ER backups and poor-quality but expensive insurance: The American Way!

The January 22 edition of the Arizona Star (Tucson) reprinted a piece from the Arizona Republic (Phoenix) titled “'I've never seen it this busy': Here's why Arizona emergency departments are jammed”. The article is paywalled, but you don’t really need to read it since that headline basically is the story: all over the state, including its two biggest cities, waits for non-emergencies (and sometimes emergencies) in ERs is many hours to, sometimes, days! The article discusses some reasons, including the increase this winter in respiratory diseases like flu, RSV, and, yes COVID (despite everyone pretending it has gone away; see NY Times “California and Oregon Ease Covid Isolation Rules, Breaking With C.D.C.”). In fact, there has been a lot of respiratory disease this winter, and as reported by “Your Local Epidemiologist”, Katelyn Jetelina, and while it seems to be declining, there could well be more peaks.

The colder weather makes the most vulnerable, those without housing, even more vulnerable. Also contributing to the ER backup in Arizona is the increase in the number of “winter visitors” (also known as “snowbirds”) who are coming back “after” the pandemic, who are often older and do not have a regular source of care here. And, yes, also that too many of us who live here year round do not have a regular source of care because, as in most places, there are not enough primary care clinicians (see “Primary Care, Private Equity, and Profit: How to ensure poor quality care for the American people”, Sept 28, 2023 and “We need more primary care to serve our people: Why do the medical schools lie?”, Dec 12, 2023). So people go to the emergency room, or to an urgent care center where they are told to go to the emergency room “if it gets worse” or, when it is serious enough, right away.

But there is something else going on here. That is the breakdown of the American health care system, particularly the insurance system and the ways people are covered (or not) for health care costs. It is breaking down at all levels: there are not enough doctors, especially in primary care (see the blog posts cited above), insurance companies and employers are covering less and less of the cost of health care and requiring those who have insurance to pay more and more, and private equity (see the referenced blog above) has taken over many practices and is squeezing them for maximum profit without regard to what it does to the quality of the “product”, which is our health care. Private equity in the healthcare sector follows the same playbook it follows everywhere: squeeze profit out, diminish services, and if it bankrupts the company too bad; they already have theirs. And when it is insurance companies that take over the practices (such as United Health Care owning Optum) the result is about the same. No one is minding the people-serving part of the store.

Yes, there are plenty of uninsured people, including the homeless, and those who are “too rich” (hah!) to get Medicaid, which in most states requires an income far below (often way less than half) the poverty level (which is about $31,000 for a family of 4), and anyway is also, in most states, pretty much limited to women with small children and virtually never covers single adults. But there are also the under-insured, those with terrible insurance coverage because it is all they can afford, as employers cut back on their contributions and insurance companies raise their rates and the financial burden on the insured including through copays, deductibles, and denied care (kind of like both raising the price and shrinking the size of a candy bar, except with much more serious outcomes). In addition, the expenditures by employers on health insurance (even when it is inadequate) is money that is not spent on wages, thereby increasing income inequality, as documented recently by Hager, Emanuel, and Mozaffarian in JAMA Open Network. And, since health insurance premiums are tax deductible for employers (although not for employees!) they prefer it to paying higher wages. What is the result of having insurance that doesn’t pay for what you hoped and expected it would when you or a family member is seriously ill? You go into debt. So the proportion of medical debt held by insured people as opposed to “self-pay” (uninsured, virtually all poor) people, has risen from 11.1% to 57.6% in 4 short years, from 2018 to 2022. Quintupled. The system, to the extent that it can be called a system at all, is broken.

But why? How? While there are still undoubtedly those, including politicians, pundits, and health administrators (all of them WELL-insured, you can be sure!) who blame it on some kind of “overuse” by patients (the medical word for “people”), there are actually 2 real causes:

1. Abuse, corruption, and illegal behavior by insurance companies in pursuit of ever-more profit, and
2. The failure of government entities to prevent them from doing so, or to prosecute them when they do.

Really? Really. Not only are insurance companies inadequately regulated, and able to effectively abstain from paying for care by repeatedly denying it and creating other obstacles, they frequently simply break the law, as documented in a study by ProPublica and reported by the Nonprofit Quarterly:

‘The findings point not just to bad behavior on the part of health insurance companies but also to a failure of the state regulatory apparatuses that oversee health insurance coverage to enforce laws already on the books: … If explicit laws on the books, spelling out mandatory coverage requirements, aren’t enough to prevent insurers from denying coverage, how are ordinary people to push back?

The answer, ProPublica’s Cheryl Clark found, is that those fighting for their own coverage are forced to navigate a “mind-boggling labyrinth” of bureaucracies set up by insurers and often barely regulated.”

It’s pretty bad, and it’s getting worse. Poor and uninsured people suffer the most, but employed and insured people are right behind them. Their medical debt increases in part because they think they have insurance and actually seek care, rather than avoiding it, as uninsured people often do. Which is, of course, terrible – how can there possibly be any justification at all for a “system” that encourages people to not seek care when they are sick, that provides too few primary care doctors or other clinicians to care for them, that makes them wait hours or days in ERs to be seen, and then saddles them with unpayable – but of course credit-destroying -- medical debt when they do get care?

Who are the worse criminals? The insurance companies and private equity firms who directly cause these problems by pursuing only maximum profit? Or the politicians who allow it to happen, who at best tinker around the edges, trying to limit (only occasionally with any success) the worst abuses? Should we run our fire departments like that? Police? The answer is in part tight regulation, prosecution of abuses and illegal activities including putting senior executives in prison, and really, finally, creating a universal coverage system in which each person has good coverage, can get good care, and be treated as a human being.

Like the executives, politicians and pundits expect for themselves.

Guns good? Depends on what you believe. Guns dangerous? No question.

People like guns.

People hate guns.

People are scared of guns.

Guns are good for sport, like hunting animals.

Guns are good for war.

Guns are good for self-protection, in case “they” come for you.

Guns are good for going out and killing other people because:

·        They might otherwise come for you.

·        They are bad people because they are:

o   The wrong religion.

o   The wrong race or ethnicity.

o   Believe in abortion.

o   Are liberals.

o   Support restrictions on guns.

Guns are bad because they can be and are used for all of the reasons above.

Whether guns or good or bad or dangerous or not is irrelevant because “Second Amendment”.

If you like, substitute “automatic rifles” for guns in all or any of the above.

All the above are true.

There are definitely people who are terrified that “they” will be coming for them.  “They” could be the government (except when the government is on their side), or they could be, you know, “them”, the other.

Probably not for deer hunting; 30 or 40 rounds of high-power automatic rifle fire can really tear up the meat.

It could be post-apocalyptic, where they are, like Mad Max, fighting for survival. They believe that they need thousands of rounds of ammunition for all their guns (after all, ammo stores might not be open after the apocalypse) and high-capacity, high-speed automatic weapons are going to be more effective in protecting themselves and their families from, well, whatever.

