.
In his Perspective “Why we don’t spend enough on public health” in the New England Journal of Medicine (May 6, 2010;362(10):1657-8), David Hemenway of the Harvard School of Public Health goes beyond the familiar complaint of the field that it is underfunded, particularly in contrast to medical care, despite the fact that it responsible for a much greater proportion of, well, the public’s health. He describes, as the title states, why.
“Medicine is primarily a private good — the patient receives the main benefit of any care provided. Payments usually come from the individual patient and, in the developed world, from private and governmental insurance. Public health, on the other hand, provides public goods — such as a good sewer system — and relies almost exclusively on government funding.”
The fact that public health provides a more general good would seem to be, well, good, but because it doesn’t as easily benefit a particular individual (me, or someone I know, or at least someone I can see a picture of) it is less engaging. People, Hemenway points out, are “wired” to value present need more than future benefit; cost today for potential benefit tomorrow is not easy to “buy” and is certainly rarely politically popular. In addition, the absence of disease (because it was prevented) is less obvious – and thus unfortunately less valued – than the cure of a disease that didn’t have to occur. We don’t wake up every morning and say “thank goodness I don’t have cholera because we have a clean water supply!”, but would be very grateful for a cure if we did contract cholera.
In addition, of course, and very importantly, Hemenway notes that while there are well-heeled advocates for spending money on medical care (e.g., pharmaceutical companies, hospitals, doctors), the money is generally working against public health measures which often threaten extra cost to business – regulation of air and water pollution, environmental restrictions, occupational health laws, smoking bans, alcohol restrictions. And especially gun-control, where opposition to minimal studies supported by the CDC on this major health problem were so opposed by congressmen influenced by the gun lobby that they effectively stopped research into this area. Or, more recently, where members of Congress such as Sen. Lindsey Graham (R-SC), tie themselves into verbal knots trying to show how hard they will be on suspected terrorists, and how many Constitutional rights they are willing to abridge – unless it is the Second Amendment, and mainly the NRA. When addressing the issue of restricting the ability of people on the “no-fly” list to buy guns Sen. Graham is uncompromising: “I think you’re going to far here.” (“Congress Up in Arms”, Gail Collins, May 6, 2010) .
Hemenway cites the example of “Baby Jessica” who fell down a well in Texas in 1987 whose story gripped the country: “As a nation, we will spend tens of millions of dollars to save one Baby Jessica but are often unwilling to spend an equivalent amount to prevent the deaths of many statistical babies…The scandal that people remember about Hurricane Katrina is not so much the lack of preventive measures (e.g., stronger levees) that would have averted the calamity but the inadequate rescue efforts.”
This is why TV commercials for “Save the Children” and like charities that show the faces of actual children, or even better the agencies that allow us to “adopt” specific developing-world children by sending money to them, the individual kids, are so much more effective than general appeals for contributions to help the oppressed around the world. It is also why, when the New York Times published “Faces of the Dead” on the 7th anniversary of the Iraq war, it was so much more powerful than simply saying “more than 4,000 have died”, or even listing their names. It is now an interactive site; click on any of the little boxes and the photo changes to that dead serviceman or woman, with their name, age, hometown and service branch. Please check this site out, but have a box of tissues beside you.
The more common tack taken by public health experts has been to try to provide more and more data, to policymakers and the public, about the importance of public health measures past, current, and (potentially) future, in the expectation, or at least hope, that this will convince them and result in a greater commitment (spelled, like all commitment, “M-O-N-E-Y”) to public health undertakings. Hemenway’s piece, demonstrating that anecdote, personal stories, and treatment of existing conditions that are actually hurting people, are more powerfully convincing than data, evidence, and effective prevention, must be very frustrating. Indeed, the issue (and I would say the problem) goes beyond public health to health and medical care in general; indeed it applies to most issues in the policy arena. Data, whether presented in “dry” tables, journal articles, Congressional testimony, or the media, does not seem to change peoples’ minds.
Hemenway says that “societal change is hard”, but so is individual change. The case for this conclusion is clearly presented by Christie Aschwanden in “Convincing the Public to Accept New Medical Guidelines”, in e-zine Miller-McCune, April 20, 2010. In this important piece, Aschwanden begins by looking at the unwillingness of long-distance runners to change their use of ibuprofen (“Vitamin I”) for preventing pain and inflammation even when studies demonstrated that its use made these problems worse and those results were presented to the athletes. The conflict between the phenomenon called “naïve realism”, which is “the idea that whatever I believe, I believe it simply because it’s true,” versus the actually more naïve belief that “truth wins”. She discusses the recent breast cancer screening recommendations, and the belief (in part the result of a successful program of “education” from cancer awareness organizations) that the more screening of the more people, the better.
“For years, women were taught the necessity of early detection for breast cancer based on the notion that breast cancer is a relentlessly progressive disease that will inevitably kill you if you don’t remove it in time. That story about breast cancer — call it the “relentless progression” mind model — is easy to grasp, makes intuitive sense and offers a measure of comfort: Every cancer is curable as long as you catch it in time.”
This is not a correct model, but it is hard to convince someone who had a mammogram, found cancer, had it treated, and is now alive, that mammography screening for everyone is not a good idea, much less that her cancer had a certain percent chance (much lower than prostate cancer, to be sure) of regressing on its own. I have addressed the breast cancer recommendations previously (Breast Cancer Screening and Evidence-based Medicine, November 25, 2009), so will rather focus on the studies that show, as she quotes social psychologist Robert J. MacCoun, “If a researcher produces a finding that confirms what I already believe, then of course it’s correct. Conversely, when we encounter a finding we don’t like, we have a need to explain it away.” I have previously noted that “data is only useful if it confirms my preconceived notions”; Aschwanden’s article cites study after study showing the same, on medical issues from breast cancer to low back pain. The President has called for more comparative effectiveness research (as have I, Comparative effectiveness research, March 27, 2010) but “How do you convince doctors and patients to dump established, well-loved interventions when evidence shows they don’t actually improve health?”
More generally, this is not just an issue with health beliefs. Aschwanden cites studies that demonstrated that people who believed Sadaam Hussein has weapons of mass destruction continued to believe it after being show evidence that it was not true. The opposite may occur, in fact; the presentation of facts that contradict your beliefs may serve to remind you of why you believe it and reinforce them. “It comes down,” Aschwanden writes, “to something the satirist Stephen Colbert calls ‘truthiness,’ a term he coined in a 2005 episode of his Comedy Central show, "The Colbert Report". ‘Truthiness is what you want the facts to be, as opposed to what the facts are,’ Colbert said. ‘It is the truth that is felt deep down, in the gut.’”
I admit to some my own truthiness. I want to believe, despite all this evidence, that people can be convinced by the evidence. That we will reconfigure the great imbalance of funding for individual medical care and public health because of the opportunity to improve people’s health and prevent disease; that we will choose prevention, screening, and treatment strategies based on evidence of effectiveness rather than myth or the financial benefit that accrues to the vendor of the service, and that we can unlearn that which is wrong as well as learn anew what is right. And that, even in the political arena, policy decisions may be guided by facts and reality rather than convictions. I know this is naïve, but I really want it to be true. Doesn’t that count for something?
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Saturday, May 15, 2010
Sunday, May 9, 2010
Health Outcomes: The interaction of class and health behaviors
.
I have recently discussed (Poverty, Primary Care and the Cost of Medical Care, February 10, 2010) the “Whitehall Studies” conducted by Sir Michael Marmot and colleagues that “demonstrate that there is a more or less linear correlation between health (including longevity) and increasing social class". That piece discussed the report of a panel headed by Marmot, “Fair Society, Healthy Lives”, that shows that these problems have not been resolved. A new paper from the follow-up “Whitehall II” study, conducted by Silvia Stringhini and colleagues from both Britain and France, “Association of socioeconomic position with health behavior and mortality”, (JAMA Mar24/31,2010;303(12):1159-66), examined the role of alcohol, tobacco, diet, and physical activity in accounting for these differences over an extraordinarily long 24-year follow-up period.
Stringhini, et. al., found that in fact adverse health behaviors accounted for about 42% of the increase in mortality in lower socioeconomic groups (which was about 1.6 times as high in lowest than in the highest socioeconomic group). Smoking was the most powerful negative factor, with the others contributing a smaller amount. “There was a marked social gradient in health behaviors at baseline. Participants in the lower socioeconomic positions were more likely to smoke, abstain from alcohol consumption, follow an unhealthy diet, and be physically inactive and less likely to consume heavy amounts of alcohol.” Most of this is consistent with the observations of physicians and epidemiologists in the US, with the surprising exception of alcohol use being lower in lower income groups. This may be a difference between the US and Britain; in Britain, in the 20th century, cirrhosis was a disease largely of the upper class who could afford the highly taxed, and high alcohol content, distilled spirits. Another possibility (and this is my speculation, not data) is that the lower socioeconomic group studied by Whitehall II in England may have a large component of Muslims, who do not drink. In any case, the impact of smoking, poor diet, and physical inactivity accounted for a significant part of the class difference in mortality, although it did not account for even the majority of that difference.
Thus, this study supports two well-established assumptions: 1) that adverse health behaviors are a significant contributor to ill health and higher age-adjusted mortality rate, and 2) that people in lower socioeconomic groups have worse health and higher mortality rates, much, but not all, of which can be associated with their higher rates of adverse health behaviors. Previous work on the results of Whitehall have suggested, and demonstrated evidentiary support for, the hypothesis that stress in daily life (of worrying about how you will pay the rent and feed your family, whether you are going to lose your job, or, particularly in the case of ethnic and racial minorities, not only whether you will be arrested or harassed by the authorities but the indignities of ongoing discrimination), mediated through only partially understood neurochemical pathways, account for much of this effect. However, to the extent that people can divest themselves of risky health behaviors, they can decrease, if not eliminate, their higher risk for adverse health outcomes.
In the same issue of JAMA, James R. Dunn of McMaster University in Canada, has a very insightful editorial commenting on the Stringhini article, “Health behavior vs the stress of low socioeconomic status and health outcomes” (JAMA, Mar24/31, 2010;303(12):1199-1200). He repeats the caution of the Whitehall authors that the population studied in the Whitehall cohort may not be representative of the British population overall (and, by extension, of the US or Canadian population). Indeed, the cohort was originally selected by Marmot and colleagues to reduce the confounding that might come from general studies of people in different classes because of occupational risks. Dunn points to the association of the stress of low socioeconomic status and the prevalence of adverse health behaviors: “…it is possible to consider both factors [stress and behavior] as part of the same pathway between relatively low socioeconomic status and health. Unhealthy behaviors are more common among individuals with low socioeconomic status because of the stress of low socioeconomic status. Accordingly, there is a direct causal pathway between low socioeconomic status and poor health as well as an indirect causal pathway through health behavior, which reinforce one another over the lifecourse.” That is, the stress of being poor makes you more likely to do unhealthful things that we know about (smoking, poor diet, low physical activity) that make you less healthy, and also makes you less healthy through a pathway that we don’t completely understand.
Dunn notes that while changing health behaviors in lower socioeconomic populations would be a good thing, “The problem is that traditional individually oriented health behavior education interventions are not very effective, and individuals with low socioeconomic status have been notoriously difficult to reach with such programs”. He discusses a variety of early childhood developmental characteristics, especially “executive function” and “self regulation” which might increase the probability of not adopting or stopping adverse health behaviors, which are on average less well developed in those growing up in lower socioeconomic groups, presumably also as a result of the stress impacting them as young children.
The relatively good news from the Stringhini study is that the prevalence of many adverse health behaviors did decrease over the time period studied. For smoking, the prevalence decrease from 10.1% to 4.8% in the highest, and from 29.7% to 16.5% in the lowest socioeconomic groups and unhealthy diet from 5.8% to 1.0% and 14.9% to 5.2% respectively diet; on the other hand, sedentary behavior increased from 6.6% to 21.4% in the highest and from 35.4% to 41.6% in the lowest socioeconomic groups. Again, extending this to the whole British population is uncertain, and in the US the prevalence of obesity (a combination of both poor diet and physical inactivity) is growing at a staggering rate in all age groups, and especially in low socioeconomic groups.
The take-home message is that all people should be encouraged and supported to adopt healthful and eschew unhealthful behaviors, particularly related to smoking, diet and exercise, and the degree to which any programs can be demonstrated to be successful for large numbers of individuals or, better yet, groups, they should be promulgated and replicated. However, to have greater success, programs will have to strike closer at the etiologies of these behaviors. A lower level, achievable (and achieved in some jurisdictions) by legislation, exemplified by indoor smoking bans, calorie and fat content labeling of foods, especially fast foods, and banning the use of toys as gifts in fast-food meals (as recently done in Santa Clara County, CA), can have much more significant impact (see “Promoting health through tobacco taxation” by Ali and Koplan from JAMA, and “Cardiovascular effect of bans on smoking in public places: a systematic review and meta-analysis” by Meyer, et. al., in JACC, cited in The Public’s Health: Smoking and Salt, February 6, 2010).
The greatest changes, however, involve even more significant societal changes: the elimination of the wide disparity in income and opportunity, thus socioeconomic status, and of racism. Health-focused, as well as social justice focused, policies should try to achieve this end, but in the US it will be a long time coming. In the meantime, it remains a good idea to choose your parents wisely; being born white and rich still significantly enhances your health status.
.
I have recently discussed (Poverty, Primary Care and the Cost of Medical Care, February 10, 2010) the “Whitehall Studies” conducted by Sir Michael Marmot and colleagues that “demonstrate that there is a more or less linear correlation between health (including longevity) and increasing social class". That piece discussed the report of a panel headed by Marmot, “Fair Society, Healthy Lives”, that shows that these problems have not been resolved. A new paper from the follow-up “Whitehall II” study, conducted by Silvia Stringhini and colleagues from both Britain and France, “Association of socioeconomic position with health behavior and mortality”, (JAMA Mar24/31,2010;303(12):1159-66), examined the role of alcohol, tobacco, diet, and physical activity in accounting for these differences over an extraordinarily long 24-year follow-up period.
Stringhini, et. al., found that in fact adverse health behaviors accounted for about 42% of the increase in mortality in lower socioeconomic groups (which was about 1.6 times as high in lowest than in the highest socioeconomic group). Smoking was the most powerful negative factor, with the others contributing a smaller amount. “There was a marked social gradient in health behaviors at baseline. Participants in the lower socioeconomic positions were more likely to smoke, abstain from alcohol consumption, follow an unhealthy diet, and be physically inactive and less likely to consume heavy amounts of alcohol.” Most of this is consistent with the observations of physicians and epidemiologists in the US, with the surprising exception of alcohol use being lower in lower income groups. This may be a difference between the US and Britain; in Britain, in the 20th century, cirrhosis was a disease largely of the upper class who could afford the highly taxed, and high alcohol content, distilled spirits. Another possibility (and this is my speculation, not data) is that the lower socioeconomic group studied by Whitehall II in England may have a large component of Muslims, who do not drink. In any case, the impact of smoking, poor diet, and physical inactivity accounted for a significant part of the class difference in mortality, although it did not account for even the majority of that difference.
Thus, this study supports two well-established assumptions: 1) that adverse health behaviors are a significant contributor to ill health and higher age-adjusted mortality rate, and 2) that people in lower socioeconomic groups have worse health and higher mortality rates, much, but not all, of which can be associated with their higher rates of adverse health behaviors. Previous work on the results of Whitehall have suggested, and demonstrated evidentiary support for, the hypothesis that stress in daily life (of worrying about how you will pay the rent and feed your family, whether you are going to lose your job, or, particularly in the case of ethnic and racial minorities, not only whether you will be arrested or harassed by the authorities but the indignities of ongoing discrimination), mediated through only partially understood neurochemical pathways, account for much of this effect. However, to the extent that people can divest themselves of risky health behaviors, they can decrease, if not eliminate, their higher risk for adverse health outcomes.
In the same issue of JAMA, James R. Dunn of McMaster University in Canada, has a very insightful editorial commenting on the Stringhini article, “Health behavior vs the stress of low socioeconomic status and health outcomes” (JAMA, Mar24/31, 2010;303(12):1199-1200). He repeats the caution of the Whitehall authors that the population studied in the Whitehall cohort may not be representative of the British population overall (and, by extension, of the US or Canadian population). Indeed, the cohort was originally selected by Marmot and colleagues to reduce the confounding that might come from general studies of people in different classes because of occupational risks. Dunn points to the association of the stress of low socioeconomic status and the prevalence of adverse health behaviors: “…it is possible to consider both factors [stress and behavior] as part of the same pathway between relatively low socioeconomic status and health. Unhealthy behaviors are more common among individuals with low socioeconomic status because of the stress of low socioeconomic status. Accordingly, there is a direct causal pathway between low socioeconomic status and poor health as well as an indirect causal pathway through health behavior, which reinforce one another over the lifecourse.” That is, the stress of being poor makes you more likely to do unhealthful things that we know about (smoking, poor diet, low physical activity) that make you less healthy, and also makes you less healthy through a pathway that we don’t completely understand.
