.
I have written in several previous posts (most recently Universal Coverage and Primary Care: The US needs both, May 27, 2010) about the challenges facing American medicine, particularly regarding specialty choice (=not primary care, not rural, not underserved) of US allopathic graduates, and the problems this has already created in providing health care to the American people, which is only likely to worsen as this trend continues. I have noted that, in the production of physicians as in any other process, the outcome results from variables in inputs (who is admitted in this case), the process itself (in education, the curriculum, both formal and informal), and output variables (in the case of physicians, what the practice environment is: reimbursement, work load, quality of life, respect and regard within the profession and community). I have argued that, while output variables may be the most important in terms of specialty choice and practice location, it is the one over which medical educators have the least control. While the curriculum, the process through which we educate medical students, is critical (see Are we training physicians to be empathic? Apparently not., Sept 12, 2009), it is likely that the characteristics of the students selected is most important in determining practice location, particularly for rural areas, but also for urban underserved settings (Medical Student Selection, Dec 14, 2008). Selecting students who grew up in the suburbs of major cities (what Robert Bowman, MD, who has done much research in this area, calls “major medical centers”) in homes with high socioeconomic status and excellent high school and college educations (which is what is mainly done) will result in students with excellent test performance and is likely to produce skilled physicians, but not ones likely to practice in rural or underserved areas.
Students from rural areas, from underserved communities, from low socioeconomic status backgrounds, and from underrepresented minority groups are much more likely to serve these populations, as are students who are older at the time of matriculation. But their lower grades and MCATs, may make them less likely to be accepted, and to have difficulty with the pre-clinical medical curriculum. Students, even from privileged backgrounds, whose prior life history includes significant service are also more likely to work in urban underserved settings; less so (although more than their colleagues without these characteristics) in rural areas. But what about schools of other types or medical schools not in the US?
In a conversation with US Senator Sam Brownback on a visit to his office last year, members of the Kansas Academy of Family Physicians (KAFP) noted the challenges in getting KUMC graduates to work in rural areas. In an off-the-cuff response (I don’t mean to suggest that this was thought-out or his real position; I use the statement as a basis for comment) he suggested that we then just start a medical school at Kansas State University that would train rural primary care doctors. This type of response to a system that is not having the impact that policy makers wish for is common – create a new school, or focus on another different type of school (e.g., osteopathic), or another profession (nurse practitioners, physician’s assistants). But, of course, if they take the same sorts of students and offer them the same range of career opportunities, why would one expect different outcomes? Osteopathic graduates, while still entering family medicine and primary care at higher rates than allopathic, are increasingly becoming specialists. NPs, and especially PAs, are increasingly joining specialty physician practices and remaining in urban areas with high income potential rather than high need. Why would they not? Would you, or your children?
Because there are far more residency training positions than there are US graduates, many of these positions are filled with international medical graduates. A special group of these are “US IMGs”, Americans who, unable to be admitted to US medical schools, attend those outside the country. In the Caribbean, there are many schools, for-profit, set up for precisely this purpose. I recently had the opportunity to give the “White Coat Ceremony” talk to the class entering the largest of these: Ross University School of Medicine (http://www.rossu.edu) on the island of Dominica. Ross, in existence for over 30 years and now owned by DeVry, the largest for-profit educational company in the US, has a “business model” that enrolls 3 classes per year paying tuition much the same as a private US private school or an out-of-state student at a US public medical school. After the first two years, students do clinical clerkships in 70 hospitals in the US that are affiliated with the school – and paid by them. The student body is ethnically very diverse, with over half the members of the class I spoke to born outside the US (although 95% are US citizens or permanent residents; the rest mostly Canadian), but not including a large percentage of students from traditional underrepresented minority groups, and certainly not many from poor families. Ross graduate disproportionately enter primary care specialties, but this is almost certainly because primary care is less competitive than many subspecialties, and the fact that they didn’t train at US schools puts them at a competitive disadvantage in the selection process. Nonetheless, there are several positive things to be said about the Ross experience. First, Ross has a single mission – medical education. The considerable funds it generates are not required to support a large research or clinical enterprise, but can be directed to that mission. Second, it takes students who, because of their grades, wouldn’t – didn’t – get into US medical schools, and gives them a chance to succeed. If there is a high failure rate as a result, there are also unquestionably outstanding doctors produced who would not have otherwise existed. They are able, because of their business model, to take a “chance” on these students – and if they work hard, they can be successful.
