Prostate Screening and the Public’s Health

For the first time in several years, I am writing about prostate cancer screening. I had hoped that this was sufficiently covered in 2009, with PSA Screening: What is the value? (March 21) and the excellent guest piece by Robert Ferrer, PSA Screening: “One of Medicine’s Great Success Stories”? (October 27), and finally a bit of celebration in 2011 with PSA redux: The USPSTF finally recommends NOT getting it! (October 14). However, like the proverbial bad penny (or to use a more au courant analogy, zombie), this issue continues to return from the dead. The most recent effort is “Bring Back Prostate Screening”, a NY Times op-ed piece by Deepak A. Kapoor on July 6, 2015.
What Dr. Kapoor is suggesting is obvious from the title, but the question is “is there some new information, some new research, that now makes such screening more reasonable or appropriate?” The answer, unfortunately (because it makes more work for the zombie hunters) is “no”. Dr. Kapoor suggests that there is. He notes research is this field is “… now paying off.” He says that the decision to recommend against prostate screening by the US Preventive Services Task Force “…didn’t take into account adaptations that urologists have made to help better identify patients likely to develop deadly prostate cancers.” He cites the increased sensitivity of PSA screening, the individualization of it to the risks of different men, and the use of PSA trajectory (its rate of increase, or not), as well as new methods of assessing cancer like MRI. However, his assertion is incorrect; all of this information was available to the USPSTF when it made its recommendations, and was taken into account. It is not new.
“At the time,” Dr. Kapoor notes, “I and many other urologists warned of public health repercussions. Our fears have materialized. Since 2010, fewer biopsies have been performed and fewer prostate cancers found. But studies show an increase in the risk that a cancer, when found, will be more aggressive.” This sounds scary, but it is to be expected; when you stop screening everyone you won’t find the cancers early. A big part of recommending against PSA screening was that so many of the cancers it identified were indolent and not going anywhere; the aggressive cancers will be the ones that eventually show up. Indeed, he actually acknowledges that “No increase in cancer mortality has been observed,” but continues to raise the alarm with “…that may be a matter of time; aggressive cancers are less treatable.” So maybe we should be scared.
Well, in fact all prostate cancer is treatable. All cancer is; in fact all conditions are. The question is how effective is the treatment? Does it cure? Does it prolong life? Does it improve the quality of remaining life? This is the area that Dr. Kapoor and his colleagues do not address, because, for prostate cancer, the answer is basically no. If you have the more common kind of prostate cancer, it is slow-growing (indolent) and may even disappear itself; you will die with it, rather than from it. If you have the less-common aggressive form, you may well die from it, and unpleasantly; prostate cancer metastases go to bone and cause a lot of pain. Sadly, however, treatment does not seem to impact this. The “cures” from treatment of prostate cancer are of the ones that would have “cured” themselves, or at least not have manifested with symptoms. The mortality from aggressive deadly cancers is not changed by treatment. This is the critical point that discussions of the sensitivity and specificity of PSA or any other kind of screening often ignores. Not only can they not reliably distinguish between the indolent and aggressive types of cancer well, even if they could and we had a test to reliably tell which one you had, it is only of importance if treatment can make a difference. And in terms of mortality, it doesn’t. What about the other results from treatment? Improved quality of life? Well, here even Dr. Kapoor notes that “cancer treatment can reduce quality of life.” If you consider impotence, urinary incontinence, and the many unpleasant and painful effects of radiation on the rectum to lower quality of life, you betcha.
We can dismiss Dr. Kapoor’s comments by saying he is a urologist, and they make their money treating prostate cancer; can you imagine the impact on their income if we didn’t treat it? But this misses the far bigger issue, which is that we are enamored with – and, more important, spend huge amounts of money on– high-technology interventions rather than the prosaic, low-tech interventions that have actually been demonstrated to improve the public’s health. Screening for prostate cancer, and overuse and reliance on mammographic screening for breast cancer, are huge industries which (even in breast cancer) have had relatively little impact on mortality. Providing good prenatal care and preventing unwanted pregnancy, ensuring treatment of common diseases like hypertension and diabetes, ensuring that children are not only immunized against infectious disease but are well-fed, well-housed, and well-educated, and free from poisoning by environmental toxins (including bullets) – the basic components of public health and primary care — may seem less sexy and stimulate our collective psyches less, but they are the things that actually increase population health.
One of the newer fascinations is genomics, the identification of each person’s sequence of DNA. The promise of “precision medicine” is that we will find out who has the risk gene for which disease, and treat it directly and appropriately; treatment for cancer will be based on the genes you have just as treatment for bacterial infections is based on the organism identified by culturing it in a microbiology laboratory. It is so exciting! It is so “sci-fi today”! The American Board of Family Medicine, for example, is planning to create a new self-assessment module (“SAM”, tests that family doctors have to complete one of each year to maintain their Board certification) on genomics. On the other hand, it doesn’t think we need one on contraception, which is too small an area (isn’t it just part of “women’s health”? Oh, do men have a role in contraception also?), unlike genomics, which could affect EVERYTHING!
Except, so far, it hasn’t and there is little evidence to suggest that it will anytime soon. I wrote a blog on the topic on February 1, 2015 (“Precision medicine, trade policy and the cost of drugs: benefiting people or profit for business?) after the appearance of a Times op-ed by Mayo Clinic cancer expert Michael Joyner (“’Moonshot’ medicine will let us down”, January 15, 2015); Dr. Joyner has more recently contributed more comprehensive articles on the topic to JAMA (“Seven questions for personalized medicine[1]) and The Lancet (“Is precision medicine the route to a healthy world?”[2]) in which he makes the important point that most disease is not the result of a single gene, but rather the result of a complex interplay of different genes and the environment. Indeed, the only cancer-specific genes that have been identified so far are the breast cancer genes BRCA1 and BRCA2, and no treatment has emerged; we simply say “get mammograms more often and consider prophylactic mastectomy”.
Spending all this money on precision medicine, on high-tech interventions, expensive drugs and devices is like blowing your house budget on art for the walls before you have built it. Some art is great, some is mediocre, and some is poor, but none will hang well on a jerry-rigged house made poorly of shoddy materials because there was no money left. Some high-tech, expensive interventions are worthwhile but what we really need to increase the population’s health is public health nurses making home visits to pregnant and recently delivered women, and their children; public health nurses or community health workers or even doctors making visits to people’s homes to assess the real risk factors to their health and reasons that they might not be able to comply with treatment plans. We need more primary care, not more interventionalists. But most important, we need to apply what we know works, what we know how to do, to everyone.
That is how we move the needle on population health.



[1]Joyner MJ, Paneth N, Seven Questions for Personalized Medicine, JAMA. 2015 Jun 22. doi: 10.1001/jama.2015.7725. [Epub ahead of print]
[2]Coote, John H, Joyner, Michael J. Is precision medicine the route to a healthy world?. The Lancet385.9978 (Apr 25, 2015): 1617.

“Blockbuster” drug or slanted reporting: never forget “cui bono”

‘Drug Aimed at Inflammation May Lower Risk of Heart Disease and Cancer’, by Denise Grady in the New York Times, August 27, 2017, reports on a study in the New England Journal of Medicine, ‘Antiinflammatory Therapy with Canakinumab for Atherosclerotic Disease’ by Paul M. Ricker, et al. The study, funded by the drug’s manufacturer, Novartis, examined the impact of the use of canakinumab (brand name: Ilaris) on heart attack survivors. The drug is in a class called “monoclonal antibody inhibitors” (as is almost anything ending in “…mab”); in its case, it inhibits antibodies known as “interleukin 1β”. The main effect is anti-inflammatory, which is why it was originally developed for treatment of juvenile rheumatoid arthritis, an inflammatory disease. However, research showing that inflammation plays a major role in coronary artery disease (the cause of heart attacks) stimulated this large multi-center, drug-company sponsored, trial.
So what did the study show? Of the over 10,000 people in the study, those who were treated with canakinumab had lower rates of what the study designers defined as the “primary end point”, the main thing that they were looking for, “nonfatal myocardial infarction, nonfatal stroke, or cardiovascular death.” That is, did patients have another heart attack or stroke, whether they lived or died. The lower rates in the canakinumab groups were statistically significant, with the group that did the best, the middle-dose (they tested 3 different dosages), having 3.86 “events” per 100 person-years, compared to 4.50 for the placebo group. In absolute terms, there were, thus, 0.64 fewer “events” for each 100 person-years (which is a valid concept, one person taking a drug for 100 years, or 100 people for one year, or any combination in between).
There was, however, no significant difference in “all cause” mortality between the treated and untreated groups, mainly because of the increase in deaths from infections in those treated.  This is not surprising because the anti-inflammatory effect of canakinumab also decreases the body’s immune response. It is also not surprising that the people most likely to die of infection were those who were oldest and sickest in the first place. Six people developed tuberculosis.
Given that the cost of the drug is about $200,000 a year (think about that!), 100 person-years of treatment would cost $20,000,000. And for this price, 0.64 fewer people have a cardiac “event”, and no fewer people die. And some untold number suffering serious side effects from canakinumab, including the infections that occurred that didn’t kill them (not reported). These could be really serious – long hospitalizations for sepsis or pneumonia or cellulitis, non-fatal but significant events like amputations, etc. No wonder the Times article quotes Dr. David J. Maron, the director of preventive cardiology at Stanford University School of Medicine, as saying “This is fantastic”! Dr. Maron, I imagine, has terrific insurance.
Of course, it didn’t cost Novartis $200,000 a year for the drug for the study; that is the retail price that it plans to charge hospitals, insurers, and patients. We have no idea what the drug actually costs Novartis to manufacture; the price they will charge is based on the highly scientific formula called “what the market will bear”. For their own bizarre reasons (see Elizabeth Rosenthal’s “An American Sickness” and this commentary by Jacob Hacker) insurers may gladly pay for this drug (they get to keep a percent, and a higher price means a higher percent, and they just raise rates). Or they may get a discounted charge. Certainly, many poor and uninsured people are not likely to get it. Maybe – probably – Novartis will have a program for giving the drug for little or no money to poor people. But, given how common coronary heart disease (CHD) is, they are incredibly unlikely to give it for free to every uninsured person who has CHD. Maybe they’ll give them a discount, say 90%. Then the poor person would only have to pay $20,000 a year out of pocket. To reduce their risk of another coronary event by 0.0064 per year. And have no lower likelihood of dying. And a greater likelihood of severe infection. Maybe this is, after all, a boon to the poor and uninsured, as they are unlikely to get this terrific opportunity.
The other amazing thing is the actual story in the Times, and what that says about health journalism. As noted by the insightful Howard A. Rodman, the
·        Headline says: “Drug… May Lower Risk of Heart Disease and Cancer”
·        The 2nd paragraph tells us it is a “major milestone”
·        The 3rd paragraph quotes Dr. Maron saying “This is fantastic.”
But then you have to scroll down to find
·        In the 5th paragraph, that the drug costs $200,000 per year. It’s available only from Novartis, and that Novartis paid for the study.
·        And in the 7th paragraph, that the drug suppresses immune response. In the study, the number of deaths from drug-caused infections equaled the number of lives saved.
Lead with the positives, and then let us down later, maybe after those of us scanning the article have stopped reading.
Is the Times trying to mislead us? I don’t think so. I think that they want, however, to get our attention, get us reading, show us blockbusters. Blockbusters are good for getting attention. It is a big article for the New England Journal of Medicine also. This is why there is a built-in prejudice in medical journals for publishing articles with positive results, and why the authors do their best to “spin” results to positive. As if the incredible amount of work they have put in to the study, not to mention the interest of the sponsor, in this case, a pharmaceutical company that makes the drug in question, was not sufficient impetus. After all, getting our attention is what it is all about; it is why reality TV is so big, and why a reality TV star is now POTUS; see Matt Taibbi’s piece “The Media Is the Villain – for Creating a World Dumb Enough for Trump”. He notes that “If a meteor crashes into jello night at the Playboy mansion, it doesn’t matter if you send Edward R. Murrow to do the standup. Some things sell themselves.” Maybe a drug that treats a disease that treats heart disease isn’t that big, but it is big; after all, as Grady notes, “Cardiovascular disease is the leading cause of death worldwide and in the United States, where it killed nearly 634,000 people in 2015. Globally, it killed 15 million,” (paragraph 4, if you’re tracking it).
Neither does this mean that published scientific research is unreliable. Some of it is very good science (even this study is generally good science, despite the published report in NEJM and the coverage in the Times being unconscionably skewed to the positive). Some of it actually reports on drugs or other interventions that make a difference. Sadly, however, in addition to the “blockbuster” effect that the media (including medical journals) want to cover, those interventions that will make a lot of money for a company get more publicity. Especially when the company funds the research. Aspirin, by the way, is still cheap, and it is more effective than this drug, recommended by the US Preventive Services Task Force (USPSTF) for prevention of CHD in adults with greater than a 10% 10-year risk.
I tell medical and other health professions students (at all levels) that, although the Introduction and Discussion sections of the article may seem most interesting, the important parts to read are the Methods and Results, which have the meat (or soy, if you’re vegan) and from which you should draw your own conclusions, without the authors’ spin. If you’re not a health professional, and depend on the mass media for coverage, then you better read the whole article and not stop after the fanfare. It is the reporter’s job to provide the necessary information, but your job to read it wisely.
Certainly, health professional or reporter or consumer, look at who is funding the study. It is important information. And think about conflict of interest. And think, of course, about cui bono. It is likely to be the manufacturers, and maybe the researchers, and sometimes those who are wealthy or well-insured enough to get the drug or intervention (when it is of benefit).
And, surprise, it is never likely to be the poor, uninsured, or those most in need.

McConnell, the GOP and Trumpcare: We care about lowering taxes for the rich, not your health care!

“Mr. McConnell has always taken pride in protecting his members.”  — NY Times, June 23, 2017
First, let’s start with a reminder about how insurance works. Money (“premiums”) is collected from everyone, or as many people as possible, and when the bad thing happens (insurance is almost always about protecting against bad things, like car accidents, or fires, or death, or illness), the victims are compensated. If it pays out more than it collects, then the insurance company goes bankrupt and can no longer pay out. This works for all types of insurance, whether for-profit (as most is in the US), not-for-profit (like many health-insurance companies in other countries), or social insurance where everyone is a client and government is the insurer. Insurance companies, especially for-profit insurance companies, have to build in a profit margin as well. In addition, they prefer insure people who are at low risk of requiring payout, and not to insure or charge higher premiums to those who are at higher risk (e.g., younger drivers, for car insurance). This process is known as “underwriting”.
If an insurance company is forced to insure a lot of high-risk people (as they were under ACA) and can’t charge them really a lot (under ACA they could charge 3 times as much), they need a lot of low-risk people to pay premiums to be able to fund their probable payouts; thus the “individual mandate”. For social insurance, such as government financed health insurance programs (as in many other developed countries, or Medicare and Federal employee and military programs in the US), it is actually not necessary that more money come in from premiums than is paid out, because the government can (if it wishes) subsidize the loss from other funds. This is, of course, a political decision on how to allocate tax dollars and how many tax dollars to collect.
The Senate Republican leadership has made its position on this completely clear with its recently unveiled “health care” bill, the “Better Health Care Act” (BHCA). Crafted by Majority Leader McConnell and a small group of white men from a small group of places (for example, 2 senators each from Utah, Wyoming, and Texas). It will and should be called #Trumpcare; while the President didn’t write it, he has endorsed it and will sign it if it passes the Senate and the House reconciliation. It is clearly a tax-cut-for-the-wealthy bill that derives funding from the reduction (and sometimes elimination) of health care coverage for a very large percent of Americans; this is detailed by the NY Times’ Margot Sanger-Katz in “Shifting Dollars From Poor to Rich Is a Key Part of the Senate Health Bill”, June 22, 2017. The Times also has a piece by Sanger-Katz and Haeyoun Park that contains a clear listing of what will be cut from the ACA in order to fund these tax cuts, “How Senate Republicans plan to dismantle Obamacare”, summarized in the graphic. However, the details are important; even the parts of the ACA that the BHCA “keeps” are largely undercut by other parts of the bill. For example, it keeps the requirement that insurers must issue policies to people with pre-existing conditions (which can range from heart disease and cancer to endometriosis and broken bones and everything else), which is good. But it raises the amount that insurers can charge these people from 3 times as much under ACA to 5 times as much. This is a big deal, and a bad deal, for people with disabilities and for older people who are, (surprise!), much more likely to have pre-existing conditions.
While BHCA (Trumpcare) repeals the individual mandate, which will make some people happy (until they get sick) and the employer mandate (which will make employers happy), it also repeals the subsidies for out-of-pocket costs and decreases funding for subsidies to make policies on the exchanges affordable. The new bill would make either premiums or deductibles (or both) unaffordable for many Americans. It limits and sometimes eliminates the requirement that insurers provide “essential health benefits”, like preventive care and contraception, allows insurers to set annual and lifetime limits on how much they have to pay, and makes major negative changes to Medicaid. Medicaid is currently largely paid for by the federal government, 50%-80+% depending on the average state income, and 90-100% for people covered by Medicaid expansion. The “changes” include (gradually, so the impact won’t be seen for the 2018 election) cutting and capping the amount the federal government pays, shifting costs to the states, which often will not be able (or willing) to cover them.

This will affect a lot of people. Medicaid is now the largest insurer in the US, covering 69 million Americans, even though many states did not expand it under the ACA to cover poor adults. What it does is summarized in “How Medicaid works and who it covers” by Abby Goodnough and Kate Zernike. It covers, as seen in the accompanying chart, 79% of poor children (and more than a third of ALL children), 64% of nursing home patients (many of whom were middle class before the NH wiped out their savings!), 60% of children with disabilities, 49% of births, 30% of adults with disabilities. The people who will suffer from Medicaid cuts are old people in nursing homes, children, and disabled people (many of whom are able to stay in the community and even keep jobs rather than being in nursing homes because of this support). With the caps on lifetime benefits, it means, as Dr. Eve Shapiro points out in an Op-Ed in the Arizona Daily Star, that a premature baby on private insurance could exceed her lifetime limit on coverage before she even leaves the hospital”! And, with the right convergence of decisions by the state, the same could happen to an infant with Medicaid.
This is a big deal. Ideologues and pundits and politicians like to debate theoretical issue to see who scores the most points. They want to be the “most conservative”, the most “anti-abortion”, the most “pro-industry”, the most “anti-tax”. If they are articulate they may think that making their smarmy points makes them win. And I guess it does. Except the losers are not those on the other side of a debate podium, they are the majority of the American people, the politicians’ constituents, who don’t get treatments, don’t get diagnosed, do get sick and die. Lives, not ideologies, are at stake.
Except, of course, it is about ideology. This is made clear in “A debate that shows what each party cares about” by Neil Irwin the Times. No one, certainly not a senator who has to run for re-election, wants to say that they are about making it harder or impossible for many (often the majority) of their constituents to be able to access health care, or to pay for it, or to get the treatments and therapies they need. But make no mistake: every senator who votes for this bill is saying exactly that, that they value tax cuts for the most privileged above basic health care for the rest of us. “This plan will improve the affordability of health insurance,” lied Sen. McConnell in a recent opinion piece in the Cincinnati paper.

Yes, “Mr. McConnell has always taken pride in protecting his members.” And his donors. It is too bad that he has no interest in protecting the rest of us.

Hospital charge variation and Medicare equipment fraud: two forms of gaming the “non-system”

There has been extensive coverage of the recently published report from the Center for Medicare and Medicaid Services (CMS) that revealed dramatic differences in the prices charged for medical services between hospitals, not only between regions but also within the same city. “Hospital Billing Varies Wildly, Government Data Shows”, in the NY Times May 8, 2013, reports that “A hospital in Livingston, N.J., charged $70,712 on average to implant a pacemaker, while a hospital in nearby Rahway, N.J., charged $101,945…In Saint Augustine, Fla., one hospital typically billed nearly $40,000 to remove a gallbladder using minimally invasive surgery, while one in Orange Park, Fla., charged $91,00. …In one hospital in Dallas, the average bill for treating simple pneumonia was $14,610, while another there charged over $38,000.” 
Bloomberg News notes that treatment of psychoses ‘showed the greatest price discrepancies, with the most expensive hospital charging $144,523, more than 52 times its cheapest peer,’ and the ‘most common procedure in the data, treatment of simple pneumonia and lung inflammation with complications, had prices ranging from $5,093 to as much as $124,051.’” The Kansas City Star reports, in “New data reveal puzzling differences in hospital charges”, that “… the hip replacement surgery that one hospital in Ada, Okla., charges at $5,304 cost $223,373 at a hospital in Monterey Park, Calif.,” and giving a local example, “In Kansas City, charges for that surgery range from $24,874 at Truman Medical Center Lakewood to $66,268 at the University of Kansas Hospital.”  Among the many other news sources covering this are Wall Street Journal (“Data shine light on hospital bills”), USA Today, AP,  Los Angeles Times, Washington Post, and others.  The LA Times article notes that the data call “into question medical billing practices just as U.S. officials try to rein in rising costs.”
But, of course, this information should come as no surprise; it confirms something not only well-known by hospitals and physicians for a very long time, but repeated reports by investigative journalists over the last several years. These have included  Atul Gawande’s article, “The Cost Conundrum in The New Yorker June 1, 2009 (my blog coverage in Medicare Costs: “All Politics are Local”, June 11, 2009) and Steven Brill’s February 2013 Time magazine piece “Bitter Pill: Why Medical Bills are Killing Us”, which I discussed in Squeezing the needy: a truly flawed financing system for healthcare, March 2, 2013. Hospitals’ “charge masters” list “list prices” for any number of procedures and equipment which, as noted above, vary wildly. Although Medicare performed the study, in fact Medicare does not pay those prices or anything close to them; it sets its own payment schedule for these procedures which does not vary much between hospitals. However, as Gawande makes clear in “The Cost Conundrum”, there is a second problem arising from the fact that some hospitals seem to do – and bill Medicare for – a far larger number of procedures than are done by other hospitals caring for similar populations.
So why do they have these charges and why do they vary so widely? They vary because different amounts of “fixed costs”, the expenses that hospitals have that are not for the individual patient (staff, building maintenance, equipment, etc.) are loaded into these charges, as are more or less profit. They are high because there are occasional payers (fewer all the time) who do link their payments to charges, such as Worker’s Compensation. While Reutersquotes HHS Secretary Kathleen Sebelius as saying “When consumers easily compare the prices of goods and services, (providers) have strong incentives to keep those prices low. But even basic information about health premiums and hospital charges has long been hidden from consumers. These rates can vary dramatically in ways that can’t be easily explained,” it is not clear that posting the prices, or having smaller differences, would be of much help to most people. 

