Friday, October 13, 2017
The flood of “fake news” threatens serious damage to our society as surely as floods have recently destroyed much of the Caribbean and coastal US or fires have burned up much of Northern California. While it is President Trump (whom I call the #Trumpenik, from the Yiddish “trombenik”, a lazy person or ne'er-do-well; a boastful loudmouth) who uses the term most often, in fact it is he and his allies who create most of the falsehoods. A central and terrifying one is the denial by the President and his EPA of global warming, certainly linked to the increase in horrific storms and fires, and the counter-scientific efforts of his administration to make it worse by increasing the burning of fossil fuels and refusing efforts to contain climate change despite the fact that it is “Trump country” that is supplying much of our nation’s alternative energy.
Key to this fake news is the use of “fake facts” to support reactionary political agendas. While these agendas are mostly about making more money for the richest people and corporations rather than the middle and working-class Americans who support them, they also exploit a bizarre antipathy toward science among a good hunk of our population. (One explanation is that science sometimes reveals facts that are incompatible with pre-existing beliefs, so we reject them. However, the Catholic Church finally got over its opposition to Galileo, so maybe there is, eventually, hope.) Indeed, these people don't oppose all scientific facts, but rather those that make them uncomfortable despite being true. This is suggested by the efforts to manufacture false “scientific” facts to buttress social agendas. A prominent example is the use of “fetal pain syndrome” to justify efforts to limit access to abortion, particularly in the second trimester. The flaw here, of course, is that the evidence for fetal pain is slim to none, certainly before the third trimester, as shown is several reviews of the literature, and discussed at length in this article in Popular Science. LiveScience.com notes that “The American College of Obstetricians and Gynecologists (ACOG) said it considers the case to be closed as to whether a fetus can feel pain at that stage [20 weeks] in development.” Of course, while the number of people who would change their positions on the availability of second-trimester abortion if they believed that the fetus experienced pain during the procedure would be small to minimal, it provides a convenient, if false, cover for efforts to restrict access, including a House bill that passed just this month in Congress.
This use of fake facts and junk science has recently been expanded beyond restricting abortion to efforts to limit access to contraception for women. Let’s get this completely straight: access to contraception has been a terrific thing. It has given women – and men – much greater control of their reproduction, dramatically reduced the incidence of unintentional pregnancy (although this still remains far too high), and, duh!, even reduced the incidence of abortion. While the decision to use contraception should and does remain up to the individuals involved, it needs to be easily available to them. Thus access is critical. For many – including but not limited to teens – access is, instead, very limited, and there are ongoing efforts in Congress and in many states to further restrict it. Particularly onerous and vile is the effort of the Trump administration to roll back the ACA’s mandate for insurers to cover birth control, pandering to the religious right.
A terrific piece by Aaron Carroll on October 10, 2017 in the NY Times, “Doubtful science behind arguments to restrict birth control access”, details and refutes the bogus claims made by those who want, bizarrely, to do so. These include the idea that access to contraception has not reduced unintended pregnancy (it absolutely and most assuredly has, and greater availability would further reduce it). The Trump (and at the time, Tom Price-led) Department of Health and Human Services used cherry-picked and archaic data to support its tortured argument. Carroll notes that “In 2011, the unintended pregnancy rate hit a 30-year low. And the teenage pregnancy rate and teenage birthrate right now are at record lows in the United States. This is largely explained by the use of reliable and highly effective contraception.”
HHS also argues that there are health risks, especially from hormonal contraceptives. There are, of course, but there are health risks and side effects from any drug treatment, and the risk of harm from the treatment has to be weighed against the probability of benefit. Ironically, in the care of hormonal contraception, the most significant side effects (both symptoms and even blood clots) are similar to (if generally less severe than) those from the condition contraception is designed to prevent – pregnancy. That is, not using contraception because of concern about these side effects and then getting pregnant increases the risk of these adverse events!
