Michael Marmot, the British Medical Association, and the Social Determinants of Health

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The social determinants of health are real and profound. They are the aspects of life outside the medical office and hospital, outside of drugs and surgery, that affect our health. Income differences, education differences, and differences in social cohesion, to name a few, have been extensively described in the literature and have even made some headway in the medical curriculum at many schools. Addressing health disparities is a major focus of our Healthy People 2020 effort. Recognizing and addressing the social determinants of health has been, and will continue to be, the primary focus of this blog. A few recent posts addressing this topic include Healthful Behaviors: Why do people adopt them? Or not? October 8, 2011 and "Health in All" policies to eliminate health disparities are a real answer, August 18, 2011, and a little longer ago, Social Determinants, Personal Responsibility, and Health System Outcomes, September 12, 2010.

Some of the most important work in the area of social determinants of health has been done by the British physician and epidemiologist Sir Michael Marmot, whose “Whitehall” studies, begun decades ago, showed that health status was associated with socioeconomic class. He has continued this with his recent work “Fair Society, Health Lives”[1]. Thus, it should not come as a surprise that it was under Dr. Marmot’s recently-completed tenure as President that the British Medical Association (BMA) issued its report “Social Determinants of Health: What Doctors Can Do”, in October 2011. It is more interesting that Dr. Marmot, in his introduction to the report, notes that “ … as I mentioned in my presidency acceptance speech, I was surprised at being approached to be president at all,” because “My work has been focused on inequalities in health where I have emphasised the circumstances in which people are born, grow, live, work, and age rather than anything specifically to do with health care provision. I have emphasised not just the causes of health inequalities—behaviours, biological risk factors—but the causes of the causes. The causes of the causes reside in the social and economic arrangements of society: the social  determinants of health. More than that though more recently my work has looked at what can be done to address these issues across the life-course.”

Many of us in medicine, even on this side of the Atlantic, were thrilled that the BMA had chosen Dr. Marmot as its president precisely for these reasons. The current report shows that this was well-placed enthusiasm, for it marks a the commitment of the BMA to improving the health of the British population even, and perhaps especially, when that requires physicians to work outside of their “usual” venues. That is, when the work requires collaboration with other professionals, particularly educators but also social service agencies, to be effective. And to exercise their roles as community leaders, not simply purveyors of drugs, operations, and individual advice: “We recognise that not every doctor has the opportunity to change the social determinants of health throughout the life course of individual patients and have thus included other ways in which they can make a difference, as doctors working as community leaders.”

“Social Determinants of Health: What Doctors Can Do” presents conceptual models and large-scale goals, as well as principled statements of how physicians must act to create conditions of social justice and reduce the gradient of health disparity that results from different life circumstance. For example, it takes from “Fair Society, Healthy Lives” the following set of policy objectives that physicians and their organizations should work towards:

A - Give every child the best start in life

B - Enable all children, young people and adults to maximise their capabilities and have

control over their lives

C - Create fair employment and good work for all

D - Ensure healthy standard of living for all

E - Create and develop healthy and sustainable places and communities

F - Strengthen the role and impact of ill health prevention

          (These are expanded upon in “Annex A”, beginning on p. 26)

However, the paper goes beyond these generalities and provides specific examples of programs that have been and are in place in different communities across Britain that have made an impact on these areas. The BMA commits that they “will keep examples of effective actions on our website, and encourage the World Medical Association to garner international examples, to aid doctors seeking ways to make a difference.” One example of this two-phased approach of identifying the problems and seeking examples of solution is in “The Health Impacts of Cold Homes and Fuel Poverty report”, whose main findings of direct impacts included:

          - Countries which have more energy efficient housing have lower excess winter deaths (EWDs).

          - EWDs are almost three times higher in the coldest quarter of housing that in the warmest quarter.

          - Around 40% of EWDs are attributable to cardiovascular diseases.

          - Around 33% of EWDs are attributable to respiratory diseases.

          - Mental health is negatively affected by fuel poverty and cold housing for any age group.

          - Cold housing increases the level of minor illnesses such as colds and flu and exacerbates existing conditions such as arthritis and rheumatism.

          - Cold housing negatively affects dexterity and increases the risk of accidents and injuries in the home.

Main findings of indirect impacts:

- Cold housing negatively affects children’s educational attainment, emotional well-being and resilience.

- Fuel poverty negatively affects dietary opportunities and choices.

- Investing in the energy efficiency of housing can help stimulate the labour market and economy, as well as creating opportunities for skilling up the construction workforce.”

They then describe a program in Manchester that is working to addresses this problem.

Another intervention is occurring in an impoverished part of England, where the “Bromley-by-Bow Centre aims to serve the local community by providing a wide range ofservices and activities, which are integrated and co-operative in nature. They host the local GP surgery, a variety of social enterprises, a children’s centre, artists’ studios, a healthy living centre, and provide adult education courses, care and health services for vulnerable adults, outreach programmes and a range of advice services. This approach enables GPs to refer patients to services that help to tackle the social determinants of ill health, including welfare, employment, housing and debt advice services.”

A society can never achieve a significant improvement in health, or decrease health disparities, unless it consciously and forthrightly addresses the social determinants of health. Physicians can be leaders in this effort, or they can sit comfortably in their offices and hospitals tending to the individual health problems of people that could have been prevented before. Dr. Marmot says  

“During my tenure I have been struck, but not surprised, by members’ utter commitment to

improving the health, not just of individual patients, but of society as a whole….As the year progressed I could see more and more how my tenure at the BMA and my work on the social determinants of health were a perfect fit. Time after time I was faced with examples where doctors were working tirelessly to increase fairness and social justice by acting on the social determinants of health to reduce health inequalities.”

That makes me proud of my colleagues in Britain and in the BMA, but these are also characteristics of many doctors in the US. And of many medical students, who are driven by their desire to make a difference. The US is not the UK (we don’t, for one really big example, have a national health service or even a national health insurance program!), but we have real needs and real caring people, including physicians. We just need to keep focused on health and how to improve it and not be dissuaded by tangential issues. We need to maintain the energy and idealism of medical students and ensure that it grows, rather than withers, thoughout their careers.

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[1] Marmot M, Allen J, Goldblatt P et al (2010) Fair Society, healthy lives: strategic review of health inequalites in England post 2010. London.

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Fluoridation: Dental health for all

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Fluoridation of the water supply is one of the great public health benefits of the 20^th century. It is also one of the persistently more controversial. Ideological opposition (to “the government” doing anything) has mixed with paranoia (they are poisoning us) to create a pretty sustained grass-roots movement, one that has blocked this effort in many places in the country. Now, according to Lizette Alvarez’ article in the NY Times “Looking to save money, more places decide to stop fluoridating the water” (October 14, 2011), saving money has been added to these arguments. The threat is that communities which have had the benefits of fluoridated water will lose them. This is apparently the what is happening in Pinellas County, Florida (the Clearwater/St. Petersburg area), as well as in Fairbanks, Alaska.

