Weight and class: who is obese and why should we care?

One of the things that people are most fixated upon, in both the health arena and in society at large is weight. In popular culture, weight is a major issue. Celebrities are (mostly) thin; when they are not, and look like more of the regular people who are around us, they are seen as unusual. Diet books and “fad” diets abound as do classes to help us exercise. Issues of body image are major stressors for adolescents in particular, and health problems like anorexia are all too common. And, yet, an increasing number of Americans are obese, and health problems that are certainly associated with obesity – notably, but not only, Type II diabetes – are rapidly growing.

There is a major class association with weight; as income and class go down, prevalence of obesity goes up. Perhaps ironic compared to earlier centuries, when being heavy was associated with money – that is, the ability of the person to afford all that food – and poor people were starving. But if ironic, it is serious; the abundance of cheap, high-calorie foods in our society mean that poor people are not denied the opportunity to have lots of calories, but the stressors of poverty that affect all aspects of social life are still there, creating obesity as just one more problem to be confronted (or not).

In this context, a recent article in JAMA by Katherine M. Flegal and colleagues has garnered a lot of attention. “Association of All-cause mortality with overweight and obesity using standard Body Mass Index Categories: A systematic review and meta-analysis”[1], reviewed 97 studies with over 2.8 million people and encompassing 270,000 deaths, and performed a meta-analysis (a set of statistical techniques that allows accounting for studies that are somewhat different in design and have different numbers of people). The results were that people whose body mass index (BMI, a ratio of weight to height) was in the “overweight” range (25-30) had lower all-cause mortality than those in the “normal” range (18.5-25). In fact, the all-cause mortality rate was no higher for those in the range of “grade 1 obesity” (30-35) than for those in “normal” weight range. However, it was higher for those with grade 2 obesity (35-40), grade 3 obesity (>40) and for all obesity taken together (>30). In addition, unsurprisingly, the “hazard ratios” for mortality were greater for the same BMI when heights and weights were self-reported rather than measured (suggesting people under-estimate or under-report their weight, which would mean their BMIs are actually higher than reported).

This is not, of course, really new news, since all of the studies reviewed had been previously published. There was already a sense among many in the medical field that people at the “low end” of overweight (say 26-27) might be as least as healthy (have as low a mortality risk) as those at the low end of “normal” (18.5-25).  Heymsfield and Cefalu, in their editorial commenting on this study, “Does body mass index adequately convey a patient’s mortality risk?”,[2] say “Persons with a BMI between 18.5 and 22 have higher mortality than those with a BMI between 22 and 25. Placing these persons in a single group raises the mortality rate for the normal weight group. The average resulting from combining persons in the lowest mortality category (BMI of 22-25) with those who have greater mortality (BMI of 18.5-22) might explain why the NHLBI category of normal weight has an observed mortality similar to class 1 obesity (BMI of 25-30).”

If people with a BMI of 18.5-22 have a higher mortality rate than those with a BMI of 25-30, why, for goodness sakes, is 18.5-25 considered “normal”. For reference, a 5’4” person with a BMI of 18.5 would weigh about 108lbs, at a BMI of 22 it would be 128lbs, at 25, 145lbs, and at 30, 175lbs. For a person who is 5’10”, the weights at the same BMIs would be about 129, 152, 174, and 207. I think most people would not think that the lower range was normal except for models and marathon runners (hey, I’m overweight and would like to lose about 10-15 pounds of fat, but I think I’d be pretty sick before I lost the 60 lbs needed to get me to 22! My son was heavy when he developed Type I diabetes as a young adult, and went from a BMI of about 32.5 to about 21; let me tell you, he looked bad!), but the real question is “what are the healthiest ranges to be at”? This is what official recommendations should be based on, and it is clear from the work reported by Flegal and colleagues that this is not the case for the current numbers.

The relationship between adiposity (presence of significant amounts of excess fat) and risk for many diseases is well-established; the relationship between adiposity and BMI less well so. Variables include amount of muscle mass (not a risk factor but leading to greater weight-for-height), sickness (people who lose weight as a result of disease), and overall body structure. I tried to find out where these ranges come from, but have, so far, been unsuccessful. I found the references to the “Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults”, put out by an expert panel in 1998, but at least their “Executive Summary”^[3] does not reveal the source of how the “normals” were derived; they are just asserted. 

Obviously, this is going to be controversial. Paul Campos’ op-ed piece in the NY Times on January 3, 2013, “Our absurd fear of fat”, makes many of the same points I have, but letters generated in response range from those lauding it and saying people (especially children) should be taught to be proud of their bodies, to those arguing it minimizes the health dangers of obesity. What is clear, though, is that the fixation on “ever thinner” that exists in much popular culture has no place in health discussions. The JAMA article strongly suggests that our standards for “normal”, “overweight” and “obese” BMI are too low, although not irrelevant. It calls our attention to a tendency to other similar areas in which health professionals have adopted uni-dimensional disease markers and driven them even lower, to result in poor health outcomes for many. Recent examples include blood sugar (or its related value, hemoglobin A1c), blood pressure, and cholesterol. Studies that held everything else equal found benefit in lower values, so experts kept driving down the definitions of normal and desirable for these tests. Unfortunately, not everything else is equal. Pushing the desirable hemoglobin A1c level of people with diabetes to 5% instead of 6% led to a lot of morbidity from hypoglycemia; lowering cholesterol goals led to toxicities from drugs; lowering blood pressure goals to poorer functioning and greater mortality in some populations, especially the elderly. Most people don’t exercise regularly, but rather than lauding all efforts to exercise, “experts” keep raising the bar for how often, how long, and how intense exercise should be.

So let’s get back to class, and its associated characteristics. It is time for health professionals to recognize that they are also social service professionals and members of a society whose broad policies have a much more profound impact upon health than small numbers variation in BMI, blood pressure, cholesterol, and blood sugar. We need to treat, as well as support and encourage, people at the extremes whose health is at risk, but we shouldn’t fall prey to definitions that name more people as diseased and needing interventions and distract us from the real business at hand.

