Expecting everything from primary care: reasonable?

In 2003, Kimberly Yarnall and colleagues from Duke University published an article in the American Journal of Public Health documenting that it would take 7.4 hours a day, essentially an entire workday, for a primary care physician to perform all the preventive services recommended by the US Preventive Services Task Force (USPSTF) on a typical population of 2500 patients.[i]  Six years later, they wrote a follow-up article in which they added the time it would take to also deliver care for the acute and chronic conditions that patients actually came to their doctor for, and it came to 21.7 hours of a 24-hour day![ii] One year after that, in What’s Keeping Us So Busy in Primary Care? A Snapshot from One Practice, Richard Baron wrote about a day in his practice, where, in addition to seeing an average of 18.1 patient visits per day (the one activity they were paid for), they also returned an average of 23.7 telephone calls, and 16.8 email messages. They refilled 12.1 prescriptions, reviewed 19.5 laboratory reports, 11.1 imaging reports and 13.9 consultation reports per day, and also filled out large amounts of paperwork that they do not report on because they are not captured by their electronic medical record, such as “…administrative forms (e.g., for physical examinations for work, camp, and school and Family Medical Leave Act forms), correspondence received from health plan (e.g., disease-management letters), and reports on home care and physical therapy.”[iii]

When I wrote about this, in Primary Care: What takes so much time? And how are we paying for it? (May 21, 2010), I discussed the incredible burden that this placed on primary care physicians, and how unrealistic it was to expect this of them. I addressed an article by David Margolius and Thomas Bodenheimer, Transforming Primary Care: From Past Practice To The Practice Of The Future,[iv] in which they envision the effective and efficient provision of primary care by well-designed teams. I also expressed some skepticism about how likely this would be to happen. So, now it is another 9+ years since the Baron article, and how far have we come? Not, as it turns out, all that far. The impetus in medicine, from health systems, payers, and primary care physicians’ own specialty colleagues, is for more and more work to be expected from primary care providers, both in terms of direct patient care (acute, chronic and preventive) and the kind of paperwork and form-filling-out described by Baron. This comes, unsurprisingly, with little additional financial reimbursement to the doctors or practice (or financial support from health systems for the kind of expanded teams envisioned by Margolius and Bodenheimer), and certainly without more hours in the day!

Why? For one thing, it’s easier. If you don’t know where something fits in the always-getting-more-complex-and-confusing health system, assign it to primary care providers. This is particularly attractive if you are a specialist and it’s something you don’t want to do. And, if you are a health system manager, if it is something that is poorly reimbursed. Think about it. The surgical subspecialist, for example, wants to operate on people. S/he wants, perhaps, to consult with patients about their particular problem, and maybe even their concerns about it, but mostly wants to operate, and to generate the income that comes from operating and not to fill their time up with additional paperwork, or blood pressure checks, or FMLA requests. When they do follow-up they mainly want to follow up the narrowly-defined surgical problem; if there are other complications that are acute, there are consultants for that; if there are longer-term issues that will need to be dealt with, there are primary care providers for that.

Similarly, the health system makes money from procedures being done, and wants their proceduralists, say this subspecialty surgeon, to generate the surgical procedures that make them money, not “waste their time” on more poorly reimbursed medical activities -- or certainly paperwork. When such work can be done by others – nurse practitioners or physician’s assistants, or scribes or nurses, or anyone who gets paid less, then it is financially efficient to fund those positions. In her New York Times article “The Business of Health Care Depends on Exploiting Doctors and Nurses” (June 8, 2019), Danielle Ofri, a physician at Bellevue Hospital in New York, makes a truly important point: that health care professionals actually care about their patients, and want to do the right thing, and will work hard even when that requires more hours than they have or are being paid for. In this sense, it is the health systems (individually) and the health system (writ large) that is profiting. But it is also true that the degree of exploitation (and payment) is not the same for all health professionals; it is not the same for nurses and doctors, and it is not the same for primary care doctors and many subspecialists.