Dunn notes that while changing health behaviors in lower socioeconomic populations would be a good thing, “The problem is that traditional individually oriented health behavior education interventions are not very effective, and individuals with low socioeconomic status have been notoriously difficult to reach with such programs”. He discusses a variety of early childhood developmental characteristics, especially “executive function” and “self regulation” which might increase the probability of not adopting or stopping adverse health behaviors, which are on average less well developed in those growing up in lower socioeconomic groups, presumably also as a result of the stress impacting them as young children.
The relatively good news from the Stringhini study is that the prevalence of many adverse health behaviors did decrease over the time period studied. For smoking, the prevalence decrease from 10.1% to 4.8% in the highest, and from 29.7% to 16.5% in the lowest socioeconomic groups and unhealthy diet from 5.8% to 1.0% and 14.9% to 5.2% respectively diet; on the other hand, sedentary behavior increased from 6.6% to 21.4% in the highest and from 35.4% to 41.6% in the lowest socioeconomic groups. Again, extending this to the whole British population is uncertain, and in the US the prevalence of obesity (a combination of both poor diet and physical inactivity) is growing at a staggering rate in all age groups, and especially in low socioeconomic groups.
The take-home message is that all people should be encouraged and supported to adopt healthful and eschew unhealthful behaviors, particularly related to smoking, diet and exercise, and the degree to which any programs can be demonstrated to be successful for large numbers of individuals or, better yet, groups, they should be promulgated and replicated. However, to have greater success, programs will have to strike closer at the etiologies of these behaviors. A lower level, achievable (and achieved in some jurisdictions) by legislation, exemplified by indoor smoking bans, calorie and fat content labeling of foods, especially fast foods, and banning the use of toys as gifts in fast-food meals (as recently done in Santa Clara County, CA), can have much more significant impact (see “Promoting health through tobacco taxation” by Ali and Koplan from JAMA, and “Cardiovascular effect of bans on smoking in public places: a systematic review and meta-analysis” by Meyer, et. al., in JACC, cited in The Public’s Health: Smoking and Salt, February 6, 2010).
The greatest changes, however, involve even more significant societal changes: the elimination of the wide disparity in income and opportunity, thus socioeconomic status, and of racism. Health-focused, as well as social justice focused, policies should try to achieve this end, but in the US it will be a long time coming. In the meantime, it remains a good idea to choose your parents wisely; being born white and rich still significantly enhances your health status.
.
Tuesday, May 4, 2010
Big Finance & Big Oil -- Teabaggers and Racism
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The news coverage would suggest that President Obama and the Democratic Party should just give up now; the teabaggers and the Republican naysayers have convinced the American people and we all now believe in – what was it again? No taxes? No health care? That regulating banks is likely to increase the probability of having to bail them out? No matter; Scott Brown in Massachusetts was the leading edge and soon the entire Senate will be Republican (although if passing a bill with only 59% of the votes in the Senate is “undemocratic” what do we even care? Oh yes; 59 Democratic votes is a minority while 51 Republican votes is a smashing mandate!) Yes, the Repubs claim the mandate (although the Democrats are out-fundraising them).
Nonetheless, it seems pretty amazing that President Obama, whose victory 18 months ago seemed to usher in a new era in politics, now appears so significantly weakened, and on the defensive. I’d suggest that there are several issues. The first is, to recall the Bill Clinton election reminder, the economy (stupid!) It has taken, in case anyone hasn’t noticed, a tremendous blow, brought on by the selfish misdeeds of a bunch of evil financiers abetted by government non-regulation, begun under the same Clinton and exacerbated by the administration of the Worst President in History (WPH), George W. Bush. For whatever reason – his personality, his actual beliefs, his political calculations – Obama never loudly, consistently and firmly put all the blame on his predecessor, the WPH, missing the potential benefit from a tactic that worked so well for Franklin Roosevelt. When things are economically terrible people are upset and angry. We are told that the economy is getting better, and it is clear that stocks are improving and Goldman Sachs is doing great (unless they are actually indicted on criminal, as well as civil, charges (Nelson D. Schwartz, Goldman’s earnings fail to shift focus from case, NY Times April 20, 2010), but lots and lots of people still don’t have jobs, or the houses they once had. And of course, President Obama’s appointment of so many ex-Clintonite Friends of Wall Street (FWS’s) to leadership on his economic team has created the impression that he is sympathetic to them, which maybe he is. Except he is in the process of trying to pass a bill that increases regulation on the banks, which the Republicans, as much the party of wealth as they ever were, are opposing with nonsensical claims that it will increase the probability of bailouts (see Paul Krugman, NY Times April 16, The Fire Next Time, and especially Matt Taibbi in Rolling Stone, "The Feds vs. Goldman", April 26, 2010).
The health reform bill recently passed, the Patient Protection and Affordability Act, is another target of attack. I have recently written about the contents of this law (PPACA, The New Health Reform Law: How will it affect the public's health and primary care? , April 22, 2010),and of the many ways in which it will actually help people as well as the many flaws. The flaws include that it doesn’t have a coherent mechanism to control costs, and the cost of paying for it is one of the bases upon which it has been attacked. While I clearly would rather see a Medicare-for-all single-payer system, not least because of the enormous immediate savings and potential for long-term cost control, as well as, um, the fact that EVERYONE WOULD BE COVERED BY THE SAME SYSTEM, putting us all in the same boat where we belong, the cost argument doesn’t work for those who opposed health reform and wanted to keep the same system. The new law is flawed because it deals the insurance companies in, with millions of new customers, but it at least puts some restrictions on them. Continuing the same non-system that we are currently in, with increasing numbers of people unable to afford coverage, losing coverage when they get sick, and even more and more of the middle class “squeezed” by costs (“The Squeeze on the Middle Class”) was financially, as well as morally, unsustainable. Attacks on the bill because of the cost from those who are not single-payer supporters are ridiculous.
And, of course, there is racism. Make no mistake; there are a lot of people who are still racist, who are furious that a black man is President of the United States, and will do and say anything to make him unsuccessful. This issue is being addressed by many columnists; they are articulate and correct: see the excellent pieces on the tea party movement by Charles M. Blow (A Mighty Pale Tea, NY Times April 17, 2010) and Welcome to Confederate History Month by Frank Rich (NY Times, April 18, 2010). The “whitewashing” of the motivation of the secessionists in the Confederacy (it was about slavery, St-pid!) is a very disturbing counterpoint to the current racist attacks on the President. Blow writes from Grand Prairie, TX about the fact that the teabaggers are almost all white, while it is blacks and Hispanics, at the bottom of the socioeconomic ladder, who are most negatively affected by the economy. I recently was in Hawaii, and driving to the airport in Lihue, Kauai, passed a demonstration and immediately knew it was teabaggers because, unlike a roadside collection I’d seen the day before which turned out to be a rally for a mayoral candidate, the whole crowd was white! Lest you think this might have to do with the demographics of the area, Kauai County has only 32.9% non-Hispanic white residents (and an astounding 21.3% who identify themselves as two or more races).
The governments of most countries of the developed world, led by the US under administrations of both parties and with Congresses of both parties, deregulated the financial industry with the expectation that it would do well for the economy. (Interestingly, the one G8 country that probably suffered the least because of financial regulation, Canada, has now elected a Conservative government led by Stephen Harper that is trying to out-do the US Bush administration!) The economy did do well, for a while, better for the wealthy than the working class or poor, until it all came crashing down, burying the most vulnerable but letting the perpetrators escape to their yachts. Maybe (if there is any ironic justice) they will be ruined by the oil slick from the BP explosion in the Gulf of Mexico, but probably not; it will again be the poor and working people, minority or otherwise, and the environment, that take the big hit. Oil companies were also deregulated, allowed to drill offshore, and probably not well examined to make sure that their safety was as tight as it could be. But heck, we needed the oil! And now we will pay the price.
Who could ever have imagined that big finance and the oil industry could not be trusted to be responsible and do their part to care for the rest of us? Well, of course, lots of people but not the ones with the money to get the attention of legislators and the administrations. And apparently not the teabaggers, both their cynical leaders who continue to support these big industries and oppose regulation, or their troops, overwhelmingly white, who yet again are being taken in by a racist divide and conquer strategy.
.
The news coverage would suggest that President Obama and the Democratic Party should just give up now; the teabaggers and the Republican naysayers have convinced the American people and we all now believe in – what was it again? No taxes? No health care? That regulating banks is likely to increase the probability of having to bail them out? No matter; Scott Brown in Massachusetts was the leading edge and soon the entire Senate will be Republican (although if passing a bill with only 59% of the votes in the Senate is “undemocratic” what do we even care? Oh yes; 59 Democratic votes is a minority while 51 Republican votes is a smashing mandate!) Yes, the Repubs claim the mandate (although the Democrats are out-fundraising them).
Nonetheless, it seems pretty amazing that President Obama, whose victory 18 months ago seemed to usher in a new era in politics, now appears so significantly weakened, and on the defensive. I’d suggest that there are several issues. The first is, to recall the Bill Clinton election reminder, the economy (stupid!) It has taken, in case anyone hasn’t noticed, a tremendous blow, brought on by the selfish misdeeds of a bunch of evil financiers abetted by government non-regulation, begun under the same Clinton and exacerbated by the administration of the Worst President in History (WPH), George W. Bush. For whatever reason – his personality, his actual beliefs, his political calculations – Obama never loudly, consistently and firmly put all the blame on his predecessor, the WPH, missing the potential benefit from a tactic that worked so well for Franklin Roosevelt. When things are economically terrible people are upset and angry. We are told that the economy is getting better, and it is clear that stocks are improving and Goldman Sachs is doing great (unless they are actually indicted on criminal, as well as civil, charges (Nelson D. Schwartz, Goldman’s earnings fail to shift focus from case, NY Times April 20, 2010), but lots and lots of people still don’t have jobs, or the houses they once had. And of course, President Obama’s appointment of so many ex-Clintonite Friends of Wall Street (FWS’s) to leadership on his economic team has created the impression that he is sympathetic to them, which maybe he is. Except he is in the process of trying to pass a bill that increases regulation on the banks, which the Republicans, as much the party of wealth as they ever were, are opposing with nonsensical claims that it will increase the probability of bailouts (see Paul Krugman, NY Times April 16, The Fire Next Time, and especially Matt Taibbi in Rolling Stone, "The Feds vs. Goldman", April 26, 2010).
The health reform bill recently passed, the Patient Protection and Affordability Act, is another target of attack. I have recently written about the contents of this law (PPACA, The New Health Reform Law: How will it affect the public's health and primary care? , April 22, 2010),and of the many ways in which it will actually help people as well as the many flaws. The flaws include that it doesn’t have a coherent mechanism to control costs, and the cost of paying for it is one of the bases upon which it has been attacked. While I clearly would rather see a Medicare-for-all single-payer system, not least because of the enormous immediate savings and potential for long-term cost control, as well as, um, the fact that EVERYONE WOULD BE COVERED BY THE SAME SYSTEM, putting us all in the same boat where we belong, the cost argument doesn’t work for those who opposed health reform and wanted to keep the same system. The new law is flawed because it deals the insurance companies in, with millions of new customers, but it at least puts some restrictions on them. Continuing the same non-system that we are currently in, with increasing numbers of people unable to afford coverage, losing coverage when they get sick, and even more and more of the middle class “squeezed” by costs (“The Squeeze on the Middle Class”) was financially, as well as morally, unsustainable. Attacks on the bill because of the cost from those who are not single-payer supporters are ridiculous.
And, of course, there is racism. Make no mistake; there are a lot of people who are still racist, who are furious that a black man is President of the United States, and will do and say anything to make him unsuccessful. This issue is being addressed by many columnists; they are articulate and correct: see the excellent pieces on the tea party movement by Charles M. Blow (A Mighty Pale Tea, NY Times April 17, 2010) and Welcome to Confederate History Month by Frank Rich (NY Times, April 18, 2010). The “whitewashing” of the motivation of the secessionists in the Confederacy (it was about slavery, St-pid!) is a very disturbing counterpoint to the current racist attacks on the President. Blow writes from Grand Prairie, TX about the fact that the teabaggers are almost all white, while it is blacks and Hispanics, at the bottom of the socioeconomic ladder, who are most negatively affected by the economy. I recently was in Hawaii, and driving to the airport in Lihue, Kauai, passed a demonstration and immediately knew it was teabaggers because, unlike a roadside collection I’d seen the day before which turned out to be a rally for a mayoral candidate, the whole crowd was white! Lest you think this might have to do with the demographics of the area, Kauai County has only 32.9% non-Hispanic white residents (and an astounding 21.3% who identify themselves as two or more races).
The governments of most countries of the developed world, led by the US under administrations of both parties and with Congresses of both parties, deregulated the financial industry with the expectation that it would do well for the economy. (Interestingly, the one G8 country that probably suffered the least because of financial regulation, Canada, has now elected a Conservative government led by Stephen Harper that is trying to out-do the US Bush administration!) The economy did do well, for a while, better for the wealthy than the working class or poor, until it all came crashing down, burying the most vulnerable but letting the perpetrators escape to their yachts. Maybe (if there is any ironic justice) they will be ruined by the oil slick from the BP explosion in the Gulf of Mexico, but probably not; it will again be the poor and working people, minority or otherwise, and the environment, that take the big hit. Oil companies were also deregulated, allowed to drill offshore, and probably not well examined to make sure that their safety was as tight as it could be. But heck, we needed the oil! And now we will pay the price.
Who could ever have imagined that big finance and the oil industry could not be trusted to be responsible and do their part to care for the rest of us? Well, of course, lots of people but not the ones with the money to get the attention of legislators and the administrations. And apparently not the teabaggers, both their cynical leaders who continue to support these big industries and oppose regulation, or their troops, overwhelmingly white, who yet again are being taken in by a racist divide and conquer strategy.
.
Wednesday, April 28, 2010
Primary Care and Rural Areas
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"The primary care physician and health reform”,[1] by Robert H. Brook and Roy T. Young of the RAND Corporation, appears In the April 21, 2010 issue of JAMA. Rather than review the various components of the new Patient Protection and Affordable Care Act (PPACA), as I have recently on this blog, they focus on the need to increase the number of medical students entering primary care, an issue I have also previously addressed. It is a good piece and worth reading, but contains this interesting paragraph:
“One approach to this situation is to do nothing. As a result, the number of primary care physicians in practice will continue to decline. Patients who want a primary care physician will probably need to pay some kind of retainer and enroll in a concierge-type practice. Those who cannot afford this luxury will have to endure a medical care system that is even more fragmented than it is today.”
Clearly, they do not endorse this as a desirable plan, and go on to suggest that the alternative is to find a way to get 50% of American medical student graduates beginning with those entering June 2010 to enter family medicine, general internal medicine or general pediatrics (which raises the question of: Why not those who are already in medical school?) They emphasize both the importance of closing the salary gap (which we have heard many times) and redefining the role of the primary care physician, something we hear less about. The basis for this is contained in an earlier paragraph:
“The scope of practice for primary care physicians is contracting…the 200 000 physicians who identified themselves as office-based primary care clinicians… manage most of the care for diabetes, hypertension, and obesity; address acute problems such as viral or bacterial infections; and provide general examinations. On the other hand, a large proportion of the visits for conditions that could be managed by primary care physicians such as rheumatoid arthritis, epilepsy, depression, angina pectoris, and other chronic conditions are diagnosed and managed over time by specialists. The role of primary care physicians in the hospital has also narrowed, driven by the emergence of hospitalists and the trend to move a substantial portion of medical care to outpatient facilities.”
Taken together, the two paragraphs that I have quoted contain the implicit assumption that “the patient” we are discussing lives in a major metropolitan area with a large number of physicians, especially subspecialty physicians. However, at least 20% of Americans live in rural areas where this is not true, and many others live in underserved (read: poor) urban and suburban areas. While 23% of family physicians practice in rural areas, they are the only primary care specialty (and we can include here nurse practitioners and physicians assistants) that distribute themselves in this way; NPs and PAs, as well as general pediatricians and what remains of general internists cluster overwhelmingly in urban areas and their suburbs. When the only doctors in town, and for a long way around, are family physicians, they are going to manage the rheumatoid arthritis, epilepsy, depression, angina, etc. And they are most unlikely to charge concierge fees for their patients to be able to access them. However, rural areas remain underserved because 23% of family doctors, while parallel to the percent of rural people, is still too low a percent of all doctors.