Which is creating a more just, fair, equitable and safe society.

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[1] Flegal KM, et al., “Association of All-cause mortality with overweight and obesity using standard BMI Categories: A systematic review and meta-analysis, JAMA Jan 2 2013;309(1):71-82

[2] Heymsfield SB, Cefalu WT, Does body mass index adequately convey a patient’s mortality risk?” JAMA Jan2 2013;309(1):87-88.

[3] Expert panel, “Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: executive summary”, Am J Clin Nutr, 1998;68:899-917.

Mental Illness and Guns: A public health perspective

I have been somewhat reluctant to write about the issues surrounding the mass shootings that have become epidemic in our country. Since the Newtown elementary school massacre it appears as if everyone else has done so, and I didn’t know what, if anything, I could add that would be of value. I still don’t, but I would like to try to emphasize the public health and medical issues here. Everyone talks about getting beyond rhetoric, but mostly we hear rhetoric and have yet to see results.

In his column in the New York Times on December 28, 2012, “Guns and Mental Illness”, Joe Nocera addresses those two aspects of the controversy, which I agree are the key ones. However, while I generally think his points are valid, I disagree with his characterization that gun control is a “liberal” issue while mental health has been the focus of conservatives. For good, or bad, and too often bad, both issues have been neglected by too many for too long. When it comes to death, dramatically in the case of mass killings such as Newtown or Aurora or Columbine, much more commonly in “simple” individual killings, and most commonly in the case of suicide, they are tied together. Nocera starts with mental health, so I’ll start with guns.

I have written about guns several times before (“Mexican Murders and US Guns”, March 24, 2009,

 “The Arizona shootings: When will we ever learn?“, January 9, 2011, “Why we don’t spend enough on public health”, September 22, 2011, and even discussed a New England Journal of Medicine article (Why we don’t spend enough on public health”)[1]  by Dr. David Hemenway of the Harvard School of Public Health and Director of their Injury Control Research Center and Youth Violence Prevention Center (“Public Health and Changing People's Minds, May 15, 2010). Guns are efficient and effective killing machines. This is, after all, the reason that hunters and warriors like them. They can be made more efficient, by being automatic or semi-automatic, and by having magazines that hold many bullets. These are generally considered positives on the war side (and by gangsters), but are often seen as “un-sporting”, so that most states have laws governing their use in hunting. The statistics on gun violence in the US are staggering, and seen from a public health perspective represent a severe and continuing epidemic. Likely the best book on this topic is “Private Guns, Public Health”[2], by Dr. Hemenway. He presents extensive statistics on injury and death resulting from guns, and emphasizes a addressing this problem through efforts to both increase the safety of guns themselves (as we have for cars) and limiting their availability (as we have for cigarettes). This is a harm-reduction approach.

Much of the data cited by Hemenway is sobering, and some is so downright shocking that one might think it difficult to ignore. There are over 30,000 suicides in the US per year, and a high proportion are from guns, because guns are much more effective, and are less likely to allow a second chance; the “success” rate for suicide by gun exceeds 95% while for intentional overdoses it is less than 5%. One of the populations most at risk for suicide is young men; Hemenway notes that the successful suicide rate in this group is several times higher in “low gun control” states (mostly Southern and Mountain) than in “high gun control” states (mostly Northeast and Hawaii). This is not because of less suicidal intent in, say, Massachusetts than Montana, but the easy availability of guns.[3]

But we know about the effectiveness of guns. You can kill someone with a baseball bat, or a knife, or a lead pipe or wrench or candlestick in the Library, but not as efficiently, reliably, effectively, and potentially randomly as you can with a gun. The recent episode of a knife-wielder in China is one example. Adam Lanza wouldn’t have been able to kill many with a candlestick. Innocent children are rarely victims in drive-by knifings. The NRA used to say “guns don’t kill people, people kill people”. Yes, but they do it much better with guns. Now they say that the solution to “bad guys with guns” is “good guys with guns”. This is so ridiculous (can you imagine a bunch of “good guys” blazing away at whoever they thought might be the shooter in the dark in the Aurora, CO, theater?) that NRA bumper stickers are now being amended by new ones saying “Not MY NRA!” in response.

What about mental health? Nocera does an excellent job of summarizing the problem confronting the chronically mentally ill; with a progressive philosophy of “de-institutionalization” mental hospitals were closed with the promise of comprehensive, community-based mental health services being available in the community. But, of course, funding was not forthcoming for those services, nor does it appear that it will ever be adequate. Nocera is correct in saying conservatives have pointed to mental illness (rather than guns) as the cause of such violence, but in addition to not supporting any gun regulation, these same “conservatives” have led the charge in de-funding and under-funding mental health services. The constituency supporting such services, especially for those who cannot afford private care, is not big or effective enough. Apparently these politicians are in favor of supporting (retroactively) mental health care for those who commit mass murder, but not prospectively for the millions in need. One word that is commonly used for such an approach is “hypocrisy”, but this does not shame politicians.

I have written about the “sensitivity” and “specificity” of tests, particularly with regard to screening.  However, the same concept can be used for assessing risk of any condition, such as mental illness and the probability of committing gun violence on a large scale. If “committing mass murder” (as opposed to individual homicide or suicide) is considered the disease, then assessing for mental illness would be pretty sensitive – that is most mass murderers are mentally ill and there are relatively few “false negatives” – people who are mass murderers but not mentally ill. But it is pathetically not specific, for the overwhelming number of mentally ill persons will never be mass murders. They would be “false positives”. But this in no way means that they should not receiving comprehensive and effective mental health services.

So, which is the greater problem? Which should be addressed first? The answer is both, and, more to the point, either would be an improvement. On guns, there need to be bans on assault and automatic weapons and on high-capacity clips and “cop-killer” bullets, and background checks on gun purchasers and closure of the “gun show loophole”. On mental health, there need to be ubiquitous and well-funded mental health treatment programs in all of our communities, with outreach workers and close collaboration with primary care medical providers. Both strategies are critical, both are quite (although, obviously, not completely) effective in other countries.

