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This is a guest blog post by Seiji Yamada, MD, University of Hawaii.
The Commission on the Education of Health Professionals for the 21st Century, chaired by Julio Frenk (Dean of the Harvard School of Public Health) and Lincoln Chen (President of the China Medical Board), published its report in the December 4, 2010 issue of the Lancet. Titled “Health professionals for a new century: transforming education to strengthen health systems in an interdependent world,” the report was released in the centennial year of the Flexner Report of 1910. In contrast to the Flexner Report, however, the current report broadens its focus from medicine alone to include nursing and public health education. In addition, instead of focusing on the U.S., the report takes global health to be within its purview.
As noted by Richard Horton, the editor of the Lancet, "A strong case is made that the present content, organisation, and delivery of health professionals' education have failed to serve the needs and interests of patients and populations."
The commission reviews a century of reforms in health professional education, identifying the Flexner Report as a key document of the first generation. The Flexner report is widely credited with placing American medical education on a scientific basis and leading to the closure of institutions that did not meet its standards. (A critical view of the Flexner Report, that it was a means for allopathic medicine to enhance its dominance over competing philosophies of health and healing might be gleaned from Paul Starr’s The Social Transformation of American Medicine.)
The Commission associates the second generation of reforms with the “instructional breakthroughs” of problem-based learning (PBL) and disciplinarily integrated curricula. Identifying McMaster University as its pioneer, the key aspects of PBL are identified as its learner-centered philosophy and small groups. Newcastle and Case Western are identified as the pioneers of disciplinarily integrated curricula. Other second generation instructional innovations include the use of standardized patients, a focus on the patient-doctor relationship, earlier introduction to patients, and expanding clinical sites to include community settings. (p. 1932)
My own medical school experience (University of Illinois at Chicago, 1983-1987) was singularly uninspired and had none of these elements. I’m assuming (hoping) that UIC is doing better now. It was not until residency (family practice at Cook County Hospital, where Josh Freeman was one of my teachers) that I was introduced to training in the community setting (the South Lawndale Health Center). But it does make me wonder to what extent these “second generation” reforms have been instituted in U.S. medical schools.
I was introduced to PBL (as well as disciplinary integration, discussions about the patient-doctor relationship in the family medicine clerkship, clinical experiences for MS1s, and student rotations in community health centers) when I joined the faculty of the University of Hawaii John A. Burns School of Medicine (UH JABSOM). Initially skeptical, I have become a proselytizer for PBL in a way that only a former unbeliever can be. (My friend Mark Durand prefers to say that he once was a sinner, now he’s a preacher.)
I do know that PBL has become the organizing principle of medical education in only ten or so U.S. medical schools. The institutional barriers to changing over an entire curriculum to PBL are significant. Basic science departments generally have to give up ownership of courses, as disciplinary integration is inherent to PBL. In addition, the faculty resources for conducting small group tutorials are significant. PBL fails without faculty enthusiastic about serving as tutors.
The Commission calls for a third generation of educational reforms. They call for health professional education that is patient-centered and population-centered. By “population” is meant the global population. The goal is that all people around the world have access to health care. “The ultimate purpose is to assure universal coverage of the high-quality comprehensive services that are essential to advance opportunity for health equity within and between countries.” (p. 1924)
This point is what makes this report of interest for the readers of Medicine and Social Justice. Our educational system is charged with creating the next generation of workers who will transform the health care system into one that will serve all of humanity. This cannot be achieved without inculcating an ethic of social justice.
The Commission calls for two educational outcomes in this third generation of reforms: transformative learning and interdependence in education. “Transformative learning is the proposed outcome of instructional reforms; interdependence in education should result from institutional reforms.” (p. 1924) Generally, we tend to view our role as educators as informative and formative: we transmit knowledge to our learners (inform) and place them in settings to develop professional attitudes (form), so that they become competent and eligible for licensure. However, if we expect the next generation to lead the reform of the health system so that it delivers health for all, then we must train them to become agents of change, that is, we must inculcate transformative learning.
The second outcome called for by the Commission, interdependence in education, reflects the need for teamwork in the delivery of all health services. Disciplinary boundaries among the health professions can be overcome by interprofessional and transprofessional educational models. [The Commission defines interprofessional as teamwork with other health professional students and transprofessional as teamwork with "basic and ancillary health workers, administrators and managers, policy makers, and leaders of the local community" (pp. 1943-1944).] This will require integration of institutions as well as disciplines. Curricula will need to take more advantage of global flows of information and educational resources.
The University of Hawaii made a foray into community-based interprofessional education in the early 1990s, when the schools of social work, nursing, public health, and medicine collaborated education at community health centers. Initially funded by the Kellogg Foundation, then by the Area Health Education Center (AHEC), this effort petered out after about ten years. With external funding running dry, the various schools involved failed to commit resources to the effort.
With regards to the transprofessional educational model - in a separate piece, Marshall MacLachlan of Trinity College, calls for integrative expertise in research and research training for global health. Noting that global health is a composite field, MacLachlan proposes “integrating research about ‘what’ (content), with research about ‘where’ (context) and ‘how’ (process).” (p.2) As an example, he offers “Paul Farmer’s work on HIV/AIDS (Content), his socio-political analysis of power relations (Context), and his service delivery role in Partners in Health (Process).” (p.3) Of course, Farmer is a neo-polymath (to use MacLachlan’s term), but MacLachlan’s point is that “these people tend to emerge individually, we don’t have an explicit way of producing or encouraging such skills, or encouraging a more integrative orientation in general; and we don’t have a structure for teaching it.” (p.3)
But the fact of the matter is that our learners are demanding such teaching. As Skip Burkle points out (personal communication), young people and second career adults are demanding educational programs in humanitarian assistance. He notes that the majority of people responding to the Haiti earthquake were under thirty years old, and for many, it was their first experience in disaster assistance. Young people recognize that their working years will be spent in a globalized world, and that much of the world is characterized by poor governance and poor social and physical protections. Burkle, Clarke, and VanRooyen point out that humanitarian community inadequately translates humanitarian action into public policy. Young people recognize that they will also need to lead at the policy level.
At UH JABSOM, students formed their own organizations, the Global Health Interest Group (GHIG) and the Partnership for Social Justice (PSJ). Students in the PSJ are organizing their own leadership workshop to learn about how to improve the health system. They are motivated by a moral belief in health as a human right and the need for more social justice in health and medicine. The tasks in store for us as teachers are self-evident. Our students are demonstrating their commitment to globalism, to social justice, and to a conception of health that transcends narrow disciplines. We need to make sure that we can help prepare them to achieve these goals.
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Wednesday, March 9, 2011
Thursday, March 3, 2011
Fighting for freedom abroad -- and at home
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In two side-by-side Op-Ed pieces in the NY Times on Sunday, February 27, 2011, Nicholas Kristof and Frank Rich discuss apparently very different topics. Rich’s piece, “Why wouldn’t the Tea Party shut it down?”, can be described as “depressing-with-a-glimmer-of-hope.” It compares the current situation in Congress, with a new, empowered, Republican majority with 83 freshman and firm ideology, to that of 1995, when a similar class of mid-term-elected Republicans took control under Newt Gingrich with their “Contract for America”. The similarities are obvious, but he points to the differences as well. Structurally, these include the advent of FoxNews trumpeting the GOP line that this is all about cutting spending and reducing the deficit, and pressures such as Gingrich himself urging current Speaker of the House John Boehner to push ahead with this agenda. Importantly, it highlights the role of massive funding of this agenda by the secretive-but-being-dragged-into-the-open billionaire Koch brothers, whose financial self-interest is being massively served by the Republican policies of tax cuts for the wealthy, and even more by gutting of all regulation of the oil industry (EPA) and financial industry (SEC, IRS and others). As the House moves toward actually shutting down funding for the government, it hopes (believes?) that it can convince the public to blame the President.
What is the “glimmer”? First of all, this strategy did not work in 1995, when the Republicans, not Bill Clinton were blamed for the government shutdown. Second, in 1995 the economy was in very good shape, while now it is still a disaster. While the unemployed and fearing-unemployment portion of the public, may not want to pay taxes, they are their slightly-better-off countrymen both need and want the services provided by the government in that small sliver of discretionary spending (not counting Medicare, Medicaid, and the military) that is on the table. People want their Medicare and Social Security and Veteran’s benefits and are not going to be happy if the checks don’t come because the Republicans shut down government. Moreover, Rich notes that “…the latest Pew survey found that Americans want to increase, not decrease most areas of federal spending – and by large margins in the cases of health care and education.”
Republicans think that they can continue screaming “deficit” and Americans will ignore the fact that the cuts that they propose, targeting social programs they are ideologically opposed to (Head Start, Planned Parenthood, etc.), will not make any significant difference in the deficit, while the cuts they oppose, such as repealing the tax-cuts for the wealthiest individuals and corporations, would. Maybe people will. Hopefully, especially if the President can make these points clearly, they won’t.
Kristof, on the other hand, provides a tale of inspiration and hope-with-a-serious-measure-of-caution. In “Unfit for Democracy?” he challenges the “crude stereotype” that the peoples of the Middle East (along with those of Africa, China, and other parts of the non-western-European world) are “too politically immature for democracy.” He acknowledges the state failures of Yugoslavia after Tito and the Congo; he is aware of the fears that regime change led to civil war in Iraq, chaos in Somalia[1], repressive theocracy in Iran. I have had friends tell me that the uprisings in the Middle East are about economic opportunity, not freedom. I’m sure economics, in these very poor countries, are part of it, but people are bravely dying for freedom, and they are at home, and not in the military.
Kristof tells us of unspeakable tortures endured in Bahrain, of the bravery of the double amputee he met in Cairo who wheeled his chair to the front lines as Mubarak’s thugs attacked with “rocks, clubs, and Molotov cocktails, of people marching unarmed in Bahrain toward security forces who had opened fire on them the day before.” That while there have been bad, even horrible, outcomes when people have overthrown repressive governments, “countries usually pull through”. That the solution cannot be the continuance in power by the current corrupt and brutal dictators. This is a myth perpetrated by the very dictators themselves to justify their continuance in power, to justify both pocketing most of the money and oppressing their own people.
What is the relationship between these two stories? Tyrants in power share with elites in power the professed (and often believed) myth that those who they oppress are lesser peoples, inferior races, too “childlike” to manage themselves not to mention be “trusted” with managing their country. Bigotry and exploitation exist in a homeostatic relationship, one used to “justify” the other, in a history of atrocities, from the colonialist “White Man’s Burden” to Hitler’s attempt to exterminate all Jews in the Holocaust. This position characterized attitudes toward American Indians, black people, immigrants in the late 19th and early 20th century, workers and the labor movement, and women. It justified – in our country, built on the idea of freedom and democracy – not only discrimination, degradation, and intimidation, but violent repressive attacks on: American Indians (genocide), black people (slavery and Jim Crow), immigrants, workers, and even women.
Well, these days are not over. American Indians and Black Americans, as well as other minorities continue to be on the bottom rungs of our economic and social order. Attacking immigrants is the new paradigm, with Arizona and its continued escalation of ignoble and often unconstitutional laws being hand-in-glove with the iron fists of those such as the Sheriff of Maricopa County (a worthy successor to the evil Sheriff of Nottingham, Robin Hood’s nemesis on the old television program). Wisconsin moves to the front lines in attacks on workers, with its governor seeking to eliminate collective bargaining under the myth that it is about money, despite the complete accession of the public sector unions to the financial cuts (and despite the fact that it is their own money they are giving back).[2] An astute observer notes: “You look at what is happening in the Middle East where people long kept "under the thumb" are expressing their yearnings for freedom and then contrast that with the fomenting battles over pensions and collective bargaining here in the US. It doesn't take long to start asking "What is wrong with this picture?![3]" What indeed?
“In Egypt and Bahrain in recent weeks,” Kristof writes, “I’ve been humbled by the lion-hearted men and women I’ve seen defying tear gas and bullets for freedom we take for granted. How can we say that these people are unready for a democracy that they are prepared to die for?”
Most of us in the US, those who are not the mostly young and mostly poor and working class people deployed in the at-best-futile wars in Afghanistan and Iraq, are not in danger of dying from government-directed violence. But we are certainly in danger of losing the freedom as our rights are all sold off to the highest bidder, and we must stand against it.
[1] See also the article on the Somali pirates and what the response might be,
[2] See Rick Ungars piece on Forbes.com, “The Wisconsin Lie Exposed – Taxpayers Actually Contribute Nothing To Public Employee Pensions”.
[3] R. Aistrope, personal communication.
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In two side-by-side Op-Ed pieces in the NY Times on Sunday, February 27, 2011, Nicholas Kristof and Frank Rich discuss apparently very different topics. Rich’s piece, “Why wouldn’t the Tea Party shut it down?”, can be described as “depressing-with-a-glimmer-of-hope.” It compares the current situation in Congress, with a new, empowered, Republican majority with 83 freshman and firm ideology, to that of 1995, when a similar class of mid-term-elected Republicans took control under Newt Gingrich with their “Contract for America”. The similarities are obvious, but he points to the differences as well. Structurally, these include the advent of FoxNews trumpeting the GOP line that this is all about cutting spending and reducing the deficit, and pressures such as Gingrich himself urging current Speaker of the House John Boehner to push ahead with this agenda. Importantly, it highlights the role of massive funding of this agenda by the secretive-but-being-dragged-into-the-open billionaire Koch brothers, whose financial self-interest is being massively served by the Republican policies of tax cuts for the wealthy, and even more by gutting of all regulation of the oil industry (EPA) and financial industry (SEC, IRS and others). As the House moves toward actually shutting down funding for the government, it hopes (believes?) that it can convince the public to blame the President.
What is the “glimmer”? First of all, this strategy did not work in 1995, when the Republicans, not Bill Clinton were blamed for the government shutdown. Second, in 1995 the economy was in very good shape, while now it is still a disaster. While the unemployed and fearing-unemployment portion of the public, may not want to pay taxes, they are their slightly-better-off countrymen both need and want the services provided by the government in that small sliver of discretionary spending (not counting Medicare, Medicaid, and the military) that is on the table. People want their Medicare and Social Security and Veteran’s benefits and are not going to be happy if the checks don’t come because the Republicans shut down government. Moreover, Rich notes that “…the latest Pew survey found that Americans want to increase, not decrease most areas of federal spending – and by large margins in the cases of health care and education.”
Republicans think that they can continue screaming “deficit” and Americans will ignore the fact that the cuts that they propose, targeting social programs they are ideologically opposed to (Head Start, Planned Parenthood, etc.), will not make any significant difference in the deficit, while the cuts they oppose, such as repealing the tax-cuts for the wealthiest individuals and corporations, would. Maybe people will. Hopefully, especially if the President can make these points clearly, they won’t.
