Kathleen Sebelius as Secretary of HHS

As a citizen of Kansas, I probably know more than the average American about the new nominee for Secretary of HHS, Governor Kathleen Sebelius. On the whole, I think that she is a good choice who will be effective as well as honest, without the baggage ($128K tax and close relationships with lobbyists) that Sen. Daschle had. However, Sen. Daschle gave a great speech at his confirmation hearing, pointing out that every other country with decent health outcomes starts from a base of primary care, moving up through secondary and tertiary care if they can afford it. The US, on the other hand, starts with funding tertiary care, and runs out of money before providing comprehensive primary care (see picture; this is an unstable format!)

I hope that Governor Sebelius can be as articulate at her confirmation hearing, but hope much more that she will press for such important change as Secretary. While she is not a single-payer advocate, she has advocated coverage for all, which is a good start; indeed, “Cover Everybody!” should be our mantra, although there is a lot of bad and overpriced coverage out there – so Rep. Conyers’ assertion that “what we want is access to high quality health care for everybody” is really the goal.

While Gov. Sebelius, the daughter of former Democratic governor of Ohio John Gilligan and daughter-in-law of a prominent long-time Republican congressman from Kansas, was early in her career Executive Director of the Kansas Trial Lawyers Association, and as such not popular with physicians, her subsequent tenure as a legislator, state Insurance Commissioner, and Governor has been very positive regarding health care, and even healed many of the wounds with physicians. Her most important decision as insurance commissioner was blocking the sale of Blue Cross/Blue Shield of Kansas to a private company, Anthem, in 2002, saying it would raise costs for Kansans. This was a good decision, occurring during a time when the insurance industry was, across the country, consolidating its hold on health care. It gained her great popularity and was a major reason she was elected Governor later that year.

She is seen as a Democrat who is able to work across party lines, a necessary characteristic in a very “red” state, where both houses of the legislature have become increasingly dominated by the what is known as the “conservative” wing of the Republican party; whether “conservative” or not, they are ideologically driven in much the same way as the increasingly marginalized national GOP is, except here in Kansas they are in control.

I would also add, if we want to know the kind of person she is, that in 2005 I was headed down to New Orleans for a conference. Waiting at SW Airlines, I looked up from my book and saw her sitting across from me. Someone else recognized her and razzed her for not taking her state "jet". She replied, "First, it's not a jet, and second, this is not state business. I'm taking a few days to meet my husband down in New Orleans for the Jazz and Heritage Festival".
So she waited in line with everyone else, and as I helped her put her bag in the overhead rack, remember thinking "I can't imagine Arnold Schwarzenegger or George Pataki (then Gov of NY) doing this - flying with the hoi polloi on SW, personal business or not." Or, for that matter, Tom Daschle.

She has some excellent health advisors in Kansas, and if they accompany her to DC, I would be optimistic about effective change.

Defining "Streetlight" Research

In my last post (“Quality and Chronic Disease Management”) I use the term “streetlight” research without defining it, so I thought that I should do that. It is based on an old joke:

A guy is walking down the street one night a finds another guy on his hands and knees searching in the gutter under a streetlight. He asks what he is doing, and the second guy says “I dropped my car keys.” So the first guy offers to help, but after some time they are unsuccessful, so he asks “Where exactly did you drop them?”
“Down the block,” the second guy says, pointing.
“So why are we looking here?” the other asks in exasperation.
“Well,” the second guy replies, “the light’s better!”

Thus:
Streetlight research. You do the research that it seems feasible (cost, effort) even though it may not answer the real question that you have. (“Well, that would be much too difficult a study to do.”) It can get published, get you promoted, and even get you famous, but it still doesn’t answer the question you originally had.

Quality and Chronic Disease Management

JAMA (Feb 18, 2009) has an interesting commentary by Patrick Conway and Carolyn Clancy of the Agency for Healthcare Research and Policy (AHRQ) on “Transformation of Health Care at the Front Line”,[1] which tries to address issues of quality assessment and cost, and emphasizes the need for studies to be done at the “front line” of medical care – actual community-based practices, rather than only at academic health centers. AHRQ has funded much of this research, including funding of projects carried out by “practice based research networks”, networks of community based practitioners, usually coordinated at an AHC (frequently in departments of Family Medicine or Preventive / Community Medicine). They note the existence of a “multitude of quality organizations” that have developed standards and measures, but call on them to focus on “high priority measures such as those that influence outcomes on high-prevalence diseases, demonstrate baseline performance variability, and have potential mechanisms to improve results…measures should increasingly focus on patient-centered outcomes.” They also note that current measures, which focus on individual clinician-patient interactions, undervalue the importance of teams in care.

Conway and Clancy also address Health Information Technology, Comparative Effectiveness, Quality Collaboratives and Learning Networks, and very importantly, Clinician Training. This last includes what seems to be slightly odd: “This focus on quality improvement, coordination of care, and measuring results is especially critical for training future generalist physicians.” I am certain that this means to address the fact that generalist physicians will be critical in coordinating patient care, not to exempt subspecialists from quality improvement; after all, the effectiveness of standards implemented by and measured in the practices of generalist physicians will be completely negated if subspecialists are not subject to the same standards; if they are allowed to continue, as is very often the case currently, to provide procedures because they are available, may be effective, are profitable but not necessarily cost-effective, and done in isolation from an approach to the overall care of the patient.