The bugbear for religious conservatives in this debate is their fear that contraceptive availability will increase people – especially teens -- having sex, but for the rest of us the concern is how this would impact the unintended pregnancy rate. Carroll cites a “2016 study in The New England Journal of Medicine showed that the unintended pregnancy rate among women who earn less than the federal poverty line was two to three times the national average in 2011. An earlier study showed that in the years before, that rate was up to five times higher.” From a cost point of view, the study’s author, Jeffrey Peipert, notes that “Every dollar of public funding invested in family planning saves taxpayers at least $3.74 in pregnancy-related costs.” For women (and their partners), especially those who are low-income or teens, the direct cost for contraception is sometimes prohibitive, especially for the most effect type of contraception, long-acting reversible contraception (LARC), IUDs and hormonal implants, that have a high one-time up-front cost. It is the programs to make these more affordable and available are exactly the ones being targeted for major cuts. And, in the “adding insult to injury” department, the justification for cutting some programs is sometimes the existence of other programs, which are also being targeted for cuts!
The use of junk science, sadly but unsurprisingly, is not limited to contraception, abortion and even climate change. In a Viewpoint piece published in JAMA, October 10, 2017, “Flawed theories to explain child physical abuse”, John Leventhal documents a new trend in legal cases of child abuse. Defense attorneys bring in “medical experts” who testify that something else could have caused the child’s injuries. These include real diseases that could cause the findings but are both uncommon and can be ruled out with proper workup, real diseases that are very uncommon and unlikely to cause the findings, and essentially made-up conditions to explain the findings. Since child abuse is generally not a controversial area (nobody claims to be in favor of it!) the reasons for this seem to be mainly personal gain – such “experts” make big money for this testimony. There are not that many real experts in child trauma willing to offer absurd pseud-explanations for the injury, so there will be fewer of you willing to testify in defense of the perpetrators, so you again stand to make a lot more money.
In any case, the use of fake or fraudulent science and fake facts to support political agendas is one of the many bad things growing in the fertile “don’t try to tell me the facts” environment in Trumpian politics. The administration is now allied with “traditional” Republicans to facilitate rape of the planet in pursuit of gains for the wealthiest, and with “populists” in pursuit of social repression. There is some irony in that these advocates for “freedom” (e.g., from gun control) are so intent on denying it to others (e.g., gays, women, poor people, children), but apparently this is a long-standing US tradition (see: slavery), which inspired Abraham Lincoln’s famous quote “Those who deny freedom to others deserve it not for themselves,” There is also irony in the pursuit of the cloak of (fake) scientific facts to facilitate an anti-scientific agenda.
But the irony is not nearly sufficient satisfaction to mitigate the terror.
Monday, September 25, 2017
This is a guest post by Seiji Yamada, MD, MPH.
A shorter version recently appeared on the KevinMD blog, http://www.kevinmd.com/blog/2017/09/heres-glucometer-turned-doctor-medicaid.html
In a recent Vox interview, Senator Brian Schatz of Hawaii announced his plans to sponsor a bill to allow individuals without insurance to buy Medicaid coverage for themselves. As a family doc who cares for patients on Medicaid in safety net clinics in Senator Schatz’s home state, I cannot support such a plan.
While private insurance companies offer supplemental insurance, Medicare continues to be run largely by the federal government. In contrast, while Medicaid programs receive federal funding, they are largely run by state governments. In a trend known as Medicaid managed care, in recent decades, states have been contracting out Medicaid to private insurance companies.
Prior to 1994, Hawaii’s state Medicaid system was run by HMSA, Hawaii’s Blue Cross/Blue Shield. During the Clinton presidency, the buzzword was managed competition, the idea being that insurance corporations would compete on price to provide publicly funded health insurance. Thus in 1994, the State of Hawaii devolved to managed care Medicaid and started farming out Medicaid to other corporations besides HMSA. In 2009 Medicaid managed care was extended to the aged, blind, and disabled.