Kristof, on the other hand, provides a tale of inspiration and hope-with-a-serious-measure-of-caution. In “Unfit for Democracy?” he challenges the “crude stereotype” that the peoples of the Middle East (along with those of Africa, China, and other parts of the non-western-European world) are “too politically immature for democracy.” He acknowledges the state failures of Yugoslavia after Tito and the Congo; he is aware of the fears that regime change led to civil war in Iraq, chaos in Somalia[1], repressive theocracy in Iran. I have had friends tell me that the uprisings in the Middle East are about economic opportunity, not freedom. I’m sure economics, in these very poor countries, are part of it, but people are bravely dying for freedom, and they are at home, and not in the military.
Kristof tells us of unspeakable tortures endured in Bahrain, of the bravery of the double amputee he met in Cairo who wheeled his chair to the front lines as Mubarak’s thugs attacked with “rocks, clubs, and Molotov cocktails, of people marching unarmed in Bahrain toward security forces who had opened fire on them the day before.” That while there have been bad, even horrible, outcomes when people have overthrown repressive governments, “countries usually pull through”. That the solution cannot be the continuance in power by the current corrupt and brutal dictators. This is a myth perpetrated by the very dictators themselves to justify their continuance in power, to justify both pocketing most of the money and oppressing their own people.
What is the relationship between these two stories? Tyrants in power share with elites in power the professed (and often believed) myth that those who they oppress are lesser peoples, inferior races, too “childlike” to manage themselves not to mention be “trusted” with managing their country. Bigotry and exploitation exist in a homeostatic relationship, one used to “justify” the other, in a history of atrocities, from the colonialist “White Man’s Burden” to Hitler’s attempt to exterminate all Jews in the Holocaust. This position characterized attitudes toward American Indians, black people, immigrants in the late 19th and early 20th century, workers and the labor movement, and women. It justified – in our country, built on the idea of freedom and democracy – not only discrimination, degradation, and intimidation, but violent repressive attacks on: American Indians (genocide), black people (slavery and Jim Crow), immigrants, workers, and even women.
Well, these days are not over. American Indians and Black Americans, as well as other minorities continue to be on the bottom rungs of our economic and social order. Attacking immigrants is the new paradigm, with Arizona and its continued escalation of ignoble and often unconstitutional laws being hand-in-glove with the iron fists of those such as the Sheriff of Maricopa County (a worthy successor to the evil Sheriff of Nottingham, Robin Hood’s nemesis on the old television program). Wisconsin moves to the front lines in attacks on workers, with its governor seeking to eliminate collective bargaining under the myth that it is about money, despite the complete accession of the public sector unions to the financial cuts (and despite the fact that it is their own money they are giving back).[2] An astute observer notes: “You look at what is happening in the Middle East where people long kept "under the thumb" are expressing their yearnings for freedom and then contrast that with the fomenting battles over pensions and collective bargaining here in the US. It doesn't take long to start asking "What is wrong with this picture?![3]" What indeed?
“In Egypt and Bahrain in recent weeks,” Kristof writes, “I’ve been humbled by the lion-hearted men and women I’ve seen defying tear gas and bullets for freedom we take for granted. How can we say that these people are unready for a democracy that they are prepared to die for?”
Most of us in the US, those who are not the mostly young and mostly poor and working class people deployed in the at-best-futile wars in Afghanistan and Iraq, are not in danger of dying from government-directed violence. But we are certainly in danger of losing the freedom as our rights are all sold off to the highest bidder, and we must stand against it.
[1] See also the article on the Somali pirates and what the response might be,
[2] See Rick Ungars piece on Forbes.com, “The Wisconsin Lie Exposed – Taxpayers Actually Contribute Nothing To Public Employee Pensions”.
[3] R. Aistrope, personal communication.
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Monday, February 28, 2011
Common Sense Family Doctor blog: Maybe PSA's time has finally come -- to an end!
I highly recommend reviewing Dr. Kenny Lin's blog post on "Common Sense Family Doctor" regarding PSA testing, http://commonsensemd.blogspot.com/2011/02/psa-testing-will-science-finally-trump.html
It reviews not only Dr. Lin's experience in helping write the guidelines but the political pressure to "trump" science.
Hopefully, now, the evidence on the non-utility of PSA testing is clear -- but read his piece for the details.
It reviews not only Dr. Lin's experience in helping write the guidelines but the political pressure to "trump" science.
Hopefully, now, the evidence on the non-utility of PSA testing is clear -- but read his piece for the details.
Friday, February 25, 2011
We are moving in the wrong direction: the health care crisis and American hubris
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The passion for democracy and liberation from tyranny continues to spread across the Middle East, with major actions (and reactions from dictators) taking place in Bahrain, Yemen, Libya and even Iran. While decades of US foreign policy has focused on supporting these dictators while talking democracy, the people in these countries are looking at the US as a model, not of foreign policy, but of democracy. They may have economic interests, but -- in Libya, for sure, they are willing to die for freedom. Finally, our President, from whom we (and they) had expected great things, is speaking on behalf of freedom.
However, as I wrote last week, things are moving in the wrong direction in the US itself, where right-wing zealots funded by billionaires have taken over not just Congress but the legislatures of many states. Wisconsin is the prime example of an attempt, which may yet be successful, to strip the basic rights of labor unions to organize and fight for their members, a class war thinly veiled by statements of fiscal responsibility negated by the fact that the unions have already agreed to the financial cuts. On NPR’s Morning Edition on Feb 21, 2011 Steve Inskeep,the host interviewing Senate President Scott Fitzgerald, who is carrying the water for Gov. Scott Walker’s bill, could barely contain his irritation as Sen. Fitzgerald kept dodging the questions, reiterating boilerplate talking points rather than answering.
However, as I wrote last week, things are moving in the wrong direction in the US itself, where right-wing zealots funded by billionaires have taken over not just Congress but the legislatures of many states. Wisconsin is the prime example of an attempt, which may yet be successful, to strip the basic rights of labor unions to organize and fight for their members, a class war thinly veiled by statements of fiscal responsibility negated by the fact that the unions have already agreed to the financial cuts. On NPR’s Morning Edition on Feb 21, 2011 Steve Inskeep,the host interviewing Senate President Scott Fitzgerald, who is carrying the water for Gov. Scott Walker’s bill, could barely contain his irritation as Sen. Fitzgerald kept dodging the questions, reiterating boilerplate talking points rather than answering.
And we are not doing so well. In Empire at the End of Decadence (NY Times, Feb 18, 2011), Charles Blow provides a stunning graphic chart comparing the United States to other countries in the developed world across a variety of areas on which we do, or should, pride ourselves. We don’t come out very well. Among the International Monetary Fund’s (IMF) 33 advanced countries, we are not in the best in any of the 9 areas. We are dead last in prison population per 100,000 (745, more than twice 2nd place Israel’s 325), and tied for worst, with Korea, with 16% of people indicating that they had not enough money for food in the last year. In the only direct health measure, life expectancy at birth, we are, at 78.24 years, ahead of only 5 of the other 32 countries; Slovakia at 75.62, is the lowest, and Taiwan is jus t behind us at 78.15 (the other 3 are Slovenia, Cyprus, and the Czech Republic).
While Republicans rant about individual mandates and repealing “Obamacare”, the health insurance crisis is not over. In the New York Times, Feb 20, 2011, Donna Dubinsky wrote “Money won’t buy you health insurance”. This “co-founder of Palm Computer and Handspring, is the chief executive of a computer software company” describes the difficulty that she had in obtaining insurance on the private market despite being quite well-to-do when neither she nor her husband worked for a large company any more. After being denied coverage at all because of “pre-existing conditions” (“For me, it was a corn on my toe for which my podiatrist had recommended an in-office procedure. My daughter was denied because she takes regular medication for a common teenage issue. My husband was denied because his ophthalmologist had identified a slow-growing cataract,” she finally found a company that would insure them at a high rate with a high deductible, and the rates have continued to rise although they pay (because of the deductible) most of the bills themselves.
The point is not that she is in tough straits. I am sure Ms. Dubinsky would agree that there are a lot of people who we should have a lot more sympathy for than her; people who are homeless and jobless and hungry, and millions more who are on the verge of becoming so. And yet there are many who continue to see the uninsured as “other”, the “them”, rather than the “me and my neighbors”, despite the fact that many of their neighbors, and relative, and friends, must be in this boat. Ms. Dubinsky’s article points out, if there were any more evidence needed, that insurance companies are greedy and absolutely not to be trusted with the health care of the American people. The Affordable Care Act, (ACA) mandates individuals to purchase health insurance, ostensibly the objection of the Republican right (who are presumably either well insured or healthy and optimists), which was the only way the insurance companies would buy in: they basically said “We can only allow no underwriting (denying insurance to people they assess as too high a risk) this if you make everyone buy insurance.”
Should you even think for a moment that for-profit insurance companies are anything but self-serving, it is worth looking at Jacob S. Hacker and Carl DeTorres’ scorecard, The Health of Reform (NY Times, Feb 17.2011). They grade the ACA in Rollout, Reaction, and Results and give the overall program so far a “B”. The reaction of the insurance companies gets a “C”: “Eager to have millions of new private customers, the big private plans and their lobby are against repeal. Still, they spent tens of millions of dollars supporting the anti-reform candidates in the elections and are fighting key consumer protections and cost controls”.
Paul Krugman is generally a supporter of the ACA health plan, believing that it actually will be a major step to addressing our fiscal problems. “What would a serious approach to our fiscal problems involve? I can summarize it in seven words: health care, health care, health care, revenue. “He continues (Willie Sutton Wept, NY Times, Feb 18, 2011),
“What would a serious approach to our fiscal problems involve? I can summarize it in seven words: health care, health care, health care, revenue….What would real action on health look like? Well, it might include things like giving an independent commission the power to ensure that Medicare only pays for procedures with real medical value; rewarding health care providers for delivering quality care rather than simply paying a fixed sum for every procedure; limiting the tax deductibility of private insurance plans; and so on. And what do these things have in common? They’re all in last year’s health reform bill. That’s why I say that Mr. Obama gets too little credit. He has done more to rein in long-run deficits than any previous president. And if his opponents were serious about those deficits, they’d be backing his actions and calling for more; instead, they’ve been screaming about death panels.”
So, while the President’s plan might be criticized for being a giveaway to insurance companies, the right is attacking it for all the things it actually does well!
Dubinsky ends her article “If members of Congress feel so strongly about undoing this important legislation, perhaps we should stop providing them with health insurance. Let’s credit their pay for the amount that has been paid by the taxpayers, and let them try to buy health insurance in the individual market. My bet is that they all would be denied. Health insurance reform might suddenly not seem to them like such a bad idea.”
Maybe, but some folks have no shame. It is not a bad idea, it is, as Krugman demonstrates, a pretty good idea from an economic as well as health standpoint. And Blow may be right when he says that, rather than confront the realities of developing a population with the health and education to compete in a global economy, too many people “…would prefer to continue to bathe in platitudes about America’s greatness, to view our eroding empire through the gauzy vapors of past grandeur.”
That is not a conceit that we can afford.
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Saturday, February 19, 2011
The challenge of expanded Medicaid and the dearth of primary care physicians
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The shortage – current and future – of primary care physicians in the US has been a recurrent theme on both this blog and many other venues in journals and the blogosphere. In addition, several posts relating to the Affordable Care Act (ACA) have noted the difficulty Massachusetts has had since it implemented an individual mandate, with many more people covered and not enough primary care doctors to see them (Solving Medicare costs and the budget deficit: primary care, cost-effectiveness, and universal health coverage, Jan 5, 2011; PPACA, The New Health Reform Law: How will it affect the public's health and primary care?, Apr 12, 2010). Apparently, there are a lot of states that will be in worse shape than Massachusetts, according to a study by Leighton Ku and colleagues in the New England Journal of Medicine.
In The States' Next Challenge — Securing Primary Care for Expanded Medicaid Populations (NEJM 10Feb2011;364(6):493-5) the authors look at the expansion of Medicaid mandated in ACA, to 133% of poverty for nonelderly adults by 2014, and note that this expansion will be far greater for states that currently have the most restrictive eligibility for Medicaid than those that have the most generous (e.g., Massachusetts). They note that this will require far more primary care doctors, and observe that many of these same states have the greatest deficit in primary care capacity. Using a creative approach, they create a “Medicaid expansion index” to identify how much a state’s Medicaid population will grow as well as a “primary care capacity index”. They standardized them so 100 was the average, and combined them to get a relative assessment of each state’s “challenge”; over 100 is worse than average, under is better. The scores ranged from 212.6 (Oklahoma) to 15.2 (Massachusetts, in fact!). Unsurprisingly, the states that face the greatest challenges are mostly in the South and Midwest, like Oklahoma, while the other states with low scores tend to be in the Northeast. Some of this is, as Ku notes, a primary care physician deficit in those states with high scores, while and much of it is a result of the fact that these high-score states have such limited current eligibility for their current Medicaid programs that they will have the largest number of newly-insured people.
The authors acknowledge that the “Access to care is determined in local service areas, not at the state level. Access problems could be more severe in rural or inner-city areas than in suburban communities, for example.” No doubt they will be; as many posts on this blog (e.g., Primary Care and Rural Areas, Apr 28, 2010) have noted, distribution of providers (not only physicians but nurse practitioners and other “midlevels”) is not even close to adequate, both for primary and subspecialty care. There are too few providers in the inner-city, but in rural areas the situation is worse -- 20% of Americans live in these areas, but well under 10% of doctors practice there. Only family physicians distribute in proportion to the population, but 20% of family physicians is not anywhere near 20% of doctors. Other primary care specialties, such as pediatrics, are very concentrated in urban areas (Primary Care, Pediatrics, and Physician Distribution, May 21, 2009).
Ku, et.al., express some guarded optimism, suggesting that expanded insurance coverage will support more primary care doctors – but note that the expansion also doesn’t begin until 2014. Given the long time frame to create physicians in any specialty, this will at best leave us with several years of shortages. And, at the current rate, “at best” is unlikely. The authors emphasize the need for training more primary care doctors, especially in the most “challenged” states, but really make no suggestions that are likely to have a significant impact, citing such things as expanded scope for “midlevels” (does not address distribution) and expectation that increased funding for Federally-Qualified Health Centers (FQHCs).
In the very next article in the same issue of the NEJM, Stephen R. Smith does make some suggestions for change that would likely produce more primary care doctors. In A Recipe for Medical Schools to Produce Primary Care Physicians[1], he starts with the admissions process, suggesting that admissions be MCAT (Medical College Admissions Test) “blind”, meaning that above a pre-defined minimum score, MCAT scores will not be considered (so that a student with a very high score is considered “more desirable” than one with just a high score). He emphasizes the need to select students “…who express a desire to serve underserved populations, who demonstrate altruism, and who are committed to social responsibility” because “they are more likely to go into primary care”. (However,expressing interest is not the same as actually having interest. See the experience of Pennsylvania’s Commonwealth Medical College. [2]) He suggests that the curriculum be based on a “patient-centered learning approach” with continuity follow-up of actual patients and teaching of “basic science” in the context of these actual patients. He urges that the entire curriculum be built around the competencies needed for a primary care physician, that students be taught in inter-professional teams, and that community-based settings be used for training.