While there a very many Caribbean medical schools, of different ages, quality, and size, operated more-or-less on the Ross model, a quite different model exists on another island – Cuba. Whatever its failures, one of the great successes in Cuba since the revolution of 1959 has been the expansion of medical care to the entire citizenry of the nation, and exportation of trained physicians, both Cuban nationals (they are even on Ross’ home island of Dominica) and those from other countries educated in Cuba. The Latin American Medical School (Escuela Latino-Americana de Medicina – ELAM), which educates students from other Latin American countries, began to take students from the US a number of years ago. Unlike those attending Ross and other costly schools, US students at ELAM are virtually all from low socioeconomic backgrounds and mainly from underrepresented minority groups. Tuition is free and living expenses are paid, but there are prices for the students to pay. Admission requires a bachelor’s degree, but students are still required to spend the entire 6 years of medical school that is the usual for countries outside the US and Canada, or 7 if they need to learn Spanish first. They live in minimal dormitories, have very limited access to the internet (1-2 hours per week), and work very hard. They receive a medical education that particularly emphasizes public health, community medicine, and prevention. They promise to complete their training and enter practice in service to the communities from which they come, but it is a promise – obviously the Cubans have no way to enforce this. They receive no training in the US prior to graduation unless they are able to arrange summer observerships on their own, and are not particularly prepared for the “National Board” exams, the USMLE, that are required for US licensure and admission to US residencies. MEDICC (Medical Education in Cooperation with Cuba) , a US group that exists to support US students at ELAM and its graduates, tries to find them mentors who will help orient them to the health system in their own country, the US, teach them about applying to US residencies, and offer guidance in the study for USMLE. The first US graduates of ELAM have entered a few US residencies this year; I have met one, who is phenomenal. Other US medical educators are working with ELAM graduates and offering both advice and opportunities for volunteer training.
The US students at ELAM are the “right students”. They come from underserved backgrounds, are committed to their communities, and are willing to work very hard (perhaps ten years between bachelor’s degree and entering a residency). The question, of course, is not “how can they go to that Communist country?” but rather why are we allowing Cuba to pick up the role that our own medical education system fails to fulfill. Indeed, it would be particularly for those who oppose Cuba and socialism to develop such programs in our own country.
Senator Brownback, if we are going to start a new school in Kansas, let’s model much of it on ELAM. Let’s make it free, and recruit students from underserved communities and underrepresented minority groups, and low socioeconomic backgrounds, and teach them public health and prevention and primary care, and send them out to serve their communities of origin. In the meantime, let us at least have a “sliding scale” loan repayment program where the percent of your loan your repay is tied to your post-residency income, as well as your practice location and specialty choice.
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Wednesday, June 2, 2010
Thursday, May 27, 2010
Universal Coverage and Primary Care: The US needs both
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In “Reinventing Primary Care: Lessons from Canada for the United States” (Health Affairs, May2010;29(5):1030-5), the eminent scholar Barbara Starfield provides just that – lessons from Canada for the United States. For decades, advocates of comprehensive health reform have pointed to our northern neighbor and suggested that a “single payer” system such as that in Canada would be a more-than-reasonable solution. In Canada, provincial governments provide the funding for health care services, under the guidance of the five principles set out in the Canada Health Act of 1972: public administration, comprehensiveness, universality, portability, and accessibility. The principle of universality means that every Canadian is covered, with the same health insurance benefit package, as every other Canadian. (In fact, because the various programs that are together called “Medicare” in Canada are provincial, it would be more accurate to say that every resident of a province has the same benefit package as every other; however, all provinces provide coverage for all essential services; more can be found on the website http://www.canadianhealthcare.org/.)
Dr. Starfield’s article goes systematically through a variety of indicators of health status and costs, comparing the two countries, citing both similarities and differences between them. Overall, the US looks much worse in health status and much greater in cost. While not the best performer among the Organization for Economic Cooperation and Development (OECD) countries (representing the most developed, “first world”, countries) in almost any area, Canada is ahead of the US in most, often significantly. A few examples from her “Exhibit 1” include Life Expectancy at birth (Canada ranks 9, the US 25), Potential Years of Life Lost at age 70 (Canada is 13, the US is 21), and Infant Mortality (Canada is 24, the US 26). Canadians have a lower death rate for conditions “amenable to medical care”, meaning that if you got care you’d be less likely to die, and the differences are not (as is sometimes asserted) due to racial differences between the two countries:
“Studies of deaths from treatable conditions also show better performance of the Canadian health system compared with that of the United States, and the differences are not a result of existing racial disparities. That is, the worse health of the U.S. population compared with that of Canadians is found even when comparisons are restricted to the white population. Longterm comparisons show that the life expectancy of Americans has been worse than that of Canadians since the beginning of the twentieth century, but that most of this difference was a result of lower life expectancy among African Americans. However, this situation changed in the 1970s, when Canadian life expectancy rose even above that of white Americans.