The situations in Florida and Alaska may well be different, however. The decision in Fairbanks is apparently tied to the relatively high levels of naturally-occurring fluoride in the water there, which would make fluoridation an unnecessary cost. In Florida, however, the decision seems to be driven by cost as well as the same issues I note above. “I’m in opposition to putting a medical treatment into the public drinking water supply without a vote of the people who drink that water,” said Norm Roche, a newly elected Republican county commissioner who spent 10 years doing policy research for the county Water Department and who led the turnaround effort. “We had a dozen to 15 doctors, dentists, dental hygienists and chemists here who want us to continue this practice but who could not agree themselves on how best to use fluoride.” The article does not further define what Mr. Roche means by “how best to use”, leaving us to imagine if this is an issue of putting it in the water vs another method (fluoridated toothpaste, fluoride treatments at home, fluoride varnishes by health providers) or disagreement as to whether it should be used at all.

In fact, the medical and dental community are pretty much in agreement that fluoride is good for preventing tooth decay, and that dental caries are a major cause of disability both medically and socially. It is hard for a child with a toothache to concentrate at school, not to mention the teasing that can come from having a mouthful of rotting teeth. This latter continues into adulthood; people with bad teeth (or no teeth) are seen as less smart and less competent, and are less likely to be hired in most jobs.

Fluoride works. In my “middle years”, my Chicago dentist had a pretty good idea of my age because he knew when the water in New York City, where I grew up, was first fluoridated. My “6-year molars” were covered with filled cavities (necessitating, all those years later, a lot of restoration work by him), while my “12-year molars”, which erupted after fluoridation, were almost cavity-free.  I sure remember getting all those cavities filled, before dentists had high-speed drills or used anesthesia for such a simple, common procedure. My childhood self would certainly advocate for fluoride to prevent that discomfort!

There are, indeed, side effects to high levels of fluoride, whether naturally occurring or otherwise. The main sign of “fluorosis” is “marble teeth disease”, with “grotesque” brown staining of the teeth. It was an investigation into this condition in Colorado Springs in 1909 that led to the discovery both that the cause was high fluoride levels in the water, and that these teeth had virtually no decay (“The Story of Fluoride”, from the National Institutes of Dental and Craniofacial Research). This led to work that identified a level of fluoride that could be added to drinking water that was sufficient to prevent decay but too low to produce this condition.

After spending most of my life in New York and Chicago, one of the most dramatic things to catch my attention early in my stay in San Antonio, Texas, were the young children with stainless steel teeth, whose mouths distressingly reminded me of “Jaws”, the James Bond villain (albeit without the points!). I soon learned two things: 1) the stainless steel teeth were the result of having a great pediatric dental program at our dental school which could fix the mouths of children whose “baby teeth” had all rotted out, allowing them to be both pain-free and able to eat, and 2) the water in San Antonio was not fluoridated, which was a major cause (in combination with other behaviors, such as use of sugared drinks in baby bottles, feeding sugared soft-drinks to young children beyond the bottle years,  and “bottle propping” which leaves the milk – and milk sugar – in the baby’s mouth) of the decay the led to the need for such repair. While only a small percentage of children in San Antonio had such stainless steel teeth, a very large percentage had significant and disabling tooth decay.

I also discovered that efforts to pass fluoridation had been defeated in San Antonio on at least two occasions in the past few decades. The opposition was largely from right-wing, John Birch Society, anti-government groups, but also included those who were from the other end of the political spectrum but believed in “natural” health, and thus opposed addition of fluoride. In 2002, an initiative spearheaded by the Mayor of San Antonio, finally led to passage of fluoridation for that city. During this campaign, virtually all the major politicians, all the dentists, physicians, and public health people, and most of the foundations and money were for the initiative. Nonetheless, it passed by only 52% of the vote. The good news here, I guess, is that it is an example of the power of regular people, not very well funded, to resist change being imposed on them. Unfortunately, it was contrary to their health interests.

As I note, the opposition was not solely from the right. During my time in San Antonio, I frequently attended open meetings of a group of progressives in a local Mexican restaurant. Primarily mainstream liberal Democrats, and including the late San Antonio New Deal mayor and newspaper columnist, Maury Maverick, the group was diverse, including socialists and “Greens” and even libertarians, whose interests in lack of government restrictions and privacy invasions gave them common cause. These last two groups, the Greens and libertarians, were opposed to fluoridation. The national Green presidential candidate, Ralph Nader, on a stop in San Antonio, even came out in opposition to the initiative. As a health care provider, I did my best to argue for the benefits of fluoridation, but was unable to win them over.

One argument made they made (at least the libertarians) was that “fluoride might be beneficial, but the government should not put it in our water supply”. Parents could use fluoridated toothpaste or fluoride rinses on their children’s teeth, or bring them to the dentist for fluoride varnish. Well, they could, but often they didn’t, and it was the children who would suffer the caries and their long-term consequences. Indeed in the ‘90s a new syndrome, dubbed “yuppie baby carie syndrome” was identified in children of well-off parents who made their infant formula with bottled water. (The causes of caries from bottle propping and unfluoridated water are well-described in the Wikipedia entry on “Early Childhood Caries”.) Of course, the spread of bottled water to a much wider socioeconomic group makes this even a bigger potential problem. Indeed, some water from natural springs contains minerals, sometimes including fluoride, while the bigger mass-products products from Coke – Dasani – and Pepsi – Aquafina – are municipal tap water that has been “purified” and thus do not.  (This does not even begin to touch on all the environmental costs of bottled tap water, from plastic bottles to transporting tap water from one part of the country to another, but that’s another story.)

San Antonio, and more recently San Diego, are victories for fluoridation, while many cities, such as Wichita, remain unfluoridated, and others, such as Pinellas County and Fairbanks are going the other way. If Fairbanks has sufficient natural fluoride, then supplementation is an unnecessary cost. For those communities without adequate natural fluoride, it is a big mistake.

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No way to run a hospital, no way to run a healthcare system

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In a  feature article in the NY Times on October 2, 2011, “Nowhere to go, except room 516” (retitled “Stuck in bed, at hospital’s expense” on-line), John Leland tells the story of Raymond Fok, a man admitted to a NYC hospital for a stroke while on his way to his kidney dialysis appointment, and hospitalized for 19 months. The reason for his extended hospitalization was not his medical illness. Although that illness was very significant, including both his kidney failure requiring dialysis and the stroke that resulted from bleeding into his brain, these are common conditions which almost never lead to hospitalization for more than a couple of weeks. Most often people in such situations are discharged to a skilled nursing facility (SNF) for rehabilitation, although occasionally people who recover very well and have a supportive family can go home, often with home-based physical therapy.

The reason that Mr. Fok did not leave the hospital was because there was nowhere for him to go. An undocumented resident of the city in which he had lived for 23 years, he was uninsured and ineligible for publicly-funded coverage (eg, Medicaid).  No nursing home, skilled nursing, or rehab facility would take him without a source of funding. Although only 58, had he been legally in the US, he would have been eligible for Medicare because of his need for kidney dialysis. It was not just that his family didn’t have money; they were not to be found. He had limited information to share with them, and it was a year before a family member was “discovered” visiting him. His wife and 2 sons are also undocumented, although his 18 year old daughter, born in the US, is a citizen. Finally he did go home, after accumulating a cost to New York Downtown Hospital of $1.4 million. Medicaid did end up paying for some of it. About $114,000, or 10%. The hospital absorbed the rest of the cost.

New York Downtown is in an area in which there are many immigrants, a large percentage of whom are not in the US legally. The hospital may not have many patients whose length of stay, and cost of care, are quite as much as Mr. Fok’s, but they certainly end of caring for a much higher percent of people who can and do pay little or nothing as do hospitals in neighborhoods that are more well to do neighborhoods (although, it turns out, Mr. Fok and his family live in Brooklyn, a long distance from NY Downtown). It seems a little unfair, kind of like a roll of the dice or a game of Russian roulette, that this hospital should have to bear the cost of his care because he ended up there.