One very large effort to address quality were the 15 randomized trials of care coordination for chronic disease in Medicare patients known as the Medicare Coordinated Care Demonstration, supported by the Centers for Medicare and Medicaid Services (CMS), and reported on by the independent evaluator, Mathematica Policy Research, Inc., in the Feb 11, 09 issue of JAMA.[2] Each of these trials was conducted by an institution (community hospital [3], academic medical center [3], integrated delivery system –i.e, hospital and associated practices [1], private for profit care-coordination agency [5], long-term care facility [1], retirement community [1]hospice [1]) and involved 15 states + DC (Iowa and Maryland were in two each, and one hospital covered patients in 4 states). The main effort was to use care coordination to try to decrease hospitalizations, and thus costs (as hospitalization is the main driver of cost) in various chronic disease populations. Most of these programs used nurses (usually RNs, though in one case LPNs, to call – with greatly varied frequency, or visit in only a few of the cases) patients with chronic diseases. The bottom line is that they didn’t work to reduce costs through reduced hospitalizations, although they do not really report on benefit to patient outcomes (as previously addressed in this blog, improved outcomes may not cost less). Two of the programs did have fewer hospitalizations, and two had significant increases in cost (one program was in both groups). Two (including the other program with fewer hospitalizations) had non-statistically-significant trends toward lower cost.

A very important factor is that the participants in these studies were different from the mean for all Medicare beneficiaries. They were had higher educational levels, and were less likely to be Hispanic, younger than 65 (since people who are on Medicare < 65 must be disabled, this would potentially select for healthier people, or at least exclude a large number of sick ones), or on Medicaid (a proxy for poverty). They also had nearly three times higher costs/beneficiary in the year prior to entry into the study ($1555 vs $552). An even more important issue is that the programs were allowed to set their own criteria for entry into – and exclusion from – their study populations:

“Four programs explicitly excluded beneficiaries younger than 65 years [who, as noted above, would be particularly sick] and 13 programs excluded those patients with end-stage renal disease or receiving dialysis. Fourteen programs excluded beneficiaries with certain other conditions, including terminal illness, conditions that affected their ability to learn self-management (e.g., serious mental illness or dementia), or conditions that were complex to manage but unrelated to target diagnoses (e.g., human immunodeficiency virus/AIDS)…”

Such exclusions make the studies easier to conduct, and would tend to make the outcomes look better (although they still didn’t) but make them less useful to apply to the real world, where people do have mental illness, HIV/AIDS, end-stage renal disease, and even more, have multiple chronic diseases, not just one or two. Many of them are also poor, on Medicaid, disabled, and Hispanic. Thus, while these studies, in multiple settings, seem to fit the criterion of “front line” that Conway and Clancy describe, the exclusions and the differences in the study populations from all Medicare beneficiaries would limit their applicability even if they were effective; they are still “effectiveness” than “efficacy” studies.

In this regard, this study is another illustration of the problems of most research studies, whether laboratory, clinical, or even (as this one) community based. They are “streetlight” studies that set out to answer questions that are possible, or easy, to answer, rather than the actual questions that we need answers to. By excluding participants, paying them, providing free benefits (all of which may be components of ethical research, ironically), by setting conditions not replicable in the entire community, their usefulness can be very limited. The Medicare studies, based in the community and involving sick people are, even with their limitations, more useful than most. Unfortunately, they did not demonstrate savings, but savings alone cannot be the only criterion (we have addressed cost-effectiveness, Feb. 13). Conway and Clancy speak of “patient-centered outcomes”, but we really need more – patient-important outcomes, by which really we mean mortality and quality of life.

Finally, as I have to note so often, studies of quality, and of cost, and even of cost-effectiveness, are taking place in the context of our current non-system of health care, with ridiculous financial motivators for practice and no coordinated national approach to health or health policy, and are therefore extraordinarily limited. A national health financing system, single payer or otherwise, will not guarantee quality or cost control, but its absence will virtually guarantee failure when pilot programs, even “successful” ones, are moved into the general population.

[1] Conway PH, Clancy C, “Transformation of health care at the front line”, JAMA 18Feb09;301(7):763-5
[2] Peikes D, Chen A, Schore J, Brown R, “Effects of care coordination on hospitalization, quality of care, and health care expenditures among Medicare beneficiaries: 15 randomized trials”, JAMA 11Feb09;301(6):603-18.

Performing procedures: Who is capable and how should we pay?

A recent article in the British Medical Journal reported on a comparison between physicians and nurses performing endoscopy in the UK.[1] They specifically looked at “upper endoscopy” (esophago-gastro-duodenoscopy) and flexible sigmoidoscopy, not full colonoscopy which has largely replaced flexible sigmoidoscopy as a screening tool. Their conclusions show that there were no differences in outcomes at 1 day, 1 month, or 1 year in the two populations, and that the patients of the nurses indicated greater satisfaction, particularly with the teaching and explanation that they received. This study is consistent with the findings of one published in 1994 in the New England Journal of Medicine by William Maule.[2] Nursing journals and other advocates have pointed to the latest study as indicating that nurses are, or can be, as “good as” doctors[3]; certainly within the limits of the study it does provide such evidence. The editorial accompanying the BMJ article discusses many of the limitations of the study, which I will not go into here, except to say that none of them particularly indicate that nurses trained to do endoscopy do not perform as well as physicians.[4]