Medicaid also generally reimburses at lower rates than Medicare or private insurance. (Senator Schatz proposes to fix this.) However, low reimbursement is only one reason that physicians in private or group practice take few Medicaid patients today. Another reason is the administrative hassles to care put up by insurance companies as well as the difficulties of dealing with multiple insurance companies. Thus, Medicaid patients have relatively restricted networks of providers from which to choose. Many are therefore seen by safety net providers such as Federally Qualified Health Centers (FQHCs) or training clinics.
The modern practice of medicine is complicated enough, but the different requirements and different formularies of different insurance companies complicates it to Kafkaesque levels. I believe that the powerlessness and helplessness induced by this nightmarish bureaucracy is a major cause of physician burnout. I want to give just one example. Let us say that one of our patients has newly diagnosed diabetes. Let us say that he has Medicaid. Just to prescribe him a glucometer, I have to go through the following:
Patients on Medicaid must enroll with one of the following: HMSA, AlohaCare, Ohana (WellCare), United Healthcare, and Kaiser. I need to go to the insurance section of the patient’s Electronic Health Record (EHR) to find out which insurance corporation is responsible for this patient. Then I go to The Prescribing Guide (http://prescribingguide.com/), a cheat sheet developed and maintained by my family medicine faculty colleague Chien-Wen Tseng, MD. The prescribing guide tells me which brand of glucometer to prescribe.
Each insurer contracts with a different glucometer manufacturer, so I can’t just prescribe a generic glucometer. I have to figure out whether to prescribe Freestyle, or OneTouch, or AccuChek. Because the contracts are continually re-negotiated, the preferred brand can change every six months. If you enter the wrong brand, the pharmacy will reject it and tell you to get a prior authorization.
Next, I have to identify the ICD-10 code that corresponds to the highest complexity of the patient’s diabetes. Does she have nephropathy, or neuropathy, or ophthalmopathy? I often have to review the patient’s labs to see if the creatinine/GFR is abnormal. Am I going to place the patient on long-term insulin? Because if I am, I can justify asking for test strips for more than once a day testing. The number of times per day the glucose is to be measured, the ICD-10 code, and whether or not the patient is on insulin has to be on the prescription. If not, the pharmacy will reject it.
Now that I have prescribed a glucometer, I can now start working on prescribing a diabetes medication.
And I’ve yet to address the fatigue, the blood pressure, or the back pain for which his friend’s oxycodone worked real good, Doc.
. . .
“All the world's a stage, And all the men and women merely players” -Shakespeare
Was this theater of the absurd composed by Alfred Jarry? Samuel Beckett? No, this play was composed by the layers of business administration types that have piled onto the health care system over the past couple of decades to bring corporate-style efficiency to medicine. Insurance companies limit their costs by imposing roadblocks. By making it so time-consuming and so frustrating to get anything done, we physicians throw up our hands and decide, no it’s not worth the hassle to order a different medication or sophisticated tests. Perhaps my patient gaining weight on a sulfonylurea would benefit from a glucagon-like peptide 1 receptor agonists or a sodium glucose transporter 2 inhibitors instead. But the prior authorization form requires me to list the dates that the patient has taken every other diabetes medication she has ever been prescribed . . .
For those physicians who are employed by hospitals or other institutions, we are finding that our employers are engaging in an arms race with the insurers by hiring their own army of coders and billers. These coders and billers find our documentation lacking in order to maximize return. So now we are told to write addenda to chart notes entered months ago - in order to justify higher reimbursement. These coders and billers shake their heads sadly and say to themselves, “Dr. Yamada, you are such an idiot.”
. . .
The new interns started in July. When they were medical students, I taught them about the pathophysiology of diabetes, about the evidence base of what treatments have been shown to improve patient outcomes, about how to discuss lifestyle measures, about the social determinants of the development of diabetes. Now that they’re interns, though – all of that goes out the window. Now that they’re managing real patients, I teach them how to enter billing codes into the electronic health record, and how to get a glucometer covered by insurance.
They look at me with incredulity. They are dumfounded by how irrational and Byzantine our health system is. They realize that I am no longer teaching them medicine. Because there is no time for that now. There is only throughput. Treat ‘em and street ‘em.