I do not mean to be critical of Brook and Young; their commentary is good and makes excellent points, not the least of which is that even people living in urban and suburban areas want to have, and deserve, primary care physicians: “Virtually everyone would like to have a primary care physician—a trusted physician who provides comprehensive, continuous care.” I also commend their clear statement that most of the chronic conditions cared for by specialists – in metropolitan areas, where there are specialists – can be perfectly well taken care of by primary care physicians in either urban or rural settings. I mean only to point out that even the most thoughtful and well-meaning commentators can miss the special and critical needs of rural people, and make assumptions that do not apply to inhabitants of those areas.
The irony is that while insurers, including Medicare, pay higher rates to subspecialists for caring for conditions that generalists could care for, as Brook and Young point out, generalists are reduced to spending more of their time doing procedures, which are more highly reimbursed, in order to make ends meet. This takes away from the time that they can spend with patients being the “trusted physician who provides comprehensive, continuous care”. Producing enough primary care physicians to provide this care to the 80% of people in urban and suburban areas, as well as to usually be the only physicians in rural communities is going to be a big challenge. The only way this is going to happen is to bring the vast difference in income expectations for students dramatically down, and fast.
The fastest way, which should begin immediately, is for Medicare to readjust its fee schedule in such a way that proceduralists can do the procedures, subspecialists can care for the rare and unresponsive or conditions in their narrow area, and generalists can care for the complexity of the whole patient, and for all of them equal amounts of work will bring in much more nearly equal amounts of income. This will mean reducing the income of subspecialists and proceduralists as well as increasing the income of family doctors, but it is a much better solution for the population’s health than turning primary care doctors into rare, concierge-type commodities.
[1] Brook RH, Young RT, “The primary care physician and health care reform”, JAMA Apr21,2010;303(15):1535-6
.
"The primary care physician and health reform”,[1] by Robert H. Brook and Roy T. Young of the RAND Corporation, appears In the April 21, 2010 issue of JAMA. Rather than review the various components of the new Patient Protection and Affordable Care Act (PPACA), as I have recently on this blog, they focus on the need to increase the number of medical students entering primary care, an issue I have also previously addressed. It is a good piece and worth reading, but contains this interesting paragraph:
“One approach to this situation is to do nothing. As a result, the number of primary care physicians in practice will continue to decline. Patients who want a primary care physician will probably need to pay some kind of retainer and enroll in a concierge-type practice. Those who cannot afford this luxury will have to endure a medical care system that is even more fragmented than it is today.”
Clearly, they do not endorse this as a desirable plan, and go on to suggest that the alternative is to find a way to get 50% of American medical student graduates beginning with those entering June 2010 to enter family medicine, general internal medicine or general pediatrics (which raises the question of: Why not those who are already in medical school?) They emphasize both the importance of closing the salary gap (which we have heard many times) and redefining the role of the primary care physician, something we hear less about. The basis for this is contained in an earlier paragraph:
“The scope of practice for primary care physicians is contracting…the 200 000 physicians who identified themselves as office-based primary care clinicians… manage most of the care for diabetes, hypertension, and obesity; address acute problems such as viral or bacterial infections; and provide general examinations. On the other hand, a large proportion of the visits for conditions that could be managed by primary care physicians such as rheumatoid arthritis, epilepsy, depression, angina pectoris, and other chronic conditions are diagnosed and managed over time by specialists. The role of primary care physicians in the hospital has also narrowed, driven by the emergence of hospitalists and the trend to move a substantial portion of medical care to outpatient facilities.”
Taken together, the two paragraphs that I have quoted contain the implicit assumption that “the patient” we are discussing lives in a major metropolitan area with a large number of physicians, especially subspecialty physicians. However, at least 20% of Americans live in rural areas where this is not true, and many others live in underserved (read: poor) urban and suburban areas. While 23% of family physicians practice in rural areas, they are the only primary care specialty (and we can include here nurse practitioners and physicians assistants) that distribute themselves in this way; NPs and PAs, as well as general pediatricians and what remains of general internists cluster overwhelmingly in urban areas and their suburbs. When the only doctors in town, and for a long way around, are family physicians, they are going to manage the rheumatoid arthritis, epilepsy, depression, angina, etc. And they are most unlikely to charge concierge fees for their patients to be able to access them. However, rural areas remain underserved because 23% of family doctors, while parallel to the percent of rural people, is still too low a percent of all doctors.
I do not mean to be critical of Brook and Young; their commentary is good and makes excellent points, not the least of which is that even people living in urban and suburban areas want to have, and deserve, primary care physicians: “Virtually everyone would like to have a primary care physician—a trusted physician who provides comprehensive, continuous care.” I also commend their clear statement that most of the chronic conditions cared for by specialists – in metropolitan areas, where there are specialists – can be perfectly well taken care of by primary care physicians in either urban or rural settings. I mean only to point out that even the most thoughtful and well-meaning commentators can miss the special and critical needs of rural people, and make assumptions that do not apply to inhabitants of those areas.
The irony is that while insurers, including Medicare, pay higher rates to subspecialists for caring for conditions that generalists could care for, as Brook and Young point out, generalists are reduced to spending more of their time doing procedures, which are more highly reimbursed, in order to make ends meet. This takes away from the time that they can spend with patients being the “trusted physician who provides comprehensive, continuous care”. Producing enough primary care physicians to provide this care to the 80% of people in urban and suburban areas, as well as to usually be the only physicians in rural communities is going to be a big challenge. The only way this is going to happen is to bring the vast difference in income expectations for students dramatically down, and fast.
The fastest way, which should begin immediately, is for Medicare to readjust its fee schedule in such a way that proceduralists can do the procedures, subspecialists can care for the rare and unresponsive or conditions in their narrow area, and generalists can care for the complexity of the whole patient, and for all of them equal amounts of work will bring in much more nearly equal amounts of income. This will mean reducing the income of subspecialists and proceduralists as well as increasing the income of family doctors, but it is a much better solution for the population’s health than turning primary care doctors into rare, concierge-type commodities.
[1] Brook RH, Young RT, “The primary care physician and health care reform”, JAMA Apr21,2010;303(15):1535-6
.
Thursday, April 22, 2010
PPACA, The New Health Reform Law: How will it affect the public's health and primary care?
.
A great deal remains to be done before any of the parts of the new health reform law, the Patient Protection and Affordable Care Act (PL 111-148), begins to affect people. Regulations have to be written, appropriations (in many cases, where they are not included in the law) need to be made (or not). There are a number of lawsuits pending, including several by states’ attorneys general. While these suits probably have little constitutional basis, nothing is certain when it comes in front of a Supreme Court that has recently declared (in Citizens United) that corporations have the same rights as people, at least in terms of giving money to political campaigns. However, it is a good time to look at this bill – at least parts of the massive 2,600 pages – and consider the impact on health, medicine, and social justice.
I indicated in a guest blog piece on Health Strong, “Why we need health reform”, before the bill became law, that the three key problems that exist, and need to be the touchstones to examine for the new law’s effectiveness, are:
1) Access – does it increase access for the 45+ million uninsured, tens of millions of underinsured, and tens of millions more whose premiums, co-pays and deductibles are becoming more and more prohibitive while the extent of their coverage drops?
2) Cost containment – as medical care costs approach 20% of GDP they threaten to choke off other, key social programs. Is there a viable method for cost control?
3) Health -- medical care, and even health care, are not health (Health is more than Medical Care, Jan 10, 2010). The goal must be to improve people’s health, of which medical care contributes only 15 % at best. In addition to genetics, individual behaviors and the socioeconomic environment are better predictors of health than medical care. At a population level, it is arguably true that improving educational opportunity for all children would provide greater increases in health status than all medical care.
The new health reform law will certainly increase financial access to health care for many people, an estimated 32,000,000. To the extent that this improves actual access will depend upon elimination of other barriers including geographic, transportation, co-pays and deductibles for those who are not fully subsidized, the existence of enough providers (especially in primary care) and the ability of people to get to the place where they can be seen (e.g., many people lose a day’s pay if they go to the doctor). The law will also (provided insurance companies can be prevented from “gaming” the system) prohibit denial of coverage for pre-existing conditions (for children this year; for everyone in 2014) and prevent rescissions – canceling your policy when you get sick.
In addition, as I have previous noted (Primary Care and the Medical Home, Today and Tomorrow, Primary Care and Residency Expansion), there need to be doctors or other providers; in particular there need to be primary care doctors. In rural areas, health care means essentially only primary care, and as has been noted by many of these blog pieces by Robert Bowman (Ten Biggest Myths Regarding Primary Care in the Future, Top Ten Reasons for Future Subspecialist Physicians To Be Concerned) and myself, this means family doctors, because this is the only “form” of primary care that “distributes” to where the population is – 20% of Americans live in rural areas and 23% of family doctors practice in such setting; no other primary care form (physician, NP, PA) come close. However, the need for primary care providers is not only in rural areas; in suburban and urban areas people still need a physician who is “their” doctor, not the doctor for only a piece of their body or a particular condition, someone who can coordinate and manage all their preventive, chronic, and acute care. And there are not, as we have also demonstrated, enough of them. Massachusetts discovered this when its statewide health reform dramatically increased the number of state residents with financial coverage; there were not enough primary care doctors to see all these people. We have also discussed the fact that medical students are not choosing family medicine and other primary care specialties in adequate numbers. (Note that our physician workforce is less than 30% primary care and dropping; to get to 50-60%, the ideal ratio in all international studies, in less than a generation, will require more than 50% entering true primary care training.)
What does the health reform law do for these issues, particularly in producing primary care doctors and related issues? Here are some of its components, with page numbers in the law in parentheses for anyone who wants to read the law in more detail:
· Primary care physicians (defined in a reasonable way) will received a 10% increase in reimbursement from Medicare for 5 years, as will general surgeons practicing in rural areas.
· The annual threat to all physicians from Medicare cuts will be addressed.
· Medicaid will reimburse primary care physicians at the higher Medicare rate for 2 years (2013-14).
These changes (pp 1413ff) will help primary care providers survive, but are not likely in themselves to reverse the trend of students entering subspecialties. (The American Academy of Family Physicians, AAFP’s, Robert Graham Center (“Does graduate medical education also follow green?”, ref below) estimates that a 35% increase in primary care reimbursement would be needed for students interested in family medicine to feel that they would earn enough to be able to pay off their medical school debts). In addition, residency training is addressed in several ways:
· Unused residency “slots” (positions Medicare would pay for) are to be distributed with a preference for primary care and rural training (pp 1421ff),
· Medicare GME money would pay for training in non-hospital settings, addressing the problem of hospitals wanting to keep residents in-house and thus limiting their training in community settings (pp 1431ff),
· Teaching Health Centers, especially in federally-funded Community Health Centers, would be encouraged with grant money (pp 1457ff).
· Training grants for primary care (“Title VII”) will be re-funded, and there will also be new grants, both with specific funding priorities rewarding schools and residencies that send graduates into underserved and rural areas (pp 1315ff, pp 2343ff), as well as grants to fund Preventive Medicine residencies (pp 2349ff).
Access to care will also be enhanced by large increases in funding for Community Health Centers (CHCs) (pp1479ff) and for loan repayment for doctors who work in underserved areas through the National Health Service Corps (NHSC). It will also provide funding for the creation of Primary Care Extension Services, which I have previously advocated (pp1404ff). The Medical Home concept, which identifies a multi-disciplinary “home” for each patient, requires advanced management techniques like electronic medical records and easy patient access, and pays for prevention and care coordination, is supported through an “Innovations Center” and the law requires payment for these services from insurers (p 2048). Funding is also provided for national and state health care workforce planning. In addition several new programs, including one that creates US Public Health Service “scholars” who will receive tuition and stipends (pp. 1372ff), and a major initiative to train dental therapists to provide basic dental care in areas where there are no dentists or even dental hygienists, are included, as are demonstration projects to reduce fees for underserved people (pp. 2357ff), and training Community Health Workers (pp. 1346ff).
On the downside, more than 23 million people, including all undocumented residents will remain uninsured. Clearly, covering the undocumented is a “hot button” political issue, but not allowing it is a classic example of “head in the sand”; these people are here, they work, they pay taxes – and they get sick and use expensive emergency rooms for care of conditions that could have been treated much earlier and better. The law is also a windfall for both insurance companies (who will get paid at their outrageous rates for all these new customers) and pharmaceutical companies. There are no structural systems for really controlling costs.
In summary, the good parts of the new law are that it is good for primary care practice, probably good for providers in general, expands funding for primary care education, provides more funding for CHCs and the NHSC, creates funding for Medical Homes, Primary Care Extensions, and other innovative programs. More people will be covered, it will prohibit denying coverage for pre-existing conditions and prevent rescissions, and will create restrictions on “medical loss ratio” – that is, insurers will have to pay at least 85% of the premiums they collect on actually paying for health care (imagine that!).
On the negative side, it leaves lots of people uninsured, is very complicated (it phases in over many years and it is still not clear how – or even whether – all the components will be implemented), there is no real mechanism for cost control, and it is good for insurance companies and good for drug companies (a bad thing – e.g., Insurance company greed: To know them is to not trust them). It also creates incredible complexity in coverage, with different members of families likely being eligible for coverage through different programs.
We will see how this plays out, but it would have been (and still remains) a much better idea to simply include everyone into Medicare, creating a single payer for everyone, a simpler and much less costly administrative mechanism, and a real opportunity to control costs. Those, including most (or all) Republicans who are critical of this bill because of the cost are neither advocating (in fact, they desperately oppose) a single-payer system that would really save money, nor even recognizing that continuing the way we were going was about the worst choice. Maybe it is too much to ask them for logical consistency. But those of us who are committed to social justice must continue the struggle. Re-read Dr. Ferrer’s blog piece The Sharp End of Ideology.
References:
· The bill – HR 3590 http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=111_cong_bills&docid=f:h3590eas.txt.pdf
· MEFS summary www.medicaleducationfutures.org
· Community Catalyst summary http://www.communitycatalyst.org
· Kaiser Family Foundation summary http://www.kff.org/healthreform/8023.cfm
· STFM Summary & implementation timeline http://www.stfm.org/advocacy/news.cfm
· Implementation timeline (AAFP)
· Aaron HJ, Reischauer RS, “The war isn’t over” NEJM, 8Apr10;362(14):1259-61
· Himmelstein DU, Woolhandler S, “Obama’s reform: no cure for what ails us”, BMJ 3April2010, 340:742
· Weida NA, Phillips RL Jr, Bazemore AW. Does graduate medical education also follow green? Arch Intern Med. 2010 Feb 22;170(4):389-90
.
A great deal remains to be done before any of the parts of the new health reform law, the Patient Protection and Affordable Care Act (PL 111-148), begins to affect people. Regulations have to be written, appropriations (in many cases, where they are not included in the law) need to be made (or not). There are a number of lawsuits pending, including several by states’ attorneys general. While these suits probably have little constitutional basis, nothing is certain when it comes in front of a Supreme Court that has recently declared (in Citizens United) that corporations have the same rights as people, at least in terms of giving money to political campaigns. However, it is a good time to look at this bill – at least parts of the massive 2,600 pages – and consider the impact on health, medicine, and social justice.
I indicated in a guest blog piece on Health Strong, “Why we need health reform”, before the bill became law, that the three key problems that exist, and need to be the touchstones to examine for the new law’s effectiveness, are:
1) Access – does it increase access for the 45+ million uninsured, tens of millions of underinsured, and tens of millions more whose premiums, co-pays and deductibles are becoming more and more prohibitive while the extent of their coverage drops?
2) Cost containment – as medical care costs approach 20% of GDP they threaten to choke off other, key social programs. Is there a viable method for cost control?
3) Health -- medical care, and even health care, are not health (Health is more than Medical Care, Jan 10, 2010). The goal must be to improve people’s health, of which medical care contributes only 15 % at best. In addition to genetics, individual behaviors and the socioeconomic environment are better predictors of health than medical care. At a population level, it is arguably true that improving educational opportunity for all children would provide greater increases in health status than all medical care.
The new health reform law will certainly increase financial access to health care for many people, an estimated 32,000,000. To the extent that this improves actual access will depend upon elimination of other barriers including geographic, transportation, co-pays and deductibles for those who are not fully subsidized, the existence of enough providers (especially in primary care) and the ability of people to get to the place where they can be seen (e.g., many people lose a day’s pay if they go to the doctor). The law will also (provided insurance companies can be prevented from “gaming” the system) prohibit denial of coverage for pre-existing conditions (for children this year; for everyone in 2014) and prevent rescissions – canceling your policy when you get sick.
