Multimorbity, primary care,social determinants, and universal insurance: where they all come together

Tinetti, Fried, and Boyd, writing in JAMA June 20, 2012, discuss “Designing health care for the most common chronic condition – multimorbidity.”[1] They note that adult patients with only a single chronic disease are the exception (e.g., only 17% of people with coronary disease have that as their only chronic condition) and the rate of multi-morbidity increases with aging. However, the medical system is organized around individual diseases, both in terms of reimbursement (based upon International Classification of Diseases, 9^th Edition, or ICD-9, codes) and in terms of specialty structure. Thus, cardiologists care for heart disease (only), oncologists for cancer (only), endocrinologists for diabetes and thyroid disease, etc.

Moreover, they observe that even more recent efforts to reward quality have been single-disease focused, with metrics related to acute myocardial infarction (heart attack), pneumonia, and particular surgical procedures. This is added to the fact that these criteria focus on hospitalized patients, rather than on efforts to keep them well. They state that “To align with the clinical reality of multimorbidity, care should evolve from a disease orientation to a patient goal orientation, focused on maximizing the health goals of individual patients with unique sets of risks, conditions, and priorities.”  This is a long way of saying care should be patient-centered. They also say that “The process for assigning responsibility for providing clinical care also needs redesign, perhaps beginning with a systematic process for determining which clinician should have primary responsibility for helping patients make decisions,” which is a long way of saying people need generalists, or primary care physicians.

This group does not want to call them generalists, though. Perhaps this is because they are from Yale, a school well-known for its research and for its high-tech tertiary and quarternary care capability, but woefully weak in training physicians to provide general, or primary care. It doesn’t even have a Family Medicine department, despite the fact that this is the specialty that provides the largest number of primary care physicians, so these authors are from Internal Medicine. They have suggested that such physicians be called comprehensivists rather than generalists because the latter term “fails to capture the breadth of skills and expertise required”  to care for patients with multiple comorbidities.

While this article suggests nothing new (for example, I have addressed these issues several times, including Primary Care: What takes so much time? And how are we paying for it?, May 21, 2010 and Primary Care’s Image: A Problem?, November 17, 2009), it is good that it keeps these issues on the table. Providers, particularly hospitals, want to be paid for metrics that are easily identifiable and relatively easy to achieve. Students choosing careers often want to pick a field in which they can feel that they are masters of a limited field of knowledge.Patients sometimes want to get help for a specific problem from a particular specialist. But everyone is better served if there is coordination of care and decisions regarding the care of one condition take the others into consideration. This means that medications which have negative interactions or countervailing effects are less likely to be prescribed. It means that the difficult decision about whether or not to have a particular surgical procedure is taken in the context of all of the health issues confronting the person. It means that decisions about interventions in desperate situations or at end of life are made wisely, and in full possession of the available information, without bias toward treatment of a particular disease regardless of its impact on others.

In a recent “Doctor’s Blog” on the British Medical Journal’s (BMJ) “doc2doc” site [disclaimer: I also blog at this site] one doctor presented their thoughts on “Is prevention ALWAYS better than cure?”. I do not agree with all of Dr. Lush’s points, and am not sure I even understand them all, but that “…as we get older the risks of many diseases increases so that many patients end up on a cocktail of preventative drugs, probably 2 antihypertensives, aspirin, beta blocker, statins, anti-inflammatory medications, diuretic, asthma treatment, type 2 diabetic treatments, analgesics, etc etc.” is a fact. Many of these medications can be for either prevention or treatment or both (remember the concepts of secondary and tertiary prevention, so that treatment of one condition – say high blood pressure – can be prevention of another – say heart attack), but they often lead to patients saying “too much!” Worse than that, some may have opposing effects – the anti-inflammatory medication you take for your arthritis can lead to GI bleeding and kidney failure. The narcotics you take for your pain, in addition to the more well known negatives of addiction, cause constipation so serious it may well be the source of even worse symptoms.

Even the presence of a National Health Service is not sufficient. A study from Scotland published recently in the Lancet, “Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study”, demonstrates an extremely high rate of multi-morbidity in that county, with much higher rates in poorer communities. The “[O]nset of multimorbidity occurred 10–15 years earlier in people living in the most deprived areas compared with the most affluent”. The authors conclude that their findings “…challenge the single-disease framework by which most health care, medical research, and medical education is configured. A complementary strategy is needed, supporting generalist clinicians to provide personalised, comprehensive continuity of care, especially in socioeconomically deprived areas.”

Of course, unlike Britain, which has a National Health Service, the US does not cover everyone. A Kaiser Family Foundation (KFF) “health reform subsidy calculator”, cited by Don McCanne in his Quote of the Day, demonstrates the amazing out-of-pocket costs for health insurance that come with slight incremental increases in family income, and would be mitigated, although not eliminated, by the Affordable Care Act. This creates a real difference in our two health cultures, because many people in the US do not seek care because of the financial barriers, and then only for acute episodes.

In terms of having a supply of physicians who can fill the role of caring for multiple morbidities, Britain has much more extensive primary care base than the US. It is possible that their system has as great a risk as ours of generalists not being sufficiently “comprehensivist”; our system, with more hospitalists, is moving in the British direction of having primary care doctors who do not follow their patients into the hospital. But in the US, we are without a sufficient number or percent of primary care doctors altogether.