It would not be unfair if the hospitals in New York, or in the United States, were “all in it together”. If they were not in competition with one another. If getting paid for services were not dependent on the luck of whether the people who need care are insured, or eligible for insurance. But that is not the case. In Canada, for example, most hospitals are not publicly-owned, but they are funded by a global budget negotiated with the health ministry of the Province in which they are located. And, of course, Canadian Medicare is a single-payer national health insurance program that means that all people are covered by insurance.

In the United States, however, hospitals compete. Rather than having a rational basis for creating health resources – enough beds, enough x-rays and MRI and CT machines, enough operating rooms, etc. – for the population of a community, it is “every hospital for itself”. In more densely populated communities, services are frequently duplicated (or triplicated, or quadruplicated!) A community of a certain size may “need”, say, one MRI machine. But if a particular hospital has that MRI machine, it gives them a competitive advantage over other hospitals; now each other hospital “needs” one. So we have too many. Thirty years ago the federal government supported local “PSRO”s that made such decisions, but they were very unpopular (with the “losers”). Today we have each hospital trying to build bigger, fancier units for the care of certain profitable conditions like cancer or heart disease, in hopes of attracting patients (insured patients, of course) to their institution rather than to a competitor. That is, we build an oversupply of resources to care for certain conditions (the ones for which reimbursement is profitable) and for certain patients (those who live in metropolitan areas and are insured).

On the other hand, we have communities, primarily rural communities, where there are no hospitals, and where people have to drive long distances for care. The state of Kansas is among those with the largest number of “critical access” hospitals, usually very small and the only ones in the county. They are rarely profitable, but are kept alive because they receive both county funds and enhanced reimbursement from government payers (Medicare and Medicaid). Despite this extra funding, the majority are losing money; if only operating revenue is considered, most are (see the graphics).

What kind of a health system is this? In urban areas we overbuild capacity of beds, imaging systems, and the like, and hospitals compete for paying patients, especially those whose diseases, such as cancer and heart disease, have a high-margin of profit. In rural areas, patients often have to commute long distances for care. The result is that if you are insured and have a high-profit-margin disease, you are a sought after customer; if you are not, or live in a rural area, you are probably out of luck.

And, if you are such a patient and no one wants to pay for you but you find your way to the hospital, like Raymond Fok, then the hospital is out of luck. This is no way to run healthcare. It is no way to run a society.

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PSA redux: The USPSTF finally recommends NOT getting it!

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The US Preventive Services Task Force (USPSTF), the independent group of physicians and scientists who make recommendations to the government, medical community, and American people on the value of screening tests, recently came out with a new recommendation on the use of laboratory tests for Prostate Specific Antigen (PSA) in screening for prostate cancer.  It recommended AGAINST it --in their terms, a “D” recommendation. Previously, USPSTF had recommended against PSA screening for men over the age of 75, but had not taken a position for or against screening in younger men (an “I” recommendation, insufficient evidence to recommend for or against screening).

My belief is that this is a good, appropriate, and very overdue recommendation which will come as no surprise to those who have read this blog for some time. I, and guest authors, have addressed this issue several times (PSA Screening: What is the value?, Mar 21, 2009; PSA Screening: “One of Medicine's Great Success Stories"?, Oct 27, 2009 (by Robert Ferrer);, Men’s Health? Women’s Health? Valid screening opportunities or “Hallmark Holidays”?, Mar 15, 2011). In addition I have often linked to and cited the work of Kenny Lin, MD, who writes the Common Sense Family Doctor blog, and resigned from the Agency for Healthcare Quality and Research (AHRQ) as a member of the USPSTF support team in November, 2010, over his perception that these recommendations were being delayed by political considerations. Dr. Lin has also written about PSA testing often  (including  "It is time to stop this [PSA] June 21, 2011, PSA testing: will science finally trump politics? Feb 28, 2011) and has recently addressed the new recommendations on Oct 7, 2011, Shannon Brownlee on the pros and cons of early cancer screening.

Of course, a lot of people do not think that this recommendation is a good thing. Two large groups, in particular, oppose the new recommendations: urologists and others who earn their livings treating prostate cancer and “advocacy” groups, supported by many high-profile (as well as just regular folks) men who have survived prostate cancer. Many of these men are quoted in Gardner Harris’ NY Times article “US panel says no to prostate screening for healthy men”, October 7, 2011. One of those who is quoted (actually not in the published NY Times piece, but in another version of Harris’ article published in the Seattle Times, is my colleague Brantley Thrasher, MD, Chair of the Department of Urology at the University of Kansas Medical Center, who said, "It appears to me that screening is accomplishing just what we would like to see: diagnose and treat the disease while it is still confined to the prostate and, as such, still curable."

I like Brant Thrasher, I think he is a good and knowledgeable doctor and great surgeon, but I strongly disagree with him on this one.  As much as we would like, and believe me as a family doctor I would like, and Kenny Lin would like, a test that could find disease early while it was still curable and make a difference in people’s live, PSA is not that test and, at this point prostate cancer is not that disease. These are two separate issues, so let’s take them separately.

PSA is not a good test. Yes, it is often, maybe usually, elevated in men with prostate cancer. Of course, in some men with prostate cancer it is not above the “normal” cutoff. This has led some advocates of PSA screening to suggest use of “PSA velocity”: check it yearly and watch the rate of rise rather than the absolute value. But the bigger problem for PSA as a screening test is that it is often elevated in men who do not have prostate cancer but just have a big prostate (“hypertrophy”, almost universal in men above a certain age), or even DO have cancer, but the very-slow-growing-that-is-not-going-to-kill-you-before-you-die-of-something-else kind, which is by far the most common variety. These men are subjected to ultrasounds, biopsies, and treatments that cause significant morbidity (impotence, incontinence of urine, and “radiation proctitis” of the rectum and anus, developing congestive heart failure from hormone treatment, to name a few) with no benefit.  Baylor physician and panel chair Virginia Moyer notes in the Times article that “This test cannot tell the difference between cancers that will and will not affect a man during his natural lifetime. We need to find one that does.” In 2010, Richard Ablin, PhD, who discovered the a prostate specific antigen (but not the PSA test) in 1970, called use of the test “a public health disaster” and “not much better than a coin toss.” (“The Great Prostate Mistake”, NY Times, March 9, 2010.

But the bigger issue is that there is no good evidence that treatment of any kind – surgical, radiation, hormonal – makes any difference in the outcome of prostate cancer. Surgeons like Brant Thrasher think it does, and he may be some day proven correct , at least in some circumstances, currently there is much more evidence supporting that it doesn’t than that it does. If you have the common, less-aggressive kind of prostate cancer, you won’t die from it, with or without treatment. If you have the rarer, highly-aggressive kind, you will probably die from it, with or without treatment.  The Times article notes that  “…advocates for those with prostate cancer promised to fight the recommendation. Baseball’s Joe Torre, the financier Michael Milken and Rudolph W. Giuliani, the former New York City mayor, are among tens of thousands of men who believe a P.S.A. test saved their lives.” They may believe it, but they are probably (I obviously don’t have access to their medical records) wrong. The test diagnosed prostate cancer, they were treated for prostate cancer, and they are alive. QED. But it’s false logic, an association that doesn’t demonstrate cause. If they are alive now, they would be alive (at least as far as the prostate cancer is concerned) without the treatment. And they wouldn’t have those “little” problems like incontinence and impotence that seem like a small price to pay for not dying of cancer, but are a big price if the treatment didn’t make any difference. The famous folks who have died of prostate cancer, like Frank Zappa, died despite treatment.