These are all good ideas. They are consonant with recommendations I have made (of course, this makes them good :)!). While they do not look at “output variables” (mainly income/reimbursement), they do address the two areas over which medical schools have the greatest control – the students they admit (“input variables”) and the curriculum (the “process”). The suggestions that Smith makes have all been tried, and they all work to a significant degree to increase the number and percent of primary care doctors. At the University of Kansas, for example, we do have essentially “MCAT-blind” admissions, and look for the characteristics he suggests, among others, believing that such personal characteristics as caring, altruism, and communication skills are not only important for primary care, but for all physicians. The problem is absolutely not that we don’t know what works; we do. The problem is that we have, nationally, lacked the commitment to implement these strategies on a large enough scale to have a sufficient impact on the supply of physicians.
There are two big issues, though. Obviously, the first is that “output variables” – mainly the enormous differential in expected physician income – are not addressed. This is critical. As long as reimbursement policies by Medicare (see “Outing the RUC: Medicare reimbursement and Primary Care”, Feb 2, 2011) and other insurers dramatically favor subspecialists and especially proceduralists, there will not be enough primary care doctors. Indeed, the other “problem” medical students often identify with primary care – less than appealing “lifestyle” (read: “too much work”) is related to this; if you make a lot more per hour, you have to work fewer hours.
The other big issue is that Smith addresses his suggestions to the many new allopathic (“MD”) medical schools being currently created. He notes that these are (mostly, although not all) designed to increase production of primary care physicians (although, as noted in the footnote about the Commonwealth Medical College, even those may have trouble getting students who are actually interested in primary care), and he is correct that adopting his suggestions, among others, is more likely to keep them on that path. However, this is too simple; it forgives existing medical schools from fulfilling this responsibility, and they absolutely should not be so forgiven. This is particularly true for the most “elite” schools, many of them private and in the Northeast and very “selective” (indeed “selectivity” – the percent of applicants that you turn down – is a criterion for high rank by US News and World Report). Such schools are also the ones with the highest amounts of National Institutes of Health (NIH) research support, and pride themselves on producing researchers. Different schools, the refrain goes, have different mission; we produce “physician scientists”, somebody else should produce the primary care doctors (hey, like those “new schools!”).
The problem is twofold. First, these schools produce a lot of physicians, and they need to produce the kind of physicians that the community needs. Second, these schools set the standard for what most other schools want to be like – to be highly ranked by US News and get lots of NIH money. The last big expansion of medical schools, in the early 1970s, was also supposed to produce primary care doctors, but many or most of them immediately abandoned that mission and began trying to be like Harvard or Johns Hopkins. What needs to happen is that Harvard and Johns Hopkins need to look more like the University of Kansas, and produce a much higher percent of community-serving primary care doctors. In fact, so does the Warren Alpert School of Medicine at Brown University, where Dr. Smith works.
So, in case I haven’t been clear, two things need to happen:
1. Current physician reimbursement formulas need to be abandoned, and Medicare needs to adopt a reimbursement scheme that will result in primary care physicians having at least 70% of the income of subspecialists. Where Medicare leads, private insurers will follow.
2. All medical schools must adopt admissions policies that de-emphasize high exam scores and emphasize desirable personal characteristics, and lead to much greater diversity of students by socioeconomic status, geographic origins, and race/ethnicity. They need a curriculum that reinforces these skills, problem solving, independent learning, and communication. The elite private schools should take the lead; where they lead others will follow.
When? What should be the timeline? Immediately. Right now. No delays. Both should have been done yesterday.
[1] Smith SR, “A Recipe for Medical Schools to Produce Primary Care Physicians”, NEJM 10Feb2011;364(6):496-7 (online available only to subscribers)
[2] The Commonwealth Medical College in Scranton, Pennsylvania selected its students based on an expressed interest in primary care, but found that in their first class, on a pre-matriculation survey (before they even started school!) only 23% still said they wanted to be primary care doctors! (Tracy & Smego, “Discordance of Self-reported Career Goals of First-year Medical Students During Admission Interviews and Prematriculation Orientation”, Family Medicine, Jul-Aug 2010.
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The shortage – current and future – of primary care physicians in the US has been a recurrent theme on both this blog and many other venues in journals and the blogosphere. In addition, several posts relating to the Affordable Care Act (ACA) have noted the difficulty Massachusetts has had since it implemented an individual mandate, with many more people covered and not enough primary care doctors to see them (Solving Medicare costs and the budget deficit: primary care, cost-effectiveness, and universal health coverage, Jan 5, 2011; PPACA, The New Health Reform Law: How will it affect the public's health and primary care?, Apr 12, 2010). Apparently, there are a lot of states that will be in worse shape than Massachusetts, according to a study by Leighton Ku and colleagues in the New England Journal of Medicine.
In The States' Next Challenge — Securing Primary Care for Expanded Medicaid Populations (NEJM 10Feb2011;364(6):493-5) the authors look at the expansion of Medicaid mandated in ACA, to 133% of poverty for nonelderly adults by 2014, and note that this expansion will be far greater for states that currently have the most restrictive eligibility for Medicaid than those that have the most generous (e.g., Massachusetts). They note that this will require far more primary care doctors, and observe that many of these same states have the greatest deficit in primary care capacity. Using a creative approach, they create a “Medicaid expansion index” to identify how much a state’s Medicaid population will grow as well as a “primary care capacity index”. They standardized them so 100 was the average, and combined them to get a relative assessment of each state’s “challenge”; over 100 is worse than average, under is better. The scores ranged from 212.6 (Oklahoma) to 15.2 (Massachusetts, in fact!). Unsurprisingly, the states that face the greatest challenges are mostly in the South and Midwest, like Oklahoma, while the other states with low scores tend to be in the Northeast. Some of this is, as Ku notes, a primary care physician deficit in those states with high scores, while and much of it is a result of the fact that these high-score states have such limited current eligibility for their current Medicaid programs that they will have the largest number of newly-insured people.
The authors acknowledge that the “Access to care is determined in local service areas, not at the state level. Access problems could be more severe in rural or inner-city areas than in suburban communities, for example.” No doubt they will be; as many posts on this blog (e.g., Primary Care and Rural Areas, Apr 28, 2010) have noted, distribution of providers (not only physicians but nurse practitioners and other “midlevels”) is not even close to adequate, both for primary and subspecialty care. There are too few providers in the inner-city, but in rural areas the situation is worse -- 20% of Americans live in these areas, but well under 10% of doctors practice there. Only family physicians distribute in proportion to the population, but 20% of family physicians is not anywhere near 20% of doctors. Other primary care specialties, such as pediatrics, are very concentrated in urban areas (Primary Care, Pediatrics, and Physician Distribution, May 21, 2009).
Ku, et.al., express some guarded optimism, suggesting that expanded insurance coverage will support more primary care doctors – but note that the expansion also doesn’t begin until 2014. Given the long time frame to create physicians in any specialty, this will at best leave us with several years of shortages. And, at the current rate, “at best” is unlikely. The authors emphasize the need for training more primary care doctors, especially in the most “challenged” states, but really make no suggestions that are likely to have a significant impact, citing such things as expanded scope for “midlevels” (does not address distribution) and expectation that increased funding for Federally-Qualified Health Centers (FQHCs).
In the very next article in the same issue of the NEJM, Stephen R. Smith does make some suggestions for change that would likely produce more primary care doctors. In A Recipe for Medical Schools to Produce Primary Care Physicians[1], he starts with the admissions process, suggesting that admissions be MCAT (Medical College Admissions Test) “blind”, meaning that above a pre-defined minimum score, MCAT scores will not be considered (so that a student with a very high score is considered “more desirable” than one with just a high score). He emphasizes the need to select students “…who express a desire to serve underserved populations, who demonstrate altruism, and who are committed to social responsibility” because “they are more likely to go into primary care”. (However,expressing interest is not the same as actually having interest. See the experience of Pennsylvania’s Commonwealth Medical College. [2]) He suggests that the curriculum be based on a “patient-centered learning approach” with continuity follow-up of actual patients and teaching of “basic science” in the context of these actual patients. He urges that the entire curriculum be built around the competencies needed for a primary care physician, that students be taught in inter-professional teams, and that community-based settings be used for training.
These are all good ideas. They are consonant with recommendations I have made (of course, this makes them good :)!). While they do not look at “output variables” (mainly income/reimbursement), they do address the two areas over which medical schools have the greatest control – the students they admit (“input variables”) and the curriculum (the “process”). The suggestions that Smith makes have all been tried, and they all work to a significant degree to increase the number and percent of primary care doctors. At the University of Kansas, for example, we do have essentially “MCAT-blind” admissions, and look for the characteristics he suggests, among others, believing that such personal characteristics as caring, altruism, and communication skills are not only important for primary care, but for all physicians. The problem is absolutely not that we don’t know what works; we do. The problem is that we have, nationally, lacked the commitment to implement these strategies on a large enough scale to have a sufficient impact on the supply of physicians.
There are two big issues, though. Obviously, the first is that “output variables” – mainly the enormous differential in expected physician income – are not addressed. This is critical. As long as reimbursement policies by Medicare (see “Outing the RUC: Medicare reimbursement and Primary Care”, Feb 2, 2011) and other insurers dramatically favor subspecialists and especially proceduralists, there will not be enough primary care doctors. Indeed, the other “problem” medical students often identify with primary care – less than appealing “lifestyle” (read: “too much work”) is related to this; if you make a lot more per hour, you have to work fewer hours.
The other big issue is that Smith addresses his suggestions to the many new allopathic (“MD”) medical schools being currently created. He notes that these are (mostly, although not all) designed to increase production of primary care physicians (although, as noted in the footnote about the Commonwealth Medical College, even those may have trouble getting students who are actually interested in primary care), and he is correct that adopting his suggestions, among others, is more likely to keep them on that path. However, this is too simple; it forgives existing medical schools from fulfilling this responsibility, and they absolutely should not be so forgiven. This is particularly true for the most “elite” schools, many of them private and in the Northeast and very “selective” (indeed “selectivity” – the percent of applicants that you turn down – is a criterion for high rank by US News and World Report). Such schools are also the ones with the highest amounts of National Institutes of Health (NIH) research support, and pride themselves on producing researchers. Different schools, the refrain goes, have different mission; we produce “physician scientists”, somebody else should produce the primary care doctors (hey, like those “new schools!”).
The problem is twofold. First, these schools produce a lot of physicians, and they need to produce the kind of physicians that the community needs. Second, these schools set the standard for what most other schools want to be like – to be highly ranked by US News and get lots of NIH money. The last big expansion of medical schools, in the early 1970s, was also supposed to produce primary care doctors, but many or most of them immediately abandoned that mission and began trying to be like Harvard or Johns Hopkins. What needs to happen is that Harvard and Johns Hopkins need to look more like the University of Kansas, and produce a much higher percent of community-serving primary care doctors. In fact, so does the Warren Alpert School of Medicine at Brown University, where Dr. Smith works.
So, in case I haven’t been clear, two things need to happen:
1. Current physician reimbursement formulas need to be abandoned, and Medicare needs to adopt a reimbursement scheme that will result in primary care physicians having at least 70% of the income of subspecialists. Where Medicare leads, private insurers will follow.
2. All medical schools must adopt admissions policies that de-emphasize high exam scores and emphasize desirable personal characteristics, and lead to much greater diversity of students by socioeconomic status, geographic origins, and race/ethnicity. They need a curriculum that reinforces these skills, problem solving, independent learning, and communication. The elite private schools should take the lead; where they lead others will follow.
When? What should be the timeline? Immediately. Right now. No delays. Both should have been done yesterday.
[1] Smith SR, “A Recipe for Medical Schools to Produce Primary Care Physicians”, NEJM 10Feb2011;364(6):496-7 (online available only to subscribers)
[2] The Commonwealth Medical College in Scranton, Pennsylvania selected its students based on an expressed interest in primary care, but found that in their first class, on a pre-matriculation survey (before they even started school!) only 23% still said they wanted to be primary care doctors! (Tracy & Smego, “Discordance of Self-reported Career Goals of First-year Medical Students During Admission Interviews and Prematriculation Orientation”, Family Medicine, Jul-Aug 2010.
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Sunday, February 13, 2011
Freedom abroad, health at home: experiments in preventive health care
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First, we must celebrate the victory of the people of Egypt in ousting the 30-year dictator Hosni Mubarak, and we revel in the democratic character of both this peaceful revolution and that in Tunisia last month. We hope that all of the dreams and aspirations of the masses of people involved are realized – freedom of speech, freedom for women and minorities, freedom from hunger. Thinking and reading about it brings tears of joy and admiration for these brave people. It is truly inspiring and encouraging to see this part of the world moving in the right direction. I feel that it may be wrong to have a post that dilutes this excitement with discussion of other topics, but take comfort in the fact that the papers, magazines, and blogosphere are talking about little else.
...
Unfortunately, at the same time it is sobering to think about how much, in the US, we are moving in the wrong direction (see Bob Herbert, “When democracy weakens”, NY Times, Feb 12, 2011). Politicians elected, with money coming from the wealthiest corporations and individuals, on the platform of promising to create jobs, do nothing of the kind (see Robert Reich, “The recession isn’t over until the jobs come back”, Kansas City Star, Feb 12, 2011. At the federal level, to the extent Congress is doing anything, it is giving money away to the richest and taking away from poor and working people. State legislatures are also focused on eliminating support for poor people, as well as oppressing immigrants and banning gay marriage – or any rights for gay people (see Charles Blow, “Repeal, restrict, and repress”, NY Times, Feb 12, 2011). And, of course, on further restricting abortion rights. Indeed, there are those in Congress who wish to eliminate Title X funding for contraception. Given that contraception is the most effective way to decrease the abortion rate, this seems bizarre, but only if you are into “reality-based” policy making.
Where is the good news in our country? We all know that there are lots of good people out there, doing lots of good things. In health care, much of the positive news is people pitching in, volunteering to try to fill the holes left by a health care system that does not, despite the Affordable Care Act (ACA), provide care for much of our population. One example is the JayDoc Clinic, an operation entirely run by students from the University of Kansas School of Medicine, featured in the Feb 12 Kansas City Star (“Student run JayDoc clinic serves the uninsured”). Great work, and a great article, but one result is going to be more people who are in need hearing about it, and further overwhelming the clinic. The JayDoc, like so many “safety net” clinics, is a “finger in the dike”, struggling to survive in providing basic care while billions are spent on what Don Berwick, currently head of the Center for Medicare and Medicaid Services (CMS) and his colleague Brent James at the Institute for Healthcare Improvement (IHI) call “rescue care”.