But I would be happy if we would do one of them. I mostly, however, hear a lot of talk and am fearful that we will, ultimately not do either.

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[1] Hemenway D, “Why we don’t spend enough on public health”, NEJM 6May2010;362(10);1657-8.

[2] Hemenway D. “Private Guns, Public Health”. University of Michigan Press. Ann Arbor. 2004.

[3] Full disclosure: Ten years ago, my 24-year old son committed suicide with a gun. As far as I know, he’d never used one before. He left his home in a “high gun control” state and went to a “low gun control state” where he knew no one, acquired the gun, and completed his suicide. A testimony to the impossibility of preventing suicide? A condemnation of the ease with which he obtained the gun? Make of this what you will.

When is the doctor not needed? And who should take their place?

A lengthy editorial in the New York Times, December 16, 2012, "When the doctor is not needed”, discusses how a variety of other health professionals can help to meet the health care needs of the American people when there are not enough physicians. The editorial names, specifically, pharmacists, nurse practitioners, retail clinics (mostly staffed by nurse practitioners), “trusted community aides”, and self-care. It is very good that the Times recognizes the shortage of doctors (and, here, primary care doctors) and the fact that the planned fixes in the Affordable Care Act are not likely to solve the problem, issues that I have often addressed, recently in Health reform, ACA, and Primary Care: Is there still a conundrum? (November 24, 2012). It is also good that the Times recognizes the important contributions that can be made by health professionals other than physicians, by “trusted community aides” and very importantly, by self-care.

As the editorial points out, both pharmacists and nurse practitioners (and physician’s assistants) have a significant knowledge base, and can (depending on state law) practice independently. In our clinic, we work closely with both, and even have a real interdisciplinary educational clinic in which medical students, nursing students, and pharmacy students see actual patients together, under the supervision of faculty from all three disciplines. We have long had nurse practitioner faculty seeing patients with us, and an NP is the medical director of our clinic. Pharmacists work collaboratively with us, particularly in the hospital, and can manage not just drug refills but dosage adjustments and alternative drug regimens in the outpatient setting as well. As the Times editorial and my earlier posts make clear, the promise of ACA to produce sufficient numbers of primary care physicians is likely to take a long time, if it comes at all, as a result of the combination of adverse reimbursement and the long pipeline to produce doctors. If we are to have any hope of having adequate primary care for our population, everyone – doctors, nurses, nurse practitioners, pharmacists, physician’s assistant, et alia, will have to work “at the top of their license” so that doctors are not expected to “do it all”, and the others have the opportunity to really demonstrate their skills.

Unfortunately, however, it will not solve the problem. I don’t say this because I am a doctor (I am) or a primary care doctor (I am), or because most of the statements about the effectiveness of pharmacists and nurse practitioners cited by the Times come from pharmacists and nurse practitioners. I say it because the biggest problems in access to health care are economic and geographic, about people in rural areas and poorer parts of urban areas not being able to access health care because there are no providers there. This is not going to change if we have more pharmacists or nurse practitioners; they want to stay in the cities and suburbs from which they come just like the doctors. They do not “diffuse” into underserved areas. The retail clinics at which many work, often actually based in chain pharmacies, may provide a significant service (see my previous post, Retail clinics: power to the patient, June 28, 2012), but they are also located in cities and suburbs, and serve basically the same population that more traditional medical practices do.

In addition, there is the issue of money / health insurance. Many people, particularly the working poor, whether in cities or rural communities, do not have health insurance. And while some may have the cash to go to a retail clinic, if one is available,  most are unlikely to have enough to cover a big ER or hospital bill. Maybe ACA will help, but its primary method of expanding coverage will be through expansion of Medicaid, and this looks as if it will not happen in many states, which have said they will not participate or (like mine, Kansas) have not yet said. Plus, even if Medicaid is expanded, this does not mean that people will be able to access care. Maybe through a retail clinic, maybe via a nurse practitioner or primary care doctor. But specialist care is becoming increasingly unavailable to Medicaid (and, of course, uninsured) patients, as noted in this recent article by Anna Gorman in the Los Angeles Times, “Health care crisis: not enough specialists for the poor”, December 15, 2012. Health policy expert and retired family physician Don McCanne commented on this in his “Quote of the Day” (December 17, 2012), noting that from the beginning of Medicaid (Medi-Cal in California) this has been a problem.

Dr. McCanne says that there have been enough specialists for Medicare, but I fear even this may be changing; our hospital notes that Medicare is its worst payer and that it loses money on Medicare patients. And, as physician practices continue to be acquired by hospitals (which I discussed on December 1, 2012, in Gaming the system: Integration of healthcare services can just raise costs, not quality), the cost of care is increasing (as noted by the Charlotte Observer, in “As doctors flock to hospitals, bills spike for patients”, December 17, 2012). And pharmacists and nurse practitioners are even more likely than physicians to be employed by big hospitals or health system or other corporations (such as the chain pharmacies in which most pharmacists work and which host most retail clinics).

Now “trusted community aides”, as the NY Times editorial calls them, are something different. While that editorial refers to two pediatric practices, in Houston and Harrisonburg, VA, where patients pay about $17 a visit, this concept is in much wider use – and should be used even more. Sometimes called community health workers or (from the Spanish) promotoras (health promoters), these are lay people, not doctors or nurses or pharmacists, who have been trained to do basic health assessments, recommend treatment (usually in consultation with a nurse or doctor by phone) and help patients do a better job of taking care of their own health. They are most effective when they are from the community and culture of the patients they care for (see the discussion of community health workers in Camden and you: the cost of health care to communities, February 18, 2012). Why do I believe that they have more promise? Because they are recruited from the communities that they will serve, and in which they have roots and ties, they are going to continue to serve those communities. This model has worked for dental care in Alaskan Native communities, and in urban inner city communities like Camden. In the case of rural communities, the concept can also be used to increase the skills of nurses. Enhancing and expanding the training of a nurse in a rural community, someone who has family there, or training community health workers who live there, will improve access in those areas in a way that simply will not happen by producing more doctors and nurse practitioners who come from and train in major urban centers.