In addition, as I have previous noted (Primary Care and the Medical Home, Today and Tomorrow, Primary Care and Residency Expansion), there need to be doctors or other providers; in particular there need to be primary care doctors. In rural areas, health care means essentially only primary care, and as has been noted by many of these blog pieces by Robert Bowman (Ten Biggest Myths Regarding Primary Care in the Future, Top Ten Reasons for Future Subspecialist Physicians To Be Concerned) and myself, this means family doctors, because this is the only “form” of primary care that “distributes” to where the population is – 20% of Americans live in rural areas and 23% of family doctors practice in such setting; no other primary care form (physician, NP, PA) come close. However, the need for primary care providers is not only in rural areas; in suburban and urban areas people still need a physician who is “their” doctor, not the doctor for only a piece of their body or a particular condition, someone who can coordinate and manage all their preventive, chronic, and acute care. And there are not, as we have also demonstrated, enough of them. Massachusetts discovered this when its statewide health reform dramatically increased the number of state residents with financial coverage; there were not enough primary care doctors to see all these people. We have also discussed the fact that medical students are not choosing family medicine and other primary care specialties in adequate numbers. (Note that our physician workforce is less than 30% primary care and dropping; to get to 50-60%, the ideal ratio in all international studies, in less than a generation, will require more than 50% entering true primary care training.)
What does the health reform law do for these issues, particularly in producing primary care doctors and related issues? Here are some of its components, with page numbers in the law in parentheses for anyone who wants to read the law in more detail:
· Primary care physicians (defined in a reasonable way) will received a 10% increase in reimbursement from Medicare for 5 years, as will general surgeons practicing in rural areas.
· The annual threat to all physicians from Medicare cuts will be addressed.
· Medicaid will reimburse primary care physicians at the higher Medicare rate for 2 years (2013-14).
These changes (pp 1413ff) will help primary care providers survive, but are not likely in themselves to reverse the trend of students entering subspecialties. (The American Academy of Family Physicians, AAFP’s, Robert Graham Center (“Does graduate medical education also follow green?”, ref below) estimates that a 35% increase in primary care reimbursement would be needed for students interested in family medicine to feel that they would earn enough to be able to pay off their medical school debts). In addition, residency training is addressed in several ways:
· Unused residency “slots” (positions Medicare would pay for) are to be distributed with a preference for primary care and rural training (pp 1421ff),
· Medicare GME money would pay for training in non-hospital settings, addressing the problem of hospitals wanting to keep residents in-house and thus limiting their training in community settings (pp 1431ff),
· Teaching Health Centers, especially in federally-funded Community Health Centers, would be encouraged with grant money (pp 1457ff).
· Training grants for primary care (“Title VII”) will be re-funded, and there will also be new grants, both with specific funding priorities rewarding schools and residencies that send graduates into underserved and rural areas (pp 1315ff, pp 2343ff), as well as grants to fund Preventive Medicine residencies (pp 2349ff).
Access to care will also be enhanced by large increases in funding for Community Health Centers (CHCs) (pp1479ff) and for loan repayment for doctors who work in underserved areas through the National Health Service Corps (NHSC). It will also provide funding for the creation of Primary Care Extension Services, which I have previously advocated (pp1404ff). The Medical Home concept, which identifies a multi-disciplinary “home” for each patient, requires advanced management techniques like electronic medical records and easy patient access, and pays for prevention and care coordination, is supported through an “Innovations Center” and the law requires payment for these services from insurers (p 2048). Funding is also provided for national and state health care workforce planning. In addition several new programs, including one that creates US Public Health Service “scholars” who will receive tuition and stipends (pp. 1372ff), and a major initiative to train dental therapists to provide basic dental care in areas where there are no dentists or even dental hygienists, are included, as are demonstration projects to reduce fees for underserved people (pp. 2357ff), and training Community Health Workers (pp. 1346ff).
On the downside, more than 23 million people, including all undocumented residents will remain uninsured. Clearly, covering the undocumented is a “hot button” political issue, but not allowing it is a classic example of “head in the sand”; these people are here, they work, they pay taxes – and they get sick and use expensive emergency rooms for care of conditions that could have been treated much earlier and better. The law is also a windfall for both insurance companies (who will get paid at their outrageous rates for all these new customers) and pharmaceutical companies. There are no structural systems for really controlling costs.
In summary, the good parts of the new law are that it is good for primary care practice, probably good for providers in general, expands funding for primary care education, provides more funding for CHCs and the NHSC, creates funding for Medical Homes, Primary Care Extensions, and other innovative programs. More people will be covered, it will prohibit denying coverage for pre-existing conditions and prevent rescissions, and will create restrictions on “medical loss ratio” – that is, insurers will have to pay at least 85% of the premiums they collect on actually paying for health care (imagine that!).
On the negative side, it leaves lots of people uninsured, is very complicated (it phases in over many years and it is still not clear how – or even whether – all the components will be implemented), there is no real mechanism for cost control, and it is good for insurance companies and good for drug companies (a bad thing – e.g., Insurance company greed: To know them is to not trust them). It also creates incredible complexity in coverage, with different members of families likely being eligible for coverage through different programs.
We will see how this plays out, but it would have been (and still remains) a much better idea to simply include everyone into Medicare, creating a single payer for everyone, a simpler and much less costly administrative mechanism, and a real opportunity to control costs. Those, including most (or all) Republicans who are critical of this bill because of the cost are neither advocating (in fact, they desperately oppose) a single-payer system that would really save money, nor even recognizing that continuing the way we were going was about the worst choice. Maybe it is too much to ask them for logical consistency. But those of us who are committed to social justice must continue the struggle. Re-read Dr. Ferrer’s blog piece The Sharp End of Ideology.
References:
· The bill – HR 3590 http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=111_cong_bills&docid=f:h3590eas.txt.pdf
· MEFS summary www.medicaleducationfutures.org
· Community Catalyst summary http://www.communitycatalyst.org
· Kaiser Family Foundation summary http://www.kff.org/healthreform/8023.cfm
· STFM Summary & implementation timeline http://www.stfm.org/advocacy/news.cfm
· Implementation timeline (AAFP)
· Aaron HJ, Reischauer RS, “The war isn’t over” NEJM, 8Apr10;362(14):1259-61
· Himmelstein DU, Woolhandler S, “Obama’s reform: no cure for what ails us”, BMJ 3April2010, 340:742
· Weida NA, Phillips RL Jr, Bazemore AW. Does graduate medical education also follow green? Arch Intern Med. 2010 Feb 22;170(4):389-90
.
Friday, April 16, 2010
VISA and colchicine: maybe the banks and Pharma really ARE in it for the money!
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This is a guest posting by R. Stephen Griffith, MD, Chair of the Department of Family and Community Medicine at the University of Missouri-Kansas City.
A recent article explains in some detail one of the devious ways the banking industry, and the recently spun-off companies of VISA and MasterCard, make the money it takes to support the executive salaries and bonuses. (“How Visa, Using Card Fees, Dominates a Market”, Andrew Martin, NY Times, Jan 4, 2010)
Each time one of us swipes a debit card at a retail outlet, the retail outlet pays a banking institution a fee. That seems like an honest way to make a living, but the plot thickens. If we punch in the secret code associated with the card, the bank gets a few cents. If instead of using the code we sign the receipt the bank gets a bigger fee. Apparently there is no more expense associated with the latter method, but the fees negotiated by VISA et. al with the retailers provides for the higher fees. The individual banks then receive the fees, which encourages them to “push” more of the VISA’s (or which ever company is offering them the best deal). The credit card companies expand their reach, the banks make more money, and everyone involved in the deal is happy. In fact, the higher the cost per transaction the credit card company can negotiate makes more money for the bank, and so a bidding war develops in which the higher the fee, the more the banks gravitate to that company. The fee can be up to 75 cents per transactions—many multiples of the fee for a swipe and use of the code. This is transparent to the consumer, who willingly signs or puts in his/her code as requested by the retail outlet. Of course, the unwitting consumer eventually pays the extra expense (passed on from the retailer as part of the cost of doing business). Just another way for the banks to make a living.
There are those of us who would suggest that this is “gouging” the customer and there should be some repercussion to the perpetrators. I was among the inflamed and insulted when I read the article. But then this horrible thought crossed my mind: as a well meaning and cost conscious family physician, how many times have I committed the same offense?
The relationship between physicians and Pharma has been a topic of discussion since I was in medical school, although until relatively recently I have seen very little response from the medical community. The representatives of Pharma host our meetings and visit our offices, give us food, pens, pads, tickets to games, sometimes even trips to nice places. Associated with the gifts is also free “education” about why the product about which they are educating the physician is better than generic or “me, too” drugs made by another company. The docs are given samples which they can provide their patients to try the new drug out and “help save money for the patients.” Of course, if the medication works, a prescription for the drug will be given. The extra expense (sometimes an extraordinary amount of extra expense!) of the newer drug is borne by the patient or the patient’s insurance after a co-pay (which results in higher premiums the patient pays.)
So the medical community’s “scam” is we get lots of benefits and the expense of those benefits is borne by someone else—our patients.
To be fair, not all physicians accept gifts from Pharma. And in the last few years or so, the value of the gifts has been more restrained. And a growing number of physicians are refusing to even meet with representatives from Pharma, refusing the samples and the false economy of providing them, refusing the gifts and “education”. Creating distance from Pharma is a good thing—they are as fun to hate as the banking industry. And if you doubt the amount of greed in Pharma, please read this: “An Old Gout Drug Gets New Life and a New Price, Riling Patients”, Jonathan D. Rockoff, Wall St. Journal (and below, as it may not be completely available on the WSJ site.)
The article is about colchicine, a drug for the treatment of acute gout (and a few other things) that has been around for more than a century—long before the advent of the FDA. The FDA has encouraged pharmaceutical companies to study some of the older drugs for true effectiveness, and the company can then apply for a three year patent on the medication. URL Pharma, Inc. did the clinical trials on less than 1,000 patients, and proved that a drug everyone already knew worked, worked. Amazing! They received a three year patent, and now a pill that was $4 per month long before the $4 per month plans existed, is $5 per pill! Since it is usually given twice a day, the drug will now cost patients $10 per day when it formerly cost about a quarter.
Stories like this and the one about banks makes it easy to feel distaste for the banking industry and Pharma. Where is the justice in banking executives making millions and then being bailed out by taxpayers? Where is the justice of Pharma making huge (I would argue inappropriately huge) profits from the ills of our patients? I just wish the profession of medicine (and I) hadn’t played a part.
(From the Wall St. Journal),
An Old Gout Drug Gets New Life and a New Price, Riling Patients
By JONATHAN D. ROCKOFF
A centuries-old drug used to treat excruciating gout pain had cost just pennies a tablet—until last year. Now, the retail price has skyrocketed to more than $5 and some of the manufacturers have ceased production amid a battle over marketing rights.
The tale of how this common gout drug, colchicine, became the costlier branded drug Colcrys offers a window into the Byzantine world of drug pricing. The price rise is a consequence of a Food and Drug Administration effort to improve the safety of long-used but unapproved drugs, with a trade-off often made between drug affordability and safety.
In July 2009, a Philadelphia drug maker received FDA approval to exclusively market colchicine for gout attacks for three years. The company, URL Pharma Inc., was taking advantage of a push to bring medicines predating the FDA, like colchicine, under the agency's regulatory umbrella. The FDA offers exclusive marketing rights if a drug maker conducts clinical trials.
URL Pharma had commissioned studies that confirmed its colchicine product's safety and efficacy, while demonstrating it should be taken at a lower dose than typical and not used with certain other medicines. The company is marketing its drug as Colcrys—and the retail cost averages $5 per pill, according to DestinationRx, a health-care data provider.
URL is also suing longtime manufacturers of unapproved colchicine, saying the companies are now illegally marketing their products. Some of the companies are fighting the lawsuits. Some themselves have raised prices—including one increase of just under a dollar per tablet to $1.17, according to DestinationRx. The higher price for Colcrys was first reported by Kaiser Health News.
There were 3.5 million prescriptions and $6.4 million in sales in 2008, according to the most recent data available from IMS Health, a drug-data firm.
"It's not a new product. It's been out for hundreds of years. To all of a sudden have to pay $125 or $150 a month, after it only cost $5 or $10 a month, is a real problem," said Stanley Cohen, a Dallas doctor who is the president of the American College of Rheumatology. He met with the FDA to express concern about the price increase.
The chief executive of URL Pharma, Richard Roberts, said that it priced Colcrys in line with other approved, branded drugs used to treat gout pain. To help patients afford Colcrys, Dr. Roberts said, the company is offering to pay a portion of co-pays, and it is providing a three-months' supply to low-income patients for $15.
Eileen Wood, vice president of pharmacy and health-quality programs at CDPHP, an insurer in New York state, said insurers will have to absorb much of the added expense. URL's contribution was "not any new therapeutic tool, not new science; they just added cost," she said.
Nancy Sparks Morrison, a retired schoolteacher who suffers from familial Mediterranean fever, an inflammatory disorder that's treated with colchicine, said she is buying colchicine from Canada because she can't afford Colcrys. Ms. Morrison said she plans to get help from URL Pharma to pay for Colcrys because the company has just expanded its assistance program. "I'm retired on Social Security, and I have a small pension," said Ms. Morrison, 71 years old, who lives outside Charleston, W.Va.
The price increase is an unintended consequence of the FDA's nearly four-year-old initiative to regulate unapproved drugs. These medicines were sold before the FDA was established, and therefore weren't required to undergo approval. After decades of use, the medicines are considered safe by doctors, but haven't been proven to satisfy the agency's standards. Colchicine's use has been traced back to the sixth century, according to the FDA.
Seventy drugs that were grandfathered have been approved since the FDA began its initiative, most notably pain reliever Vicodin, from Amneal Pharmaceuticals LLC, the FDA said.
The FDA had hoped a significant price increase wouldn't follow Colcrys's approval and regrets the increase, said Janet Woodcock, director of the agency's Center for Drug Evaluation and Research. Dr. Woodcock encouraged more competition, saying another company could seek approval for colchicine's regular use in gout, rather than the acute use that URL Pharma received approval for.
There had been no standard for dosage before FDA approval. Colchicine's excessive use can cause side-effects, such as severe diarrhea that is potentially fatal. The FDA said it receives reports of five deaths a year, on average, involving patients who took colchicine tablets.
"We took bad guidance, even guesswork, and made this evidence-based medicine," Dr. Roberts said.
Closely held URL Pharma, which is owned by a hedge fund, a private investor and employees, is a longtime seller of generic drugs, including colchicine. When the FDA launched its push, the company began searching for those with safety risks whose patients could benefit from clinical testing, Dr. Roberts said.
URL Pharma said its 17 clinical trials of colchicine involved a total of 988 patients. The trials showed that gout patients need take two tablets after an attack and one more an hour later, the FDA said. Trials also demonstrated side-effects from use with certain other medicines, including some antibiotics and antihypertensive medicines. Those are now flagged on the label of Colcrys.
After obtaining FDA approval of Colcrys, URL Pharma went to federal court to sue manufacturers of colchicine, including Excellium Pharmaceutical Inc., Vision Pharma LLC, Watson Pharmaceuticals Inc. and West-Ward Pharmaceutical Corp., saying they have been illegally marketing their colchicine products since Colcrys's approval. A fifth company, Qualitest Pharmaceuticals, settled and stopped production. The four companies are fighting the lawsuits.
"You have this product out for at least a hundred years and all of a sudden it's no good?" said Lou Dretchen, who oversees sales and marketing at Excellium of Fairfield, N.J. Mr. Dretchen said the small, closely held generic drug maker stopped colchicine production after URL Pharma sued. The other companies declined to comment.
.
This is a guest posting by R. Stephen Griffith, MD, Chair of the Department of Family and Community Medicine at the University of Missouri-Kansas City.
A recent article explains in some detail one of the devious ways the banking industry, and the recently spun-off companies of VISA and MasterCard, make the money it takes to support the executive salaries and bonuses. (“How Visa, Using Card Fees, Dominates a Market”, Andrew Martin, NY Times, Jan 4, 2010)
Each time one of us swipes a debit card at a retail outlet, the retail outlet pays a banking institution a fee. That seems like an honest way to make a living, but the plot thickens. If we punch in the secret code associated with the card, the bank gets a few cents. If instead of using the code we sign the receipt the bank gets a bigger fee. Apparently there is no more expense associated with the latter method, but the fees negotiated by VISA et. al with the retailers provides for the higher fees. The individual banks then receive the fees, which encourages them to “push” more of the VISA’s (or which ever company is offering them the best deal). The credit card companies expand their reach, the banks make more money, and everyone involved in the deal is happy. In fact, the higher the cost per transaction the credit card company can negotiate makes more money for the bank, and so a bidding war develops in which the higher the fee, the more the banks gravitate to that company. The fee can be up to 75 cents per transactions—many multiples of the fee for a swipe and use of the code. This is transparent to the consumer, who willingly signs or puts in his/her code as requested by the retail outlet. Of course, the unwitting consumer eventually pays the extra expense (passed on from the retailer as part of the cost of doing business). Just another way for the banks to make a living.
There are those of us who would suggest that this is “gouging” the customer and there should be some repercussion to the perpetrators. I was among the inflamed and insulted when I read the article. But then this horrible thought crossed my mind: as a well meaning and cost conscious family physician, how many times have I committed the same offense?