The reality is, as I have often observed before, is that a comprehensive national health insurance system is a necessary, if not sufficient, component of a plan to actually ensure health. Two other major components are also necessary. The first is addressing the social determinants of health, which are largely associated with class/socioeconomic status, and the second is having an adequate primary care base, And, while, as the Scottish study indicates, the national health service in Britain does not guarantee either, it does provide a vehicle for addressing the second and mitigates the impact of the first.

The absence of such a system in the US makes the problems of an inadequate primary care workforce and the impact of socioeconomic disparities much worse.

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[1] Tinetti ME, Fried TR, Boyd CM, “Designing health care for the most common chronic condition – multimorbidity”, JAMA 20Jun2012;307(23):2493-4.

One thing to NOT worry about: paying for health care -- in France

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I recently saw the film Le Havre, a film set in that French city and made, in French, by Finnish director Aki Kaurismäki. It was a very good film, generally well-reviewed (here is the New York Times review), and part of its appeal for me is its unabashed portrayal of working-class people as the central characters. One of the plots involves the illness of the female lead, Arletty, who suffers severe abdominal pain, is brought to the hospital, and is told that it will be terminal (although, the doctor observes, “miracles do happen”.) I don’t need to share any more of the plot, because what I found striking was really incidental to it.

Kaurismäki goes to some length to depict both the poverty and dignity of his characters. It is an imaginable working class poverty -- this is not the Mumbai of Slumdog Millionaire – but it is certainly poverty. Arletty’s husband is a shoeshine man; they live on an alley off a small street in a house that evokes the apartment of Ralph and Alice Kramden on The Honeymooners. When he sees his wife in such pain, her husband’s main concern is how he will get her to the hospital. He goes to the street to ask a shopkeeper if he can use her phone (they don’t have one), and she offers to drive them.

What is not a concern is whether they can afford her medical care. As I am used to being in the US, to caring for people of limited means, of seeing people in the free clinic who cannot afford to go to the doctor or people admitted to the hospital when they finally show up in the emergency room with disease that is far gone because they haven’t sought care, I found this a bit jarring. I was waiting for Arletty to protest that it was “nothing” (she has been in some denial already), for fear that they couldn’t afford medical care. But she doesn’t, and he says nothing about it, and goes off to find transportation. We could see the same thing in an American movie, and we would expect the same thing in our own lives – when your wife is really sick, you take her to the hospital, you worry about the bills later.

Except that wasn’t why. They weren’t worried about the bills. Because it was France. With a national health insurance system, where everyone, even the wife of a self-employed shoeshine guy living in a tiny house off an alley, has health coverage. In the film, Arletty is in the hospital for several weeks, but of all the issues that occur, how the couple will pay for it never comes up. Not at all. It is not even a thought in their minds. But it is a thought in mine, and I keep having to remind myself that it is not part of the plot because it is not an issue that French people have to concern themselves with. The illness, yes. Whether she will survive, yes. Whether he will earn enough money each day to buy dinner, yes. But not how to pay for several weeks of hospitalization. Amazing.

There was another aspect of the healthcare portrayed in the film that struck me. The hospital was simple and unostentatious. It looked a little dated, old-fashioned, like the houses and the shops and the working-class lives of the characters, even though the film and its theme are contemporary. Maybe this is also something about France. The hospital is clean, freshly-painted, with clean linen, and private rooms, and IV poles and doctors and nurses. But it is simple. The ceilings are not high, there is not expensive art on the walls, or carpets, or hallways twice as wide as they need to be. It is functional. It is not third-world, but it is basic. It is pretty unlike my hospital, or most of the hospitals that we see in the US (except some of the oldest public institutions). If someone with private health insurance saw this hospital in, say, Kansas City, they would be unimpressed. They might rather, next time, seek one that was “nicer”. Fancier. With really good hotel accommodations. This is what we look for in the US, what we expect. Surely this is what they lose in such national-health-insurance countries as France.

I checked this with a friend, who is from Canada. He said that this is the way hospitals in Canada are; clean, and functional, but not fancy. He told me he was shocked when his wife had a baby in Kansas City and there were hardwood floors. What for, he wondered? Of course, we know what they are for. They are to help to provide a competitive advantage, to make people choose one hospital over another. For the same reason that hospitals buy new MRI scanners when the hospital down the street has one that is underutilized. Why they have fundraisers to be able to support their cancer center, to attract people with cancer (and, of course, insurance!) to them, rather than to the perfectly good cancer center across town. Why, as depicted in a recent New York Times “Opinionator” by Ezekiel Emanuel and Stephen D. Pearson (“It costs more, but is it worth more?”), hospitals such as Mayo Clinic are building their own billion-dollar proton-beam accelerators to treat cancer when there are more than enough in the country to treat the relatively small number of people who require this kind of cancer therapy.

Because, in the US, healthcare provision functions much more as a business than as a social good. The “product” is healthcare for people, but the product is only of value when it can be sold to those who can pay. We have hospitals that compete for some of our people, while there are others who can barely get care. This competition model can work, just as it works for other products – vendors compete for those who can afford it and ignore those who cannot. If we want healthcare to be an industry, a business, rather than health care.

Le Havre is a very good film, and it does not shy away from social issues. In fact, it addresses many of them. But access to health care is not one, it is not Sicko! The themes I discuss here are just in the background of the film,and I imagine they are not even noticed by French audiences. Or Finnish ones. Being able to afford medical care is not an issue in those places.

Which is as it should be.