“Differences in death rates have increased over time, with Canada improving in rank and the United States declining in rank. Differences by cause of death for conditions amenable to medical care are on the order of 25–60 percent lower in Canada than among U.S. whites and have increased over time since the 1980s.”
Starfield attributes the difference primarily to two features of the Canadian health system, a “universal, publicly accountable health insurance system”, and the presence of a strong primary care base. The first should be a “gimme”; of course such a system would make a difference, of course it is likely to improve the health of the population and reduce the burden of disease, physical, psychosocial, and financial, on both the individual and their family and the society. It is absolutely obvious that a rational, mature, and responsible society would provide financial access to health care for its people.
Unfortunately, that is not the case for the US, the only OECD country which does not have such a system, relies on “employer-based health insurance for the nonelderly population”, and it is not going to change under the new health reform law, the Patient Protection and Affordable Care Act (PPACA). PPACA, even when fully implemented, will not cover everyone, will not control costs, will allow insurance companies to charge up to 3 times the premium for older (and note that this would be pre-Medicare; “older” could be over 40!), and will not have either the universality or public accountability to ensure quality care. We will continue to hear the pain of patients such as the woman featured in the “2009 Road Trip Video” by Mad As Hell Doctors (http://www.madashelldoctors.com/) who pulls off her turban to review her hair lost to chemotherapy, and tells us that “when I found out I had breast cancer I was worried that I might die, but I was terrified about how I would pay for it.”[1] Come on. This is simply not acceptable in a wealthy developed country. Those who do not support such a system are either incredibly greedy, selfish, and corrupt, as are the insurance companies and their minions in Congress, or incomprehensible.
The other difference between the US and Canada that Dr. Starfield emphasizes is the presence of a strong primary care base. She notes that “Several international studies have confirmed the importance of three health-system characteristics of countries that achieve better health at lower cost: government attempts to distribute resources, such as personnel and facilities, equitably; universal financial coverage either through a single payer or regulated by the government; and low or no cost sharing for primary care services…U.S. policy achieves none of the three structural characteristics of good health systems. Canada achieves all three. “
I have repeatedly written about the lack of sufficient primary care capacity, and primary care production, in the US, and clearly I am not alone. It has become almost a deafening chorus, with report after report identifying the deficiency in primary care, and the need to increase the number and percent of medical students entering primary care; much of this is presented in “Who will provide primary care and how will they be trained?”, the proceedings of a conference in April 2010 sponsored by the Josiah Macy, Jr. Foundation. PPACA does commit significant resources to supporting primary care, but we are far from having a sufficient number of primary care providers or a reasonable geographic distribution of those we have. Canada and the other OECD countries have at least 50% of their physician workforce in primary care. When Canada saw that percent decreasing, they took strong action to reverse it, and now have a majority of their medical students entering primary care.[2] The US, on the other hand, has only about 16% of its physician workforce entering primary care. [3],[4]
So how we will change this? Not by anything we are doing now. We have less than 30% primary care doctors, and we need to get to at least 50%, but are producing 16%. This is, obviously, going in the wrong direction. Doubling the production of medical students entering primary care will still have us going in the wrong direction, and we are nowhere near getting to double. Even if we produce 50% a year, on average, from all medical schools, it will take 30 years, a generation, to get to that goal. And we are very, very far from that goal. The BEST medical schools in terms of placing students in family medicine and other primary care specialties, such as the one I work at, the University of Kansas, are not close. Most other medical schools are much worse. Many, particularly the private, Eastern, “elite” medical schools highly ranked by US News do not even accept any responsibility for producing physicians who are in the specialties that are needed to meet the health care needs of the American people.
The University of Kansas School of Medicine will be establishing a rural track in Salina, KS, where 8 students per year, committed to rural health, will spend their entire 4 years. The goal is that 75% will enter rural practice and 50% primary care, and preferably both. Great idea. Except this is 8 students in one medical school! The entire KU medical school, and those of all states – “from Colorado, Kansas, and the Carolinas too, from Virginia to Alaska, from the old to the new, from Texas and Ohio and the California shore”[5], as well as those “elite” schools who feel no responsibility, all need to produce as high a percent of their graduates entering primary care as possible, to average over 50% nationally.