I don’t doubt that this is encouraging to nurses, and to nurse educators, who have frequently been disparaged by implications that their education and training did not provide them with the background to perform as well as physicians. However, the important point here is not a nurse/doctor one, but rather the fact that endoscopy, like many medical procedures, is essentially a psychomotor skill, which should be able to be successfully taught to anyone who is moderately intelligent and moderately dexterous. In Britain, they have taught this skill to a large number of nurses, who apparently do it very well, as did the nurses in the US reported upon by Maule 15 years ago. But why should such training be limited to nurses? It is obvious that many procedures, including endoscopy, require significantly less psychomotor skill (and probably knowledge) than complex automobile mechanics, such as, say, rebuilding a transmission. Yet our automobile mechanics, even transmission specialists, while well trained, are not required to even attend college, not to mention receiving education and training as rigorous as nursing or medical school. Not to mention the 4 years of college, 4 years of medical school, 3 years of internal medicine residency, and 2 years of gastroenterology fellowship that are required in the US for a physician to become a GI specialist, the primary group doing endoscopy. For those who wish to note that working on a car is less serious than working on a person, I suggest that there is likely much greater risk to the health of the people riding in a car with a poorly rebuilt transmission or other major mechanical work than from a poorly done colonoscopy.

It seems obvious that adequate – even excellent – training could be received by those attending a two-year community college course, comparable to those training our radiology and laboratory technicians. A well-trained technician doing 10 or 20 endoscopic procedures a day would be very good indeed, and would free the well-trained gastroenterologist to make the complex medical decisions that do require a great deal of medical knowledge, skill and experience rather than spend their time performing relatively simple procedures. So why don’t we do it that way? Why do superbly educated gastroenterologic physicians choose to spend their time doing these procedures?

The answer, of course, is money, and the perverted, inappropriate and nonsensical way that we reimburse for health care in this country, in which the value assigned to procedures of any kind far exceeds that assigned to thinking and caring and talking and decision making (so-called “evaluation and management”, or E&M, care). In the US system of assigning value to different numeric codes, representing the work done for a patient, E&M “codes” are routinely, and absurdly, assigned a lower number of “relative value units” (RVUs) and thus reimbursed at much lower rate than procedural “codes”. For example, for approximately 30 minutes spent by a physician doing a visit with an established patient Medicare (2007) would pay $94.20, while the payment for a colonoscopy would be $203 and for a cataract removal, $670! This does not just apply to major surgical procedures, or even relatively large non-surgical procedures such as endoscopy. A physician can collect more money for cleaning the wax from a person’s ears (a procedure!) than for the entire well-person visit! Spending 5 minutes wrapping a gel-infused elastic bandage (“Unna’s boot”) around a foot with an ulcer on a person with diabetes will pay several times more than the entire visit listening to, examining, educating, and prescribing treatment for the patient. What utter nonsense!

The most important point made about the article in BMJ is a relatively minor sentence in the editorial: “Nurse led services in the United Kingdom have been encouraged by government policy, a shortage of doctors, a willingness of nurses to adopt expanded roles, and a salaried NHS workforce where professionals re not in competition for income from patients” (my emphasis). This is the heart of the matter. Where absurd reimbursement systems are not driving inappropriate use of resources, incenting highly trained physicians to do what could be done by nurses or, as I suggest, by well-trained technicians, we could actually decide what kind of care should be done by whom, and how much time should be spent on it, by what was in the best interest of people’s health.

[1] Williams J, Russell I, Durai D, et. al., “Effectiveness of nurse delivered endoscopy: findings from randomized mult-institution nurse endoscopy trial (MINuET), BMJ 2009;338:b231
[2] Maule WF, Screening for Colorectal Cancer by Nurse Endoscopists, NEJM Jan201994;330(3):183-87.
[3] Lomas C, “Endoscopy nurses 'equal' doctors”, NursingTimes.net, Feb 16, 2009 http://www.nursingtimes.net/news/breakingnews/2009/02/endoscopy_nurses_equal_doctors.html
[4] Norton C, Grieve A, Vance M, Editorial: Nurse-delivered colonoscopy, BMJ 2009;338:a3049

New Orleans: Have we still no shame?

I don’t usually post things about me, and what I did – it isn’t that kind of blog – but sometimes I come across things that do relate to issues of social justice.

I just returned from a meeting in New Orleans. I hadn’t been there since several months before Hurricane Katrina; that visit, in May, at a lovely time of year in New Orleans was a very pleasant memory in contrast to the devastation that I know occurred, that I have seen pictured. Three and a half years later, the French Quarter, where we stayed, looks ok. Ten days before Mardi Gras, there are even big parades, to show New Orleans is “back”. But it is not back. On the way to and from the airport the devastation is still apparent, the ruined buildings and blue tarps on the roofs of the Ninth Ward obvious even from the highway. Our group spent an afternoon working, planting, well, plants at City Park, a 1300 acre (compared to 800 acres for NYC’s Central Park) largely privately supported venue that is near to Lake Ponchatrain and was devasted by the storm. It felt good to do the work, to know that in some small way we were contributing to the rebuilding of New Orleans.

But why has it taken so long? It seemed that, with all the articles published, all the criticism of FEMA, and Homeland Security, and GWB, and “Heckuva job, Brownie!” that there was no more to know. But there is. Two experiences in particular. My friend Pat, talking to a ranger at a local park, asked why the Dutch, with their expertise in dikes and land reclamation, had not been consulted. They had, he said, and had arrived two days before. Two days before! Three and a half years late! But the Army Corps of Engineers didn’t think it needed to learn from anyone. Of course, they – the Corps – just handed in their plan for rebuilding the levees two weeks ago. The one that was due in December, 2007. (The ranger noted, as a sidebar, that he had been in Biloxi, MS after the storm, and that the Dutch Army landed on the beach and helped to feed people. Thank you!)