The Times quotes Thomas Kirk, of Us TOO, the nation’s largest advocacy group for prostate cancer survivors, saying “The bottom line is that this is the best test we have, and the answer can’t be, ‘Don’t get tested.’” He’s wrong. That is the answer. We not only need a test that can distinguish the “bad” kind of prostate cancer that will kill you from the kind that probably won’t, we need treatments that evidence shows makes a difference in survival and quality of life if you do have the bad kind. In the meantime, getting tested is likely to create more harm than benefit.

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Healthful Behaviors: Why do people adopt them? Or not?

While I am not a psychologist or psychiatrist, I am both a family physician and a person. As such, I have observed human behavior for a long time. I have noted some psychological behaviors seem to be very common in the people that I have met both personally and professionally.  I won’t say that they are “human nature”, since this phrase almost always refers to something that the speaker believes in or finds dominant in his/her environment, and is usually very culturally bound. However, they are common. One of these is the tendency to deny the magnitude of risk inherent in the risky things we do (or the risks we take because of things we don’t do). At the same time, we magnify the degree of risk inherent in the things we pride ourselves on not doing (or doing, when we see doing them as if beneficial, and not doing them as risky). As a corollary, we are likely to criticize those who adopt the risky behaviors that we do not, or do not adopt the beneficial behaviors that we do. That is, judging others is easy.

Perhaps because many of these potential risks are to our health and safety, these attitudes are common in health care and public health workers. Health professionals who do not smoke, and have never smoked, often severely condemn those who do. But alcohol? A little wine is good for you, right? Maybe, but it depends on who you are. If you have a tendency towards alcoholism, or are pregnant, or are going to drive, it is not good for you. Or for others. Public health workers can strongly advocate for wearing bicycle and motorcycle helmets, and using infant car seats, but it is just possible that once or twice they were late for something and drove too fast or too carelessly. And hopefully didn’t have an accident, but could have, and certainly increased their risk for it. From a risk/benefit point of view (fire trucks and ambulances and police aside), being late for work is NEVER a reason to drive faster or more carelessly; in fact, because there is a natural temptation to do so, conscious governance of that temptation is the beneficial behavior.

The utility of adopting a healthful, or not adopting an unhealthful, behavior is complex. It depends on the likelihood of something bad happening, how bad that thing is, and how many people it affects. So eating unhealthful food and not exercising is bad, but mainly for the person (and their immediate family) if they get sick or die. Smoking in public places, and even more, driving less than carefully or under the influence of alcohol or drugs potentially affects more people. Not immunizing your children because it allows you prevent a common but unpleasant effect (getting a lot of shots) and possibly a bad but extraordinarily rare long-term effect (whether real, like Guillain-Barre from swine flu shots or not, like autism[1] must be balanced against both the risk of their acquiring the disease and its sequelae, as well as the impact on the overall population that results if lots of children, not just yours, are unimmunized.

Not long ago I saw a patient in her early 30s who was pretty obsessed with getting breast cancer. She had no particular risk factors (no first-degree female relatives with it), but had previously talked a physician into ordering a mammogram when she was just 28 (it was normal), and wanted another one. We discussed the risk, but she was pretty fixated on breast cancer. We also talked about other risks, of much more concern to me than to her: smoking 2 packs of cigarettes per day, having 3 different sexual partners and rarely using condoms, and having untreated hypertension. I suggested, strongly but I hope appropriately, that all of these were much greater risks to her health than was breast cancer. I don’t know that I got through.

I imagine that it is pretty easy for health professionals to agree with me about the relative risks for this woman. Why she was so concerned about breast cancer rather than her real risks is another question. Some obsessive neurosis? Excessive effectiveness of breast cancer awareness advertising? I’d suggest that in large part it is about personal responsibility, about whether she would have to take action to prevent a bad outcome. If she were really worried about the risk from blood pressure, from smoking, from unprotected sex with multiple partners (and she should be), she would have to do something, take some action to change her life, to take medicine, to give up an addiction. This would be hard. On the other hand, since there are no clear behaviors she would need to change to avoid breast cancer, this is a safer – that is, less challenging – thing to be concerned about, to be fixated on.

Are the rest of us so different? Even those of us who have almost no dangerous or risky habits or behaviors (are there such? If we apparently have none, there is a fair chance that we might be suffering from obsessive-compulsive disorder, also a potential risk!) Besides, some of us may always take care to wash our hands when using the restroom (and even use our elbows to turn off the water, as I saw a very young man do in a public place the other day), but take the risk of riding our bicycles on public thoroughfares. Or we may practice what we believe to be healthful eating, and may regularly ingest herbs and give our children vitamins that there is little or no data to support doing, but not give them immunizations.

Reducing health risk is also impacted by societal memory, or the lack thereof. This has been examined in the case of abortion rights, where younger women who have grown up during a period when abortion was legal (if increasingly unavailable, largely resulting from the campaign of terror from violent anti-abortion forces) do not see the urgency of fighting to continue it. It also often true in the case of HIV/AIDS, where young people who did not grow up seeing all their friends die of the disease before effective treatment was available may find themselves adopting the same high-risk behaviors. Or for those who never saw the devastation of epidemics of pertussis or diphtheria, or of measles, or of awful outcomes from Hemophilus influenza infections, to not see immunizing their children as critically important.

In addition, when we as individuals have good outcomes (or don’t have bad ones) we may tend to think it is deserved rather than attributing it to good fortune. We haven’t had car accidents because we are good drivers, not because we are lucky. We think we are healthy because we bike to work, or “eat right”, not because we are young and in a low-risk group. When we are older, we may believe that we are less ill than our friends because we do healthful things like yoga or take certain herbs, not because we lucked out in not getting cancer (or being born into a family with resources who could feed us well and educate us and provide us with other advantages) See also Social Determinants, Personal Responsibility, and Health System Outcomes, Sept 10, 2010).

I am not going to say “let s/he who is without sin cast the first stone”. I would, rather, ask all of us to recognize that an honest appraisal of our own risk behaviors is a first step to understanding those of others, and to helping them, and helping our society, achieve greater health.

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[1] Data on vaccines presented at the recent American Academy of Family Physicians (AAFP) meeting suggest the chance of an adverse vaccine outcome is approximately equal to the chance of winning the lottery, and that of dying from a vaccine about equal to spontaneously having quadruplets.

Are primary care physicians fees a major contributor to the high costs of US healthcare? No.

A recent article in Health Affairs by Miriam J. Laugesen of Columbia University and Sherry A. Glied of the Department of Health and Human Services has generated a lot of attention. “Higher Fees Paid To US Physicians Drive Higher Spending For Physician Services Compared to Other Countries”[1] looked at the amount paid to 1) primary care physicians for office visits, and 2) orthopedic surgeons for hip replacements, in the US, and compared them to five other countries (Australia, Canada, France, Germany, and the United Kingdom). The study also looked at overall physician income in those countries, and at a variety of factors that contribute to both. These factors include the mix of public (primarily Medicare in the US) and private insurance and the ratio of what private insurance pays relative to the public payer, cost and extent of medical education, and overhead expenses. They noted the relative income of primary care physicians to orthopedists in the various countries. Their stated reason for this study is that “The differential in spending on physician services is greater than the overall difference in total health spending between the United States and other nations.”