The relationship between physicians and Pharma has been a topic of discussion since I was in medical school, although until relatively recently I have seen very little response from the medical community. The representatives of Pharma host our meetings and visit our offices, give us food, pens, pads, tickets to games, sometimes even trips to nice places. Associated with the gifts is also free “education” about why the product about which they are educating the physician is better than generic or “me, too” drugs made by another company. The docs are given samples which they can provide their patients to try the new drug out and “help save money for the patients.” Of course, if the medication works, a prescription for the drug will be given. The extra expense (sometimes an extraordinary amount of extra expense!) of the newer drug is borne by the patient or the patient’s insurance after a co-pay (which results in higher premiums the patient pays.)
So the medical community’s “scam” is we get lots of benefits and the expense of those benefits is borne by someone else—our patients.
To be fair, not all physicians accept gifts from Pharma. And in the last few years or so, the value of the gifts has been more restrained. And a growing number of physicians are refusing to even meet with representatives from Pharma, refusing the samples and the false economy of providing them, refusing the gifts and “education”. Creating distance from Pharma is a good thing—they are as fun to hate as the banking industry. And if you doubt the amount of greed in Pharma, please read this: “An Old Gout Drug Gets New Life and a New Price, Riling Patients”, Jonathan D. Rockoff, Wall St. Journal (and below, as it may not be completely available on the WSJ site.)
The article is about colchicine, a drug for the treatment of acute gout (and a few other things) that has been around for more than a century—long before the advent of the FDA. The FDA has encouraged pharmaceutical companies to study some of the older drugs for true effectiveness, and the company can then apply for a three year patent on the medication. URL Pharma, Inc. did the clinical trials on less than 1,000 patients, and proved that a drug everyone already knew worked, worked. Amazing! They received a three year patent, and now a pill that was $4 per month long before the $4 per month plans existed, is $5 per pill! Since it is usually given twice a day, the drug will now cost patients $10 per day when it formerly cost about a quarter.
Stories like this and the one about banks makes it easy to feel distaste for the banking industry and Pharma. Where is the justice in banking executives making millions and then being bailed out by taxpayers? Where is the justice of Pharma making huge (I would argue inappropriately huge) profits from the ills of our patients? I just wish the profession of medicine (and I) hadn’t played a part.
(From the Wall St. Journal),
An Old Gout Drug Gets New Life and a New Price, Riling Patients
By JONATHAN D. ROCKOFF
A centuries-old drug used to treat excruciating gout pain had cost just pennies a tablet—until last year. Now, the retail price has skyrocketed to more than $5 and some of the manufacturers have ceased production amid a battle over marketing rights.
The tale of how this common gout drug, colchicine, became the costlier branded drug Colcrys offers a window into the Byzantine world of drug pricing. The price rise is a consequence of a Food and Drug Administration effort to improve the safety of long-used but unapproved drugs, with a trade-off often made between drug affordability and safety.
In July 2009, a Philadelphia drug maker received FDA approval to exclusively market colchicine for gout attacks for three years. The company, URL Pharma Inc., was taking advantage of a push to bring medicines predating the FDA, like colchicine, under the agency's regulatory umbrella. The FDA offers exclusive marketing rights if a drug maker conducts clinical trials.
URL Pharma had commissioned studies that confirmed its colchicine product's safety and efficacy, while demonstrating it should be taken at a lower dose than typical and not used with certain other medicines. The company is marketing its drug as Colcrys—and the retail cost averages $5 per pill, according to DestinationRx, a health-care data provider.
URL is also suing longtime manufacturers of unapproved colchicine, saying the companies are now illegally marketing their products. Some of the companies are fighting the lawsuits. Some themselves have raised prices—including one increase of just under a dollar per tablet to $1.17, according to DestinationRx. The higher price for Colcrys was first reported by Kaiser Health News.
There were 3.5 million prescriptions and $6.4 million in sales in 2008, according to the most recent data available from IMS Health, a drug-data firm.
"It's not a new product. It's been out for hundreds of years. To all of a sudden have to pay $125 or $150 a month, after it only cost $5 or $10 a month, is a real problem," said Stanley Cohen, a Dallas doctor who is the president of the American College of Rheumatology. He met with the FDA to express concern about the price increase.
The chief executive of URL Pharma, Richard Roberts, said that it priced Colcrys in line with other approved, branded drugs used to treat gout pain. To help patients afford Colcrys, Dr. Roberts said, the company is offering to pay a portion of co-pays, and it is providing a three-months' supply to low-income patients for $15.
Eileen Wood, vice president of pharmacy and health-quality programs at CDPHP, an insurer in New York state, said insurers will have to absorb much of the added expense. URL's contribution was "not any new therapeutic tool, not new science; they just added cost," she said.
Nancy Sparks Morrison, a retired schoolteacher who suffers from familial Mediterranean fever, an inflammatory disorder that's treated with colchicine, said she is buying colchicine from Canada because she can't afford Colcrys. Ms. Morrison said she plans to get help from URL Pharma to pay for Colcrys because the company has just expanded its assistance program. "I'm retired on Social Security, and I have a small pension," said Ms. Morrison, 71 years old, who lives outside Charleston, W.Va.
The price increase is an unintended consequence of the FDA's nearly four-year-old initiative to regulate unapproved drugs. These medicines were sold before the FDA was established, and therefore weren't required to undergo approval. After decades of use, the medicines are considered safe by doctors, but haven't been proven to satisfy the agency's standards. Colchicine's use has been traced back to the sixth century, according to the FDA.
Seventy drugs that were grandfathered have been approved since the FDA began its initiative, most notably pain reliever Vicodin, from Amneal Pharmaceuticals LLC, the FDA said.
The FDA had hoped a significant price increase wouldn't follow Colcrys's approval and regrets the increase, said Janet Woodcock, director of the agency's Center for Drug Evaluation and Research. Dr. Woodcock encouraged more competition, saying another company could seek approval for colchicine's regular use in gout, rather than the acute use that URL Pharma received approval for.
There had been no standard for dosage before FDA approval. Colchicine's excessive use can cause side-effects, such as severe diarrhea that is potentially fatal. The FDA said it receives reports of five deaths a year, on average, involving patients who took colchicine tablets.
"We took bad guidance, even guesswork, and made this evidence-based medicine," Dr. Roberts said.
Closely held URL Pharma, which is owned by a hedge fund, a private investor and employees, is a longtime seller of generic drugs, including colchicine. When the FDA launched its push, the company began searching for those with safety risks whose patients could benefit from clinical testing, Dr. Roberts said.
URL Pharma said its 17 clinical trials of colchicine involved a total of 988 patients. The trials showed that gout patients need take two tablets after an attack and one more an hour later, the FDA said. Trials also demonstrated side-effects from use with certain other medicines, including some antibiotics and antihypertensive medicines. Those are now flagged on the label of Colcrys.
After obtaining FDA approval of Colcrys, URL Pharma went to federal court to sue manufacturers of colchicine, including Excellium Pharmaceutical Inc., Vision Pharma LLC, Watson Pharmaceuticals Inc. and West-Ward Pharmaceutical Corp., saying they have been illegally marketing their colchicine products since Colcrys's approval. A fifth company, Qualitest Pharmaceuticals, settled and stopped production. The four companies are fighting the lawsuits.
"You have this product out for at least a hundred years and all of a sudden it's no good?" said Lou Dretchen, who oversees sales and marketing at Excellium of Fairfield, N.J. Mr. Dretchen said the small, closely held generic drug maker stopped colchicine production after URL Pharma sued. The other companies declined to comment.
.
Sunday, April 11, 2010
Doctors and Health Reform: How should a physician's politics affect their patient care?
.
President Obama’s health reform bill (officially the "Patient Protection and Affordable Care Act, PL 111-48) has finally passed, but the furor over it has not died down, with Republican’s harnessing their electoral future to continued opposition. To the new law, certainly, but more significantly to anything that might actually begin to address the health care needs of the American people, to cover the uninsured, to protect those with pre-existing conditions, to provide a basis for cost control, or to improve people’s health. Opponents of the plan talk incessantly about its cost, but offer no alternative. The question for the President is whether enough of the benefits of the bill will kick in and have a positive effect on people soon enough to overcome the negative bluster.
Among the groups still trying to figure out the impact of the new law on them are health care providers, including hospitals and physicians. While physicians, as a group, tend to support the Republican party, especially on the single issue of malpractice (with the trial lawyers being, conversely, big Democratic contributors), most major medical organizations have come out in favor of health reform, and in general have endorsed proposals that go significantly beyond those of the new law. Even the AMA, which opposed every national health insurance plan including Medicare, has acknowledged the need for health reform. The two largest physician specialty organizations, the American College of Physicians (ACP – internists) and the American Academy of Family Physicians (AAFP) have endorsed universal health care. Where do they stand now?
On a recent morning news show discussing the impact of health reform on doctors, one of the regular hosts asked about malpractice, saying that “every time I go to my doctor, he talks to me about the malpractice issue”, so apparently many doctors feel fine about lobbying their patients. I don’t know any of the details; after all this patient is a newsman, and may bring up the question of health policy issues, so perhaps this is not something that doctor talks with all his/her patients about. But we recently learned of a Florida urologist who posted a sign saying “If you voted for Obama seek urologic care elsewhere. Changes to your healthcare begin right now. Not in four years.” (Urologist Posts His Politics on His Florida Office Door, Damien Cave, New York Times, April 2, 2010). Predictably, and probably correctly, the criticism focused upon whether such a sign was inappropriate, whether it was wrong to refuse to treat people because you didn’t like their politics (although the doctor, Jack Cassell, “…told the Orlando Sentinel that he has not refused to treat any patient for his or her political views and does not quiz patients about their politics, but he also does not plan to take the sign down.”)
More interesting, to me, is the question of whether the financial self-interest of doctors should be of concern to their patients, and how much that should count for in making policy. Clearly, when reimbursement is so low that the cost of running the practice is more than the revenue coming in (more likely to be the case for, say, family physicians than, say, urologists), a medical practice run as a business cannot survive. It is even true that the business needs to not only not lose money, but to make enough for the physicians to have a reasonable income. But if a physician is making, compared to most people, a very large amount of money (and I have no idea whether this is true of Dr. Cassell), is it reasonable for him/her to expect people to be compassionate if it drops to only a large amount? Should Americans be concerned if a subspecialist’s take-home pay drops from, say, $450,000 to $350,000? I know the doctor would be, but what about everyone else?
I find most interesting is how the expression of this sentiment, whether Dr. Cassell continues to treat Obama supporters or not, gets to the heart of the real issues in the health care debate. To the extent that a doctor can choose which patients to treat, or whether a patient can choose which doctor to visit, maybe this could work out. But it postulates medical care as a commodity to be sold, and that its purchase depends on a patient having sufficient money, or insurance, to buy it. It absolutely does not see medical care as a right that all people should have equal access to based on their medical need. For many of those who use a high proportion of medical care (perhaps especially urologic care) that insurance is provided by Medicare, a government-run, tax dollar supported entitlement program. Health reform as passed into law currently expands the pool of people who will have insurance coverage, and thus be able to pay the doctor. It is a far cry from Medicare-for-all, which I support, and which all people who support the current Medicare-for-some that currently exists, and are not entirely selfish, should support. If Dr. Cassell can survive as a urologist in Florida without taking those socialist Medicare dollars I would be surprised; if he is willing to take them, he should be supportive of Medicare-for-all.
Maybe he is. Maybe everyone has misinterpreted him. Maybe that is why he is so upset about the new law – that it doesn’t cover everyone fairly. If so, more power to him. If he is already refusing Medicare, at least he is logically consistent. However, if he takes Medicare but is opposed to even so mild a plan as the new health care law for expanding coverage to others, then he is just out for his own self interest.
The real issue remains: is access to medically-necessary health care a right, as it is considered in every other first-world country, or is it a commodity to be carefully husbanded by those who have it and sold to those who can meet the price? The real concern is not Dr. Cassell’s medical ethics, but his (and others’) worldview.
.
President Obama’s health reform bill (officially the "Patient Protection and Affordable Care Act, PL 111-48) has finally passed, but the furor over it has not died down, with Republican’s harnessing their electoral future to continued opposition. To the new law, certainly, but more significantly to anything that might actually begin to address the health care needs of the American people, to cover the uninsured, to protect those with pre-existing conditions, to provide a basis for cost control, or to improve people’s health. Opponents of the plan talk incessantly about its cost, but offer no alternative. The question for the President is whether enough of the benefits of the bill will kick in and have a positive effect on people soon enough to overcome the negative bluster.
Among the groups still trying to figure out the impact of the new law on them are health care providers, including hospitals and physicians. While physicians, as a group, tend to support the Republican party, especially on the single issue of malpractice (with the trial lawyers being, conversely, big Democratic contributors), most major medical organizations have come out in favor of health reform, and in general have endorsed proposals that go significantly beyond those of the new law. Even the AMA, which opposed every national health insurance plan including Medicare, has acknowledged the need for health reform. The two largest physician specialty organizations, the American College of Physicians (ACP – internists) and the American Academy of Family Physicians (AAFP) have endorsed universal health care. Where do they stand now?
On a recent morning news show discussing the impact of health reform on doctors, one of the regular hosts asked about malpractice, saying that “every time I go to my doctor, he talks to me about the malpractice issue”, so apparently many doctors feel fine about lobbying their patients. I don’t know any of the details; after all this patient is a newsman, and may bring up the question of health policy issues, so perhaps this is not something that doctor talks with all his/her patients about. But we recently learned of a Florida urologist who posted a sign saying “If you voted for Obama seek urologic care elsewhere. Changes to your healthcare begin right now. Not in four years.” (Urologist Posts His Politics on His Florida Office Door, Damien Cave, New York Times, April 2, 2010). Predictably, and probably correctly, the criticism focused upon whether such a sign was inappropriate, whether it was wrong to refuse to treat people because you didn’t like their politics (although the doctor, Jack Cassell, “…told the Orlando Sentinel that he has not refused to treat any patient for his or her political views and does not quiz patients about their politics, but he also does not plan to take the sign down.”)
More interesting, to me, is the question of whether the financial self-interest of doctors should be of concern to their patients, and how much that should count for in making policy. Clearly, when reimbursement is so low that the cost of running the practice is more than the revenue coming in (more likely to be the case for, say, family physicians than, say, urologists), a medical practice run as a business cannot survive. It is even true that the business needs to not only not lose money, but to make enough for the physicians to have a reasonable income. But if a physician is making, compared to most people, a very large amount of money (and I have no idea whether this is true of Dr. Cassell), is it reasonable for him/her to expect people to be compassionate if it drops to only a large amount? Should Americans be concerned if a subspecialist’s take-home pay drops from, say, $450,000 to $350,000? I know the doctor would be, but what about everyone else?
I find most interesting is how the expression of this sentiment, whether Dr. Cassell continues to treat Obama supporters or not, gets to the heart of the real issues in the health care debate. To the extent that a doctor can choose which patients to treat, or whether a patient can choose which doctor to visit, maybe this could work out. But it postulates medical care as a commodity to be sold, and that its purchase depends on a patient having sufficient money, or insurance, to buy it. It absolutely does not see medical care as a right that all people should have equal access to based on their medical need. For many of those who use a high proportion of medical care (perhaps especially urologic care) that insurance is provided by Medicare, a government-run, tax dollar supported entitlement program. Health reform as passed into law currently expands the pool of people who will have insurance coverage, and thus be able to pay the doctor. It is a far cry from Medicare-for-all, which I support, and which all people who support the current Medicare-for-some that currently exists, and are not entirely selfish, should support. If Dr. Cassell can survive as a urologist in Florida without taking those socialist Medicare dollars I would be surprised; if he is willing to take them, he should be supportive of Medicare-for-all.
Maybe he is. Maybe everyone has misinterpreted him. Maybe that is why he is so upset about the new law – that it doesn’t cover everyone fairly. If so, more power to him. If he is already refusing Medicare, at least he is logically consistent. However, if he takes Medicare but is opposed to even so mild a plan as the new health care law for expanding coverage to others, then he is just out for his own self interest.
The real issue remains: is access to medically-necessary health care a right, as it is considered in every other first-world country, or is it a commodity to be carefully husbanded by those who have it and sold to those who can meet the price? The real concern is not Dr. Cassell’s medical ethics, but his (and others’) worldview.
.
Monday, April 5, 2010
Primary Care and the Medical Home, Today and Tomorrow
.
