law (PL 111-148), the 'Accountable Care Organization') to help develop such programs in the interest of promoting the health of its patients. Indeed, we should and must if we are interested in promoting health and not just casting blame.
[1] Putnam, Robert D., 2000, Bowling Alone: The Collapse and Revival of American Community, Simon & Schuster, New York, NY
[2] Klinenberg, Eric., 2002, Heat Wave: A Social Autopsy of a Disaster in Chicago, University of Chicago Press, Chicago.
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