Meeting the basic health care needs of the really-needy is not only right and compassionate, but is likely to cost less (in dollars and pain) if it prevents serious illness later. Since this does not seem to be a focus of government, which is busy cutting taxes on billionaires like David and Charles Koch and cutting access to contraception, some progressive and thoughtful parts of the private sector have been creating models across the country. Many of these are detailed by surgeon and writer Atul Gawande in his article “The hot spotters: can we lower medical costs by giving the neediest patients better care?” (New Yorker, Jan 24, 2011).
Gawande examines several cities where efforts have been made to identify the sickest, neediest, and highest-cost-users of health care, and intervene to try to reverse or ameliorate the causes. Some of them, like the lead story of the program in Camden, NJ, are the result of hard and extended volunteer work, by Dr. Jeffrey Brenner and friends. Others, such as in Atlantic City, result from partnerships between existing institutions (in this case, a hospital and a union). None are the result of wise governmental leadership investing in these programs to reap a benefit of greater health and lower cost. In Red, Blue, and Purple: The Math of Health Care Spending, Oct 20, 2009, I discussed the implications of the fact that most people use little health care, and a small percent use most of it. Managed care in the late 1990s failed in part because it put major hurdles in the way of receiving health care for the large proportion of the population whose health care use accounted for a small percent of health care spending in any case.
The programs described by Gawande do the opposite; they identify the actual people who account for most of the health costs in these communities and provide services and support to help those people. In Camden, for example, 1% of the population – 1000 people – accounted for 30% of its costs. 900 people in two buildings (a nursing home and a low-income housing project) accounted for more than 4000 hospital visits and $200,000,000 in health care bills over a 6 ½ year period. And, as Gawande points out, Camden is not unique. There is no money for this from the public sector or insurance industry because it is being spent (in addition to insurance company profit and administrative waste) on “rescue care” for people with conditions that advanced so far because they never received sufficient preventive and primary care.
Public funds are also
not being spent (indeed, as noted above, they are being cut) to support the myriad other “determinants of health”, social, economic, cultural and linguistic that are necessary for them to take advantage of preventive and primary care, to have the capability (Capability: understanding why people may not adopt healthful behaviors, Sep 24, 2010) of improving their health. Planning to achieve reductions in health care costs by “solutions” such as increasing copayments and deductibles so that people have “more skin in the game” are based on belief but not on facts. Gawande cites the experiences of benefit manager Verisk Health, which showed that such obstacles caused people to use less of all kinds of care – including primary and preventive care – until they finally got so acutely ill that needed to come to an emergency room, get admitted, go into an intensive care unit, so that costs in fact went up. One man “…had badly worsening heart disease and diabetes, and medical bills over 2 years in excess of $80,000. The man, dealing with higher co-payments on a fixed income, had cut back to filling only half his medication prescriptions for his high cholesterol and diabetes. He made few doctor visits. He avoided the ER – until a heart attack necessitated emergency surgery and left him disabled with chronic heart failure. The higher co-payments had backfired…” This outcome has been known for a long time; the RAND health insurance experiment in the 1970s and published in the New England Journal of Medicine in 1983[1] (see also: Joseph P. Newhouse, "Free for all?: lessons from the RAND Health Insurance Experiment", RAND 1993) showed that the opposite strategy – elimination of co-payments and deductibles -- resulted in higher utilization of health care; of both that which might be seen as “unnecessary” (colds) and that which was clearly necessary. And it saved money.
The interventions that have had success in Camden and other places were not “one size fits all”. Different people had different issues that required different interventions. Some were about poverty, some were about substance abuse or mental illness, some were about cultural misunderstandings or about language, and on and on. Interventions required more from nurse case managers for some people, social workers for others, physicians and nurse practitioners for others, and “health coaches” or promotoras for others. A lot of the latter; people who were familiar with the needs of the high-utilizer patients, who spoke their language, lived in their communities, and were often willing to “talk like [my] mother” to them.
And it is not always successful. But it is successful enough, far more successful than just pouring dollars into rescue care, that it needs to move beyond the limits that volunteers and a few forward-thinking institutions are constrained by. It needs to recognize the critical nature of teams, of integrating preventive and primary health care with basic social (and sometimes legal) services, with meeting core needs for food, housing and transportation that are all too often not even considered by policy makers. Funding is key; depending on volunteers in such efforts as these, or the JayDoc student–run free clinic will never come close to being a solution.
About Dr. Brenner’s program in Camden, Dr. Gawande writes “It remains unclear how the program will make ends meet”. In fact, these sorts of programs need to become the mainstream of health care and service delivery, and need to become the priority of federal, state, and local government.
[1] Brook RH, et. Al., “Does Free Care Improve Adults' Health? — Results from a Randomized Controlled Trial”,N Engl J Med 1983; 309:1426-1434.
.
First, we must celebrate the victory of the people of Egypt in ousting the 30-year dictator Hosni Mubarak, and we revel in the democratic character of both this peaceful revolution and that in Tunisia last month. We hope that all of the dreams and aspirations of the masses of people involved are realized – freedom of speech, freedom for women and minorities, freedom from hunger. Thinking and reading about it brings tears of joy and admiration for these brave people. It is truly inspiring and encouraging to see this part of the world moving in the right direction. I feel that it may be wrong to have a post that dilutes this excitement with discussion of other topics, but take comfort in the fact that the papers, magazines, and blogosphere are talking about little else.
...
Unfortunately, at the same time it is sobering to think about how much, in the US, we are moving in the wrong direction (see Bob Herbert, “When democracy weakens”, NY Times, Feb 12, 2011). Politicians elected, with money coming from the wealthiest corporations and individuals, on the platform of promising to create jobs, do nothing of the kind (see Robert Reich, “The recession isn’t over until the jobs come back”, Kansas City Star, Feb 12, 2011. At the federal level, to the extent Congress is doing anything, it is giving money away to the richest and taking away from poor and working people. State legislatures are also focused on eliminating support for poor people, as well as oppressing immigrants and banning gay marriage – or any rights for gay people (see Charles Blow, “Repeal, restrict, and repress”, NY Times, Feb 12, 2011). And, of course, on further restricting abortion rights. Indeed, there are those in Congress who wish to eliminate Title X funding for contraception. Given that contraception is the most effective way to decrease the abortion rate, this seems bizarre, but only if you are into “reality-based” policy making.
Where is the good news in our country? We all know that there are lots of good people out there, doing lots of good things. In health care, much of the positive news is people pitching in, volunteering to try to fill the holes left by a health care system that does not, despite the Affordable Care Act (ACA), provide care for much of our population. One example is the JayDoc Clinic, an operation entirely run by students from the University of Kansas School of Medicine, featured in the Feb 12 Kansas City Star (“Student run JayDoc clinic serves the uninsured”). Great work, and a great article, but one result is going to be more people who are in need hearing about it, and further overwhelming the clinic. The JayDoc, like so many “safety net” clinics, is a “finger in the dike”, struggling to survive in providing basic care while billions are spent on what Don Berwick, currently head of the Center for Medicare and Medicaid Services (CMS) and his colleague Brent James at the Institute for Healthcare Improvement (IHI) call “rescue care”.
Meeting the basic health care needs of the really-needy is not only right and compassionate, but is likely to cost less (in dollars and pain) if it prevents serious illness later. Since this does not seem to be a focus of government, which is busy cutting taxes on billionaires like David and Charles Koch and cutting access to contraception, some progressive and thoughtful parts of the private sector have been creating models across the country. Many of these are detailed by surgeon and writer Atul Gawande in his article “The hot spotters: can we lower medical costs by giving the neediest patients better care?” (New Yorker, Jan 24, 2011).
Gawande examines several cities where efforts have been made to identify the sickest, neediest, and highest-cost-users of health care, and intervene to try to reverse or ameliorate the causes. Some of them, like the lead story of the program in Camden, NJ, are the result of hard and extended volunteer work, by Dr. Jeffrey Brenner and friends. Others, such as in Atlantic City, result from partnerships between existing institutions (in this case, a hospital and a union). None are the result of wise governmental leadership investing in these programs to reap a benefit of greater health and lower cost. In Red, Blue, and Purple: The Math of Health Care Spending, Oct 20, 2009, I discussed the implications of the fact that most people use little health care, and a small percent use most of it. Managed care in the late 1990s failed in part because it put major hurdles in the way of receiving health care for the large proportion of the population whose health care use accounted for a small percent of health care spending in any case.
The programs described by Gawande do the opposite; they identify the actual people who account for most of the health costs in these communities and provide services and support to help those people. In Camden, for example, 1% of the population – 1000 people – accounted for 30% of its costs. 900 people in two buildings (a nursing home and a low-income housing project) accounted for more than 4000 hospital visits and $200,000,000 in health care bills over a 6 ½ year period. And, as Gawande points out, Camden is not unique. There is no money for this from the public sector or insurance industry because it is being spent (in addition to insurance company profit and administrative waste) on “rescue care” for people with conditions that advanced so far because they never received sufficient preventive and primary care.
Public funds are also
not being spent (indeed, as noted above, they are being cut) to support the myriad other “determinants of health”, social, economic, cultural and linguistic that are necessary for them to take advantage of preventive and primary care, to have the capability (Capability: understanding why people may not adopt healthful behaviors, Sep 24, 2010) of improving their health. Planning to achieve reductions in health care costs by “solutions” such as increasing copayments and deductibles so that people have “more skin in the game” are based on belief but not on facts. Gawande cites the experiences of benefit manager Verisk Health, which showed that such obstacles caused people to use less of all kinds of care – including primary and preventive care – until they finally got so acutely ill that needed to come to an emergency room, get admitted, go into an intensive care unit, so that costs in fact went up. One man “…had badly worsening heart disease and diabetes, and medical bills over 2 years in excess of $80,000. The man, dealing with higher co-payments on a fixed income, had cut back to filling only half his medication prescriptions for his high cholesterol and diabetes. He made few doctor visits. He avoided the ER – until a heart attack necessitated emergency surgery and left him disabled with chronic heart failure. The higher co-payments had backfired…” This outcome has been known for a long time; the RAND health insurance experiment in the 1970s and published in the New England Journal of Medicine in 1983[1] (see also: Joseph P. Newhouse, "Free for all?: lessons from the RAND Health Insurance Experiment", RAND 1993) showed that the opposite strategy – elimination of co-payments and deductibles -- resulted in higher utilization of health care; of both that which might be seen as “unnecessary” (colds) and that which was clearly necessary. And it saved money.The interventions that have had success in Camden and other places were not “one size fits all”. Different people had different issues that required different interventions. Some were about poverty, some were about substance abuse or mental illness, some were about cultural misunderstandings or about language, and on and on. Interventions required more from nurse case managers for some people, social workers for others, physicians and nurse practitioners for others, and “health coaches” or promotoras for others. A lot of the latter; people who were familiar with the needs of the high-utilizer patients, who spoke their language, lived in their communities, and were often willing to “talk like [my] mother” to them.
And it is not always successful. But it is successful enough, far more successful than just pouring dollars into rescue care, that it needs to move beyond the limits that volunteers and a few forward-thinking institutions are constrained by. It needs to recognize the critical nature of teams, of integrating preventive and primary health care with basic social (and sometimes legal) services, with meeting core needs for food, housing and transportation that are all too often not even considered by policy makers. Funding is key; depending on volunteers in such efforts as these, or the JayDoc student–run free clinic will never come close to being a solution.
About Dr. Brenner’s program in Camden, Dr. Gawande writes “It remains unclear how the program will make ends meet”. In fact, these sorts of programs need to become the mainstream of health care and service delivery, and need to become the priority of federal, state, and local government.
[1] Brook RH, et. Al., “Does Free Care Improve Adults' Health? — Results from a Randomized Controlled Trial”,N Engl J Med 1983; 309:1426-1434.
.
Wednesday, February 9, 2011
Education in Medicine: The characteristics of future physicians
Education in Medicine: The characteristics of future physicians: "In my blog from 2/4/11 'Why do we put so much import on the MCAT?', I discussed some of the negative characteristics that can be associated ..."
Tuesday, February 8, 2011
Non-preventive Health Screenings: Common Sense Family Doctor
A good review of the (non-) value of many highly marketed screening tests (these are "sold" at health fairs) by Dr. Kenny Lin, the Common Sense Family Doctor.
http://commonsensemd.blogspot.com/2011/02/preventive-health-screenings-that-are.html#comment-form
http://commonsensemd.blogspot.com/2011/02/preventive-health-screenings-that-are.html#comment-form
Saturday, February 5, 2011
AMA response to "Outing the RUC"
.
In general, I do not post comments regarding "Comments" posted to my blog. I appreciate them, would encourage you to post them and will reply personally if asked and given an email address, but the nature of a blog does not really encourage dialogue among readers. This is because once you have read a post, you are unlikely to come back and check to see if there are any "comments" posted that you might wish to comment further on.
I am making an exception in this case to call attention to the comment from the American Medical Association.
They indicate that "The entire premise of this column is false." They note that "The RUC often recommends increases for primary care services; RUC recommendations have resulted in $4 billion in annual increased payments for office and hospital visits – the most common services performed by a primary care physician." I note that this is not entirely responsive; while the "office and hospital visits" are the m
ost common services provided by primary care physicians, they are also provided by many subspecialists, and we don't know what % has gone to PCPs vs. subspecialists, nor do they indicate what % of Medicare physician payments $4billion is. The sources of my information are cited; also the data in the graphic showing that the ratio of subspecialists to PCPs is INCREASING, not DECREASING, is the important point. Indeed, the graphic here, from the recently-released 20th report of the Council on Graduate Medical Education (COGME) shows that this definitely affects entry into primary care.
In general, I do not post comments regarding "Comments" posted to my blog. I appreciate them, would encourage you to post them and will reply personally if asked and given an email address, but the nature of a blog does not really encourage dialogue among readers. This is because once you have read a post, you are unlikely to come back and check to see if there are any "comments" posted that you might wish to comment further on.
I am making an exception in this case to call attention to the comment from the American Medical Association.
They indicate that "The entire premise of this column is false." They note that "The RUC often recommends increases for primary care services; RUC recommendations have resulted in $4 billion in annual increased payments for office and hospital visits – the most common services performed by a primary care physician." I note that this is not entirely responsive; while the "office and hospital visits" are the m
ost common services provided by primary care physicians, they are also provided by many subspecialists, and we don't know what % has gone to PCPs vs. subspecialists, nor do they indicate what % of Medicare physician payments $4billion is. The sources of my information are cited; also the data in the graphic showing that the ratio of subspecialists to PCPs is INCREASING, not DECREASING, is the important point. Indeed, the graphic here, from the recently-released 20th report of the Council on Graduate Medical Education (COGME) shows that this definitely affects entry into primary care.Please add your comments if you wish.
Wednesday, February 2, 2011
Outing the RUC: Medicare reimbursement and Primary Care
.