Zombies. Or “them”.

If you believe this stuff, and your social circle and the sites that you frequent on the Internet completely reinforce these beliefs, there is no reason to doubt that it is true. Even if you used to not believe them. (Remember, perfectly rational people from the Midwest have moved to California and, after some time being among only Californians, have come to think that it is normative to believe in the healing power of crystals.)

If you do not believe this stuff, and your social circle and the sites that you frequent on the Internet completely reinforce your non-belief, you become convinced that the folks that do are both crazy and deluded. Which they may be.

If you think that these people watch too many movies and zombie TV shows, you’re right; the most important FACT is that there will be a much more limited number of people who are alive to duke it out after a nuclear war; let’s see, after nuclear winter, roughly ZERO!

If you think that there is a certain cognitive dissonance in thinking that people on the left are pansy snowflakes and also fearing that they’ll be coming after the heavily armed folks with the fears, you’re right, but so what?

Total logical contradictions have never been a problem for them in the past (see, e.g., “Donald Trump – Christian”).

There are a lot of folks in the “I need more guns and ammo” camp who are strongly opposed to mass murder, although there are pretty many (including in Congress) who are able to make arguments (sure, weird syllogisms, but hey…) defending folks who go to peaceful demonstrations with loaded weapons looking for other people to shoot. Charlottesville? Kenosha?

It is a “prevent defense”, I guess. There are even more who are opposed to slaughtering children in school (hardly anyone comes out specifically in favor of that), but are 100% against any proposal that might make it more unlikely.

Because, you know, if you make psychotic minors unable to purchase an AR-15 without a waiting period, the next thing will be government agents confiscating your deer rifle. Or Uzi.

No one is in favor of school shootings, but we have them almost every day. In every state. We look at the news, open the paper, hear our phones ding, and we see the newest one. And our Congress, and our state legislatures, all of whom are against school shootings, can’t seem to do anything to prevent them. Even though we – and they – know exactly what would do it.

Make guns very hard to get. Especially for young people. The brain does not fully mature until at least the mid-20s and the last part to develop is the frontal cortex where executive function and judgement reside.

Especially for automatic weapons.  Especially with those with histories of violence. Yes, crazies but mainly not them. Mostly those who have or have threatened to use violence. You see, shooting people, especially lots of people, that may or may not be crazy, but it is for sure violence. Any abuser of any kind, any barroom brawler, anyone who threatens violence.

But of course they won’t. Maybe because it would lose them votes, or maybe they just believe the same things. Maybe they believe their own stories.

But, you know, you can kill people with a knife. Or a baseball bat. Or a garotte. Of course, it is not easy to kill a whole lot of people from 100 feet away with any of those.

I would be remiss to not mention suicide. They constitute the majority of gun deaths. Yes, suicide is an individual’s choice, but it is not necessarily an unchangeable choice. The “successful” suicide rate among teens and young adult males 16-24 is TEN TIMES higher in the states with the loosest gun laws as in those with the most restrictive. Are young men in, say, Montana more depressed than those in, say, Connecticut? I don’t know, but suicide attempts, especially in young people, are very often impulsive, and the easy availability of a gun makes that impulse easier to follow. And attempts at suicide by gun are much more likely to be “successful” (called lethality) than those by poison, or gas, or hitting yourself on the head with  brick. 

In the US it is often people in poor and minority communities who suffer the most random death. But it is older white men who commit suicide most. Often with guns that they had right there.

If you think we should make guns, especially automatic weapons, less easily available, especially to those most likely to use them for killing people, great. But lots of others do not agree. Of course, they include those most likely to use them for killing people.

 

The rest of the wealthy world could provide an example of what to do, but you know what? They are not Americans. A number of countries have higher gun-death rates than the US, mostly those at war (e.g., Ukraine) or in the midst of narco terrorism. We are not.

But we have a lot of guns, and that helps us make up the difference.

We need more primary care to serve our people: Why do the medical schools lie? (reposted from April 5, 2021)

I recently re-read this blog post from 2-1/2 years ago, and decided that it was still important as well as relevant and accurate. So, in a "first" I am reposting it, since some folks may have missed it:

Every year the nation’s medical schools graduate thousands of people with MD and DO degrees. But this is just the start of becoming a practicing physician; they now need to complete residency programs in a specialty area, ranging from 3 to as many as 8 years, to become family physicians, surgeons, radiologists, dermatologists, orthopedists, etc. Indeed, for many physicians this “postgraduate” training (meaning post-medical school, since medical school itself is post-graduate, requiring a bachelor’s degree for entrance) can have two components as well. First there is the primary residency program, say an internal medicine residency of 3 years, and then there is subspecialty training, usually called “fellowship”, where that internist becomes a cardiologist, or endocrinologist, or pulmonary medicine physician. While the internist who completes 3-year residency may practice general internal medicine and thus become a primary care physician for adults, those subspecialists do not. A similar process exists for pediatrics. Family physicians completing their 3 year residencies can also do fellowships in a limited number of areas, and some limit their practices to sports medicine or geriatrics or adolescent medicine, but most add these skills to their primary care practice. And, of course, geriatrics and adolescent medicine are, like general internal medicine or general pediatrics, primary care for a particular population.

This is important. Primary care doctors provide care for their patients that is comprehensive and unrestricted, other than by age for pediatrics, internal medicine, and geriatrics. They meet the World Health Organization (WHO) criteria for primary care, providing continuous, comprehensive, community-and-family-centered care. Distilled down, this means that primary care physicians see their patients for everything, whatever concerns them, referring when needed. They are the doctors for their people, not for a particular disease or set of diseases. The lack of sufficient numbers of primary care doctors has significant negative impact on the health of our people. Of course, it falls hardest on those who are always most disadvantaged – the poor, members of minority groups, and rural residents. But it also has negative impact upon the health of privileged people who see lots of subspecialists, in two ways. One is that the specialist may be expert in their field, but miss appropriate treatments, and especially preventive measures, outside it. The other is that many specialties and subspecialties rely on and extensively use care that is very high-tech and expensive, which can lead to people getting tests and treatments that are not only costly but may not be of any benefit, and indeed may lead to harm.

 So, when a medical school claims that it is good at producing primary care physicians, this is serious, and should be accurate. But it usually is not, because schools want to look as good as possible so establish criteria that make them look good, counting a wide variety of specialties that their graduates might enter as “primary care”. The biggest “offender” in this regard is counting all graduates entering internal medicine residency programs as entering primary care. As described above, some of these end up doing fellowships to become subspecialists and do not practice primary care; indeed, “some” is an understatement as it is about 80%. In addition, about half the rest end up practicing as “hospitalists”, taking care of hospitalized patients only, rather than practicing primary care. So an approximation would be to assume about 10% of those entering internal medicine residencies will practice primary care. In pediatrics, continuing as a general pediatrician is much more common; the appropriate multiplier is probably 60%, and for family medicine as much as 95%. There are also residency programs in a combination of medicine and pediatrics (Med/Peds) which can produce primary care doctors, and whose graduates are less likely to pursue subspecialty training; however, they are very likely to choose only one of those areas (adult medicine or pediatrics) and also to become hospitalists.