Primary care physicians may inadvertently encourage this. As Ofri describes, they want to be professional and responsible, to know about everything that is going on with their patients. They want to be the physician for the patient, not the disease, to coordinate and manage all the care, to interpret for their patients what other doctors are telling them, especially when the messages that the patients are getting are mixed or unclear. This is what makes them good doctors. However, it is also what makes them really good candidates for being the “buck-stops-here” venue, the “take care of everything no one else can or wants to”, especially if these tasks, from the larger health system point of view, are not reimbursed or poorly reimbursed in themselves but are required by payers (private and government insurers) to be done in order for the system to get reimbursed for the high-ticket items (such as surgery) that they provide.

This is not irrational. It makes sense for people to do the work that only they can do, to, in the jargon, “work at the top of their license". But this requires changes in reimbursement. In particular, the concept that a single episode of treatment (e.g., surgery) is worth a lot more than the ongoing continuous lifelong management of a person’s health needs to be re-examined. But for this to work, adequate resources – especially human, like enough primary care doctors so that they don’t have the 2500 patients each, and enough support nurses and assistants and clerks and scribes to address the workload – have to be available.

Some primary care providers have moved into “direct primary care”, where, for a fee beyond insurance reimbursement, they provide (presumably) all the primary care needs of smaller group of patients. It has its pluses, but without adequate numbers of providers and without a national health insurance system covering everyone, it leaves too many people out; it becomes another “market niche” for those who can afford it, and this is not what health care should be.

I have heard it said that there are 3 entities that are always identified as likely places when something additional is suggested to be added to health care: primary care, nursing education, and black churches. Nursing education because, you know, nurses should know how to do that (whatever that is today). Black churches, you know, because they are important institutions in the community, with credibility, so if they urge people to healthier behaviors it may work better than when outside health professionals do. Could be a good idea. Maybe the nursing schools or black churches could hire people who could use the jobs to do this work.

But, as in primary care, rarely are these “good ideas” backed up with money, with sufficient funding to make it happen, to employ people, to support them. That money, of course, needs to go to for health systems, subspecialists, insurance companies, and mega-corporations.

Time for a change.

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[i] Yarnall KSH, Pollak KI, Østbye T, Krause KM, Michener JL, Primary Care: Is There Enough Time for Prevention?

MD Am J Public Health. 2003 April; 93(4): 635–641.PMCID: PMC1447803. PMID: 12660210

[ii] Yarnall KSH, Østbye T, Krause KM, Pollak KI, Gradison M, Michener JL, Family Physicians as Team Leaders: ‘Time’ to Share the Care, Prev Chronic Disease Apr2009;6(2):A59),

[iii] Baron R, What’s Keeping Us So Busy in Primary Care? A Snapshot from One Practice, New England Journal of Medicine, Apr29,2010;362(17):1632-6

[iv] Margolius D, Bodenheimer T, Transforming Primary Care: From Past Practice To The Practice Of The Future, Health Affairs May 2010, 29(5): 779–784.

Global Health at Home: Caring for Migrant Families on their U.S. Arrival

The American Academy of Family Physicians (AAFP) sponsors an annual Global Health Summit. This year’s conference, in Albuquerque, NM, was the largest so far. The conference started primarily as a venue for family physicians who volunteer their time abroad, providing health care and teaching in generally less developed countries. These were for both long (a year or more) or short trips, often sponsored by religious organizations. They also can include work done through government (eg, Peace Corps) or non-governmental but non-religious organizations (eg, Partners in Health, Doctors without Borders, Doctors for Global Health), but the religious root of much of this work is still apparent in the use of the term “mission trip” for most short-term such activities, especially involving medical students or residents. Overall, most such organizations, including those largely or partially sponsored by churches or religiously-affiliated organizations, no longer make religious proselytizing or efforts to “convert the natives” a significant part of these trips, and focus instead on health care and health system development (although there are certainly exceptions). Many of the leaders in this field are also involved in development of health systems in countries across the globe and in international health organizations and efforts including WONCA (the World Organization of Family Doctors), the World Health Organization (WHO) and its sub-groups such as the Pan-American Health Organization (PAHO), and The Network-Towards Unity for Health.