Along with many others, I have written extensively about the need for more primary care physicians in the US. I have also addressed the various disincentives that exist for medical students to enter primary care specialties, such as family medicine, rather than narrower subspecialties or procedural specialties. One of these is the lower income earned by doctors in primary care; this is felt by many to be one of the major issues in specialty selection, and is increasing in impo
rtance as students graduate from medical school with larger and larger debt burdens, often exceeding $200,000. A study by the Robert Graham Center of the American Academy of Family Physicians (AAFP), “Income disparities shape medical student choice”, finds that the difference in income between primary care on subspecialists has been increasing since 1981, and that by now there is a difference of $3.5 million in the lifetime income of the average subspecialist (not even the most highly paid) and the average primary care physician.
So why is there such great variation in the reimbursement of different specialists? It is not on hours worked; many studies have taken this into account and found that on an hourly basis there is a great variation. The Wall St. Journal’s Anna Wilde Matthews and Tom McGinty, in “Physician panel prescribes the fees paid by Medicare”, describe a study done for the Medicare Payment Advisory Commission, MedPAC, that found a wide-range in per-hour reimbursement, from $101 for primary care physicians to $161 for surgeons to $193 for radiologists and $214 for dermatologists. It is not on the basis of length of training; all physicians go to medical school and the training, for example, for surgeons is considerably longer than that for dermatologists. Is it how hard the work is? After all, not everything is brain surgery. Well, to an extent, but there is considerable latitude in how “hard” is valued. What about “necessary to the health of a person” or “necessary to the health of the population”? Hardly. Let’s discuss this some more.
First, it is important to understand that the reimbursement paid to physicians by Medicare is essentially the basis for payment from all payers; contracts and reimbursements are almost always based upon multiples of what Medicare pays. Depending upon the size of the physician group negotiating with an insurance company, the particular multiplier may be greater or smaller, but Medicare reimbursement is the yardstick. Medicare payment itself is based on a formula that is primarily based upon the work that a certain activity involves, with several smaller modifications (regional variation, malpractice cost, etc.). This formula is described by health economist Uwe Reinhardt in his December 10, 2010 Economix blog for the NY Times, “The little-known decision makers for Medicare physicians fees”. Based on complex (or not) scenarios constructed for this purpose, the amount of “work” involved in over 7,000 “procedures” (for this purpose, “procedure” includes things like office visits of varying length and complexity) are assigned relative value; indeed they are assigned “relative value units” (RVUs).
But over time things change. A surgical procedure that might have taken a long time and required a hospital stay may now be done quickly in an outpatient setting. Counseling and managing several complex diseases in a primary care setting may take a lot more work and time. So the relative values may change, and reimbursement could go up or down for any of these “procedures”.
Except that, in order to keep Medicare spending from spiraling even more out of control than it has, the total number of RVUs has to stay constant. So when the number of RVUs (specifically, work-RVUs, or wRVUs) for one procedure goes up, those for others have to go down. Enter the RUC.
Several recent articles, included the Matthews and McGinty and the Reinhardt pieces cited above, have addressed the role played American Medical Association’s (AMA) Relative Value Scale Update Committee, or RUC, an organization most physicians, not to mention most other Americans, have never heard of. This group of appointed doctors makes recommendations to the Center for Medicare and Medicaid Services (CMS) about the relative amount that Medicare should pay for different physician activities. While not required to do so, CMS takes the recommendations of the RUC more than 95% of the time. While about half the services provided by physicians are in primary care, primary care doctors, according to an article in the New England Journal of Medicine by Washington state Congressman and physician Jim McDermott, “Harnessing our opportunity to make primary care sustainable”, only 6% to 13% of the 29 physicians on the RUC are in primary care. While they are supposed to be unbiased toward their own specialties, this does not seem to be what happens. Psychologically, even when they are trying to be fair, they know more about what they do and how “hard” it is than they do about what others do. Concretely, it may be easier to measure the work involved in “1 colonoscopy” or “1 gall bladder surgery” or “reading one chest x-ray” than the complex variation in primary care visits. In any case, the record demonstrates that RVU assignment, and thus reimbursement, has continued to go up for specialist procedures and thus down for primary care.
So we have a bunch of physicians, appointed essentially by their specialty societies, making recommendations on how much physicians should get paid, and a bunch of specialists deciding how to value what they do compared to what others do (certainly a conflict of interest, as defined by Howard Brody and discussed by me in The AAFP, Coca-Cola, and Ethics: Serving the public interest?, August 20, 2010), and a tremendous dominance of non-primary care over primary care physicians among this group. Why should we be surprised that we get the results that we get?
More important, for the health of the American people, the decisions made about reimbursement drive what procedures are done and what activities physicians pursue. Since reimbursement is based on “work”, not “benefit” – to the individual or certainly to the population – we get the bizarre mix of health care services that we have. Writing in Kaiser Health News, Brian Klepper and David C. Kibbe, in an article titled “Quit the RUC”, note this:
“But there is a more insidious and destructive issue at hand. The perverse incentives that are embedded in fee-for-service physician payments influence care decisions and are a principal driver of the health system's immense excesses. Encouraged by the RUC, sometimes unnecessary specialty procedures may appear more valuable and appropriate than primary care services. The system pays more for invasive approaches, so conservative treatment choices that are lower cost and lower risk to the patient may be passed over, especially near the end of life. The resulting waste, half or more of all health care dollars, has fueled a cost explosion that has led the industry and the larger economy to the brink of instability.”
Different solutions have been proposed. Klepper and Kibbe suggest that the primary care professional groups drop out of participation in the RUC altogether (“Quit the RUC”). Reinhardt feels that there is value in getting advice from this independent group, but that CMS should be much more cautious about taking its recommendations. McDermott agrees, or suggests that at least the number of RUC members be adjusted or increased to include a much larger percentage of primary care physicians.
One or more of these solutions needs to occur. Most importantly, the solution needs to look at overall benefit when assigning reimbursement value. I considered titling this piece “Wreck the RUC” (alliterative and less offensive than the other obvious, rhyming, option). If we are interested in improving the health of the American people, we need more primary care doctors, and we need to address all the open and hidden factors that are in place to work against such change. The RUC is a good place to start.
.
Along with many others, I have written extensively about the need for more primary care physicians in the US. I have also addressed the various disincentives that exist for medical students to enter primary care specialties, such as family medicine, rather than narrower subspecialties or procedural specialties. One of these is the lower income earned by doctors in primary care; this is felt by many to be one of the major issues in specialty selection, and is increasing in impo
rtance as students graduate from medical school with larger and larger debt burdens, often exceeding $200,000. A study by the Robert Graham Center of the American Academy of Family Physicians (AAFP), “Income disparities shape medical student choice”, finds that the difference in income between primary care on subspecialists has been increasing since 1981, and that by now there is a difference of $3.5 million in the lifetime income of the average subspecialist (not even the most highly paid) and the average primary care physician.So why is there such great variation in the reimbursement of different specialists? It is not on hours worked; many studies have taken this into account and found that on an hourly basis there is a great variation. The Wall St. Journal’s Anna Wilde Matthews and Tom McGinty, in “Physician panel prescribes the fees paid by Medicare”, describe a study done for the Medicare Payment Advisory Commission, MedPAC, that found a wide-range in per-hour reimbursement, from $101 for primary care physicians to $161 for surgeons to $193 for radiologists and $214 for dermatologists. It is not on the basis of length of training; all physicians go to medical school and the training, for example, for surgeons is considerably longer than that for dermatologists. Is it how hard the work is? After all, not everything is brain surgery. Well, to an extent, but there is considerable latitude in how “hard” is valued. What about “necessary to the health of a person” or “necessary to the health of the population”? Hardly. Let’s discuss this some more.
First, it is important to understand that the reimbursement paid to physicians by Medicare is essentially the basis for payment from all payers; contracts and reimbursements are almost always based upon multiples of what Medicare pays. Depending upon the size of the physician group negotiating with an insurance company, the particular multiplier may be greater or smaller, but Medicare reimbursement is the yardstick. Medicare payment itself is based on a formula that is primarily based upon the work that a certain activity involves, with several smaller modifications (regional variation, malpractice cost, etc.). This formula is described by health economist Uwe Reinhardt in his December 10, 2010 Economix blog for the NY Times, “The little-known decision makers for Medicare physicians fees”. Based on complex (or not) scenarios constructed for this purpose, the amount of “work” involved in over 7,000 “procedures” (for this purpose, “procedure” includes things like office visits of varying length and complexity) are assigned relative value; indeed they are assigned “relative value units” (RVUs).
But over time things change. A surgical procedure that might have taken a long time and required a hospital stay may now be done quickly in an outpatient setting. Counseling and managing several complex diseases in a primary care setting may take a lot more work and time. So the relative values may change, and reimbursement could go up or down for any of these “procedures”.
Except that, in order to keep Medicare spending from spiraling even more out of control than it has, the total number of RVUs has to stay constant. So when the number of RVUs (specifically, work-RVUs, or wRVUs) for one procedure goes up, those for others have to go down. Enter the RUC.
Several recent articles, included the Matthews and McGinty and the Reinhardt pieces cited above, have addressed the role played American Medical Association’s (AMA) Relative Value Scale Update Committee, or RUC, an organization most physicians, not to mention most other Americans, have never heard of. This group of appointed doctors makes recommendations to the Center for Medicare and Medicaid Services (CMS) about the relative amount that Medicare should pay for different physician activities. While not required to do so, CMS takes the recommendations of the RUC more than 95% of the time. While about half the services provided by physicians are in primary care, primary care doctors, according to an article in the New England Journal of Medicine by Washington state Congressman and physician Jim McDermott, “Harnessing our opportunity to make primary care sustainable”, only 6% to 13% of the 29 physicians on the RUC are in primary care. While they are supposed to be unbiased toward their own specialties, this does not seem to be what happens. Psychologically, even when they are trying to be fair, they know more about what they do and how “hard” it is than they do about what others do. Concretely, it may be easier to measure the work involved in “1 colonoscopy” or “1 gall bladder surgery” or “reading one chest x-ray” than the complex variation in primary care visits. In any case, the record demonstrates that RVU assignment, and thus reimbursement, has continued to go up for specialist procedures and thus down for primary care.
So we have a bunch of physicians, appointed essentially by their specialty societies, making recommendations on how much physicians should get paid, and a bunch of specialists deciding how to value what they do compared to what others do (certainly a conflict of interest, as defined by Howard Brody and discussed by me in The AAFP, Coca-Cola, and Ethics: Serving the public interest?, August 20, 2010), and a tremendous dominance of non-primary care over primary care physicians among this group. Why should we be surprised that we get the results that we get?
More important, for the health of the American people, the decisions made about reimbursement drive what procedures are done and what activities physicians pursue. Since reimbursement is based on “work”, not “benefit” – to the individual or certainly to the population – we get the bizarre mix of health care services that we have. Writing in Kaiser Health News, Brian Klepper and David C. Kibbe, in an article titled “Quit the RUC”, note this:
“But there is a more insidious and destructive issue at hand. The perverse incentives that are embedded in fee-for-service physician payments influence care decisions and are a principal driver of the health system's immense excesses. Encouraged by the RUC, sometimes unnecessary specialty procedures may appear more valuable and appropriate than primary care services. The system pays more for invasive approaches, so conservative treatment choices that are lower cost and lower risk to the patient may be passed over, especially near the end of life. The resulting waste, half or more of all health care dollars, has fueled a cost explosion that has led the industry and the larger economy to the brink of instability.”
Different solutions have been proposed. Klepper and Kibbe suggest that the primary care professional groups drop out of participation in the RUC altogether (“Quit the RUC”). Reinhardt feels that there is value in getting advice from this independent group, but that CMS should be much more cautious about taking its recommendations. McDermott agrees, or suggests that at least the number of RUC members be adjusted or increased to include a much larger percentage of primary care physicians.
One or more of these solutions needs to occur. Most importantly, the solution needs to look at overall benefit when assigning reimbursement value. I considered titling this piece “Wreck the RUC” (alliterative and less offensive than the other obvious, rhyming, option). If we are interested in improving the health of the American people, we need more primary care doctors, and we need to address all the open and hidden factors that are in place to work against such change. The RUC is a good place to start.
.
Thursday, January 27, 2011
The Devil Inside: Access to Mental Health Care in the United States
.
This is third and final posting in a series on the shooting of 13 people in Tucson and its implications for health and social policy in the US. This post is by Robyn R. Liu, MD, who is a family physician in the frontier town of Tribune, KS, in the far western part of the state.
The day Gabrielle Giffords and 19 others were shot is one of those days that most Americans will remember where they were when they heard the news. What I will remember is my husband saying, “A congresswoman was shot in Arizona. She was on Sarah Palin’s crosshairs map.” As our picture of the alleged shooter became more complete, we realized he was not playing John Hinckley, Jr. to Palin’s Jodie Foster. Rather, he is in all likelihood a very disturbed, mentally ill young man.
A CNN/Opinion Research poll demonstrates that most of the public agrees, and thinks that the lack of mental health resources was in part responsible for the horrific act of that day: 41% said a “great deal,” and 29% said a “moderate amount.” When NPR went to a gun show held in Tucson just seven days after the shooting, the man at the front of the line said, “Mentally ill individual, very troubled individual that unfortunately slipped through the cracks somehow. And I think that’s what we need to look at, is how did this fellow get missed.”
As a primary care doctor in a frontier state, I can tell you, those cracks are pretty big.
I wrote a piece last week for another blog about one patient’s experience with the mental health system here in Kansas. This was a patient with insurance and a continuity relationship with a psychiatrist – and even she “fell through the cracks” more than once, although her violence was all self-directed and thus never made headlines. We do not know what Jared Lee Loughner’s health insurance status was, nor whether he had ever sought a therapeutic relationship with a mental health professional. We do know that although his behavior got him rejected from both college and the military, he was able legally to purchase a handgun and a 30-round magazine. As Dr. Dora Wang noted this week in Psychology Today, “It’s easier to get a gun than mental health care.”
I decided to do some looking into mental health services in Arizona. I went to the home page of the Arizona Medicaid program, forthrightly if a bit unfeelingly called the “Arizona Health Care Cost Containment System,” or AHCCCS. I already knew that AHCCCS was looking at cuts in Governor Jan Brewer’s new budget, since by her direction 98 people had had their transplants rescinded under this program. The Division of Behavioral Health Services website describes how the governor’s proposed 2011 budget would alter Medicaid eligibility criteria for “childless adults” like Loughner, possibly removing coverage for 5,200 Arizona citizens with “serious mental illnesses.” The writer hopes, however, that a loophole in the policy will allow “more than 80% of these folks” to maintain coverage under a different Medicaid category. Oh, thank goodness! Now only 1,040 seriously mentally ill people will suddenly find themselves high and dry in Arizona.