This will not be easy. It will probably mean taking different people into medical school, not those with the most elite educations and well-to-do backgrounds, not the children of the faculty, but those who are from rural areas and minority communities and want to go back to them; not those who want to become tertiary and quarternary care super-specialists but those who want to work in the community; not those likely to enter laboratory research (a noble career, but why take up seats in medical school?), but those who want to care for people. It will require rethinking and reprioritizing. But it must happen.
Dr. Starfield notes that “Universal health insurance alone is not sufficient to raise a country’s health levels to match those of countries with the best levels. Within the United States, there is a greater relationship between the presence of a good supply of primary care physicians and life expectancy than there is between either broad insurance coverage or affordability of voverage and life expectancy. Universal coverage alone, particularly if not organized through a single payer with uniformity of benefits, could expand access to inappropriate services.”
Well, we need both, the single payer system and the commitment to primary care. And we need action, not more words. And we need it now.
[1] Note that this comment may not appear on the abridged version of the wonderful video that appears on this website.
[2] McKee ND, McKague MA, Ramsden VR, Poole RE. Cultivating interest in family medicine: family medicine interest group reaches undergraduate medical students. Can Fam Physician. 2007;53(4):661–5.
[3] Roehrig C. Presentation to the Council on Graduate Medical Education, 2009 Nov 18. Data from the American Association of Medical Colleges Graduation Questionnaire.
[4] Sandy LG, Bodenheimer T, PawlsonLG, Starfield B. The political economy of U.S. primary care. Health Aff Millwood). 2009;28 (4):1136–45.
[5] From the late great Phil Ochs, “Power and Glory”, copyright Phil Ochs.
.
In “Reinventing Primary Care: Lessons from Canada for the United States” (Health Affairs, May2010;29(5):1030-5), the eminent scholar Barbara Starfield provides just that – lessons from Canada for the United States. For decades, advocates of comprehensive health reform have pointed to our northern neighbor and suggested that a “single payer” system such as that in Canada would be a more-than-reasonable solution. In Canada, provincial governments provide the funding for health care services, under the guidance of the five principles set out in the Canada Health Act of 1972: public administration, comprehensiveness, universality, portability, and accessibility. The principle of universality means that every Canadian is covered, with the same health insurance benefit package, as every other Canadian. (In fact, because the various programs that are together called “Medicare” in Canada are provincial, it would be more accurate to say that every resident of a province has the same benefit package as every other; however, all provinces provide coverage for all essential services; more can be found on the website http://www.canadianhealthcare.org/.)
Dr. Starfield’s article goes systematically through a variety of indicators of health status and costs, comparing the two countries, citing both similarities and differences between them. Overall, the US looks much worse in health status and much greater in cost. While not the best performer among the Organization for Economic Cooperation and Development (OECD) countries (representing the most developed, “first world”, countries) in almost any area, Canada is ahead of the US in most, often significantly. A few examples from her “Exhibit 1” include Life Expectancy at birth (Canada ranks 9, the US 25), Potential Years of Life Lost at age 70 (Canada is 13, the US is 21), and Infant Mortality (Canada is 24, the US 26). Canadians have a lower death rate for conditions “amenable to medical care”, meaning that if you got care you’d be less likely to die, and the differences are not (as is sometimes asserted) due to racial differences between the two countries:
“Studies of deaths from treatable conditions also show better performance of the Canadian health system compared with that of the United States, and the differences are not a result of existing racial disparities. That is, the worse health of the U.S. population compared with that of Canadians is found even when comparisons are restricted to the white population. Longterm comparisons show that the life expectancy of Americans has been worse than that of Canadians since the beginning of the twentieth century, but that most of this difference was a result of lower life expectancy among African Americans. However, this situation changed in the 1970s, when Canadian life expectancy rose even above that of white Americans.
“Differences in death rates have increased over time, with Canada improving in rank and the United States declining in rank. Differences by cause of death for conditions amenable to medical care are on the order of 25–60 percent lower in Canada than among U.S. whites and have increased over time since the 1980s.”
Starfield attributes the difference primarily to two features of the Canadian health system, a “universal, publicly accountable health insurance system”, and the presence of a strong primary care base. The first should be a “gimme”; of course such a system would make a difference, of course it is likely to improve the health of the population and reduce the burden of disease, physical, psychosocial, and financial, on both the individual and their family and the society. It is absolutely obvious that a rational, mature, and responsible society would provide financial access to health care for its people.