The other involves the attached photograph, not very clear as it was taken with a cell phone of a sign pretty high on a wall. If you can’t read it, it says:

“Tulane Community Health Center at Covenant House. Sustained through a generous gift from the People of Qatar.” And to the right of the logo: “Qatar Katrina Fund.”

Very generous of the people of Qatar. I am certain that the Tulane Community Health Center is providing vital health care services to the people of that community thanks to the funds from the People of Qatar.

But I am the only one who feels just a little bad, a little nauseous, that the “richest country in the world”, the home of all those multibillionaire financiers and bankers who are still rich, even after the collapse of the economy that they engineered with the able assistance of the US government, must rely on the generosity of the people of Qatar to fund a clinic in one of its own cities, three and a half years after a major natural disaster?

Where are our priorities? Where have they been? Is it possible that anyone could feel a government, a nation, that pursued policies of socialism-for-the-rich while ignoring the most basic human needs of its own people, is not worthy of shame? And that anyone who doesn’t feel that way, the people who actually made and make up the government, the policy makers and the talking heads who supported them and still support the same disastrous policies, are not evil and probably criminals?

Where is our shame?

Economics and Disease Prevention

In a brief, less than 3-page commentary in the February 4, 2009 JAMA, (“A closer look at the economic argument for disease prevention”),[1] Steven Woolf systematically, succinctly, and thoroughly addresses the breadth of issues surrounding assessment of prevention methods and their cost, and the comparison to treatment. It is a “must read” for anyone interested in health, prevention, medical care, or health economics. I have nothing to add to this excellent presentation, but for any readers who cannot get JAMA, I will attempt to identify and summarize some of the key points, below.

· Framing the question as “whether preventive strategies save money” is incorrect. Some may, indeed, but for others, as for any goods and services we purchase, the question is what value we, as individuals or a society, get for our expenditure (cost-effectiveness), particularly in comparison to other options (most commonly disease treatment). Often this is measured in QALYs (quality-adjusted life years; see post January). “Services ordinarily are considered to have reasonable cost-effectiveness if they cost less than $50,000 to $75,000 per [QALY], but payers routinely cover treatments that cost more than $100,000 per QALY.”

· Many preventive measures have been demonstrated to be very cost-effective – “Among 25 recommended preventive services 15 cost less than $35,000 per QALY and 10 services cost less than $14,000 per QALY”, while others actual do save money – “childhood immunizations, smoking cessation, and aspirin prophylaxis among patients at increased risk for cardiovascular disease”. However, some are not: “…offering services to low-risk patients, frequent rescreening, and pursuing aggressive targets (e.g., reducing low-density lipoprotein cholesterol levels to <100mg/dL).”

· Some services can be shown to be cost-effective in comparison to doing nothing, but are not when compared to an alternative intervention. This is parallel to the requirement that new drugs only need to be shown to be superior to placebo to be approved, not to alternative existing therapies (my comment, not his).

· The adoption of behaviors by individuals (such as smoking cessation or exercise) may be of great benefit and cost-effectiveness in themselves, but programs to induce such behaviors may or may not be. For example, physician counseling to patients to stop smoking is cost-effective (<$5000 per QALY) but physician counseling for patients to exercise is of uncertain effectiveness and cost/benefit.

· Econometrics doesn’t capture everything; “Even if prevention and treatment cost the same per QALY, patients prefer the former to avoid the ordeal of illness.” Of course, but not always considered!

· What level of effectiveness are we looking at and, importantly, who pays? “…some community…preventive services (e.g., tobacco taxes, immunization requirements, seatbelt requirement) offer low cost per QALY or net savings.”, but may not be as important to, or even considered by, physicians, hospitals and health plans concerned with medical care, and require social or governmental intervention. “Community interventions may outperform clinical interventions, on both effectiveness and economic value. Opening a new cardiac center may cost more and do less for the health of local citizens than banning smoking in public places.”

· While prevention only accounts for 2% to 3% of health care expenditures, preventive interventions are (rightly) scrutinized for effectiveness and cost-effectiveness, treatment interventions (wrongly) rarely are. “Policy makers will rightly deny coverage for cancer screening until trials demonstrate an effect on mortality, but they readily extend coverage for new diagnostic tests simply because they boast greater accuracy or are advocated by specialists….The question that dogs prevention – will it save money? – is rarely posed for a new imaging device, a new antibiotic, or a surgical procedure.” Woolf persuasively argues that, whatever the origins of this “double standard” may be, it must disappear if we are ever to control health care spending. “The same questions posed for prevention must now be applied to disease treatments: does the intervention improve health outcomes, and how strong is the evidence? If the intervention is effective, is it cost-effective (a good value)? Can other options achieve better results, or the same results at lower cost?”

I have quoted extensively from the piece because it is so well-written and clear. Although based on the work of many researchers, it provides an outstanding expostulation of the issues it covers. It should be read and pondered by all health systems, providers, and policy makers.

[1] Woolf SH, “A closer look at the economic argument for disease prevention”, JAMA 4Feb2009; 301(5):536-8.