March 18, 2010 was “match day”, the day that the seniors at US allopathic medical schools, along with many from osteopathic (DO) schools and thousands of graduates of non-US schools (including many who are Americans) “open their envelopes” and find out where they will be doing their post-graduate residency training. Most have already chosen their specialty and are waiting only to find out with which program they have “matched”. This year, for the first time in many years, the number of US medical students matching in family medicine has risen from the prior year. Not by much – there were, according to the American Academy of Family Physicians (AAFP) report, 75 (2.1%) more positions offered, and 2,404 (91.4%) of the 2,630 positions offered were filled on match day, the highest percentage in history. 1,184 of these are US grads, which was 101 more than last year and the highest number since 2004. This is good because, as I have often indicated, we need more primary care physicians and family medicine is the only specialty where virtually all graduates practice primary care. However, more sobering, it also notes, “The majority of positions offered and filled in the NRMP, however, continue to be in nonprimary care subspecialties.”
The Association of American Medical Colleges (AAMC)’s “Reporter” for March, 2010, contains an article by Scott Harris (written before the current match results were in), “Primary care in medical education: the problems, the solutions”. He notes that
“Primary care is generally defined as family medicine, internal medicine, and pediatrics, although it is the adult-oriented specialties for which the problem exists most pointedly, physician workforce experts say. In the 2009 Main Residency Match, 3,703 U.S. allopathic senior students matched to an internal or family medicine residency program, compared with 4,617 in 2000 and 5,020 in 1996. According to AAMC data, all primary care practitioners entering general practice after residency are down from 8,162 in 2000 to an estimated low of 6,757 in 2007. The Council on Graduate Medical Education (COGME) claims that all primary care physicians currently comprise 35 percent of practicing physicians, but that number is rapidly declining because of increased retirements and fewer new doctors to replace them. Recent COGME studies show that fewer than 20 percent of all U.S. medical students are choosing primary care specialties.”
This formulation recognizes the problem of most of the graduates entering internal medicine specialty training ending up as subspecialists. If we are currently at 30-35% primary care, 20% of new students won’t get us to the 50% we need. In fact, even if 50% of graduates enter primary care specialties, it will be a generation before that number is achieved.
Harris’ main focus, however, is on the “hidden curriculum” in medical schools, the influences outside the formal curriculum from teachers and peers that encourages students to enter non-primary care specialties. He quotes students and faculty members who identify the problem. One is David Deci, a family physician at the University of Wisconsin, who says "Modern medicine is enthralled with high-tech measures. We're all drawn to bells and whistles. The contribution that can be made through a long-term relationship with a patient needs to be shown as well. When you're working with an elderly patient with multiple conditions and diseases, and you manage to keep him out of the hospital for two years, you've made a great contribution. But it's harder to demonstrate that than it is to show the value of removing a tumor with gamma knife surgery." Another is Jeffrey Borkan, chair of Family Medicine at Brown and (now) past-president of the Association of Departments of Family Medicine (ADFM), who notes “Medical education is all about context. There can be an inherent bias because of who the trainers are and where the education happens. U.S. academic medical centers and medical schools tend to be in urban areas and have a predominance of specialist and subspecialist physicians, providing care in tertiary and quaternary hospital settings. Primary care and primary care physicians and educators can be underrepresented in these settings, even though present in the broader community and country." Most distressing is the student (planning to enter radiology) who tells of a family medicine program director discouraging him from entering the field. Harris’ article also has descriptions of programs at a number of medical schools, including new ones and those that have been around a long time, who have programs and plans for changing or modifying this “hidden curriculum”. How well they will work, however, especially against the financial pressure of greater reimbursement for narrower specialties, remains to be seen.
There are some hopeful trends on the horizon. The new health reform bill promises some increased reimbursement and other support for family medicine. At a recent private meeting with the President, a family medicine chair was told that Mr. Obama understood that family medicine was the crucial specialty for providing care for the American people. The ADFM and other primary care organizations are working with the Patient-Centered Primary Care Collaborative (PCPCC), a network of employers such as IBM, health insurers, providers and drug manufacturers who recognize that health systems built around primary care keep people healthier and save them money. Of course, the “save them money” part may be the most important part for many of the corporations. It is an important venture, although the family physicians in the collaborative will have to remain on guard that the health of people remains the most important focus. Merck’s slogan, for instance, may be “Where patients come first”, but the reality of their practice has been much more “Where profits come first” – $6 billion in one recent year, despite the Vioxx recall; some details can be found at Sourcewatch.com.
I certainly hope that all these efforts work. Goodness knows, we need them. And I hope that the many medical schools who are not on board, whose focus has never been primary care, who feel their main missions are biomedical research and quarternary care rather than training the doctors our country needs, will rethink their curricula – formal and hidden – as well.
.
March 18, 2010 was “match day”, the day that the seniors at US allopathic medical schools, along with many from osteopathic (DO) schools and thousands of graduates of non-US schools (including many who are Americans) “open their envelopes” and find out where they will be doing their post-graduate residency training. Most have already chosen their specialty and are waiting only to find out with which program they have “matched”. This year, for the first time in many years, the number of US medical students matching in family medicine has risen from the prior year. Not by much – there were, according to the American Academy of Family Physicians (AAFP) report, 75 (2.1%) more positions offered, and 2,404 (91.4%) of the 2,630 positions offered were filled on match day, the highest percentage in history. 1,184 of these are US grads, which was 101 more than last year and the highest number since 2004. This is good because, as I have often indicated, we need more primary care physicians and family medicine is the only specialty where virtually all graduates practice primary care. However, more sobering, it also notes, “The majority of positions offered and filled in the NRMP, however, continue to be in nonprimary care subspecialties.”
The Association of American Medical Colleges (AAMC)’s “Reporter” for March, 2010, contains an article by Scott Harris (written before the current match results were in), “Primary care in medical education: the problems, the solutions”. He notes that
“Primary care is generally defined as family medicine, internal medicine, and pediatrics, although it is the adult-oriented specialties for which the problem exists most pointedly, physician workforce experts say. In the 2009 Main Residency Match, 3,703 U.S. allopathic senior students matched to an internal or family medicine residency program, compared with 4,617 in 2000 and 5,020 in 1996. According to AAMC data, all primary care practitioners entering general practice after residency are down from 8,162 in 2000 to an estimated low of 6,757 in 2007. The Council on Graduate Medical Education (COGME) claims that all primary care physicians currently comprise 35 percent of practicing physicians, but that number is rapidly declining because of increased retirements and fewer new doctors to replace them. Recent COGME studies show that fewer than 20 percent of all U.S. medical students are choosing primary care specialties.”
This formulation recognizes the problem of most of the graduates entering internal medicine specialty training ending up as subspecialists. If we are currently at 30-35% primary care, 20% of new students won’t get us to the 50% we need. In fact, even if 50% of graduates enter primary care specialties, it will be a generation before that number is achieved.
Harris’ main focus, however, is on the “hidden curriculum” in medical schools, the influences outside the formal curriculum from teachers and peers that encourages students to enter non-primary care specialties. He quotes students and faculty members who identify the problem. One is David Deci, a family physician at the University of Wisconsin, who says "Modern medicine is enthralled with high-tech measures. We're all drawn to bells and whistles. The contribution that can be made through a long-term relationship with a patient needs to be shown as well. When you're working with an elderly patient with multiple conditions and diseases, and you manage to keep him out of the hospital for two years, you've made a great contribution. But it's harder to demonstrate that than it is to show the value of removing a tumor with gamma knife surgery." Another is Jeffrey Borkan, chair of Family Medicine at Brown and (now) past-president of the Association of Departments of Family Medicine (ADFM), who notes “Medical education is all about context. There can be an inherent bias because of who the trainers are and where the education happens. U.S. academic medical centers and medical schools tend to be in urban areas and have a predominance of specialist and subspecialist physicians, providing care in tertiary and quaternary hospital settings. Primary care and primary care physicians and educators can be underrepresented in these settings, even though present in the broader community and country." Most distressing is the student (planning to enter radiology) who tells of a family medicine program director discouraging him from entering the field. Harris’ article also has descriptions of programs at a number of medical schools, including new ones and those that have been around a long time, who have programs and plans for changing or modifying this “hidden curriculum”. How well they will work, however, especially against the financial pressure of greater reimbursement for narrower specialties, remains to be seen.
There are some hopeful trends on the horizon. The new health reform bill promises some increased reimbursement and other support for family medicine. At a recent private meeting with the President, a family medicine chair was told that Mr. Obama understood that family medicine was the crucial specialty for providing care for the American people. The ADFM and other primary care organizations are working with the Patient-Centered Primary Care Collaborative (PCPCC), a network of employers such as IBM, health insurers, providers and drug manufacturers who recognize that health systems built around primary care keep people healthier and save them money. Of course, the “save them money” part may be the most important part for many of the corporations. It is an important venture, although the family physicians in the collaborative will have to remain on guard that the health of people remains the most important focus. Merck’s slogan, for instance, may be “Where patients come first”, but the reality of their practice has been much more “Where profits come first” – $6 billion in one recent year, despite the Vioxx recall; some details can be found at Sourcewatch.com.
I certainly hope that all these efforts work. Goodness knows, we need them. And I hope that the many medical schools who are not on board, whose focus has never been primary care, who feel their main missions are biomedical research and quarternary care rather than training the doctors our country needs, will rethink their curricula – formal and hidden – as well.
.
Wednesday, March 31, 2010
Obama and the Seder: Freedom and Multiculturalism
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The New York Times on March 28, 2010 had a front-page article on the Seder planned at the White House for this year, apparently the second annual one (not counting the impromptu one during the campaign two years ago) – “Next year in the White House: a Seder tradition” by Jodi Kantor. I became a little teary reading it, but I tend to do that about things that are about bringing people from different backgrounds together, sharing, and finding common-ness. Just as I tend to get furious and angry about those who sow distrust, difference and divisiveness. I was going to say “sow hate”, but it’s hard to attack people and say you’re against hate, although it is their hatred I abhor.
The Seder is the celebration of Passover, marking the story of Exodus, the liberation of the Jewish people from slavery in Egypt. Its significance for African-Americans who were in slavery in this country is obvious, and was obvious to the slaves who were being converted to Christianity and learning this story as they suffered in bondage; many of the spirituals they created used the thinly-veiled metaphor of the Israelites in captivity. Thus it should not be surprising that it is the first African-American President who brings the Passover tradition of the Seder to the White House, or that it is attended by “mostly Jewish and African-American guests”. Nor is it surprising that the event is a “ritual that neither the rabbinic sages nor the founding fathers would recognize.” Hopefully this will not matter to those Jews who observe the Passover with the fully religious celebration, although it may offend some of those who are interested only in division and distrust. I was once warned, on being invited to a Seder, that this was a “Jewish” holiday, and that the host would not enjoy bringing in references to those “others”.
At least that host was aware that many people do. It was certainly true in the secular tradition in which I was raised, in which Passover, not Rosh Hashanah or Yom Kippur which are the High Holy Days of the Jewish religion, was the main holiday precisely because it honored liberation and appealed to larger human hopes. It was true of our Seders, in which “Go Down, Moses” was as integral a tune as “Dayenu”. In addition to remembering the enslavement of Jews and African-Americans, remembrance of the Holocaust was of course central, with particular focus on the Warsaw Ghetto Uprising* of 1943 (a 40-day armed resistance to Nazi deportation of Jews from the Ghetto, the final episode beginning with a Nazi attack on Passover eve), was a part of our Seder having occurred not very long in the past. In modern secular Seders, the plight – enslavement, genocide, torture, especially when it is conducted by religion or ethnicity or gender or race or sexual orientation – is remembered and condemned.
Of course, the story of the Exodus is also a story of ethnic exceptionalism – the name of the holiday comes from the story that the Angel of Death “passed over” the houses of the Israelites, smeared with lamb’s blood, as he systematically killed the first-born son in the house of the Egyptians. But it is the story of the liberation, of the undying hope for freedom in the human spirit, that is its most important characteristic, that resonates most for me and many others (possibly including those at the White House Seder). In a world of individualism, group-ism, exceptionalism, it is important that we remember that we are all people, and all in it together.
I recently posted on this blog’s “sister” Facebook page a quote from “The Volunteer” the journal of the Archives of the Abraham Lincoln Brigade (ALBA), the group focused on remembering and documenting the participation of Americans as volunteers on the side of the Republic in Spanish Civil War. It was about the effort to identify a black volunteer (Mystery Photo: Gift to Obama Puts ALBA in the Spotlight) in a photo taken by Catalan photographer Agusti Centelles that his children wanted to send as a gift to President Obama. Although not yet identified by name, the soldier is apparently Afro-Cuban, not African-American. But, the article by James Fernández and Sebastiaan Faber, continues:
“In the end, of course, who he was is not that significant —nor, for that matter, which nation issued his passport. National identities were of little importance in the Spanish Civil War. The almost 40,000 volunteers resisted being singled out as heroes; they had joined an international, multi-ethnic and multi-racial coalition because they believed fascism was a global threat that demanded international solidarity, and they went to Spain despite the fact that many foreign governments opted for non-intervention.”
On the blog page I ask “Could there be anything more beautiful?” I mean not only the fight against fascism, but at a deeper level: Can we maintain our own identities and traditions but understand that, at our core, we are the same?
*Many of the links are to Wikipedia entries, because they are well-know and easily accessible. There are much better and more authoritative sources, however, for spirituals, the Warsaw Ghetto Uprising, the Spanish Civil War, and the other links
.
The New York Times on March 28, 2010 had a front-page article on the Seder planned at the White House for this year, apparently the second annual one (not counting the impromptu one during the campaign two years ago) – “Next year in the White House: a Seder tradition” by Jodi Kantor. I became a little teary reading it, but I tend to do that about things that are about bringing people from different backgrounds together, sharing, and finding common-ness. Just as I tend to get furious and angry about those who sow distrust, difference and divisiveness. I was going to say “sow hate”, but it’s hard to attack people and say you’re against hate, although it is their hatred I abhor.
The Seder is the celebration of Passover, marking the story of Exodus, the liberation of the Jewish people from slavery in Egypt. Its significance for African-Americans who were in slavery in this country is obvious, and was obvious to the slaves who were being converted to Christianity and learning this story as they suffered in bondage; many of the spirituals they created used the thinly-veiled metaphor of the Israelites in captivity. Thus it should not be surprising that it is the first African-American President who brings the Passover tradition of the Seder to the White House, or that it is attended by “mostly Jewish and African-American guests”. Nor is it surprising that the event is a “ritual that neither the rabbinic sages nor the founding fathers would recognize.” Hopefully this will not matter to those Jews who observe the Passover with the fully religious celebration, although it may offend some of those who are interested only in division and distrust. I was once warned, on being invited to a Seder, that this was a “Jewish” holiday, and that the host would not enjoy bringing in references to those “others”.
At least that host was aware that many people do. It was certainly true in the secular tradition in which I was raised, in which Passover, not Rosh Hashanah or Yom Kippur which are the High Holy Days of the Jewish religion, was the main holiday precisely because it honored liberation and appealed to larger human hopes. It was true of our Seders, in which “Go Down, Moses” was as integral a tune as “Dayenu”. In addition to remembering the enslavement of Jews and African-Americans, remembrance of the Holocaust was of course central, with particular focus on the Warsaw Ghetto Uprising* of 1943 (a 40-day armed resistance to Nazi deportation of Jews from the Ghetto, the final episode beginning with a Nazi attack on Passover eve), was a part of our Seder having occurred not very long in the past. In modern secular Seders, the plight – enslavement, genocide, torture, especially when it is conducted by religion or ethnicity or gender or race or sexual orientation – is remembered and condemned.
Of course, the story of the Exodus is also a story of ethnic exceptionalism – the name of the holiday comes from the story that the Angel of Death “passed over” the houses of the Israelites, smeared with lamb’s blood, as he systematically killed the first-born son in the house of the Egyptians. But it is the story of the liberation, of the undying hope for freedom in the human spirit, that is its most important characteristic, that resonates most for me and many others (possibly including those at the White House Seder). In a world of individualism, group-ism, exceptionalism, it is important that we remember that we are all people, and all in it together.
I recently posted on this blog’s “sister” Facebook page a quote from “The Volunteer” the journal of the Archives of the Abraham Lincoln Brigade (ALBA), the group focused on remembering and documenting the participation of Americans as volunteers on the side of the Republic in Spanish Civil War. It was about the effort to identify a black volunteer (Mystery Photo: Gift to Obama Puts ALBA in the Spotlight) in a photo taken by Catalan photographer Agusti Centelles that his children wanted to send as a gift to President Obama. Although not yet identified by name, the soldier is apparently Afro-Cuban, not African-American. But, the article by James Fernández and Sebastiaan Faber, continues:
“In the end, of course, who he was is not that significant —nor, for that matter, which nation issued his passport. National identities were of little importance in the Spanish Civil War. The almost 40,000 volunteers resisted being singled out as heroes; they had joined an international, multi-ethnic and multi-racial coalition because they believed fascism was a global threat that demanded international solidarity, and they went to Spain despite the fact that many foreign governments opted for non-intervention.”
On the blog page I ask “Could there be anything more beautiful?” I mean not only the fight against fascism, but at a deeper level: Can we maintain our own identities and traditions but understand that, at our core, we are the same?
