Ebola, risk, and the public’s health

My friend Allen Perkins received a text from his college-student daughter asking if she should be worried about the Ebola virus. His reply, discussed in “Ebola virus and the dread factor” in his excellent blog, “Training Family Doctors” was “Are you considering moving to west Africa?” This was wise and profound fatherly advice, based upon an understanding of the epidemiology of disease. While is it obviously a serious problem in West Africa (particularly Liberia, Sierra Leone, and Guinea), it is not in the United States. Many other things are much more of a threat in the US, including, as Allen points out, “death from bee stings” (100 per year in the US).
Ebola might someday become a significant problem in the US, but it is unlikely and is not now. Many other health problems are. College students like Allen’s daughter should be sure that they have all their recommended immunizations for diseases that can be prevented by vaccine, including HPV and meningococcus, a very serious and often deadly cause of meningitis that can become epidemic where young people live together in close quarters, like college dormitories (and army bases). Yet, many do not receive these immunizations for reasons that range from passively not getting it done (less of a problem in schools where it is required) to having beliefs, or having parents who have beliefs, that vaccines are dangerous and should be avoided (in some cases this can trump school requirements). They are, by the way, wrong. The net benefit far outstrips the risk. Having your child get meningococcal meningitis and die or have serious brain damage, or get cervical cancer, is not something you want.
But focusing on conditions over which we have little or no control, rather than the ones we do, is fairly epidemic in this country (and likely others). Dr. Perkins focuses on the “dread factor”, about how news reports (not to mention thriller movies) whip up fear about these diseases. On the other hand, mostly what we can do is fear them, while the diseases which we individually might be able to have an impact on would require us to have to maybe do something hard: change our diet, start exercising, stop smoking, not drink so much or at the wrong times. I have written in the past about a patient who had a terror of breast cancer, a disease for which she was not at an increased risk based both on her youth and lack of family history. On the other hand, she did not seem particularly worried about the health risks of her uncontrolled high blood pressure, smoking two packs of cigarettes a day, or having unprotected sex with several different men.
Most of us can see that this is not logical, and maybe even snicker a little about her poor decision making. But it is only a little extreme. Many, perhaps most, of us, could do a better job of eating right, of exercising, of not smoking or drinking excessively (which for many people is “at all”). If not Allen’s daughter, many of her classmates are at much greater risk from going out and getting drunk on a weekend night, increasing their risk of motor vehicle accidents, sexual assault, poor judgment in choosing voluntary sexual encounters, and long term habituation for those with a predilection for or family history of alcoholism, just for starters. But taking action to prevent such bad outcomes is hard, requires effort, and often means not doing things we like in the short term, such as eating tasty-but-unhealthful foods, drinking with friends, smoking when we are addicted to nicotine, driving when we (or the driver) is only a “little drunk”, or having to do unpleasant exercise. Or it can conflict with our self-image: wearing a bicycle or motorcycle helmet, eschewing doing things that our friends are doing. Worrying about things that we can do nothing about, like breast cancer or Ebola, may be a little irrational, but it is in some way comforting because if the bad thing happens we are an innocent victim.
In addition, there are actions a society can take, that could make even more of a difference from a public health, population health, point of view, saving more lives, but these require political will. Sadly, this is often more lacking than individual will. Guns are the prime example; many state legislatures and legislators make it a point of personal pride to advocate for there being no restrictions at all on what kind of guns (e.g., automatic weapons) and ammunition (e.g., armor piercing bullets) people can have or where they can carry them (everywhere, open or concealed). Helmets and alcohol regulation are other areas where opportunity for prevention is often missed. Car safety has been increased by car and highway redesign and tobacco has been increasingly regulated (against the opposition of the industry, it should be noted, in both cases) for the benefit of public health, but many opportunities remain.
Indeed, expanding health coverage to all those below 133% of poverty by Medicaid expansion continues to be opposed by those who want to be seen as against Obamacare. This may be irrational from a public health point of view, but in many states it is rational, if offensive, for being re-elected. The most unjust and inequitable part of it all is how the effects of poor public health policies most affect the most vulnerable, poorest, least empowered people in our society, or indeed any society. Public health education campaigns tend to focus on diseases that have well-funded advocacy groups and affect the majority population; a recent qualitative study of African-American women found that they were very aware of the threat of breast cancer, but hardly at all of stroke – a disease statistically more likely to affect them.
Speaking of public health, it is gratifying to see some newspaper coverage of Ebola that is not sensationalist or scary.U.S. Colleges See Little Risk From Ebola, but Depend on Students to Speak Up”, by Richard Pérez-Peña in the NY Times, August 30, 2014, addresses the small but real risk that may affect colleges from students who have (unlike Allen’s daughter) actually traveled to West Africa. Even better is “Leadership and Calm Are Urged in Ebola Outbreak” by Donald G. McNeil, Jr., which presents a rational, thoughtful, public health approach, and discusses public health strategies which have been used in the past in major crises and are beginning to be implemented in West Africa. These strategies center around the use of local, respected experts who can effectively communicate with the people in their countries, rather than international aid agencies. The goal is to help people to utilize appropriate prevention and protection measures rather than panic. Again, as in the case of the other personal behaviors described above, this can be hard for people, especially when it contradicts cultural and religious values (such as how the dead are buried). But having voices who are local, who understand the culture, and have both medical/public health credentials and individual credibility, is extremely important. Of course, unlike the Ebola “scare” articles, these were both on page 8 of the newspaper, but have a more prominent position on that day’s Times homepage.
So what are the lessons? Understanding risk is not always easy, especially when an epidemic with a hugely high mortality rate threatens.  Doing something is harder than not doing anything, and it can thus be tempting to worry more about the things that we can’t do anything about rather than those we could reasonably take action on. The same is true for public health issues that need to be addressed at a societal level.
And, of course, it is always the most vulnerable who suffer the most.