Masters of the Universe: They need a long fall

The Sunday (February 8, 09) New York Times had an (as usual) excellent column by Frank Rich, “Slumdogs Unite!”. It addresses the issues of tax problems, conflict of interest, especially in the financial sector, and confidence of the public in the new Obama appointees. I would add only one thing: when I read the sentence “Most ‘ordinary Americans’ still don’t understand why banks got billions while nothing was done (and still isn’t being done) to bail out those who lost their homes, jobs and retirement savings.”, I initially misread “bail” as “jail”. Maybe that was wishful thinking. I suspect most “ordinary Americans” would think, as do I, that jail would be a good place for these financial “titans”!

Some of this suspicion is highlighted by an even more pointed column by Eugene Robinson, a member of the Washington Post Writers Group, which appeared in my local Kansas City Star on Monday, February 9, 09. Quoting liberally from Sen. Claire McCaskill’s “These people are idiots,” speech (referring to the financial executives who have been paying themselves billions from the federal (read: your money) bailout, Robinson cautions them to “…pay attention to those citizens outside, the ones with the pitchforks and torches.” Going beyond, but not missing the opportunity to discuss at length, the horror people feel at the arrogance and greed of our “masters of the universe”, including the craziness of the average CEO making 344 times what the average worker makes, Robinson adds the following:

“No longer does it make any sense to reward those who work in the financial industry so lavishly compared with the way we compensate those who, say, build tractors or write software or teach our children. Salaries should be reasonable and bonuses – much more modest ones – should be reserved for those who actually, you know, make money. If some of Wall Street’s vaunted “talent” balks and flees, terrific. It was “talent” that got us here.”

Couldn’t say it better. Maybe, if we insist on not jailing them, and not taking away all their money and using it for balancing the national debt and having them live in surplus FEMA trailers (all of which I advocate), they can learn an honest trade doing something truly necessary. Like collecting trash. But maybe they don’t deserve such a good job.

Universal Health Insurance or Universal Quality Health Care?

Jonathan Gruber, an MIT economist, has a piece in the January 29 issue of the New England Journal of Medicine entitled “Universal Health Insurance Coverage or Economic Relief – A False Choice”.[1] He clearly delineates the case for proceeding with health reform even in – perhaps especially in – these difficult economic times. He argues that rather than “Universal coverage…” being “…a luxury that we must do without in order to make way for other programs that will stimulate the economy”, that it is not only necessary for people’s health, but will in itself stimulate the economy. He suggests that “broad subsidies that make affordable health insurance available to lower-income families would improve not only the health of these families but the health of our economy, by freeing up funds that the families could spend on other consumer goods.”

Other ways it would stimulate the economy include elimination of “job lock”, the common (he states as much as 25%) circumstance in which people are afraid to leave their jobs, even for new and exciting opportunities (and “the most productive positions”), for fear of losing their health insurance, especially when they have pre-existing conditions. He notes that universal health insurance, if it required electronic health records and other methods of information sharing, would also be a great economic stimulus to the information technology industry. He cites the “white paper” issued by Sen. Baucus (D-MT), calling for dramatic investment in primary and preventive care, and the creation of the “patient centered medical home”, both things I have written about and strongly supported in previous posts. Finally, he discusses how having universal health coverage will allow us to focus on controlling spiraling health care costs: “I have witnessed this effect firsthand in Massachusetts, where for years our advocacy community focused exclusively on expanding coverage for medical expenditures and therefore opposed most initiatives that might have put that goals at risk, even those that might have meant controlling costs. Since Massachusetts passed its universal-coverage plan, this powerful advocacy community has shifted its attention to controlling costs as a means of preserving the program’s affordability to the state.”

These are all important points, and Dr. Gruber’s case for moving ahead with health reform as expeditiously as possible is on target. However, his position is inadequate, incomplete, and likely doomed to not achieve the goals he articulates because of several major misconceptions or issues insufficiently thought through. While his endorsing primary care and prevention is great, he goes on to state that “Such an approach would shift the focus of the health care system from specialists to preventive care practitioners with much lower barriers to entry, such as those for nurse practitioners and registered nurses.” This is a deeply flawed concept on several levels.

First, there is a major qualitative distinction between the skill set and practice role of registered nurses and nurse practitioners. Glossing over this is the most obvious indication of a fantastic lack of understanding of medical care and health care delivery. As documented by my guest author Robert Bowman in the January 15 entry “Ten Biggest Myths Regarding Primary Care in the Future”, nurse practitioners do not provide enough “standard primary care years” of practice to meet our needs, and without a more comprehensive approach to addressing the primary care/subspecialist imbalance, NPs (and physicians’ assistants) are likely to continue to move from primary care into higher-paying positions in subspecialty care. This leads to the third flaw, the idea that we can increase the number of practitioners in the primary care / preventive specialties without limiting the production of subspecialists. These “partialists” are paid an enormous amount for caring for “pieces” of people and are paid especially well for providing procedures, many of which involve mainly psychomotor rather than cognitive skill. Not every procedure is “brain surgery”; many are routine activities that could easily be done by technicians trained at a community college level (as are X-ray and laboratory technicians). However, they are so highly reimbursed that there is great pressure to 1) keep the entry level high (physician subspecialist), and 2) increase the volume of these procedures – many studies have demonstrated that in the weird inverted “market” of medical care, it is the availability of subspecialists and technology that drive demand rather than vice versa. Only by dramatically decreasing the financial incentives to enter subspecialties while increasing incentives to enter primary care can we reach the proper ratio of primary care to subspecialty care providers. (If our goal is to have 50% primary care providers, while we currently have 30% or less, we will need to have a much greater than 50% primary care provider output or it will be more than 30 years before we achieve this goal.)