*Many of the links are to Wikipedia entries, because they are well-know and easily accessible. There are much better and more authoritative sources, however, for spirituals, the Warsaw Ghetto Uprising, the Spanish Civil War, and the other links
.
Saturday, March 27, 2010
Comparative effectiveness research
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I’m a doctor, so maybe I have a different take on this than other people, but somehow I don’t think so. I would imagine most folks would want to know, before being put on a new, expensive medication (and in medications, “new” virtually always = “expensive”) a little more about it than that it worked better than nothing, or a placebo (which is not always the same thing, given the “placebo effect” – folks sometimes improve somewhat if they think a drug is going to work). I would imagine they’d want to know that it works better than, or as well as, or at least almost as well as, the drug that they are taking, or another drug, or especially a long-established, effective, we-know-how-well-it-works-and-the-side-effects-too, and frequently generic and cheaper, drug.
Studies that do this are called “comparative effectiveness research” (they can also be used for devices and other treatments). You would think, then, that there would be consensus that a new drug should be tested against existing drugs for the same condition and shown to be superior, or at least (in the scientific parlance) “non-inferior”. Not true; the FDA just requires studies that show it is better than placebo. This issue has been getting a lot of attention in the medical and scientific communities recently. A major contribution to this discussion was the recent study published by Michael Hochman and Danny McCormick in JAMA, March 10, 2010, “Characteristics of published comparative effectiveness studies of medications” (JAMA. 2010 Mar 10;303(10):951-8). This study looked at 328 previous studies evaluating medications and found that less than a third (104) had compared the drug against something other than placebo. Only 11 compared the drug against non-drug (“non-pharmacologic”) treatments; among the others only 45 compared two or more drugs, 32 with different pharmacologic “strategies”, and 16 different dosing schedules. Most of these, 90 of the 104, were financed by non-commercial sources (e.g., the government); the placebo studies were almost all funded by pharmaceutical manufacturers, who fund, it should be noted, more than half the medical research done in this country. This would be a good and noble thing, were it not actually a self-serving and thus often bad thing. Since many people cannot access the JAMA article (and might find it harder to understand it anyway), Hochman and McCormick also published an op-ed piece in the Los Angeles Times, “Medicine in the dark” which is clear and persuasive. In the same JAMA issue, two HHS physicians, Patrick Conway and Carolyn Clancy (who is head of the Agency for Healthcare Research and Quality, AHRQ, that supports much comparative effectiveness research), comment on the Hochman and McCormick article and call for increased comparative effectiveness research (“Charting a path from comparative effectiveness funding to improved patient-centered health care”, JAMA. 2010 Mar 10;303(10):985-6). They do not comment on the pharmaceutical industry funded studies.
Most practicing physicians are not active clinical researchers, and even those who are usually have a very limited research focus. Therefore, physicians need access to accurate and unbiased research, and need to spend the time keeping up with important new information that may impact your care. (By “important”, here I mean something that actually may benefit your health or that of another patient, not something that may benefit the bank accounts of the drug company shareholders – which I am sure is important to them.) Before beginning you on a new drug for your condition, especially when it is more expensive – often very much more expensive – and newer (please note that with drugs “newer” does not always – in fact, uncommonly, mean better. It does, however, virtually always mean “used and tested less so we are not necessarily aware of all adverse effects”, so you would hope that your doctor had reason to believe it was going to work better (or at least not worse) for you than your old treatment, and that this belief was based on independent reliable sources. That is, if not the original research, at least on independent reviews and summaries (like that of Hochman and McCormick, or The Medical Letter), and not simply information provided to them by drug salesmen. If you see lots of pens, pads, clocks, and other doodads with pharmaceutical company logos in your doctor’s office – not to mention if you get those neat “free samples” (which are never free; you and others buying the drug eventually pay for them) of the newest, most expensive drugs being pushed by the drug companies, you might begin to get suspicious. You might even ask your doctor how much time s/he spends with drug company reps and how much of his/her information comes from them, and has s/he ever audited his/her charts to actually find out (whatever s/he believes) if s/he is prescribing more of drugs pushed by drug reps? You might even complain. Doctors are sensitive to their patients’ complaints.
But what about when the doctor does look at the original research, but the research itself is largely funded by drug companies, who frequently suppress negative results? And if, as Hochman and McCormick point out, most of them just compare the new drug to placebo, not other established treatments? What value is there in that? Well, Peter Pitts, interviewed on NPR’s Morning Edition in their story on this issue on March 10, 2010, thinks there is value. He says doctors need to know what options are available. Of course, Mr. Pitts is a spokesman for the Center for Medicines in the Public Interest, a group whose name is absolutely contradictory to its function, since it functions in the interest of the pharmaceutical industry, which funds it. (And, really importantly, should never be confused with the absolutely wonderful Center for Science in the Public Interest, a truly great public interest organization that interprets research and advocates for food safety, the environment, and other issues that we need real scientists to help us to understand.)
As a physician, I agree with Mr. Pitts that we need to know what options are available. And, apparently unlike Mr. Pitts and the industry he represents, I think we need to know the whole story and how those options compare to one another, not a placebo. And I think you would want your doctor to know that also.
.
I’m a doctor, so maybe I have a different take on this than other people, but somehow I don’t think so. I would imagine most folks would want to know, before being put on a new, expensive medication (and in medications, “new” virtually always = “expensive”) a little more about it than that it worked better than nothing, or a placebo (which is not always the same thing, given the “placebo effect” – folks sometimes improve somewhat if they think a drug is going to work). I would imagine they’d want to know that it works better than, or as well as, or at least almost as well as, the drug that they are taking, or another drug, or especially a long-established, effective, we-know-how-well-it-works-and-the-side-effects-too, and frequently generic and cheaper, drug.
Studies that do this are called “comparative effectiveness research” (they can also be used for devices and other treatments). You would think, then, that there would be consensus that a new drug should be tested against existing drugs for the same condition and shown to be superior, or at least (in the scientific parlance) “non-inferior”. Not true; the FDA just requires studies that show it is better than placebo. This issue has been getting a lot of attention in the medical and scientific communities recently. A major contribution to this discussion was the recent study published by Michael Hochman and Danny McCormick in JAMA, March 10, 2010, “Characteristics of published comparative effectiveness studies of medications” (JAMA. 2010 Mar 10;303(10):951-8). This study looked at 328 previous studies evaluating medications and found that less than a third (104) had compared the drug against something other than placebo. Only 11 compared the drug against non-drug (“non-pharmacologic”) treatments; among the others only 45 compared two or more drugs, 32 with different pharmacologic “strategies”, and 16 different dosing schedules. Most of these, 90 of the 104, were financed by non-commercial sources (e.g., the government); the placebo studies were almost all funded by pharmaceutical manufacturers, who fund, it should be noted, more than half the medical research done in this country. This would be a good and noble thing, were it not actually a self-serving and thus often bad thing. Since many people cannot access the JAMA article (and might find it harder to understand it anyway), Hochman and McCormick also published an op-ed piece in the Los Angeles Times, “Medicine in the dark” which is clear and persuasive. In the same JAMA issue, two HHS physicians, Patrick Conway and Carolyn Clancy (who is head of the Agency for Healthcare Research and Quality, AHRQ, that supports much comparative effectiveness research), comment on the Hochman and McCormick article and call for increased comparative effectiveness research (“Charting a path from comparative effectiveness funding to improved patient-centered health care”, JAMA. 2010 Mar 10;303(10):985-6). They do not comment on the pharmaceutical industry funded studies.
Most practicing physicians are not active clinical researchers, and even those who are usually have a very limited research focus. Therefore, physicians need access to accurate and unbiased research, and need to spend the time keeping up with important new information that may impact your care. (By “important”, here I mean something that actually may benefit your health or that of another patient, not something that may benefit the bank accounts of the drug company shareholders – which I am sure is important to them.) Before beginning you on a new drug for your condition, especially when it is more expensive – often very much more expensive – and newer (please note that with drugs “newer” does not always – in fact, uncommonly, mean better. It does, however, virtually always mean “used and tested less so we are not necessarily aware of all adverse effects”, so you would hope that your doctor had reason to believe it was going to work better (or at least not worse) for you than your old treatment, and that this belief was based on independent reliable sources. That is, if not the original research, at least on independent reviews and summaries (like that of Hochman and McCormick, or The Medical Letter), and not simply information provided to them by drug salesmen. If you see lots of pens, pads, clocks, and other doodads with pharmaceutical company logos in your doctor’s office – not to mention if you get those neat “free samples” (which are never free; you and others buying the drug eventually pay for them) of the newest, most expensive drugs being pushed by the drug companies, you might begin to get suspicious. You might even ask your doctor how much time s/he spends with drug company reps and how much of his/her information comes from them, and has s/he ever audited his/her charts to actually find out (whatever s/he believes) if s/he is prescribing more of drugs pushed by drug reps? You might even complain. Doctors are sensitive to their patients’ complaints.
But what about when the doctor does look at the original research, but the research itself is largely funded by drug companies, who frequently suppress negative results? And if, as Hochman and McCormick point out, most of them just compare the new drug to placebo, not other established treatments? What value is there in that? Well, Peter Pitts, interviewed on NPR’s Morning Edition in their story on this issue on March 10, 2010, thinks there is value. He says doctors need to know what options are available. Of course, Mr. Pitts is a spokesman for the Center for Medicines in the Public Interest, a group whose name is absolutely contradictory to its function, since it functions in the interest of the pharmaceutical industry, which funds it. (And, really importantly, should never be confused with the absolutely wonderful Center for Science in the Public Interest, a truly great public interest organization that interprets research and advocates for food safety, the environment, and other issues that we need real scientists to help us to understand.)
As a physician, I agree with Mr. Pitts that we need to know what options are available. And, apparently unlike Mr. Pitts and the industry he represents, I think we need to know the whole story and how those options compare to one another, not a placebo. And I think you would want your doctor to know that also.
.
Sunday, March 21, 2010
Doctors, morality and behavior: where is the moral compass?
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In their New York Times article on March 1, 2010, about “Doctors without Morals”, Leonard S. Rubenstein and Stephen N. Xenakis contrast the investigation into the Bush administration lawyers involved in the authorization of torture (who they feel were let off much too easily, with an assessment of “poor judgment”, not professional misconduct) with the complete lack of investigation into the doctors and psychologists who participated in the torture itself, as well as the CIA’s Office of Medical Services that investigated the activities when they were questioned by the agency’s Inspector General, and found that, well, everything was ok.
“According to Justice Department memos released last year, the medical service opined that sleep deprivation up to 180 hours didn’t qualify as torture. It determined that confinement in a dark, small space for 18 hours a day was acceptable. It said detainees could be exposed to cold air or hosed down with cold water for up to two-thirds of the time it takes for hypothermia to set in. And it advised that placing a detainee in handcuffs attached by a chain to a ceiling, then forcing him to stand with his feet shackled to a bolt in the floor, ‘does not result in significant pain for the subject.’” Waterboarding, when limited to “12 applications over two sessions within 24 hours, and to five days in any 30-day period,” was ok.
The questions is “Who are these people? Other questions, such as “How did they get to be doctors?”, “How can they sleep at night?”, “How can they have been put in charge of this?”, and “How come they still are allowed to practice medicine?” Most important is “Why was there no investigation?” Doctors are investigated by their state licensing boards and others all the time. They can lose their licenses for minor drug offenses, and are subject to severe restrictions and monitoring for risky behaviors involving drugs or alcohol, even if no actual patient was hurt (yet). They can be, and are, sued for all sorts of things, sometimes real malpractice, sometimes in the hope, by patient and lawyer, that they or their insurance company will agree to a monetary settlement in order to avoid the time, pain, and expense of a trial, even when they are not guilty. They are subject to fraud investigations by Medicare, sometimes found liable for honest mistakes.
But actually condoning and designing and implementing torture on actual people with actual damage? Apparently, if done by the CIA, not even worthy of investigation. It is absolutely intolerable and outrageous. Another question is “how did people get this way?” Are they born without moral compass? Were they ethical health professionals who just got so carried away by being part of the CIA that they lost their way? Is the role of the Office of Medical Services particularly despicable because it involved time and thought and did not occur in the health of the moment? I think another question we have to ask is whether we have tolerated less severe moral lapses in physicians that have made this a slippery slope rather than a fall off a cliff.
Where is the dividing line between ethical and unethical behavior in physicians and other health professionals? Clearly, to most of us, it lies somewhere this side of doing or condoning torture (except to the folks involved in the torture directly, in the Office of Medical Services who ok’ed it, and in the licensing and disciplinary boards within and outside of government who have not investigated). But what about facilitating and performing capital punishment? All reputable medical societies say it is unethical for physicians to be involved, but obviously the government authorizes and pays those who do. What about taking bribes from drug companies for using and endorsing their products? The issue of physicians’ conflict of interest has certainly been in the news, but bribes? Well, if I’m a realtor who gives you a present for having listed your house with me, that isn’t a bribe, since it is your money at risk. If I am a company who gives you, as a legislator, money for voting on a public works project that benefits the company, that is a bribe, since it involves the public’s money for which you have fiduciary responsibility, not your own. I would suggest that pharmaceutical and medical device companies give gifts to physicians not so they individually will use their products, but so they will recommend, or even more actually prescribe them, to patients. This is a bribe.
What else besides gifts from drug and device makers, from pens to large corporate board fees, from free samples to tips to resorts, might challenge the morality of physicians?
And, in the particular case of the torture-doctors: Rubenstein and Xenakis say, “This is an unconscionable disservice to the thousands of ethical doctors and psychologists in the country’s service. It is not too late to begin investigations. They should start now.”
Yup.
.
In their New York Times article on March 1, 2010, about “Doctors without Morals”, Leonard S. Rubenstein and Stephen N. Xenakis contrast the investigation into the Bush administration lawyers involved in the authorization of torture (who they feel were let off much too easily, with an assessment of “poor judgment”, not professional misconduct) with the complete lack of investigation into the doctors and psychologists who participated in the torture itself, as well as the CIA’s Office of Medical Services that investigated the activities when they were questioned by the agency’s Inspector General, and found that, well, everything was ok.
“According to Justice Department memos released last year, the medical service opined that sleep deprivation up to 180 hours didn’t qualify as torture. It determined that confinement in a dark, small space for 18 hours a day was acceptable. It said detainees could be exposed to cold air or hosed down with cold water for up to two-thirds of the time it takes for hypothermia to set in. And it advised that placing a detainee in handcuffs attached by a chain to a ceiling, then forcing him to stand with his feet shackled to a bolt in the floor, ‘does not result in significant pain for the subject.’” Waterboarding, when limited to “12 applications over two sessions within 24 hours, and to five days in any 30-day period,” was ok.
The questions is “Who are these people? Other questions, such as “How did they get to be doctors?”, “How can they sleep at night?”, “How can they have been put in charge of this?”, and “How come they still are allowed to practice medicine?” Most important is “Why was there no investigation?” Doctors are investigated by their state licensing boards and others all the time. They can lose their licenses for minor drug offenses, and are subject to severe restrictions and monitoring for risky behaviors involving drugs or alcohol, even if no actual patient was hurt (yet). They can be, and are, sued for all sorts of things, sometimes real malpractice, sometimes in the hope, by patient and lawyer, that they or their insurance company will agree to a monetary settlement in order to avoid the time, pain, and expense of a trial, even when they are not guilty. They are subject to fraud investigations by Medicare, sometimes found liable for honest mistakes.
But actually condoning and designing and implementing torture on actual people with actual damage? Apparently, if done by the CIA, not even worthy of investigation. It is absolutely intolerable and outrageous. Another question is “how did people get this way?” Are they born without moral compass? Were they ethical health professionals who just got so carried away by being part of the CIA that they lost their way? Is the role of the Office of Medical Services particularly despicable because it involved time and thought and did not occur in the health of the moment? I think another question we have to ask is whether we have tolerated less severe moral lapses in physicians that have made this a slippery slope rather than a fall off a cliff.
Where is the dividing line between ethical and unethical behavior in physicians and other health professionals? Clearly, to most of us, it lies somewhere this side of doing or condoning torture (except to the folks involved in the torture directly, in the Office of Medical Services who ok’ed it, and in the licensing and disciplinary boards within and outside of government who have not investigated). But what about facilitating and performing capital punishment? All reputable medical societies say it is unethical for physicians to be involved, but obviously the government authorizes and pays those who do. What about taking bribes from drug companies for using and endorsing their products? The issue of physicians’ conflict of interest has certainly been in the news, but bribes? Well, if I’m a realtor who gives you a present for having listed your house with me, that isn’t a bribe, since it is your money at risk. If I am a company who gives you, as a legislator, money for voting on a public works project that benefits the company, that is a bribe, since it involves the public’s money for which you have fiduciary responsibility, not your own. I would suggest that pharmaceutical and medical device companies give gifts to physicians not so they individually will use their products, but so they will recommend, or even more actually prescribe them, to patients. This is a bribe.