The concept that a significant portion of the US’ extremely high health care costs is due to high physician reimbursement has long been widely accepted, but the assertion that a part of the blame lies with high primary care incomes is rather new, and is the part of this article that has engendered the most attention. Robert Pear’s NY Times piece on September 7, 2011, “Doctor Fees Major Factor in Health Costs, Study Says” and the response letter from the American Medical Association (AMA) addressed the first part (both/all specialities). The second issue, the article’s focus on the fees of primary care physicians generated pushback from the president of the American Academy of Family Physicians (AAFP), Roland Goertz, who issued strong criticism of the implication that it is primary care physicians who account for the high cost of US healthcare (AAFP President Refutes Claims That Primary Care Physician Incomes Contribute to High Health Care Costs.) More basic information on the economic issues and assumptions that inform this kind of work are described quite clearly by Uwe Reinhardt in a Times “Economix” column on September 18, 2011, “The role of prices in health care spending”.

So what does the Laugesen and Glied study really show? It does show that primary care physicians in the US makes more than primary care physicians in the five other countries, and in some cases a good bit more. It also shows that orthopedic surgeons in the US make a lot more than orthopedic surgeons in other countries. These differences are not due primarily to seeing more patients (patients in those other countries have more visits than do primary care physicians than those in the US, averaging 5.95 per capita per year to the US’ 3.8, and orthopedists do not do significantly more procedures) but rather to the higher fees paid by private insurance in the US.

The study also shows, very significantly, and as emphasized by Dr. Goertz, that the ratio between the income of orthopedists and primary care doctors is much higher in the US than in those other countries. This bolsters the argument that, to the extent doctors’ fees contribute to the high cost of health care in the US, it is much more because of specialist rather than primary care, reimbursement.  The authors of the study note that “Most other countries, however, have moved further away from fee-for-service

than the United States has”, and that “Where physicians may charge fees above the national schedule, the practice is consistently more common among orthopedic surgeons than among primary care

physicians, regardless of country.”

A key finding of the study that also supports Goertz’ argument is that [my bold] “Overall, fees paid by Medicare to US physicians for office visits are comparable to those paid by public insurers in several other countries, and fees paid by US private insurers are slightly higher than those paid by private insurers in other countries. In contrast, fees paid by public payers to orthopedic surgeons for hip replacements in the United States are considerably higher than comparable fees for hip replacements in other countries, and fees paid by private insurers in the United States for this service are double the fees paid in the private sector elsewhere .” This is exacerbated by the fact that “In general, Americans are very low users of office visits and relatively high users of hip replacement surgery.”

US orthopedic surgeons earned at least 50% more than those of other countries, and the ratio of primary care to orthopedist income was the lowest in the US, 42%, compared to 60% in other countries. The authors note that “The differences in incomes relative to fees provide more confidence in the overall comparability of the data. They suggest that higher US fees are a consequence not only of higher practice expenses, but also of higher rewards for the skill and time of physicians.” The authors also address the greater cost of medical education to the individual in the US, but conclude that the increased reimbursement more than compensates for this difference. Work by the Graham Center (see figure) shows that medical student specialty choice is highly tied to projected income.

One factor not addressed in most of the commentary on this article is that the authors of the study say “In the United States this definition [of primary care] includes family practice, general practice, internal medicine, obstetrics and gynecology, and pediatrics.” They do this despite the fact that “this” refers to the immediately preceding sentence, which presents the 2008 definition from the Organization for Economic Cooperation and Development (OECD) of a “primary care physician as one who does not limit practice to certain disease categories”. This definition certainly does not include obstetrics/gynecology (OB/GYN). Why, then, do they include OB/GYNs? Unsurprisingly, the answer is largely political; the argument in the US was that many women receive their “primary care” from their OB/GYN. This logic, however, is deeply flawed. To the extent that women do so, they are not receiving comprehensive primary care, because OB/GYNs care for conditions involving the reproductive system and women are more than their reproductive tracts. Lest this be seen primarily as a matter of my personal sensitivity as a family physician, there is a very important issue because including them can dramatically skew the income data. As OB/GYNs are largely surgeons, their fees and income are much higher than those of the other specialties that are actually primary care, and raise the measured income of “primary care” physicians when they are included.

Laugesen and Glied show that “US primary care physicians earn about one-third more than do their counterparts elsewhere” but that “…neither public insurance nor private insurance generalist physician fees for basic office visits are much higher in the United States than in many of the comparison countries. Instead, US primary care doctors do somewhat better overall mainly because a much larger share of their incomes is derived from private insurance. In other countries where private primary care practice is permitted, the market share of this form of practice is relatively small.” They go on to say, however, that “For orthopedic surgeons, the story is quite different. US orthopedic surgeons earn much higher incomes than do their counterparts abroad, and there are more such surgeons per capita here than almost anywhere else. In consequence, comparison countries spend only about one-quarter as much as the United States spends on orthopedic surgeons. Rates of hip replacement surgery are not higher in the United States than elsewhere, although rates of other procedures performed by orthopedic surgeons may be. Much of the difference in earnings appears to be due to differential fees. Public-sector fees for hip replacement surgery in other countries are about half as high, on average, as Medicare fees in the United States.”

Finally, the ratio of primary care physicians (essentially all general and family physicians) to specialty physicians in other countries is much higher than in the US, so this is also an area in which their costs are lower. That is, more care is provided by primary care doctors and less by more expensive (even in those countries) specialists. Thus, the problem with health costs in the US is not the high cost of primary care. It is the private for-profit marketplace and the excessive fees paid by private insurance for surgical procedures and other specialty care that drives physicians’ fees to be so much higher in the US.

Among the many other changes that we need in our health system, two important ones are increasing the percent of our physician workforce that is primary care, and creating greater equity in the reimbursement among physicians.

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[1] Health Affairs, 30, no.9 (2011):1647-1656

Shall we be callous or shall we be people? There is hope.

This is a repost from yesterday from my other, non-medical, blog "Life the Universe, and a Few Things". I have gotten some positive feedback on it, so have decided to post it to MSJ as well.


Charles Blow, who appears every Saturday in the New York Times, is one of my favorite columnists. He is terse and articulate. His column always features a fascinating graphic with data that presents additional insight into his topic. Sometimes his topic is overtly political, as when he recently wrote about the disappointment many, including African-Americans, feel in President Obama. Frequently it is about people, especially poor people, especially children, and the incredible challenges that they face in this land of “everything for the rich and squeeze the most needy”. His colleague, Nicholas Kristof, often writes about the plight of children in the rest of the world. Between them, we learn a great deal of about the desperate situation of so many, as in Kristof's On Top of Famine, Unspeakable Violence, September 25, 2011.

So, on September 24, 2011, it was uplifting to have a column presenting something good happening for these children, It Takes a Village. Blow describes his visit to the Dorothy Day Apartments on Riverside Drive in West Harlem, a “former drug den” converted in 2003 to housing for destitute and homeless families. Most of the adults were drug addicts or are HIV victims or mentally ill or all these. He writes about the cheerfulness of the design of the entire building (including the art gallery on the top floor with views of the Hudson River), of the yoga done by “wee little legs that barely have kneecaps” on mats placed in a courtyard that was previously 6 feet deep in garbage.  It has been successful by any measure – no teenage pregnancies, successful graduations from high school and entry into college, and done at a cost far less than “housing” people in prison, shelters, or mental hospitals.