“Welcome to the desert of the real,” I say. “Get used to it.”
. . .
The MBAs who manage us physicians say, “It’s not about throughput. It’s about quality. We’re not going to pay you for throughput any more. We’re going to pay for performance. We don’t care how many times you see the patient. We only care about their A1cs.”
OK, then, tell me how you get better outcomes with a patient with diabetes without seeing them every once to talk with the patient about diet and exercise, to prescribe a glucometer so they can learn how diet and exercise affects their glucoses. What is the point of telling the homeless patient to bring down their A1cs by eating more fresh vegetables? What use is the A1c when the patient has cancer? What does the patient dealing with domestic violence care about her A1c? To measure the quality of care provided by a physician through A1cs is like the drunkard searching for his keys under the streetlight because that’s where the light is. The A1c is easily measured. Other aspects of medical care are not so easily assessed.
. . .
Insurance companies and their corporate mind-set have so thoroughly taken over American medicine that we can hardly see the forest for the trees any more. EHRs, essentially designed for reimbursement purposes, define the patient encounter – such that physicians look only at their screens. I can’t afford to make eye contact with my patients, or I’ll fall hopelessly behind. Was there a time that we used to eat lunch? Nowadays, lunchtime is for finishing with charting or dealing with phone calls. Dealing with medication refills, or lab or x-ray results? Planning for the patients on tomorrow’s schedule? We do that in the evenings or weekends by remote access to the electronic health record.
Though Senator Schatz’s proposal would make Medicaid something like the public option that didn’t make it into the Affordable Care Act, it would likely leave intact insurance company-run Medicaid managed care – with its restricted networks and administrative hassles. As a practicing physician, I would like to get corporate profits and the layers upon layers of bureaucrats out of medicine. The American physician is in a predicament like that of Josef K in Kafka’s The Trial. The rules are obscure and seem to be constantly changing. We are never told what crime we committed to justify our being treated the way we are. The sense of a lack of agency and helplessness induced is one major cause of physician burnout. The practice of American medicine needs to be rationalized, so that we health workers can go back to focusing on the medicine. Medicare for All is what we need. Not all the inefficiencies and irrationalities of the modern practice of medicine will be fixed by Medicare for All – but patients and doctors need a way out of this Kafka novel.
Tuesday, August 29, 2017
‘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.
Monday, August 7, 2017
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.
Thursday, July 20, 2017
In his JAMA “Viewpoint” article, “Social Mission in Health Professions Education: Beyond Flexner”, June 17, 2017, Fitzhugh Mullan makes a convincing case for medical schools to be committed to their social mission. He takes his definition from the “Beyond Flexner” website (www.beyondflexner.org), which says “Social mission is about making health not only better but fairer—more just, reliable, and universal”. He details what this means in terms of commitment to reducing health disparities, increasing access to healthcare in both rural and urban underserved communities, increasing diversity within the health professions. These serious issues have been identified for decades, but in fact the trend may be toward getting worse instead of better.
Mullan cites some examples of medical schools, primarily newer and “community based” schools, that are working toward these goals. These include Morehouse and Mercer (founded in an earlier wave of medical school expansion in 1975 and 1982 respectively), those of a more recent expansion in the 2000s (Florida International University and the AT Still Mesa Campus), and those yet to come (the merger of Geisinger Health System and Commonwealth University, Kaiser Permanente School). But he also talks about “mainstreaming”, the need for consciousness about, and implementation of, social mission to be a characteristic of all medical schools.
I believe that the most important measures of a health professions school’s social mission are its outputs. Using the 3 criteria identified by Mullan and colleagues in their seminal 2010 Annals of Internal Medicine article “The social mission of medical education: ranking the schools”, we need to look at whether its graduates are more diverse, whether they practice in underserved areas, and whether they are more likely to be in primary care specialties. The 2010 article showed that some schools do better -- more often those that are public, newer, and not in the Northeast -- but the fact is that none is doing all that well.