Finally, Gruber’s flip comment plays directly into the idea, entrenched in the medical profession and medical trainees, that subspecialties, because they earn so much more, require greater skill and intelligence and thus merit higher “barriers to entry” than primary care. This is absolutely not so. In addition to the issue of high reimbursement for relatively simple psychomotor procedures noted above, “partialists” only care for one aspect of a person’s health. Thus, an individual’s care is not only spreading among many providers, increasing fragmentation, but dramatically increases cost by multiple subspecialist referrals for conditions (“I’m a cardiologist; I do hearts. If your knee hurts, see an orthopedist”). The specialty of primary care (I am aghast that Gruber is inane enough to contrast “primary care provider” and “specialist”) provides care for the whole person. Rather than managing a single condition or organ system, the primary care provider manages many chronic diseases, sometimes with help from consultants whose recommendations s/he has to coordinate and rationalize in his/her role as the primary consultant to the patient. S/he also cares for acute problems. And provides preventive care, counseling and screening. And understands the impact of the family and community of each person, and on their health and their ability to address their health needs. And “asks for trouble”, even when the patient doesn’t complain of a problem (“Are you feeling safe at home?). And, most importantly, recognizes that the role of primary consultant to the patient means working hard to understand the patient’s world-view, to speak their language, and realize that “knowing the right answer” is absolutely meaningless unless it can be translated into health benefit for the patient. This is a skill set that is exceedingly complex, difficult to develop and maintain, and requires the highest level of cognitive and interpersonal skills, and requires constantl improvement over time. In Gruber’s Massachusetts, health reform has been stymied by the insufficient number of primary care providers to care for all the newly-insured despite a wealth of subspecialist / partialists. His comments implying the simplicity of primary care do nothing to advance the quality of health care to our population, which is after all the goal of health reform -- not coverage but access to high quality care for all.

Beyond these issues with primary care, Gruber’s analysis is fatally flawed in its assumption that expanding insurance coverage – with the government paying for it – is the solution to universal coverage. He only tangentially addresses the issue once, saying “Other countries, such as the Netherlands and Switzerland, have demonstrated that it is possible to have both universal coverage (even coverage provided through private insurance companies) and much lower health care spending.” As clearly noted in T.R. Reid’s “Frontline” piece “Sick around the world”,[2] Switzerland’s insurance companies are – and were even before universal coverage – not for profit. This makes a tremendous difference.

To suggest that we should have universal coverage paid for by the government through for-profit insurance companies, is exactly equivalent to giving enormous government bailouts to the financial sector that they can use to pay stockholder dividends and executive bonuses! (Whoops, we did that!) It is absolutely wrong and misguided. It is morally and logically bankrupt, and, ultimately, financially bankrupting.

[1] Gruber J, “Universal Health Insurance Coverage or Economic Relief – A False Choice”. NEJM 29Jan,2009;360(5):437-9.
[2] http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/

Prevention and Cost

Health Affairs, Jan-Feb 2009, has several articles on preventing chronic illness, examining the value and cost-effectiveness of various prevention strategies. In “Preventing chronic disease: an important investment but don’t count on cost savings,”[1] Louise Russell uses the techniques of cost-effectiveness analysis (CEA) to look at a number of prevention and screening strategies and looks at the cost per QALY (quality-adjusted life year) compared to treating the disease. What becomes clear is that the more that the prevention strategy is targeted to a high-risk group, the more cost-effective it is, that is, the less the cost per additional QALY.

“For low-risk men ages 45-54 with LDL cholesterol between 160 and 189 mg/dl, the additional cost of statins [moderate cholesterol-lowering agents] in 1997 was $270,000 per healthy year, or about $400,000 today. For smokers ages 45-54 with LDL above 190 mg/dl, high blood pressure, and poor HDL [good] cholesterol, cost per healthy year is much less: $57,000 in 1997, or $85,000 today. For men with established heart disease, statins are highly cost-effective: under $10,000 per healthy year in 1997, or $15,000 today.”

The primary reason for the difference, of course, is the large number of people who need to be treated to prevent one person from dying; the higher risk the population considered, the lower that ratio. The other variable, obviously, is the frequency of screening. Doing a test every year costs twice as much as doing it every two years; unless the condition occurs and progresses so quickly that twice as much disease is uncovered and prevented (or treated successfully) the CEA will be worse. A good example is Pap smear tests for cervical cancer, arguably the best (most effective in preventing morbidity and mortality) screening test we have. “…screening every 3 to 5 years is cost-effective compared with no screening, but costs rise rapidly with more frequent screening. Compared to screening every 2 years, annual screening cost $1 million per healthy year in 1995, or more than $3 million today.” There are certainly women who are at higher risk of cervical cancer, and should be screened annually, but this illustrates that, even in the case of the best screening test, going from the benefit to some to screening for all is not always – or even usually – a good thing.