And self care? Sure, for the right things. These things include most of the diagnoses (notably excluding immunizations) that retail clinics provide care for. For colds, for minor injuries, people have should be able to care for themselves. Where it gets tricky is when the “self” has multiple chronic diseases (say diabetes, hypertension, congestive heart failure, chronic lung disease, arthritis, low thyroid, and high cholesterol – a very common combination in any primary care practice). These people can provide more of their own care, but need the guidance of a skilled health professional, most often a primary care physician. The NY Times article provides some examples of the use of self-care and it has great potential, particularly when coupled with “trusted health aides” who can help, and teach.

All of these ideas have merit, but the issue of geographic and socioeconomic diffusion is largely ignored by most of those who tout their profession as the solution. Of course, as Dr. McCanne concludes his comments on specialists not seeing poor people, “I'll say it once again. If we had an improved Medicare single payer system that treated everyone equitably, we would not have this problem.”

Yes, certainly there would still be problems, but that would be a great start.

Index to Medicine and Social Justice: Year 4, 12/2011-11/2012

The Withers Lecture : Justice, Social Justice, Health and Health Care

5/19/12: Part I

5/25/12: Part II

5/29/12: Part III

6/4/12: Part IV

Health Reform/ACA

11/24/12: Health reform, ACA, and Primary Care: Is there still a conundrum?

11/17/12: ACA after the election: Is it is the "fiscal cliff" or the social cliff that matters to people?

9/2/12: Financial Incentives, maybe; corporate profit, no!

7/19/12: The Oregon Lottery: Far from enough, but at least they are doing something

3/4/12: ACA benefit programs: will state to state variation be good or bad?

1/21/12: One thing to NOT worry about: paying for health care -- in France

1/14/12: It’s definitely not about the bike – but is it even about ACOs?

12/2/11: Medicare: A lifeline, not a Ponzi scheme

Health Research and Evidence

9/9/12: Research basic and applied: we need them both

7/4/12: The "Annual Physical": Screening, equity, and evidence

6/21/12: Rationing, Waste, and Useless Interventions

4/22/12: Patient-centered research: answering the questions that matter to people

4/14/12: "Eggs Benedict" and "Choosing Wisely": often the best thing to do is nothing

2/12/12: The high cost of drugs: treating cancer and cholesterol while building profit

1/28/12: "Abandoning ship": is debunking ineffective screening and therapy removing hope or just removing risk?

12/21/11: Avastin®, Plan B®, and Magical Thinking

The Health System and Social Justice

10/27/12: Medicare, falls, families, and risk: "Qualifying" to be in a safe place

10/20/12: Simple treatments: bad doctors or a bad health system?

8/10/12: Medical errors: to err may be human, but we need systems to decrease them

7/26/12: Variations in the cost of medical care: Sense and sensibility

6/28/12: Retail clinics: power to the patient

5/12/12: Specialty Hospitalists: what is best for the patient?

5/5/12: Value-based purchasing: whose values?

2/26/12: Latinos and health care in Kansas City, Kansas

2/18/12: Camden and you: the cost of health care to communities

1/8/12: Cui bono? Is healthcare financing about funding providers or caring for patients?

12/18/12: To improve health the US must spend more on social services

Medical Education

6/16/12: Beyond Flexner: Taking the Social Mission of Medical Schools to the next level

3/24/12: Beyond Flexner Conference on the Social Mission in Medical Education

Primary Care

11/24/12: Health reform, ACA, and Primary Care: Is there still a conundrum?

9/29/12: Primary care, specialty care: what about health?

9/23.12: Social determinants key to the future of Primary Care

8/18/12: The Primary Care Conundrum

8/2/12: Doctor shortage or shortage of the right doctors?

12/10/11: GME funding must be targeted to Primary Care

Providers, values, and health

11/3/12: Health is not a commodity: Let us get the language right

10/13/12: Physician advocacy: for patients and for social change

10/6/12: Abortion and women's health: who truly has a conscience?

8/24/12: Quality and price for everyone: Bigger may be better in some ways, but not all

7/12/12: Multimorbity, primary care, social determinants, and universal insurance: where they all come together

6/10/12: Improving health in poor countries -- and reducing it in the rich

4/7/12: How people die, and how should we?

3/29/12: Reproductive Rights -- and wrongs

3/11/12: Alabama, “illegals”, and hate: We must take back the narrative

2/3/12: Komen and Planned Parenthood: The politics of abortion meet the politics of breast cancer

Other

11/10/12: "The Public Health and Social Justice Reader"

3/17/12: The 2012 Matthew Freeman Social Justice Awards

Does AAMC have an answer for the primary care shortage? No.

The December 5, 2012 issue of JAMA is its annual “medical education” issue, and contains a number of interesting studies and commentaries for those interested in the topic. In terms of increasing the number of primary care physicians, an issue which I have often addressed, the “original contribution” is “General medicine vs. subspecialty career plans among internal medicine residents”[1] by West and Dupras. This study discovered that only 21.5% of third-year internal medicine residents were planning careers in general medicine (which might be primary care), while 9.3% planned careers as “hospitalists” and 65.3% planned to be sub-specialists (cardiologists, gastroenterologists, pulmonologists, endocrinologists, etc.), with 4% undecided.

This is not a significantly different result from that found by Garibaldi, et al., in “Career plans for trainees in internal medicine residency programs[2] published in 2005 in Academic Medicine, and first discussed by me in “A Quality Health System Needs More Primary Care Physicians” 4 years ago, December 11, 2008. Garibaldi’s number was 27% of 3^rd (final) year residents and 19% of first years. What West and Dupras add is that only 39.5% of graduates of specifically-designated “primary care” internal medicine residencies are actually planning to become primary care physicians.  Apparently all of the discussion about the need for more primary care doctors has not swayed the decisions of these residents, who, at the conclusion of their initial 3 years of training can “go either way”; the way that they are going is to subspecialization.