The longer we as a society refuse to provide universal health care, with complete parity for mental health, the wider these cracks are going to get. It wasn’t an illegal immigrant who shot down a federal judge, a pastor, two homemakers, a social worker, and a little girl in cold blood. A retired Marine is not lying in the hospital with bullet wounds he suffered trying to protect his now-dead wife because of a drug-smuggling Mexican. Arizona is worried about protecting its borders, but its greatest threat may already be inside. Imagine over 1,000 Loughners walking the streets with no means to get help: it’s absolutely chilling.
...
Postscript from Josh:
In the January 27, 2011 NY Times, columnist Gail Collins quotes Senator Tom Coburn of Oklahoma from an appearance on "Meet the Press":
“The people that are going to commit a crime or are going to do something crazy aren’t going to pay attention to the laws in the first place. Let’s fix the real problem. Here’s a mentally deranged person who had access to a gun that should not have had access to a gun.”
As Senator Coburn is a physician, he should know. And, hopefully, he will sponsor legislation to create some rational limits on gun access, as well as increasing access to mental health services. But I wouldn't hold my breath.
.
This is third and final posting in a series on the shooting of 13 people in Tucson and its implications for health and social policy in the US. This post is by Robyn R. Liu, MD, who is a family physician in the frontier town of Tribune, KS, in the far western part of the state.
The day Gabrielle Giffords and 19 others were shot is one of those days that most Americans will remember where they were when they heard the news. What I will remember is my husband saying, “A congresswoman was shot in Arizona. She was on Sarah Palin’s crosshairs map.” As our picture of the alleged shooter became more complete, we realized he was not playing John Hinckley, Jr. to Palin’s Jodie Foster. Rather, he is in all likelihood a very disturbed, mentally ill young man.
A CNN/Opinion Research poll demonstrates that most of the public agrees, and thinks that the lack of mental health resources was in part responsible for the horrific act of that day: 41% said a “great deal,” and 29% said a “moderate amount.” When NPR went to a gun show held in Tucson just seven days after the shooting, the man at the front of the line said, “Mentally ill individual, very troubled individual that unfortunately slipped through the cracks somehow. And I think that’s what we need to look at, is how did this fellow get missed.”
As a primary care doctor in a frontier state, I can tell you, those cracks are pretty big.
I wrote a piece last week for another blog about one patient’s experience with the mental health system here in Kansas. This was a patient with insurance and a continuity relationship with a psychiatrist – and even she “fell through the cracks” more than once, although her violence was all self-directed and thus never made headlines. We do not know what Jared Lee Loughner’s health insurance status was, nor whether he had ever sought a therapeutic relationship with a mental health professional. We do know that although his behavior got him rejected from both college and the military, he was able legally to purchase a handgun and a 30-round magazine. As Dr. Dora Wang noted this week in Psychology Today, “It’s easier to get a gun than mental health care.”
I decided to do some looking into mental health services in Arizona. I went to the home page of the Arizona Medicaid program, forthrightly if a bit unfeelingly called the “Arizona Health Care Cost Containment System,” or AHCCCS. I already knew that AHCCCS was looking at cuts in Governor Jan Brewer’s new budget, since by her direction 98 people had had their transplants rescinded under this program. The Division of Behavioral Health Services website describes how the governor’s proposed 2011 budget would alter Medicaid eligibility criteria for “childless adults” like Loughner, possibly removing coverage for 5,200 Arizona citizens with “serious mental illnesses.” The writer hopes, however, that a loophole in the policy will allow “more than 80% of these folks” to maintain coverage under a different Medicaid category. Oh, thank goodness! Now only 1,040 seriously mentally ill people will suddenly find themselves high and dry in Arizona.
The longer we as a society refuse to provide universal health care, with complete parity for mental health, the wider these cracks are going to get. It wasn’t an illegal immigrant who shot down a federal judge, a pastor, two homemakers, a social worker, and a little girl in cold blood. A retired Marine is not lying in the hospital with bullet wounds he suffered trying to protect his now-dead wife because of a drug-smuggling Mexican. Arizona is worried about protecting its borders, but its greatest threat may already be inside. Imagine over 1,000 Loughners walking the streets with no means to get help: it’s absolutely chilling.
...
Postscript from Josh:
In the January 27, 2011 NY Times, columnist Gail Collins quotes Senator Tom Coburn of Oklahoma from an appearance on "Meet the Press":
“The people that are going to commit a crime or are going to do something crazy aren’t going to pay attention to the laws in the first place. Let’s fix the real problem. Here’s a mentally deranged person who had access to a gun that should not have had access to a gun.”
As Senator Coburn is a physician, he should know. And, hopefully, he will sponsor legislation to create some rational limits on gun access, as well as increasing access to mental health services. But I wouldn't hold my breath.
.
Friday, January 21, 2011
Tucson is worth struggling for...
.
This guest post by William Bemis is the second of three related to the recent shootings of Gabrielle Giffords and others in Tucson (in Pima County), AZ. Shortly before the shootings, the NY Times reported on a decision by the AZ Board of Education (a state agency in the capital, Phoenix) to close a Latino studies class in a Tucson High School. Urged by family members to consider relocation, Mr. Bemis, a psychotherapist and my brother-in-law, wrote this response, speaking of the Arizona city whose City Council had previously voted to ask the state to rescind its anti-immigrant law; after the shooting, at my request, he added additional material.
No, my dear, it's time for us and others like us to re-double our efforts to not only preserve Pima County as an island of sanity in this sea of ideological madness, but help the rest of the state and the nation see that leaving all the levers of power in the hands of racist corporate stooges is not going to take us anywhere but down. Having lived in this state for over 40 years now, I've seen this before - with Evan Meacham and Fife Symington, for example. After each of these lunatic lurches to the right, the state came back to at least a more moderate centrist political configuration. Arizona will never be Massachusetts or Oregon or Minnesota, but I, for one, am not ready to leave and concede this beautiful and unique place to the hate mongering front men for big money interests.
I loved living in New York, but we could never afford it, and besides, although their antics are less spectacularly loony, I wouldn't call the New York state government an example to emulate. Where else? Illinois? Puh-leeze! California? Are we talking about the homeland of Nixon, Reagan, Robert Dornan, et al? Sadly, Californios have also had to deal with home grown right wing fanatics, que no? Oregon? A more congenial political environment, perhaps, and a beautiful state, but too much rain!
It isn't just here, is it? I think we have to take the long view. The so-called conservatives (what do they wish to conserve besides entrenched wealth?) are riding high right now, both here and in Washington, but in the next couple of years they are going to amply demonstrate the meaness and poverty of their ideas. Contrary to the self delusions of Russell Pearce, Jan Brewer, Mitch McConnell, and John Boehner, I think these folks are cruising for a fall. I am more worried about the failure of those of us who do not share their agenda to take advantage of this moment than I am of the pseudo-populist, big money financed Tea Party. They have the money, so we all have to write our more modest checks and work all the harder. Our own apathy and discouragement is the enemy.
Moments after writing the above, I heard the news that Gabrielle Giffords, our Congresswoman, had been shot by yet another disturbed young loner of the type who seem to implement "Second Amendment solutions " to their private frustration and alienation on an almost daily basis now, thereby spreading their own psychic pain to all the rest of us. Cue the required messages of horrified shock and condolences from politicians of all persuasions, including even Sarah Palin who put Gabby's district literally in the rifle sight cross hairs and who tells her followers, "Don't retreat, RELOAD!" Some of those messages are no doubt sincere, but the one politician who was the most eloquent to me was Pima County Sheriff Clarence Dupnik, who doesn't get nearly the amount of press as his counterpart in Maricopa County, possibly because he is a hardworking, low key, decent, and fair public servant, which never seems to make good copy. Sheriff Dupnik's comments about political vitriol triggering mentally unbalanced individuals goes right to the heart of the current political climate in Arizona and across the country.
Gabrielle Giffords is a self-described "Blue Dog Democrat". For me, her politics are way too centrist in an era when what used to be the core values of the Democratic Party are under siege. If only she fit the liberal label that the Tea Party would like to pin on her! Though Gabby's stances on a lot of issues frustrated me, I worked as a volunteer on her election campaigns because I knew she was absolutely the best person we could hope to have elected to Congress from her district, which is Republican overall and in many precincts virulently racist and violent. Gabby is smart, dedicated, articulate, hard-working, extremely personable, and so much better than her recent opponent whom she barely defeated that I would have been ashamed if he had won and I hadn't done what I could to put her back in office. She is surviving so far the bullet that passed through her brain, and the trauma surgeons are optimistic, but I can't help but wonder if she does survive if she will ever be able to function again at the level she did prior. I read somewhere that she was advised recently that she had been too inaccessible in the past, though I seem to remember hearing frequently over her four years in office about her holding meetings for constituents to communicate with her. I wonder now if our congresspeople, like so many others in the public eye will have to be so security conscious that normal interaction and give and take between them and their constituents will be impossible. Yet another weakening of democratic process in this country.
Some of the murdered in this incident include a nine year old girl who wanted to learn more about politics and government, a well-respected federal judge, Gabby's constituent services director, and three civic minded elderly retirees.
We couldn't afford to lose any of them, either. But, we mustn't think that the easy availability of guns had anything to do with this tragedy. "A well regulated militia, being necessary to the security of a free state, the right of the people to keep and bear Arms shall not be infringed." I suppose it would only show my hopelessly liberal anti-freedom bias to suggest that a little more regulation of our vast militia of arms bearing people might be in order.
.
This guest post by William Bemis is the second of three related to the recent shootings of Gabrielle Giffords and others in Tucson (in Pima County), AZ. Shortly before the shootings, the NY Times reported on a decision by the AZ Board of Education (a state agency in the capital, Phoenix) to close a Latino studies class in a Tucson High School. Urged by family members to consider relocation, Mr. Bemis, a psychotherapist and my brother-in-law, wrote this response, speaking of the Arizona city whose City Council had previously voted to ask the state to rescind its anti-immigrant law; after the shooting, at my request, he added additional material.
No, my dear, it's time for us and others like us to re-double our efforts to not only preserve Pima County as an island of sanity in this sea of ideological madness, but help the rest of the state and the nation see that leaving all the levers of power in the hands of racist corporate stooges is not going to take us anywhere but down. Having lived in this state for over 40 years now, I've seen this before - with Evan Meacham and Fife Symington, for example. After each of these lunatic lurches to the right, the state came back to at least a more moderate centrist political configuration. Arizona will never be Massachusetts or Oregon or Minnesota, but I, for one, am not ready to leave and concede this beautiful and unique place to the hate mongering front men for big money interests.
I loved living in New York, but we could never afford it, and besides, although their antics are less spectacularly loony, I wouldn't call the New York state government an example to emulate. Where else? Illinois? Puh-leeze! California? Are we talking about the homeland of Nixon, Reagan, Robert Dornan, et al? Sadly, Californios have also had to deal with home grown right wing fanatics, que no? Oregon? A more congenial political environment, perhaps, and a beautiful state, but too much rain!
It isn't just here, is it? I think we have to take the long view. The so-called conservatives (what do they wish to conserve besides entrenched wealth?) are riding high right now, both here and in Washington, but in the next couple of years they are going to amply demonstrate the meaness and poverty of their ideas. Contrary to the self delusions of Russell Pearce, Jan Brewer, Mitch McConnell, and John Boehner, I think these folks are cruising for a fall. I am more worried about the failure of those of us who do not share their agenda to take advantage of this moment than I am of the pseudo-populist, big money financed Tea Party. They have the money, so we all have to write our more modest checks and work all the harder. Our own apathy and discouragement is the enemy.
Moments after writing the above, I heard the news that Gabrielle Giffords, our Congresswoman, had been shot by yet another disturbed young loner of the type who seem to implement "Second Amendment solutions " to their private frustration and alienation on an almost daily basis now, thereby spreading their own psychic pain to all the rest of us. Cue the required messages of horrified shock and condolences from politicians of all persuasions, including even Sarah Palin who put Gabby's district literally in the rifle sight cross hairs and who tells her followers, "Don't retreat, RELOAD!" Some of those messages are no doubt sincere, but the one politician who was the most eloquent to me was Pima County Sheriff Clarence Dupnik, who doesn't get nearly the amount of press as his counterpart in Maricopa County, possibly because he is a hardworking, low key, decent, and fair public servant, which never seems to make good copy. Sheriff Dupnik's comments about political vitriol triggering mentally unbalanced individuals goes right to the heart of the current political climate in Arizona and across the country.
Gabrielle Giffords is a self-described "Blue Dog Democrat". For me, her politics are way too centrist in an era when what used to be the core values of the Democratic Party are under siege. If only she fit the liberal label that the Tea Party would like to pin on her! Though Gabby's stances on a lot of issues frustrated me, I worked as a volunteer on her election campaigns because I knew she was absolutely the best person we could hope to have elected to Congress from her district, which is Republican overall and in many precincts virulently racist and violent. Gabby is smart, dedicated, articulate, hard-working, extremely personable, and so much better than her recent opponent whom she barely defeated that I would have been ashamed if he had won and I hadn't done what I could to put her back in office. She is surviving so far the bullet that passed through her brain, and the trauma surgeons are optimistic, but I can't help but wonder if she does survive if she will ever be able to function again at the level she did prior. I read somewhere that she was advised recently that she had been too inaccessible in the past, though I seem to remember hearing frequently over her four years in office about her holding meetings for constituents to communicate with her. I wonder now if our congresspeople, like so many others in the public eye will have to be so security conscious that normal interaction and give and take between them and their constituents will be impossible. Yet another weakening of democratic process in this country.
Some of the murdered in this incident include a nine year old girl who wanted to learn more about politics and government, a well-respected federal judge, Gabby's constituent services director, and three civic minded elderly retirees.
We couldn't afford to lose any of them, either. But, we mustn't think that the easy availability of guns had anything to do with this tragedy. "A well regulated militia, being necessary to the security of a free state, the right of the people to keep and bear Arms shall not be infringed." I suppose it would only show my hopelessly liberal anti-freedom bias to suggest that a little more regulation of our vast militia of arms bearing people might be in order.
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Saturday, January 15, 2011
Risk, Primitive Reactions, and Human Health Behaviors
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NPR’s “All Things Considered” recently reviewed several scary events from 2010 (“The year in fear: fright or fallacy?”). Reporter Jon Hamilton spoke with Dr. David Ropiek, Director of Risk Communication at the Harvard Center for Risk, about what made these events (Toyota’s acceleration problems, the Deepwater Horizon oil spill and the use of chemical dispersants, etc.) particularly frightening. Dr. Ropiek said that people tend to make decisions, and react positively or negatively, based on very simplistic (and usually unconscious) criteria, rather than on careful critical analysis of the relative benefits of one course of action over another, with the most important criterion being “is there immediate danger?” The reason he gave was that our basic neurobiology was unchanged over human history while our culture and society was remarkably more complex than when quick decisions were mostly about achieving immediate results (fight or flee). “We use a risk-perception system that evolved in simpler times, when the risks were bad guys with clubs, and the dark, and wolves. It's quick. But quick isn't necessarily the best for the complicated stuff we face in modern society.” Thus, for example, even though the evidence would show that the human and environmental danger of the oil spill was in the oil much more than any risk from chemical dispersants, “Just the word chemicals in your listeners' minds is currently setting off a little organ in their brain called the amygdala, which is the 24/7 radar in our brain that says - is there danger in that data?”; that is, our fears are triggered by the word (chemicals) which we have come to associate with danger.