Kansas only state to increase number of uninsured: A how NOT to do it strategy

The title of Alan Bavley’s article, “Kansas is only state to see an increase in its uninsured rate, survey says”, (Kansas City Star, August 5, 2014) kind of says it all. It could be seen as a victory by some. Four years after the passage of the Affordable Care Act (ACA), aimed at expanding health coverage to more Americans by a combination of strategies including the creation of both state-run and federally-run (for those states that chose not to run their own) insurance exchanges to match people seeking coverage with insurance companies and subsidizing premiums for the moderately low-income, and expanding Medicaid for the very low-income, Kansas has succeeded in actually reducing the number of people covered!

The adult uninsured rate in Kansas rose from 12.5 percent last year to 17.6 percent during the first half of this year, giving the state the seventh-highest rate in the nation, according to data collected as part of the Gallup-Healthways Well-Being Index…. in other states uninsured rates declined or remained unchanged. Kansas was the only state with a statistically significant increase in the percentage of uninsured residents.
One could construct a fantasy out of whole cloth demonstrating how this proves why the opponents of the ACA were right all along; that it is not increasing health care coverage because it is evil and socialist, and that the increased costs for some people, along with cuts in the number of employed folks because of policies that do not always support “job creators” (read: very rich people) have decreased our employer-based insured group. Of course, that would be incorrect, but I expect to see it anyway.

In fact, those governing my state have worked very hard to make this happen. Governor Brownback and most of the state legislature are strong opponents of Obamacare, and have done what they could to make it not succeed. When the Supreme Court ruling allowed states to opt out of expanding Medicaid, Kansas did so, eliminating the very poor (under 133% of poverty) from the method the law intended for them to receive coverage. Kansas also chose not to develop a state-run insurance exchange and pu up as many obstacles as it could to the federally-run one. One of two Court of Appeals decisions (discussed in this blog in ACA: Where are we? And where should we go?, July 27, 2014) ruled that subsidies could be available only to enrollees in state-run exchanges (which Kansas doesn’t have); it hasn’t gone into effect yet, because another district’s Court ruled the other way, so we will have to wait for the Supreme Court to decide, but if it is upheld would bolster the number of Kansans not getting insurance.

But a decrease in the number of insured? The only one? Surely that is a notable accomplishment. How did we pull that off? “’It’s eye-popping. Kansas really sticks out,’ said Dan Witters, research director for the Well-Being Index, an ongoing national poll that surveys people’s health, relationships and finances.” For starters, it could, possibly, not be exactly true, but a data anomaly of the survey somehow. This is basically the position of the state’s Insurance Commissioner, Sandy Praeger, who said

…the number “appears to be an anomaly that needs more review. To have the uninsured jump that much in one year would be unprecedented.” The uninsured numbers in Kansas have hovered around 12 to 13 percent for many years, Praeger said, adding, “We will try to find out where the discrepancy is.”
This is worth noting, as Praeger is one of the few honest, trustworthy, and non-ideological members of state government in Kansas. Note that she does not claim that it is a liberal lie, or that it is a good thing, but just that it is inconsistent with previous data and she will try to find out why there is a discrepancy. If that is the reason, I’m sure she will.