In addition, some (or many) schools include in the primary care numbers specialties that are simply not primary care at all. Most commonly, they include emergency medicine and obstetrics/gynecology. Emergency medicine does indeed provide first-contact care, but it does not provide continuity. Obstetrics/gynecology can provide some aspects of primary care (and indeed OBGyns may be the only doctors some young women see) but it is limited in that it is not comprehensive; women are more than their reproductive tracts, and they can have a variety of conditions OBGYN does not care for (diabetes, hypertension, heart disease, depression, arthritis, asthma and other lung problems, substance abuse, etc., to name a few). Perhaps the most egregious abuse is counting all students who enter internal medicine “transitional” or “preliminary” years. Such one-year programs, which have replaced the old “rotating internships”, are required for many specialties such as neurology, anesthesiology, radiology, ophthalmology, dermatology, and others, whose practitioners do not do primary care at all.

If we want to know how well a school is doing in graduating students who actually practice primary care at the end of their residency and fellowship training, these inflated numbers do not inform us. Fortunately, one of the most popular sources of information on medical (and other) schools, US News, has worked with the Robert Graham Center, the policy center of the American Academy of Family Physicians (AAFP) to develop and publish a metric that does show which schools actually produce primary care physicians, available at https://www.usnews.com/best-graduate-schools/top-medical-schools/graduates-practicing-primary-care-rankings. The top of this list is dominated by schools of osteopathic medicine, which consistently graduate higher numbers of primary care physicians, and, among the allopathic schools, the mainly public schools who have been doing well in this area for a long time. The private, largely northeastern, schools that usually top rank lists are nowhere to be found.

It is important to look at this list, not the list of “Top Primary Care Schools”, to get accurate data on production of primary care physicians. The metric on percent of students going into primary care has also been fixed in the “Top Primary Care” rankings, so it is better, but it still only accounts for 40% of that ranking. “Peer Assessment” (subjective rankings) account for 30%, half from medical school deans and other leaders, and half from residency directors. The other 30% is half “faculty resources” (largely faculty ratio) which may be skewed to the advantage of research-intensive schools, because it includes faculty who are mostly in laboratories and not teaching, and half “student selectivity” (based on student grades and MCAT scores), which is actually negatively associated with entry into primary care. This doesn’t mean the students that enter primary care are not as smart; it means that the cachet of attending a research-intensive school makes the competition greater. Unsurprisingly, adding these other criteria does affect the rankings; Harvard, for example, is now #8 in “best primary care schools”, although it ranks #141 of 159 schools in percent of graduates practicing primary care. (In contrast, the University of Kansas, which ranks #9 in primary care, below Harvard, ranks #17 in graduates practicing primary care, at 37.8%). Reputation affects peer assessments in at least 3 ways. One is spillover effect -- well, it’s Harvard, and good in everything so it must be good in primary care. A second is the ignorance of non-primary care deans and residency directors about what kinds of doctors the school produces. Finally, the fact that “good in primary care” can mean things other than what specialties the graduates enter can have an effect; there are schools in which the family medicine and other primary care faculty are well-known for their research and leadership in national organizations, but which do not graduate very many students into primary care disciplines.

The fact remains, though, that the US very short of the primary care doctors it needs to provide quality health care to the American people. The way to begin to change that is to stop deceiving ourselves. Then we can start the process of producing a higher percentage, in every school.

The insurance company mafia and Medicare Advantage: Taking your money and denying you care

If the government were considering ways of making small businesses function more effectively to meet the needs of their customers and make a reasonable living for their owners, they would consider the stakeholders. Those might reasonably be the owners, the customers, and perhaps the suppliers. And, of course the gangsters who supplied “protection" to the owners – that is, protecting them from damage that might occur if the owners didn’t pay up.

Oh. You don’t think so? Why would we include the gangsters who just prey upon these businesses, drive up costs and thus probably prices, and threaten bodily harm to innocent people? Well, why not? After all, they have a stake in those businesses as well. If this seems like a ridiculous idea, consider the fact that we do it whenever we consider changes to our healthcare system in the United States. Except, in that case, it is the health insurance, a huge parasitic industry that preys on the health of the American people by sucking out billions in profit from funds intended to pay for our actual health care. We not only allow it, we encourage it!

The patchwork nature of health insurance coverage in the US is incredible. Many folks are coverage by policies held by their employers, or the employers of family members, but the employer contribution has been decreasing with increases in what employees have to pay in premiums, co-pays, and co-insurance. Others are covered by government programs – indeed, when considering all of these including Medicare, Medicaid, military families and retirees, employees and families of federal, state, and local government – public funds are more than half our health expenditures, rising to about 60% if the taxes foregone by the government because (unlike wages) employer contributions but not employee contributions) to health insurance are tax free. And still others have insurance through the ACA (Obamacare) or actually pay their whole cost. And, of course, lots and lots of people are uninsured.

And the coverage for those who are insured varies tremendously, from plan to plan, insurer to insurer, employer to employer. Many policies are so bad that those who have them are almost as bad off as the uninsured – but they are paying for it. People get low-cost policies because this is what they can afford,  but pay the price when they find out they are sick. It is bad, bad, bad, inefficient, incredibly expensive, and, like all “protection” plans, beneficial only to the insurance company mafia. But it is even, in a way, more egregious when we consider how it has cannibalized Medicare, the federal program that is supposed to cover the aged, blind, and disabled. Not that it is ok to screw the younger, non-blind or disabled portion of our population, but Medicare, passed in 1965, was supposed to ensure health care for the elderly, who are, in fact, more likely to be sick.

But then we get “Medicare Advantage” (also known as Medicare Part C), pushed by successive Republican administrations and assented to by the Democrats who seem to believe the hype. Let’s be clear about what MA is and is not. It is NOT Medicare, the program funded by your Medicare taxes from your paycheck (Part A) or general revenue + you (Part B). It is private health insurance being paid for with Medicare dollars (and the MA insurers get more, per capita than Medicare itself). It is usually a PPO or HMO plan, which can (and does, its essential character) restrict the health care providers (doctors, hospitals, etc.) you can use, and can and does make it more difficult to get care by denying payment (illegal as such; it is supposed to cover, by law, everything Medicare does, but it can delay and delay by repeated denials) or requiring prior authorization for – everything. Sometimes until it is too late and you die. We’ll look at some examples.