Commenting on this article, Mark Schwartz (“The US primary care workforce and graduate medical education policy"[3]) notes that, in contrast to internal medicine, a larger percent of pediatric residency graduates, 45%, were planning to enter primary care, which is actually a decrease because of pressures in the discipline to create more pediatric subspecialists. Only family medicine, at over 90%, remains a reliable specialty for producing primary care physicians. Schwartz notes that the Council on Graduate Medical Education (COGME) has recommended a minimum of 40% primary care for an optimally-functioning health system (increased from the 32% at the time of its 20^th report, in 2010), but obviously the movement is in the opposite direction. Moreover, he talks about a 40% “rate” of entry into primary care; however, a 40% entry rate is only a sustaining percent once we are at 40% --an entry rate of 40% will take an entire generation, about 30 years, to yield a 40% primary care workforce. And, indeed, many, including many on COGME, believe that 40% is too low and the actual goal should be 50-60%. Nonetheless, it is all academic when the current rate of entry into primary care will not even replace the current under-30%.

Schwartz also looks at the fact that Medicare supports the majority of graduate medical education through two related programs, Direct Graduate Medical Education (DGME) funding, about $3B, which is to support resident salaries and teaching costs, and Indirect Medical Education (IME) funding, about $6.5B, which is intended to compensate hospitals, the primary sponsors of residency programs, for the increased costs involved in providing patient care in a training environment. Unfortunately for these hospitals (and other program sponsors), the Medicare Payment Advisory Commission (MedPAC), which advises Congress on Medicare policy, has indicated that IME payments exceed the cost differential by $3.5B. There are various proposals for what to do with this money; while MedPAC advocated using it for a pay-for-performance program for GME, both Simpson-Bowles and the administration have advocated using it to pay down the national debt (i.e., chopping it). The Association of American Medical Colleges (AAMC) wants to use it to increase the supporting number of residency positions, currently capped by the balanced budget amendment at 98,000, correctly noting that although the number of graduates from US medical schools is increasing (through class size expansion and opening new schools), this will not increase the number of physicians if the number of residency slot is constant.

Darrell Kirch, President of AAMC, avoids discussion of GME in his editorial in this issue (“Transforming admissions: the gateway to medicine”)[4] choosing instead to comment on an article by Kevin Eva and colleagues from McMaster University in Canada [5]  about using a technique called the multiple mini-interview (MMI) to increase the admission of students with desirable non-cognitive characteristics (i.e., those not well measured by grades and standardized examination scores) to medical school. Kirch says that “…medical schools are moving toward a broader view of medical school readiness that emphasizes the competencies applicants have demonstrated in addition to their academic credentials,” and that “This change is essential to identify future physicians with the skills and knowledge to manage illness in the 21^st century.”

So what do we have. Not enough internal medicine residents entering primary care. Not enough students entering the only true primary care specialty, family medicine. Expansion of medical school classes to produce more US graduates, but no expansion of residency positions, which will largely mean US grads will replace international medical graduates (IMGs) in residency positions (which may in itself not be entirely positive, as described in yet another article in this issue [6]). On the front end, we have increasing recognition that characteristics other than standardized test performance are the most important for future doctors, but only tepid experiments at changing the selection process.

The AAMC could be at the center of advocating for, and in their member institutions, implementing, some solutions to these problems, but currently the solutions they have proposed are far from adequate. Students will be more interested in primary care if they are selected based on the characteristics that are associated with choosing primary care, not mainly on grades and test performance (which are often inversely associated). This is not what Dr. Kirch is advocating. They will continue to be interested in primary care careers if their faculty and overall medical school experience support and encourage them. Most medical schools do not. Increasing the number of residency positions will not increase the proportion of primary care physicians if the expansion is in all specialties, but only if it is limited to primary care. The AAMC has not backed this idea. Finally, the decision to pursue a primary care career by entering family medicine training, or by opting for primary care on completing internal medicine or pediatric training, will only be achieved if the anticipated income differential is addressed, which will require decreased income for the currently most highly paid subspecialists at least as much as increasing that of primary care doctors. The AAMC does not have a position advocating this.

A wonderful “Piece of My Mind” in this issue of JAMA, “Not born in the USA” by Vijay Rajput [7] addresses many of these issues, including how the increased competition for US residency slots by IMGs will drive their test scores even higher, but how these scores do not really prepare someone to be a “humanistic” physician. The strategies mentioned above, including recruiting and matriculating students concerned about people and interested in primary care and care of the underserved, supporting them through their education, offering increases in residency slots only for primary care, and reducing the income differentials for primary care, will address the problems.

Medical schools, the AAMC, and the various agencies of the federal government (especially the Center for Medicare and Medicaid services) need to fully commit to these strategies. It is time for the talk to lead to real action.

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[1] West CP, Dupras DM, General medicine vs subspecialty career plans among internal medicine residents. JAMA. 2012 Dec 5;308(21):2241-7. doi: 10.1001/jama.2012.47535

[2] Garibaldi, RA, Popkave C, Bylsma W, “Career plans for trainees in internal medicine residency programs”, Acad Med 2005 May;80(5):507-12

[3] Schwartz, MD. “The US primary care workforce and graduate medical education policy”. JAMA 2012 Dec5;208(21):2252-3.

[4] Kirch, DG. Transforming admissions: the gateway to medicine. JAMA 2012 Dec5;308(21):2250-1.

[5] Eva KW et al., “Association between a medical school admission process using the multiple min-interview and national licensing examination scores”. JAMA 2012; 308(21):2233-40.

[6] Traverso G and McMahon GT, “Residency training and international medical graduates: coming to America no more”, JAMA 2012; 308(21):2193-94.

[7] Rajput, V. “Not born in the USA”. JAMA 2012; 308(21):2197-98.

Medicare: Consumer choice or choosing your poison? How about coverage for everyone?