But there are reasons to think that the numbers may not be inaccurate, even if they turn out not to be quite as bad as this survey indicates. Since the election of Governor Brownback in 2010, and with the support of the legislature, taxes in Kansas have been slashed, particularly income tax rates on high-income people and corporations and business taxes. The motivation was a profound belief in supply-side economics, that tax cuts would stimulate job growth.  Unfortunately, it has not. Job growth in Kansas has been more sluggish than in the country as a whole, and the state is facing enormous deficits. Cuts in spending have been dramatic, but the problem is, in fact, on the supply side – not enough tax revenue.  People don’t have jobs, and thus often don’t have enough income to qualify themselves for the exchanges, even if subsidies are allowed by SCOTUS to continue. The state has a very large number of undocumented workers (and most are indeed working, or in families of people working) who would not be eligible for coverage by any part of ACA, and can only get it if their employers pay for it. Which many do not.

While many states with Republican governors have pursued many of the same tacks as Kansas, including limiting the impact of ACA and cutting taxes, Kansas has been in many ways a test case for these strategies, even more than Wisconsin, because of its strong Republican tradition. Americans for Prosperity has a very strong political and financial influence in the state, and it is heavily financed by the Koch brothers whose Koch Industries is based in Wichita, Kansas (where Charles Koch still lives). Cutting taxes for the wealthy and corporations, and blocking any opposition to fossil fuel expansion, is the cornerstone of state politics, not ensuring the health or well-being of its residents.

In a larger sense, however, this is more than a story about Kansas. It may be the only state with a statistically significant increase in uninsured in the last year, but it is far from the state with the largest percentage of uninsured. Many other states that have not expanded Medicaid, and cut social services, have similar situations. Sadly, of course, many of these states (particularly in the southeast) started pretty far down, much worse than Kansas did, and have dug themselves deeper in the hole. The real story, I think, is in the states that, despite being southern and conservative, have chosen to expand Medicaid, and have seen real benefit for their people.

The Gallup poll found that the 10 states with the largest reductions in uninsured rates this year had all expanded their Medicaid programs and had either created their own exchanges or partnered with the federal government on an exchange. Arkansas saw the steepest decline, from 22.5 percent uninsured in 2013 to 12.4 percent this year. Kentucky was second with a decline from 20.4 percent uninsured to 11.9 percent.


Good policies can actually help. The state with the actual highest rate of uninsured people is Texas. “Look out, Texas,” Governor Brownback stated in announcing his original tax cuts, “here comes Kansas!”  He was talking about job growth, which we haven’t achieved, but we are making much more progress on denying people access to healthcare coverage.

Opioids and other pharmaceuticals are the tip of the iceberg: It’s the profit, stupid!

The NPR program “Fresh Air”, with Terry Gross, had Anna Lembke, MD as a guest on December 15, 2016. Dr. Lembke is the author of the recent book “Drug Dealer, MD”, in which she apparently (per the discussion on air; I have not read it) implicates physicians and pharmaceutical companies in the widely discussed “opioid epidemic”. Dr. Lembke is a Stanford psychiatrist and director of the addiction medicine fellowship there, and she is able to articulately describe what is known and what is not about the neurological impact of opiates and opioids on the brain. One important point she makes is that continued use of opioids causes tolerance and a need for higher doses; in addition she describes how chronic use of opioids causes a pain syndrome of its own (decreased tolerance to pain) in some people, and how weaning them off opioids can actually decrease or eliminate their pain.

Her key issue, however, is that the epidemic of opioid use was orchestrated by the pharmaceutical manufacturers of opioid analgesics, who heavily promoted them, created the perception among doctors and the public that physicians were heartlessly undertreating the pain that their patients were in, and hooked in (mostly) well-meaning doctors to become, in essence, their pushers (“Drug Dealer, MD”) while they made huge profits. And continue to do so. And, as the reaction to this epidemic begins to form, continues to promote new syndromes that require treatment with their drugs.

An example of this is “OIC”, opioid-induced constipation, which made its first big appearance during the Super Bowl of 2016. The commercial left it a vaguely mysterious ailment, but it is a real one. Of course, the commercial was a prelude to an advertising campaign, in this case for Movantik ®, a partial opioid antagonist manufactured by a collaboration between AstraZeneca and Daiichi Sankyo designed to treat this condition. Constipation, in fact, is the only side effect of opioids that does not decrease with continued use, so as a person uses higher and higher doses of the opioids to try to control their pain, their constipation gets worse and worse, sometimes requiring surgery and occasionally death from a ruptured colon. My reaction, while understanding we would soon see a drug for this condition promoted, was that it was a cynical and disturbing attempt to “normalize” opioid addiction. “Oh, you have this problem? Well, it’s not just you! LOTS of people have OIC!” It turns out that I was not the only one with this reaction; Ahiza Garcia on in a piece on CNN Money called “Super Bowl drug ad sparks big backlash”, quotes Dr. Andrew Kolodny, executive director of Physicians for Responsible Opioid Prescribing: “It’s very disturbing to see an ad like that. It’s normalizing the chronic use of opioids, which aren’t demonstrated to be safe over the long term.”