In a piece subtly titled “Deny, deny, deny”, NBC News on Oct 31, 2023 describes how rural hospitals, usually the sole community provider, are losing so much money from MA plans denying their claims that they are either in danger of closing or at least will no longer accept MA. That, of course, creates major problems for their patients covered by MA plans – remember, they are not a problem until you get sick! ‘Rose Stone of Holly Springs, Miss., said she stopped going to her doctor after her Medicare Advantage plan wouldn't pay for the visits. “It was a mess,” Stone told NBC News. “I didn’t go to the doctor because I was going to have to pay out-of-pocket money I didn’t have.”’

The Washington Post, on Nov 29, 2023, in Hospitals and doctors are fed up with Medicare Advantage, discusses that they are not only fed up, but they are refusing to accept MA plans because it does not pay them for the services that they provide. Scripps Health in San Diego joined Mayo Clinic and many other facilities in not taking any MA plans. The problem with the article is it can be read to imply that doctors and hospitals are greedy, since ‘Medicare Advantage plans are pretty popular with both lawmakers and ordinary Americans — they now enroll about 31 million people, representing just over half of everyone in Medicare, by KFF’s (Kaiser Family  Foundation) count.’ Popular with lawmakers because, a lot, they are heavily lobbied by insurers and get campaign contributions from them. Popular with ordinary Americans in the same way that a lot of things are popular – they are heavily advertised and cheaper on the front end than having to buy a Medicare Supplement plan because Medicare only pays 80% of the money it approves for covered services. And they provide glasses, and dental, and often drugs without a separate Part D plan, and even gym memberships! Great! Until you really need care…like Ms. Stone.

Or like the woman who was denied coverage by Cigna for a lung transplant and died, as discussed by former insurance executive and current whistleblower Wendell Potter in his substack, “Health Care Un-Covered”, on Nov 27, 2023. Or the reports of massive denials, including those that break the law, identified by ProPublica in partnership with Scripps News and reported by Potter on Nov 30, 2023. These are not isolated stories; they occur all the time.

Potter also testified in favor of retirees from Cortland County,  NY, when the county was trying to push them all into an MA plan run by UnitedHealth. For this year, at least, they were successful, arguing basically about how Prior Authorizations (PAs) required by UnitedHealth would limit their care. At the last minute, under discovery, they obtained a (possibly incomplete) list of services requiring PA…essentially everything (see the list at the end of this post)! And if anyone is worried that these doctors and hospitals wanting to be paid for the work that they actually do for people’s health (remember – insurance companies do ZERO of this!) will bankrupt the MA plans, we can look at their profits. In a piece Potter wrote looking at how Cigna is trying to acquire Humana to get a piece of the MA market he provides the profit made by the largest players in the industry: Cigna $7.28B on revenues of $181B, Humana $4.2B on revenues of $93B, and industry leader UnitedHealth $28.4B on revenues of $324B – nearly 9%! ALL of this is on money that was intended to be spent on providing health care to Medicare recipients! No wonder they can pay for your gym membership! They sure ain’t hurting!

Other countries have much less complex and arcane coverage systems. You’re born, you’re covered. Everyone is in, no one is out. Pretty much everyone is in the same plan. That is what we could have if we had an expanded (to everyone) and improved (covering 100%, not 80%, of ALL necessary services, including mental health, dental, vision, hearing, drugs, long-term care) Medicare for All.

But the insurance company mafia stands in the way. Contact your senators and congresspeople! 

    From Wendell Potter, list of services (possibly incomplete) requiring PA from UnitedHealth:

The list includes:

• Cardiac rehabilitation services
• Intensive cardiac rehabilitation services
• Chiropractic services
• Outpatient diagnostic colonoscopy
• Supplies to monitor blood glucose
• Continuous glucose monitors
• Therapeutic shoes for people with diabetes
• Durable medical equipment
• Diagnostic hearing and balance evaluations
• Home infusion therapy
• Inpatient services in a psychiatric hospital
• Medicare Part B drugs and non-chemotherapy drugs to treat cancer
• Medicare-covered chemotherapy drugs to treat cancer and the administration of that drug
• Opioid treatment services
• Outpatient diagnostic tests and therapeutic services and supplies, including x-rays and other radiation therapies
• Lab tests and other diagnostic tests
• Outpatient mental health care
• Outpatient rehabilitation services
• Outpatient substance abuse services
• Outpatient surgery and other medical services at hospital outpatient and ambulatory surgical centers
• Partial hospitalization services and intensive outpatient services
• Basic hearing and balance exams
• Some telehealth services
• Second opinions prior to surgery
• Non-routine dental care
• Monitoring services in a physician’s office or outpatient setting
• Medically necessary medical and surgical services that are provided at home or nursing home
• Prosthetic devices
• Pulmonary rehabilitation services
• Skilled nursing care
• Supervised exercise therapy
• Outpatient services provided by an ophthalmologist or optometrist
• Eye exams for people with diabetes

Running and Depression: Be careful about spreading the results of research until you understand it.

During the COVID pandemic, a great deal of scientific and medical literature was published on line without going through the normal peer-review process. The justification was that things were happening so fast that scientists and doctors needed quicker access to the information being discovered to be able to implement prevention and treatment strategies.  Many of these were published on sites like MedRxiv (https://www.medrxiv.org/content/about-medrxiv), with little or no peer review. Some of these articles were later shown to be flawed, either in terms of the science of the research methods or in the presentation of the conclusions to be drawn from that research. In a number of cases, these articles, which would likely not have been published in normal (peer-review) circumstances were “taken down”, “unpublished” if you will. This was criticized by many during the pandemic, such as Rapid publications risk the integrity of science in the era of COVID-19, by Bagdasarian, Cross and Fisher.

Except, of course, nothing can truly be “taken down” from the internet. If it is out there, it can be copied, saved, reposted. Certainly this has been shown to be true on social media, where embarrassing posts (e.g., sexual, racist, etc.) have continued with lives of their own even after the original was taken down. In the case of medical and scientific articles, the information is out there, and the study can be referred to and cited by others. And with the thousands and thousand of such articles published on line, only a small percent are ever taken down, even if the methods used in the research are flawed, and the conclusions presented are inaccurate. This was the source of a lot of misinformation during the pandemic, transmitted on social media because it was “in a scientific journal”.

Hopefully we are past that (fingers crossed!), but we are still not without other misleading research being reported. As with almost everything, on line or in print or conveyed by mouth, people are more likely to believe things that reinforce what they already believe (“confirmation bias”), and in general, regarding medical and scientific information, most people are willing to read just the “bottom line” (is “X” good for you? Is “Y” better than “Z” for “A”?), which is usually far too simplistic. This is not limited to laypeople, few of whom have the expertise to actually read and interpret a research study; many doctors (and sadly residents and medical students) read only the Abstract or at best the Conclusion, skipping or skimming over the only important parts of a research paper, the Methods and Results. Reading the Abstract may be adequate to decide whether to read the whole article (“if they actually found what they say they found, do I care?”) but should never be conflated with actually having read it, and thought about it.