It is now after December 7^th, and Medicare recipients have had their open enrollment period and made their choices for next year. Good or bad, affordable or bank-breaking, is something they will find out during the coming year. Will their policy allow them a reasonable choice of doctors and hospitals, or force them into certain ones which may, or may not, offer quality in the areas of service they need? Will the policy cover them if they are out of their home geographic area and need healthcare? Only for an emergency, or for regular care? Does this just mean a small additional co-payment, or does it mean the whole visit will be out-of-pocket? And that emergency visit – is that approved as all-inclusive, or does the ER need to contact the insurer again for every procedure, whether minor and cheap, like running an electrocardiogram, EKG, or more major and costly, like surgery? What about drugs? Medicare’s drug plan (“Medicare Part D”) is supposed to lose its “donut hole” under the Affordable Care Act (ACA), but how will that affect any individual? And if I am just on cheap generic drugs now, but may need to be on something really expensive in the future, will that be covered? And, oh, yes, will I be able to see my own doctor? I think maybe I’ll just stay on the plan I have, and understand (sort of). Oh, but you say that plan is changing?

One thing we can say about decisions that Medicare recipients make this December 7^th is that they will not know if they were wise, informed, or smart until after they see how it works out; it is far too complex, there are too many variables, and too many competing claims by insurers and possibly inaccurate information being proffered for people to make what they can be confident is a wise, smart, informed decision. One example of this complexity is offered by Frank Lalli in his piece in the New York Times of December 2, 2012, “A health insurance detective story”. Lalli, a retired journalist, has multiple myeloma, a kind of blood cancer, and takes a very expensive drug that retails for $11,000 a month! (Note: this blog piece will not address the issue of whether there should be any drug that people need that costs $11,000 a month. You probably have your own opinion.) Up until now, Lalli has been protected against great personal expense because his insurance, through his former employer, Time-Warner, had a cap of $1,000 a year in out-of-pocket expenses. That, however, is being dropped this year. So, he wondered, how much will he have to be paying for this lifesaving drug? Not even (yet) whether he can afford it – can’t know that until he knows how much it would be. So he made a call.

Or, rather, more than 70 calls. To his employer, to their contracted drug carrier, to Medicare, to the drug’s manufacturer, to AARP, and back and back again. Finally he learned – he doesn’t know: “The answers I got ranged from $20 a month to $17,000 a year. One of the first people I phoned said that no matter what I heard, I wouldn’t know the cost until I filed a claim in January. Seventy phone calls later, that may still be the most reliable thing anyone has told me.” No one seems to know. One person at the drug carrier is “sure” he will be ok and be able to afford it. Or, maybe not: “Well, ‘pretty sure.’ She’s excited. She’s been with the company only a few months. This will be her first quote.” So, until he files his first claim, Frank Lalli doesn’t know if his treatment is going to cost him $20 or $17,000 a month, or anything in between. Somehow, I guess, they’ll figure it out when it’s time to make him pay; it is just telling him in advance that no one seems to know how to do. Luckily for Mr. Lalli, he is just trying to find out what he will have to pay for his drug therapy; he is not, simultaneously, trying to decide which health insurance plan he should sign up with (although he did consider changing his drug benefit plan, until he discovered that his health insurance with Time-Warner requires him to continue using the same one).

In some ways, it would be reassuring to think that Frank Lalli was your half-senile grandfather who can’t operate a computer or a cell phone and gets lost on the way to the corner store. Then maybe you could go over, look at the materials, maybe make a few calls, and help him to make the best choice. Unfortunately, this isn’t the case. Mr. Lalli may have cancer, but he has his smarts (after all, they’re publishing his piece in the Times.) And as a journalist he wasn’t an art critic, or a sports writer. He “…had a long career as a business journalist, beginning at Forbes and including eight years as the editor of Money, a personal finance magazine.” He understands business practice, so the problem here is not simply one of business practices and the profit motive getting in the way of providing the best health care for the American people, something that I have often criticized (see recently, e.g., Gaming the system: Integration of healthcare services can just raise costs, not quality, December 1, 2012). It is not good business practice. It is not even bad business practice. It is psychotic; it is Kafka-esque. It is not something that anyone can figure out. It is bizarre that we have come up with such a system; indeed, it is incredible that someone or ones could even design it. “Must have taken a committee,” a cynic might say, but they’d be only partially right. It took dozens of committees, of Congress, of regulators, and of think-tankers, mostly not talking to each other. Frequently, looking at such a mess, it is tempting to blame the “bureaucrats”. However, if you dig deep enough you will usually find that the reason different government departments have different, often conflicting, rules, goes to the legislation. They have to abide by the law, and the laws drafted by different legislators and different committees and often very specific in some particular area about which the legislator writing the law was very concerned. This may be a result of personal experience, or a constituent concern, or (most likely) a concern on the part of a generous lobbyist.

What is most amazing is that there is a whole cohort of pundits and politicians and thinkers (using the term loosely) who believe this is a good thing. They talk about “consumer choice” as if people cared what insurance company they had. They don’t. People care about who their doctor is, about where they will be hospitalized, about whether they will be able to get the medications that they need, and about whether they will be able to afford to pay for this all. They don’t care which insurance company provides for this. If they are the idealized “informed consumer”, however, they may well wish to know how to compare them. Good luck. That information, whatever the theory, is not really available. Not to Frank Lalli. And not to your grandfather.

I have often written about single-payer health systems, and I still think that this is the way to go. But there are alternatives. In Switzerland, for example, there are multiple insurance companies, but there is a single benefit plan. That is, your core benefits are prescribed by law and companies cannot compete on the price of them. You can then choose your carrier by what extra bells and whistles they may offer, but you know what you will get for necessary care and what you will pay.

This is reasonable. What we have now is not. It is not even conscionable. And, unless you want to believe that all the right-wing, consumer-choice politicians and pundits are both rich and selfish as well as evil or stupid (and they may be), it is not even a system that they could find their way through.

We know that there are better ways. And we need one, now.