While such international work remains the mainstay of global health activity, there is also increasing interest in addressing needs in the US. To some degree, this reflects a long-standing discussion regarding the degree to which many doctors and students are more interested in going abroad on such trips than providing care to the needy at home. Of course, this need not be a contradiction, and many of the most active physicians in global health also spend the bulk of their time in the US working with underserved communities. But there are also those, including many students, who are attracted to such trips for other reasons. These include “medical tourism” – using the trip as an excuse for an exotic vacation, particularly if the place they are going is near beaches or mountains. They also include what might be called “medical opportunism”, where students go because they will get to do things to people on these trips that would be forbidden for them to do in the US, especially procedures. On the positive side, they can, provided the physicians or students are open to it and do not just talk to each other and can go beyond the “we are here to help you” mentality, allow learning and increase intercultural understanding, as well as increase knowledge of conditions that are more prevalent in the developing world. In addition, some of these conditions, as a result of the climate crisis and other factors, are moving north into our own country, so we see Chikungunya and dengue and other formerly tropical diseases. The key distinction is in how these trips are approached; they should be of benefit to you, but are not, ultimately, about you, but about collaboration with people, and health care providers, in other countries.

One increasing area of interest that tends to bridge this US/international divide involves the care of migrants coming to the US, an issue that has becoming increasingly front and center over the last few years. While the care is done in the US, the people are coming from other countries; in the case of our southern border primarily Central America and Mexico, but people come from all over the world. Several presentations at the Global Health Summit addressed different aspects of “Border Health”, each of which is important and each of which creates the need for linkages with other aspects of the health system. One is the care of people who permanently live along the US/Mexico border. The border, of course, is artificial, and many families live on both sides including Native Americans, such as the Tohono O’odham of Arizona, whose reservation crosses the border. This is a special case of care for the poor and underserved. Another is the care of people who are migrant workers, who may “live” in the border area for much of the year, but move to other regions of the US to follow the harvest. This creates the need for linkages with migrant health providers across the country. A third is the care of just-arrived migrant families who present at our southern border and may spend just a few days in our border communities before moving on to other parts of the US where they have sponsors. This creates the need for communication with appropriate health facilities in those areas, both for general health care and “warm hand offs” for individuals with particular needs. Such needs include those with ongoing chronic diseases often made worse by the journey, acute but severe issues such as injuries (including traumatic amputation by trains) and acute renal failure from dehydration crossing the desert, pregnancies (especially those that are high risk), and newborn but small or premature infants, etc.

“Global Health at Home: Caring for Migrant Families on their U.S. Arrival” was the title of a presentation by three Tucsonans who volunteer at the Casa Alitas migrant shelter, Anna Landau, MD MPH, Patricia J. Kelly, PhD MPH FNP, and myself. Originally accepted as a seminar, it was “upgraded” to a plenary presentation when the originally scheduled Ostegaard Speaker, Michael Kidd of Australia, was unable to attend due to family issues. While it was an honor to be selected, it was also gratifying to note the level of interest among the participants, from those doing similar work in cities on the border such as San Diego, El Paso, and Yuma, AZ, to those across the US who see these people as patients in their home communities, from big US cities to small towns in SW Georgia.

I have attached the slides in 'Links to Documents', found on the right side of the blog screen. It is important to recognize that medical care, which given the fact that guests are usually present for only 1-3 days, follows a public health model of dealing with acute needs and screening for infectious disease, is only a small part of the Casa Alitas operation. Hundreds of volunteers – and all are volunteers -- work on food preparation and service, contacting sponsors and arranging transportation, collecting and sorting and distributing clothing, doing laundry, driving guests to the bus station, and the multiple other needs that migrants have. I would also like to quote some parts of an email sent out by the Reverend Delle McCormick, a long-time leader in working with migrants in Tucson, after the recent move of Casa Alitas, which she has given general permission to share widely:

Every day is a triumph of small steps toward smoothly operating, warmly encouraging, just and loving spaces for our guests and volunteers. We have fallen for this new place and time. With each move we get more nimble, creative, and courageous in what we do together. Love shines here….Despite new draconian immigration policies at the border, we still have received 2484 men, women, and children at our new Casa Alitas Welcome Center shelter, making a total of 17,418 since October of 2018 when we stepped up our efforts to provide shelter for families seeking asylum.

Our volunteers still provide extra touches to encourage the human dignity and rights of every person who passes through our door. We hear and hold the most harrowing of stories: from 80+ year-old Sra. T. who stayed with us for a month because we couldn’t locate her sponsor, to the young man who had his toes burned off because he couldn’t pay for his release from kidnappers, to the woman who was shot in the head by her husband, to the daughter whose 68 year-old mother, who is blind, was detained, to the teenager kidnapped and prostituted and beaten by the local gang,  to the many, many others, each of whom has harrowing stories that drove them to leave everything behind to seek asylum.

If anyone is interested in learning more about the work in Tucson at Casa Alitas, in coming to volunteer, or in donating, more information is available at the website https://ccs-soaz.org. Donations can be made directly to CCS at  Support Migrant Aid - Tucson and through its GoFundMe page https://www.gofundme.com/casa-alitas-for-migrant-families.

Hospitals increase cost of health care...and pick and choose what they market to whom

The greed of pharmaceutical and insurance companies is the stuff of legend. There can be no justification for the huge costs that the American people have to bear as a result. Their administrative costs and profits alone are unconscionable and drive up the cost of health care so much that it takes a completely self-serving and willfully ignorant Democratic presidential candidate to disingenuously ask “how will we pay for” Medicare for All – and we  have a lot of them. The financial cost is, however, is not the most evil part of what they do. That would be the deaths and disability and bankruptcy that affects so many Americans because the insurance companies deny them care and the pharmaceutical companies make their drugs unaffordable. (This is a mild term for drugs that can cost $30,000-$100,000 a year and more!)

I have written about these issues many times. More recently I have also written about the role that providers (mainly hospitals and “health systems”, but also some physicians, nursing homes, etc.) play in the two-pronged scandal of the US health care system – too expensive and too unavailable to too many. There are some hospitals (I include “health systems” but will use “hospital” to avoid confusion with the “health care system”) that are actually for-profit, but most are officially “non-profit”. This means that they don’t have shareholders – and don’t pay taxes – but they otherwise behave just the same, trying to make as much money as possible. They say that they plow this back into the services that the hospitals provide, but it also includes salaries for C-suite executives that look just as outrageous as those in the “for-profit” sector.

More important, the “improvement” in services does not always – or even usually – create new services that were absent from the community previously, or make them available to more people than previously, say the poor and uninsured. They are usually efforts to attract insured, paying, profitable patients away from other hospitals by building a new, fancier cancer center, or heart center, or orthopedic center. Hardly ever pediatrics (except neonatal intensive care) or mental health – they only want to expand those services that are big profit centers. In this way, it is parallel to the behavior of drug companies; they prefer to minimally modify existing big sellers to get a piece of that market (“me-too” drugs) rather than to develop drugs to meet needs not currently being met.

It is good to see the hospitals being called out by major health system critics. Elisabeth Rosenthal, president of Kaiser Health News, wrote an important article on September 1, 2019 in the New York Times (where was once the health reporter) titled “That Beloved Hospital? It’s Driving Up Health Care Costs”, in which she makes many of the same points. She writes that

Data shows that hospitals are by far the biggest cost in our $3.5 trillion health care system, where spending is growing faster than gross domestic product, inflation and wage growth. Spending on hospitals represents 44 percent of personal expenses for the privately insured, according to Rand.

A report this year from researchers at Yale and other universities found that hospital prices increased a whopping 42 percent from 2007 to 2014 for inpatient care and 25 percent for outpatient care, compared with 18 percent and 6 percent for physicians.