There are other issues besides cost when people who have a low likelihood of a disease are screened. They may be “false positives” – have a positive test but not have the disease – and undergo more tests that could be unpleasant, expensive, risky, or all three – before they find out they are really disease free. This is a difficult concept, even for medical students, but the reason is that if a disease is very uncommon – as most are – then even a good test may find more false than true positives.[2]

In the same issue, Ron Goetzl talks about different conceptions of prevention. These vary greatly, with the public (and legislators) often meaning very different things than academics or health professionals; moreover, health professionals are often afflicted with biases toward prevention of diseases in their “area”; a specialist will see a much higher percent of people with a very advanced or serious form of a disease than a generalist (because they have often been referred) and thus may have a perceptual overestimate of the commonness (prevalence) of that disease. Goetzl describes a variety of types of prevention: screening (discussed above), immunizations, and various public policies that may limit risk: “…raising taxes on cigarettes, limiting employees’ exposure to toxic substances, mandating seat-belt use, screening for cancer, restricting alcohol scales to minors, building bicycle paths, and eliminating sales of sugary beverages in schools”.[3] He notes that while these policy interventions, and immunizations, may be prevention, screenings are actually identification of disease in its early stages when treatment can prevent progression. He then talks about health promotion, a kind of primary prevention that rarely or ever requires medical intervention, “…managing one’s weight, being physically active, eating a healthy diet, not smoking, drinking moderate amounts of alcohol[4], getting enough rest, surrounding oneself with family and friends, driving safely, managing stress, and, in general, living what most would agree is a healthy lifestyle.” Well, anytime one says “most would agree” one has abandoned the world of evidence for belief systems, but you get the point. Pretty much all these things are cost-effective and work very well. Goetzl also addresses secondary prevention – treatment of early disease to prevent worse disease, such as treating high cholesterol, high blood pressure, or stopping smoking. He notes that “Although these interventions rarely save money, certain ones offer high value in terms of adding QALYs at a relatively low cost”.

If cost-effectiveness analysis can help us to understand what the cost per benefit (usually $ per QALY) is, it is also important to understand that I may be willing to spend a lot more on ME per QALY than on you, or particularly someone I don’t know;. Thus the importance of having standards, not individuals choosing enormously expensive screening interventions for themselves (which can often, as noted above, backfire by finding “disease” that is not present, not treatable or less risky than the diagnostic and treatment interventions.

Goetzl’s most important point is to counter the argument that prevention is not worthwhile because …”people have to die of something – all prevention does is postpone the time of eventual death and introduce new and more costly diseases that are the consequences of aging. As Woolf points out, the aim of prevention is not to replace one disease with another, but to compress the time one is sick or disabled before one’s ultimate demise.”

Much disease can be prevented, much suffering can be averted. Some of the preventions are behavioral changes such diet and exercise and not smoking, and real progress has been made in this arena. Others require social policies – seatbelt laws, safer cars, even safer guns. Yet others use social policies to facilitate individual behavior change – eliminating sweets from schools, making public places smoke free, prominently displaying calorie counts on fast food items. And, yes, some are medical: immunizations and some screening tests and some treatments for early disease. But people cannot expect that everything can be prevented by medicine, or found early, or successfully treated even when treatment is offered – and even when it is “successful” (that is, diseases sometimes get better or do not progress regardless of treatment, but the benefit is attributed to the treatment if it has been instituted (prostate cancer, for example).

Just because something makes sense doesn’t make it true; it is a research question, not an answer. If something doesn’t make sense, you probably won’t study it, but if it does you need to do the research to find out if it is true. People – their biology and their behavior – is too complex for something to be true just because it makes sense in one dimension. And certainly not because you just “want” it to be.



[1] Russell, LB, “Preventing chronic disease: an important investment but don’t count on cost savings”, Health Affairs, Jan/Feb 2009;28(1):42-45.
[2] Consider a disease which is very common; say 1 in 1000 people have it. And let’s say the test for it correctly identifies 9 of 10 people who have it and misses 1 (this is known as 90% sensitivity), and is negative in 9 of 10 people who DON’T have it (90% specificity). If we test the 1000 people, the one person who has it will probably have a positive test (true positive). But 10% of the 999 who don’t have it – 99.9 people – will have a false-positive test. So there are 99.9 false positives for every true positive; a person with a positive test is 100 times as likely to NOT have the disease as to have it (1% positive predictive value). However, if we take a population where the risk is 10 times as great, 1 in 100, then of the 1000 people there will be 9 (90% of 10) true positives and 90 (90% of 900) false positives, so the positive predictive value is up to 10% (1 in 10 positives is a true positive).
[3] Goetzl, RZ, “Do prevention or treatment services save money? The wrong debate”, Health Affairs, Jan/Feb 2009;28(1):37-41
[4] “ drinking moderate amounts of alcohol…” – his phrase, not mine. To suggest “not smoking” but “drinking moderate amounts of alcohol” is the most healthful demonstrates a clear bias and is not evidence based. From a health perspective, “not drinking alcohol” is the best choice.

Social Justice: Economic Stimulus and Bailout

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

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

President Obama rescinds Global Gag Rule

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

Congratulations and thank you, President Obama!