And while peer review should ensure that the methods, probably, were legitimate and that therefore the results are accurate, it does not always flag potential problems, particularly with regard to overstating the significance of the results in the conclusion -- or a one-sentence abbreviated conclusion. A recent study (and I pick on it not because it is more egregious than most, but because it was brought to my attention by Medscape, reporting on its presentation at an international conference), is ” Antidepressants or running therapy: Comparing effects on mental and physical health in patients with depression and anxiety disorders”, published in the Journal of Affective Disorders, May 2023. The study, done by a group of researchers in the Netherlands, in fact showed, as Medscape reports, that while both anti-depressant medications and running helped depression, running was better for overall physical health. That is good news if you are a runner, I guess, or if you have been wondering if taking up running would be good for your depression. But if your take-away is something like “See? Natural things – like running – are better for you than drugs!”, there are some details you need to pay attention to. Like who was studied. In any study, it is critical to see if the population studied is similar to you (or your patient, if you are a health care clinician). In this case the average age of participants was about 38. So if you are in that age range, it could apply to you. If you’re 70, the age of the oldest participants, maybe taking up running might not be the best idea.

But a much more important flaw in this study is illustrated by saying “taking up running”: it has to do with the allocation of people to the different treatments, running or medication. In a good study, participants are randomized to one treatment or another. In this study, people chose the treatment they wanted to try, with only those left over allocated to one treatment or another. 83 people chose running with another 13 assigned to it; 36 people chose medication, with another 9 assigned to it. So of the 141 participants, 83, 59%, chose running. Although those already exercising more than once a week were excluded, it is still possible, if not likely, that many of that 59% were, at least in the past, runners, or people who wanted to run. This is what is called a potential confounder, something that is associated with the treatment and the result, and leads to results that are much less convincing than does random allocation.

So does this mean running is not as good or better than drugs for treatment of depression? No (although obviously it requires the physical capability of being able to run). This study provides evidence that in a group of 141 people, average age 38, 58% female, 59% of who chose to be in the running “arm” of the study, it worked as well. But those are important caveats that make the study weaker, and less likely to work for someone who doesn’t fit the profile.

Enough of this study. I chose it because it came to my attention, but also because it was published in a reputable, peer-reviewed journal, and it is not totally worthless – but to draw the conclusion that “running is as good as drugs for depression and better for your overall health” is true for anyone, for you, could be inaccurate.

The impression that one can take away from hearing from someone that “a scientific study showed that…” (and tell me you never hear that!) can be a little, a lot, or completely wrong unless you both read the whole study and have enough background to understand what it does not say as well as what it does. Beyond “was this a well-done study?” and “was it published by reputable scientists in a reputable journal?”, the questions of “to whom are the results most likely to apply?” is also important. You may think yourself healthy and in good shape for your age, but a study of, say, 25 year olds, may not apply to you if you’re 65. The most reliable characteristic is replication of the results by other well-designed studies.

Is there a social justice issue here? I do not know. Probably well-off people have better access to doctors and other professionals, but they also have more choice and are able to choose the ones that they know have the same beliefs (or biases) that they do; for example, exercise is good, drugs are bad, natural is good, etc. My personal (not statistically valid!) experience is that people who are likely to believe something because it shows what they want to be true and to discount studies that show what they don’t want  to be true, come from all socioeconomic, ethnic, and other groups.

But my advice is to take a deep breath, and not believe everything you hear, or read, is 100% true, and certainly not that it is more broadly applicable that whatever the research showed.

Even if you want to.

People are more important than profit. Period.

In his recent piece, ‘An Appropriate Anger’ on his Substack “The Reframe”, writer AR Moxon states that “All people have an intrinsic and indestructible worth that cannot be measured”.

He notes:  “That’s not true of everything, you know. If a car stops functioning properly, it’s no longer as valuable as it was when it was functioning properly…[but] It’s not that way with people who, as it so happens, are not things.”

I happen to agree with that, and honestly believe that most people do. But not everyone does. Moxon has some things to say about the businesses, and the people who hide behind the corporate logo, who clearly think that profit is more important than people and act on it. He particularly focuses on healthcare as he had a very scary event with a person close to him. But healthcare is a particularly good example of the core problem that he cites. Healthcare is a system which people want to believe, and often in the face of powerful evidence to the contrary do believe, exists to help them. In fact, it is actually an incredibly efficient and effective producer of profit for the industry, often at the expense of the health of the people it ostensibly exists to help.

What makes this worth continuing to comment upon is the ongoing, aggressive, and accelerating rate at which it is happening. No sooner can one say “well, this is bad, but at least we have X as an alternative” than X is taken away or modified into a profit-producing structure that decreases availability and quality of care for people while increasing their costs. And, as a result, harming their health. (Just in recent blogs I have written about ‘Why are we paying wealthy corporations billions to limit our healthcare?, July 23, 2023; ‘Older adults cannot afford healthcare even if they are insured: Time for a new system!’, Aug 22, 2023; ‘The problems with our US 'Healthcare' system are well documented. We need to start with the solution!’, Sept 3, 2023;  ‘Primary Care, Private Equity, and Profit: How to ensure poor quality care for the American people’, Sept 28, 2023).  The perpetrators of these evils – and they are evils -- are corporations including insurance companies, health care providers, and pharmaceutical companies, often now overlapping in a vertical integration, as for example with UnitedHealth’s ownership of the physician group Optum that now provides more income and profit than its insurance business! But the perpetrators are also the people that run those corporations and make their decisions.

Groups that study the healthcare system, such as the Commonwealth Fund and the Kaiser Family Foundation, continue to issue increasingly distressing, indeed terrifying, reports about the state of US healthcare, the access people have to it (or not), and the impact that this has upon their health. The Commonwealth Fund in particular has published a series of pieces that, although written in a calm manner, create great alarm in me because of their content. ‘High U.S. Health Care Spending: Where Is It All Going?’, Oct 4, 2023, notes that ‘The United States spends twice as much per person on health as peer nations’ and concludes that

More than half of excess U.S. health spending was associated with factors likely reflected in higher prices, including more spending on: administrative costs of insurance (~15% of the excess), administrative costs borne by providers (~15%), prescription drugs (~10%), wages for physicians (~10%) and registered nurses (~5%), and medical machinery and equipment (less than 5%). Reductions in administrative burdens and drug costs could substantially reduce the difference between U.S. and peer nation health spending.

[Note that wages for physicians and nurses is on 15% of this total!]