Large health insurers, like CMS, do not pay the posted “charges”; although they pay more than Medicare or Medicaid, their payments to hospitals are usually tied to Medicare charges as a multiple (e.g., they might pay 2 times Medicare). Of course, the group that most clearly gets screwed are people with no insurance at all, who are in fact billed for the entire list charge. They are, also of course, very unlikely to be able to pay any significant portion of those charges (minus the rare sheik or hedge fund manager who might show up). Therefore, the difference between owing $24,874 to Truman Medical Center Lakewood or $66,268 to the University of Kansas Hospital for hip replacement surgery may be largely theoretical to them, but in the meantime, it can, and frequently does, absorb their life savings, ruin their credit, and throw them into bankruptcy. And there are “middle class” uninsured families who might be able to pay off $24,874 over a few years, but for whom $66,268 is more than they could pay in a lifetime. (Fortunately, most hospitals, including I know the University of Kansas Hospital, do develop payment plans for patients, which, if they make payments that are agreed on can preserve their credit.)
Meanwhile, in “Medicare anti-fraud effort has Missouri roots” (Kansas City Star May 7, 2013), Lindsey Wise, the paper’s Washington correspondent, describes how the concerns of a St. Louis physician that she was receiving requests from medical device sellers for approval of medical equipment that she hadn’t ordered, and that it turns out her patients hadn’t requested, led her senator, Claire McCaskill, to hold federal hearings. As noted by Sen. McCaskill, “Most Americans have seen ads on TV or received calls or letters promising medical equipment ‘at little or no cost to you,’”  but, as she adds, “there is always a cost to you, because it is paid for by federal tax dollars.”  Both Dr. Kennedy’s patients and others testifying before McCaskill’s committee said they often receive several calls per day from device retailers. Investigations of two companies that had faxed unsolicited requests to Dr. Kennedy discovered, respectively, a 68% and 92% “error rate”, a euphemism for what may well be fraud.
Why mention these two separate issues, Medicare fraud by medical device companies and huge charge disparities among hospitals for the same procedures, in the same blog post? While definitely different – the device sellers, at least those who are guilty of such practices (“Please don’t convict the entire industry,” says the executive director a trade association that represents medical equipment companies), are unscrupulous and perhaps committing fraud, while the hospitals are not – they share they key characteristic of seeking profit by “gaming” the system. Medicare pays for medically necessary equipment (including scooters, oxygen, diabetes monitors, etc.) for patients who need them, and some companies selling them do aggressive direct-to-consumer marketing (as do pharmaceutical companies), to try to increase their sales. Hospitals post exorbitant “prices” for their services that bear little relationship to the cost of providing them (as proven by the wide variation) in hopes that the occasional payer will pay them, or at least pay a percentage of them (unlike Medicare’s fixed reimbursement). What they have in common is the exploitation of a nonsensical non-system of health care in which profit is pursued by taking advantage of its intrinsic disorganization.
For medical supplies, while Sen. McCaskill’s committee discovered many cases where patients did not want the equipment physicians were asked to approve, there are many others cases in which the patient is convinced that it would be good to have, say, a scooter that they don’t have to pay for —  even when the doctor thinks it is not necessary or might even be harmful (for example, when a person who doesn’t exercise because of their weight gets a scooter and does even less activity and thus gains more weight). Fraud is fraud, should be investigated, and it appears that it is being done.
For hospital charges, however, the solution is different. It would be to have a national payment system that, possibly with regional differences based on the cost of labor and other variables, pays a fixed amount for services, as does Medicare – a single payer system. It probably needs fixes (Medicare may currently pay too little, requiring private insurers to subsidize that care; certainly the law should allow the uninsured to be billed at no more than Medicare would pay), but a little rationality would go a long way.

Doctors and health reform: maybe they do stand for health!

The new GOP health plan, the American Health Care Act (AHCA), aka “Trumpcare”, has crashed to defeat. The President, who pushed hard for it, looks like his greatest nightmare, a “loser”. It is worth thinking, however, about who opposed it. In Congress it was Democrats and (the few) moderate Republicans and very right-wing Republicans are against it, for different reasons. From outside government the response was pretty negative, with a 17% approval rating (amazing they could still think they could pass it!). Far-right “conservatives” thought that AHCA was too much like Obamacare in that it actually provides some federal support for some people, and  they don’t believe in the government ever helping anyone, except maybe themselves and their friends. (Oh, yes, and fabulously rich people. They deserve a lot of help.) The criticism from most of the rest of the universe (to say “the left” would be inaccurate, since it includes many quite a bit right of center, since, in fact, “Obamacare” started life as a Republican plan) was mostly because it would be a disaster for health coverage for Americans. Projections by the Congressional Budget Office (CBO) were that 24 million people would lose their health insurance, that access to care would be more and more limited, especially for the middle class and poor, and that costs would rise for patients exponentially. Also that the public health and preventive health infrastructure would be gutted and many of our advances in those areas lost.
The main “positive” in the CBO’s projection was that it would reduce the federal deficit by $337 billion over 10 years. This was only because it shifted costs to others, to states and employers and individuals. Those who could not pay with money would pay with their health and sometimes their lives. While, as I have pointed out (‘We have a bill! The GOP’s plan to cut taxes on the rich and health care for the rest of us, March 16, 2017) many would have lost their insurance because of cuts in subsidies through the exchanges, the biggest impact would have been through the loss of Medicaid. This is clearly explained by Dr. Daniel Derksen, a family physician and director of the University of Arizona’s Office of Rural Health in a video on MedPage Today.
Among the many groups criticizing the draconian cuts in health care (as well as taxes on the rich) are almost all of the major hospital associations (including the American Hospital Association, the Catholic Hospital Association, and others), and physicians’ groups, most notably the American Medical Association (AMA) as well as most specialty societies including the American Academy of Family Physicians (AAFP), the American College of Physicians (ACP), as well as many others. They have been joined by the major nursing organizations and by patient advocacy groups. It should not be surprising, I suppose, that most of these groups would be critical of such a devastating attack on health care for Americans, but if it isn’t, it is at least a relief. The AMA is important in part because of its major role in opposing most historical expansions of health care access by the government, including President Truman’s attempt to get a national health insurance program (where they were successful) and President Johnson’s creation of Medicare and Medicaid (where they were not).
Of course, not all health providers and certainly not all physicians opposed the AHCA’s changes. MedPage Today published quotes from a number of physicians, and some were quite supportive; Darrell S. Rigel, a dermatologist at NYU, for example, said “It looks like it is a significant improvement over the ACA [the Affordable Care Act, aka Obamacare].” The most noteworthy physician advocate for the AHCA and Trumpcare was naturally Tom Price, MD, the Secretary of Health and Human services. As I discussed before his appointment (“Trump, Price, and Verma: Bad news for the health of Americans, including Trump voters, December 3, 2016), Secretary Price, as a congressman from Georgia was a leader in the Tea Party caucus and an opponent of ACA or any other program to expand health coverage to Americans. Another recent voice to both support AHCA and channel the administration and GOP’s contempt for regular people is Rep. Roger Marshall, an obstetrician from Great Bend, KS who is the Representative from Kansas’ “Big First” district. Dr. Marshall told the Washington Post that “the poor just don’t want health care”. He kind of walked back those remarks later, but his analysis is telling:

“Just like Jesus said, ‘The poor will always be with us,’ ” Marshall said in response to a question about Medicaid, which expanded under Obamacare to more than 30 states. “There is a group of people that just don’t want health care and aren’t going to take care of themselves.” He added that “morally, spiritually, socially,” the poor, including the homeless, “just don’t want health care….The Medicaid population, which is [on] a free credit card as a group, do probably the least preventive medicine and taking care of themselves and eating healthy and exercising. And I’m not judging; I’m just saying socially that’s where they are,” he told STAT, a website focused on health-care coverage. “So there’s a group of people that even with unlimited access to health care are only going to use the emergency room when their arm is chopped off or when their pneumonia is so bad they get brought [to] the ER.”

I may not be the best person to comment on his bizarre interpretation of the Gospel, but I can say that for many of us the challenges that poor people face in just getting through their lives are reasons why we need to make health care accessible, not reasons to just write them off. I also wish that I could say that, in my experience, physicians with attitudes like those of Price and Marshall are rare, but sadly they are not. To some degree, there are differences by specialty, with primary care physicians and psychiatrists more likely to support government-involved health care and even single payer plans than surgeons (including orthopedists). I am sure that at least in part this difference is driven by income; while all physicians have relatively high incomes compared to most Americans (top 10%), some specialties, including orthopedics (at the top), radiology, cardiology, surgery, and dermatology make much more; the mean reported income for orthopedists, about $467K (which seems low to me based on those I know) is about the cutoff for the top 1%. When a friend of mine (who later became a surgeon) was on his surgical rotation in medical school, he was impressed by all the talk in the surgeon’s lounge about the “Big Board” – until he found out they meant the stock market, not the board listing upcoming surgeries! And primary care doctors are not immune; when I lived in Texas one family physician regularly railed against the liberal government spending our money. One day, however, his attacks were on delays in payments to doctors from Medicare. Umm…
Doctors are, of course, like other people. Their perspectives vary widely, with most being caring and some caring mostly for themselves. My family physician colleague’s self-centered view is not so different from that of those Trump voters who are now against the AHCA because they see that their benefits are being cut; see “Trump budget cuts put struggling Americans on edge”, NY Times March 18, 2017. The authors cite a retired nurse with lung cancer whose heat was cut off in the middle of the winter; she was rescued by a heating subsidy funded by the federal government and likely to be cut. “I understand what he’s trying to do, but I think he’s just not stopping to think that there are people caught in the middle he is really going to hurt,” she said. Somehow, I suppose, she thought that the cuts would only be to other people…
So, while it is true that doctors, like others, often share the perspectives of their class, and callously disregard or rationalize opposition to ensuring health care for everyone, they often do understand the situations their patients are in and serve as advocates for them. In 2001, the AMA passed its “Declaration of Professional Responsibility: Medicine’s Contract with Humanity”.  It includes the following “Advocate for social, economic, educational, and political changes that ameliorate suffering and contribute to human well-being.”  The AMA was on the right side of the AHCA fight. I hope that most doctors agree with, and even practice, that principle.

I hope Tom Price and Roger Marshall are aberrant exceptions.

Matthew Freeman Social Justice Lecture and Awards 2015 at Roosevelt University

The 2015 Matthew Freeman Social Justice Lecture and Awards at Roosevelt University in Chicago were given and presented this year on March 26, 2015. The lecture was given by Carlos Javier Ortiz. Mr. Ortiz is a highly-honored photographer and photojournalist, and his presentation was therefore much more visual than many previous lectures.  Based on the photographs from his book and gallery display “We All We Got”,the images and accompanying talk focused upon the lives of poor people of color in Chicago, particularly those of families of young people who had been killed, often as incidental victims. Ortiz developed long-lasting relationships with some of these families, and his photographs document that, even with these losses, life goes on.
But it does not go on smoothly or easily. Affixed to the back cover of his book is a fold-out list, by year, from 2007 to 2014, of the hundreds and hundreds of Chicago Public School students who have been victims of gunshots and stabbing deaths. In his talk, Ortiz notes that in more affluent suburban communities, such premature deaths are rare and often kept from young people, while on the south and west sides of Chicago grammar school classes may be taken to the funerals and wakes, such as that of Siretha White in 2006 pictured below. Diane Latiker and her husband are building a memorial, brick by brick, to young people lost to violence. Begun in 2007, it has more than 370 stones, and Ortiz tell us, is behind by more than 200.
We who are not part of these communities may see them as apart; indeed one mural depicts downtown Chicago as separated from their neighborhood by almost-impassable mountains (there are, in case you wondered, no mountains in Chicago). Our news media nationally cover tragedies involving the death of white young people as at Columbine and Sandy Hook; local news may cover the accidental killings of young Black girls such as Siretha White, but the deaths of young Black men, who may have been linked to gangs, is not news. But their families, and communities, suffer, as does our whole society which affords them no future.
This theme is tied to that noted by Richard E. Wallace, one of the amazing Roosevelt students to receive the Matthew Freeman Award. Wallace, who is a father and labor organizer while maintaining a straight-A average, works with day laborers. These people awake at 4am every day to be in line to be picked up so they can work for minimum wage doing tasks from backbreaking physical labor to shipping your Amazon packages so that they can provide at least minimal housing, food, and water for their families. With this life of constant work for barely subsistence wage, they have no hope of getting out or advancing, recalling the lives of ante-bellum slaves in the South. He is one of the founding members of the Stop Mass Incarceration Network at Roosevelt, and the professor who nominated him said “I have probably learned as much, if not more, from Richard Wallace as he has learned from me.  I think he is one of the brightest and best embodiments of the university’s mission that we have seen.”
 
Danielle Cooperstock, the other reward recipient, is also amazing. She “is majoring in Social Justice Studies with a minor in Women’s and Gender Studies. In 2012, Danielle connected with PIRG through a transformational learning course on educational and economic inequality issues. She continues to work with this community organization and many others to this day. For the past two years, Danielle has worked as a student disability and peer mentor at the Academic Success Center. Additionally, she is a crucial leader of two Roosevelt activist groups, RISE and RU Proud, both of which motivate other Roosevelt students toward social justice goals.”

These are two incredible young people, and I had a desperately-needed sense of hope and optimism on meeting them and hearing what they have done. And I thank Roosevelt University for its explicit social justice mission and its nurturance and support of students like these two. Should you have the capability, it is certainly worthy of your support.

The Trump Election, the ACA and health care in America: Not with a bang but a whimper

As you may have already heard, Donald J. Trump won the election and will be the next President. “The media”, from the mainstream to the left, have moved from excoriating him as a candidate with outrageous personal characteristics and terrifying policy proposals, to excoriating him as President-elect, with less emphasis on his personal characteristics and more on what future policy is likely to be. There is special and valid emphasis on the people who are his main advisors, right wing zealots like Steve Bannon, and the hawkish, sometimes completely out of touch with reality, group. 

There are many  post-hoc analyses of why Clinton lost – I recommend Naomi Klein’s discussion of neoliberalism and what the most scary aspects of a Trump presidency are. Regarding the latter the always-terrific Noam Chomsky’s interview on Truthout,firmly identifies global warming and climate change as the greatest threat to the continuation of the world. He emphasizes this threat by noting that 40% of Americans are not concerned about the long-term impact of global warming because they believe that Christ will return and the rapture will occur in the next several decades.
There will, certainly be many other major threats, some of which, like nuclear war, could end the world. After the election, I was reminded that T.S. Eliot wrote in The Hollow Men, “this is the way the world ends, not with a bang but a whimper,” and yet the bang is not out of the question. In less apocalyptic, but just as serious terms, many people in America, whole populations, have real reason to be fearful. Obviously Muslims and “illegal immigrants” have been the victims of the most direct attacks by the President-elect and his advisors, and have a great deal to fear, but the list goes on to include Latinos who are here legally, citizens, members of other groups based on race/ethnicity (African-Americans) or other characteristics (LGBT). It includes women who may seek not only abortions but effective and available contraceptive care – and their partners. It affects all of us who value justice, diversity, peace, civil rights and civil liberties, opportunity, and freedom. We may see some irony in the last two, as they were clarion calls by many Trump supporters, but it has always been clear that for much of this group “freedom” was the freedom to do what they want (carry guns, practice their religion, etc.) and not any concept that would apply to everyone (be safe, have reproductive rights, practice their religion). Opportunity was always about the opportunity of some people to get ahead and not lose ground.
Many Trump supporters, but of course not those who are or will be in leadership in his administration, will be among those who suffer, because income and wealth will be major drivers of suffering, as they always have been. This is not to minimize the impact of race; as Dr. Camara Jones analyzes in her discussions of the “social determinants of equity”, class may be the final mediator of social, and especially health, disadvantage, but it does not explain why there are so many Black and other minority people in the lower class. Yes, surveys have shown that the bulk of Trump voters were white people in the “middle class” ($50,000-$90,000) range, but there were also many lower income whites. Indeed, while conservative ideologues in the Republican party railed against the ACA because it actually provided benefits to people in a “socialist” way, most voters who were hostile to it were motivated by (in addition to racism; it was after all “Obamacare”, named for our African-American President) the fact that premiums were going up to unaffordable levels, and the coverage that they received, when they got sick, was inadequate.
Of course, to be concerned about your premiums and deductibles and co-pays going up under the health insurance exchanges, you have to be covered by them. And, if we didn’t have “Obamacare”, you wouldn’t be covered at all, especially if you have a “pre-existing condition” or have to be paying a lot more if you could. Trump recently seem to be recognizing this, noting that there are popular as well as unpopular aspects of the ACA, and that junking the whole thing, as Republicans have voted to do dozens of times, might be a bad move. The things people like about ACA are that they can get coverage, that they can’t be denied coverage for a pre-existing condition, that there is “community rating” which means that they can’t be charged an especially high premium because they are sick, and that children can stay on their parents’ policies until 26. What they don’t like is high and increasing premiums, high deductibles, high co-pays, discovering the insurance that they could afford is lousy and doesn’t cover what they need and, in many cases, community rating, which means that if you are young and healthy you pay more.
Trump, in characteristic fashion, promises us we will only get rid of the bad parts, and keep the good parts, so the results will be terrific! Too bad President Obama didn’t think of that. Or me. Or that it isn’t possible within the constraints of the ACA. The ACA was designed to deal in insurance companies and their profits to a more-inclusive national health plan. This was the quid pro quo: we’ll do community rating and insure everyone regardless of pre-existing condition, you have to make everyone buy insurance (the “individual mandate”). But lots of healthy, and especially young, people are not buying insurance, gambling that they will stay healthy. If they get “caught” (and most don’t) the penalty is far less than the cost of the insurance. So they win. Until they lose. Of course, many who buy insurance get the lowest cost policy they can and then they really lose. And if they buy better coverage the insurance companies get mad. Much analysis of the history of ACA and its roots, as well as speculation about its future, is covered by Himmelstein and Woolhandler in this PNHP post.

And it doesn’t come at a good time. The Commonwealth Fund just released a report showing that Americans have more challenges in receiving needed health care than in 10 other rich countries. Well, it hasn’t been a good time for a while. This report just shows, basically, the same thing that Commonwealth and others have been reporting for years.
So what can we expect, as a nation, from a Trump administration? Well, there is odds-on betting that we will get a right-wing, anti-abortion, anti-reproductive rights Supreme Court. And, if not actually a wall, major deportations and harassment of immigrants. And real anti-Muslim activity. Hate crimes are already up, per the Southern Poverty Law Center, with really bad people feeling emboldened by the Trump rhetoric; we can only hope his Justice Department will prosecute these crimes at least as aggressively as they do immigrants. We will probably get more of the same in attacks by police on minorities, and especially on policies that enrich the richest and hurt the poor. We will get little or no action on climate change. And we will not get the jobs that have been lost back, whatever the President-elect promises.
 
Protests will continue, centered as they have been in the small islands of the nation that voted Democratic – and where most of the people in the US live. We need to be sure that the losses I describe above do not come easily, that we do not keep our heads down, that we make waves.

And, in healthcare, we probably will not get single payer, although this would solve the problem and allow Donald Trump to actual give us most of the good without most of the bad. If he would only.

Medicaid expansion will leave out many of the poorest: What is wrong with this picture?

In States’ Policies on Health Care Exclude Some of the Poorest, in the New York Times on May 25, 2013, Robert Pear describes how this bizarre situation has come to pass. Basically, it is because the programs established by the Affordable Care Act (ACA) of insurance exchanges and federal subsidies for low-income people, via tax credits, was never the ACA’s plan for the lowest-income Americans. They were supposed to be covered by expansion of the Medicaid program, a federal-state partnership that covers some poor people and varies widely, both in terms of who is covered and what that coverage consists of, from state to state. Recognizing that, coming out of the “Great Recession”, many states were strapped for money, the ACA also included a provision that the first 3 years of the expansion would be paid entirely by the federal government, and that the feds would pay 90% of the cost thereafter.
This, however, was not sufficient inducement for many states to agree to expand Medicaid. They might have if the Supreme Court decision that found the ACA constitutional had not excluded one provision – that, unless the states’ expanded Medicaid they would lose all their current Medicaid funding. The result was the decision in many states to not participate in Medicaid expansion, thus effectively leaving out the mechanism for covering the poorest; tax credits were designed to provide subsidies for those who earned from the poverty level to 4 times the poverty level ($11,490 to $45,960 for a single person) with Medicaid expansion covering those below it. However, many states (virtually all Republican-controlled, although not all those that are Republican controlled) have opted out of this program, leaving those below the poverty level uncovered. The head of the Louisiana Primary Care Association notes that “If the breadwinner in a family of four works full time at a job that pays $14 an hour and the family has no other income, he or she will be eligible for insurance subsidies. But if they make $10 an hour, they will not be eligible for anything.”
 While these states may not have more than half the country’s total population, they do, according to the Times, have more than half the uninsured (they include Texas, the nation’s second most populous state, which has an uninsured rate of about 30%, and Florida, the fourth most-populous, whose legislature has decided not to expand Medicaid despite the support of Republican governor Rick Scott for expansion).  “The Congressional Budget Office estimates that 25 million people will gain insurance under the new health care law. Researchers at the Urban Institute estimate that 5.7 million uninsured adults with incomes below the poverty level could also gain coverage except that they live in states that are not expanding Medicaid.”
The state “featured” in Pear’s article is my home state of Kansas, possibly because of the willingness of the state’s insurance commissioner, Sandy Praeger (pictured here with Secretary of Health and Human Services Kathleen Sebelius, who, the Times does not indicate, was formerly Governor of Kansas, and, before that, Praeger’s predecessor as insurance commissioner), to discuss the situation. Kansas, historically not one of the more generous states for Medicaid, “…provides no coverage for able-bodied childless adults. And adults with dependent children are generally ineligible if their income exceeds 32 percent of the poverty level.” Thus, Ms. Praeger said, “In most cases, she said, adults with incomes from 32 percent to 100 percent of the poverty level ($6,250 to $19,530 for a family of three) ‘will have no assistance.’ They will see advertisements promoting new insurance options, but in most cases will not learn that they are ineligible until they apply.” Whoops. Gotta fix that.
Or not. There is no plan, in Kansas, Texas, Florida, or any of the other states not opting for Medicaid expansion to help to cover these people. Most of the arguments you will hear against doing so cite “costs too much money”, but this is, simply, baloney. The governors and legislatures currently running these states do not, actually, believe in covering anyone (except, of course, themselves and their friends). They believe this is “socialism”. What they believe in is cutting taxes, particularly on the wealthiest individuals and corporations, which Kansas has  aggressively done since Governor Brownback was elected in 2010. The ostensible argument, from the governor, is that low taxes will lead to greater business growth, which will benefit the economy, and help to balance the budget. The first is your basic “trickle down”, proved wrong in every instance since it was first made popular in the 1980s, and the second is a negative tautology – even if business does grow, the extremely low tax rates will make balancing the budget very hard. Indeed, this year Governor Brownback is stumping the state to drum up support for not cutting the higher education budget, but this seems to be falling on deaf ears in the legislature, which sees such spending cuts as yet another opportunity to cut taxes.
Praeger, as insurance commissioner, does not make the decision about Medicaid expansion, but her office is responsible for informing the public about its opportunities to gain insurance on the exchanges (that will be federally-run, because Kansas has also opted out of running its own) and also informing those “poorest of the poor” that the ads for coverage will not be for them. It is obvious that she feels very badly about it; this former state senator and mayor of Lawrence, and former chair of the National Association of Insurance Commissioners (NAIC) is a person with a heart and a concern for people (yes, Virginia, there are Republicans with a heart, and Kansas used to be full of them!). The insurance commissioner does make some decisions; Sebelius, in 2002, blocked the sale of Blue Cross/Blue Shield of Kansas to the for-profit Anthem, stating it would not be in the best interest of the people of Kansas. Many credit that very popular decision for helping her to win the governorship later that year (yes, Virginia, we sometimes elected Democrats as governor!).
It is way too early to know how these decisions will affect elections at either the state or national level. The Times article indicates that “Administration officials said they worried that frustrated consumers might blame President Obama rather than Republicans like Gov. Rick Perry of Texas and Gov. Bobby Jindal of Louisiana [and one might add Kansas], who have resisted the expansion of Medicaid.” However, and very unfortunately, the poorest of the poor do not vote in high numbers. Perhaps the opposite will happen, with those slightly more well-off, who vote at slightly higher rates, crediting the Obama administration for their new coverage, and blaming the state governors and legislatures.
And, of course, this does not even take into account undocumented people living in the US, many of them the breadwinners for families that are composed of citizens, “legal” and “illegal” members.  Children who were born here are citizens (and eligible for programs such as Medicaid and the State Children’s Health Insurance Program, S-CHIP) while often their parents are eligible for nothing. This is not the way to improve health, or to foster family values. But it is consistent with another, anti-immigrant, agenda.
Other first-world countries cover everyone. Not some, many or most people. Everyone. They do it in different ways: Britain has a National Health Service, Canada a single-payer health system which is the government, Switzerland a multi-payer (private) system with a required benefits package and pricing structure. Other countries, Japan and Taiwan, France and Germany, do it differently, but they all cover everyone. We could too.
It’s sad for all of us that we won’t. And it’s life and death for the neediest.
___________________________________________
More data from American Medical News: Millions uninsured on patchwork Medicaid expansion map

Who is left out of ACA, and how does this affect Health for All?

The Affordable Care Act (ACA, Obamacare) has been very successful, despite the pronouncements of doomsayers (mostly Republicans). More than 10 million people who were previously uninsured have received coverage, and this has dramatically increased their access to health care. However, many people remain without health insurance, and many more are barely able to afford their premiums or can afford only the most basic plans. These people fall largely into three groups: those who the law was never planned to make eligible (mainly those people who are living in this country without documents), those people who make less than 133% of the poverty level but were not previously eligible for Medicaid and live in states that have not opted for Medicaid expansion, and lower-income people above 133% of poverty who have either not bought insurance on the exchanges or bought it and have since dropped it.
The first group, those without papers, comprise over 11 million real human beings in this country, people who work and go to school and get sick and visit our emergency rooms. That they are not even considered in ACA or any other proposal considered politically viable is a head-in-the-sand approach that ignores both human suffering and the cost of providing care to them. This cost is often shifted to hospitals, doctors, and volunteer organizations, such as the student-run Jaydoc Free Clinic in Kansas City, KS. The work that volunteers do is admirable, like that of the people celebrated by the first President Bush as “1000 points of light”, but it is not the way a wealthy country should have to provide care to people.
The second group is composed of those that the ACA intended to be covered by Medicaid expansion, but who live in states that have opted not to expand Medicaid. Given that the federal government would have picked up 100% of the bill for the first 4 years and then 90% thereafter, it is financially a good deal for the states. The reason that states like Kansas have not done so is entirely political; these are all states with Republican governors and/or Republican-controlled legislatures (although it does not include all of those!) whose core political position is opposition to anything coming from President Obama. Their proposed health plan is — well, nothing, but they are against Obamacare, and against expanding Medicaid, and if this seems not only mean but economically stupid, so be it. People who in other states can access care when they need it are going without care or showing up in extremis in ERs. Hospitals end up footing the costs for people who could have been insured..
In Kansas, the first hospital closure that might have been forestalled with Medicaid expansion has occurred. Closing of Kansas hospital adds to Medicaid expansion debate (Kansas City Star, October 18, 2015) describes the closure of Mercy Hospital in Independence, KS. Doctors from relatively nearby towns that still have a hospital report increases in ER visits from people from Independence.There are many reasons that contributed to this closing, including the fact that residents of rural areas such as Independence are older and sicker than the national or state average, but a large proportion of them would have been eligible for expanded Medicaid had the state implemented it. The article makes clear that “While Medicaid expansion may not have saved Mercy Hospital, there are some in Montgomery County who say it could save many individuals.”
The Kansas Hospital Association (KHA) has been lobbying hard for Medicaid expansion because their members are losing money caring for uninsured people who are covered in the states that have expanded Medicaid. These hospitals are absorbing the impact of cuts to MediCARE which were supposed to be offset by the decrease in the uninsured resulting from the expansion of MediCAID, which is of course not happening in states such as Kansas, and it sees Mercy as the first domino to fall. KHA has a lot of influence in the state capital, Topeka, and rarely loses battles that it engages as strongly as it has this one, but so far there has been no movement from the Governor or legislature. While some legislators are beginning to rethink the issue: “ ‘My sense is a lot of legislators are saying we need to have that discussion (about Medicaid expansion). We need to take a hard look at that issue,’ said Rep. Linda Gallagher, a Lenexa Republican. ‘I do support that myself’”, others are adamantly opposed: “’I know that’s on the table. I don’t think any decision has been made on that,’ said Rep. Tony Barton, a Leavenworth Republican. ‘I think it would be moving in the wrong direction. I’ll leave it at that.’” And well he might leave it at that, as there is really nothing he can say that makes economic or social sense. It is a quintessential statement of opposition, being against something because, well, he is against it.
The Star article makes clear that Independence, KS has had, like many small towns, difficulty in recruiting and retaining physicians, but even those towns with doctors have hospitals with major financial challenges that could be helped by Medicaid expansion. Dr. Doug Gruenbacher, board chair of the Kansas Academy of Family Physicians (KAFP), an organization representing the family doctors who are the mainstay of rural health care, practices in Quinter, KS. While Quinter has fewer than 1000 residents (compared to Independence’s 9300), its group of family doctors cares for people from perhaps a dozen surrounding counties. Dr. Gruenbacher wrote a letter to the Salina Journal (October 10, 2015) calling for Medicaid expansion. He says “I know that my hospital [Gove County Medical Center] and more importantly, my patients, would benefit from the expansion.”
This leaves the third group of people who have had little or no benefit from the ACA: those who have  either not been able to afford to purchase insurance on exchanges, despite subsidies, or have dropped it as a result of rate increases by insurance companies. In “Insurance Dropouts Present a Challenge for Health Law” (NY Times, October 11, 2015), Abby Goodnough focuses on people in Mississippi, another states that has not expanded Medicaid. She observes that many of those who are working and making more than 133% of poverty are eligible for subsidies on the exchanges – indeed, 95% of Mississippians receiving coverage this way have subsidies, the highest percentage in the nation – but increasingly are finding the premiums more than they can afford on their tight budgets. Sometimes people were dropped from their insurance companies simply because they did not provide some information that the law requires to prevent undocumented people from signing up. Sometimes they just couldn’t afford it.
The ACA prohibits insurers from denying coverage for those with pre-existing conditions, but does not prohibit them from charging more for that coverage. And they do. “Walter Whitlow, 56, a remodeling contractor in Volente, Tex., said he had never seen the emails the federal marketplace sent him asking for additional proof of income after he signed up for a Humana plan in January. Doctors diagnosed throat cancer in February, and in June he learned from his oncologist’s office that his monthly premium had gone to $439 from $103 and his deductible to $4,600 from $900.” Whoops. Glitch.
Or not. The ACA was an attempt to accommodate many political interests, and thus is a conglomeration of different programs. Its commitment to insurance companies, whose support seemed to be necessary to pass the bill, was to have the “individual mandate”, so that the insurers, now required to cover everyone, would have everyone, not just the sickest, in their risk pool. However, beyond this, the ability of insurers to increase premiums for the sick was projected to be a problem, but the advantages of passing the program outweighed it. ACA is not intended to ensure health for all, but coverage for most (except those noted above). In the aggregate, it has been of great benefit. But for individuals, like Mr. Whitlow, the impact has been disastrous.
It is important to remember that this impact is not because we passed a bill that tried to cover as many people as possible, as opponents of ACA maintain without any data. It is because that bill did not go far enough, did not cover everyone, did not provide sufficient protection for people from the predatory practices of insurance companies. These are not the reasons that most ACA opponents want to fix, although they should be fixed. Dismantling ACA will not help the people who are described above, suffering despite this program; it would only vastly increase their number.
But change is necessary. We do, in fact, need a comprehensive national health program that simply, like those of most countries, covers everyone. Like Medicare for all. This will not solve all problems. It will not necessarily bring doctors to rural Kansas. It will not insure quality. It will not, in itself, completely control costs. But it is a necessary, if not sufficient, step.
Our mission as family physicians is to provide care to all Kansans, not just the insured,” Dr. Gruenbacher writes. The next step is to make sure that there are no Kansans, or Americans, left out. 

Why poor people choose ERs: we need a system designed to meet everyone’s needs

“Understanding Why Patients Of Low Socioeconomic Status Prefer Hospitals Over Ambulatory Care”[1], by Shreya Kangovi and her colleagues in the July, 2013 issue of Health Affairs, tries to help us answer that question in order, presumably, to help re-design ambulatory care in order to change that preference. A general assumption of health policy is that use of hospital emergency rooms for “routine care” is expensive, inappropriate, provides worse patient outcomes, distracts emergency room staff from caring for the true emergencies that they are presumably there for, and is a significant cause of the overall high health care spending in the US. Although the whole article is available on-line only to Health Affairs subscribers, a summaryis presented on the Robert Wood Johnson Foundation (RJWF) website, because Dr. Kangovi was an RJWF Clinical Scholar.

The authors conducted a qualitative study interviewing 64 people who frequently used the emergency room as their source of medical care, using trained community members to engender greater trust on the part of the patients, mostly lower income African-Americans, to conduct the interviews, in two hospitals in the Philadelphia area.  “Study respondents (both the insured and uninsured) explained that they consciously chose the ER because the care was cheaper, the quality of care was seemingly better, transportation options were more readily accessible, and, in some cases, the hospital offered more respite than a physician’s office.”

These findings should be surprising to many students of public policy, but they were the legitimate perspectives of the people who were using these services, those Kangovi correctly notes, whose “…voices are seldom heard in policy discussions.”  Understanding their concerns is critical, not because they are always “right”, or represent everyone, but because those concerns reflect their experiences, and the degree to which our current strategies are not working, and the degree to which our future strategies are unlikely to work if they do not take into consideration these issues. Three themes generated by the researchers, with supporting quotes from the folks who were interviewed:

  • Convenience. “You must call on the same day to set up a [primary] care appointment … whenever they can fit you in.” This open-access scheduling resulted in people taking days off from work and still being unable to see a doctor. It also made it impossible for many to access transportation covered by Medicaid because the transport arrangements had to made 72 hours in advance. Late hospital hours also made care more available.  
  • Cost. “I don’t have a co-pay in the ER, but my primary [physician] may send me to two or three specialists and sometimes there is a co-pay for them. Plus there’s time off from work to go to several appointments.”
  • Quality. “The [primary care doctor] never treated me or my husband aggressively to get blood pressure under control. I went to the hospital and they had it under control in four days. The [physician] had three years.”
Any health care provider who has worked in an ER or in ambulatory care can validate these concerns, and also respond to them. The most obvious is Cost. Obviously care in an ER is not free; indeed the cost is a major driver of efforts to get people to not use it. But the patient, at the time of service, doesn’t have to put down cash, put down a co-payment, put down real money now. There will be a bill, but that will be something that goes on their (likely existing and mounting) debt burden.

Convenience is, perhaps, a poor choice of words; it suggests something purely volitional, as if people were choosing to have their hair done during the day rather than go to the doctor. Convenience in the way that a middle class person understands it is not what these folks are talking about. They may not have a car or a family member with one (or perhaps it is being used by a family member to get to work), public transportation may be unavailable, unreliable or inaccessible to them given their medical problems, and if they have jobs, they are often not those that just allow you to take a sick day to go to the doctor, but mean they lose pay. Despite efforts to have “extended hours”, most ambulatory care offices are open mainly during regular business hours, during the day weekdays, when the folks who work there want to work, not when it is necessarily most “convenient” for patients. Let’s get this straight, it is not “convenient” to wait 6 hours in an ER to be seen; if this is better than the alternative, the alternative is seriously flawed!

Quality is another issue, and the quotation chosen is very open to criticism. The hospital had 4 days of complete control of the person’s life, giving them their medicines and minimizing any external issues, while the doctor had 3 years in which the person was responsible for taking their medicine, choosing their diet, and deciding where to rank health among the many competing priorities in their lives. As any of us who have worked in medicine know, the control that was achieved in the hospital may well evaporate once someone is back in their regular environment.

Really, this is largely an issue of money, of resources. The authors emphasize that not all the patients were uninsured, but those who had insurance almost all had Medicaid. Not only is Medicaid not equivalent to private insurance (it pays less and lots of doctors do not take it) but it is only available to really poor people. People who are poor enough to have Medicaid have all those issues listed above under “Convenience” and “Cost” that go beyond the direct cost of medical care, but inform every decision that they make in their lives.

Policy is made, in almost every area, by the “haves”, those with money and political power. At the rawest, it is a blatant example of “let’s do for us, and screw those without power”, as for example the farm bill that cuts food stamps for the neediest while continuing support for giant agribusiness (well discussed by Paul Krugman in  “Hunger Games, USA”, NY Times July , 2013[2]). More subtly, and with much less intentionality, not to mention hostility, it is made from the perspective of people who have a lot, who cannot even imagine the lives, decisions, and trade-offs made every day by “have-nots”. The “haves” may identify a lot that is wrong with the health care system, but they do not even think of things like not having transportation, or not being able to take off from work to go to clinics open during working hours, or not having childcare. They are not mean people, but they do not see.

In her comments, Kangovi looks at plans to develop Accountable Care Organizations (ACOs). “Our findings suggest that these efforts could backfire by making hospitals even more attractive to these patients. We also debunk the notion that people from these groups abuse the emergency room for no reason and need to be taught how to use it properly.”  The real issue is that there are not the financial incentives to provide high-quality care that is accessible in terms of both cost and the other obstacles people face (e.g., transportation, childcare, office hours). The financial incentives are to try to avoid these patients all together, keep them out of the ER, keep them out of your office; to develop “Patient-Centered Medical Homes” that are centered around the kinds of patients you want to have, and not those you would rather not have show up (and go to the ER!).

We need a system that, first of all, ensures that taking care of everyone is (at least financially) desirable. That means a system in which everyone has the same insurance coverage (a single-payer system), and one that is designed to pay more when providing care for people with greater needs, both medical and social. We need a wrap-around system that enables the most needy to have access to the transportation, childcare and other issues that they need to be able to utilize their medical coverage, and to the education, jobs, food, and housing that they need to be able to have a reasonable chance at health. We don’t need a patchwork system of “good ideas” that do not, in themselves or together, create a real safety net for people.

If we have one that is so full of holes that gaming it for profit is the main activity of hospitals, doctors, and other providers, we have no reason to be critical of the least powerful finding the ways around it that work best for them.



[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  

[2]Krugman indicates the logic “…goes something like this: ‘You’re personally free to help the poor. But the government has no right to take people’s money’ — frequently, at this point, they add the words ‘at the point of a gun” — “and force them to give it to the poor.’  It is, however, apparently perfectly O.K. to take people’s money at the point of a gun and force them to give it to agribusinesses and the wealthy.”

Insurance coverage and access to care in the US

In the New York Times’ “Upshot” of October 24, 2016, Dr. Aaron E. Carroll discusses “Why the U.S. Still Trails Many Wealthy Nations in Access to Care”. He notes the increase in insurance coverage of the American people since Obamacare, but also that insurance coverage is not the same as access to care. He cites the most recentCommonwealth Fund survey of international health systems to demonstrate that, compared to most of the other ten wealthy countries that were studied, Americans have greater difficulty getting an appointment and being seen. (Canada is worse than the US in many of these measures, but not all; see discussion below.) Indeed, he also notes that when the populations of these countries are divided up between above-average and below-average incomes, the folks with below-average income in most of these other countries have better access than the above-average in the US.
A major reason that Carroll cites for the poor access is the low percent of primary care physicians in the US, a fact supported by data from the Organization for Economic Cooperation and Development (OECD, the “rich countries” group). It is true. There are not enough primary care doctors — family physicians and general internists and general pediatricians — to meet the access needs of the people of this country. There are plenty of excellent specialists; in fact, in many major metropolitan areas there are too many of them, sometimes leading to too many interventions that both increase the cost to the system and the risk to patients. Traditional “supply and demand” economics would suggest that limits on demand would force a constraint on the number of specialists, but it hasn’t happened yet; none of them are starving. This is because, in medicine, supply often drives demand rather than vice versa. When are people finally getting enough procedures, and when does it cross into too many? People don’t understand medical care, what is “good” for them and what is “too much”, much less the cost-benefit ratio. Indeed, doctors usually do not. But they do know what they know how to do, and that it will make them money.
This is a major area that having sufficient primary care physicians would help. If everyone has a family doctor that they can trust, whose income is not tied to procedures or referrals, they can help you to understand these complex issues. But there are far from enough; less than 30% of doctors in the US are in primary care, compared to 50%+ in other wealthy countries, and that is dropping as fewer students choose primary care careers. Many reasons for this are cited by studies (the culture of academic medical centers, status, work-life balance, etc.) but the real bottom-line reason is the bottom line: primary care physicians earn way less than most other specialists. Not just a little, but often half or a third as much as the highest paid specialists. Pay for primary care is going up with demand, but 10-15% increases will not change specialty choice; between income increases for primary care and decreases for specialties (heaven forfend!) the ratio needs to be at least 70%. Specialists know this; they want primary care doctors to do all the things that they themselves are not able or don’t want to do for their patients and are not opposed to primary care salaries going up — although of course they themselves don’t want to see their own incomes go down.
Getting the care you need is a combination of having enough providers for you to be able to find and get in to see, and adequate coverage. Insurance, as we have long seen even before Obamacare, is not all the same; there is good insurance (although hardly, any longer, great insurance) and lousy insurance, and there is no insurance that is both cheap and of high quality (although, again, there are plenty of plans that are costly and of poor quality). Premiums are the tip of the iceberg; deductibles (how much you have to pay out of pocket before your insurance kicks in), co-pays (how much you have to pay each time you access care), co-insurance (what percent of “covered” care you have to pay) also impact on out of pocket costs. As, of course, does the overall cost of care (by providers) and drugs (by drug companies), and what services are not covered by your insurance.
As an example, if you are over 65, try figuring out what plan to buy for your Medicare Drug Coverage (“Part D”). There are the monthly premiums. And the deductibles. And the co-pays. And those vary by type of drug (generic vs. brand-name, preferred vs. non-preferred), and sometimes they are by a fixed $-per-prescription amount and sometimes by a percent. And if you order by mail it is different. On the bright side, most vendors offer you a calculator into which you can put the drugs you take, and it puts it all together and tells you which is cheapest for you. Until, of course, the drugs you take change.
This is insane, of course, but only if you happen to care about what works best for actual people, and not what makes the most money for private for-profit companies like insurers. Drew Shenaman, cartoonist for the Newark Star-Ledger, in the accompanying editorial cartoon, makes it very clear what the real reason is that insurers are pulling out of Obamacare. Their interests are not our interests. Surprise!
 
So we have excellent quality medical care available in the US, if you are geographically and financially able to access it, except sometimes it is not needed and done anyway. We have too many doctors in some specialties and far too few primary care doctors, and even they are not distributed well across the US. We have insurance companies that are focused on making profits, rather than on providing access, and sell complex, difficult-to-understand products that often have a “gotcha” at the point when we are most vulnerable. While access to appointments may be a little better in the US than in Canada (but not other countries), cost to the individual is way higher in this country than in Canada; access to care has both financial and non-financial components.
Not everything can be reduced to dollars, but a lot can. The money spent on health care in this country should be spent on providing health care, not on profit for insurance companies, providers, drug companies, and the like. If private insurance is to be part of the system, it needs to be non-profit and highly regulated. There need to be more primary care doctors, and the way to make this happen is for them to get paid much closer to the same amount of money for the work that they do as other specialists. Medicare can and should lead the way on this. Physician distribution should be fixed by augmenting the incomes of doctors in rural areas, not punishing them. None of this guarantees quality care, but without it quality is a pipe dream.
Obamacare was good insofar as it went. It didn’t go far enough, and now we need to fix it.

We have a bill! The GOP’s plan to cut taxes on the rich and health care for the rest of us

Every day it gets more difficult to write about the new “American Health Care Act” (AHCA) that has been introduced in the House of Representatives by Speaker Paul Ryan because every day there is so much more news about it, and so much more criticism of it that appears in the press. Even before its introduction, the bill was attacked for being likely to significantly increase the number of uninsured Americans while providing windfall tax cuts for the wealthiest.
It did not disappoint. Consistent with predictions, the nonpartisan Congressional Budget Office (CBO) estimates that initially 14 million people will lose coverage, with the number rising to 24 million in 10 years. These estimates are discussed in detail, and clarified, in “Deciphering CBO estimates” at the Kaiser Health News site. The largest number of people who will lose coverage will do so because of the changes – but let’s call them what they are, “cuts” – to federal funding of Medicaid (discussed by the Health Affairs blog), which would shift costs to the states, most of which will be unable or unwilling to absorb these costs. The 31 states that have expanded Medicaid to all those under 138% of the federal poverty level  under the Affordable Care Act (ACA) will be faced with having to fund a lot more from their own coffers; poor people in the states that have not expanded Medicaid eligibility will continue uncovered. The other group that will lose coverage will be those who have bought subsidized insurance on the ACA-created marketplaces and who will no longer be able to afford the premiums. Yes, the new GOP plan calls for tax credits to help pay premiums, but they will be far less than under the ACA and far from enough to cover the actual cost.
This change will have the biggest impact on the older, sicker poor who are not yet eligible for Medicare (and, while I we will not address it here, the GOP leadership certainly has plans for cutting Medicare!), whose premiums will go up because of two important changes the AHCA will make. It will end the “individual mandate” of ACA, so that those who feel that they do not need health insurance can pass on buying it, which means the pool of insured will lose those healthier people and have a pool more skewed to those who are sicker and will actually usehealth care. This will tend to drive premiums up for them, and the AHCA also allows insurers to charge 5 times as much to older people as younger. As reported by Thomas Kaplan and Robert Pear in the NY Times on March 13, 2017
Under current law, in 2026, a single 21-year-old earning $26,500 with an insurance policy that costs $5,100 a year would get a tax credit of $3,400 and would have to pay $1,700 of the premium. Under the Republican bill, that person’s share of the cost would drop to $1,450.
By contrast, a 64-year-old earning the same amount would fare much worse. That person’s $15,300 health plan would be offset by a $13,600 tax credit under current law, leaving the consumer responsible for $1,700. Under the Republican plan, health insurers would be free to charge older people more, raising that person’s premium to $19,500. But the tax credit would be only $4,900, and that person’s share of the premium would then be $14,600.
That’s a bite! And, ironically, as pointed out by Noam Levey in the Los Angeles Times (March 12, 2017), it will hurt Trump/GOP voters more than Democratic voters, because those Trump voters – and the counties and states which went for Trump in which they live — are more likely to be in this older, sicker, group. This group of Republican voters did not like Obamacare because the premiums, co-pays, and deductibles were going too high and the coverage was not always great, especially for the plans they could afford. Trump, and the GOP, promised them high-quality, affordable coverage. These folks believed them. They voted for them. And they are not going to get it, certainly not from the AHCA. Levey notes that “…In nearly 1,500 counties nationwide, such a person stands to lose more than $6,000 a year in federal insurance subsidies. Ninety percent of those counties backed Trump…[a]nd 68 of the 70 counties where these consumers would suffer the largest losses supported Trump in November.” What can you do. Politicians lie. This one was a whopper.
What is the reason for this? Many of Congress’ and Washington’s leading “conservatives” say that they believe that the role of government should be as close to zero as possible, and certainly think that the government has no business being involved in the insurance marketplace to ensure that people without resources have health coverage; to them, the AHCA is too much like the ACA in that it actually makes some effort to help some people, if weakly. There are a few of these “conservatives”, in and out of Congress, who really believe this and act on such beliefs. Uniformly, they are not poor, are not close to poor, and are not likely to be negatively affected. There is a much larger contingent that only believe government should not help most people. They support legislation that benefits rich people, like the AHCA, which uses the money it will save (and the CBO says that it will reduce the deficit over 10 years by $337 billion) to give tax cuts, not evenly distributed, but very much skewed to the highest incomes. This is where the [mean] rich people come in; they fund the Congresspersons, and this is what they want. Rep. Michael Burgess (R, TX), Chairman of the Energy and Commerce subcommittee on health, is quoted in the Times on March 11 (“The GOP’s high-risk strategy for health law repeal”) as saying “If you ask someone to give up something, there will be resentment,” and he is correct. That it is regular people who are being asked to give up something by Mr. Burgess and his colleagues, so that his rich patrons can save even more on their taxes, is something he doesn’t focus on.
One of the most iconic differences between ACA and AHCA focuses on equity: the subsidies (and tax credits for those who paid taxes) under ACA were tiered to income. The tax credits that replace subsidies under AHCA are tiered to age. Of course, as I have noted, older people are more likely to be sick, but they are not all of the same need; some older people have lots of money, and some have none. The same is true for younger people, including those with medical need. In any case, the tax credits in AHCA will not, as demonstrated above, be sufficient for those without significant other resources to buy health coverage, even if they are in the more-highly-subsidized older group. The Times’ Alan Rappeport reports on March 16, “One certainty in health bill: tax cuts for the wealthy”, with 40% of the cuts going to the top 1%, and the bill providing the necessary basis for further tax cuts for the rich. Rappeport quotes Mike Mulvaney, the White House budget director: “We promised at the outset that we were going to repeal all of the taxes. Who cares if someone else benefits?” Well, maybe the people who will suffer for their benefit? The same issue of the Times contains a brief and informative piece by Mr. Pear, “Putting Republicans’ plan on the Obamacare scale”, examining the criticisms of ACA and how the AHCA solves them (or not).
President Trump apparently feels conflicted; he promised the repeal of ACA, and the Congress wants to do that. He also knows that any plan that comes out that does this will be called “Trumpcare”, just as the ACA was called “Obamacare”. Enough Republican senators are concerned that the House’s AHCA will make it too hard for too many people to afford insurance that they might vote against it, so “Mr. Trump was left to strike a balance between siding with House Republicans while also distancing himself from the details, with top aides conceding that the legislation needed modifications before it could pass the full Congress,” (”G.O.P. Senators Suggest Changes for Health Care Bill Offered by House” NY Times, March 14).

For the rest of us, it is an impending disaster.

The frustration of actually trying to get health care: the other meaning of access

I have written about the quality of care that people in the US receive, and about access to and the cost of care, but another very important issue is the actual process of obtaining appropriate care. This is a major source of frustration for patients and their families, and can drive anger against the system, against doctors, against insurers, against the government. People who experience this frustration and anger want it to change, and sometimes want to lash out, offering an opportunity to be intentionally misled by influential others for their political ends. The demonization of the Affordable Care Act (“Obamacare”) is a good example. Obamacare actually did lots of good things, starting with insuring tens of millions who did not previously have coverage; it also forbid insurers from charging more to those with pre-existing conditions, and allowed children to stay on their parents’ plans until they are 26. Actually, it did little or nothing bad, if the criterion is access to care. A few people saw increased premiums, mainly the healthy young and those who previously had such terrible policies that they were both cheap and essentially worthless. While the Republican congress tried to repeal it, it turned out that, surprise, people would be worse off without it.
On the other hand, frustration with the obstacles to obtaining appropriate care are real, every day, and in-your-face for patients and their families. I have recently been experiencing these from the perspective of the patient (or family) rather than that of the provider, as I work at getting care for my 92-year-old father. My experience with the provider perspective helps me to understand the situation from both sides, and hopefully to try to figure out which obstacles are rational and which are simply unnecessary.
Let me start by largely absolving any of my father’s individual providers; all those involved with him – physicians both general and specialist, physical therapists, and more recently the nurses, social workers, and nurse practitioners through the palliative care agency – are committed, caring and hard-working. They do their best to help him, to be available, to respond when a problem, minor or urgent, arises. However, there are obstacles in the way. Many services require a referral from a physician, from calling in prescriptions, to ordering lab tests or x-rays (and getting the results), to getting physical or occupational therapy, to enrolling in palliative care. While none of these individually may seem to be burdensome for the doctor, there can be many for any individual patient, multiplied by the number of patients a physician sees who need these services. While it is sometimes the specialist who makes such a referral or fills out such a form, it most often “rolls downhill” to the primary care provider. That provider has to have a very large number of patients to get by and make a living, so the phone messages and faxes and lab results pile up while s/he is spending all day actually seeing his/her patients. Rationalizing the delivery of care means trying to get nurses or other staff to deal with as many as possible, but lots of these require a doctor (or other licensed provider, such as a nurse practitioner) to interpret, approve, or sign off on.  And having more staff costs more money, and means (particularly for the primary care provider, whose reimbursement is much lower than for many specialists) having more patients. Thus, a vicious circle, often compared (from the provider’s point of view) to running on a hamster wheel; for patients, this often seems like obstructionism.
Of course, it often is obstructionism, but rarely on the part of the individual provider. The reason is, unsurprisingly, money. For the providers of care, or more usually the companies for which they work (whether for-profit or not), the issue is reimbursement by insurers, including Medicare and Medicaid. There are rules that must be followed, forms that must be filled out, referrals that must be signed, and procedures to go through, or payment will not be forthcoming. And then the provider, whether physician, nurse practitioner, physical therapist, pharmacist, or social worker, whether self-employed or working for a company, doesn’t get paid. And, depending on how often this occurs, will make less, fire staff, or go broke. In addition, insurance companies themselves often create obstacles to payment (such as the time-honored one of just refusing to pay the first time or two, because maybe the provider will give up), but this is more often true for costly surgeries than lower-cost preventive and treatment services. And sometimes the practices seem almost incomprehensible as in insurers requiring patients to use brand-name rather than generic drugs and thus have to pay more out of pocket (“Take the generic, patients are told. Until they are not”, NY Times, August 6, 2017); one word, not used in the article but clearly described: kickback.
To be fair, many of the rules that seem to be obstructions are not only about saving money; they are about both preventing fraud and even patient safety. There absolutely are major fraudsters out there, doctors and home-health companies and nursing homes and every sort of medical support provider (even hospitals), who try to and often succeed in bilking Medicare (and other insurers) out of millions of dollars in inappropriate (“do you want a scooter at no cost to you?” – but someone else is paying!) or truly fraudulent (there is no patient) care. In fact, some care, even if you want it, even if someone is willing to provide it (if they get paid), is not appropriate for you, or your family member. Medicare and other insurers do set criteria, and require that it be documented. This can actually be good, not only for all of us as taxpayers but for our health and safety.
But often it isn’t good. It sometimes makes care that is appropriate, evidence-based, and desired, hard to get. It takes a long time. It takes lots of phone calls, and hours on hold or waiting for calls back. It has messages lost in piles, or over the weekend. It should not happen, but it does. And it is frustrating. The “Triple Aim” guiding progressive health care has received a lot of attention. It is to deliver high-quality care in a cost effective manner that is satisfying to patients. To document the last, many hospitals, provider groups, and companies send out “patient satisfaction” surveys, which are at best cosmetic and at worst destructive. People don’t fill them out “right”; they tend to reflect an overall impression that leads people to mark each of the ostensibly-separate questions “great” or “terrible”. Also, in forming this global impression, folks understandably often overvalue the things that they can assess (like the quality of food or attractiveness of the facility) compared to things that they cannot (such as the actual quality of care). This is, by the way, where providing good customer service makes a big difference, and while some places are getting better, the medical care industry is generally weak in this critical area.
As in almost everything, those with the least get the least. The uninsured, the poorly insured, and the just poor, provide the least incentive to providers (getting paid) to meet their needs. Government regulations that require certain services for Medicare or Medicaid without paying for them result in greater strain on those providers who provide care to people in these groups. Many providers, especially in some fields or medical specialties or geographic areas, try to avoid them. They locate in wealthier neighborhood, don’t take folks who are uninsured (or on Medicaid, and sometimes even Medicare), or offer indulgent, wonderful “concierge” services for those who can pay a significant retainer. Thus works the “market” in health care. A terrible way to go.
A universal health insurance system won’t make all these problems go away; even with it, systems can still be poor, providers can be uncaring. But it will help a lot. Because everyone is covered, there is no “vendor lock”; the market can function well because people choose their providers based on service, not because they are forced to because they are locked in to a limited pool. Information flows between primary care and specialists and therapists and labs and imaging because if it doesn’t folks are free to take their business elsewhere. The way competition should work; competition on providing the best product and service.

And, because we would all be in it together, in the same system, the most empowered will make sure it works for them, and thus, hopefully, for us all.

Medicaid expansion or not: everyone needs coverage

In an echo of my blog post of November 17, 2013, “Dead Man Walking: People still die from lack of health insurance”, the New York Times’ lead article on November 29, 2013 was “Medicaid growth could aggravate doctor shortage”. The main point in my blog was that, to the degree that there is a doctor shortage exacerbated by increasing the number of people who have health insurance (from Medicaid expansion or insurance exchanges or any other reason), the shortage was already there. If the reason that it was not felt earlier was because people, not having health insurance, did not seek care, does not change the fact that these people were here and were as sick as they were or are. To the extent that they were not getting health care because they were uninsured is a scandal. If anything, that people will now have coverage and thus seek care is an unmasking of an extant but unmet need.
The Times article looks particularly at Medicaid because many doctors will not see Medicaid patients since the payments do not cover their costs (or, in many cases, because they can fill their schedules with people who have better-paying health insurance). Those physicians who do accept Medicaid often feel that they will not be able to take more Medicaid patients for the same reason, and it is unlikely that those who are already not accepting Medicaid will begin to. The problem is significant for primary care, even for institutions like Los Angeles’ White Memorial Hospital that already care for large numbers of Medicaid patients. In the NY Times article, my friend Dr. Hector Flores, Chair of the Family Medicine Department at White Memorial, notes that his group’s practice already has 26,000 Medicaid patients and simply does not have capacity to absorb a potential 10,000 more that they anticipate will obtain coverage in their area.
The problem for access to specialists may be even greater. There are already limited numbers of specialists caring for Medicaid patients in California and elsewhere, for the reasons described above: they have enough well-insured patients, and Medicaid (Medi-Cal in California) pays poorly. It is also possible that some specialists have less of a sense of social responsibility (even to care for a small proportion of patients who have Medicaid or are uninsured), and their expectations for income are may be higher. The San Diego ENT physician featured at the start of the Times article, Dr. Ted Mazer, is one of the relatively small number of subspecialists who do take Medicaid, but indicates that he will not be able to take more because of the low reimbursement.
Clearly, Dr. Mazer and Dr. Flores’ group are not the problem, although it is likely that they will bear a great deal of the pressure under Medicaid expansion; if their practices have been accepting of Medicaid up until now, they are likely to get more people coming. The Beverly Hills subspecialists (see: ads in any airline magazine!) who have never seen Medicaid, uninsured, or poor people up until now are unlikely to find them walking into their offices. And, if they call, will not schedule them. So what, in fact, is the real problem?
That depends a bit upon where you sit and how narrow or holistic your viewpoint is. From the point of view of doctors, or the health systems in which they work, the problem is inadequate reimbursement. As a director of a family medicine practice, I know that you have to pay the physicians and the staff. For providers working for salaries, it is the system they work for that needs to make money to pay them. The article notes that community clinics may be able to provide primary care, but does not note that many of them are Federally-Qualified Health Centers (FQHCs) which receive much higher reimbursement for Medicaid and Medicare patients than do other providers. The Affordable Care Act (ACA) will reimburse primary care providers an enhanced amount for Medicaid for two years, through 2014, and yet not only is there no assurance that this will continue, but in many cases has yet to be put into place. And the specialists are not receiving this enhanced reimbursement (although the truth is that many of them already received significantly higher reimbursement for their work than primary care physicians).
From a larger system point of view, Medicaid pays poorly because the federal and state governments that pay for it (although the federal government will pay 100% of the expansion for 4 years and 90% after that) want to spend less. However, they do not want to be perceived as allowing lower quality of care for the patients covered by Medicaid, so they often put in requirements for quality that increase costs to providers which increases the resistance of those already reluctant to accept it. Another factor to be considered is that Medicaid has historically not covered all poor people; rather it mainly covers young children and their mothers, a generally low-risk group. (It also covers nursing home expenses for poor people, which generally consumes a higher percent of the budget.) Expansion of Medicaid to everyone who makes 133% of poverty means that childless adults, including middle-aged people under 65 who have chronic diseases but have been uninsured, will now have coverage.
While the main impact of Medicaid expansion is in states like California that actually have expanded the program, even in states like mine (Kansas), which have not, Medicaid enrollment has gone up because of all the publicity, which has led people already eligible but not enrolled to become aware of their eligibility (called, by experts, the “woodwork effect”). The Kansas Hospital Association has lobbied very hard for Medicaid expansion, but this has not occurred because the state has prioritized its political opposition to “Obamacare”. The problem for hospitals is that the structure of ACA relies on the concurrent implementation of a number of different programs. Medicare reimbursements have been cut, as have “disproportionate share” (DSH) payments to hospitals providing a larger than average portion of unreimbursed care. This was supposed to have been made up for because now formerly uninsured people would be covered by Medicaid (that is hospitals would get something); however, with the requirement that piece removed (thanks to the Supreme Court decision and the political beliefs of governors and state legislatures), the whole operation is unstable. That is, the Medicare and DSH payments are down without increases in Medicaid.
From a larger point of view, of course, the problem is that the whole system is flawed, and while the ACA will help a lot more people, it is incomplete and is dependent on a lot of parts to work correctly and complementarily – and this does not always happen, as with lack of Medicaid expansion. A rational system would be one in which everyonewas covered, and at the same rates, so that lower reimbursement for some patients did not discourage their being seen. These are not innovative ideas; these systems exist, in one form or another in every developed country (single payer in Canada, National Health Service in Britain, multi-payer private insurance with set costs and benefits provided by private non-profit insurance companies in Switzerland, and a variety of others in France, Germany, Taiwan, Scandanavia, etc.). If payment were the same for everyone, empowered people would ensure that it was adequate. Payment should be either averaged over the population or tied to the complexity of disease and treatment (rather than what you could do, helpful or not). We would have doctors putting most of their work into the people whose needs were greatest, rather than those whose reimbursement/difficulty of care ratio was highest. There are other alternatives coming from what is often called “the right”, but as summarized in a recent blog post (“You think Obamacare is bad…”) by my colleague Dr. Allen Perkins, they are mostly, on their face, absurd.
Our country can act nobly and often has. ACA was a nice start, but now we need to move to a system that treats people, not “insurees”.

Cost of health care increases poverty around the world, and in the US

The title of the press release from the World Bank, “New WHO and World Bank Group Report Shows that 400 Million Do Not Have Access to Essential Health Services and 6% of Population Tipped into or Pushed Further into Extreme Poverty because of Health Spending”, about says it all. Or does it? Certainly, it summarizes the core information provided by that study, and that is pretty bad. Even in a world whose population this year reached 7 billion that is a big number (nearly 6%), and remember that it is talking about “…essential health services—including family planning, antenatal care, skilled birth attendance, child immunization, antiretroviral therapy, tuberculosis treatment, and access to clean water and sanitation.” This is not coronary artery bypass surgery (as essential as that seems to those of us who need it), or knee replacement (which may make it possible for us to walk with less pain), or even tight control of our diabetes (possibly less prevalent in populations that are chronically malnourished), still less entirely elective care.
We are talking about access to clean water and sanitation. We are talking about the fact that the greatest cause of death in the world is waterand that most of those deaths are in children. We are talking about the absence of the most fundamental aspects of access to health, not to mention health care and medical care.  While not a focus of the World Bank report, in many places war makes it worse, adding to the lack of basic services an extraordinary need for major medical care. In his New York Times Op-Ed piece of June 21, 2015, Nicholas Kristof describes the chilling war being waged by the government of Sudan against its own people in the Nuba Mountains, with daily bombings of civilians. He describes the deaths and maiming of children, and the inadequacy of even the most committed physicians to help in the atrocious conditions that exist there. An 8-year old boy, who had just lost several siblings to the bombing, showed extraordinary courage,” the lone doctor at the hospital remembers, “but he would scream every day from pain as his dressings were changed.” While he “persevered for weeks”, “flies were laying eggs in his wounds, and soon the burns were crawling with maggots. Dr. Catena says that he would cut out the maggots, and the next day more would return.”
Yes, most of these 400 million are not in the US, are in developing (a euphemism, perhaps) countries. But in the US there is great need also; every day in our cities we see people who have not had access to TB or HIV treatment, who have delayed care because they are uninsured and cannot afford the cost, until they are so sick that their treatment costs far more than it otherwise would have. We see women who do not come for antenatal care until very late in their pregnancies if at all, missing the chance to discover and treat relatively minor problems until they become major. Fortunately, it is uncommon in the US for them to not receive “skilled birth attendance” since the law requires hospitals to provide care when women come in in labor, but they often appear with no records of whatever prenatal care they may have had. An excellent post on the blog of Medical Care Section of the American Public Health Association (unfortunately, access is limited to APHA members), “For Medicaid enrollees, a choice: PCP or emergency department?”, by Sandhya V. Shimoga, describes the problems that Medicaid patients, particularly those newly covered by Medicaid expansion in those states that have done so, in finding primary care providers; they continue to have to use the ED instead, often (again) with conditions far worse than they would have otherwise had. This, of course, does not count the largely insured people in the US who elect not to immunize their own children, secure in the knowledge that most other people are and that they will have access to care if anything does go wrong. Which it often, by the way, does.
And then there are states like mine, Kansas, that have chosen not to expand Medicaid, so that people similar to those Shimoga describes in Oregon and California do not even have a choice. The people of this state, once proud of its education and health care, have seen their rate of uninsurance increase relative to the states which have expanded Medicaid (Kansas only state to increase number of uninsured: A how NOT to do it strategy, August 9, 2014). The “solution” backed by the Republican Party and state governors such as Kansas’ Governor Brownback, is to further decrease the number of insured people by suing on a wording issue in the Affordable Care Act (ACA, “Obamacare”) that might invalidate the federally-run insurance exchanges which have allowed low-income-but-not-desperately-poor people in states like Kansas to gain insurance coverage.
This is a bold strategy, likely to work as well as Governor Brownback’s experiment in reducing taxes on the wealthy and businesses in 2012, which left the state with an $800 million budget deficit this year (on a budget of only about $8 billion). Half was replaced with one-time funds (eg, raiding the state highway fund) and the other half, after a marathon legislative session that ended a month late, with the largest tax increase in state history. However, these were all regressive taxes, mainly a sales tax increase, that hurts the poor and middle class; the 2012 cuts stayed in place for the wealthy, so I guess in that sense it did work. Business pays less tax, and if you own your business (say, self-employed lawyers or doctors) you pay no state income tax although your employees do. Kansas spends less now than neighboring Nebraska, which has 2/3 as many people. Now if we can only get rid of those federally-sponsored exchange so even more people will be uninsured…
The World Bank report calls for universal health coverage. “The world’s most disadvantaged people are missing out on even the most basic services,” says one official, who adds that a “… commitment to equity is at the heart of universal health coverage.” The report said that 17% of people were pushed into poverty (<$2/day) and 6% into “extreme poverty” (<$1.25/day) by the cost of emergency health care. Few Americans make anywhere near that little, but the cost of living, and of health care, is much higher and the same trend exists here; medical expenses are the largest cause of personal bankruptcy (see Fox Business’ 2014 report).
As more countries make commitments to universal health coverage, one of the major challenges they face is how to track progress,” says another World Bank official, commenting on the study. Of course, if a country, such as the US, does NOT make a commitment to universal health coverage, this is not a problem.
Except, of course, for the people without health care.

Corporate mergers, retail clinics, and monopoly capital

Two huge mergers have recently been announced in the health insurance sector. First, Aetna announced its intention to acquire Humana for $35 billion, creating a behemoth. Not to be outdone, Anthem (the enormous group of formerly non-profit Blue Cross/Blue Shields that have gone for-profit) announced it will buy Cigna for $47 billion. Consolidation in the industry is moving fast, and soon there will be oligopoly. Robert Reich, in his July 5, 2015 article The Choice Ahead: A Private Health-Insurance Monopoly or a Single Payer discusses these mergers, observing that

Executives say these combinations will make their companies more efficient, allowing them to gain economies of scale and squeeze waste out of the system. This is what big companies always say when they acquire rivals.
Yes, indeed. They always say it, and while sometimes they achieve efficiencies– this usually involves firing people — it almost never benefits the consumer; prices almost always go up. Remember airline mergers? Bought a ticket lately? Despite the rhetoric of capitalism about competition, virtually all companies would prefer to be monopolies, control the industry, and set prices, guaranteeing huge profit. If they cannot, the next best thing is oligopoly, control by a few companies, with collusion so that they all make huge profits. Competition is their bugbear. Yes, we have federal regulators, but the result of their regulation has been those airline mergers. And telecommunications mergers. And financial services mergers. And banks too big to fail. So don’t count on them.
Health insurance companies are not the only mega-corporations profiting from “health care” by siphoning off money that could actually be spent improving health, or at least providing medical care. Obviously, there are drug companies (as I recently discussed in Chemotherapy, Quality of Life, and Corporate Profit on July 26, 2015), but also big pharmacy chains (like CVS, Rite Aid, and Walgreens) as well as other retailers that usually have a pharmacy (like Walmart, Kroger and Target) that have now branched out into providing health care, through what are known as “retail clinics”.
In the New England Journal of Medicine on July 15, 2015, John Iglehart writes about “The expansion of retail clinics—corporate titans vs. organized medicine”.[1] Here the case against the corporations is less clear, or at least the case in favor of organized medicine is. Iglehart points out that the opposition from organizations like the AMA, the American Academy of Family Physicians (AAFP), and American Academy of Pediatrics (AAP) have focused on the lack of continuity of care and “disruption of the patient-physician” relationship. Recently, opposition has softened (I guess folks know when they’ve lost) except from the AAP. It seems to me that these clinics provide a menu of services that primarily is focused on acute care for relatively minor infections and injuries, immunizations, and monitoring of chronic diseases like high blood pressure, and are pretty popular with the people who use them. They are conveniently located (for the people who use them), generally have little or no wait, and are staffed by professionals (usually nurse practitioners) who know what they are doing.
The problems with such retail clinics fall into two broad categories. First, when people use them inappropriately, not for acute or minor conditions, but as their usual source of care. For healthy younger people, this may be all they need. For older folks and others with chronic conditions such as high blood pressure, diabetes, hyperlipidemia, chronic lung disease, heart disease, etc., they are not sufficient. The danger is when people only seek care when they have symptoms, such as (particularly) pain, whether to such a retail clinic, traditional physician’s office, or emergency room, and ignore prevention and management of their chronic conditions. I do not fault the providers in these settings; there is evidence that they urge people with such needs to follow up with their primary provider. But, once the acute symptoms are gone, they may not. Some of this, sadly, may be financial.
The other problem is more interesting, and gets back to the financial issue. Providers and the organizations representing them (“organized medicine”) has real concerns because such retail clinics “cherry pick”, or skim the easy cases that pay for (or more than pay for) themselves, leaving physicians with the care of patients with diseases that take more time and are reimbursed less per hour (or minute) of work; this destroys the business model of primary care practice. As long as we depend upon a fee-for-service, reimbursed-for-care-provided, private medical model, this puts a real burden on physician practices which, while looking bigger than the small retail clinics, are usually tiny compared to the corporations that own those clinics.
Another medical area in which there is a clearer case of fear of competition disguising itself as virtue is in the shrill hostility of US-based medical schools, represented by the Association of American Medical Colleges (AAMC) to off-shore (mainly Caribbean-based) medical schools, as described by Robert Goldberg in Discrimination against foreign medical schools is bad for your health in the online publication “The Hill”. The argument against such schools from the AAMC is in part that the students are “lower quality”, the ones rejected by US medical schools. The flaw here is that there are many highly-qualified students who do not get into US medical schools, demonstrated by the recent dramatic expansion of the number of US schools and the class size of existing schools. Are there Caribbean schools of poor quality? Yes. Is the academic preparation of students in Caribbean schools, on average, lower than those in US schools? Probably. Is this a reason to try to put them out of business, by both bad-mouthing and trying to limit the access that their students have to educational loans? I don’t think so.
Our US medical schools get talented students, and then put them through a process that ends up producing doctors underrepresented in the primary care specialties and overrepresented in urban – and especially suburban – areas. As I have often pointed out, we produce the wrong mix of doctors who practice in the wrong mix of places. If (and it is, of course, an if) graduates of off-shore medical schools are likely to fill the medical needs not being met by graduates of US medical schools, then the title of Goldberg’s piece is correct. The same might be said for retail clinics, if indeed they were mostly present in underserved communities, but, based on the business models of their owners, they are generally not.
So, then, we see a spectrum of corporate involvement in health care ranging from the off-shore, for-profit medical school, to the acute care clinics run by large retailers, to the consolidation into oligopoly of health insurance companies, to the large pharmaceutical manufacturers. We also see a response of tepid regulation of the latter two, and protectionism by organized medicine and organized medical schools to the first two. None of these are good for our health. What would be good for our health would be the rational use of health care dollars to provide health care, for everyone, of the right kind in the right setting.
Reich ends his article with
If we continue in the direction we’re headed we’ll soon have a health insurance system dominated by two or three mammoth for-profit corporations capable of squeezing employees and consumers for all they’re worth – and handing over the profits to their shareholders and executives. The alternative is a government-run single payer system – such as is in place in almost every other advanced economy – dedicated to lower premiums and better care.
Which do you prefer?
I feel like raising my hand and waving it in the air saying “I know, I know!”



[1]Iglehart JK, The expansion of retail clinics—corporate titans vs. organized medicine, NEJM 15 Jul 2015;373(4):301-303

The US health and social service system is evil

I have often written about how our health system is “deeply flawed”, but I realize that there are many ways in which this is a grand understatement. I initially intended to call this piece “health insurance companies are evil”, but realized that this singled out but one player. I mean, insurance companies are at least as evil as other parts of the health and social services sector, but naming only one part both does a disservice to that part, which is acting rationally in relationship to the other aspects of the system, and tends to forgive the others.
The thing wrong with our health system is that it is a mess; there are dozens or hundreds of ways to have health insurance coverage, or not, and each costs a different amount and covers different conditions, for different percentages, with different amounts of coinsurance and co-payment and deductibles. A single-payer health system, where everyone is covered with the same benefits for the same care (all that is needed, none that is not) and payments tiered to income, is the only rational and effective way to make sure that we have the possibility of quality health care. There can be no quality without equity. While I will not spend more time here making this case, because I and others have previously done so extensively, I will refer to it.
What is evil is how the system affects our actual people. However, people are not really ever seriously considered in “health reform” (or social service “reform”). Yes, people’s suffering sometimes gets mentioned by political candidates, who note that some people are paying too much or are not getting care. Indeed, this has been a big theme of Republican candidates who are critical of Obamacare, but whose only plans are ones which will make it a lot worse for most people. Actually making the system work for people is never really on the table, because when the political negotiations begin, the big players (insurance companies, providers, drug companies, device manufacturers, etc.) enter the picture.
Let’s get right down to it: people in the US, even those who are citizens, just do not get the coverage and services to which they are fully entitled, not to mention the coverage and services that they actually need. You have to sign up for Medicare, pay for Part B (which is what covers everything except inpatient hospitalization, including doctors’ fees), choose and pay for a Part D plan. If you are lucky enough to be able to afford one, you have to look through a maze of possible Medicare supplement plans and hope you chose correctly, given the multiple variables of your health status, the benefits profile, where you live, your actuarial as well as self-perceived probability of getting ill, and what you can afford. Even Social Security, a benefit that you have paid into for your entire working life, requires you to sign up and show you are eligible. This is nonsense; there is no reason it should be this way. We start with a non-system that does not cover everyone, provides inadequate coverage for those who do have it, and makes it difficult to sign up, presenting numerous obstacles which allow people to fall through the cracks.
Actually, this is more than nonsense; to the extent that people pay the price of inability to navigate the system with their health, it is evil. It would work, and be much simpler, if everyone, when they retire, got Medicare. And if Medicare covered everything for everyone wherever they live. Why not just make sure everyone gets Social Security? Why make it the responsibility of the person to demonstrate that they not only are truly eligible but that they can get through a jungle of options, often confusingly computer based, when they are getting to the end of their careers? Of course, if we had a single payer system, everyone would be in and there would be no change when you retired or became 65; you’d already be in a system in which everything you need and nothing you don’t need is fully covered.
Actually, in a good system you’d be better than “fully covered”. You’d be covered appropriately; you would, whoever you are, get the care that you need, but you would not be eligible for coverage for things that you don’t. We would have a health system that provided necessary, appropriate, and proven diagnosis and treatment for people, rather than emphasizing the provision of services which were most profitable to the providers. Insurers would not do their best to risk-select, would not be able to charge more for some people than others (and they can under Obamacare; they have to cover you even with a pre-existing condition, but can charge more), and would not even have to be for-profit. I favor a single-payer health care system such as Canada’s, a (fully-funded) Medicare for all, as does Sen. Sanders. But there are other reasonable alternatives; Switzerland, for example, has, instead of a single payer, multiple insurance companies. But these companies have to cover everyone, provide the same benefits, charge the same price, and be non-profit.
Critics of Sen. Sanders often say that a Medicare-for-All system would bankrupt us. This is also nonsense.  It presumes the built-in profit for insurance companies. It presumes that we would continue to pay the most of the most complex and high-tech procedures, and let providers (via the complex system of the RUC —  Changes in the RUC: None…How come we let a bunch of self-interested doctors decide what they get paid?, July 21, 2013, which essentially sets the Medicare rates on which all other payments are based) set the rates for their own procedures. The evidence is in every other wealthy country, all of which spend much, much less on health care and have much, much better outcomes. They also provide much better social services, not only for the needy and the poor, but for everyone. Retirees get their pensions. And they keep their health care.
The system works in these other countries; that is, if your interest is in ensuring that everyone gets the health care they need, the pension benefits to which they are entitled. If your interest is in maximizing the income of (some) providers and the profit for insurance and drug companies, then they don’t work as well. So I guess our system is not necessarily evil, it depends upon your values.

But, then, I would argue that the values on which the system is de facto based, though, are evil ones.

The urban-rural divide and the health of people in both settings

I recently wrote about the impact of the massive vote for Donald Trump by “white working class” voters and how it will have repercussions for their health, as well as that of others, if the policies advocated by the Republican majority (as exemplified by Secretary of HHS nominee Rep. Tom Price) are implemented. And there is little doubt that they will be implemented, but slowly, so people are less aware of what is being done to them. As Medicare is increasingly privatized, as vouchers that cannot cover the cost of health insurance for those with chronic disease are implemented, “Medicare for all” will increasingly seem a poor idea. And people’s health will suffer. I wrote about the cynicism of the AMA and the AAMC in endorsing Mr. Price; they are doing more than “kissing the ring”, as a colleague suggested. They are lauding the fact that one of “theirs”, a doctor, will be in this role, not an insurance executive. But if anyone had a doubt about whether having an “MD” at the end of your name guarantees a concern for people’s health, Mr. Price is the poster child for “not so”.

The other big divide demonstrated by the election is urban-rural, and this one is also real. A majority of the people in the US are jammed into small geographic areas, urban islands. Maps that portray “red states” and “blue states” seem to be an ocean of red because of physical size; think New Jersey  (population about 9 million, with 8700 square miles, more than 1000 people/sq mi) vs. Montana (just over 1 million, in 147,000 square miles, less than 7 people/sq mi). The contrast is even greater if we look at counties; most of the population of even “blue” states is concentrated in a few urban counties, although, conversely, there are many “blue” seas and islands in “red” states, cities like Houston, Dallas, San Antonio, St. Louis, Kansas City, etc. The media has recently been awash in articles about the way that our Electoral College system advantages rural areas; because of the 2-Senate-seat-per-state rule, a Wyoming voter has 5 times the clout of a Californian. See, for example, Steven Johnson’s “Why blue states are the real Tea Party” in the NY Times, December 4, 2016. He points out that at the time of the writing of the Constitution, the urban northern states were in debt while the southern states were solvent – largely through the magic of the free labor of slavery. Now cities are the engines of our economy; they are where ambitious and educated young people go, leaving rural areas increasing older and poorer (as well as whiter).

But we need to remember that there is tremendous need in rural America, as there is in the inner city. Rural areas are poor, and underserved both medically and in terms of social services (as well as, of course, in the other things you’d expect – access to groceries, for example). Those rural areas that are located in “red” states are even worse off, because those states spend far less on health care and social services in the first place so that their more isolated communities are in the worst shape. And yet, as Johnson points out, they get far more federal aid for tax dollar contributed: New Jersey receives $0.61 on the dollar while Wyoming gets $1.11. The Trump campaign, and the Republican Party, strongly appealed to voters in these areas, but Trump and his proposed cabinet all live and work in cities; they are not rural billionaires. Tom Price is a suburban doctor; he does not deliver care to the rural poor, as do Rural Health Clinics.
So there is tremendous need in rural communities, but their political clout, which is both unfair and anti-democratic, is not being used to actually help the people there, but rather to limit positive policies in urban areas. The North Carolina “bathroom law”, to force people to use the restrooms of the gender of their birth, was a reaction to the city of Charlotte (a blue “lake”) making it legal for people to use the restroom of their current gender. The most well-publicized efforts currently are threats by Trump and his people to forbid cities from declaring themselves “sanctuaries” for immigrants (see NY Times debate on whether sanctuary cities have a right to defy Trump, December 1, 2016; “yes” by Cesar Vargas and “no” by Jan C. Ting). These cities are trying to exert their local control over such important issues, while states (generally supported by rural populations that do not actually have to deal with these problems) try to restrict their ability to do so. These hypocrites are against government regulation when it comes to their rights to carry guns or graze their cattle on public land (things they want to do), but are all for it when it comes to things important to others, like deciding who can marry, where one can go to the bathroom, whether people can get an abortion or even contraception. “Those who deny freedom to others,” said Abraham Lincoln, “deserve it not for themselves”, which I first learned as a young stamp collector; it appears at the 4 cent American Credo stamp.
If the selective interpretation of what “freedom” means is not enough, if rampant discrimination and bigotry is not enough, there are other, health related, concerns that go with this divide. For example, federal funds for HIV care go to the area where patients are from. However, a large percentage of gay HIV patients leave those areas for the cities where they are more accepted. Thus the cost of providing that care is borne by the cities, while the money flows to the rural areas where services are not available – and often the victims themselves are not welcome.
A recent article published in Science Direct by Jason Beckfield and Clare Bambra, “Shorter lives in stingier states: Social policy shortcomings help explain the US mortality disadvantage”demonstrates that the lack of social services in the US leads to shorter lives than in other Organization for Economic Cooperation and Development (OECD) countries, i.e., the rich countries. The “highlights” of their study are that:
• The US combines a laggard welfare state with shorter life expectancy compared to the OECD.
• Fixed-effects models show associations between life expectancy and social policy generosity.
• US life expectancy would be 3.77 years longer if the US welfare state were just average
In this article “state” refers to nation-states, comparing the US to other OECD countries, but similar differences can be seen among the US states, again depending upon their social services, including public health and access to health care. This is supported by a new study from the Commonwealth Fund which finds that “adults in the U.S. are more likely than those in the 10 other countries to go without needed health care because of costs”. A third of U.S. adults “went without recommended care, did not see a doctor when sick, or failed to fill a prescription because of costs”, as compared to as few as 7-8% in other countries. They were also the “most likely to report material hardship. Fifteen percent said they worried about having enough money for nutritious food and 16 percent struggled to afford their rent or mortgage.”

This is not good for our country, not good for our health, and not good for our lives. And as far as we can see, the new administration’s plans are not to fix it but to make it worse.

Are resident doctors unhappy? Why?

In a New York Times “Upshot” piece on December 7, 2017, Dhruv Khullar notes that “Being a doctor is hard. It’s harder for women”. I do not doubt it, especially the second part. Dr. Khullar goes through a host of reasons for why it is harder for women, most of them related to sexism (including internalized sexism) such as having children, having the bulk of the responsibility for maintaining a household, being seen as less smart or competent by supervisors and colleagues, and on and on. The idea that “being a doctor is hard” is also one I can agree with. However, Dr. Khullar’s piece focuses mainly on residents, medical school graduates who are in specialty training. He opens it with a parody of Tolstoy’s Anna Karenina: “Happy medical residents are all alike. Every unhappy resident would take a long time to count.”

This is where I take issue, at least a little, with his perspective. Mainly this is because I do not remember being unhappy as a resident several decades ago. Tired, often, but not unhappy. I liked the work I did, as a family medicine resident at Cook County Hospital in the late 1970s, both caring for patients in the hospital on a variety of specialty services and in our hospital and community-based outpatient practices. I liked my colleagues, in family medicine and in other departments, and liked working with them. I learned a lot from them. I don’t recall most of my colleagues being unhappy either, and checked with a few with whom I am still in touch, and they also do not recall being unhappy. One, indeed, said he wasn’t even that tired, as he slept through most noon conferences!

There were not only fewer women residents and medical students, but they were (in my  experience) less likely to be married and have children. A small minority of students in my medical school class were married, but now it is common. I married (another resident) and we had our first child during residency, but when I was a program director, the majority of my residents were married by the time they started (I remember a year when five women started the program with different last names than they had interviewed with).

Yet several studies do tend to support Dr. Khullar’s assertions about residents in general being unhappy, as well as feeling overworked, and I think my experience as a family medicine program director and that of one of my colleagues (and former wife) as an internal medicine program director, support the idea that more recent residents seem unhappier, at least compared to us, then, at that hospital. There could be many reasons for this, including the possibility that memory is inaccurate, and distance dulls the pain, but I don’t think that this is the main one.

Another reason could, theoretically, be that the work was less or easier back then. Indeed, at Cook County Hospital in the late 1970s most residents had every-fourth-night call, a direct result of having a residents’ union in the hospital that negotiated working conditions. Dr. Khullar asserts that “The structure of medical training has changed little since the 1960s, when almost all residents were men with few household duties.” I think that he is wrong about this. Residents who trained in the late ‘60s and early ‘70s, before me and the union, often had every other night call (yes, work all day and all night and the next day, then go home and crash and come back to work). There is a reason that these doctors in training are called “residents” and “interns”; Cook County had a residents’ residence, where many actually lived and all had “call rooms” where we could get, maybe, a couple of hours rest. Although call was every 4th night, there were no other “hours rules”; Cook County had 16 medical services, with 4 taking call every 4thnight and taking every 4th admission, and the two interns on each service thus taking every 8th, but this could easily be 10 or more patients per intern per night. And one didn’t get to go home the next day at a certain time even though other services were on call. One specific example was CT scans; Cook County Hospital didn’t have one then, but the private hospital across the street, Rush, did. We could take our patients there, but only at night, when they were finished with their routine scans, and the patients had to be accompanied by the Cook County intern caring for them. Often at midnight, the night after they had been admitted. Residents also did most of the work; attending physicians were not in the hospital at night, and in the day had time only to round on new admissions and those who were very sick. Even having every 4th night call was a big change from every other or 3rdnight, but I do not think we had less work than most residents have today.

My point is not to try to disparage the tiredness or unhappiness of more recent residents by citing the “bad old days” when things were worse and we had to walk to school in the snow uphill both ways (although the weather was worse in Chicago then, thanks to global warming, and it was possible in winter to arrive and leave in the dark, and thanks to the system of tunnels under Cook County never see the sun). It is simply to note that workload is not the sole, or main, determinant of whether residents are happy or not. And here I can just speak from my limited experience. Many of us who were residents at Cook County Hospital were there for a reason. From the several Chicago medical schools and those further afield, we came because we were committed to providing the best possible care for people who were poor, underserved, and often ignored. We knew, and daily had reinforced, that our best efforts could not make up for the impact of poverty and discrimination; that despite the fact that the hospital did not charge patients, even for outpatient medications (although they had to wait hours for their prescriptions to be filled) the obstacles to their health were enormous. But we, most of us, cared, and tried to do our best. Our residency was not just a step on the path to a career as a successful physician, but an opportunity to work with and try to help people who had real need. We had a mission, not necessarily in the religious sense (although many who came as residents to Cook County were inspired and motivated by their religious convictions).

And, as a result of this shared mission we were each others’ greatest support, personally as well as medically. Medically, the 4 services with 4 residents, 8 interns, a chief resident, and medical students, shared an “admitting ward”, as so we were all together, to consult, to review x-rays, and help with procedures. But personally, we could reinforce each others’ beliefs, and provide support, succor, and even inspiration. I think that was the biggest part, for me at least.

Certainly, my experience at Cook County may not have been typical for residents of the era (indeed, that is part of why I chose it). Certainly, there were unhappy residents then, and uncommitted residents then, and women residents who were burdened with the care of the household and children. And, as certainly, there are now and have been ever since, happy and committed and inspirational residents. I guess “if you’ve seen one, you’ve seen one”. But I am pretty sure that a commitment to something greater than yourself and your self-interest helps a lot, as does training in a place where many of your colleagues feel the same way. And maybe that’s a lot of what we need as doctors, not just residents.


And as people.

Helping primary care help the health of all of us

I recently described how primary care can improve the health of our population – proven by dozens of studies – as well as save significant money.  Recently, the distinguished family physician George Rust, MD, co-director of the National Center for Primary Care at Morehouse School of Medicine in Atlanta, made many of the same points in his testimony in front of the Senate HELP Committee’s Subcommittee on Primary Health and Aging (Dr. Rust is pictured here with Subcommittee Chair Sen. Bernie Sanders, I-VT). Rust specifically asked for significantly increased funding for Title VII and Title VIII, the sections of the Public Health Service law that provide grant funding for, respectively, primary care medicine and nursing programs, saying that they would represent “solid investments in the primary care workforce.”
Rust also called for separating the funding for residency training provided by Medicare for primary care from hospital training of subspecialists, arguing that the current system has resulted in  “absurd proportions of subspecialists and hospitalists.” I have often argued this (for example in GME funding must be targeted to Primary Care, December 10, 2011), noting that hospitals have an interest in training specialists and subspecialists who do things (usually procedures, given our current reimbursement system) that make money for hospitals, and much less for training the primary care doctors that are needed in the community. The problem is that, because academic medical centers provide a great deal of tertiary (and quarternary) care, the mix of primary care and subspecialist and super-subspecialists may be appropriate there, but not for the overall community. However, since these are the places where new physicians are minted and trained, providing the right mix for the community, for the rest of the state and country, means having a very different mix of specialists in training from those working there. This is hard; it is a very common reaction to want to replicate yourself, to want the “best” students to enter training in your specialty, so for an academic medical center which looks like the upside-down pyramid to train doctors in proportion to the right-side-up pyramid is a major challenge! Rust then suggests moving primary care training “back to its community roots”, and says “Instead, let’s create direct, sustainable funding for community-based outpatient residency programs that train doctors to keep people out of the hospital”.
As strong as Dr. Rust’s arguments are, primary care will still have problems. One of the comments on the posting at the “AAFP News Brief” that covered this testimony  said “I must be missing something. Can anyone explain how creating more residency slots will increase med student interest in family medicine?” I believe that this is an excellent point – if we cannot fill the slots that exist today for family medicine, particularly with excellent medical students, how will increasing the number of slots improve things? One of the answers, certainly involves reimbursement, dramatically decreasing the difference between what primary care doctors earn and what more highly-paid subspecialists earn; work by the Altarum Institute cited by Jerry Kruse, MD MSPH in his article “Income Ratio and Medical Student Specialty Choice: The Primary Importance of the Ratio of Mean Primary Care Physician Income to Mean Consulting Specialist Income”, suggest that the ratio should be about 80%.
However, there are other factors at work. Sometimes they are referred to as “lifestyle” (perhaps defined as hours of work needed to generate a certain income, or what I have called the income/work hours ratio) but they are more profound than that. In the May/June issue of the Annals of Family Medicine, Christine Sinsky and her colleagues refer to it as “the joy of practice”. “In Search of Joy in Practice: A Report of 23 High-Functioning Primary Care Practices” [1] identifies the “deep dissatisfaction” experienced by primary care physicians who care for adults (general internists and family physicians) demonstrated by the many reports of high “burnout” rates. The authors relate this to the extraordinary amount of time that physicians spend doing paperwork and administrative functions, and the pressure by employers to generate high numbers of visits; doctors experience this as alienating and not the reason that they became physicians.
We propose joy in practice as a deliberately provocative concept to describe what we believe is missing in the physician experience of primary care. The concept of physician satisfaction suggests innovations that are limited to tweaking compensation or panel size. If, however, as the literature suggests, physicians seek out the arduous field of medicine, and primary care in particular, as a calling because of their desire to create healing relationships with patients, then interventions must go far deeper. Joy in practice implies a fundamental redesign of the medical encounter to restore the healing relationship of patients with their physicians and health care systems. Joy in practice includes a high level of physician work life satisfaction, a low level of burnout, and a feeling that medical practice is fulfilling.”
The authors go on to list a number of common problems, and solutions that have been found by one or more of the 23 practices that they visited and analyzed in detail. They included:
·       Reducing work through pre-visit planning and pre-appointment laboratory tests;
·        Adding capacity by sharing the care among the team;
·         Eliminating time-consuming documentation through in-visit scribing and assistant order entry;
·         Saving time by re-engineering prescription renewal work out of the practice;
·         Reducing unnecessary physician work through in-box management;
·         Improving team communication through co-location, huddles and team meetings;
·         Improving team functioning through systems planning and workflow mapping.
These are all good ideas, and the solutions are sometimes creative, sometimes painfully obvious, and sometimes obstructed by our bizarre health system. One of my favorites, the second, is an example of the latter:
We observed that team development must often overcome an anti–team culture. Institutional policies (only the doctor can perform order entry), regulatory constraints (only the physician can sign paperwork for hearing aid batteries, meals delivery, or durable medical equipment), technology limitations (electronic health record work flows are designed around physician data entry), and payment policies that only reimburse physician activity constrain teams in their efforts to share the care. An extended care team of a social worker, nutritionist, and pharmacist may be affordable only in practices with external funding or global budgeting.”
Thus is illustrated the tie-in between innovations that can make practice again joyful and the payment reform and re-working of our entire non-system which we desperately need! There is a long way to go; as the authors point out, no single practice has solved every problem. But the linkage is clear – a medical care system designed to reward expensive interventions for a relatively small number of people has created an inappropriate mixture of physicians as well as an incentive for hospitals to focus mainly on such procedures, as it has increased the burden on, and in many cases taken the joy out of, being a primary care physician. It is important to remember that it is not just about the doctors (I try to remind my students and residents, precious as each of them are to themselves and their families and often to me, that ultimately it is not about them). The authors put it this way:
“The current practice model in primary care is unsustainable. We question why young people would devote 11 years preparing for a career during which they will spend a substantial portion of their work days, as well as much of their personal time at nights, on form-filling, box-ticking, and other clerical tasks that do not utilize their training. Likewise, we question whether patients benefit when their physicians spend most of their work effort on such tasks. Primary care physician burnout threatens the quality of patient care, access, and cost-containment within the US health care system.”
Both the macro-structural changes in the structure of the system as identified by Dr. Rust and the more micro-level changes in the practices of primary care clinicians identified by Dr. Sinsky and colleagues need to occur to make us have a sustainable, healthful, system of health care. And they need to happen soon.


[1] Sinsky, C, et al.,, “In Search of Joy in Practice: A Report of 23 High-Functioning Primary Care Practices”, Ann Fam Med May/June 2013 vol. 11 no. 3 272-278, doi: 10.1370/afm.1531  

The Supremes and ACA: Is opposing coverage for the poor really just mean?

In the context of the historic and momentous Supreme Court decision legalizing gay marriage across the US, and its affirmation of the Fair Housing Act, the third of the “trifecta” of progressive decisions announced this week, the ruling against those who argued that the ACA forbid federal financial support of federally-sponsored rather than state-sponsored insurance exchanges, seems rather pedestrian. After all, it just decided that the intent of the ACA was to achieve what its intent was – greater insurance coverage for the American people – and this would not be invalidated by 4 poorly-chosen words in a 1,000 page bill. What is more worthy of note is that there were three Supreme Court Justices who voted against it, when it was clearly not a real issue of law but an end-run to get it invalidated on a technicality. The low point of the dissent was Justice Scalia’s juvenile characterization of the majority decision as “jiggery-pokery”, an archaic expression most recently used in the public domain in a Harry Potter movie. Of course, Scalia could make a fair Harry Potter villain; not the potent evil of Lord Voldemort, but more of a scowling, snarling Severus Snape.
But the decision has real meaning. It means that millions of Americans in the 34 states that elected to not establish state-based exchanges and thus depend upon federal ones will not lose their health insurance. That is a good thing for those people, and it is a good thing for America. It does nothing for those people who were excluded by the SCOTUS decision 3 years ago (also written by Chief Justice Roberts) that, while validating ACA, precluded requiring states to expand Medicaid. This left millions more in the states that have not done so (like mine, Kansas) without insurance.  It certainly does nothing for the millions of those without legal documentation who live here, or the many others who fall between the cracks of the law. It still leaves us without the moral, medical, social, and economic advantages that come from a truly universal health system such as any of those adopted by every other wealthy nation, which achieve better health for less cost (see graphic). But it does make us seem slightly less cruel and benighted.
Not that this will end the discussion. A small article in the New York Times of June 27, 2015 notes that “Legal challenges remain for health law”.  These include a lawsuit by House Republicans led by Speaker John Boehner maintaining ACA is invalid because it spends money not appropriated by Congress, and a series of suits by religious organizations about the law’s requirement that they cover contraception. Indeed, the whole opposition to the law has becoming akin to a religion itself; according to its opponents (obviously also including all the Republican candidates for President) it is bad as a matter of faith, even though it does so much good. Yes, it does good in costly ways, ensuring that insurance companies make their profit; it does it in arcane ways; it does it in ways which in fact cost some people more than they might have otherwise paid. But it provides several million people the opportunity to not be the Donna Atkins or Tommy Davis of the future (see Dead Man Walking: People still die from lack of health insurance, November 17, 2013).
In response to a blog in which I posted a map that shows that the vast majority of those remaining uninsured are in the states of the former Confederacy and suggested that while Southern people might not be meaner than others, the impact of their policies was (Medicaid expansion and uncovered lives: are people meaner in the South?, February 8, 2015), Bobby Cohen wrote in a comment “If meanness doesn’t explain the rejection of Medicaid expansion by Southern states, what does?” Well, for many people, I suppose, it is ignorance, of the sort demonstrated by “Keep the government’s hands off my Medicare!” or what I have called the “Craig T. Nelson fallacy” (“I’ve been on food stamps and welfare. Anybody help me out? No. No.”!!). Or the beliefs of some of the people in southeast Kansas interviewed for Kai Wright’s excellent article “Life and Death in Brownback’s Kansas”, published in the June 22/29 issue of The Nation where it seems that “Everyone is convinced that someone else is getting a better deal, that somewhere a horde of Kansans are gaming the system and preventing the truly needy from getting help.” In a true “What’s the Matter with Kansas”[1]illustration, even the doctor at the community health clinic who is fighting hard to get care for her impoverished patients who would have otherwise had Medicaid is conflicted; Brownback, after all, is a strong anti-abortion advocate, as is she.
All of these may explain some of the position of the leaders of this movement, but a better explanation can be found in the answer to one of the questions in “Steven Pinker’s Mind Games”, a psychology quiz on the NY Times website: “the best liar is the one who believes his own lies”. But it is hard to look at, not to mention listen to or read, the hard-core right-wing justices on the Supreme Court (who, unlike the GOP’s many presidential candidates are not even running for office) without thinking that they are, essentially, mean. They are not only against helping people when it will cost them, not altruists (another Pinker question), but even when it will save them money (again, see graphic).
I do not claim to be a legal scholar of the status of any of the Supreme Court Justices, or indeed the President. I gained some understanding from “The elusive right to health care under US law”, by Prah Ruger, Ruger, and Annas in the June 25, 2015 issue of the New England Journal of Medicine, published before any of these SCOTUS decisions were announced.[2]It’s a good and readable article which helps medical people like me understand some of the logic of court decisions. One line I found of particular interest was “American constitutionalism has championed negative liberties more than positive rights.” The idea is that the Constitution says government should not be allowed to take away our individual liberties (e.g., our guns) but not so much that we have a right to things (e.g., health care).
And yet, as pointed out by Gail Collins in “Supremes hit a high note”, this Court has “…destroyed the nation’s campaign finance laws, limited workers’ rights to challenge wage discrimination and women’s rights to control their bodies. And basically disemboweled a 50-year-old Voting Rights Act that Congress had renewed by increasingly large margins on four different occasions.” These decisions, almost all of which came out differently from those of the last 2 days only by the “swing vote” of Justice Kennedy (Chief Justice Roberts did join the majority in the decision on ACA), do not always follow this logic. It is quite an extension of the idea of liberty to say that corporations are people (the founders certainly didn’t think so) or money is speech. It is quite opposite protecting individual liberty to have laws limiting the ability of women to obtain contraception or abortion (although they can sure have guns!). Whether put forward by ignorant bigots, self-serving politicians, or sanctimonious Supreme Court Justices, the concept is most consistently “people should be allowed to do whatever they want, as long as they want the same things I do, but not what I disapprove of”. Sometimes, particularly when describing the actions of the powerful, this is described as political. But I think Dr. Cohen is right; it is essentially mean.
A phrase we commonly hear is that “mean people suck”. They do, but more important, when they have positions of power, they can do a lot of damage to others.
  



[1]Thomas Frank. “What’s the matter with Kansas?”. Henry Holt. 2004 [interestingly, published in the UK and Australia under the title “What’s the matter with America?”!] ISBN 0-8050-7339-6.
[2] Jennifer Prah Ruger, Ph.D., M.S.L., Theodore W. Ruger, J.D., and George J. Annas, J.D., M.P.H., The Elusive Right to Health Care under U.S. Law, N Engl J Med 2015; 372:2558-2563June 25, 2015DOI: 10.1056/NEJMhle1412262

Does quality of care vary by insurance status? Even Medicare? Is that OK?

While the Affordable Care Act will not lead to health insurance coverage for everyone in the US (notably poor people in the states that do not expand Medicaid, as well as those who are undocumented), it will significantly improve the situation for many of those who are uninsured (see What can we really expect from ObamaCare? A lot, actually, September 29, 2013). The hope, of course, is that health insurance will lead to increased access to medical care and that this access will improve people’s health, both through prevention and early detection of disease, and through increased access to treatment when it is needed, including treatment that requires hospitalization. Implicit in this expectation is the assumption that the quality of care received by people will be adequate, and that the source of their insurance will not affect that care.
This may not be true. I spent a large portion of my career working in public hospitals. I absolutely do not think that the care provided by physicians and other staff in those hospitals was different for people with different types of insurance coverage (many or most patients were uninsured), and indeed for many conditions the care was better. But the facilities were often substandard since they depended upon the vagaries of public funding rather than the profit generated from caring for insured patients. The physical plants were older and not as well maintained, staffing levels were lower, and availability of high-tech procedures often less. There are changes; the Cook County Hospital I worked in through the late 1990s, with antiquated facilities including open wards and no air-conditioning, has been replaced by the very nice (if overcrowded) John P. Stroger, Jr. Hospital of Cook County. University Hospital in San Antonio, where I worked in the late 1990s, may have been seen by the more well-to-do as a poor people’s hospital, but in many areas, including nurse turnover and state of the art imaging facilities, it outdid other hospitals in town. Still, the existence of public hospitals suggests two classes of care, and as we know separate is usually unequal.
But what about the quality of care given to people with different insurance status in the same hospital? Surely, we would expect there not to be differences; differences based on age, yes; on illness, yes; on patient preference, yes. But who their insurer is? Sadly, Spencer and colleagues, in the October issue of Health Affairs, call this assumption into question. In “The quality of care delivered to patients within the same hospital varies by insurance type”[1], they demonstrate that the quality of care measures for a variety of medical and surgical conditions are lower for patients covered by Medicare than for those with private insurance. Because Medicare patients are obviously older, and thus probably at higher risk, the authors controlled for a variety of factors including disease severity. The most blatant finding was that “risk adjusted” mortality rate was significantly higher in Medicare than in privately insured patients.
This is Medicare. Not Medicaid, the insurance for poor people, famous for low reimbursement rates. It is Medicare, the insurance for older people, for our parents, for us as we age. For everyone. Medicare, the single-payer system that works so well at covering everyone (at least those over 65). (One of the reasons the authors did this study was the existing perception — and some evidence — that Medicaid and uninsured patients, as a whole, received lower quality care, but that was related to their care often being delivered at different hospitals.) The increase in mortality rates for Medicare patients compared to others with the same diagnosis was often substantial. But why?
Our hospital clearly has demonstrated that, essentially, Medicare is its poorest payer, and that, on the whole, it loses money on Medicare patient. This may well be true at other hospitals, but in itself should not account for lower quality of care, just lower profit. I would strongly doubt that either our hospital or the physicians caring for them believe that they deliver lower quality care to Medicare patients or that they are more reluctant to do expensive tests or provide expensive treatments when they are indicated. And yet, at the group of hospitals studied (if not mine, perhaps), it is true. The authors speculate as to what reasons might be. One thought is that Medicare (and other less-well-insured patients) might have worse physicians (“slower, less competent surgeons”); in some teaching hospitals, perhaps they are more likely to be cared for by residents than attending physicians. However, I do not believe, and have not seen good evidence, that this is the case. Another possibility is that newer, more expensive, technologies are provided for those with better insurance. Not good evidence for this, either, nor for another theory, that more diagnoses (“co-morbidities”) are listed on patient bills to justify higher reimbursements. I think that there is an increasing trend to do this (not necessarily inappropriately), and that, as the authors indicate, the trend is greater among for-profit than teaching hospitals, but in itself this does not suggest a significant difference for privately insured patients compared to those covered by Medicare.
What, then, is the reason? Frankly, I don’t know. It could be simply a coding issue; that is, in order to get greater reimbursement, hospitals list more intercurrent (co-morbid) conditions for private patients in hopes of greater reimbursement, which makes them appear sicker compared to Medicare patients when the latter are actuallysicker. Or it may be that less experienced physicians and surgeons care for them. Or it may be that, despite the willingness of physicians, hospitals are less likely to provide expensive care for patients who, like those covered by Medicare, are reimbursed by diagnosis, not by the cost of treatment. Indeed, there may be other patient characteristics that lead to inequities in care that confound this study, but the idea that it may be because they are insured by Medicare is pretty disturbing.
Actually, in any case it is disturbing. It is already disturbing enough that a large portion of the US population is uninsured or underinsured, and that even with full implementation of the ACA there will still be many, if fewer, of us in that boat. It is disturbing to think that those who are poor and uninsured or poorly insured receive lower quality of care, possibly from less-skilled or less-experienced physicians, than those with private insurance. It is understandable (if not acceptable) that hospitals, physicians, and rehabilitation facilities might prefer to care for relatively young, straightforward patients with a single diagnosis, low likelihood of complications, and clean reimbursement. But if people are receiving poorer-quality care because they are our seniors, that is neither understandable nor acceptable.
It is another strong argument for everyone being covered by the same insurance, by a single-payer plan. Then, whatever differences in quality might be discovered, it would not be by insurance status.



[1]Spencer CS, Gaskin DJ, Roberts ET, “The quality of care delivered to patients within the same hospital varies by insurance type”, Health Affairs Oct2013;32(10):1731-39.

What do the American people want in a healthcare plan? Not what Trump, Price and the GOP will give them

Readers of this blog are probably aware that I am a member of Physicians for a National Health Program (PNHP) and, like that organization, support the creation of a single-payer health system in the US. Sometimes referred to as a Canadian-type health system, or as in Sen. Bernie Sanders’ presidential campaign, “Medicare for All”, it is pretty easy to understand, and is a system that has worked not only in Canada but, in modified forms, in most developed countries in the world. The key feature of such a system is that it is one program that covers everyone in the country, “Everybody In, Nobody Out”in the title of the book by the late Quentin Young, MD, a former President and executive director of PNHP and a “tiger for social justice” in the words of his Chicago Sun-Times obituary.
Such a system would replace the bewildering, dazzling, complex, confusing mess of the current US health care system, with its hundreds of different private insurance policies with widely varying benefits, premiums, and coverage, as well as the federal programs of Medicare, federal-state partnerships like Medicaid and the ACA’s health insurance exchanges, and of course that persistent, pesky mass of 30 million or so uninsured. And the underinsured, who are effectively uninsured, because they buy the only policy that they feel that they can afford only to find out when they need it that it, surprise, doesn’t cover what they need!
Much of the defense of the ACA has been based on the fact that an insurance pool must have healthy as well as sick people. This is a core tenet of insurance, which would otherwise be unaffordable. Life insurance cannot work if it only covers people on their deathbeds; car insurance cannot work if it only is purchased at the time of an accident, homeowner’s insurance cannot work if it is only bought by people in the midst of a fire. If this were how insurance worked, there would be no need for it, for the premiums would be basically the same as paying for the cost of the services. To have it otherwise, as insurance, requires a pool of money contributed by folks, whether directly or through their taxes, who are not immediately benefiting to cover those who need it. In fact, though, understandably but impossibly, people want coverage for when they are sick, but don’t want to pay when they are not. People may not want to pay a lot when they are healthy (or think that they are) but they want coverage for their sick parents, or newborn with health problems, or when they are diagnosed with cancer, or when their adolescents are in a car wreck. These are things that don’t happen to most of us most of the time but happen to enough of us over our lives that we know enough to fear or expect it. A national single-payer system gets rid of this problem, by having the largest possible risk pool.
But the people of the US did not elect Bernie Sanders, and he did not even get the Democratic nomination. We elected (OK, the Constitutional unfairness of the Electoral College elected) Donald Trump, whose positions may be erratic and change frequently, but whose appointments to Cabinet-level posts are remarkably consistent. Most are from the most right wing of the Republican Party, not unlike we would have expected from Ted Cruz. Despite a campaign that attacked Wall Street and the support Hillary Clinton received from the financial sector, he has appointed many Wall Streeters, including several former (and current) folks from Goldman Sachs — most recently, their lawyer whose wife still works for them, to head the SEC. Foxes guarding the henhouse abound; climate change deniers will head the EPA and Department of Energy. And in the same vein, we have, for Health and Human Services nominee, Rep. Tom Price, the orthopedic surgeon from Georgia about whom I wrote recently (“Trump, Price, and Verma: Bad news for the health of Americans, including Trump voters”, December 3, 2016).
Rep. Price certainly does not stand for a single-payer national health system. Nor does he stand for ensuring health care for the vulnerable, whether poor, elderly, rural, or sick, as demonstrated in an excellent piece in the New England Journal of Medicine by Sherry A. Glied and Richard Frank, Care for the vulnerable vs. cash for the powerful – Trump’s pick for HHS”. It notes that he “…favors converting Medicare to a premium-support system and changing the structure of Medicaid to a block grant,” which would mean that not only Medicaid, and the coverage people have received under ACA, but even Medicare which has protected seniors for 50 years, would be under threat. The article contains information about his positions on other issues, including favoring greater access to armor-piercing bullets, opposing regulations on cigars and on tobacco as a drug, opposing the reauthorization of the Violence Against Women Act and laws prohibiting discrimination against LGBT people. In terms of ensuring health coverage he is as mean as they come:
His voting record shows long-standing opposition to policies aimed at improving access to care for the most vulnerable Americans. In 2007–2008, during the presidency of George W. Bush, he was one of only 47 representatives to vote against the Domenici–Wellstone Mental Health Parity and Addiction Equity Act, which improved coverage for mental health care in private insurance plans. He also voted against funding for combating AIDS, malaria, and tuberculosis; against expansion of the State Children’s Health Insurance Program; and in favor of allowing hospitals to turn away Medicaid and Medicare patients seeking nonemergency care if they could not afford copayments.
But he is the President-elect’s health guy, and we might think that the folks who voted for Mr. Trump will get what they wanted. Except they probably won’t, other than that small slice of voters representing the wealthiest providers, insurers, drug manufacturers, corporate executives, and pundits (like the Wall St. Journal’s Kim Strassel). The health situation in the US is bad, particularly for lower income whites, whose mortality rate has, remarkably, as reported by the Commonwealth Fund, been static rather than decreasing or in some cases (low income women) increasing. These are many of the same folks who voted for Donald Trump, and are presumably looking for a solution. The Kaiser Foundation recently conducted focus groups among Trump voters in states have been hard hit by job losses and were key swing states in the election – Ohio, Michigan, and Pennsylvania. The participants either had Medicaid or were covered by ACA. The results are summarized by an op-ed in the New York Times by Kaiser’s CEO, Drew Altman, “The health care plan Trump voters really want”, January 5, 2017.
If these Trump voters could write a health plan, it would, many said, focus on keeping their out-of-pocket costs low, control drug prices and improve access to cheaper drugs. It would also address consumer issues many had complained about loudly, including eliminating surprise medical bills for out-of-network care, assuring the adequacy of provider networks and making their insurance much more understandable.
That’s what they want. That’s what I want. It is what I believe a single-payer system would deliver. But it sure isn’t what they are going to get from Tom Price, or from whatever “replacement” the Republicans come up with for ACA.
And that’s more than a shame.  It’s a scandal.

More wealth, more health: what can we do to mitigate disparities?

The Washington Post’s “Wonkblog” reviewed a report by economists discussing “The stunning — and expanding — gap in life expectancy between the rich and the poor” (Max Ehrenfreund, Sept 18, 2015). One focus of the article, which is based on a report from the National Academy of Sciences, is that (in the words of the alternative title of the Wonkblog piece that displays in the URL), “the government is spending more to help rich seniors than poor ones”. A big reason for this is that the greater life expectancy of the more well-to-do means that they collect benefits from Social Security and Medicare for longer. But, of course, the real issue is that there is such a difference in the life expectancy of rich and poor. Ehrenfreund illustrates this with two dramatic graphs:

This is a pretty significant difference. What are the reasons for it? The report (and the article based on it) indicate that while differences in “lifestyle” (smoking and obesity, mainly) account for some of the difference, it is less than 1/3. The study also alludes to the impact of “stress”. This may seem vague, non-specific, or ubiquitous: aren’t we all stressed? Don’t rich people have a lot of stress because wealth is often accompanied by great responsibility? Such interpretations sometimes leads “stress” as a factor in longevity to be discounted by many commentators. But the impact of stress on health is a real thing, and it is well documented. Many people are familiar with the old terms “Type A” and “Type B” personalities, and how being Type A (more stressed) can lead to a greater risk of disease, particularly heart attack. But the real concern is a kind of stress that is more common in poorer people. This is the continuousstress, from worrying about whether you and your family will have enough food to eat and a place to live, whether you will have a job, whether it is safe to walk down the street, whether (especially if you are a young Black man) the police are going to stop you at any moment, that has major negative health effects. The mechanisms through which this occurs are incompletely elucidated, but certainly involve the neuroendocrine system, the release of hormones that prepare the body for “fight or flight” by refocusing blood flow to muscles, increasing heart rate, etc. Such a response is very useful in an emergency, but when it is happening most or all of the time, and the body does not have the time and rest to fully recuperate, it results in real health damage. This hormonal response allows a person to run fast, from an attacker or for sport, for a short time, but if the challenge never stops, the body eventually wears out
This sort of stress on the body may be the “final common pathway” through which many of the negative life situations that poorer people are more likely to find themselves in exact their toll, but there are also other factors. People’s health, and thus their life expectancy, is to a large extent determined by their early childhood experience. The relative income of their families of origin that affects their childhood nutrition and education, their warmth in the winter, and the amount of transmitted stress that their parents felt, is also a big determinant. While this disparity at the start of life is something that can be mitigated, by some, through future success, it can never be completely erased. That is, while rich people from poor backgrounds may have better health later in life than those who stay poorer, they have on average worse health than those who started out wealthy and stayed that way. “Choose your parents wisely,” I tell my medical students, “if they are both long-lived and rich, it bodes well for your future health.” Luckily for them, the majority of medical students come from at least upper-middle-income families.
Another big determinant is education, and many studies show the correlation of higher levels of education with longer life and better health. Of course, education is highly correlated with income, both on the front end (children from higher-income families are more likely to achieve higher educational levels) and on the back end (those children from families of lower socioeconomic status who are successful have usually become so through education). In the US, income is related to education in part because our schools are largely funded by local tax bases, so that wealthier people live in better funded, and educationally better, school districts. People from other countries often have difficulty understanding that we have “good” and “bad” school districts; as one friend said “where I come from all schools are the same! No one would choose where to live based on the quality of the schools!” This concept is so alien to me that I had difficulty understanding them!
In addition, education does not take place only in school. Children from upper-income families are more likely to have educated parents, who not only encourage them to pursue educational success, but read to them and talk to them from the very beginning of their lives. These are also families in which survival needs do not displace the priority of children getting an education. In 1943, the psychologist Abraham Maslow published his hierarchy of needs; survival must come before self-actualization. This was originally conceived of for the individual, but is also true of families and communities. A similar pyramid has been developed to describe the impact of Adverse Childhood Events (ACEs). ACEs are a ways of thinking about the combination of negative impacts including hunger, homelessness, physical abuse, sexual abuse, neighborhood dangerousness, etc., that have been shown to have a lifelong negative impact. In addition to being associated with higher future rates of drug abuse and mental illness, they are associated with higher rates of just about everything bad. The Adverse Childhood Experiences studyconducted by Kaiser Permanente beginning in 1995-97 is the most significant study on this topic. It is ongoing and being replicated in many other countries.
 
Of course, lower income people are exposed to other risks beyond these. People living in “worse” neighborhoods have a greater likelihood of being homicide victims. Those neighborhoods are much more likely to be exposed to environmental pollutants in the air and water and even from the earth (such as toxic waste dumps). Many lower-income people work in more dangerous jobs, especially true in rural areas (farming, ranching, logging, highway construction, etc.) Indeed, the potential for “confounding” results from such exposures was the reason that Michael Marmot and his colleagues did their classic series of studies showing the direct correlation of higher socioeconomic status (class) and better health by examining people who worked for the government in the same offices in London (thus the name “the Whitehall studies”).
Wealthy people have a longer life expectancy than poor people, and wealthy countries have longer life expectancies than poorercountries, and those with wider gaps between the rich and poor have wider gaps in life expectancy; in this regard the US is at greater risk than wealthy nations with smaller gaps. The neat interactive website from Gapminder allows you to track wealth with life expectancy over time since 1800. The GINI index measures the income disparities within countries, and its use allows correlating income inequality with life expectancy; like several other health measures (e.g., infant mortality) life expectancy goes down with increasing inequality even when a country (such as the US) is rich overall.
So yes, our Social Security and Medicare systems mean that those who live longer will have more financial benefit, and that they are more likely to be more well-to-do than those who die younger. In addition, those who are poorer are more likely to live longer with disability. But the real news is that poverty and social deprivation work in many synergistic ways to decrease the health of the poor. This is what we need a coordinated and comprehensive strategy to address.

And the first step is recognizing and acknowledging it.

The high cost of US health care: it’s not the colonoscopies, it’s the profit

On June 2, 2013, the Sunday edition of the New York Times ran a major investigative article by Elizabeth Rosenthal called “The $2.7 Trillion medical bill”, with the subtitle “Colonoscopies explain why the US leads the world in health expenditures”. It is a damning article about the US health care system, and the fact – fact – that our costs are much higher than those in other countries but our outcomes are often worse, and large portions of our population are not even covered.
Of course, it is not all colonoscopies. Yes, the average cost for a colonoscopy in the US is $1,155 compared to $655 in Switzerland (for example). And many cost much more; in the first paragraphs of the article we hear about charges of $6,385, $7,563.56, $9,142.84 and $19,438 — “…which included a polyp removal. While their insurers negotiated down the price, the final tab for each test was more than $3,500.” ! But the graphic at the top of the article compares US prices for other common procedures with those of other first-world countries: Angiogram $914 US, $35 Canada; hip replacement $40,364 US, $7,731 Spain; MRI $1,121 US, $319 Netherlands; Lipitor (atorvastatin, a drug to treat high cholesterol) $124 US, $6 New Zealand.
But colonoscopies provide a good example for why we pay so much more for procedures – and it is not because they are of higher quality:

“Colonoscopies… are the most expensive screening test that healthy Americans routinely undergo — and often cost more than childbirth or an appendectomy in most other developed countries. Their numbers have increased manyfold over the last 15 years, with data from the Centers for Disease Control and Prevention suggesting that more than 10 million people get them each year, adding up to more than $10 billion in annual costs. Largely an office procedure when widespread screening was first recommended, colonoscopies have moved into surgery centers — which were created as a step down from costly hospital care but are now often a lucrative step up from doctors’ examining rooms — where they are billed like a quasi operation. They are often prescribed and performed more frequently than medical guidelines recommend.
The high price paid for colonoscopies mostly results not from top-notch patient care, according to interviews with health care experts and economists, but from business plans seeking to maximize revenue; haggling between hospitals and insurers that have no relation to the actual costs of performing the procedure; and lobbying, marketing and turf battles among specialists that increase patient fees.”
Welcome to the world of for-profit health care. Where the principle of “maximize profit” determines what health care institutions do. Where “what we do” (our “product”) is health care, but we prefer to do it on those with really good insurance. Where we adjust our charges to maximize the difference between what it costs us and what we are paid. Where the rules set by insurers or government with the aim of regulating costs are seen as challenges to be gamed for maximum profit. The movement of colonoscopies – and many other procedures – from doctors’ offices to “surgi-centers” is a great example. If performing colonoscopy in an office was unsafe, moving to a surgi-center might be a good idea, but there is little evidence that it was. Moreover, the increased price for performing a procedure in such a center far exceeds the increased cost of doing it there; the reason for the move is not patient safety, but taking advantage of a loophole to be able to charge more.
Rosenthal’s article is a long one; it extensively documents both the high cost of health care in the US and the reasons why it is so high, which are rarely related to quality. This is illustrated by an article published in the Times a few weeks earlier, “New Jersey hospital has highest billing rates in the nation”, by Julie Creswell, Barry Meier, and Jo Craven McGinty. “The most expensive hospital in America is not set amid the swaying palm trees of Beverly Hills or the luxury townhouses of New York’s Upper East Side,”they write, but Bayonne Medical Center, in Bayonne, NJ, where the average charges are 4.1 times the national average charge, not to mention what Medicare will pay. For some services it is much higher: “Bayonne Medical typically charged $99,689 for treating each case of chronic lung disease, 5.5 times as much as other hospitals and 17.5 times as much as Medicare paid in reimbursement. The hospital also charged on average of $120,040 to treat transient ischemia, a type of small stroke that has no lasting effect. That was 5.6 times the national average and 23.6 times what Medicare paid.
How can they get away with this? Who will pay them so much? After all, if I can buy a Chevrolet for $25,000 at one dealer in town, why would I pay $75,000 for the same car somewhere else? Ah, but health care is different. For one thing, you might be sick when you have to find a hospital to care for you, and you might live in Bayonne! Of course, Medicare will only pay what Medicare pays, but if you have most types of commercial insurance (not to mention, of course, if you are uninsured), it is another story. To guard against excessively inflated charges, most insurers have contracts with providers (hospitals, doctors, etc.) that determine how much they will pay for a procedure or treatment of a disease. This saves the insurer money. In addition, in order to encourage you to go somewhere that they have negotiated these lower rates, “in-plan” hospitals, they pay a lower percent of the cost – and you pay more – if you go “out of plan”.
And it is precisely this effort to control costs that many for-profit hospitals (like Bayonne) have turned on its head to generate greater income. They have gone “out of plan” for all health plans. This means that when you show up in their ER, or are admitted, you have a higher co-pay, and co-insurance charge, and the insurer pays them more money. Which is why the insurer doesn’t want you to go there, and you might (once you knew this) not want to go there either. Except, of course, you’re sick, and you live in Bayonne, and it is the closest ER. Talk about gaming the system!
Spending & Coverage (2010)
France
U.S.
Total health spending per capita
$3,974
$8,233
Government health spending per capita
$3,061
$3,967
% uninsured
0%
15.7%
Health outcomes (2010)
Life expectancy at birth (2011)
81.3 yr.
78.7 yr.
Infant mortality per 1,000 births
3.6
6.1
Costs per episode (2012)
Doctor’s office visit
$30
$95
Hospital day
$853
$4,287
Angioplasty
$7,564
$28,182
Appendectomy
$4,463
$13,851
Childbirth delivery (normal)
$3,541
$9,775
Hip replacement
$10,927
$40,364
Heart bypass
$22,844
$73,420
Tests (2012)
Abdominal CT scan
$183
$630
Angiogram
$264
$914
MRI
$363
$1,121
Name-brand drugs (30-day prescription, 2012)
Cymbalta
$47
$176
Lipitor
$48
$124
Nexium
$30
$202
Sources: Organisation for Economic Co-operation and Development and International Federation
of Health Plans.
I have implied that much of the reason for the high cost of health care in the US is the high cost of procedures. Frankly, that is true. It is why procedural specialists make so much more than primary care physicians. This is why decreasing the difference in income potential for proceduralists and primary care doctors would be good for everyone and save money: there would be more people doing primary care and less incentive to do unnecessary procedures. Consumers Report, in its July 2013 issue, has an article on the patient-centered medical home (PCMH) movement, which seeks to achieve the “triple aim” of higher quality, greater patient satisfaction, and lower cost. The article, “A doctor’s office that’s all about you”, also addresses the high cost of care in the US, comparing it specifically to France, which spends 11.6% of its GDP on health care and  “is generally acknowledged as having one of the world’s best health care systems.” Needless to say, the comparison is not flattering to the US, which spends 17.6% of GDP on health care.
Richard Wender, MD, a leader in US family medicine, commenting on the “Colonoscopies” article, says “Using health care as a driver of corporate economics as opposed to a public good is the fundamental cause of our medical inflation.” Lee Green, MD, an American who is now a family medicine leader in Canada, adds “Having practiced most of my career in the US, and now practicing in Canada, the contrast is quite evident. 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. If you’re poor and uninsured, that’s none – no matter how much you need it. If you’re well-insured, it’s a lot – including quite a bit you don’t need, and even some that is harmful.”

This is crazy. We know the problem, and we know the solutions. All we need is the will to implement them. Maybe this continued exposure will generate it. We can hope so.

Integrated Health Systems and Cost: The Price is the thing!

When the Affordable Care Act (ACA) was being developed, much emphasis was put on the effectiveness of integrated health systems as a way to save money but still deliver quality health care. Many studies from various research centers had looked at cost to Medicare and found that places – usually smaller cities – with large integrated health systems spent less on Medicare without noticeable decrements to quality. These systems can have a single provider of both inpatient and outpatient care (such as the Mayo Clinic) or close collaborations, including shared electronic medical records (as in Grand Junction, CO). The presumption of policy makers creating ACA was that Medicare spending, which is much easier to track, would reflect overall spending. However, a recent article from the National Bureau of Economic Research by Zack Cooper, Stuart Craig, Martin Gaynor and John Van Reenen, The Price Ain’t Right? Hospital Prices and Health Spending on the Privately Insured, demonstrates that this assumption was incorrect. Reviewing overall costs in the 306 Hospital Referral Regions (HRRs, developed by the Dartmouth Atlas of Health Care) in the US, they discovered wide discordance between Medicare costs and overall healthcare costs. Indeed, many of the places that were highly-touted for lower-Medicare-costs-but-still-high-quality, notably Grand Junction, CO (which was, for example, cited as a success story by Atul Gawande in his June, 2009 New Yorker article “The Cost Conundrum”) have far higher than average costs overall. (Dr. Gawande has just had a new piece in the New Yorkerdiscussing the implications of this new article.)
The New York Times coverage of this study, by Kevin Quealy and Margot Sanger-Katz, The Experts Were Wrong About the Best Places for Better and Cheaper Health Care(December 15, 2015), includes a terrific feature that allows interactive access to the data collected by Cooper and his colleagues. You can put in a town (really, HRR) and find out where it ranks in terms of both Medicare and private costs. Grand Junction, for example, while ranking 3rd lowest of the 306 HRRs for per-capita Medicare spending, was the 42nd most expensive for private insurance spending. Rochester, MN, home of the Mayo Clinic, is another city lauded for its low Medicare costs (14thlowest), but its private spending is 10th highest! McAllen, TX, cited by Gawande in 2009 for being #1 in Medicare spending (and now still #4) is only 140th in private insurance spending. Tucson, AZ, on the other hand, while only in the lower middle (82nd from the bottom) in Medicare spending, is 7th lowest for overall costs. The Kansas City region, where I live, was atypically near the middle for both, 142nd lowest for Medicare and 82nd  lowest for private costs. New York City is high in both, but it is 2nd for Medicare and 34th (quite a bit lower) for private insurance. The map in the article depicts HRRs as low, middle or high for both Medicare and private insurance.

So, what’s up? Were the experts trying to fool us? No, but the flaw  was the assumption that Medicare spending reflected overall spending. The data in this article demonstrates that it does not. It also reveals something about integrated health systems, especially those that dominate their smaller cities, given that some of the “top performers” for Medicare, like Grand Junction and Rochester, MN, were so high for private insurance. The integrated nature of these plans allows them to save money on patients by a variety of methods – they can be seen in ambulatory settings rather than in hospitals or ERs, and they share electronic medical record systems, and thus the information recorded therein, saving money by not having to repeat tests, x-rays, etc. This lower utilization is good for these health systems because Medicare is a relatively low payer, and because they can’t negotiate these rates – Medicare pays what it pays (it is a single-payer system, with minor regional variations). However, the same characteristic – being the dominant player in town – allows such integrated health systems to negotiate much higher rates with private insurers. Thus the mismatch; overall cost is a multiple of price for each service times the number of services delivered. These systems decrease the number of services for people insured by Medicare, for whom they cannot control the price (whether this does or does not decrease quality is a separate question) but they raise the price for services to people with private insurance. That places like Tucson and Kansas City have relatively lower prices for private insurance reflects the absence of a single large dominant system in those cities.

‘“Price has been ignored in public policy,” said Dr. Robert Berenson, a fellow at the Urban Institute, who was unconnected with the research’, in the Times article. Other health policy experts, such as Princeton’s Uwe Reinhardt, have been warning about this for decades. In the effort to pass the ACA, and please both providers and insurers, this point was in fact ignored, and it is the source of most of the common legitimate criticism of the ACA – that in many places decent health insurance policies bought through the health exchanges are unaffordable. With higher prices in these regions, insurers pass on the cost to their customers.  This is illustrated in the NPR story “Obamacare Deadline Extended As Demand For Health Insurance Rises” on December 18, 2015, which documents both the success of ACA measured by the large increase in the number of people signing up for coverage and their frustration at the frequently-high cost of this coverage. Of course, this is completely unrelated to the criticisms leveled at ACA by the Republican candidates for President and their allies in Congress, whose “solution” – abolish ACA – is Marie Antoinette-like. While the French queen is reputed to have said, in response to being told that the peasants had no bread, “then let them eat cake!”, Republicans, hearing that many people cannot afford health insurance on the exchanges even with subsidies, or get Medicaid in states (that they control) which have not expanded it, respond “let them pay out of their own pocket!”

The issues and solutions are clearly laid out by the reliably insightful Dr. Don McCanne is his “Quote of the Day” on this topic. A solution cannot come from a jerry-rigged program that allows either insurers or health systems or both to maximize their profit. It needs to come from a system that starts with price controls, most effectively by a single-payer system such as Medicare. There are, as he notes, still risks – mainly that health systems may under-utilize services when they cannot make profit, leading to lower quality of care. But we can guard against this both on the regulatory end, by measuring quality outcomes and holding providers responsible, and through the market because the incentive to not provide services to Medicare patients because they can be more profitably provided to the privately -insured (the “opportunity cost”) goes away.
The infatuation of both policy makers and providers for integrated health systems is not entirely misplaced. The potential savings from shared data and not repeating tests, and more importantly for caring for people in the most clinically appropriate setting (inpatient, ER, outpatient surgery center, primary care, long-term care) is a real positive feature of these systems. But to the extent that these providers are allowed to use their market muscle to raise prices to insurers which are passed on to beneficiaries, it becomes a real negative.

The key feature of a good health system is that it is not focused on balancing the financial interests of big insurers and big providers, but that it puts the benefits to patients, to the people’s health, first.

Treatments that don’t cure the disease; we are spending money on the wrong things

In “Heralded treatments often fail to live up to their promise” (Kansas City Star, May 17, 2014), Alan Bavley, writing with Scott Canon, continues to demonstrate that he is one of the excellent health journalists – excellent journalists – in the US, along with Elisabeth Rosenthal of the New York Times. The common practice in the news media (and, thanks to a typo, “medica”) is to hype the new, exciting, dramatic, expensive, and hard to believe even though you want to. In politics, we often see the media acting as flaks for the government, the rich, and the powerful (sometimes, of course, these can be in conflict). Bavley and Rosenthal  and their ilk actually do investigative journalism, trying to the best of their ability to find out the truth rather than to reprint press releases.

The article begins with a review of a surgical procedure that was designed to control high blood pressure (hypertension) without drugs, by cutting some of the nerves to the kidneys. It made sense, it was seen as a big breakthrough (“The potential benefit was huge,” said a cardiologist). Unfortunately, when actually subjected to appropriate scientific study, it didn’t work. Or, rather, it worked just as well as placebo, a sham surgical procedure. The same cardiologist remarks ““This could be considered the biggest disappointment in cardiology of this century, but “the medical community went about it right.” 

Science worked. Unfortunately, the authors add,
“If only that were always the case. A combination of industry marketing, overly eager doctors, demanding patients and news media ready to cheer on anything that sounds like a breakthrough is popularizing many drugs, surgeries and other treatments long before they’re adequately tested. Far too often, they’re ultimately proved ineffective, no better than older, cheaper therapies, or even hazardous. Billions of dollars are wasted and tens of millions of patients are put at risk”

Yup. They go on to cite the Vioxx scandal, in which Merck concealed evidence of its biggest-selling drug causing an increase in heart disease. But that was taken off the market; many other unproven (or worse, proven to be ineffective) treatments are not. They talk about arthroscopic knee surgery, still often being done for conditions for which it has been shown to be no more effective than a sham procedure. They discuss surgical robots, costing upwards of $1.5 million, and proton-beam radiation treatments (those babies, the machines, really cost a lot!) for which the evidence of effectiveness compared to more standard and much cheaper treatment is mixed, at best. But hey, if you’re a hospital, and the competition has robots and proton-beam accelerators, who’s going to come to you if you don’t have one? Poor people? Heaven forfend!

And it is all about getting the advantage on the competition to make more money. A good argument can, and should, be made that competition in hospitals helps no one. That if there were an expensive item that there were an actual medical need for one of in the community, there should be one, not one at every hospital. But that would presume that the goal of the health system was to increase the health of the American people at the lowest effective cost. It isn’t. It’s to make money. If I can get your patients to come to me instead, it is seen as a victory (from a competitive business sense). It is really a loss for the health of our people and the pocketbooks of us all.

It is particularly depressing because that money is not buying us health. If you still harbored the belief that “we have the best health care system in the world”, it’s time to acknowledge that you are wrong (although we forgive you given the hype!). We should all know how expensive our health care system is, that we spend way more than any of the other developed countries (members of the Organization for Economic Cooperation and Development, OECD). The attached graph, from Steven Woolf, MD, PhD, who was a plenary speaker at the recent Society of Teachers of Family Medicine Annual Conference, shows a comparison of spending and life expectancy for the OECD countries. That’s the US way off to the right, spending more than anyone by far, but having a life expectancy close to the Czech Republic. Better than Mexico, Poland, Slovakia, Hungary and Turkey, but at enormously greater cost!

Woolf was the lead author of the Institute of Medicine’s (IOM) recent report “Shorter Lives, Poorer Health” , which presents depressing, but unfortunately accurate, data on our health status. We are among the “leaders” in death rates from communicable and non-communicable diseases and from injuries. Only for a few causes are our death rates better than the average. Our life expectancy at birth is worse than any of the 17 comparison countries for men, and second worst for women. Our probability of survival to age 50 is lower than any of 21 comparison countries. At any age until 75, we are never better than 15 out of 17 in terms of life expectancy. We do have better survival rates once we reach age 75, but there is no information on how much of that is keeping people alive despite poor quality of life.

Want more? In case you think it is only the minority populations (although that would be part of our population), non-Hispanic whites rank no higher than 16 of 17 at any age below 55. And the only portion of our population for whom mortality rates have risen is non-Hispanic whites with less than 12 years of education. From 2005-2009, the US had the highest infant mortality rate of the 17 countries and the 31st highest in the OECD. Non-Hispanic whites and mothers with 16+ years of education also have higher infant mortality rates than those in other countries. Among the 17 peer countries, mortality from transport accidents decreased by 42% in the OECD between 1995 and 2009, but by only 11% in the US. The same trends hold for child and adolescent health – and ill-health and mortality.

And then there are the areas where we really shine, particularly health issues related to guns.
  • In 2007, 69% of US homicides (73% of homicides before age 50) involved firearms, compared with 26% in peer countries.
  • A 2003 study found that the US homicide rate was 7 times higher (the rate of firearm homicides was 20 times higher) than in 22 OECD countries.
  • Although US suicide rates were lower than in those countries, firearm suicide rates were 6 times higher.
We have the highest child poverty rates in the OECD, our preschool enrollment is below most countries, and the ratio of social services spending to medical spending is below almost all other OECD countries.
This is insanity. We are spending enormous amounts of money, but we are spending it so that our hospitals can compete with each other, so that we can deliver the most expensive and high-tech care whether it benefits people’s health or not, and we then do not have any money left to do the things that would really enhance health: expanding education, creating jobs, decreasing poverty, ensuring that people had homes and enough to eat.

Not to mention the guns.

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 Medicineexamined “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.comwebsite, 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.

Guns and the Public’s Health: what can we do?

 “A well regulated Militia, being necessary to the security of a free State, the right of the people to keep and bear Arms, shall not be infringed.”
Recognize those words? The Second Amendment to the Constitution of the United States, what all the fuss is about. In addition to the confusing use of commas, apparently more generously applied in the 18thcentury, we have two key phrases. The final phrase, “shall not be infringed”, is read by the NRA and other “gun rights” zealots (and it is important to remember that only a minority of NRA members, and a smaller minority of gun owners, support this position) to mean essentially “no legislation regulating guns in any way”. That includes assault rifles, semi-automatic and maybe even automatic rifles, armor-piercing (“cop killer”) bullets, and any other weapon or gun modification that creative minds can come up with. Of course, it has been noted that none of these types of weapons were available at the time of the Constitution, when firearms were muzzle-loaded muskets, quite different from current weapons (see graphic).

The NRA take the position that there is qualitatively no difference, as noted by its President, Wayne LaPierre, after the December 2012 massacre at Sandy Hook Elementary School: “Absolutes do exist. We are as ‘absolutist’ as the Founding Fathers and framers of the Constitution. And we’re proud of it!” Others (including me, in case you were wondering) would disagree, and say that clearly at some point the quantitative difference becomes qualitative. This is the only amendment they are absolutist about; the First Amendment says “Congress shall make no law… abridging the freedom of speech…”, but it has long been settled that it is not OK to yell “Fire!” in a crowded theater.
The other obviously important phrase is “A well regulated Militia”. Again, obviously, this has been the source of much discussion, with the NRA taking the position that “Militia” just means “everyone” (kind of a stretch), and (as far as I can tell) “well regulated” means, um, not regulated at all. Is this cherry picking the words one wants? Maybe, but I can’t imagine how it is possible to ignore completely the words “well regulated”. But does it matter? Yes, when we live in a country where
The 36,252 deaths from firearms in the United States in 2015 exceeded the number of deaths from motor vehicle traffic crashes that year (36,161). That same year, the US Centers for Disease Control and Prevention reported that 5 people died from terrorism. Since 1968, more individuals in the United States have died from gun violence than in battle during all the wars the country has fought since its inception.
Bauchner et al., Death by Gun Violence—A Public Health Crisis, JAMA, October 9, 2017[1]
Those are staggering numbers, and certainly justify the assertion that it is a “public health crisis”.
The authors also note that “60.7% of the gun deaths in 2015 in the United States were suicides, a fact often ignored. That is a majority. A large majority. If it were an election, 60.7% would be considered a landslide. But with guns it is a mudslide of death. I have written before about suicide (e.g, Suicide: What can we say? December 13, 2013, Suicide in doctors and others: remembering and preventing it if we can September 14, 2014, Prevention and the “Trap of Meaning” July 29, 2009) and its impact on myself and my family, with my son’s successful suicide-by-gun at the age of 24. My son, to my knowledge, had never used a gun before his final act. He lived in a state and city with strict gun control laws (some of which, sadly, have been eliminated by the courts). He was nonetheless able to go to another state, buy a carbine (terrific choice! No permit needed, even in those days, like a handgun would require, but short enough to reach the trigger with the barrel in his mouth!), and use it. It would be easier now, in that state and many others.
My son was apparently very committed to this act, and was successful despite some obstacles. But for many, many people it is the availability of guns that make a spur-of-the-moment decision lethal. I have noted before that nearly 95% of suicide attempts by gun are lethal while less than 5% by drug overdose are. My clinical experience is that many suicide survivors do not repeat their attempts (though many do). The successful suicide rate for young adult males in low gun control states is several times higher than in high gun control states. And on and on.
But the epidemic of suicide and murder and mass murders resulting from the easy availability of guns has not changed the legal landscape. After the Las Vegas massacre, there was a small ray of hope that maybe one of the most egregious products the white terrorist Stephen Paddock used, the “bump stocks” that effectively convert semi-automatic to automatic rifles, might be limited; even the NRA voiced some possible support. But never underestimate the cowardice and lack of moral fiber of the Congress; Speaker of the House Paul Ryan has suggested that this be done by regulation rather than legislation. This is absolutely because it will not require any congressperson to actually vote for it and thus be targeted by the zealots in the next election. Hopefully, not literally targeted by guns, but do not forget Gabby Giffords and Steve Scalise!
Dr. Bauchner, who is the editor-in-chief of JAMA, also joined the editors of several of the other most prestigious US medical journals, New England Journal of Medicine, Annals of Internal Medicine, and PLOS Medicine in an editorial that appeared in all their journals (this link is the the NEJM), ‘Firearm-Related Injury and Death — A U.S. Health Care Crisis in Need of Health Care Professionals’.[2] Again, this emphasizes the fact that guns are a public health epidemic in the US, and that there is little likelihood of anything being done at the federal level to stem its carnage. It recognizes that there is a variable response at the state level, with some states going as far as trying to legally prohibit physicians from asking about guns in the home (Florida; since struck down by the courts) while others have had stronger regulations. Many legislatures have also acted to prevent the cities in their states from acting independently to regulate guns in any way. One of the most insane was the state of Arizona suing to prevent the city of Tucson from destroying guns seized from criminals. The legislature mandated that they be sold – thus keeping them on the streets – and the Arizona Supreme Court upheld this, saying state law trumped local ordinances!
Given this situation, the joint editorial suggests that there are many things that physicians can and should do, including (quoted):
·        Educate yourself. Read the background materials and proposals for sensible firearm legislation from health care professional organizations. Make a phone call and write a letter to your local, state, and federal legislators to tell them how you feel about gun control. Now. Don’t wait. And do it again at regular intervals. Attend public meetings with these officials and speak up loudly as a health care professional. Demand answers, commitments, and follow-up. Go to rallies. Join, volunteer for, or donate to organizations fighting for sensible firearm legislation. Ask candidates for public office where they stand and vote for those with stances that mitigate firearm-related injury.
·        Meet with the leaders at your own institutions to discuss how to leverage your organization’s influence with local, state, and federal governments. Don’t let concerns for perceived political consequences get in the way of advocating for the well-being of your patients and the public. Let your community know where your institution stands and what you are doing. Tell the press.
·        Educate yourself about gun safety. Ask your patients if there are guns at home. How are they stored? Are there children or others at risk for harming themselves or others? Direct them to resources to decrease the risk for firearm injury, just as you already do for other health risks. Ask if your patients believe having guns at home makes them safer, despite evidence that they increase the risk for homicide, suicide, and accidents. [this is what the Florida law would have made illegal]
·        Don’t be silent.
The first (JAMA) editorial says:
Guns kill people….the key to reducing firearm deaths in the United States is to understand and reduce exposure to the cause, just like in any epidemic, and in this case that is guns.
The fact is that while physicians have influence and moral authority, so do other health professionals, and, in fact, so do all of us. So the advice must pertain to all of us.
Don’t be silent.



[1]Bauchner H, Rivara FP, Bonow RO, Death by gun violence—a public health crisis, JAMA online Oct 9, 2017, doi:10.100/jama.2017.16446
[2]Taichman DB, Bauchner H, Drazen JM, Laine C, Peipert L, Firearm-Related Injury and Death — A U.S. Health Care Crisis in Need of Health Care Professionals’, October 9, 2017DOI: 10.1056/NEJMe1713355

Medical schools are no place to train physicians

Doctors have to go to medical school. That makes sense. They have to learn their craft, master skills, and gain an enormous amount of knowledge. They also, and this is at least as important, need to learn how to think and how to solve problems. And they need to learn how to be life-long learners because new knowledge is constantly being discovered, and old truths are being debunked. Therefore, they must learn to un-learn, and not to stay attached to what they once knew to be true but no longer is. They also need, in the face of drinking from this fire-hose of new information and new skills, to retain their core humanity and their caring, the reasons that (hopefully) most of them went into medicine.
Medical students struggle to acculturate to the profession, to learn the new language replete with eponyms, abbreviations, and long abstruse names for diseases (many are from Latin, and while they are impressive and complicated, they are also sometimes trite in translation, e.g., “itchy red rash”). They have to learn to speak “medical” as a way to be accepted into the guild by their seniors, but must be careful that it does not block their ability to communicate with their patients; they also need to continue to speak English (or whatever the language is that their patients speak). “Medical” may also offer a convenient way of obscuring and temporizing and avoiding difficult conversations (“the biopsy indicates a malignant neoplasm” instead of “you have cancer”).  But there needs to be a place for them to learn.
So what is wrong with the places that we are teaching them now? Most often, allopathic (i.e., “MD”) medical schools are part of an “academic health center” (AHC), combined with a teaching hospital. They have large biomedical research enterprises, with many PhD faculty who are, if they are good and lucky, are externally funded by the National Institutes of Health (NIH). Some or many of them spend some of their time teaching the “basic science” material (biochemistry, anatomy, physiology, microbiology, pharmacology, pathology) that medical students need to learn. By “need to learn” we usually mean “what we have always taught them” or “what they need to pass the national examination (USMLE Step 1) that covers that material”. This history goes back 100 years, to the Flexner Report of 1910. Contracted by the AMA, educator Abraham Flexner evaluated the multitude of medical schools, recommended closing many which were little more than apprenticeship programs without a scientific basis, and recommended that medical schools be based upon the model of Johns Hopkins: part of a university (from the German tradition), grounded in science, and based in a core curriculum of the sciences. This has been the model ever since.
However, 100 years later, these medical schools and the AHCs of which they are a part have grown to enormous size, concentrating huge basic research facilities (Johns Hopkins alone receives over $300 million a year in NIH grants) and tertiary and quarternary medical services – high tech, high complexity  treatment for rare diseases or complex manifestations of more common ones. They have often lost their focus on the health of the actual community of which they are a part. This was a reason for two rounds of creating “community-based” medical schools, which use non-university, or “community”, hospitals: the first in the 1970s and the second in the 2000s. Some of these schools have maintained a focus on community health, to a greater or lesser degree, but many have largely abandoned those missions as they have sought to replicate the Hopkins model and become major research centers. The move of many schools away from community was the impetus for the “Beyond Flexner” conference held in Tulsa in 2012 (see Beyond Flexner: Taking the Social Mission of Medical Schools to the next level, June 16, 2012) and for a number of research studies focused on the “social mission” of medical schools.
The fact is that most doctors who graduate from medical school will not practice in a tertiary AHC, but rather in the community, although the other fact is that a disproportionate number of them will choose specialties that are of little or no use in many communities that need doctors. They will, if they can (i.e., if their grades are high enough) often choose subspecialties that can only be practiced in the high-tech setting of the AHC or the other relatively small number of very large metropolitan hospitals, often with large residency training programs. As they look around at the institution in which they are being educated, they see an enormously skewed mix of specialties. For example, 10% of doctors may be anesthesiologists and there well may be more cardiologists than primary care physicians. While this is not the mix in world of practice, and still less the mix that we need to have for an effectively functioning health system, it is the world in which they are being trained.
The extremely atypical mix of medical specialties in the AHC is not “wrong”; it reflects the atypical mix of patients who are hospitalized there. It is time for another look at the studies that have been done on the “ecology of medical care”, first by Kerr White in 1961 and replicated by the Robert Graham Center of the American Academy of Family Physicians in 2003 (see The role of Primary Care in improving health: In the US and around the world, October 13, 2013), and represented by the graphic reproduced here. The biggest box (1000) is a community of adults at risk, the second biggest (800) is those who have symptoms in a given month, and the tiny one, representing less than 0.1%,  is those hospitalized at an academic teaching hospital.  Thus, the population that students mostly learn on is atypical, heaving skewed to the uncommon; it is not representative of even all hospitalized people, not to mention the non-hospitalized ill (and still less the healthy-but-needing-preventive care) in the community.

Another aspect of educating students in the AHC is that much of the medical curriculum is determined by those non-physician scientists who are primarily researchers. They not only teach medical students, they (or their colleagues at other institutions) write the questions for USMLE Step 1. They are often working at the cutting edge of scientific discovery, but the knowledge that medical students need in their education is much more basic, much more about understanding the scientific method, and what constitutes valid evidence. There is relatively little need, at this stage, for students to learn about the current research that these scientists are doing. Even the traditional memorization of lots of details about basic cell structure and function is probably unnecessary; after 5 years of non-use students likely retain only 10% of what they learn; even if they need 10% — or more – in their future careers, there is no likelihood that it will be the same 10%. We have to do a better job has of determining what portion of the information currently taught in the “basic sciences” is crucial for all future doctors to know and memorize, and we also need to broaden the definition of “basic science” to include the key social sciences of anthropology, sociology, psychology, communication, and even many areas of the humanities such as ethics. This is not likely to happen in a curriculum controlled by molecular biologists.
Medical students need a clinical education in which the most common clinical conditions are the most common ones they see, the most common presentations of those conditions are the most common ones they see, and the most common treatments are the ones they see implemented. They need to work with doctors who are representative, in skills and focus, of the doctors they will be (and need to be) in practice. Clinical medical education seems to work on the implicit belief that ability to take care of patients in an intensive care unit necessarily means one is competent to take care of those in the hospital, or that the ability to care for people in the hospital means one can care for ambulatory patients, when in fact these are dramatically different skills sets.
This is not to say that we do not need hospitals and health centers that can care for people with rare, complicated, end stage, tertiary and quarternary disease. We do, and they should have the mix of specialists appropriate to them, more or less the mix we currently have in AHCs. And it is certainly not to say that we do not need basic research that may someday come up with better treatments for disease. We do, and those research centers should be generously supported. But their existence need not be tied to the teaching of medical students. The basic science, and social science, and humanities that every future doctor needs to learn can be taught by a small number of faculty members focused on teaching, and does not need to be tied to a major biomedical research enterprise. Our current system is not working; we produce too many doctors who do narrow rescue care, and not enough who provide general care. We spend too much money on high-tech care and not enough on addressing the core causes of disease.

If we trained doctors in the right way in the right place we might have a better shot at getting the health system, and even the health, our country needs.