The "Neurontin Legacy"

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

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

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

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

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

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

Martin Luther King, Jr. Day and the Inauguration

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

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

Ten Biggest Myths Regarding Primary Care in the Future

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

• Myth Number 1: Primary Care has collapsed. Primary care internal medicine has collapsed with lowest production and lowest primary care retention levels. Those associated with internal medicine primary care perceive collapse. But primary care remains. Existing dedicated primary care practitioners continue to deliver primary care despite insufficient support. There are 5 training sources of primary care. Some are remaining steady and some are dropping. The ideal primary care provider would contribute 35 Standard Primary Care (SPC) years: a 35 years career, actively in practice 100% of those years, and 100% remaining in primary care and 100% or top volume of primary care. Among the 5 forms of primary care training, family medicine remains steady in primary care with over 25 Standard Primary Care (SPC) years per graduate. Pediatrics is also steady, but with only 16 SPC years per graduate. The other 3 forms have more graduates who are inactive or part-time, have fewer years in a career, retain a lower percent of graduates in primary care (retention), and have a lower volume of primary care. They thus make limited contributions with fewer SPC years per graduate. Internal medicine, nurse practitioner, and physician assistant forms have declined to less than 4 SPC years per program graduate. Collapse of primary care is found for forms that depart primary care during training, at graduation, and each year after graduation under the assault of poor primary care support. [1]
  
  
• Myth Number 2: Nurse practitioners will take over more primary care duties. Nurse practitioners will continue to supply less than 12% of the primary care supplied by the five primary care training forms using past measures as well as future estimates.[1, 2] Increasing departures to hospital and specialty careers, lowest activity (inactive, part time), lowest volume of primary care, and greatest delays in entering primary care limit nurse practitioner primary care contributions.
  

• Myth Number 3: Physician assistants will take over more primary care duties. Less than 30% of new physician assistants enter primary care and active physician assistants will dip below this level in the next 3 years.[3] Physician assistants will continue to supply less than 12% of the primary care supplied by the five training forms. Increasing departures to emergency medicine and subspecialty careers, lower activity (inactive, part time), and lower volume of primary care limit physician assistant primary care contributions.
  
  Only if physician assistants or nurse practitioners were required to stay in the family practice mode of care would they be able to increase share of primary care, rural primary care, and underserved primary care duties.
  

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

• Myth Number 5: The United States is unable to produce enough primary care. Through policy, medical education efforts, and statewide efforts, the US has been consistently successful. The US was able to quadruple primary care graduates in the 1970s. The US increased primary care production 50% during the span of a few years in the 1990s. Historically Black, osteopathic, and many allopathic public schools have been successful for over 100 years. Primary care contributions are maximized when schools and states focus together on health access in birth to admission preparation, admission preferences, training curricula/faculty/locations, and health policy.[6]
  
  To sum up: the only way that the United States can fail to produce primary care is to admit the most exclusive students (lowest probability primary care), train in locations with the least health access emphasis (lowest influence), fail to graduate enough family physicians (permanent form), and create a health policy that rewards the most exclusive careers and locations. This, of course, is exactly how US health care is structured.

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

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

• Myth Number 8: Primary care is not marketable to the American consumer.[2, 7, 8] It is very hard to understand how respected authorities in leadership positions could make such statements. Only a severe lack of awareness explains their comments. Workforce experts, trainers and educators in major medical centers and medical schools, leaders in the Council of Graduate Medical Education and the Association of American Medical Colleges all live in areas with the highest concentrations of people, physicians, and medical schools. These experts have spent their entire lives in locations that employ the fewest primary care physicians and support primary care at the lowest levels. They have tolerated the training of medical students and residents in dysfunctional primary care settings.[9] It is not surprising that primary care does not appear marketable to those clustered in the 3,300 US zip codes which make up 4% of the land area with 75% of physicians and 95% of medical schools. This limited perspective ignores the 38,000 zip codes in which 65% of the American population and 70% of the elderly are cared for by the remaining 23% of total physicians. In these locations, 30 – 100% of the total physicians are primary care physicians.
  
  The total elimination of health care for millions is unconscionable and this is what is suggested by the statement that primary care is not marketable. The locations that depend upon primary care are also locations that offer better primary care salaries, better primary care support, better practice options to generate more revenue, lower costs of delivering health care, and lower costs of living. Those designing health care for an entire nation must place much more emphasis on care for the 65% of the population left out of the current health care design. All of medicine and medical education will pay dearly for the choices of a few leaders. Current leaders appear to have abandoned Butler’s call to a season of accountability and social responsibility for medical education.[10 ]
  

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

• Myth Number 10: Care for Age 65 and Up Will Be Provided By Geriatric Specialists. Geriatricians are a small fraction of new physicians, they are less likely to be found in locations with concentrations of older Americans, they have limited support, they have lower volume of patients, and they have some of the most complex patients. Older patients move toward locations with lower costs of living and health care and they move away from concentrations of internal medicine physicians, geriatricians, geriatric training programs, stroke centers, and heart attack centers.[12] They move steadily toward locations served predominantly by family physicians.
  
  National studies confirm patterns of care for the elderly and for all seeking ambulatory care in the United States in 2004. About 62.5% of age 65 and older patients saw a family physician compared to internists for 29%, and somewhat less than 19% seeing a nurse practitioner.[2] This is not what numbers of graduates predict since both internal medicine graduates and nurse practitioner graduates are about twice the number of family practice graduates. In 2004 family physicians led in all but one ambulatory category. In addition to seniors, family physicians were seen by 43.4% of adults seeking care, and 39% seeking women’s health care. The family physician share of 20% was second to pediatricians although family physician percentages increased for children over age 4 and for the 65% of the population beyond concentrations of pediatricians.[2] This is why increased family physicians can address pediatric care needs while more pediatricians cannot.
  
  

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

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

Mr. Bush’s Legacy: The Global Gag Rule

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

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

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

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

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

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

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

Sanjay Gupta for Surgeon General?

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

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

Enthoven: Consumer Choice Health Plan -- Again

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

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

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

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

Student Debt, Resident Hours, and Primary Care Redux

HAPPY NEW YEAR! May 2009 be a big improvement!

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

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

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

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

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

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