Similarly, people can grasp the specific, and feel the pain, for an individual more easily than for a large, amorphous population. Thus, the outpouring of concern for “Baby Jessica” falling down a well in 1987, or for the child dying of leukemia, is much stronger than that for thousands of people, especially those in other countries, dying of war, disease, or even more abstract, structural violence. It is not just the one versus the many; it is the suddenness of it. We feel for the trapped Chilean miners, or the victims of a bombing; Ropiek says “… a chronic risk doesn’t ring our alarm bells the way a catastrophic, all-at-once one does. Because it concentrates the mind to see a bunch of the tribe all whacked at once.” So a particularly gory battle or atrocity is horrifying, but when there are chronic, repeated bombings and battles (as in Iraq or Afghanistan), even though they lead to much more death, we feel less.
We can see a murderer as a bad person, but it is harder to identify the members of the “grifter class” (coined by Matt Taibbi, “Griftopia”[1] ) who are responsible for the financial system that has visited so much evil on all of us. When people hear about something they know little or nothing about, especially if it is very complex and hard to understand, they often deal with it by putting a “frame” around it, tying it to something that seems similar enough (at least in one dimension) that they feel they can hang their hat on the analogy and judge it. For example, “chemicals=bad” in the example above is such a frame; so is dealing with universal health insurance by framing it as “socialized medicine”=”socialism”=”bad”. Unfortunately, the world is far more complex than this, and more unfortunately unscrupulous politicians and opinion-makers (my frame = “selfish evil people”) take advantage of this to obscure complexity and buy into often nonsensical self contradictions (taxes=bad, deficits=bad; let’s not have either!)
When it comes to health and medicine, the same issues come into play. People perceive immediate distress with acute problems (e.g., cough, fever, and most especially pain!) and know how much they would appreciate relief. The impact of conditions that do not cause appreciable symptoms right now but will cause really bad outcomes (death, morbidity, poor quality of life) if untreated in the future, are much harder to get people to make high priorities. The doctor sees untreated hypertension in terms of a future outcome (stroke, kidney failure), but this is more difficult for the patient. Even when s/he believes and understands it intellectually, it is much less likely that the treatment of a largely asymptomatic condition will rise to the top of life’s many more urgent priorities (food, clothing, housing, childcare, work) than if it were, say, pain.
The problem is even greater for public health, as I discussed in Public Health and Changing People's Minds (Saturday, May 15, 2010) where populations are huge, timelines are long and risk is relative. Public health addresses risks for populations, not me, or my family; translating population risk into individual prior probability is fairly difficult. For most people, even the concept of risk – that a given event will not definitely have or definitely not have a particular result, but will be somewhere on the continuum between them – is something they are not accustomed to thinking about, although they use it all the time (deciding whether to cross on a red light, for example). Consciously comparing the relative risk of different actions is very difficult, especially when the results have very different timelines. A definite immediate benefit (have that tasty fried or sweet food; throw a wrapper out the window, get a big gas-guzzler, have unprotected sex) has a lot more weight than the possibility of a bad long-term outcome (besides, next time, in the future, I’m going to go on a diet, give up smoking, use condoms). Dr. Ropiek notes that because events that cause “a bunch of the tribe to be all whacked at once” happens relatively rarely, “…we tend to downplay chronic risks like car accidents, diabetes, heart disease and the flu.” Sometimes public health officials can create that fear and mobilize the attention of the populace, as with concern about the swine flu of 1976, but that is also an example of how, when predicted risk of bad outcomes doesn’t happen, it reinforces the tendency to downplay those chronic risks.
In making decisions about medical care, this sort of perception can cut either way, depending on how a person looks at it based on personal and familial experience, cultural beliefs, and the way they “frame” medical interventions, as well as how urgent or important a solution is. Some people do not trust doctors or medicines, based on these criteria, and prefer to not take medicines or advice, even when an analysis of the relative risk shows the treatment to be definitely beneficial. Others have unrealistic expectations of what medicine can do (fueled, of course, by both doctors and direct-to-consumer drug advertising), and are angry when the doctor cannot cure their viral illness, make their back pain disappear, or compensate for all of the other parts of life that are bad and make them happy. At times of serious illness, where both treatment and non-treatment have real risks, or at end of life when people are not ready to accept that it is the end of life, even a professional evaluation of relative risk/benefit is difficult, so it is hardly surprising that people return to simpler methods of decision making (will I be able to live another day? Will it end my/his/her pain?).
Hamilton ends the interview segment with: “So Ropiek says we need to acquire a new fear - the fear of getting risk wrong.” I wish us luck on that.
[1] Taibbi, M. Griftopia: Bubble Machines, Vampire Squids, and the Long Con That Is Breaking America. Random House. New York. 2010
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NPR’s “All Things Considered” recently reviewed several scary events from 2010 (“The year in fear: fright or fallacy?”). Reporter Jon Hamilton spoke with Dr. David Ropiek, Director of Risk Communication at the Harvard Center for Risk, about what made these events (Toyota’s acceleration problems, the Deepwater Horizon oil spill and the use of chemical dispersants, etc.) particularly frightening. Dr. Ropiek said that people tend to make decisions, and react positively or negatively, based on very simplistic (and usually unconscious) criteria, rather than on careful critical analysis of the relative benefits of one course of action over another, with the most important criterion being “is there immediate danger?” The reason he gave was that our basic neurobiology was unchanged over human history while our culture and society was remarkably more complex than when quick decisions were mostly about achieving immediate results (fight or flee). “We use a risk-perception system that evolved in simpler times, when the risks were bad guys with clubs, and the dark, and wolves. It's quick. But quick isn't necessarily the best for the complicated stuff we face in modern society.” Thus, for example, even though the evidence would show that the human and environmental danger of the oil spill was in the oil much more than any risk from chemical dispersants, “Just the word chemicals in your listeners' minds is currently setting off a little organ in their brain called the amygdala, which is the 24/7 radar in our brain that says - is there danger in that data?”; that is, our fears are triggered by the word (chemicals) which we have come to associate with danger.
Similarly, people can grasp the specific, and feel the pain, for an individual more easily than for a large, amorphous population. Thus, the outpouring of concern for “Baby Jessica” falling down a well in 1987, or for the child dying of leukemia, is much stronger than that for thousands of people, especially those in other countries, dying of war, disease, or even more abstract, structural violence. It is not just the one versus the many; it is the suddenness of it. We feel for the trapped Chilean miners, or the victims of a bombing; Ropiek says “… a chronic risk doesn’t ring our alarm bells the way a catastrophic, all-at-once one does. Because it concentrates the mind to see a bunch of the tribe all whacked at once.” So a particularly gory battle or atrocity is horrifying, but when there are chronic, repeated bombings and battles (as in Iraq or Afghanistan), even though they lead to much more death, we feel less.
We can see a murderer as a bad person, but it is harder to identify the members of the “grifter class” (coined by Matt Taibbi, “Griftopia”[1] ) who are responsible for the financial system that has visited so much evil on all of us. When people hear about something they know little or nothing about, especially if it is very complex and hard to understand, they often deal with it by putting a “frame” around it, tying it to something that seems similar enough (at least in one dimension) that they feel they can hang their hat on the analogy and judge it. For example, “chemicals=bad” in the example above is such a frame; so is dealing with universal health insurance by framing it as “socialized medicine”=”socialism”=”bad”. Unfortunately, the world is far more complex than this, and more unfortunately unscrupulous politicians and opinion-makers (my frame = “selfish evil people”) take advantage of this to obscure complexity and buy into often nonsensical self contradictions (taxes=bad, deficits=bad; let’s not have either!)
When it comes to health and medicine, the same issues come into play. People perceive immediate distress with acute problems (e.g., cough, fever, and most especially pain!) and know how much they would appreciate relief. The impact of conditions that do not cause appreciable symptoms right now but will cause really bad outcomes (death, morbidity, poor quality of life) if untreated in the future, are much harder to get people to make high priorities. The doctor sees untreated hypertension in terms of a future outcome (stroke, kidney failure), but this is more difficult for the patient. Even when s/he believes and understands it intellectually, it is much less likely that the treatment of a largely asymptomatic condition will rise to the top of life’s many more urgent priorities (food, clothing, housing, childcare, work) than if it were, say, pain.
The problem is even greater for public health, as I discussed in Public Health and Changing People's Minds (Saturday, May 15, 2010) where populations are huge, timelines are long and risk is relative. Public health addresses risks for populations, not me, or my family; translating population risk into individual prior probability is fairly difficult. For most people, even the concept of risk – that a given event will not definitely have or definitely not have a particular result, but will be somewhere on the continuum between them – is something they are not accustomed to thinking about, although they use it all the time (deciding whether to cross on a red light, for example). Consciously comparing the relative risk of different actions is very difficult, especially when the results have very different timelines. A definite immediate benefit (have that tasty fried or sweet food; throw a wrapper out the window, get a big gas-guzzler, have unprotected sex) has a lot more weight than the possibility of a bad long-term outcome (besides, next time, in the future, I’m going to go on a diet, give up smoking, use condoms). Dr. Ropiek notes that because events that cause “a bunch of the tribe to be all whacked at once” happens relatively rarely, “…we tend to downplay chronic risks like car accidents, diabetes, heart disease and the flu.” Sometimes public health officials can create that fear and mobilize the attention of the populace, as with concern about the swine flu of 1976, but that is also an example of how, when predicted risk of bad outcomes doesn’t happen, it reinforces the tendency to downplay those chronic risks.
In making decisions about medical care, this sort of perception can cut either way, depending on how a person looks at it based on personal and familial experience, cultural beliefs, and the way they “frame” medical interventions, as well as how urgent or important a solution is. Some people do not trust doctors or medicines, based on these criteria, and prefer to not take medicines or advice, even when an analysis of the relative risk shows the treatment to be definitely beneficial. Others have unrealistic expectations of what medicine can do (fueled, of course, by both doctors and direct-to-consumer drug advertising), and are angry when the doctor cannot cure their viral illness, make their back pain disappear, or compensate for all of the other parts of life that are bad and make them happy. At times of serious illness, where both treatment and non-treatment have real risks, or at end of life when people are not ready to accept that it is the end of life, even a professional evaluation of relative risk/benefit is difficult, so it is hardly surprising that people return to simpler methods of decision making (will I be able to live another day? Will it end my/his/her pain?).
Hamilton ends the interview segment with: “So Ropiek says we need to acquire a new fear - the fear of getting risk wrong.” I wish us luck on that.
[1] Taibbi, M. Griftopia: Bubble Machines, Vampire Squids, and the Long Con That Is Breaking America. Random House. New York. 2010
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Sunday, January 9, 2011
The Arizona shootings: When will we ever learn?
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My heart -- and those of my family, many of whom live in her district -- go out to the family and friends of Rep. Gabrielle Giffords, and Judge John Roll and all the other victims of the shooting. As politicians of all stripes have said, it is a tragedy, and the perpetrator is obviously deranged. That said, the irresponsible rhetoric of those who would never do such a thing themselves is inflamm
atory, and sets off the "weapon", the sacrificial lamb, who carries out the attack. The parallels of this to the assassination of George Tiller are obvious -- politicians, radioheads, and bloviators engage in increasing violent rhetoric and then protest innocence when an unstable disciple carries out a violent attack. Can Sarah Palin deny her "crosshairs" post (now taken down) on her website? Can Jesse Kelly, who ran against Rep. Giffords in 2010 (not to be confused with her husband, astronaut Mark Kelly) deny his posters where he posed in Marine uniform with his M-16 and invited supporters to a shooting event to remove[1] Rep. Giffords? Can Beck, Limbaugh, et.al., deny that their rantings DO affect their dittoheads -- after all, that impact is what boosts their ratings, and their incomes.
And all the protestations that the aggressive elimination of gun control laws in Arizona and other states have nothing to do with guns being used for murder; the swaggering of gun-on-hip posses showing up in coffee shops to intimidate "liberals" not creating an environment where a murderer or assassin can legally be carrying a gun, are vapid. The NRA says "Guns don't kill people -- people kill people." That is true, but people with guns are able to kill more people, more rapidly, from a greater distance. You can bludgeon someone to death, but would John Roll be dead and Gabrielle Giffords in critical condition if Jared Loughner had attacked with a baseball bat? You can kill someone with a knife, but even if Loughner were an action-movie hero and could have thrown his knife with deadly accuracy at Rep. Giffords, would 9-year-old Christina Green be dead? Come on! Be grownups! You can't say one thing -- all guns of all types should be freely available -- and then deny the inevitable result! Well, of course you can, and it is done all the time.
If there is anyone who is eligible to be considered a hero in this tragedy, it is Pima County (Tucson area) Sheriff Clarence Dupnik, who movingly spoke of
his friends, and, in what might be a "politically risky" statement condemned the "vitriol" in the public debate that leads to such horror. (Video: http://www.cnn.com/2011/CRIME/01/09/arizona.shooting/index.html). The contrast of his obviously pained and saddened but measured, rational speech to the stormtrooper raids of his more infamous counterpart, Maricopa County (Phoenix area) Sheriff Joe Arpaio could not be greater.
We grieve for the dead and the wounded, and we grieve for our country. And we will take it back, our candlelight vigils against their M-16s.
My heart -- and those of my family, many of whom live in her district -- go out to the family and friends of Rep. Gabrielle Giffords, and Judge John Roll and all the other victims of the shooting. As politicians of all stripes have said, it is a tragedy, and the perpetrator is obviously deranged. That said, the irresponsible rhetoric of those who would never do such a thing themselves is inflamm
atory, and sets off the "weapon", the sacrificial lamb, who carries out the attack. The parallels of this to the assassination of George Tiller are obvious -- politicians, radioheads, and bloviators engage in increasing violent rhetoric and then protest innocence when an unstable disciple carries out a violent attack. Can Sarah Palin deny her "crosshairs" post (now taken down) on her website? Can Jesse Kelly, who ran against Rep. Giffords in 2010 (not to be confused with her husband, astronaut Mark Kelly) deny his posters where he posed in Marine uniform with his M-16 and invited supporters to a shooting event to remove[1] Rep. Giffords? Can Beck, Limbaugh, et.al., deny that their rantings DO affect their dittoheads -- after all, that impact is what boosts their ratings, and their incomes.And all the protestations that the aggressive elimination of gun control laws in Arizona and other states have nothing to do with guns being used for murder; the swaggering of gun-on-hip posses showing up in coffee shops to intimidate "liberals" not creating an environment where a murderer or assassin can legally be carrying a gun, are vapid. The NRA says "Guns don't kill people -- people kill people." That is true, but people with guns are able to kill more people, more rapidly, from a greater distance. You can bludgeon someone to death, but would John Roll be dead and Gabrielle Giffords in critical condition if Jared Loughner had attacked with a baseball bat? You can kill someone with a knife, but even if Loughner were an action-movie hero and could have thrown his knife with deadly accuracy at Rep. Giffords, would 9-year-old Christina Green be dead? Come on! Be grownups! You can't say one thing -- all guns of all types should be freely available -- and then deny the inevitable result! Well, of course you can, and it is done all the time.