What else besides gifts from drug and device makers, from pens to large corporate board fees, from free samples to tips to resorts, might challenge the morality of physicians?
And, in the particular case of the torture-doctors: Rubenstein and Xenakis say, “This is an unconscionable disservice to the thousands of ethical doctors and psychologists in the country’s service. It is not too late to begin investigations. They should start now.”
Yup.
.
Wednesday, March 17, 2010
The Sharp End of Ideology
.
This powerful piece was written by Robert Ferrer, MD, MPH, who has previously written guest blogs. It is too bad that the pundits and policy wonks will not see it.
On any given day there are five to ten of them on our hospital service. In the room that our clinical team uses to discuss patients we reserve one of our two white boards just for them. As a group they are defined by three characteristics: they have suffered from diabetes for many years, they have lacked steady health insurance and medical care, and they are in various stages of dismemberment. Uncontrolled diabetes has damaged their blood vessels, and the ensuing gangrene or bone infections brings them to our hospital, where we care for their medical problems while the surgeons amputate toes, feet, or lower legs. The patients often lose these parts in sequential episodes as their circulation worsens and the complications progress.
Most are men, and many of them are younger than you would expect, in their late thirties or early forties. Almost all have been recently working, though the operation they now require will usually end their employability in the blue collar jobs they occupy. When we ask when they last received regular care for their diabetes, the only mystery is where they*ll fall in the range from "a year ago" to "never". And therein lies what makes these complications especially sad, because with patient education and periodic low-tech evaluations, most of the amputations could have been prevented.
The fact that they are so often not prevented emerges from an unhappy synergy between two epidemics: diabetes and uninsurance. Among large American cities, San Antonio ranks near the top for both; a quarter of its residents lack health insurance and about 1 in 10 have diabetes, though in the less affluent parts of town the diabetes statistic is closer to 1 in 4. Being poor puts one at risk for both diabetes and being uninsured, but being poor in particular locales is especially risky. What those locales share is stingy public insurance programs, (for example, the earnings ceiling above which adults with children no longer qualify for Texas Medicaid just 26% of the federal poverty level -- about $5200 for a family of four -- and, as in most states, childless adults without disabilities don*t qualify at all), and many jobs that don*t come with health insurance. In many cities, as in ours, a large number of undocumented immigrants also add to the number of uninsured.
So there are three of the big conundrums of national heath care reform: the scope of public insurance, expanding coverage under private sector insurance, and what should be done about non-citizens. (A fourth, costs, will come up later). Framed in this way, as bloodless policy questions far removed from the daily realities of the ward, the urgency is drained out of them. Raised yet another level of abstraction higher -- Socialism! -- the debate becomes an absurd joke, the cruelty of which will be felt by those who will needlessly lose limbs in the coming years if reform fails yet again.
For the patients who occupy the beds on our wards -- high-risk people in low-benefits occupations living in a low-services state -- the list of responsive policy options seems very narrow. The realistic options are heavily regulated public or private plans based on large risk pools and with adequate subsidies to ensure that cost is not a barrier to regular care. Less important than the exact mechanism, however, is that there be a path to coverage short of losing a leg, becoming disabled, and qualifying for coverage through disability benefits. As for the non-citizens, our county decided in 1997 to respond to the compelling local needs by creating a publicly funded plan that allows the working poor to access full-spectrum health care on a sliding repayment scale. Hard-liners may balk at reform that even considers these types of arrangements, but what is the alternative? Deporting people with gangrenous limbs or failing kidneys? Continuing to provide only expensive, last-minute rescue care?
Although we have much yet to learn about controlling health care costs, one clear message is that preventing complications among high-risk patients with chronic disease will yield important savings. A typical hospital bill for a diabetic patient having an amputation runs to $10,000 or $20,000 or more, not because of the surgeon*s fee, but because the patients* other diagnoses, often including antibiotic-resistant infections and failing kidneys, complicate their treatment. Investing in access and regular care before a crisis occurs saves money - as well as limbs, kidneys, and hearts.
Meaningful reform cannot be postponed any longer. George Orwell wrote that in political discourse, *words fall upon the facts like soft snow blurring the outline and covering up all the detail.* Through the seasons of debate, the the urgent needs of those suffering for lack of care have been buried beneath the snow of words. But those needs are still there, regardless of the political calculations. To pretend that there is not a way forward to a workable conclusion coldly discards the opportunity to ease the suffering for millions of our people. If that happens, many will feel the metaphorical phantom pain of another lost opportunity for reform. And a smaller subset of the vulnerable among us will experience the real thing.
.
This powerful piece was written by Robert Ferrer, MD, MPH, who has previously written guest blogs. It is too bad that the pundits and policy wonks will not see it.
On any given day there are five to ten of them on our hospital service. In the room that our clinical team uses to discuss patients we reserve one of our two white boards just for them. As a group they are defined by three characteristics: they have suffered from diabetes for many years, they have lacked steady health insurance and medical care, and they are in various stages of dismemberment. Uncontrolled diabetes has damaged their blood vessels, and the ensuing gangrene or bone infections brings them to our hospital, where we care for their medical problems while the surgeons amputate toes, feet, or lower legs. The patients often lose these parts in sequential episodes as their circulation worsens and the complications progress.
Most are men, and many of them are younger than you would expect, in their late thirties or early forties. Almost all have been recently working, though the operation they now require will usually end their employability in the blue collar jobs they occupy. When we ask when they last received regular care for their diabetes, the only mystery is where they*ll fall in the range from "a year ago" to "never". And therein lies what makes these complications especially sad, because with patient education and periodic low-tech evaluations, most of the amputations could have been prevented.
The fact that they are so often not prevented emerges from an unhappy synergy between two epidemics: diabetes and uninsurance. Among large American cities, San Antonio ranks near the top for both; a quarter of its residents lack health insurance and about 1 in 10 have diabetes, though in the less affluent parts of town the diabetes statistic is closer to 1 in 4. Being poor puts one at risk for both diabetes and being uninsured, but being poor in particular locales is especially risky. What those locales share is stingy public insurance programs, (for example, the earnings ceiling above which adults with children no longer qualify for Texas Medicaid just 26% of the federal poverty level -- about $5200 for a family of four -- and, as in most states, childless adults without disabilities don*t qualify at all), and many jobs that don*t come with health insurance. In many cities, as in ours, a large number of undocumented immigrants also add to the number of uninsured.
So there are three of the big conundrums of national heath care reform: the scope of public insurance, expanding coverage under private sector insurance, and what should be done about non-citizens. (A fourth, costs, will come up later). Framed in this way, as bloodless policy questions far removed from the daily realities of the ward, the urgency is drained out of them. Raised yet another level of abstraction higher -- Socialism! -- the debate becomes an absurd joke, the cruelty of which will be felt by those who will needlessly lose limbs in the coming years if reform fails yet again.
For the patients who occupy the beds on our wards -- high-risk people in low-benefits occupations living in a low-services state -- the list of responsive policy options seems very narrow. The realistic options are heavily regulated public or private plans based on large risk pools and with adequate subsidies to ensure that cost is not a barrier to regular care. Less important than the exact mechanism, however, is that there be a path to coverage short of losing a leg, becoming disabled, and qualifying for coverage through disability benefits. As for the non-citizens, our county decided in 1997 to respond to the compelling local needs by creating a publicly funded plan that allows the working poor to access full-spectrum health care on a sliding repayment scale. Hard-liners may balk at reform that even considers these types of arrangements, but what is the alternative? Deporting people with gangrenous limbs or failing kidneys? Continuing to provide only expensive, last-minute rescue care?
Although we have much yet to learn about controlling health care costs, one clear message is that preventing complications among high-risk patients with chronic disease will yield important savings. A typical hospital bill for a diabetic patient having an amputation runs to $10,000 or $20,000 or more, not because of the surgeon*s fee, but because the patients* other diagnoses, often including antibiotic-resistant infections and failing kidneys, complicate their treatment. Investing in access and regular care before a crisis occurs saves money - as well as limbs, kidneys, and hearts.
Meaningful reform cannot be postponed any longer. George Orwell wrote that in political discourse, *words fall upon the facts like soft snow blurring the outline and covering up all the detail.* Through the seasons of debate, the the urgent needs of those suffering for lack of care have been buried beneath the snow of words. But those needs are still there, regardless of the political calculations. To pretend that there is not a way forward to a workable conclusion coldly discards the opportunity to ease the suffering for millions of our people. If that happens, many will feel the metaphorical phantom pain of another lost opportunity for reform. And a smaller subset of the vulnerable among us will experience the real thing.
.
Saturday, March 13, 2010
Who owns US policy: let’s not forget who the bad guys are
.
The New York Times, March 7, 2010, (US enriches companies defying its policy on Iran, by Jo Becker and Ron Nixon) reveals that the US is supporting, primarily through government contracts, many companies that are involved in doing business in and with the government of Iran, a country that official US policy is to discourage companies from doing business with. Moreover, most of these corporations are doing business in the energy (especially gas and oil) sector, which is not a surprise given that Iran is a big oil producer, and also in supplying the technology for, say, developing nuclear power. Or nuclear weapons. A bunch of politicians are now posturing about this (after all, Iran is a fundamentalist Islamic state that is led by a Holocaust-denier who routinely attacks the US that many think is in the process of developing nuclear weapons), but we will see what, if anything, will happen.
So, maybe it is upsetting, but it is scarcely surprising. The US government supporting the interests of big multi-national corporations even when they are operating against the interests of the American people? If this is a shock to you, where have you been? We (the US, the world) are in the middle of (despite the pronouncements that we are “coming out of”) an enormous financial crisis brought about by the overt support by the US government of policies based upon supporting the unmitigated and unencumbered greed of the financial industry. And those policies, which have included trillions of dollars in bailouts of those companies, continue essentially unimpeded. If anyone is “coming out of” the financial crisis, it is those who brought it on, happily and blithely making their millions and billions again while a huge percent of people even in the US are unemployed, working in poor-paying jobs, and have no reasonable prospect of finding the kind of job that allows the dignity of supporting your family, having good food and a good home, sending your kids to college, and expecting a reasonable retirement. And, oh yes, having health care. The breadth of this crisis is spread wide, but those who were already poor and on the edge, disproportionately although scarcely only racial and ethnic minorities, have of course been the hardest hit. This is no joke and has people angry, angry at the financiers and angry at the government that has talked tough but not “walked the walk”. Democrats have a lot of blame, from the Clinton era policies to those of Obama and his recycled-Clinton financial advisors, but it is absurd for that criticism to be coming from Republicans. Not only was the Bush-era so aggressive in its de-regulation and support of the financial industry (and the energy industry currently involved in Iran) that it makes Clinton and Obama look good by comparison, but even now the Republicans in Congress are pushing policies that would make it even worse than those of the Administration. And that is not easy.
In health care, often the subject of this blog, the insurance industry is getting attacked. The President’s speech indicted them 13 times. But they are still there, they are still making billions in profits, and we still have at least 75 million people who are uninsured or seriously underinsured (and most of the rest of us who will find out when we get sick!). In response to great pressure, Anthem Blue Cross of California* (let’s not forget who the bad guys are!) withdrew, at least temporarily, its planned up-to-39% rate increases, but these guys are not going bankrupt, they are still making a fortune. It would not be too far-fetched to suggest that they proposed this just so they could roll it back, and make it look like they gave something up, in order to prevent people and regulators from demanding that they give up some of what they currently have. It wouldn’t be too far-fetched, but it probably underestimates their greed; I expect to see quieter efforts to increase rates return soon.
We have a conflict here. Politicians, Democratic and Republican, want to condemn the excesses of powerful corporations while continuing to take their money. Regular people, including me and a lot of teabaggers, believe the solution should be that portrayed by Wiley Miller in the March 7, 2010 comic “Non Sequitur”. (Check it out.) Somehow, we are being hosed; by the financiers, by the energy companies, by the insurance companies. (On the latter, and while we’re on comics, see “Shoe”, Thursday, March 11, 2010.)
Why would I be surprised?
*”Anthem” is the name that Wellpoint, the stock exchange-listed holding company, uses for the for-profit BlueCross/Blue Shield plans it owns, such as the one in California. Not all BC/BS are for-profit; many remain not-for-profit (e.g., BC/BS of Kansas, based in Topeka, KS, whose planned sale to Anthem was, I have previously noted, blocked by then-Insurance Commissioner Kathleen Sebelius in 2002, and BC/BS of Kansas City, based in KC, MO.) Unfortunately, market competition often has the not-for-profits behaving almost as badly, in terms of exclusions and rate hikes, as the for-proftis.
.
The New York Times, March 7, 2010, (US enriches companies defying its policy on Iran, by Jo Becker and Ron Nixon) reveals that the US is supporting, primarily through government contracts, many companies that are involved in doing business in and with the government of Iran, a country that official US policy is to discourage companies from doing business with. Moreover, most of these corporations are doing business in the energy (especially gas and oil) sector, which is not a surprise given that Iran is a big oil producer, and also in supplying the technology for, say, developing nuclear power. Or nuclear weapons. A bunch of politicians are now posturing about this (after all, Iran is a fundamentalist Islamic state that is led by a Holocaust-denier who routinely attacks the US that many think is in the process of developing nuclear weapons), but we will see what, if anything, will happen.
So, maybe it is upsetting, but it is scarcely surprising. The US government supporting the interests of big multi-national corporations even when they are operating against the interests of the American people? If this is a shock to you, where have you been? We (the US, the world) are in the middle of (despite the pronouncements that we are “coming out of”) an enormous financial crisis brought about by the overt support by the US government of policies based upon supporting the unmitigated and unencumbered greed of the financial industry. And those policies, which have included trillions of dollars in bailouts of those companies, continue essentially unimpeded. If anyone is “coming out of” the financial crisis, it is those who brought it on, happily and blithely making their millions and billions again while a huge percent of people even in the US are unemployed, working in poor-paying jobs, and have no reasonable prospect of finding the kind of job that allows the dignity of supporting your family, having good food and a good home, sending your kids to college, and expecting a reasonable retirement. And, oh yes, having health care. The breadth of this crisis is spread wide, but those who were already poor and on the edge, disproportionately although scarcely only racial and ethnic minorities, have of course been the hardest hit. This is no joke and has people angry, angry at the financiers and angry at the government that has talked tough but not “walked the walk”. Democrats have a lot of blame, from the Clinton era policies to those of Obama and his recycled-Clinton financial advisors, but it is absurd for that criticism to be coming from Republicans. Not only was the Bush-era so aggressive in its de-regulation and support of the financial industry (and the energy industry currently involved in Iran) that it makes Clinton and Obama look good by comparison, but even now the Republicans in Congress are pushing policies that would make it even worse than those of the Administration. And that is not easy.
In health care, often the subject of this blog, the insurance industry is getting attacked. The President’s speech indicted them 13 times. But they are still there, they are still making billions in profits, and we still have at least 75 million people who are uninsured or seriously underinsured (and most of the rest of us who will find out when we get sick!). In response to great pressure, Anthem Blue Cross of California* (let’s not forget who the bad guys are!) withdrew, at least temporarily, its planned up-to-39% rate increases, but these guys are not going bankrupt, they are still making a fortune. It would not be too far-fetched to suggest that they proposed this just so they could roll it back, and make it look like they gave something up, in order to prevent people and regulators from demanding that they give up some of what they currently have. It wouldn’t be too far-fetched, but it probably underestimates their greed; I expect to see quieter efforts to increase rates return soon.
We have a conflict here. Politicians, Democratic and Republican, want to condemn the excesses of powerful corporations while continuing to take their money. Regular people, including me and a lot of teabaggers, believe the solution should be that portrayed by Wiley Miller in the March 7, 2010 comic “Non Sequitur”. (Check it out.) Somehow, we are being hosed; by the financiers, by the energy companies, by the insurance companies. (On the latter, and while we’re on comics, see “Shoe”, Thursday, March 11, 2010.)
Why would I be surprised?
*”Anthem” is the name that Wellpoint, the stock exchange-listed holding company, uses for the for-profit BlueCross/Blue Shield plans it owns, such as the one in California. Not all BC/BS are for-profit; many remain not-for-profit (e.g., BC/BS of Kansas, based in Topeka, KS, whose planned sale to Anthem was, I have previously noted, blocked by then-Insurance Commissioner Kathleen Sebelius in 2002, and BC/BS of Kansas City, based in KC, MO.) Unfortunately, market competition often has the not-for-profits behaving almost as badly, in terms of exclusions and rate hikes, as the for-proftis.
.
Monday, March 8, 2010
Why we need health reform
Health Strong (healthstrong.org) has posted a guest essay by me titled "Why we need health reform" http://healthstrong.org/2010/03/why-we-need-health-reform/#more-508
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