Unfortunately, that is not the case for the US, the only OECD country which does not have such a system, relies on “employer-based health insurance for the nonelderly population”, and it is not going to change under the new health reform law, the Patient Protection and Affordable Care Act (PPACA). PPACA, even when fully implemented, will not cover everyone, will not control costs, will allow insurance companies to charge up to 3 times the premium for older (and note that this would be pre-Medicare; “older” could be over 40!), and will not have either the universality or public accountability to ensure quality care. We will continue to hear the pain of patients such as the woman featured in the “2009 Road Trip Video” by Mad As Hell Doctors (http://www.madashelldoctors.com/) who pulls off her turban to review her hair lost to chemotherapy, and tells us that “when I found out I had breast cancer I was worried that I might die, but I was terrified about how I would pay for it.”[1] Come on. This is simply not acceptable in a wealthy developed country. Those who do not support such a system are either incredibly greedy, selfish, and corrupt, as are the insurance companies and their minions in Congress, or incomprehensible.
The other difference between the US and Canada that Dr. Starfield emphasizes is the presence of a strong primary care base. She notes that “Several international studies have confirmed the importance of three health-system characteristics of countries that achieve better health at lower cost: government attempts to distribute resources, such as personnel and facilities, equitably; universal financial coverage either through a single payer or regulated by the government; and low or no cost sharing for primary care services…U.S. policy achieves none of the three structural characteristics of good health systems. Canada achieves all three. “
I have repeatedly written about the lack of sufficient primary care capacity, and primary care production, in the US, and clearly I am not alone. It has become almost a deafening chorus, with report after report identifying the deficiency in primary care, and the need to increase the number and percent of medical students entering primary care; much of this is presented in “Who will provide primary care and how will they be trained?”, the proceedings of a conference in April 2010 sponsored by the Josiah Macy, Jr. Foundation. PPACA does commit significant resources to supporting primary care, but we are far from having a sufficient number of primary care providers or a reasonable geographic distribution of those we have. Canada and the other OECD countries have at least 50% of their physician workforce in primary care. When Canada saw that percent decreasing, they took strong action to reverse it, and now have a majority of their medical students entering primary care.[2] The US, on the other hand, has only about 16% of its physician workforce entering primary care. [3],[4]
So how we will change this? Not by anything we are doing now. We have less than 30% primary care doctors, and we need to get to at least 50%, but are producing 16%. This is, obviously, going in the wrong direction. Doubling the production of medical students entering primary care will still have us going in the wrong direction, and we are nowhere near getting to double. Even if we produce 50% a year, on average, from all medical schools, it will take 30 years, a generation, to get to that goal. And we are very, very far from that goal. The BEST medical schools in terms of placing students in family medicine and other primary care specialties, such as the one I work at, the University of Kansas, are not close. Most other medical schools are much worse. Many, particularly the private, Eastern, “elite” medical schools highly ranked by US News do not even accept any responsibility for producing physicians who are in the specialties that are needed to meet the health care needs of the American people.
The University of Kansas School of Medicine will be establishing a rural track in Salina, KS, where 8 students per year, committed to rural health, will spend their entire 4 years. The goal is that 75% will enter rural practice and 50% primary care, and preferably both. Great idea. Except this is 8 students in one medical school! The entire KU medical school, and those of all states – “from Colorado, Kansas, and the Carolinas too, from Virginia to Alaska, from the old to the new, from Texas and Ohio and the California shore”[5], as well as those “elite” schools who feel no responsibility, all need to produce as high a percent of their graduates entering primary care as possible, to average over 50% nationally.
This will not be easy. It will probably mean taking different people into medical school, not those with the most elite educations and well-to-do backgrounds, not the children of the faculty, but those who are from rural areas and minority communities and want to go back to them; not those who want to become tertiary and quarternary care super-specialists but those who want to work in the community; not those likely to enter laboratory research (a noble career, but why take up seats in medical school?), but those who want to care for people. It will require rethinking and reprioritizing. But it must happen.
Dr. Starfield notes that “Universal health insurance alone is not sufficient to raise a country’s health levels to match those of countries with the best levels. Within the United States, there is a greater relationship between the presence of a good supply of primary care physicians and life expectancy than there is between either broad insurance coverage or affordability of voverage and life expectancy. Universal coverage alone, particularly if not organized through a single payer with uniformity of benefits, could expand access to inappropriate services.”
Well, we need both, the single payer system and the commitment to primary care. And we need action, not more words. And we need it now.
[1] Note that this comment may not appear on the abridged version of the wonderful video that appears on this website.
[2] McKee ND, McKague MA, Ramsden VR, Poole RE. Cultivating interest in family medicine: family medicine interest group reaches undergraduate medical students. Can Fam Physician. 2007;53(4):661–5.