If there is anyone who is eligible to be considered a hero in this tragedy, it is Pima County (Tucson area) Sheriff Clarence Dupnik, who movingly spoke of
his friends, and, in what might be a "politically risky" statement condemned the "vitriol" in the public debate that leads to such horror. (Video: http://www.cnn.com/2011/CRIME/01/09/arizona.shooting/index.html). The contrast of his obviously pained and saddened but measured, rational speech to the stormtrooper raids of his more infamous counterpart, Maricopa County (Phoenix area) Sheriff Joe Arpaio could not be greater.We grieve for the dead and the wounded, and we grieve for our country. And we will take it back, our candlelight vigils against their M-16s.
[1] “’I don't see the connection," between the fundraisers featuring weapons and Saturday's shooting’, said John Ellinwood, Kelly's spokesman. ‘I don't know this person, we cannot find any records that he was associated with the campaign in any way. I just don't see the connection.’” (AOL news)
Wednesday, January 5, 2011
Solving Medicare costs and the budget deficit: primary care, cost-effectiveness, and universal health coverage
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According to the New York Times, “Here is a basic truth about the deficit: In the long run, it cannot be fixed, without reining in spending on Medicare and Medicaid.” In a December 11, 2010 editorial titled “Health Care and the Deficit”, the Times lets us know that Medicare, Medicaid, and S-CHIP (the Children’s Health Insurance Program that covers low-income children whose families are too “rich” for Medicaid) account for more than 20% of federal expenditures, more than Social Security or national defense; and that, if unchecked, will rise to 40% by 2035. To the editorialist this is obviously unacceptable, and s/he reviews the proposals of the two recent “bipartisan” commissions that have made recommendations to reduce spending on these programs.
Overall, the editorial is good in that it is very critical of the recommendations of both commissions. “The most disturbing element of both reports is that, in their efforts to show quick savings, they shift much of the burden from the federal budget to individuals or, in some cases, to states. That may make the federal deficit look better, but it is a shell game that produces no real reduction in the cost of health care.” Bowles-Simpson (the conceived-of-as-a-deficit-reduction-but-changed-into-a-tax-cut panel, previously addressed in my blog of December 12, 2010 Tax Breaks for the "Masters of the Universe" or for the rest of us? ) wants mostly to save money by having greater “cost sharing” by Medicare beneficiaries.
While, as the editorialist points out, there is something to be said for people with any type of insurance not being completely insulated from the cost when they opt for probably-unnecessary expensive tests, the fact is that the fault is much less often on the part of the patient than on the part of the doctors who recommend these tests. This is particularly true when those doctors have a financial interest in doing the tests because they are highly-reimbursed for them. If this is the problem, then regulation should address it directly, by having Medicare, Medicaid, and other insurers use cost-effectiveness criteria rather than taking the real risk that “people on modest incomes might forgo needed care.”
The other panel, Domenici-Rivlin (another “bipartisan” group headed by a conservative Republican and a conservative Democrat), also recommends cost sharing, and goes even further by taxing the cost of health benefits that workers receive. It relies on the idea that, with cost sharing, beneficiaries will restrain their own spending. They are likely to – even at the cost of their own health. It also resurrects the idea of vouchers for people on Medicaid.
Yes: Medicare, Medicaid, and the entire US health system spend too much money; and yes: the cost of what is called “health care” is squeezing out spending on other critical social programs, such as education. But the recommendations of these two commissions, essentially capping spending while continuing to reward private health insurers through their “market-based” solutions, will only exacerbate the problem.
Meanwhile, following on the heels of Massachusetts’ experience in not having enough primary care doctors – or other providers – to meet the health needs of its increased number of insured citizens, California is experiencing the same problem, without even having a state-wide health reform. Documented in the PBS News Hour report aired November 18, 2010, “In California, facing down a family physician shortage”, residents of that state cannot find the primary care doctors they need to provide cost-effective care, and it is anticipated to get “worse” with health reform. Paul Leight, a health economist at the University of California Davis, states “So, we have more than 20 million Americans who now don't have health insurance who will have health insurance. And once they get health insurance, naturally, they're going to want to see a primary care physician.“ Naturally. And we don’t have nearly enough of them.
But, of course, as has been it seems endlessly documented on this blog and by study after study, including for example the Commonwealth Foundation’s 2010 report “Mirror, Mirror on the Wall: How the Performance of the U.S. Health Care System Compares Internationally, 2010 Update”[1], the US spends far more (2-3 times more!) and gets worse health outcomes than all other developed countries. Commonwealth’s 2008 report shows that the US, in terms of health outcomes, did worse than in its original report of 2006, and spending has continued to increase. The biggest reason for the excessive cost in the US is that it is based in a system geared to profit, by insurers, drug and device makers, and health care providers (including hospitals, doctors, nursing homes, etc.) As I have pointed out (for example, in A Modest Proposal: Bribe the Insurance Companies, August 23, 2009), it is not simply the profit itself that causes the grossly bloated cost of US health care, but the inefficient system built to ensure the continuation of that profit. To suggest solutions based on increasing the role of private, profit-incented, players as a method of controlling costs is illogical. Increasing profits will come either from increasing costs or from decreasing access to care. This is not the way to go.
The goal must not be simply reducing costs, but increasing quality. The wonderful thing about health care is that our system is so bloated and inverted in its incentives and outputs – and in having far more tertiary than primary care -- that this seeming contradiction, reduce costs and increase quality, can be achieved. Different groups push for more primary care, limitations on high cost technical procedures, and a more rational health system based upon universal access and elimination of profit. Unfortunately, taken alone, each is inadequate. Here is what the evidence shows will work:
More Primary Care. We need a system based upon primary care, so that Massachusetts, California, and the rest of the country, can have the primary care providers they need. This is the focus of the Patient Centered Primary Care Collaborative (PCPCC). This means completely changing the financial incentives at every level that lead to production of more subspecialists. The “encouragements” for increasing primary care contained in ACA are inadequate. The key issue is the inverted reimbursement system in which procedure-based subspecialists make many times the income-per-hour of primary care doctors. The reimbursement system used by Medicare (upon which all other insurers base their reimbursement), currently controlled by a specialist-dominated advisory group, needs to change entirely so that potential income is eliminated from the specialty-choice decisions of medical students, and so that procedure-based profit is eliminated from the decision of hospitals about what kind of care and specialists they wish to support.
Cost-effectiveness payment. Tied to changing the mix of primary and sub-specialty providers and their reimbursement is for Medicare and other payers to not pay for, or not pay as much for, unproven high-cost therapies, whether those are new drugs or devices or unproven procedures. This does not mean denying access to some procedures or drugs across the board to all patients; it means appropriately selecting those who are most likely to benefit. This is a complex science, but an easy concept: what is likely to be cost-effective for me may well not be for you, because we are different, in disease, disease stage, intercurrent conditions, underlying reserve, etc.
Universal not-for-profit health insurance system. This is the sine qua non, the single necessary element for improving the health of all our people. It is not sufficient in itself, but without it there is no chance to control costs, or to implement reimbursement reform, or to effectively limit the use of high-cost, low-effectiveness and/or unproven technologies.
These will work, but need to all be done. Expanding primary care and limiting expenditures on high-cost procedures will not improve everyone’s health unless we have a university health insurance system that is not based upon profit; a universal health system without increased primary care or cost-effectiveness criteria for procedures will not achieve either goal of improving America’s health or saving money. They are all necessary legs for the stool of cost-effective, high-quality, universally-accessible health care to stand up.
[1] K. Davis, C. Schoen, and K. Stremikis, How the Performance of the U.S. Health Care System Compares Internationally 2010 Update, The Commonwealth Fund, June 2010.
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According to the New York Times, “Here is a basic truth about the deficit: In the long run, it cannot be fixed, without reining in spending on Medicare and Medicaid.” In a December 11, 2010 editorial titled “Health Care and the Deficit”, the Times lets us know that Medicare, Medicaid, and S-CHIP (the Children’s Health Insurance Program that covers low-income children whose families are too “rich” for Medicaid) account for more than 20% of federal expenditures, more than Social Security or national defense; and that, if unchecked, will rise to 40% by 2035. To the editorialist this is obviously unacceptable, and s/he reviews the proposals of the two recent “bipartisan” commissions that have made recommendations to reduce spending on these programs.
Overall, the editorial is good in that it is very critical of the recommendations of both commissions. “The most disturbing element of both reports is that, in their efforts to show quick savings, they shift much of the burden from the federal budget to individuals or, in some cases, to states. That may make the federal deficit look better, but it is a shell game that produces no real reduction in the cost of health care.” Bowles-Simpson (the conceived-of-as-a-deficit-reduction-but-changed-into-a-tax-cut panel, previously addressed in my blog of December 12, 2010 Tax Breaks for the "Masters of the Universe" or for the rest of us? ) wants mostly to save money by having greater “cost sharing” by Medicare beneficiaries.
While, as the editorialist points out, there is something to be said for people with any type of insurance not being completely insulated from the cost when they opt for probably-unnecessary expensive tests, the fact is that the fault is much less often on the part of the patient than on the part of the doctors who recommend these tests. This is particularly true when those doctors have a financial interest in doing the tests because they are highly-reimbursed for them. If this is the problem, then regulation should address it directly, by having Medicare, Medicaid, and other insurers use cost-effectiveness criteria rather than taking the real risk that “people on modest incomes might forgo needed care.”
The other panel, Domenici-Rivlin (another “bipartisan” group headed by a conservative Republican and a conservative Democrat), also recommends cost sharing, and goes even further by taxing the cost of health benefits that workers receive. It relies on the idea that, with cost sharing, beneficiaries will restrain their own spending. They are likely to – even at the cost of their own health. It also resurrects the idea of vouchers for people on Medicaid.
Yes: Medicare, Medicaid, and the entire US health system spend too much money; and yes: the cost of what is called “health care” is squeezing out spending on other critical social programs, such as education. But the recommendations of these two commissions, essentially capping spending while continuing to reward private health insurers through their “market-based” solutions, will only exacerbate the problem.
Meanwhile, following on the heels of Massachusetts’ experience in not having enough primary care doctors – or other providers – to meet the health needs of its increased number of insured citizens, California is experiencing the same problem, without even having a state-wide health reform. Documented in the PBS News Hour report aired November 18, 2010, “In California, facing down a family physician shortage”, residents of that state cannot find the primary care doctors they need to provide cost-effective care, and it is anticipated to get “worse” with health reform. Paul Leight, a health economist at the University of California Davis, states “So, we have more than 20 million Americans who now don't have health insurance who will have health insurance. And once they get health insurance, naturally, they're going to want to see a primary care physician.“ Naturally. And we don’t have nearly enough of them.
But, of course, as has been it seems endlessly documented on this blog and by study after study, including for example the Commonwealth Foundation’s 2010 report “Mirror, Mirror on the Wall: How the Performance of the U.S. Health Care System Compares Internationally, 2010 Update”[1], the US spends far more (2-3 times more!) and gets worse health outcomes than all other developed countries. Commonwealth’s 2008 report shows that the US, in terms of health outcomes, did worse than in its original report of 2006, and spending has continued to increase. The biggest reason for the excessive cost in the US is that it is based in a system geared to profit, by insurers, drug and device makers, and health care providers (including hospitals, doctors, nursing homes, etc.) As I have pointed out (for example, in A Modest Proposal: Bribe the Insurance Companies, August 23, 2009), it is not simply the profit itself that causes the grossly bloated cost of US health care, but the inefficient system built to ensure the continuation of that profit. To suggest solutions based on increasing the role of private, profit-incented, players as a method of controlling costs is illogical. Increasing profits will come either from increasing costs or from decreasing access to care. This is not the way to go.
The goal must not be simply reducing costs, but increasing quality. The wonderful thing about health care is that our system is so bloated and inverted in its incentives and outputs – and in having far more tertiary than primary care -- that this seeming contradiction, reduce costs and increase quality, can be achieved. Different groups push for more primary care, limitations on high cost technical procedures, and a more rational health system based upon universal access and elimination of profit. Unfortunately, taken alone, each is inadequate. Here is what the evidence shows will work:
More Primary Care. We need a system based upon primary care, so that Massachusetts, California, and the rest of the country, can have the primary care providers they need. This is the focus of the Patient Centered Primary Care Collaborative (PCPCC). This means completely changing the financial incentives at every level that lead to production of more subspecialists. The “encouragements” for increasing primary care contained in ACA are inadequate. The key issue is the inverted reimbursement system in which procedure-based subspecialists make many times the income-per-hour of primary care doctors. The reimbursement system used by Medicare (upon which all other insurers base their reimbursement), currently controlled by a specialist-dominated advisory group, needs to change entirely so that potential income is eliminated from the specialty-choice decisions of medical students, and so that procedure-based profit is eliminated from the decision of hospitals about what kind of care and specialists they wish to support.
Cost-effectiveness payment. Tied to changing the mix of primary and sub-specialty providers and their reimbursement is for Medicare and other payers to not pay for, or not pay as much for, unproven high-cost therapies, whether those are new drugs or devices or unproven procedures. This does not mean denying access to some procedures or drugs across the board to all patients; it means appropriately selecting those who are most likely to benefit. This is a complex science, but an easy concept: what is likely to be cost-effective for me may well not be for you, because we are different, in disease, disease stage, intercurrent conditions, underlying reserve, etc.
Universal not-for-profit health insurance system. This is the sine qua non, the single necessary element for improving the health of all our people. It is not sufficient in itself, but without it there is no chance to control costs, or to implement reimbursement reform, or to effectively limit the use of high-cost, low-effectiveness and/or unproven technologies.
These will work, but need to all be done. Expanding primary care and limiting expenditures on high-cost procedures will not improve everyone’s health unless we have a university health insurance system that is not based upon profit; a universal health system without increased primary care or cost-effectiveness criteria for procedures will not achieve either goal of improving America’s health or saving money. They are all necessary legs for the stool of cost-effective, high-quality, universally-accessible health care to stand up.
[1] K. Davis, C. Schoen, and K. Stremikis, How the Performance of the U.S. Health Care System Compares Internationally 2010 Update, The Commonwealth Fund, June 2010.
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