The ‘Findings from the Commonwealth Fund 2023 Health Care Affordability Survey’ are reflected in its title, ‘How Health Care Costs and Medical Debt Are Making Americans Sicker and Poorer’. Those findings demonstrate that they are, and it is getting worse, and although the greatest impact is in those already marginalized (particularly Black Americans and those already poor), it is affecting more than half of the US population, those insured and uninsured:

Large shares of insured working-age adults surveyed said it was very or somewhat difficult to afford their health care: 43 percent of those with employer coverage, 57 percent with marketplace or individual-market plans, 45 percent with Medicaid, and 51 and percent with Medicare.

 

Commonwealth also had a series of reports, appearing every year or two, called “Mirror, Mirror on the Wall” which compared US health care costs and outcomes to other comparable (wealthy) countries. The US always did worst (see ‘US Health Rankings remain low and #Trumpcare will make them worse!’, June 18, 2017, which includes scary data tables comparing US health system performance to others). The most recent report, from 2022, has a different title that is even scarier: U.S. Health Care from a Global Perspective, 2022: Accelerating Spending, Worsening Outcomes. It includes as “highlights” (or lowlights)

·        Health care spending, both per person and as a share of GDP, continues to be far higher in the United States than in other high-income countries. Yet the U.S. is the only country that doesn’t have universal health coverage.

·        The U.S. has the lowest life expectancy at birth, the highest death rates for avoidable or treatable conditions, the highest maternal and infant mortality, and among the highest suicide rates.

Comment: These are not good things.

 It is also easy to lose health insurance. It can happen intentionally when insurance companies seek to offload high-cost individuals (ie., the sick people). This procedure (“lemon dropping”) is common in Medicare-substitute programs like Medicare Advantage and push them into regular Medicare. It is the complement to efforts to enroll only healthy seniors (“cherry picking”). The ideal insurance client, from the point of view of maximizing profit (is there another point of view?) is one who pays premiums and never uses care. Of course, if you are not yet on Medicare, you can be dropped and – that’s that. You are uninsured.

But you can also lose insurance coverage by mistake or oversight; in her Oct 25, 2023 essay ‘It Shouldn’t Be This Easy to Lose Your Health Insurance’ in the New York Times, physician Danielle Ofri describes how she lost coverage because the notification for “open enrollment” from her own HR department was collected by her spam filter, and she was put into the “basic” plan – without coverage for her family. Why does she have to re-enroll every year? And why do Medicaid patients?

The stated reason for this bureaucratic merry-go-round is that eligibility must be ascertained every year so as not to allot services to someone who doesn’t qualify. But the process of determining eligibility is highly flawed. Only some disenrolled Medicaid patients, for example, are truly ineligible; according to KFF, a health policy research organization, a majority of people (more than 90 percent in some states) were disenrolled for procedural reasons, such as missed deadlines, paperwork issues and outdated contact information. Many of these people are eligible for insurance but lose coverage because of the byzantine logistics.

Yes. Dr. Ofri was able to reinstate her coverage but not everyone can; she is not only highly educated but a physician: “For me, it took endless phone calls to fix the problem and a miserable week in which I was convinced that I’d failed my family. For millions of Americans, the system is simply unnavigable.” Especially for those Medicaid patients.

Dr. Ofri concludes with the key point:

Of course, none of this would be necessary if the only requirement for getting insurance was — as it is in many countries — being born. 

Think about that. Everybody is insured – and coverage is the same – for every person in the country. There is no enrollment or disenrollment, no coverage lapse, no inability to afford it. Everyone is covered. And it costs less – all of those countries spend less, overall and per capita, than does the US. It is administratively simpler, less costly, more effective, and results in better health status for the population. It has been adopted by every other well-to-do (and many much less well-to-do) country in the world. The US is an outlier, not in a good way, in being the only nation that doesn’t.

But American insurance companies and health care providers make huge amounts of money, money that is intended (often by the government) to be spent on providing health care but instead ends up on the positive side of a corporate balance sheet. That can be seen as a good thing, if you are a corporate executive, a completely heartless and unempathetic bastard, and, of course, you are certain that the negative impact will never affect you. We need to change that, i.e., make it affect them.

Moxon goes on at great length documenting how the “profit motive”, which can have positive effects on a society, has been so perverting by being the ONLY thing that is considered to matter (“the profit motive doesn’t care about enriching the lives of people, and it never will, any more than a garden trowel cares about the state of your garden”) that it leads to mass suffering, in health care and  “with justice, and with education, and public safety, and housing, and transport, and recreation, and water, and the arts, and elder care, and on and on and on.”

What is amazing is that so many of us have drunk enough of the Kool-Aid to believe that, while  these are not good things, we think it is inevitable and the way that things have to be. Of course, there are also those who in fact believe, either because they are ideologues or are getting rich from the corporations they control or both, or are politicians being paid from the lobbying arms of those corporations, that profit is in fact more important than people. They should voluntarily (or not) sign up on the list of people who will not get care because that would decrease profit. They are welcome to live out their principles. Until they can’t because they aren’t getting health care.

As long as the rest of us do not continue to have to sacrifice our health to their profit.

Self-centered Syllogism: Bad in public health, bad anywhere

I recently met someone who had seen a couple of my blog posts, was interested in public health, and asked a few interesting questions. My answers – or, really, comments – were things I have said and written about before, but his questions forced me to put them together, and in my opinion, the issues bear repeating.

The first question he asked was “why do we put so much emphasis on smoking but not on alcohol? After all, smoking never caused someone to beat their children or spouse, or to drive impaired and have an accident, or get into a bar fight and beat, shoot, or stab someone else.” That is true, and it raises the issue of the impact of substance abuse on the individual versus on the society (although second-hand smoke causes a lot of deaths). But the real answer is the incredible mortality caused by smoking. The CDC page identifies tobacco as the cause of nearly a half-million deaths in the US annually. While the data is from 15-20 years ago, and (hopefully) the mortality rate from tobacco has decreased as its usage has decreased, this is an astonishing statistic. Deaths from tobacco exceeded the total of deaths from alcohol, plus illegal drugs, plus accidents, plus homicides, plus suicides. It remains, even as smoking has decreased, a major health problem. The CDC says, “Tobacco is the leading cause of preventable mortality in the United States”. It was, therefore, the focus of public health efforts because of its tremendous impact on mortality.

However, of course, alcohol is also a major problem, causing both death and severe morbidity (bad outcomes besides death). It is, as my questioner noted, highly associated with violence against both family members and strangers, with automobile deaths, with homicide and not-homicide violence. It also, of course, kills people who use it, from diseases such as cirrhosis and heart disease as well as many cancers that are more common in heavy drinkers. We all have heard someone who did something very bad (commit violence against family members or strangers, have a car wreck, etc.) say “It was the alcohol. I wouldn’t have done it if I were sober”. But they were not sober, they had been drinking, and probably had often been.