Blow quotes Lady Bird Johnson saying “Where flowers bloom, so does hope”. I am reminded of the song (taken from a poem by James Oppenheim written in 1911) “Bread and Roses”, “Yes, it is bread we fight for, but we fight for roses too!” The poem is associated with the women who struck the textile mills in Lawrence, MA in 1912, and since the name of many projects and organizations, including an “integrated arts” high school in Harlem.  If I am disappointed in anything in Blow’s column, it is that he fails to mention who Dorothy Day was. Day, who died in 1980, co-founded the Catholic Worker movement in 1933, “a nonviolent, pacifist movement that continues to combine direct aid for the poor and homeless with nonviolent direct action on their behalf”. If anyone wonders if Catholics are focused only on anti-abortion, anti-contraception, and child abuse, or whether there are those practicing the precepts contained in the New Testament rather than greed, prejudice, and selfishness, the Catholic Worker Movement is a good place to start. We are very fortunate to have such a center, Shalom House, in my town of Kansas City, KS.

On the same page as Blow’s op-ed is one by Theodore R. Marmor and Jerry L. Mashaw, who are academics rather than columnists. “How do you say ‘Economic Security”?” discusses the situation in the Depression in 1934, and how the government was seen as the vehicle for helping those in need to achieve a dignified life. They talk about how the discussion has changed in the last 50 years. “In 1934, the focus was on people, family security and the risks to family economic well-being that we all share. Today, the people have disappeared. The conversation is now about the federal budget, not about the real economy in which real people live.“  They go on to say that “In 1934, the government was us. We had shared circumstances, shared risks and shared obligations. Today the government is the other — not an institution for the achievement of our common goals, but an alien presence that stands between us and the realization of individual ambitions. Programs of social insurance have become “entitlements,” a word apparently meant to signify not a collectively provided and cherished basis for family-income security, but a sinister threat to our national well-being.”

There were selfish bad guys with lots of money in 1934. But they were unable to control the debate, hard as they tried, with their control of the media (Hearst newspapers, anyone?). Somehow today they do. Occasionally, there is a burst of hope, the mass rallying of regular people to contribute to and work for Barack Obama in 2008, and the dashing of hope as this figure too seems to serve those with the most power. Marmor and Mashaw conclude  “Over the last 50 years we seem to have lost the words — and with them the ideas — to frame our situation appropriately. Can we talk about this? Maybe not.”

I’d like to say “maybe yes”. Maybe we can look at the Dorothy Day Apartments and the Catholic Worker movement and Shalom House and the dozens of groups called “Bread and Roses” and the thousands of organizations and millions of people who really want to make this country and this world a better place for actual people, and have hope. And, if we want to look back for inspiration, let me offer a few passages from FDR’s “Four Freedoms” speech of January 6, 1941:

“The basic things expected by our people of their political and economic systems are simple. They are:

Equality of opportunity for youth and for others.
Jobs for those who can work.
Security for those who need it.
The ending of special privilege for the few.
The preservation of civil liberties for all.
The enjoyment -- The enjoyment of the fruits of scientific progress in a wider and constantly rising standard of living….

Many subjects connected with our social economy call for immediate improvement. As examples:
We should bring more citizens under the coverage of old-age pensions and unemployment insurance.
We should widen the opportunities for adequate medical care.
We should plan a better system by which persons deserving or needing gainful employment may obtain it….

In the future days, which we seek to make secure, we look forward to a world founded upon four essential human freedoms.
The first is freedom of speech and expression -- everywhere in the world.
The second is freedom of every person to worship God in his own way -- everywhere in the world.
The third is freedom from want, which, translated into world terms, means economic understandings which will secure to every nation a healthy peacetime life for its inhabitants -- everywhere in the world.
The fourth is freedom from fear, which, translated into world terms, means a world-wide reduction of armaments to such a point and in such a thorough fashion that no nation will be in a position to commit an act of physical aggression against any neighbor -- anywhere in the world.”

Are we now such a different people that such aspirations are no longer possible? I hope not.

Legislating Public Health and Medical Care

It is pretty tempting, if you are a legislator and don’t like something, to try to pass a law against it. You can always find a constituency to support you, because there are people who will support almost anything. If you are lucky enough you can find a well-off and powerful constituency, or set of advocacy organizations, and then you are more likely to be successful (ref: see almost all laws passed by the Congress). Health and medical care are no exceptions; bills and laws that impact on public health and even how providers interact with their patients are increasingly common.

Some laws are very good for the public health: banning smoking in public places; requiring cars to have seat belts, airbags, and other safety features; requiring vaccination against infectious disease for entry into school. But the plethora of regulations governing the funding of health care providers from Medicare and Medicaid, the kind of documentation that needs to be submitted, and the rules that need to be followed (generally termed, collectively “compliance”) is bewildering. Complying with all the rules put forth put forth by federal agencies (including different division of Health and Human Services, as well as the Department of Justice and the Department of Treasury) requires large providers to have full-time “compliance officers” and small ones to operate at their peril. Then add in state and local regulations. These regulations are often contradictory, so complying with one violates another. The blame is usually placed on the bureaucrats that write these regulations, but in fact many of these bureaucrats are quite aware of these contradictions, but have no option, because the laws that they have to write regulations to implement are often very prescriptive. Beware the Law of Unintended Consequences!

This law, never to my knowledge passed by any legislative body, has a major impact on those that are passed, and this impact is just as true in laws regulating public health and medical practice. These effects are most serious when the law in question is passed to address a political agenda rather than to improve health. A famous example is the “gag rule” implemented in the early GW Bush years that prevented providers receiving federal funds from discussing the option of abortion with their patients. (Overturning this rule was a major, and under-recognized, accomplishment of the early Obama administration.)  A more recent example is the law passed in Florida (and now, thankfully, blocked from implementation by a federal judge) that would prohibit physicians and other medical providers from discussing gun safety with their patients. Let me be clear: the limitation was not on gun possession or use, but on doctors and nurses and public health officials talking to people about the risks that guns in the home posed to their children and themselves and how to keep the guns that they had more safe to limit accidental discharge, injury and death.  Guess what organization pushed this law? If you said “the NRA”, you’re right, but it was a “gimme”. And of course it was signed by the governor, former “health care” magnate Rick Scott, who as CEO of Columbia/HCA led the company in paying huge fines for Medicare fraud.

Those are the easy ones to find fault with. But, just as with the “compliance” issues described above, efforts to impose “good” medical practice can be flawed. Vaccine safety and benefit is a big topic I will probably post a separate piece on (short answer: get them), but there are many others. One example is the bill introduced by Sen. Jay Rockefeller (D-WV), along with Sen. Chuck Schumer (D-NY), that would require practitioners who prescribe opiates to have 16 hours of continuing medical education (CME) in their use every 3 years. This is motivated by a serious concern for the abuse of opiates, including re-sale by those receiving prescriptions, which leads to many deaths each year (and in which West Virginia leads the nation). There is no question that this is a huge problem.

We have seen two movements, often in conflict with each other, in recent times. One is the increase in the advocacy for patients with chronic pain to receive adequate treatment; the other is concerned with addiction and prescription drug abuse. Unfortunately, as in West Virginia, the same populations are often afflicted by both. Chronic pain often occurs in those who do physical labor, but people from these same populations are the ones often dying of overdose. The problem is that the same drugs that reduce pain also (initially) get people “high”, and in time create physical addiction where the “positive” effect of the “high” is replaced by pain and misery just from not having the drug. Ideally, there would be a pain reliever that was effective, did not cause any pleasurable symptoms (other than relief from pain), and was non-addictive. We don’t have one.

Will requiring this CME of physicians reduce the problem? I think that it will decrease the number of prescriptions written for opiates, and thus maybe the amount of potentially-abusable narcotics circulating in the community, but perhaps not through the intended mechanism. There is no question that there is a lot that many providers could learn about proper use of opiate pain relievers by taking such courses. One example is the use of long-acting pain relievers (methadone, sustained release patches, long-acting morphine) whose slow release controls pain while decreasing the “high” that results from a sudden infusion of narcotic. (An exception is the most widely-prescribed – and advertised, which might be related – long acting pain reliever, Oxy-Contin®, 30% of which is release immediately, making it more popular among drug abusers than other long-acting opiates.) Another is the use of the “pain contract” that limits a patient to receiving opiates from one physician, at determined intervals, refuses to ever refill if a person is found to be receiving prescriptions from multiple sources, and may require urine tests to be sure that s/he is not using other unprescribed substance.

However, for this plan to work it would require that physicians and other providers want to prescribe narcotics. Obviously some do. Many of these do so because they are concerned about the chronic pain so many patients are in; there are pain medicine specialists who come from a variety of medical backgrounds: anesthesiology, psychiatry, family medicine, internal medicine. There are certainly others (relatively few) who are “Dr. Feelgoods” who make their living prescribing narcotics and other controlled drugs in large amounts, knowing that they will be abused. But the reality is that most doctors find chronic pain patients, well, a chronic pain. They find it difficult to feel certain who is a “legitimate” pain patient and who is “abusing”, or selling, their pain medications. Or who is a “legitimate” chronic pain patient whose family members are using, or selling, that person’s pain medication, leading to both the spread of narcotics in the community and having the patient continue with unrelieved pain. These are the patients who, whether “legitimate” or “abusers”, call the office all the time for refills, call in the middle of the night, yell at the staff because they are in pain (or withdrawing from narcotics, or find their livelihood that comes from selling them is threatened). Most providers would be willing to not take the CME, and have a good excuse to not prescribe opiates, and be free from all these problems. This is, according to testimony at the recent convention of the American Academy of Family Physicians, already happening in some places. Of course, that will also mean reduced access for people who do have chronic pain.

I once lived in a moderately large condominium. I had kids, as did a couple of others, but the majority of residents were older, with no children in their homes. The association would sometimes pass rules that restricted what children could do, especially when the working parents couldn’t make the meetings. These rules affected my children and penalized me. My position was that the association’s rules should be limited to things that affected the safety of the building and maintained its property values, not just anything that 51% of the owners could agree upon. Legislatures, whether federal or state or local, can pass any law that they can get a majority to agree on (with the obvious exception of the US Senate, where apparently, at least with the current President, it requires 60% votes – 59% wouldn’t do it). It doesn’t matter how dumb the laws are, or how much they conflict with existing law, or how much trouble they cause the bureaucrats who have to write the regulations, or how confusing or sometimes impossible it becomes for folks to comply with them all. Unless the courts strike them down, they are law (thank goodness for separation of powers!).

But because you can pass a law or rule about something doesn’t always make it a good idea to do so, whether you are a legislature or a condominium association. Because the Law of Unintended Consequences is always present.

Unintended pregnancy and health disparities

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In "Health in All" policies to eliminate health disparities are a real answer, August 18, 2011, I discussed the work of Steven Woolf, MD, as it relates to health disparities. The major point of that piece is that the health and mortality differences between groups, particularly racial groups, in the United States accounts for an enormous number of excess deaths. If that gap were closed, and everyone in the US had the same age-adjusted death rate as whites, the number of lives saved would far exceed those saved by all medical care. Indeed, it would far exceed the number of lives saved even by public health interventions, at least as narrowly construed. Many of the social interventions that Woolf and colleagues indicate would be necessary to decrease disparities could be thought of as “public health” in a broader sense, because they would improve the public’s health, but in general eliminating poverty and raising educational levels are not part of the narrower public health construct.

In “Unintended pregnancy in the United States: incidence and disparities, 2006”, published on-line-before-print in Contraception, Lawrence B. Finer and Mia R. Zolna of the Guttmacher Institute report on the disparities in a particular group, women of reproductive age, in relation to unintended pregnancy. They combined data from several sources, “…on women's pregnancy intentions from the 2006–2008 and 2002 National Survey of Family Growth… a 2008 national survey of abortion patients and data on births from the National Center for Health Statistics, induced abortions from a national abortion provider census, miscarriages estimated from the National Survey of Family Growth and population data from the US  Census Bureau,” to assess rates of unintended pregnancy and disparities between groups, and compared  this data to rates in 2001.

 They found that the percent of unintended pregnancies remained high, with a slight increase (from 48% to 49% of all pregnancies) from 2001 to 2006. The actual rate increased from 50 to 52 unintended pregnancies for every 1000 women aged 15-44. There was a significant decrease in the rate of unintended pregnancies in women 15-17 years old, but this group still had the highest rates (79%, down from 89%). While the fact that an increased percentage of pregnancies in such young women were intended is not necessarily a good thing, the overall pregnancy rate per 1000 decreased from 47 to 42 in this group. The rates of unintended pregnancy went down with age, but all other age groups had an increase in their rates from 2001-2006, the largest in women 18-24. To say this again: the rates of unintended pregnancy went up in each age group except 15-17, but that group still had the highest rate, with rates decreased in each older age group.

The most important finding was the disparity in the rate of unintended pregnancy by characteristics other than age: by race/ethnicity, by income, and by educational level. The unintended pregnancy rate for women with less than a HS diploma (80 per 1000) was more than 2.5 times that of college graduates (30); the rates for women who were HS grads and those with “some college” were in between. The rate for Black women (91) and Hispanic women (82) was also 2-3 times that of white non-Hispanic women (36). Income, perhaps, had the greatest disparity: the rate for women at <100% of poverty (132) was more than 5 times the rate for women >200% of poverty (24).

OK. This is a lot of data, and maybe it is hard to follow. But the main point is simple: these are staggering differences, and they are difference based upon the same social factors that Woolf and his colleagues address. The magnitude of these differences overwhelms all the other factors that affect this rate. The women whose resources make them least able to economically provide for unplanned children are most at risk of having them.

The percent of unintended pregnancies ending in abortion also decreased, from 47% to 43%, with the greatest decrease (from 47% to 41%) in women 20-24, but rather than being a positive, this decrease is much more likely to reflect the decreased availability of abortion services than a shift in attitudes toward abortion. That is, a larger number of children are being born as a result of unintended pregnancy to families that will have difficulty caring for them. In addition, these families are getting less and less aid from public sources because the same folks who are against abortion and the protection of the “unborn” are also against social services that will help the families of the born.

This study was also the basis for the excellernt column “Failing Forward” by Charles Blow in the NY Times on August 27, 2011.  He makes these points very strongly, commenting on the policies that restrict access to abortion while effectively punishing the children:

“This is what we’re saying: actions have consequences. If you didn’t want a child, you shouldn’t have had sex. You must be punished by becoming a parent even if you know that you are not willing or able to be one. This is insane.”