Of course the greed and anti-social behavior of pharmaceutical manufacturers is neither new nor is it going away. Their efforts to use doctors and exploit the public as much as they can possibly get away with in pursuit of exorbitant profits continues to generate news, and occasionally, reaction by states. We have all heard about the huge price increase in Daraprim ® by Martin Shkreli and Turing (Drug prices and corporate greed: there may be limits to our gullibility, September 27, 2015) and Epi-Pen® by Heather Bresch and Mylan (Epi-Pen® and Predatory Pricing: You thought our health system was designed for people’s health?, September 3, 2016) and maybe thought that this publicity would rein in further abuses. But not so. Reuters just reported in “US states sue Mylan, Teva, others for fixing drug prices” that “Twenty states filed a lawsuit Thursday against Mylan NV (MYL.O), Teva Pharmaceuticals (TEVA.TA) and four other generic drug makers, saying they conspired…on pricing of two common generic drugs, according to a copy of the complaint.” Lest you think that this conspiracy is just preventing these companies from being undercut by each other, we are talking fantastic price increases for common and necessary drugs. “The drugs involved in Thursday’s lawsuit include the delayed-release version of a common antibiotic, doxycycline hyclate; and glyburide, an older drug used to treat diabetes. Doxycycline, for example, rose from $20 for 500 tablets to $1,849 between October 2013 and May 2014, according to Senator Amy Klobuchar, a Minnesota Democrat who had been pressing for action on high drug prices.” In case you missed it, this is a 9245% increase in the price of doxycycline! And it may well be up to the states to bring such legal action, since there is little reason to think that the federal government, led by President-elect Trump and his corporate cabinet, along with the Republican-dominated Congress, will be doing anything about it.

Which, of course, is the core problem, and has been for a long time. Corporate profit has become the be all and end all of US policy. Anything that increases corporate profit is seen as good. This certainly includes subterfuge, cheating, exploitation, and corruption. While this has long been the case, it is likely to increase under the Trump administration, with its depressing panoply of corporate exploiters and climate change deniers. We are likely to see not only tolerance of encouragement and celebration of such outrageous excesses. Of course, it is fine to make a profit, but that profit should be reasonable and honest; it should not be highway robbery, generated by dishonesty, exploitation, and trampling others.

The pharmaceutical company activities cited about are the result of an attitude that “if we can make some money honestly, look how much more we can make if we are corrupt!” that pervades virtually every industry, from fossil fuels (see Rex Tillerson, the Exxon CEO who is Trump’s nominee for Secretary of State) to financial services. After campaigning against Goldman Sachs, the largest investment bank, and its ties to Hillary Clinton (“I know the guys at Goldman Sachs. They have total, total control over [Cruz],” Trump said. “Just like they have total control over Hillary Clinton”), Trump has named at least four current and past Goldman execs to cabinet-level positions, including its #2, Gary Cohn, as director of the National Economic Council. And, should anyone harbor any illusion that the survival of Goldman in the face of the collapse of rivals Bear Stearns, Merrill Lynch, and Lehman Brothers has anything to do with their being more honest or less evil, less likely to have indulged in “the Big Short” and transferred all their toxic investments to their own clients, read the recent piece by Matt Taibbi in Rolling Stone, “The Vampire Squid occupies Trump’s White House”.

Speaking of Rex Tillerson, his close ties to Russia and Vladimir Putin are seen (by the President-elect) as major qualifications for Secretary of State. In this context, the New York Times Op-Ed by Andrew Rosenthal from December 15, 2016, “To understand Trump, learn Russian”. Rosenthal notes that Russian has two words for “truth”:
The word for truth in Russian that most Americans know is “pravda” — the truth that seems evident on the surface. It’s subjective and infinitely malleable….But the real truth, the underlying, cosmic, unshakable truth of things is called “istina” in Russian. You can fiddle with the pravda all you want, but you can’t change the istina.