The American Addiction Centers alcohol.org estimate that 88,000 people die from alcohol-related violence and abuse and accidents. The site also notes that “The American Society of Addiction Medicine notes that between 28% and 43% of violent injuries, and 47% of homicides, alcohol has been estimated to be involved.” That is a lot, and it could be an underestimate, but it is the closest I can get to quantifying the attributable risk for violence from alcohol. The concept of “attributable risk” in public health can be understood as the percentage of “bad outcome X” that would go away if “risky behavior Y” went away. This is different from the amount that it increases an individual’s risk; some behavior “Y” may increase your risk a lot but, because it is relatively uncommon, account for less attributable risk. Examples include asbestos and lung cancer (very high increase in risk but a lower percent of cases, compared to smoking). Or, looking at it inversely in terms of what disease a risk factor causes, smoking and lung cancer vs. heart disease. Smoking increases the risk of lung cancer more than it does heart disease, but because heart disease is so much more common, the attributable risk from smoking, the number of lives that would not be lost if people didn’t smoke, would be more from heart disease than lung cancer. An example of “smaller percentages of larger numbers can be greater than larger percentages of smaller numbers”.

So what did I say about alcohol? He identified the fact that there is a very large industry of alcohol manufacturers and sellers, which have great influence. I noted that there was (is) also a great industry of tobacco manufacturers and sellers. He said that in addition to the manufacturers, there were also many businesses, restaurants and bars whose existence depended on the sale and use of alcohol. The current emphasis we see in “alcohol reform” is “don’t drink too much”, a common “PSA” from alcohol manufacturers. The implicit message, however, is “do drink!”.

I think most of the members of our society, including many of those still smoking, recognize that any amount of smoking is bad for you, and more is worse, but I do not think that the same is true for alcohol use. The general attitude, even among medical and public health professionals, seems to be “a lot of drinking is obviously bad, for you and for others, but a little – like I do – is not.” What could be wrong with a couple of beers? A couple of glasses of wine? Especially if you’re not driving? Aren’t there studies that show a little red wine is good for you?

There are such studies but they are dated, poorly done, and wrong. Pretty much, while more is worse, there is no amount of alcohol consumption that is good for your health, and any amount is somewhat bad. We disparage those who use other drugs (heroin, cocaine, crack, meth, even still cannabis) for entertainment, but much of our society is actually built around alcohol as the “social lubricant”. Restaurants, bars, parties. Family events like weddings and funerals. Most of such entertainment revolves around alcohol. Perhaps the only place where alcohol is not the key component of “having fun” would be at an AA meeting! This issue is seriously joined by Holly Whitaker in her book “Quit Like a Woman: The radical choice not to drink in a culture obsessed by alcohol”.

The key here is that so many people drink (if “responsibly”, by which they usually mean “not too much” and “not when driving”) that they have to justify themselves by saying it is OK. I call this the “Dirk Gently Phenomenon” from Douglas Adams’ book “Dirk Gently’s Wholistic Detective Agency”. The lead character, who dies on the first page, was a millionaire who made his money by essentially developing syllogisms that took you from the data you had to the conclusion you had foreordained (his biggest client was the US Department of Defense). This is pretty much what we do in lots of areas, including alcohol use; we decide on what we want the answer to be and then look for evidence that supports it.

My new friend noted his son had been in a public health program a few years ago when the big emphasis was on obesity and its health effects. I nodded, but it not so much any more. Obesity has big health effects, yes, but it is also easy to disparage people who are overweight. This is a manifestation of another common tendency among people (including among health professionals): to be critical of people who do (or don’t do) things that come easily to you to do or not do, and conversely minimize the significance of the negative behaviors that you do (or don’t do). If you are naturally thin and have an no difficulty keeping weight off, it is easy to criticize those who are overweight. However, if you like your fancy wine or craft beer or expensive single-malt scotch, you don’t think drinking is such a bad thing. Or, for that matter, being self-righteous.

Public health is good and important. In the US, it is grossly underfunded compared to individual medical care (about 1% of health care dollars). But, like much of medicine it is also subspecialized. To a large degree, public health researchers go where the money is available for grants – in obesity, or smoking, or violence prevention, etc., and become specialists in that area. It is (or should be) different in primary care. As a family doctor, I can measure and counsel you on your blood pressure, but I cannot ignore your diabetes or lung disease and just refer you to another specialist. Similarly, while public health specialists “do obesity” or “do child seats”, this is not an option for the family physician. I need to help you to stop smoking, but cannot ignore that you need to use a seatbelt. Or get vaccinated. Or would have a greater probability of better health outcomes if you lost some weight. Or did not drink so much. Or at all.

Judging others for doing (or not doing) what we find it easy to not do (or do) and minimizing the damage caused by what we ourselves do is a big logical flaw, as is the “Dirk Gently” fallacy. They are not attractive, appropriate, or helpful or good for anyone, and are especially dangerous coming from medical or public health professionals.

Primary Care, Private Equity, and Profit: How to ensure poor quality care for the American people

 I -- and many others -- have written (frequently and recently) about the abuses of for-profit companies, and especially private equity companies, and “non-profits” that act like for-profits in health care (Private equity, private profit, Medicare and your health: They are incompatible, May 11, 2023; Privatizing Medicare through "Medicare Advantage" and REACH: The Wrong Way to Go!, Jan 20, 2023; "Private Equity": Profiteers in nursing homes, Medicare Advantage, DCEs, and all of healthcare, Sept 16, 2022). But despite our efforts, it doesn’t get any better. Indeed it gets worse.

Drs. David Himmelstein, Steffie Woolhandler, Adam Gaffney, Don McCanne, and John Geyman, have been leaders in the campaign for a national health insurance plan (e.g., Medicare for All), published an article 18 months ago in ‘The Nation’ (March 31, 2022) titled ‘Medicare for All is Not Enough’. They go through the ways in which the ownership of our health system has changed, particularly over the last decade, to focus on profit for the private owners rather than “health care”. That is to say, while a single-payer Medicare for All program would be a great thing and would limit the negative impact that for-profit insurance companies wreak on our collective health – which is considerable – as long as for-profit companies continue to own, and to increase their share of, our actual health delivery systems (hospitals, nursing homes, pharmacies, and physician practices) there will be terrible consequences, with those single-payer dollars flooding into investors’ pockets rather than patient care.

Insurance companies like United Health and giant pharmacy firms like CVS own large portions of our practice and health delivery sector. And the role of private equity companies and investors, with their “buy ‘em and burn ‘em” approach to acquisition and profit, in taking over our delivery system is at least as terrifying. As the authors state:

At least UnitedHealth and CVS plan to stay in business for the foreseeable future, and may be constrained by the worry that substandard care will damage their reputation. Private equity companies face no such constraints. They promise investors quick profits, and often sell off the businesses they’ve bought within five years, often after stripping their assets and loading them with debts that hobble future operations.