[3] Roehrig C. Presentation to the Council on Graduate Medical Education, 2009 Nov 18. Data from the American Association of Medical Colleges Graduation Questionnaire.
[4] Sandy LG, Bodenheimer T, PawlsonLG, Starfield B. The political economy of U.S. primary care. Health Aff Millwood). 2009;28 (4):1136–45.
[5] From the late great Phil Ochs, “Power and Glory”, copyright Phil Ochs.
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Friday, May 21, 2010
Primary Care: What takes so much time? And how are we paying for it?
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In a piece that has gotten a lot of attention, “What’s Keeping Us So Busy in Primary Care? A Snapshot from One Practice”(New England Journal of Medicine, Apr29,2010;362(17):1632-6), Philadelphia general internist Richard J. Baron writes about the many tasks – many of them unreimbursed – that occupy the time of the physicians in his practice. While the physicians in the practice saw an average of 18.1 patient visits per day (the one activity they were paid for), they also returned an average of 23.7 telephone calls, and 16.8 email messages. They refilled 12.1 prescriptions, reviewed 19.5 laboratory reports, 11.1 imaging reports and 13.9 consultation reports per day. They also filled out large amounts of paperwork that they do not report on because they are not captured by their electronic medical record, such as “…administrative forms (e.g., for physical examinations for work, camp, and school and Family Medical Leave Act forms), correspondence received from health plan (e.g., disease-management letters), and reports on home care and physical therapy.” That’s a lot of work that is not being paid for. This is a huge issue in providing primary care, and one that is not often appreciated by the subspecialists, medical and surgical, who are very highly reimbursed for the procedures that they do, so that the paperwork, phone calls, etc., such as they are, are well subsidized.
Dr. Baron’s report reinforces both frequent observations and studies that have been done earlier. In 2003, Yarnall, et. al., published an article that looked at the amount of time it would take a primary care physician with a typical practice of 2,500 patient to provide all of the preventive care recommended by the US Preventive Services Task Force (USPSTF) at the “A” or “B” level. In “Primary Care: Is There Enough Time for Prevention?” (Am J Public Health. 2003;93:635–641), they found that:
“In all, an annual total of 1773 hours, or 7.4 hours of every working day, is required for the provision of all recommended preventive services to a practice of 2500 patients with age and sex distributions based on the US population.”
That is a staggering statistic; in itself this is a full-time occupation, and yet it does not include any time for managing the chronic diseases that people have, or the acute conditions that are bothering them! In a later piece in 2009, “Family Physicians as Team Leaders: ‘Time’ to Share the Care” (Prev Chronic Disease Apr2009;6(2):A59), Yarnall and colleagues further assess all three types of care (preventive, chronic, and acute) and determine that together they would take 21.7 hours a day! This is reassuringly less than 24, as even doctors need to sleep and eat!
The recommendations from Yarnall, et. al., and from other recent pieces assessing the changes that will need to take place in the structure of primary care, coincide with the decisions made by Dr. Baron’s group to increase the size of their team. While the internists in Philadelphia mainly added a triage nurse, a true team requires a more comprehensive approach. Proposals planning for the Patient-Centered Medical Home (PCMH) understand that “it takes a team,” not just a physician. Among the best recent review and analyses is “Transforming Primary Care: From Past Practice To The Practice Of The Future” by David Margolius and Thomas Bodenheimer (Health Affairs May 2010, 29(5): 779–784 ). Virtually all these proposals advocate developing a team of providers, including doctors, nurses, medical assistants, pharmacists, secretaries/clerks, social workers, mental health specialists, even public health professionals, to collaboratively provide the appropriate and necessary care.
This is a great idea, but hard to implement in the current fee-for-service system, a system unlikely to change given the degree to which the new health reform law is built around insurance companies. Dr. Baron’s practice was participating in a demonstration project to provide coordination in the interest of the PCMH that was funded by the state of Pennsylvania; most practices are not. As I have said before, if proceduralist could do the procedures and subspecialists manage their particular rare or advanced disease, and allow primary care doctors to manage complexity and counsel and do prevention (and mental health professionals, and social workers, and pharmacists, and therapists to all do the things they were best able to do) rather than trying to do more procedures because they would make more money, this would make – sense.
Comprehensive care for people is a big undertaking. It is much more than consulting on one problem, or doing a single procedure and follow up. It is caring for many problems, and providing the preventive care that people need, and addressing their acute complaints, and doing counseling for both psychosocial issues and decision-making issues (e.g., “should I have this surgery?” “what is the risk of this diagnostic procedure recommended by the consultant?”) It is being available to refill lost or expired prescriptions, reviewing lab and imaging results and consultant reports, and answer questions by phone or email, and review and coordinate the care being provided by consultants. It is doing all those things that people expect that their “family doctors” (in whatever specialty they are actually certified) will do. It is a very different practice than that of a subspecialist; while for the latter “the buck stops here” for treatment decisions for a particular condition, for the former “the buck stops here”, period. There is nothing in the medical realm with which they cannot, reasonably, be expected to be involved.
Consider a patient who tells a subspecialist, say their cardiologist, about their knee pain. The cardiologist says “I don’t do knees,” and sends them back to their primary care doctor, or refers them to an orthopedist. On their next visit the patient says “I saw the orthopedist you sent me to,” and the cardiologist, reasonably, says “I don’t do knees. Do whatever s/he told you.”
Now consider the patient presenting with the same knee pain to their primary care doctor. Maybe that doctor has a good idea of what the problem is and how to treat it, but to be sure refers the patient to the orthopedist. On the return visit, the patient now wants to talk with “their” doctor about what the orthopedist said, what s/he recommended, what the primary care doctor thinks about that, and needs help making a decision. So, while for the subspecialist (cardiologist, in this example) a referral disposes of potential work, for the primary care physician, it will usually, while reassuring the doctor that the right care is being done, actually increase the amount of work.
Most primary care practices discover, as did Dr. Baron’s, that it is inefficient to have physicians doing virtually any of the work that could be done by a lower-paid staff member; this could be a nurse (which his practice did not employ initially) or a medical assistant. Subspecialists have always known this, employing nurses, physician’s assistants, and others (including medical “fellows”) to augment their productivity; for example, a surgeon can be in the operating room while a physician’s assistant sees patients in the office. But it takes money to pay such staff.
As long as the only reimbursement is for actual patient visits, and that reimbursement is spectacularly lower for primary care doctors than for subspecialists, and particularly proceduralists, the financial viability of such practices will be low, and the attractiveness to highly indebted medical students comparably low. This calls for a restructuring of the entire payment system, into one that encourages collaboration and the most appropriate management. A capitated payment system is very desirable because then patients can be “seen” in the most appropriate way based on the perception of patient and physician – phone, email, office, hospital, home – but only if that reimbursement is high enough to make the development and implementation of patient centered systems worthwhile.
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In a piece that has gotten a lot of attention, “What’s Keeping Us So Busy in Primary Care? A Snapshot from One Practice”(New England Journal of Medicine, Apr29,2010;362(17):1632-6), Philadelphia general internist Richard J. Baron writes about the many tasks – many of them unreimbursed – that occupy the time of the physicians in his practice. While the physicians in the practice saw an average of 18.1 patient visits per day (the one activity they were paid for), they also returned an average of 23.7 telephone calls, and 16.8 email messages. They refilled 12.1 prescriptions, reviewed 19.5 laboratory reports, 11.1 imaging reports and 13.9 consultation reports per day. They also filled out large amounts of paperwork that they do not report on because they are not captured by their electronic medical record, such as “…administrative forms (e.g., for physical examinations for work, camp, and school and Family Medical Leave Act forms), correspondence received from health plan (e.g., disease-management letters), and reports on home care and physical therapy.” That’s a lot of work that is not being paid for. This is a huge issue in providing primary care, and one that is not often appreciated by the subspecialists, medical and surgical, who are very highly reimbursed for the procedures that they do, so that the paperwork, phone calls, etc., such as they are, are well subsidized.
Dr. Baron’s report reinforces both frequent observations and studies that have been done earlier. In 2003, Yarnall, et. al., published an article that looked at the amount of time it would take a primary care physician with a typical practice of 2,500 patient to provide all of the preventive care recommended by the US Preventive Services Task Force (USPSTF) at the “A” or “B” level. In “Primary Care: Is There Enough Time for Prevention?” (Am J Public Health. 2003;93:635–641), they found that:
“In all, an annual total of 1773 hours, or 7.4 hours of every working day, is required for the provision of all recommended preventive services to a practice of 2500 patients with age and sex distributions based on the US population.”
That is a staggering statistic; in itself this is a full-time occupation, and yet it does not include any time for managing the chronic diseases that people have, or the acute conditions that are bothering them! In a later piece in 2009, “Family Physicians as Team Leaders: ‘Time’ to Share the Care” (Prev Chronic Disease Apr2009;6(2):A59), Yarnall and colleagues further assess all three types of care (preventive, chronic, and acute) and determine that together they would take 21.7 hours a day! This is reassuringly less than 24, as even doctors need to sleep and eat!