More on mammography: just because you don't like the results doesn't make research junk science

A recent study published in the New England Journal of Medicine, “Effect of three decades of screening mammography on breast-cancer incidence”, by Archie Bleyer and H. Gilbert Welch[1], has generated enormous controversy. This has been caused by a combination of the study’s findings, the interpretation of them by the popular press, and the reactions of those who have a vested interest in the status quo – a combination that regularly occurs any time anyone publishes any research questioning the current conduct of screening or treatment for breast cancer (see, for example, my blog post Breast cancer screening: conflicting evidence? what are the important questions for health?, October 30, 2010). It happens in other areas, also, but breast cancer is the most common and in some sense most personal of cancers for women, and has a huge advocacy community, as well as powerful groups who profit from both treating it and screening for it.

What did the study show, what does it mean to people, what is the implication for cancer screening and most important, for the health of people (overwhelmingly women) who might get breast cancer? Before addressing these questions, I think it might be helpful to review a little about screening tests, cancer, and people’s hopes and beliefs. People want to not get sick, and especially don’t want to get cancer. If they do get it, they want to be treated and get all better. Of course, despite the use of “cancer” as if it were a single disease, and the existence of organizations such as the American Cancer Society, the federal National Cancer Institute, and the many Cancer Institutes, hospitals, and specialists, it is in fact a variety of diseases that all share certain characteristics but differ in many others. These include commonness, severity, cause, and likelihood of progression or death with or without treatment. Known causes for some cancers include smoking, radiation and viruses, and for many (including most breast cancer) the cause is unknown. It is even more complicated, because just naming the organ affected (breast, lung colon) is not all there is to it, as there are different kinds of cancer that affect the same organ. Whew. This is why the idea of “a cure for cancer” is unlikely; there are cures for some, and may be cures for others in the future, but there is unlikely to be “a” cure.

Some cancers, like breast cancer, are common enough, and well-publicized enough, that women realize that there is a real risk. In that case, the hope is that there exists a screening test that can identify it early enough to intervene and make a positive difference in the outcome. The first thing is that screening tests, by definition, are only for people who have no symptoms of a disease; once they do, a test, even if it is the same test, is no longer “screening” because the probability of the disease is greater in people with a symptom. For example, if one has a lump in the breast, a mammogram may be a good diagnostic test, but it is no longer a screening test. In looking at the criteria for a good screening test, there must be:

1)      A disease a test can screen for (while this seems obvious, doctors still do tests in asymptomatic people that do not effectively screen for any disease),
2)      A reasonable sensitivity and specificity to the test (meaning people with disease are more likely to have a positive test and those without the disease to have a negative test),
3)      A test that is reasonably cheap and acceptable to patients (tests like mammography and colonoscopy, for example, are both more expensive and more uncomfortable than, say, a blood test),
4)      A more definitive test available to say more definitely whether people who screen positive actually have the disease (for most screening, although those who screen positive are more likely to have the disease than those who do not, the majority of those who screen positive still may not have the disease),
5)      An intervention that can be done in the asymptomatic stage that will prevent the disease from progressing (or else, why not wait until it is symptomatic?)

So how does mammography stack up? This is a big part of what is addressed by the Bleyer and Welch study. They have looked at 30 years of screening in the US and found that screening mammograms have uncovered a large number of early-stage breast cancers; in fact, over that time, the number of early-stage breast cancers identified has doubled (from 112 to 234 cases per 100,000 women per year). This is a good – particularly if criterion #5, above, is met – and they can be treated and prevent women from dying or suffering serious morbidity. If this is happening, then (assuming the actual rate of cancer stays the same) the number of cancers diagnosed in later stages, where intervention is less successful, should go down. That is, those cancers detected early and treated would not progress and should mean that many fewer women present with later stage cancer.  Unfortunately, this study demonstrates, that has not occurred. The decrease in late-stage cancer diagnosis has been about 8%, or 8 per 100,000 women per year. So, for every 100,000 women, we are diagnosing an additional 122 early stage cancers, but only decreasing the number of late stage cancers by 8. This means that most of the additional women found by mammography to have early stage breast cancer would not have progressed to late-stage cancer. This, then, leads to their assertion that cancer was over-diagnosed – in 70,000 women in 2008 alone. Any estimate of the number of lives saved by screening and early intervention is inflated if it includes large numbers of women whose cancers would not have progressed. In other words, many of these women diagnosed with cancer, many of whom had non-trivial interventions (surgery, radiation chemotherapy) had cancers that would, basically, have not required any treatment.

Some radiologists who do mammograms have said that this is “junk science” (“Study links mammograms to overtreatment”, Boston Globe, November 21, 2012), but it is clearly not; the findings are the findings. The implications, however, are harder to assess. Does this mean women should not get mammograms? No, certainly that would be a premature conclusion. Some of the women diagnosed with early stage breast cancer would have gone on to develop late stage cancer; if you are one of the 8, you are lucky to have been found; if one of the 114, maybe not, especially if you had to endure the potential harms of chemotherapy or radiation or both, not to mention mastectomy. It may suggest that aggressive interpretation of mammography findings are not warranted. What would be useful would be to identify mammographic findings and subsequent pathology findings on biopsy that required aggressive intervention and those that could be safely followed. One type of breast cancer that is likely to be the subject of future studies is that called ductal carcinoma in situ, or DCIS, which may be more likely than some other types to resolve.

It may well be too soon to know the answer on mammographic screening, but it is clear that it is far from the perfect screening test that everyone would like it to be. We need more studies, and more information, and mostly we need a willingness to accept the accumulated findings of research. Certainly, what we do not need is for those who have a financial stake in screening and treatment to call good research “junk science” because it comes to conclusions that they do not like.

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[1] Bleyer A, Welch HG, “Effect of three decades of screening mammography on breast-cancer incidence”, NEJM 22Nov2012;367(21):1998-2005.

Gaming the system: Integration of healthcare services can just raise costs, not quality

My last blog post addressed the promises, and challenges, posed by the creation of integrated health care plans (or their new incarnation,Accountable Care Organizations, or ACOs, as defined by the Affordable Care Act, ACA), I summarized some of the good and the bad aspects of health care integration. The good often relate to the efficiency that can arise from a single organization which, in theory, can result in financial savings to both individuals and the health “system” as a whole. Unfortunately, this does not always happen, as demonstrated in the article “A hospital war reflects a bind for US doctors”, New York Times, December 1, 2012 (Nov 30 “online”; while in the “Business Pages” online, it is front page, even continued in the first section, in the print edition).