As in all of Blow’s columns, he includes a telling graphic, here showing the “States of Child Hunger”, the rate and raw number of children in food-insecure households. There are over 17 million hungry children in the US, or 23.2% of all children. The highest rate is in DC, the lowest in North Dakota. After DC (32.3%), perhaps surprisingly, is Oregon (29.2%). However, after that, unsurprisingly, come the usual suspects , many of the states most commonly associated with poor social supports and frequently conservative Republican leadership: Arizona, Arkansas, Texas, Georgia, Mississippi, Nevada, South Carolina, Florida. Most of the New England states are clustered near the bottom (good) end of the list.

The whole thing is not good. Too many poor and hungry children, too little education, too little opportunity for too many women and their families. Too many people and families caught in the multiple challenges of poverty, poor education, and racial/ethnic minority status, all of which are independently associated with health disparities, and which are synergistic in their effect when found together. This is not a society to be proud of. This is a society that needs great change, and it is the change perhaps we’d hoped for with the election of President Obama.

Frequently, the comic strips (not even the overtly “political cartoons”) capture it best. Here is a link to a “Non Sequitur”, by Wiley Miller. Check out September 4, 2001, with the adventures of super “hero” “CongressMan”. Laugh. And then cry.

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"The Doctor's Dilemma": Balancing needs of individual patients and responsible stewardship of health resources

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On August 25, 2011, in What is the ethical role for physicians in the "business" of health care?, I cited the commentary of Reuben and Cassel in JAMA “Physician stewardship of health care in an era of finite resources”. They identify the various levels at which physicians, physician groups, payers, and government can act to influence the cost/benefit of health care decisions. A similar issue is addressed recently by Victor Fuchs in the New England Journal of Medicine “The doctor’s dilemma – what is appropriate care?”[1] He notes that:

“…organizations representing more than half of all U.S. physicians have endorsed a ‘Physician Charter’ that commits doctors to ‘medical professionalism in the new millennium.’ The charter states three fundamental principles, the first of which is the “primacy of patient welfare.” It also sets out 10 ‘commitments,’ one of which states that ‘while meeting the needs of individual patients, physicians are required to provide health care that is based on the wise and cost-effective management of limited clinical resources.’ How can a commitment to cost-effective care be reconciled with a fundamental principle of primacy of patient welfare?”

He goes on to point out that some very expensive technologies benefit people while some do not or even cause harm, and many can benefit some people but are used too widely. He notes that, for example, “U.S. patients, on average, get almost three times as many magnetic resonance imaging  [MRI] scans as Canadian patients; there is no evidence that this large differential can be explained by national differences in the medical condition of patients or that it results in significant national differences in health outcomes.” This doesn’t mean that your MRI was not indicated, nor that there may be Canadians who did not get MRIs that were indicated, but it does mean that on balance we in the US are doing too many for the degree of benefit received.

Fuchs also addresses health insurance. He notes that, as many policy critics have observed, it is often not the patient but a third-party insurer who pays the bills (with the obvious, and glaring, and unconscionable, exception of the uninsured). Therefore, there is much less incentive on the part of the physician to not order expensive tests than if the patient were paying. I know this to be true. With underinsured or uninsured patients, especially in the free clinic I volunteer in, we minimize the use of unnecessary laboratory tests and maximize the use of generic medications on the “$4 list”. These practices are – or should be --  standard care in all patients. Working in the free clinic setting helps teach our volunteer physicians, as well as our volunteer learners, how to practice more cost-effective medicine. But it is not in itself enough. The free clinic still has major problems getting patients the care they need when they do need an MRI or CT, or a medication that is not available generically, or a specialist evaluation, or an expensive test (and for uninsured people virtually all procedures are expensive!), or a hospitalization.

So I also know that Fuch’s next point, criticizing those “policy experts [who]  think that if patients had “more skin in the game” — that is, had less insurance — the problem would be solved. It would not,” is correct as well.  He points out that even those who advocate this position agree there must be a cap on how much a patient should be liable for out-of-pocket (what? $5000?), but that “the extreme skew in annual health care expenditures, with 5% of individuals accounting for 50% of spending in any given year, means that many health care decisions, and especially those involving big-ticket interventions, will be made by and for patients whose costs have exceeded the cap.” The greatest expenditures are for people who need the greatest expenditures, and will be above any acceptable cap. Most people will not be, but most health dollars are not spent on the care of most people; they are spent on this small minority (which, as I have pointed out in Red, Blue, and Purple: The Math of Health Care Spending, October 20, 2009, any of us could join at any time!).

In a similar vein, policy pundits, many of the same ones who talk of “skin in the game”, talk about “freedom of choice” and allowing people to choose the kind of insurance that best meets their needs. Right. In Social Determinants, Personal Responsibility, and Health System Outcomes (September 12, 2010), I observe that all of those making such suggestions (the “Four Ps”: pundits, policymakers, politicians, and professionals) are not likely to be ever in the uninsured group. However, even they, even the doctors, have a difficult time figuring out insurance options. So imagine how it is for others, for most people? As highlighted by Lauri Martin and Ruth Parker in JAMA (“Insurance expansion and health literacy”)[2], for those who are less educated, for the 90 million Americans who have limited health literacy, choosing the “right” plan will be virtually impossible, a total crap-shoot.

What this means is that while large-scale comparisons, like MRIs between the US and Canada, can tell us there is something wrong, they cannot solve the problem. Nor can average expenditures of insurance companies, though again they can tell us a lot. But we must realize that we cannot solve the problem by limiting the individual access of individual people rather than attending to medically-appropriate guidelines that apply to all people. We need more fences, and fewer reins[3].

Ultimately, the contradiction between the commitment to the “primacy of patient welfare” and limiting the use of expensive technology is real, and the ability of physician organizations to put them into the same document without helping to explain how to resolve this “dilemma” is sloppy policy, and unfortunately often characteristic of them. Not just of physician organizations; indeed, given the scope of fine-words-with-no-action (or negative action) prevalent in the political sector, these physician groups are to be commended for calling for action. In “Dr. King weeps from his grave”, NY Times, August 26, 2011, Cornel West observes the same distinction between the actions called for and undertaken by the Rev. Martin Luther King, Jr., and the words spoken by those who have built his memorial. “King weeps from his grave. He never confused substance with symbolism. He never conflated a flesh and blood sacrifice with a stone and mortar edifice.”

The conclusions of Dr. Fuchs, and of Drs. Reuben and Cassel, are not very different. We do not need words, or proclamations, we need system change. In Fuchs’ words: “…when physicians are collectively caring for a defined population within a fixed annual budget, it is easier for the individual physician to resolve the dilemma in favor of cost-effective medicine. That becomes ‘appropriate’ care. And it is an ethical choice… because if all physicians act the same way, all patients benefit.”

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[1] Fuchs V, “The doctor’s dilemma – what is appropriate care”, N Engl J Med 18Aug2011;365(7):585-7.

[2] Martin LT, Parker RM, “Insurance expansion and health literacy”, JAMA 24/31Aug2011;306(8):874-5.

[3] Grumbach K, Bodenheimer T, “Reins or fences: a physician’s view of cost containment”. Health Aff (Millwood). 1990 Winter;9(4):120-6