On top of who will own our care provision, there also is the issue of who will provide the care. Most developed countries, with more rational health delivery systems, rely on primary care physicians and other clinicians far more than the US does. In those other countries primary care is at least 30-40% of the physician workforce, while here it is closer to 20% and dropping, an issue I have written about often (see, for example, What is the problem with Primary Care? The US health system!, March 22, 2022).  Primary care clinicians – family physicians, pediatricians, and general internists, and the NPs and PAs who work with them – can provide not only cost-effective care but care that is comprehensive, continuous, and reassuring to people and families because they know the person who is providing it and have a relationship with them. And the cost-effectiveness is not (only) about the fact that they earn less money (see below) but because they are in a position, as a result of taking care of the “whole person” and having a long term relationship, to more wisely utilize resources when necessary. Nonetheless, there is a definite shortage of primary care clinicians, as anyone who has tried to find one recently, because they moved, or their physicians retired or had their practice bought out by a large company like Optum (a subsidiary of United Health Care, which has become UHC’s major profit center as documented by former insurance executive Wendell Potter in his “Health Care Un-covered” substack) or, sometimes in response, went into a “concierge” or “boutique” practice, can testify. Elisabeth Rosenthal, editor of Kaiser Health News, documents this in a recent piece in the Washington Post, “The Shrinking Number of Primary Care Physicians is Reaching a Tipping Point”. She notes that “fewer medical students are choosing a field that once attracted some of the best and brightest because of its diagnostic challenges and the emotional gratification of deep relationships with patients.” And she makes the important point that

One explanation for the disappearing primary-care doctor is financial. The payment structure in the U.S. health system has long rewarded surgeries and procedures while shortchanging the diagnostic, prescriptive and preventive work that is the province of primary care.

Don’t forget that one. Rosenthal discusses the terrible experience of colleague Bob Morrow, MD, who, under financial pressure, finally had to sell his decades-old practice, and then, watching how the new owner ran it (suffice it to say, not in the best interests of the patients), leave medicine. Morrow is not a depressed person, but reading about what has happened to him and thousand of other primary care doctors is enough to make you depressed.

In a data-driven “Report Card” on primary care in the US, the Milbank Memorial Fund ranks it poorly on all front, although not on the quality of the physicians:

This first national primary care scorecard finds a chronic lack of adequate support for the implementation of high-quality primary care in the United States across all measures, although performance varies across states. The scorecard finds:

1.      Financing: The United States is systemically underinvesting in primary care.

2.      Workforce: The primary care physician workforce is shrinking and gaps in access to care appear to be growing.

3.      Access: The percentage of adults reporting they do not have a usual source of care is increasing.

4.      Training: Too few physicians are being trained in community settings, where most primary care takes place.

5.      Research: There is almost no federal funding available for primary care research.

The  report card, created for Milbank by the Robert Graham Center (the policy arm of the American Academy of Family Physicians, AAFP), not only identifies these deficits, but also the importance of solving them for the health of the American people. 100,000,000 people without a primary care doctor, only able to see a physician (if they can see any physician) who has a narrowly focused, disease-based practice is a real problem. We need those specialists for when we are diagnosed with a particular condition that requires their expertise, but they are often not knowledgeable about conditions outside it. Moreover, the primary care clinician does not only care for many conditions; much more important is that they care for the person who has those conditions.

The report also endorses the conclusions from the National Academy of Science, Engineering, and Medicine (NASEM) from 2021, recommending that the US:

1. Pay for primary care teams to care for people, not doctors to deliver services.
2. Ensure that high-quality primary care is available to every individual and family in every community.
3. Train primary care teams where people live and work.
4. Design information technology that serves the patient, family, and interprofessional care team.
5. Ensure that high-quality primary care is implemented in the United States.

Finally, for the moment, an effort is actually being made in Congress to try to increase the number of primary care clinicians.  In an uncommon bipartisan effort, the bill is cosponsored by Bernie Sanders (I, VT), chair of the Senate HELP Committee and Roger Marshall, MD, an OB/GYN and conservative Republican from Kansas, as reported by Jake Johnson in Common Dreams, Sept 14, 2023. It’s a good thing to have bipartisan support, but it is, sadly, unlikely to have a major effect on increasing the primary care physician supply. Funding in the bill – about $6 billion -- goes mainly to Community Health Centers (CHCs), especially Federally-Qualified Health Centers (FQHCs). These centers can be, and usually are, good. They provide care to lower-income people and communities where access to other clinicians is difficult. Republicans like them because they are not actually “government” programs, but responsible only to their boards of directors. But, while they often rely heavily on primary care, and expanding them will increase the number of jobs for primary care clinicians, it does nothing to increase the supply of those clinicians, to convince medical students to enter family medicine, pediatrics, and general internal medicine instead of much higher-paying subspecialties.

I mention money, the Milbank report mentions money. It is a lot about money. It is increasingly difficult to convince students to enter fields where their income is likely to be a fraction of that of subspecialists (even if much better than that of most Americans), especially in the context of huge educational debt (frequently over $250K), and the lack of respect given by the medical profession and often the society at large to primary care. And, not at all to be minimized, the takeover of so many practices by for-profit corporations and private equity, with situations like Dr. Morrow’s becoming the norm rather than the exception. Some subspecialties make 2-3 or more times that of primary care doctors, which makes it increasingly difficult for students to decide to enter primary care. And while some of these subspecialties have grueling work hours (e.g., general surgery) others have much more circumscribed work hours, often shift work and little call.

There IS certainly something the federal government could do. The Center for Medicare and Medicaid Services (CMS) sets the relative reimbursement for physician services (office visits, procedures, etc.) and virtually all private insurance companies reimburse based on multiples of the Medicare rate (traditionally more, but now often less). So all CMS has to do is to revise its fee schedule, increasing the relative value of primary care visits relative to procedures. Of course, there will be great opposition from other specialists; indeed the “RUC”, a non-government committee that advises CMS on this ratio is completely dominated by subspecialists (Changes in the RUC: None.. How come we let a bunch of self-interested doctors decide what they get paid?, July 21, 2013). CMS is not required to follow the recommendations of the RUC although it usually does; CMS could ignore or adjust what the RUC recommends, or reconstitute the membership of the RUC to have more primary care doctors. Primary care physicians do not need to make as much as the highest-paid subspecialists (indeed neither do those subspecialists!) but the difference needs to be decreased. Studies have indicated that if primary care doctors earned 70% of what subspecialists do, income would no longer be a significant factor in specialty choice.

Addressing this income gap is critical for increasing the number of primary care clinicians. Then there is a lot else to do, like getting for-profit corporations and private equity out of healthcare altogether.

 

For a “humorous” depiction of the takeover of primary care by for-profit companies like Optum, check out this short piece by the brilliant Dr. Glaucomflecken: https://twitter.com/i/status/1706339952857149895