The article, by Julie Creswell and Reed Abelson, begins by focusing on the “picturesque” city of Boise, ID, where the two hospital systems in town have been buying up physician practices in order to more effectively “compete” with each other. St. Luke’s Health System, the larger, has been doing much more of the buying, so much so that the other, St. Alphonsus Regional Medical Center, is suing to prevent them “…from buying another physician practice group, arguing that the hospital’s dominance in the market was enabling it to drive up prices and to demand exclusive or preferential agreements with insurers.” Yes, driving up prices. They noted that the charge for colonoscopy has quadrupled and the charge for laboratory services is much higher. 

The CEO of St. Luke’s argues that not all prices have gone up, and, anyway, the ones that did were “underpriced” previously. This, of course, is hard to demonstrate in an industry where pricing is largely a fiction, where there are no “posted” prices and the charge to different payers varies enormously.  It is not like buying a car, where the dealer pays a certain amount to the manufacturer and you, as a customer, try to get them to charge you as close to what they paid as possible. Nor is it like buying a video game online as described in another Times article (“Retail frenzy: prices on the web change hourly”) in which you can find out if, for example, Target will respond to Amazon’s price cut by dropping its price even lower.

In health care, the “cost” to a provider (hospital or health system) includes both the “marginal cost” (what it actually costs to run that one more lab test or do that one more colonoscopy) and some percentage of their “fixed cost” for running the entire operation. Thus, ironically, by integrating and consolidating into a larger organization with a larger fixed cost, that overhead built into the price increases. The single lab test done by the health system lab has to pay part of the cost of that new MRI scanner and the technician that runs it and the super new invasive radiologist, while the price charged by the independent laboratory does not. Of course, the overall actual cost, in total, to all organizations may be going down, but the amount that the patient or their insurer pays for a low-cost test goes up!

This, as should be obvious, is not an issue limited to Boise. The Federal Trade Commission (FTC) has also gotten involved in investigations of pricing at St. Luke’s and other hospitals and health systems. The Times article quotes Jeffrey Perry, an assistant director in the FTC’s Bureau of Competition: “We’re seeing a lot more consolidation than we did 10 years ago….Historically, what we’ve seen with the consolidation in the health care industry is that prices go up, but quality does not improve.” Higher prices and the same (or lower) quality. Not exactly what we want to hear.

“Hospitals,” says Steve Messinger, president of ECG Management Consultants, an organization the Times indicated advises on physician acquisitions, “are constructing compensation in ways that are based on productivity and performance.”  Sadly, the “performance” piece only sometimes is tied to either quality of care for the patient or cost-effectiveness for the payer, but much more often to “productivity”, and particularly in how it increases revenues for the hospital. One of the ways that this can happen is by “churning” patient – increasing the number of admissions, for which hospitals get paid, but not keeping them too long because (since hospitals are paid by Medicare, at least, a fixed amount for a given diagnosis, based on a system called “DRGs”) shorter stays cost less and thus make the hospital more money. On the front end, the Office of the Inspector General of the Department of Health and Human Services is investigating whether hospitals are tying reimbursement of emergency physicians to how many patients they see per hour and the increasing the percent of ER patients who are admitted. Regarding “productivity”, one hospital noted that patients expect to be seen in a timely manner; of course, patients also expect to get appropriate and thorough care once seen, which can be inhibited by having to increase throughput. On the back end, there are several lawsuits from physicians charging that they receive bonuses if their patients are out of the hospital in less than 3 days. Now, no one wants to be in the hospital longer than necessary, and in fee-for-service payment structures there is financial incentive for doctors to keep their patients in longer as they can bill for each day, but no one wants to be rushed out of the hospital before they are well enough in order to meet a certain target length of admission.

Many of the worst “abuses” come from for-profit hospital or health care companies, such as some of those mentioned in the Times article. This is obvious; their incentive is to make money for shareholders, not to provide quality care except to the extent that it is necessary to make profits, and given the arcane nature of health care reimbursement, the association is not all that strong. Integrated health systems that have done a better job of decreasing costs and increasing quality, such as Kaiser, are usually not-for-profit. However, not-for-profit status is not a guarantee; especially when such hospitals have to compete with for-profits, they end up playing by the same rules. In addition, the Boards of Directors of non-profits are still looking at the bottom line, and are certainly not interested in losing money.

The key problem is the patchwork of rules and reimbursement systems that govern healthcare, and the opportunity for healthcare providers (hospitals, health systems, and even doctors – although they are, as the article points out, increasingly employees of those hospitals) to “game” the system, to find the holes, legal (or sometimes not) that permit them to make the most money. More admissions? Fewer readmissions? Shorter stays? More procedures? Higher prices for colonoscopies and lab tests? Whatever works for the bottom line, not for the highest quality of care of individual patients or communities.

This is nonsense. The goal should be to provide excellent health care, that which is needed by the patient and not more, at a reasonable price – and a price that can be identified. Our current payment system discourages that, and this is not right. The big, arguably necessary, step to a solution, is a single-payer (or highly regulated multi-payer) health system that provides hospitals with global budgets, not reimbursing per service item, while holding them responsible for providing quality health care to the patients in a particular community. Similarly, global (capitation) payments to physicians can permit them to rationally assign their time, staff, and resources to meeting patient needs in the most appropriate and effective manner. If a telephone call is all that is needed, why should someone take off a half-day of work to come in? Well, because that’s the only way doctors get paid, the current answer, goes away. If these global payments are combined into an integrated health system, perhaps we can have more results like Kaiser’s.

This would not solve all problems but it is the necessary if not sufficient starting point. And certainly, the profit driver is a major negative toward enhancing quality and limiting cost in healthcare.

Just thought I'd add this picture: