Why do students not choose primary care?

We need more primary care physicians. I have written about this often, and cited extensive references that support this contention, most recently in The role of Primary Care in improving health: In the US and around the world, October 13, 2013. Yet, although most studies from the US and around the world suggest that the optimum percent of primary care doctors should be 40-60%, the ratio in the US is under 30% and falling. A clear reason for this is that relative lack of interest of US medical students in entering primary care at the rates needed to maintain, not to mention increase, our current primary care ratio. In addition, the ratio of primary care to other specialty residency positions is too low. Here we confront the fact that the large majority of medical students completing Internal Medicine residencies enter subspecialty fellowships rather than practicing General Internal Medicine. At the Graduate Medical Education level, a simple way of estimating the future production of primary care doctors would be to add the number of residency positions in Internal Medicine (IM), Pediatrics (PD), Family Medicine (FM), and combined Internal Medicine-Pediatrics (IMPD) and subtract the number of fellowship positions they might enter. This still overestimates the number of general internists, however, since it does not account for doctors who practice as “hospitalists” after completing their residency because such a role does not currently require a fellowship (as does, say cardiology). Estimates are now that 50% or more of IM graduates who do not pursue fellowship training become hospitalists.

Thus, we welcome the research report from the Association of American Medical Colleges (AAMC) “The role of in medical school culture in primary care career choice”[1], by Erikson et al. that appears in the December 2013 issue of AAMC’s journal Academic Medicine. The authors surveyed all 4^th-year medical students from a random sample of 20 medical schools to assess both student and school level characteristics that were associated with greater likelihood of entering primary care. The first, and arguably most important finding, was that only 13% of these final-year medical students were planning on primary care careers. This is despite the fact that 40% were planning to enter the “primary care” residencies of IM, PD, FM, and IMPD, with most of the fall-off in internal medicine and least in family medicine. This finding strongly supports my assertions above, and makes clear that the historically AAMC-encouraged practice of medical schools reporting “primary care” rates by entry into residencies in those fields is not valid. It also, even more important, shows the extent of our problem – a 13% production rate will not get us from 30% to 40% or 50% primary care no matter how long we wait; obviously it will take us in the other direction.

The primary outcome variable of the study was entry into primary care, and it specifically looked at two school level (but perceived by students, as reported in the survey) characteristics: badmouthing primary care (faculty, residents or other students saying it is a fall back or something that is a “waste of a mind”) and having greater than the average number of positive primary care experiences. It turns out that both were associated with primary care choice (in the case of badmouthing, students from schools with higher than average reported rates were less likely to be planning primary care careers, while students who were planning such careers reported higher rates of badmouthing), but, after controlling for individual student and school characteristics, accounted for only 8% of the difference in primary care choice. Characteristics of the student (demographics such as sex, minority status or rural origin, academic performance defined as the score on Step 1 of USMLE, as well as expectation of income and feeling of a personal “fit” with primary care) and of the school (research emphasis, private vs. public,  selectivity) accounted for the rest. Interestingly, debt was not a significant factor in this study.

I would argue that many of these individual and school characteristics are highly correlated. A school that prides itself on being selective (taking students with high scores) and producing subspecialists and research scientists does not have to badmouth primary care; the institutional culture intrinsically marginalizes it. On the other side, the students selected at those schools are more likely to have those characteristics (particularly high socioeconomic status and urban or suburban origin) not associated with primary care choice. It is worth noting that the measure of academic performance in this study was USMLE Step 1, usually taken after the first 2 years and focusing more on the basic science material covered in those years, rather than USMLE Step 2, which covers more clinical material (perhaps because not all 4^th-year students studied have taken Step 2 yet). This biases the assessment of academic qualification; many studies have demonstrated high levels of association of pre-medical grades and scores on the Medical College Admissions Test (MCAT) with pre-clinical medical school course grades and USMLE Step 1 scores, but not with performance in any clinical activity, not to mention primary care. Perhaps most students improve their scores from Step 1 to Step 2, but it is particularly true for FM and primary care. A quick look at our KU students applying to our family medicine program shows an average increase of nearly 30 points in these scores.

So the problem is in the overall culture of medical schools, in their self-perception of their role (creating research scientists vs. clinicians, creating subspecialists vs. primary care doctors) and in their belief that taking students with the highest grades is equivalent to taking the best students. This culture, simply put, is bad, defined as “it has undesirable outcomes for the production of the doctors America needs”, and must change. Erikson and colleagues acknowledge that schools could do a better job of taking rural students, offer more opportunities to engage in public health and community outreach activities, and have more experiences in primary care, all of which were somewhat associated with primary care career choice. These are tepid, but coming from the AAMC, a reasonably significant set of recommendations. I say we need an immediate change in every single medical school to recruit at least half of every class with students whose demographic and personal characteristics are strongly associated with primary care choice, present a curriculum that has much less emphasis on “basic science” and more on clinical, especially public health, community health, and primary care. One of the primary bases for assessing the quality of a medical school should be its rate of primary care production, and this is going to require a major qualitative shift in their practices and the beliefs of many of their faculty and leaders.

I am NOT saying is that we don’t need subspecialists or research scientists. We do. I AM saying that the emphasis on production of these doctors compared to primary care doctors is out of whack, not just a little but tremendously so, and can only be addressed by a major sea change in attitudes and practices in all of our medical schools. I do not expect that all schools should produce the same percent of primary care physicians. Some might be at 70%, while others are “only” at 30%, but ALL need a huge increase, by whatever means it takes. Even if we produce 50% primary care physicians on average from all schools it will be a generation before we get to their being 50% of the workforce. At less than that it will take longer, and at less than 30% we will not even maintain where we are.

13% is not just “insufficient”, it is a scandalous abrogation of the responsibility of medical schools to provide for the health care of the American people. They should be ashamed, should be shamed, and must change.

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[1] Erikson CE, Danish S, Jones KC, Sandberg SF, Carle AC, “The role of in medical school culture in primary care career choice”, Acad Med December2013;88(12) published online before print.

The cost of medical care: bundling tests and blaming the victim

A great deal of discussion followed the publication of the NY Times’  June 13 article “The $2.7 trillion medical bill” (including my own blog piece The high cost of US health care: it's not the colonoscopies, it's the profit, July 28, 2013). The article began with the cost of colonoscopies and went on to address many of the sources of the high cost of US health care. A more recent piece in the New England Journal of Medicine, “The thousand-dollar Pap smear”[1] by Cheryl Bettigole seems like it could be a follow up. In some ways it is, but it also raises a number of other points that should be addressed.


Dr. Bettigole begins by describing a call from one of her patients, who complained she had been charged over $600 for her Pap smear, shocking both of them. She goes on to describe the tremendous role that Pap smears have had in (at least in developed countries) in almost eliminating the scourge of advanced cancer of the cervix; indeed, this test remains the best example we have of an effective screening test for any cancer. It is – or should – also be very cost-effective, as especially shown by studies that assume a $20-$30 cost for the test. So how did it get to be so expensive? Is it really? Is it necessary? A portion of the increased cost comes from the use of a more effective (and more expensive) method of preserving and analyzing the specimen (“liquid based”), but most of it comes from including a bunch of other tests. These include tests for human papilloma virus (HPV), recommended only for some women and at intervals less than routine Paps, and tests for sexually-transmitted infections (STIs) which may or may not be indicated based on the patient’s history and symptoms but are quite different from cervical cancer screening. Why? Because the laboratory, which makes money on this, often “bundles” these into an easy-to-order “panel” of tests (rarely accompanied by the price!), and busy clinicians check them off.

The insidiousness of this kind of effort to order more tests than planned (and, often, to find an unanticipated – and frequently unimportant – abnormality that requires more tests to follow up) is common, not solely for Pap smears but for many other lab tests, and contributes to the increased cost of health care for society, insurers, and individual people. Dr. Bettigole’s other point, however, is the role of the provider in contributing to this unnecessary cost by not ordering tests more carefully, and with attention to cost. She writes “`When I was in training, our attendings would ask a standard quiz question: “What is the biggest driver of health care costs in the hospital?’ Answer: the physician's pen. A mouse or a keyboard, rather than a pen, now drives the spending, but we physicians and our staff are responsible for ordering these unnecessary tests and hence responsible for the huge bills our patients are receiving.”

It is a good point, and we should all be careful to order tests (and treatments) cost-effectively and teach our students the same. But this is not the sole answer; we need systems that encourage this sort of test ordering, and make it more difficult to do things that are not cost effective. It is parallel to encouraging our patients (and ourselves) to adopt healthful behaviors – a good idea, but not the answer for improving the health of a society so heavily geared to encouraging poor behaviors (drinking and smoking and guns and overeating and eating empty calories, etc. etc.). The idea that the "problem" is individuals' bad behaviors appears in lots of places in society, and frequently in medicine. This is not only victim blaming but an impractical approach to problem solving. In industry, a strategy called “six-sigma” has been widely adopted; its goal is to make bad outcomes resulting from individual error occur with a frequency approaching zero. The model is airplane flight, and trying to eliminate crashes, and it works because systems are put into place that make things work rather than saying to each pilot “Be careful! Remember to push the joystick in the right direction!”


At a recent Family Medicine conference, the excellent film "Escape Fire" was shown. It addresses many issues of problems with the health care system, including delivery systems, an emphasis on high-tech “rescue” care rather than prevention, and profit seeking by insurers, providers, and drug and device makers. A part of it also features Safeway's program for employee wellness. For some reason, the leaders of the ensuing discussion chose that as the first question: "does your employer encourage wellness?"

After a while I observed that this was not the main point of the film, and that mostly it talked about the need for system change. A student indicated he agreed with most of what I said but that there should be some "individual accountability". I should have asked specifically what he meant, but did observe that they have the ultimate accountability -- they get sick and die sooner. Of course, we should encourage our patients to eat right and exercise and not smoke and drive carefully, and we should ourselves. However, like trying to get all airplane pilots to push the stick the right way, getting each individual to always do the right thing is not the way to go. Few of us never drive too fast! Yet over the last 30 years there has been a tremendous decrease in traffic-related deaths, all of it from safer roads and more safely designed cars and 0% of it from people driving more carefully.

In occupational medicine behavior change is considered a weak third option after architecture and engineering. If there is a big window next to the factory floor where it is sometimes slippery, that is an architectural flaw; it shouldn't be there. But, if it is, you can put a heavy mesh screen over it so if people do slip, they don't go through -- engineering. Telling everyone to always be careful is good advice, but not a very effective solution. And yet, in our practices, with patients, with doctors, with social problems, we (as a culture) do it all the time.

Of course, an additional consideration in solely emphasizing individual behavior change is that we are wont to do it mostly with people whose “bad” behaviors are different from our own, and people who seem to be different from ourselves. We may overeat and need to go on a diet, but they are massively obese and at fault. We may drink sometimes, maybe too much, but they are alcoholics, or drug addicts. We could do a little more exercise, but they don’t care at all for exercise and its health benefits. We sometimes indulge in a piece of cake or a donut or two, but they only eat crap. We are sometimes in a hurry and not as careful as we should be, but they are maniacs on the road.

And, of course, they often look different from us, of a different race or culture. And really often they are poorer than we are (especially when we are physicians), and confronting, on a daily basis, a lot of challenges we don’t. Do they live in a “food desert” where the nearest grocery is too far to walk and they haven’t access to a car? Or it is unsafe to walk, for food or for exercise? Have they got a job or any chance of getting a job? Or are they “lucky” enough to have 3 jobs, and no time to “work out”? Judging others is a popular pastime, but it is not only often done without adequate understanding, it is rarely useful. We can and should encourage healthful behaviors and try to identify obstacles and help people overcome them, but we must focus primarily on the systems changes that make health possible in a more efficient and effective way than expecting everyone to change their behavior.

We can. The airlines have done it. The car industry (dragged kicking and screaming) has done it. The health care system can as well.
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I am indebted to many wise comments made by many family medicine chairs on the ADFM listserve. The opinions and conclusions, however, are entirely my own.

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[1] Bettigole C, “The thousand-dollar Pap smear”, NEJM 17Oct2013;369(16):1486-7.

The role of Primary Care in improving health: In the US and around the world

At the Family Medicine Midwest conference held recently in Milwaukee, the first day’s plenary speaker was Richard Roberts, MD, from the University of Wisconsin. Dr. Roberts has a distinguished history as a health services researcher and leader in Family Medicine, having been president of both the American Academy of Family Physicians (AAFP) and the World Organization of Family Doctors (WONCA). He has extensive experience in international health, and is knowledgeable about the health systems – and their results – in countries around the world. And he continues to practice family medicine.

Some of the issues that Dr. Roberts discussed involve the health care system, and, drawing from the important work of the late Dr. Barbara Starfield, emphasize the importance of primary care to improving the health of a population. I have written about the disproportionate emphasis of medical education on hospital care, advanced disease, and high-cost rescue interventions which often fail to rescue and frequently cause complications, rather than on primary care, prevention, and early diagnosis and treatment. Dr. Roberts reminds us of the “Ecology of Medical Care” (referring to the

setting in which health care takes place), done first by Kerr White in 1961[1] and replicated by the Graham Center of the AAFP in 2003[2] with remarkably similar results. In a community of 1000 adults, in any month about 800 have a health problem or injury, 217seek attention from a doctor, 8 are hospitalized, 5 see subspecialists, and 1 or less is admitted to an academic medical center teaching hospital, which, of course, is where we train most medical students and residents, and where they get a skewed view of the prevalence of disease. They begin to see unusual or even rare things as common, and develop habits of ordering tests that are perhaps appropriate in that setting, but dramatic overuse in ambulatory practice.

In 2005, there were 34 million hospital admissions in the US, but almost 1 billion office visits. Of those, about 53% were to primary care physicians. While much is made of the increase in emergency department usage, from 1995 to 2005 ER visits were up 8% while primary care visits increased 22%. As Roberts notes (medical students should cover their ears!) primary care doctors comprise about ¼ of the physician workforce but see more than ½ of all patient visits and earn about ½ the income of subspecialists (and this is average; a much smaller fraction of the income of the most highly paid subspecialists).

Internationally, the same trends are noted. Countries with a higher “primary care score” (which largely measures the percent of the medical workforce in primary care) had lower rates of premature deaths than those with low PC scores in 1970, and over the last 4 decades, while the rate has gone down in both groups, the gap between them has widened. In an unintended “natural experiment”, the Asian economic boom of the early 1990s allowed Indonesia to greatly increased health spending, mostly in primary care; that nation saw a 70% improvement in health status in all provinces. With the collapse of that “bubble” in the late 1990s, spending on primary care went down, but not on hospital care in the big cities. This was a result not of Indonesian government decisions, but rather of the international community through organizations such as the World Bank saying “your economy is worse, but you need health care – here’s money … to build hospitals”. But health status dropped in most provinces. Not the best use of resources!

In the 1990s, Shi studied socioeconomic, environmental, and health system characteristics of US states and their relationship to health status (mortality, lifespan, deaths due to heart disease and cancer, neonatal mortality, and low birthweight). Access to primary care was the strongest predictor of greater lifespan and was second (to living in an urban area) for lower mortality rates, even ahead of education. Number of specialists and number of hospital beds were far down the list – indeed they were negative predictors![3] None of the changes in the health system since that time are likely to change this; indeed, the increase in specialists, technology, and hospitalizations have probably increased it.

What is it about primary care? Why does it make so much difference. Starfield’s work identified the fact that nations and regions with high levels of primary care have greater self-reported health status and fewer health disparities, and that the presence of primary care tends to mitigate the negative impact of income inequality.[4] This group also demonstrated that an increase of primary care physicians of 1 per 10,000 (20%) physicians decreases mortality by 40 per 100,000 (5% fewer deaths), and 1 per 10,000 (33%) more family physicians decreases mortality by 70 per 100,000 (9% fewer deaths), while an increase in specialists of 1 per 10,000 (8%) increases mortality by 16 per 100,000 (2% more deaths). [5] Dr. Roberts notes 4 features of systems with higher primary care to specialist ratios that might affect this: 1) when there are too many specialist and not enough primary care doctors, specialists may try to manage conditions outside their specialty in which they are not knowledgeable; 2) prevention and early detection save more lives and extend life more than intervention late in the disease process; 3) there is excessive utilization of procedures when there are too many specialists (supply drives demand rather than vice versa) and these often have risks; 4) the more “handoffs” there are between doctors caring for a patient, the more that care begins to resemble an elementary school game of “telephone”, where the final message heard is very different from that which began the communication.

The fact that family physicians specifically seem to improve population health status more than primary care physicians taken as a whole is apparent in the data, but the reason has not yet been identified by studies. Dr. Roberts postulates that it has to do with caring for multiple family members, and using that information to improve their care, such as when a mother’s issues are addressed at a visit ostensibly limited to caring for her child. Primary care (and possibly especially family physicians) acts to achieve all aspects of what has been identified as the “Triple Aim” of health care: greater access, lower cost and higher quality.

Primary care doctors, and especially family physicians, are doctors of “first and last resort”. They care for pregnant women and deliver their babies and care for their children as well as the other adults in the family. They tend to the “grandparents”, older adults, and manage the often complex interplay of multiple chronic diseases. They provide acute care and preventive care and are aware of the individual’s beliefs and preferences and those of the family, and the dynamics that exist between them. They care for people at the end of life, right through the end, not just until “there is no more to do”, and they remain there for the survivors.

The US could do a lot better. We need a health system that is more grounded in primary care, and we need a health system that provides access to everyone. What we don’t need is folks in Congress are committed so committed to preventing that access they will shut the government down!  Another conference speaker, Dr. Cynthia Haq of the University of Wisconsin, quoted the Ethiopian Minister of Health, with whom she had recently met. “Only in the United States,” the Minister said, “could there be discussion about whether access to health care was a human right or not.”

Oh, my. He’s right. I sure wish he were not.

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[1] White KL, Williams TF, Greenberg BG. The ecology of medical care. N Engl J Med 1961;265:885–892.

[2] Green, LA et al., “The ecology of medical care revisited”, N Engl J Med 2001; 344:2021-2025June 28, 2001DOI: 10.1056/NEJM200106283442611

[3] Shi L, "Primary care, specialty care, and life change", Intl J of Health Service,1994; 24(3):431-58

[4] Starfield BA, Shi L, Macinko J, “Contribution of Primary Care to Health Systems and Health”, Milbank Quarterly Sept2005; 83(3):457-502. DOI: 10.1111/j.1468-0009.2005.00409.x

[5] Shi L, et al., “The Relationship Between Primary Care, Income Inequality, and Mortality in US States, 1980–1995”, J Am Bd Fam Med, 1Sep2003;16(5)412-422. doi: 10.3122/jabfm.16.5.412.

Critical access hospitals: Worth subsidizing to help save rural America

If you live in a sparsely populated area, you may find it difficult to obtain medical care because doctors and hospitals are far away. The issue of geographic isolation is independent of insurance status; it is a problem that plagues Canada, where everyone has health insurance through its single payer system (coincidentally called “Medicare”), but most of the people are concentrated within a short distance of the US border, and there are vast stretches of empty (or, more to the point in this case, almost empty) land. The situation is exacerbated further by the fact that many people living in rural areas work in jobs that have a higher risk of injury which might need care (e.g., farming, ranching, logging), and by the fact that a greater percentage of people living in rural areas are older, and thus more likely to have chronic disease. However, hospitals serving rural areas are small, and may not bring in enough revenue to support their fixed costs, so hundreds of rural hospitals closed in the 1980s and 1990s.

In response, Congress created the Critical Access Hospitals (CAH) designation in 1997, allowing hospitals that meet certain criteria (initially being greater than 35 miles apart) to receive increased reimbursement from Medicare at 101% of their costs. This was very successful, not only permitting the survival of many existing rural hospitals, but the creation of new ones, particularly when states were allowed to add other criteria to the designation, creating “Necessary Provider” Critical Access Hospitals, NP-CAH. The existence of these hospitals has been seen as a top priority for many rural communities, and for the states that they are located in. However, a recent report (OEI-05-12-00080) by the Department of Health and Human Services’ Office of the Inspector General (HHS-OIG) suggests that a stricter application of the distance criterion (even 15 miles, not 35) would mean that many of these hospitals would no longer receive 101% of their costs, and that this would result in the saving of $449 million to Medicare. They provide us with a sample map of Missouri, showing which hospitals would be affected.

As reported by Mike Shields of the Kansas Health Institute (KHI) in “Inspector general’s report has rural hospitals worried”, this has the National Rural Health Association raising the alarm. It is of special interest in the middle of the country. Kansas, where former governor and current HHS Secretary Kathleen Sebelius certified 31 additional hospitals under the NP-CAH criteria, leads the nation with 83 CAHs; Iowa is second with 82. According to the OIG, “There are more than 1,300 CAHs in the United States. CAHs are located in every State except Connecticut, Delaware, Maryland, New Jersey, and Rhode Island. CAHs provided care for approximately 2.3 million beneficiaries in 2011. Medicare and beneficiaries paid approximately $8.5 billion for this care.” So it is not surprising that these hospitals, their trade association, and the states in which they are located, are very concerned; many of them would likely close if they didn’t receive the excess payments from Medicare. The question is: would it be a good idea?

Essentially, the key part of that question is not whether it would save money for Medicare; clearly it would. The question is “would it harm the access of rural people to necessary medical care”? I don’t know the answer to that; or, rather, I know the answer is that it would but I don’t know how much. Could people drive 15 miles farther to the next hospital? Probably. Many of them are already driving a number of miles. Would this be inconvenient? Probably. After all, a large percentage of the users of these hospitals (most of which are also the locations of the doctors’ or other health providers’ practices) are older, thus Medicare’s interest in them. Would people be less likely to get necessary preventive and treatment care for none emergencies? Possibly. Distance is a big issue, especially if you have to be picked up and driven by someone else. Would there be disparities in which rural residents see decreased access? Almost certainly. Many rural people with high incomes often go to larger facilities in bigger cities, or to “destination” centers, like the Mayo Clinic, for their regular care. Obviously, the poor will have less access.

But would it save sufficient money to justify this? What is the cost/benefit to saving $449 million to Medicare against the – what? Lives? Convenience? of a bunch of rural Americans? Very hard to measure, although I again (see “Why poor people choose ERs: we need a system designed to meet everyone’s needs”, August 4, 2013) call attention to the fact that “convenience” is a loaded word that does not convey the full impact of time, transportation, and competing demands that affect the lives of the most needy. It is probably a matter of priorities, and of course, who you are. Are you the majority of people, including Medicare recipients, who live in major metropolitan areas, and for whom the sheer distance to a hospital is not among the many problems that you have accessing care (although transportation might well be) or the 20% or so who live in these rural areas?

One additional point that can be brought up on either side of the argument is that CAHs are often critical in other ways, such as their economic impact on their communities. Many are among the largest employers in their towns. They are a sense of civic pride. One I know about is Kiowa County Hospital in Greensburg, Kansas, a town of 1500 in the southwestern part of the state. On May 4, 2007, most of Greensburg was leveled by a tornado. Because I drive through it a few times a year, I have watched its rebuilding and taken pictures of it. For several years, the hospital was located in Quonset huts on the north side of US Highway 54. In rebuilding the town, Greensburg, with the support of many organizations, sought to make it in many ways a model of what a small town could be, including in ways that encouraged health, such as having schools and public buildings in downtown, walkable, rather than on cheaper land on the outskirts requiring a car. And they rebuilt the hospital, which is now “the first LEED Platinum Certified Critical Access Hospital in the United States.”

So what? I mean, it’s nice that Greensburg rebuilt in an environmentally positive and health-oriented way, and that Kiowa County Hospital is LEED platinum. Yes, it’s nice that rural communities take pride in their local hospitals, and that they provide jobs for the people who live there. It’s nice that the folks who live in these parts of the country don’t have to drive quite so far to get medical care. But is that a reason for Medicare to spend all that money to subsidize them, to keep them open?

I think so. I think that, from a health point of view, minimizing the already-long distances many rural Americans have to travel to access care is a good thing. I think that having institutions that provide jobs and stabilize communities and possibly even keep towns alive is a good thing. You can say “only 20% of Americans live in rural areas”, but that is 20% of Americans. My concern is not nostalgia for a pastoral way of life I have never known, but rather a concern for these communities and the people who live there as needing support as much as poor and middle-class people in cities and suburbs. I note the irony that Kansas’ two Republican senators are very strong advocates for rural hospitals while supporting their party’s policies on cutting services for the needy, and that its Republican governor (and former senator) is a leading advocate for “let’s do whatever we can to help the Koch brothers by cutting taxes on fossil fuel producers”. But we have spent, and continue to spend, billions upon billions of dollars on subsidizing bankers, financiers, and the wealthiest American individuals, companies and businesses.

Spending a little bit on keeping rural hospitals alive seems like a whole lot better thing to do.

What can we really expect from ObamaCare? A lot, actually.

Despite the constant refrain heard from many (particularly Republicans, particularly in Congress, and particularly from the particularly self-promoting Sen. Ted Cruz of Texas) that “ObamaCare” (the Affordable Care Act, ACA) is the first sign of the coming apocalypse, and concerns from people like me that it is a great deal for insurance companies and will still leave many people without coverage, it is going to happen and it is going to be a good thing for the health of many people. It’s too bad that the crêpe being hung by the nay-sayers is believed by so many, largely a result of it being so well funded. Of course, this doesn’t mean that Sen. Cruz is going to change his tune or that I am going to stop worry about those who continue to be without insurance (especially in states that don’t expand Medicaid, like mine).

Some have suggested that the biggest fear Republicans have is that it will work, and people will benefit, and that now is the time to scare people to try to get rid of it, since once it is in place people will not want to give it up (see: Medicare). Right now, satirist Andy Borowitz can make fun of the right’s hyperbole with bits like “Fox News: Obama In Plot To Force Americans To Live Longer”, but when people actually do get health care, and the costs do go down, and maybe they do live longer, or at least live in better health (longer “healthy life expectancy”, or HALE; see The State of US Health: improved over 20 years, but not nearly enough”, July 14, 2013), they are going to be happy with it. When you can get health insurance even though you have a pre-existing condition, when you can get health insurance on the exchange marketplace even though your employer hasn’t offered health insurance to you, when you can afford the premiums because those between 133% and 400% of the poverty level will get federal subsidies, it is not likely to make you unhappy and you are very unlikely to want to give it up.

Of course, those who are under 133% of poverty were to have been covered by Medicaid expansion, and this is not going to happen in a lot of states, so these folks will be left out. Chang and Davis, writing in the Sept-Oct issue of the Annals of Family Medicine examined “Potential Adult Medicaid Beneficiaries Under the Patient Protection and Affordable Care Act Compared With Current Adult Medicaid Beneficiaries”. Using a large federal database (NHANES) they compared over 13 million people in each category, and found that the potential beneficiaries were more likely to be male and white and to have about the same level of educational attainment as current recipients. They also had better self-reported health status, and were less likely to be obese or depressed. The prevalence of diabetes and hypertension were about the same, and the potential beneficiaries were more likely to be smokers and heavier drinkers. So, in general, expanding Medicaid to this larger population would result in a healthier (and thus less costly) group to care for, although with significant risk factors. This is related to the argument I have for expanding Medicare to include everyone (a single-payer health system): the highest cost utilizers, the old and disabled, are already in it and expanding it will, thus, not cost as much more as one might think (or certainly not as much as using the private insurance market as we currently do, or even under the Obamacare expansion).

Two editorials accompany this article. Danel Derksen discusses how the ACA will offer opportunities for (and challenges to) both family physicians and public health, while J.P. Silvers compares the objectives of the plan and the results that it is likely to achieve in the real (“imperfect”) world, with emphasis on the potential for “market failure” as the limiting factor. He lists the 3 main objectives of the ACA as 1) reforming the private insurance market, 2) expanding Medicaid, and 3) changing the way that medical decisions are made. The first, the effort to get those currently left out of the insurance market primarily because they are self-employed or work for small companies, is to be accomplished by the subsidized health insurance exchanges, with quite significant subsidies; the idea is that competition will lead to lower prices and better coverage. If this doesn’t happen (“market failure”) then the goal is not going to be achieved. So far, I note, in most states it seems to be working.

Expansion of Medicaid to cover people who are below 133% of poverty and yet not currently eligible was a cornerstone of the program, and the one that the Supreme Court made optional; per this map from the www.Bankrate.com website, 23 states + DC will be expanding Medicaid, 21 will not be, and 6 are undecided. The fact that the federal government will be paying for it seems to have convinced several Republican-controlled states (e.g., Arkansas, Kentucky, North Dakota, and Arizona) that it would be a good idea. Of course, it is a good idea, and not doing it is a way for those who are themselves “feeding at the public trough” (legislators who get publicly-funded insurance) to punish the needy, falsely cloaking themselves in the language of conservatism. As Silvers notes, to really improve health, Medicaid rates will need to be high enough that providers will actually care for beneficiaries.

The third area is changing medical decision making, to both improve the quality of care and lower the cost, issues about which I have often written (see, for example, Controlling the cost of health care by doing the right thing, Sept 22, 2013). Silvers cites, in particular, comparative effectiveness research (CER) which will show us which things work and which things cost the least to achieve comparable results, and which, it is to be hoped, would actually change medical practice. He then goes on to describe the factors which exist in our “imperfect world” that threaten the achievement of these goals, because “There are serious problems in the way the US health system is organized and paid, in the information and choices available, and in the ability of participants to respond to the pressures and incentives provided in reform.” The three classes of problems he discusses are “when decisions are delegated to someone who is supposed to act strictly in our interest as an agent, but doesn’t”, such as brokers who are paid commissions from someone else for signing us up; limits on potential competitors (as arising from pharmaceutical patent protection); and “when one party in a transaction has differential information that allows them to dominate or exploit decisions”, in play with regard to physicians, hospitals, drug companies, insurance companies, and almost everyone involved in health care compared to regular folks. He notes “Finally, the plethora of perverse payment incentives is the most obvious problem in having informed free choice leading to the optimal outcomes desired.”

And this is the real point. The web of multiple strategies for achieving coverage are incredibly complicated, with roots in both the Clinton plan and Massachusetts’ “Romneycare’ and (ironically) in the ideas of right-wing think tanks over the last several decades. This patchwork of fixes has always been a Republican (and conservative Democratic) hallmark. While Silvers titles his final section “What does it mean for the future and what can be done?”, in fact he mostly tells us what the risks are rather than what could be done. There are many who suggest (or fear) that the biggest threat from a potential failure of Obamacare would be that it would make the fact that a single-payer system would be much simpler and effective more obvious; see Morici “First Obamacare, Then a Single Payer System” on www.breitbart.com, cited by Don McCanne in Quote of the Day.

That’d be nice.

Controlling the cost of health care by doing the right thing

The cost of health care and ways to decrease it are a recurring drumbeat in politics, including on this blog. However, I like many others, have also emphasized the need to increase access to necessary health and medical care to all people who need it, and to create social conditions that decrease the burden of ill health. Federal efforts have finally come up with the Affordable Care Act (ACA, Obamacare), passed in 2010, and since 2012 object of continued efforts by Republicans in Congress and in those states in which they control the governor’s office and state house to repeal or gut it. In states, most effort is focused on Medicaid, which is funded by both federal and state money. In some states, most notably Oregon (“The Oregon Lottery: Far from enough, but at least they are doing something”, July 19, 2012), this effort has been combined with increasing access; in most it has just been about cutting expenditures.


On August 4, 2013 (“Why poor people choose ERs: we need a system designed to meet everyone’s needs”), I wrote about an article from Health Affairs ¹that studied the reasons that poor people use hospital emergency rooms “inappropriately” for care, to the frustration of the ERs, primary care doctors, payers (in this case, where patients were either uninsured or covered by Medicaid, mostly government) and health policy experts. The 3 major groups of reasons were quality (perceived quality, which I believe is not valid), cost (a matter not of overall cost but out-of-pocket cost to the user at the time of service) and convenience, which I argue is a misleading word for describing a place that is actually open and will see you when you can get there.  “…it is not “convenient”,” I wrote, “to wait 6 hours in an ER to be seen; if this is better than the alternative, the alternative is seriously flawed!”


What would be a mistake, however, would be to presume that it is just inappropriate use of health services by poor people that drives up the cost of care. Indeed, this is only a small part of the “excess” cost (defined as “cost in excess of what would be needed to be provide quality care to everyone) in the US. Another good definition of “excess cost” might be the additional cost per capita spent in this country compared to many other developed countries whose health outcomes are much better than ours. For this, there are different reasons. I have discussed many of them in earlier posts, and they include procedures that didn’t need to be done, over-utilization of high-technology, under-utilization of primary care, and poor geographic distribution of medical care. To a large extent, these are summarized by the two quotes I used in The high cost of US health care: it's not the colonoscopies, it's the profit”, July 28, 2013: “Using health care as a driver of corporate economics as opposed to a public good is the fundamental cause of our medical inflation,” (Richard Wender, MD) and “The US health care system is not designed to get you the care you need, it is designed to get you the care that someone can make a profit giving you.” (Lee Green, MD).


There are other causes as well. One big one, referred to above and discussed at some length in “To improve health the US must spend more on social services”, December 18, 2011, is the fact that the US does not provide anywhere near the overall social service safety net that other developed countries do. In those other countries there is much more spent to ensure that people have adequate food, housing, education, and a living wage, which are all drivers of health status.


Another big cause, though, are our preferences, our desires, as consumers, for “all that money can buy” when it comes to our health. While this may be especially true when, as health economists often point out, it is not directly your money, but your insurance company’s, I know plenty of cases in which families have wiped out their life savings, wiped out their retirement accounts, wiped out the money that could have supported the survivors (especially true when the patient was the primary breadwinner) in pursuit of “one more” vain attempt at cure. I do not mean to suggest that treatments with reasonable probabilities of meaningful benefit should be withheld. Nor do I mean to blame just the individuals and families; clearly in most of these cases there were doctors and other health professionals holding out hope (“well, maybe we could try another bone marrow transplant and it might help”) without making sufficiently clear what both what they meant by “help” and what the odds were of success.


Yet, many doctors (including me) and hospitals will tell you that they have often recommended against interventions because they have little or no likelihood of meaningful benefit, and often a significant risk of harm, only to be told by the patient and/or family that they want to “do everything”. Often these people suspect that if they had more money, or if they were a different color, or if they were in a “better” hospital, the providers wouldn’t be suggesting that they forgo further intervention. I don’t doubt that this is sometimes justified, and I’m sure that if a patient has enough money to spend there will be someone, somewhere, whether “quack” or a “legitimate” medical center, who will take it to “do something”. But this doesn’t make it right or good. I have not seen such studies but would not be surprised if it were shown that many of those with the most resources are among those with the most unpleasant deaths; our culture values intervention, and they have the money to find some who is willing to make a profit intervening.


Everyone dies. We would all like, and like for our loved ones, to live as long as possible if our lives have meaning – some physical and/or intellectual function, some ability to contribute to or benefit from others. We would like, and like for our loved ones, to be comfortable and pain-free as we approach death. We don’t want to think that money which could help us or our loved ones is being “saved” just so it can be used to provide services to others who are richer or louder. But when something will not “help” in any meaningful way that we understand it, and which may hurt, it should not be done, and we should demand that it not be done. Not doing is often more appropriate and more powerful than doing. We must shame health care providers who advertise and promulgate interventions that are unproven, or will not help, or will harm, because they can make a profit doing it.


If we are to get to this place as a society, where the US health care system is one designed to get you the care you need rather than to get you the care that someone can make a profit giving you, we are going to have to change our attitudes. And that change of attitudes and behavior needs to start at the top of the social and economic scale, not at the bottom. No unnecessary stents for President Bush, no “executive physicals”, no inappropriate end of life interventions for the wealthy. Where the “best” in healthcare is not defined as the “most”, but the most effective and most appropriate.


A health system in which health and health care for everyone is the goal of our society.

1  Kangovi S, et al., “Understanding Why Patients Of Low Socioeconomic Status Prefer Hospitals Over Ambulatory Care” , Health Aff July 2013   vol. 32  no. 7  1196-1203; doi: 10.1377/hlthaff.2012.0825  

Competition vs. Coordination in health care: remember the patient!

Two of the most prominent policy recommendations for improving the health care “system” in the US have been increasing coordination of care and increasing competition. Both have very positive aspects, and I have written positively about the potential of both approaches, but also about the very real pitfalls. Coordination of care sounds like a “no-brainer”; everyone would like the physicians caring for them in one setting (say, in the hospital, or on a visit to a specialist, or in a rehabilitation facility or even nursing home or home care) to know what has been done to them previously, what the results have been, and what their previous providers thought. At the minimum, we want to think that there is communication, and that (often expensive) lab tests and x-rays are not repeated for no reason other than that our current provider cannot access those done somewhere else. In addition, coordination of care should mean that care is delivered in the most appropriate setting, often the most cost-effective setting, and that when we move from one setting (say, outpatient to inpatient, or inpatient to rehab) it is for good reasons based on what is best for our health, and not for bad reasons (say, what makes the most money for the providers).

Competition in health care also has value if it prevents artificially inflated charges and cost, just as it does in other parts of the market place. This may be most obvious in price-sensitive elective care, such as the Lasik® and contact lenses cited by Sen. Rand Paul, but is most important when it is absent and prices rise, such as in the case of hospitals (like Bayonne Medical Center; see The high cost of US health care: it's not the colonoscopies, it's the profit, July 28, 2013) that have a lock on a market. While business leaders  often extol the benefit of competition, in fact all prefer to have a monopoly on the market (or at least be part of a oligopoly, where only a few players exist in a market and often collude on pricing) as it maximizes their profit. Airfares are a good example; I live in Kansas City, and if I fly to NYC, the round-trip fare for a non-stop is more than twice what it is to fly to Washington, DC. This was not always true; there used to be several airlines flying non-stop from KC to NY, but now there is one. There are at least 2 flying to DC.

OK, so both coordination of care and competition can be beneficial in the healthcare marketplace. But what about when they are in competition with each other? This is the subject of a “Perspective” in the New England Journal of Medicine by Katherine Baicker and Helen Levy, “Coordination versus competition in health care reform”,[1] August 29, 2013. They point out that despite the potential benefits of care coordination, and its older cousin, consolidation, it can be anti-competitive and some health care consolidations have been investigated by the Federal Trade Commission for this very reason. The problem is not an ideological commitment to competition, it is the results: the merger of two hospitals providing similar care raises prices, as does movement of care from low-cost venues such as doctor’s offices to higher-cost (and reimbursement) venues such as surgi-centers and hospitals (see again July 28 post). Baicker and Levy note the “subtler” issue of bundling, such as occurs in the case of computer software, where in order to get one product a company makes which you want, you are forced (or encouraged, through a big discount) to buy others you may not want; to get a lower price on that great browser you have to buy the operating system, or the word-processing software. It certainly can and does occur in healthcare:  “…bundling offers providers who have market power in one product domain (such as tertiary hospital care) an opportunity to dampen competition in other product domains (such as primary care) by requiring insurers to contract with them for both products in order to receive discounts.”

Health information technology is a prime example of the tension. Heavily pushed, and subsidized, by the federal government as a way to improve coordination of care, it “can in theory promote both competition and coordination, but only if they are implemented well — an interoperable health information technology (IT) environment, for example, should promote both, but health IT without interoperability may simply lock patients in to their current providers or provider networks by making it difficult or costly to move their records, reducing competition. The opportunities for a win–win are limited.” Most providers who use EMRs will acknowledge their advantages (“I know what is happening elsewhere – at least within the system”) but complain about the huge amount of time it takes to enter data, and the fact that many large systems have bought the components of systems that facilitate billing, but often not those that offer great patient care advantages (such as the creation of “registries”, i.e., lists of the patients with similar conditions, such as diabetes, that may need similar regular interventions). And interoperability? No way. “Provider lock” – getting a healthcare system to spend so much money on your EMR product that they can’t change – has become the main strategy for most health IT companies. “The worst nightmare of most health IT companies,” says a friend who is in the field, “is that Apple will get involved and create a product that works better and is easy to use. And will probably be cheaper. So they want to lock you in.”

Baicker and Levy make three suggestions for how this tension might be resolved. One, look for “win-win” situations (could this be health IT? they ask). Two, have courts that enforce anti-trust laws look explicitly at the trade-offs. Three, look across silos to see how a seemingly positive change in one area would potentially have a negative effect in another. These are all good suggestions, but all limited and quite “iffy”. And all, I point out, as often is the case in rarefied discussions of health policy, missing the most important point: What is best for the health and health care of people, or patients? Not “consumers”, these largely hypothetical well-informed people whose problems are so non-urgent and budgets so large that they can shop for health care as they might for shoes, but the people who are sick, who are stuck in their health plans (whether government like Medicare and Medicaid or because their employer only offers one) or are uninsured?

This is where the doctors, who are often criticized (even by me; see Physicians' role in controlling health costs: do no financial harm, August 25 2013) are often right when they talk about meddling by bureaucrats. The issue is, however, that the policies adopted by Medicare and private insurers (often quite different, per Baicker and Levy) are indirect; they attempt to influence both the quality and cost of care by financial incentives or disincentives, and this permits – indeed encourages – gaming of the system, trying to maximize income while minimizing cost and risk. This is obvious, but is still true, and its impact is often to the disadvantage of people. The solution may well be more explicit regulation to directly address what needs to happen. Not micromanagement (“use this drug”), although following evidence-based treatment approaches might be among them, but those that explicitly encourage high-quality, cost-effective care. Coordinate care, but block monopolies; encourage consolidation between organizations providing complementary rather than the same services; do not pay increased costs because a system has a monopoly; demand that health IT systems be interoperable; measure quality outcomes that control for severity of illness and the socioeconomic risk factors of patients.

A single-payer health system, Medicare-for-all, could have the clout to make this happen. It could also run the risk of “non-competitiveness”. However, if we are all in, if even the most privileged have to use it, then that will protect the interests of the most vulnerable better than any form of competition that allows private companies to opt out of covering them, and puts the poor and sick and old in a separate system in which others do not have a stake.

It would be evidence of a core commitment to social justice.

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[1] Baicker K, Levy H, “Coordination versus competition in health care reform”, NEJM 29Aug 2013; 369(9):789-91, DOI: 10.1056/NEJMp1306268

President Bush's stent: inappropriate screening and care for the rich, nothing for the poor

One of the recurrent themes of this blog has been the importance of everyone having access to necessary medical care, and how the US compares poorly to other developed countries in that it does not cover everyone. Another recurrent theme has been that many medical procedures are unnecessary, sometimes even harmful, but are nonetheless provided to people who have the money or insurance to pay for them. This is not to say that greed is always the motivator; there is a powerful, if often incorrect, belief that to do something is better than to do nothing.

In this context, it is interesting to read “President Bush’s unnecessary heart surgery”, a Washington Post “Viewpoint” by Vinay Prasad and Adam Cifu published August 9, 2013. As part of his “annual physical”, the former President  (who is “…widely regarded as a model of physical fitness”), received, in addition to (presumably) the screening tests and immunizations recommended by the evidence, a cardiac stress test. Discovering an abnormality on that test led to his having a CT angiogram and finally placement of a cardiac stent.

One interpretation of this story might be “he’s lucky they did the test; they found something wrong and fixed it”. I’m afraid, along with Prasad and Cifu, that this might be the lesson taken from it by many people, and the result could be more people requesting such a test because, “hey, they found something wrong with President Bush – could I also have such a problem?” This would be unfortunate, because it is incorrect. President Bush – based on the information provided – should not have had the stress test and not have had the stent placed.

The key point is in understanding that he was (by all reports) asymptomatic. “Before he underwent his annual physical, Mr. Bush reportedly had no symptoms. Quite the opposite: His exercise tolerance was astonishing for his age, 67. He rode more than 30 miles in the heat on a bike ride for veterans injured in the wars in Iraq and Afghanistan.” While the definition of screening tests is that they are done on asymptomatic people, there are a number of criteria that have to also be present, among them that the test should detect a condition before it is symptomatic, and there should be an intervention that will prevent progression if disease is discovered. So, isn’t that true in this case? He did have the disease, a narrowing in one of his coronary arteries, right? So isn’t it good that it was discovered.

As Prasad and Cifu discuss, however, there is no evidence that stenting a coronary artery prolongs life.  “It is worth noting that at least two large randomized trials show that stenting these sorts of lesions does not improve survival.” Even for higher risk patients than Mr. Bush, survival is not increased. However, if people have symptoms of chest pain that appears cardiac in origin, for whom stress testing may be indicated (not a screening test now; they are symptomatic), treatment by angioplasty, stenting, or even bypass surgery can ease or relieve the pain. That is a good thing. But for Mr. Bush, who had no pain, there can, by definition, be no pain relief. There was some additional risk, however; in addition to the inherent low risk of doing the procedure (such as bleeding and stroke, and even, rarely, death), he now has to take anti-platelet drugs, which also confer some risk. And a stent only holds open the spot it is in; it does not prevent progression of coronary artery disease elsewhere.

The larger issue of the “annual physical” (which I have addressed previously in “ The "Annual Physical": Screening, equity, and evidence”, July 4, 2012, citing Elizabeth Rosenthal’s NY Times article “Let’s (not) get physicals”) was again the subject of a popular article, “The case against the annual checkup” by Brian Palmer on Slate.com on August 20, 2013, which states: “There are two kinds of arguments against the adult annual health checkup. The first has to do with the health care system overall, and the second has to do with you personally.” Palmer does add that

“It’s important to separate preventive care from annual checkups. Only one-half of annual checkups actually include a preventive health procedure such as a mammogram, cholesterol testing, or a check for prostate cancer. (Annual gynecological visits are excluded from these numbers, although the evidence supporting those is not particularly overwhelming either.) More importantly, only 20 percent of the preventive health services provided in the United States are delivered at annual checkups.”

He has a pretty good point, although he includes prostate cancer screening, which is not recommended or beneficial, in his list, something Prasad and Cifu do not. But I would take issue with his suggestion that you only visit the doctor when you are sick, which is in fact when doctors tend to work in the preventive services the other 80% of the time.

There are a couple of reasons for this, but the main one is that there are a lot of people (even older people at higher risk) who do not get sick, or at least sick enough to decide to come to the doctor, or at least sick enough to decide to take off from work and maybe lose income to come to the doctor. And they could benefit from preventive care as well. The list of preventive services changes from time to time, which it should as new evidence emerges, but includes immunizations, screening, and education. The list of conditions for which screening is effective and recommended by the evidence is relatively short (despite our natural desire to have more, more effective, tests) and does not include prostate cancer or ovarian cancer (thus, no reason for an asymptomatic woman to have a “routine” bimanual pelvic exam), but does include Pap smear for cervical cancer, colorectal cancer screening (which can be done with colonoscopy or regular stool screening for occult blood), bone density screening for certain age groups, and mammography. There are also recommended screening for other conditions: hyperlipidemia (mainly cholesterol), abdominal aortic aneurysm (once, in men over 60 who have smoked), HIV and Hepatitis C, as well as some screens for people who are themselves asymptomatic but whose family history places them at higher risk for a condition (e.g., diabetes). (See the Guide to Preventive Services 2012, Recommendations of the US Preventive Services Task Force, on the website of the Agency for Healthcare Research and Policy.)

Immunizations include not only annual influenza shots, but also less-frequent pneumococcal vaccine and tetanus/diphtheria/pertussis boosters, which are often not up-to-date in adults. Education may be the most important: counseling on diet, exercise, smoking, alcohol, drugs, and risk behaviors, as well as identifying victims of violence (domestic or otherwise) should not wait until these conditions have resulted in symptomatic disease.

Perhaps these preventive services should not be “annual”; there is no magic to this number, but it was chosen because it is easy to remember. Certainly many of these preventive services (now including Pap smears, bone density and mammograms) are recommended less frequently than yearly. Perhaps they can be as well delivered by other health professionals as by physicians. But there is benefit to preventive care even for asymptomatic people, and not the least is noted by Palmer: “They build relationships between doctor and patient, and open lines of communication are important in medicine.”  Yes, there are certainly many risks, which I have often pointed out, to over-testing and over-medicalization. But there are also risks to not having preventive care. And, of course, the key point here is equity: those most at risk of “too much” care and too many interventions are the more well-to-do, well-educated, and well-insured. Those most at risk of too little care, too little screening and immunization and education about how to reduce their risks and early identification of disease are the poorer, less educated, and uninsured.

The fact is that health care, like most things in our society, is very different for different socioeconomic classes. Cautioning against overuse by the privileged is one thing; being sure that this does not bleed into justifications for limiting access to necessary care for the less privileged is quite another.

Rand Paul on health policy: small brain and no heart

While politicians are rarely elected to office because of their profession (I seem to remember that when in elementary school we learned that the second most common profession in the NY state legislature, after attorneys, was undertakers!), the fact is that often fellow legislators often turn to their colleagues with expertise in a certain area to understand bills with technical implications. Legislators who are physicians, nurses and pharmacists, for example, may have influence on bills related to health care. (This is provided, of course, that they don’t involve touchstone ideological issues like abortion where facts are routinely ignored and new ones, such as “abortion causes breast cancer”, are invented.) Thus, physicians like former US Senate Majority Leader Bill Frist, a cardiac surgeon (and member of the family that founded and controlled HCA, the nation’s largest for-profit hospital chain) had great influence on medical matters.

So it is relevant to look at statements by Sen. Rand Paul (R, KY) about healthcare. Primarily known as a prominent libertarian conservative and Tea Party favorite, as well as a probable Republican presidential contender, Paul is an ophthalmologist, an eye surgeon, and thus probably is presumed to have credibility on healthcare issues. This does not seem to be diminished by the fact that he has not been Board-Certified by the mainstream American Board of Ophthalmology since 2005, being rather certified by the National Board of Ophthalmology, which, coincidentally, he founded and is president of (the Louisville Courier-Journal link is no longer live, but it is referenced in TPM). Perhaps this appeals to his libertarian base; perhaps it even is honorable if it is truly based (as he states) on “…a principled stand in response to the ABO’s ‘decision to grandfather in the older ophthalmologists and not require them to recertify….I thought this was hypocritical and unjust for the older ophthalmologists to exempt themselves from the recertification exam.’”

So what does Sen. Paul have to say about important health policy issues? Unsurprisingly he is a strong opponent of “Obamacare” and, for that matter, any universal healthcare system. He apparently has a fair amount to say about this it in his book, “Government Bullies”, which I have not read. I did, however, hear him discuss it at some length with John Oliver on a “Daily Show” appearance on August 12, 2013. His main point is that, unlike “most legislators” who have “dinosaur syndrome -- small brains and big hearts” (news to me about politicians, at least the “big heart” part. And, by the way, where does he get the idea that dinosaurs had big "hearts" other than in the physical sense?), he can help solve problems because he is not in that mold (I think he was referring to the “small brain” part, but I’m not sure!). He called upon his experience as an eye surgeon to demonstrate how the “market” controls costs by referring to how it led to big price drops for two major procedures in his specialty, Lasik® surgery and contact lenses. With regard to the former, he notes that competition among ophthalmologists has led to dramatic decreases in charges (and costs) from over $2000 an eye to less than $500. The competition for contact lenses was with large retailers like Wal-Mart, which forced him to drop his charges in order to compete. Neither was covered by insurance, so he uses them as examples of how this could work for all the other things that are covered by insurance and to which people are price-insensitive.

All but the last of these assertions are true as far as they go. The cost of both Lasik® and contact lenses have indeed dropped. So, will this work for all health costs? No, absolutely not. There is a reason that these two procedures are not covered by insurance; they are both elective procedures and thus (like cosmetic surgery and many consumer items) can be reasonably subject to market forces. One has a much cheaper and effective option that works for the medical problem: wear glasses. If you are considering Lasik or contact lenses, you can choose to not buy them now and wait until prices come down. However, most of healthcare is not elective (thus more like food and housing). Emergencies are emergencies and need to be addressed now, by the most available provider (see The high cost of US health care: it's not the colonoscopies, it's the profit, July 28, 2013, for a discussion about how hospitals like Bayonne Medical Center have turned this into a profit-making strategy).

Mark Ebell, MD, a family physician and expert in evidence-based medicine, notes a more apt comparison: “If you have a stick in your eye, I doubt that you are price shopping or waiting for ads on the radio to advertise a special for removal of sticks in the eye.” No doubt; and while not all necessary healthcare is about emergencies, most of it is not about elective procedures. Chronic diseases like hypertension and diabetes need to be treated in order to prevent their progression to serious outcomes. Preventive care like screening for cancer and immunizations are only of value if they happen before the onset of disease. Neither Lasik nor contact lenses prevent either disease or its progression. 

Dr. Ebell is unhappy that Mr. Oliver, usually quite clever, completely missed this point, and it is an extremely important one. While I do not know if Sen. Paul is aware of this and is dissembling in using this inappropriate and simplistic example as a justification for his anti-government ideology, or is he actually believes it, the fact is that it is not at all a valid argument for a market-based health system. The empiric evidence is there, both in comparisons to other developed countries and in internal comparisons between state and local experimental government and insurance programs in the US: providing comprehensive health care at costs that do not discourage or make it impossible for people to access it improves health status. Conversely, there is excellent evidence that obstacles to healthcare access do discourage people from seeking it and do result in worse health outcomes, for individuals, populations and nations.

The danger in an argument such as Sen. Paul’s is two-fold. One is that, coming from the Republicans’ most prominent physician, it will reinforce the beliefs of those who already think that the market will solve the healthcare crisis. The other is that people who are not such ideologues but whose exposure to the health system, because of a fortunate combination of relative youth, good health, and economic security, is largely for such elective, minor or episodic care, may say “yeah, that seems right”. But it isn’t; it’s wrong. A recent NPR “Marketplace” show focused on the ACA’s requirements for individual health insurance policies that preclude many low-coverage, high-deductible options currently available.[1] It featured a self-employed Californian who noted that he was having to pay much more for insurance now, even though he was never sick and, in the last 14 years, had visited a doctor only a few times. It didn’t give his age, but whatever it was he will, in the future, be older; this is a certainty. And, as we get older the probability of needing health care increases. The old maxim about the stock market – that past performance is not a guarantee of future performance – is even more true for one’s health. It is at best risky and at worst foolhardy; the more apt comparison may be to the person who falls off a 20-story building and is heard by people as he passes each floor saying “so far, so good”. Making public policy on such a basis is nonsensical.

Dr. Ebell  says, regarding Sen. Paul’s analysis, “it makes me crazy. Big brain and no heart is a bad combination.” He is right about that, but more important is that there is no evidence that Sen. Paul’s analysis indicates big brain at all.

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[1] For a good discussion of the insurance exchanges, see Harvey Matoren’s blog “The Patient’s Advocate” for August 21, 2013, and for a state-by-state portrayal of federal/state involvement in the exchanges, the Commonwealth Fund website, http://thepatientsadvocate.blogspot.com/2013/08/what-are-these-health-care-exchanges.html