The number of students entering primary care is a critical indicator because, based on national and international comparisons, a well-functioning health system should have 40-50% of physicians should be in primary care; the US is well below 30% and going down. Family medicine match rates are the most sensitive indicators of primary care production, because unlike internal medicine virtually all family physicians practice primary care, so a choice of this specialty means a commitment to primary care. In addition, it is the specialty most suited for practice in rural areas. Even if all schools consistently produced 50% primary care physicians, it would take at least a generation to get to that number for all physicians in practice, and we are far, far from this.
In 2012 John Delzell and I looked at 10 years of data (2002-2011) published annually on the family medicine match by the American Academy of Family Physicians (AAFP) documenting the number and percent of students from each medical school entering family medicine. We found only a few schools that were relatively high in both number and percent, with the University of Minnesota and the University of Kansas far ahead of the rest. And yet even those schools do not produce primary care physicians at the 50% rate. In the most recent AAFP report, on 2015 graduates, even the “socially conscious” schools cited by Mullan did not have very high numbers matching in family medicine: Morehouse 8 (12.9%), Mercer 13 (13.8%), FIU 4 (5%). Minnesota, at 42 (18.2%) had the largest number in the nation, but still had 20 fewer than it did in 1999! In 1994, the Association of American Medical Colleges (AAMC) announced Project 3000 by 2000, aiming for 3000 minority medical students into US schools by the year 2000. It failed. Today, in 2016-17, we are not only far from that number, but the percent of many minorities (especially African-American men) continues to drop.
As in any process, the results of medical (and all health professions) education are affected by 3 sets of variables. Input variables are the students enrolled, process variables include the curriculum and overall experience of students during their education, and output variables are the expectations of what the income and life experience of a graduate is likely to be. While the last is probably the most important determinant, especially given the degree of debt with which students are graduating and the fact that many specialists can earn 2-3 (or more) times as much as a primary care physician, it is also the area that schools have the least ability to influence. As Mullan and colleagues have emphasized, medical schools can influence the process variables, including the school’s vision and mission, the teaching of social mission, determinants of health, disparities, and other areas in their classrooms and clinics, experiences for students to serve such as free clinics, and mentoring and role modeling by faculty. However, making these changes seem to be insufficient to overcome the negative influence of the output variables in terms of students choosing primary care and practice in underserved areas. At least for most of the students currently in medical school.
Which brings us to the input variable: who is admitted? Clearly, from the data cited above, medical schools are not taking appreciable numbers of students from underrepresented minority groups, from rural areas, or from lower socioeconomic groups, at least not in anything close to the proportion in the population. They take, on the whole, white (and Asian) students from well-to-do suburbs of large cities who, not coincidentally, went to the “best” public and private schools and have the highest grades and Medical College Admissions Test (MCAT) scores. The problem for the health of the American people is that the strongest predictor of where a medical student will practice is where they come from; minority students are far more likely to practice in minority neighborhoods, rural students are far more likely to practice in rural areas, and white upper middle class students from the suburbs are more likely to practice in the suburbs. These are the areas that already have enough physicians (and sometimes too many). In a real sense, a physician who enters practice in a non-underserved area in a non-shortage specialty is contributing little marginal benefit to the health of the American people. The imbalance of physicians practicing in health professions shortage areas (HPSAs) vs other areas is demonstrated in the attached table from Zhang, et al.
And, most importantly, these changes and programs must happen at all medical schools and for the bulk of the classes. The time for experiments and pilot programs is done. These efforts must be scaled up, to be, in Mullan’s word, “mainstreamed”. And now is not too soon.
 Mullan F, Chen C, Petterson S, Kolsky G, Spagnola M. The social mission of medical education: ranking the schools. Ann Intern Med. 2010;152(12):804-811
 Freeman J, Delzell J, Medical School Graduates Entering Family Medicine: Increasing the Overall Number, Fam Med 2012;44(9):613-4.
 Kozakowski S, Travis A, Bentley A, Fetter G, Entry of US Medical School Graduates Into Family Medicine Residencies: 2015–2016, Fam Med 2016;48(9):688-95, (online Table A).
 Nickens HW, Ready TP, Petersdorf RG, Project 3000 by 2000 -- Racial and Ethnic Diversity in U.S. Medical School, N Engl J Med 1994; 331:472-476August 18, 1994DOI: 10.1056/NEJM199408183310712
 Zhang X, Phillips RL, Bazemore AW, Dodoo MS, Petterson SM, Xierall I, Green LA, Physician Distribution and Access: Workforce Priorities, Am Fam Physician. 2008 May 15;77(10):1378.
Saturday, June 24, 2017
“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.
Sunday, June 18, 2017
On many occasions this blog has made the point that, despite frequently-repeated claims that the US has “the best healthcare in the world”, we do not. This point is also made by dozens of other sources, recently including Kaiser Health News (KHN) editor-in-chief Elisabeth Rosenthal in her book “American Sickness”. In my book, “Health, Medicine and Justice: Designing a fair and equitable health care system”, and in many lectures I have given to physicians and students, I have cited the “37th in the world” ranking the US achieved in the comprehensive World Health Organization (WHO) report of 2000. The report’s Table 10, available as a pdf at that site, indeed lists the US as #37 in Overall Performance, just below Costa Rica and just above Slovenia. On an equally telling scale, Performance on Health Level (measured by Disability-Adjusted Life Expectancy, DALE) the US ranked #72, between Argentina and Bhutan. When many US news media led their stories with “Just ahead of Slovenia!”, the Slovenian ambassador took exception, noting that his country was working hard to improve their people's health status.
But, as I also pointed out in my lectures, this table is old, based on 1997 data, and I use it because it is the last time that WHO released such rankings. I supplement it with newer data, such as the Commonwealth Fund’s “Mirror, Mirror on the Wall” from 2014. This compares fewer countries, albeit appropriate, developed, wealthy, OECD countries. In this study, the US also ranks last overall and in many subscales; I have published this graphic before as well.
Now, we have new rankings to refer to, the Bloomberg Global HealthIndex from 2017. It would be nice to be able to say that the US had moved up from the 2000 WHO report, but now, at #34 (and still just behind Costa Rica) the change is really insignificant. Slovenia, it might be noted, has moved up, to #27, so maybe their efforts are paying off!
Given the recalcitrance of US health status to improvement, it is obviously important to look at the ”why” as well as the “what could be done?”. This is especially now, given that these ranking do not yet reflect any negative impact that may happen through the repeal of the Affordable Care Act (ACA) and its replacement by a a Republican plan (#Trumpcare). The contents of the bill that the Senate is currently working on, and which Majority Leader McConnell hopes to bring to a vote by July 4, remain secret not only to the public but also, apparently, to many or most senators. Therefore, the bill passed by the House of Representatives, the American Health Care Act (AHCA) remains our best guide to what the final plan may look like.
And it is not encouraging; the Congressional Budget Office (CBO) estimates that 23 million Americans willlose health insurance, about equally from loss of Medicaid expansion and from cuts to support for the health insurance exchanges set up by ACA. This will unquestionably mean that the overall health status of Americans will go down, both in absolute terms and relative to other nations. Without health insurance, people will not access health care, especially for prevention and “minor” problems (or problems that are not really minor but so far not, or minimally, symptomatic). This means that by the time that their health is so bad that they seek care, they are less likely to survive or do well, and also that the cost of their care will be far higher. This is not a plan to most efficiently use healthcare dollars to maximize the health of the American people.
So what is going on? In a recent blog post (“Pre-existing conditions and profit-taking: the causes of our healthcare problems, May 29, 2017) I wrote “The AHCA is basically a tax-cut-for-the-1% bill, with the money coming from the health care coverage for the rest of us.” That is true, but the question that still needs to be answered is “why”? Ultimately, it is a question of values: if the goal was to have the best possible health status for the American people, rich or poor, white or black, native born or immigrant, rural or urban, this would not be the system that we have and #Trumpcare would be designed to fix the problems with the ACA, not to exacerbate them. President Trump and the GOP have emphasized, in the campaign and since, that for many the ACA has not made insurance accessible because the premiums are too high. This is a good point, and a solution would be great; unfortunately, the AHCA would make them higher, and price out far more people. The values of the Republican leadership are clearly to maximize tax cuts and other financial benefits to the richest American people and corporations, and this AHCA will do. The perpetrators are not among those at the margins; even those congresspersons and pundits who are not truly wealthy have outstanding health insurance for life, and are certain that they will not be in the marginalized group, and that they will be able to access the “best health care in the world”.
Of course, even when you have great insurance and access to “everything”, it is not always better. Sometimes if you are too well-insured you get too much care, tests and procedures and drugs that can put you at risk of harm. And even in the “best” facilities things don’t always go well – medical errors are common, communication can be poor, and even when there are no screwups bad things can happen. Donald Berwick, head of the Institute for Healthcare Improvement (IHI), and former interim head of the Center for Medicare and Medicaid Services (CMS) talks about the US perhaps having the best “rescue care” in the world. But even that is not so good; many IHI initiatives are focused on changing that system to work better, including improvement capability, patient safety, and population health. Anyone who has been sick, or in the hospital, or had a close friend or relative in such a situation recently, can testify to the failings of our health care delivery system even for the well-insured.
So the situation in the US was not good up until now, and will almost certainly get worse with #Trumpcare. Many of the people who will suffer most are those who voted for the President and the GOP members of Congress. Maybe they think that the bad things will not happen to them and their families, but only to “others”. But they will, and we need to move up in the rankings, to be closer to other OECD countries.
Maybe the solution for the US is not to mimic France, or Italy, or Canada. But whatever the solution is, it has to pass the empiric “does it make our people’s health better?” test. And clearly #Trumpcare will not.
Monday, May 29, 2017
Elisabeth Rosenthal, the editor-in-chief of Kaiser Health News and author of “An American Sickness” (discussed in this blog on April 15, 2017, United Airlines, health care, and a system designed to privilege the powerful) has an op-ed in her old newspaper, the New York Times, on May 29, 2017 titled “We all have pre-existing conditions”. That is a good and accurate title, but a little different from the print title “The cost of pre-existing conditions”. That cost is high, to the people with those conditions, and less obviously, to the overall society. This includes their families and friends, of course, but also their employers. When a potentially treatable condition excludes you from having health insurance, you are less likely to get it treated, and more likely to get sick and miss work. The spectrum of conditions that insurance companies used in the pre-ACA era to exclude people was broad. Rosenthal notes specific examples including having had an abnormal Pap smear, a history of being on anti-depressants, a history of taking thyroid medication, and being on post-menopausal hormone treatment. Of course, once you are excluded and have no insurance, you don’t seek care for other conditions either, either pre-existing or those that develop later or might have not been recognized. Not only could insurers exclude you for having a pre-existing condition, but there was no regulation of what or how significant that condition had to be. We have heard stories of people being denied treatment for cancer because, on signing up, they had “failed to report” a pre-existing history of treatment for things as minor as an ingrown toenail or acne!
The ACA, also known as Obamacare, changed that. It eliminated the ability of insurance companies to exclude people based on their pre-existing conditions, thus rendering moot the question of what conditions could be excluded. It also prevented those insurance companies from charging more money to people with those pre-existing conditions by requiring “community rating”; they had to set their rates based upon the overall actuarial risk of the entire community in which they sell insurance. The same principle is why those of us who receive our health insurance via employers, especially large employers, usually have lower rates for better coverage – because the risk pool is everyone who works for that company, and while many are sick, many more are younger and healthier (after all, this excludes all the people who are not working). Thus, the requirement that the individual policies sold under ACA had to be based on the community rating was critical for many Americans to be able to get even close to affordable health insurance.
For many, the cost on the individual marketplace was still too high. For those whose pre-existing conditions had previously made them unable to get insurance, it was often still a boon. For those who were younger and healthier, though, who had had cheaper policies or gone without coverage altogether, they now had to pay more. After all, community rating means an average, so those at lower risk will pay more than they would have with individual rating, and certainly more than with no insurance since the ACA had the “individual mandate” requiring them to get coverage. The bigger problem is that in some geographic areas, many (or most or in some cases all) insurers decided that the benefit of offering insurance (i.e., making money) was not worth the risk of paying out for actual medical care. This is especially true in rural areas, where low population density and a higher proportion of older and therefore sicker people make for a poor risk/return ratio.
The problem, of course, for those younger and healthier people who chose to forgo coverage or, after the individual mandate, to buy the cheapest and crappiest policies, is that they can get sick. They can discover that they have cancer, whatever their age. Or get into a car accident, requiring many surgeries and long treatment and rehabilitation (did they have car insurance?). Or be burned in a fire started by smoking (did they have homeowner’s insurance? Did they opt to not pay the higher premiums that they can legally be charged for being smokers?) Or they can have a premature baby that needs treatment in a neonatal ICU. Or, particularly for the older group who knew they had a problem like hypertension, diabetes, or arthritis but were hoping they’d stay relatively asymptomatic, they can have a downturn – have a stroke or a heart attack or a serious infection or pain so bad that they can no longer work. And then they find that the “affordable” (i.e., crappy) health insurance that they bought is almost as bad as none.
So we have a conundrum. To work, health insurance has to include everyone, the sick as well as the healthy. But the healthy, especially those with lower incomes, don’t want to pay what seems to be the unfairly high rates that they have to in order for the whole system to be fair. The older and less healthy may want health insurance, but still be dissuaded by the high premiums. The sick need the coverage, but again, without the healthier paying in, the cost for them is too high, and results in either their being unable to afford it or the insurers being unwilling to cover them even if it means leaving an entire market.
Let’s look at some facts:
1. The US spends more on health care than any other county, by far.
2. The US has, on a population basis, worse health outcomes than most other developed countries, far worse than many.
1. The US spends more on health care than any other county, by far.
2. The US has, on a population basis, worse health outcomes than most other developed countries, far worse than many.
This is the true conundrum. How can we pay so much for so little? It is because we pay an enormous percent of our “health care” expenses for drug company (and drug “middlemen”, pharmacy benefits managers) profits, insurance company profits, and income for for-profit and function-like-for-profit non-profit hospitals. As documented by Eric Lipton and Katie Thomas in the May 29, 2017 Times (“Drug lobbyists’ battle cry over prices: blame the others”), there is plenty of blame to go around! In addition, the percent that is actually spent on health care on treatments (and sometimes cures) is primarily for far advanced disease, not prevention and early diagnosis and treatment. We spend almost nothing on public health and prevention.
We keep telling ourselves lies (our healthcare system is the best in the world, the ACA is the problem, drug companies need to charge so much because they spend so much on research and development, etc.) but fewer and fewer of us are believing it. Many of the people who are worst affected voted for Donald Trump and for Republican congressmen who have devised the AHCA (American Health Care Act) that will “solve” the problem by essentially eliminating health insurance coverage for 23 million Americans, 14 million in the first year alone, according to estimates by the non-partisan Congressional Budget Office (CBO). The AHCA is basically a tax-cut-for-the-1% bill, with the money coming from the health care coverage for the rest of us.
Is there any way out of this conundrum? Yes. We have the money, obviously; we are spending it. Fifty percent of health care spending is already government, 60% if you include the lost taxes from the employer portion of health insurance. We make the community being rated everyone in the US. We all have one health plan. We are all covered. We all get all necessary services. We don’t lose coverage by leaving or jobs for any reason, from family needs to an entrepreneurial start-up. The old and vulnerable among us are covered and have their needs met, and the healthy among us win by staying healthy and having coverage when we need it. We pay for it by eliminating the profit centers, and not by cutting taxes on the wealthiest of us.
It can be done. It has been done. In every other developed country. We have the resources to do it here. We must need to stand up to the entrenched and powerful profiteers.