The reason, of course is the political clout that the big hospitals can buy (with, of course, our money!).The Democratic presidential candidates are beholden (with the exception of Sens. Sanders) to both hospital contributions and the role of big hospitals as major employers and economic drivers. “In 2018, PACs associated with the Greater New York Hospital Association, and individuals linked to it, gave $4.5 million to the Democrats’ Senate Majority PAC and $1 million to their House Majority PAC. Its chief lobbyist personally gave nearly a quarter of a million dollars to dozens of campaigns last year.” Could this have anything to do with why “The cost of a hospital stay in the United States averaged $5,220 a day in 2015 — and could be as high as over $17,000, compared with $765 in Australia”? Ya think? Ask you politicians what they are going to do about it…

The media, including Kaiser Health News, has been running stories on hospitals that are aggressively pursuing lawsuits against patients who have been unable to pay their bills. On September 3, 2019, the Times ran a long piece on the poster child for this practice, Carlsbad Medical Center in New Mexico, in “As Patients Struggle With Bills, Hospital Sues Thousands”, but Carlsbad is by far not the only one. The practice is most common in towns with just one hospital, and of course, patients do not know how much they owe – or for what. It doesn’t matter if you are insured: “Ms. Price, 40, a nurse and local 4-H leader, has been sued five times by Carlsbad Medical Center, for bills totaling more than $17,000….Ms. Price said she had never received an itemized bill outlining exactly what she owed money for. The collection agency wanted the balance in full, and she was not able to work out a payment plan until after she was sued.”

This article names other hospitals that sue patients as a core business practice, and mentions over 20,000 suits in Virginia. Turns out that this was in no small part driven by the state-owned University of Virginia hospital in Charlottesville, documented by the Washington Post and MSN in “‘UVA has ruined us’: Health system sues thousands of patients, seizing paychecks and putting liens on homes”. In a quick response, the Governor of Virginia and the University vow to stop suing patients, but this has apparently not affected those already sued: ‘“Fixing the problem “is complicated,” in part because “we are legally obligated as a state agency to collect debts,” he [UVA president Ryan] said. “But we have discretion within those legal constraints to make our system more generous and more humane.”’ It also has not hurt the CEO of the hospital “…Pamela Sutton-Wallace, who will leave in November to join New York-Presbyterian Hospital as a senior vice president”. Maybe she can teach them to sue their patients…

Many of us have sort of emotional attachments to our local hospitals, where we were born, or delivered our babies, or had our life-saving surgery or other treatment; for which we raised money through bake sales and car washes, or maybe volunteered in the gift shop. But these are not the warm fuzzy hospitals you remember. Rosenthal acknowledges that many rural hospitals are in financial trouble – and they are – but supporting the fantastic (“non-”) profit of these major hospitals is not going to change that. As in every other sector of society, we have two classes of service. One is to those in major metropolitan areas with money or good insurance, with conditions that are highly-profitably reimbursed, like cancer. Preferably all of the above. There is no limit to what will be invested in them. Then there are those without money, or good insurance, who live in rural areas, or have problems that are not well reimbursed, like mental health or substance use. They will not get investment. Simple as that.

Major hospitals are big businesses and act like it. You are a customer – but, compared to other industries in which you are a customer, a particularly uninformed one. Need a car? A refrigerator? Financial services? Dental care in Mexico (had to get that one in)? You can find out what it will cost and compare prices. Hospital care? In the US? You gotta be kidding.

The answer? Improved an expanded Medicare for All, a single-payer system in which, as in Canada, hospitals get global budgets, and separate capital budgets so that they cannot use the money (profit) they earn on your care to build spas to attract high-paying patients from competitors. Where everyone gets the care they need, and no one gets excessive care. Possible? Too expensive? Ask the Canadians. Or Australians, where the average hospital bill is less than $800. Or British, or French, or Swedish, or Danish, or Dutch, or German, or Taiwanese….