The recommendations from Yarnall, et. al., and from other recent pieces assessing the changes that will need to take place in the structure of primary care, coincide with the decisions made by Dr. Baron’s group to increase the size of their team. While the internists in Philadelphia mainly added a triage nurse, a true team requires a more comprehensive approach. Proposals planning for the Patient-Centered Medical Home (PCMH) understand that “it takes a team,” not just a physician. Among the best recent review and analyses is “Transforming Primary Care: From Past Practice To The Practice Of The Future” by David Margolius and Thomas Bodenheimer (Health Affairs May 2010, 29(5): 779–784 ). Virtually all these proposals advocate developing a team of providers, including doctors, nurses, medical assistants, pharmacists, secretaries/clerks, social workers, mental health specialists, even public health professionals, to collaboratively provide the appropriate and necessary care.
This is a great idea, but hard to implement in the current fee-for-service system, a system unlikely to change given the degree to which the new health reform law is built around insurance companies. Dr. Baron’s practice was participating in a demonstration project to provide coordination in the interest of the PCMH that was funded by the state of Pennsylvania; most practices are not. As I have said before, if proceduralist could do the procedures and subspecialists manage their particular rare or advanced disease, and allow primary care doctors to manage complexity and counsel and do prevention (and mental health professionals, and social workers, and pharmacists, and therapists to all do the things they were best able to do) rather than trying to do more procedures because they would make more money, this would make – sense.
Comprehensive care for people is a big undertaking. It is much more than consulting on one problem, or doing a single procedure and follow up. It is caring for many problems, and providing the preventive care that people need, and addressing their acute complaints, and doing counseling for both psychosocial issues and decision-making issues (e.g., “should I have this surgery?” “what is the risk of this diagnostic procedure recommended by the consultant?”) It is being available to refill lost or expired prescriptions, reviewing lab and imaging results and consultant reports, and answer questions by phone or email, and review and coordinate the care being provided by consultants. It is doing all those things that people expect that their “family doctors” (in whatever specialty they are actually certified) will do. It is a very different practice than that of a subspecialist; while for the latter “the buck stops here” for treatment decisions for a particular condition, for the former “the buck stops here”, period. There is nothing in the medical realm with which they cannot, reasonably, be expected to be involved.
Consider a patient who tells a subspecialist, say their cardiologist, about their knee pain. The cardiologist says “I don’t do knees,” and sends them back to their primary care doctor, or refers them to an orthopedist. On their next visit the patient says “I saw the orthopedist you sent me to,” and the cardiologist, reasonably, says “I don’t do knees. Do whatever s/he told you.”
Now consider the patient presenting with the same knee pain to their primary care doctor. Maybe that doctor has a good idea of what the problem is and how to treat it, but to be sure refers the patient to the orthopedist. On the return visit, the patient now wants to talk with “their” doctor about what the orthopedist said, what s/he recommended, what the primary care doctor thinks about that, and needs help making a decision. So, while for the subspecialist (cardiologist, in this example) a referral disposes of potential work, for the primary care physician, it will usually, while reassuring the doctor that the right care is being done, actually increase the amount of work.
Most primary care practices discover, as did Dr. Baron’s, that it is inefficient to have physicians doing virtually any of the work that could be done by a lower-paid staff member; this could be a nurse (which his practice did not employ initially) or a medical assistant. Subspecialists have always known this, employing nurses, physician’s assistants, and others (including medical “fellows”) to augment their productivity; for example, a surgeon can be in the operating room while a physician’s assistant sees patients in the office. But it takes money to pay such staff.
As long as the only reimbursement is for actual patient visits, and that reimbursement is spectacularly lower for primary care doctors than for subspecialists, and particularly proceduralists, the financial viability of such practices will be low, and the attractiveness to highly indebted medical students comparably low. This calls for a restructuring of the entire payment system, into one that encourages collaboration and the most appropriate management. A capitated payment system is very desirable because then patients can be “seen” in the most appropriate way based on the perception of patient and physician – phone, email, office, hospital, home – but only if that reimbursement is high enough to make the development and implementation of patient centered systems worthwhile.
.
Saturday, May 15, 2010
Public Health and Changing People's Minds
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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?
.
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?
.
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.
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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.
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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
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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
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Thursday, April 22, 2010
PPACA, The New Health Reform Law: How will it affect the public's health and primary care?
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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!
.
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.
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Sunday, April 11, 2010
Doctors and Health Reform: How should a physician's politics affect their patient care?
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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
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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.
.
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