The pravda will change a lot with the new administration. Fossil fuel extraction is all good, climate change is a hoax, public education is bad, getting rid of the ACA will improve access to healthcare, immigrants are the problem, Putin is good, and gays and transgender people have no rights. That putting foxes in charge of the henhouse makes sense, and that having corporate titans in direct rather than indirect control of government will benefit us all. But the growth in the gap between the wealthiest and the rest of the people has grown under both Republican and Democratic administrations and anger at it was actually one of the drivers of the vote for Trump.


The istina, though, is that making the wealthiest wealthier and destroying the earth in the process is not the answer. Attention to the common good, for all of us, is the only thing that will move us forward, as a society and as a world.

Black men being killed by police: A public health epidemic

“Let’s do it to them before they do it to us,” was the line with which Sgt. Stan Jablonski (played by Robert Proskey) dispatched his troops on the old TV show Hill Street Blues. When Sgt. Jablonski replaced Sgt. Phil Esterhaus (on the death of actor Michael Conrad) they had to come up with a replacement for Esterhaus’ “Let’s be careful out there”. Perhaps the show’s writers felt it was ok coming from the shorter, pudgier actor than the 6’6” Conrad, but it has a very different meaning and very different connotation, an “us against them”.
Presumably the “them” was bad guys, not the regular folks that the police were supposed to be there to “protect and serve” but now, 30 years after the show went off the air, we realize how much this was, sadly, prescient. I am not going to recite the names of all the black men – and children – killed by police in recent years, including Tamir Rice, Michael Brown, Freddie Gray, Philando Castile, but it is an epidemic. Yes, more white people have been killed by police than black in both 2016and2017 – about twice as many – but the proportions are way off given that just over 12% of the population of the US is black. And what has been even more graphic is the lack of convictions, and frequently even prosecutions, of the perpetrators.
If these deaths were not at the hands of police, but rather had a different cause – an odd virus that struck down black men when being confronted by the police, or a very selective alien attack, we would not hesitate to call it an epidemic and search for the cause. But this issue is political, it is personal, it is an “us” against “them”, raising the issue is seen by many to be attack on the police, who heroically and at great risk to themselves protect us from evil. Certainly, the Governing Council (GC) of the American Public Health Association (APHA), by far the largest public health association in the nation, did not choose to identify the killing of black men by police as a public health epidemic when it voted, 65%-35%, against a resolution so designating it at the recent meeting in Atlanta. The resolution had been introduced a year before, and sent by the GC back to the authors to make changes to the language, which was done. But it was not sufficient.
If it was the language, felt, for example, to be denigrating to police, that was the issue, members of the group could have introduced and passed amendments to correct it. This point was made (after the vote) by APHA immediate past President Camara Jones, MD MPH PhD. But it was not the issue; the GC (and thus, the APHA) did not want to take a stand identifying the killing of black men by police in the United States as a public health epidemic. Speakers against the resolution cited personal but irrelevant concerns like “my brother is a policeman, and he is a good man”, as well as saying “the data is not sufficient to make the case that it is an epidemic”, which is patently false. The vote was portrayed as a scientific decision, but it was clearly a political one, a decision by the overwhelmingly white group to put their fingers in their ears, their hands over their eyes, and shut their mouths rather than standing up and saying “this is a problem”.
Many of these killings have been of people (usually men, but sometimes women or children) who were not involved in committing crimes. They result from the heightened suspicion police hold of black people in general. If you don’t believe that, you’re probably white. Just before the vote, I was at an session at the meeting discussing police violence against black men. Most of the group was minority (predominantly black) and were relatively young public health professionals, students, and junior faculty in schools of public health. A couple of speakers introduced the issue, but then opened the floor. One by one, in random order, unrehearsed, person after person in the group talked about their fears and their experiences; these were not prepared in advance, but slowly came out, one giving rise to another. A government employee noted that she had two young sons, and worried about their safety. Another woman, a public health professional, noted that her flight to Atlanta departed at 5:30am, so she’d left her home in a mostly-white suburb at 3:30am to go to the airport. She was followed by a police car all the way into the city. Another woman, a professor, talked about driving to a neighboring state and being followed by a police car that eventually stopped her for no reason or violation; in the process the officer asked “if you’re a teacher, why aren’t you in school?” The stories went on and on, from the mouths of professional people, most of them, in fact, women. 
Although many people would disagree, often virulently in with this age of Trump giving loud voice to aggrieved white men, being white in America is a privilege. It is a privilege of not thinking that you will be followed by police, or pulled over by them, or subjected to inappropriately probing questions by them. It creates an illusion, obviously held by the majority of the GC of the APHA, that it is mostly criminals, or “probably-criminals”, or people who look like they might be criminals, who are followed by, stopped by, and sometimes killed by police. But that is not the experience of black people in this country, not the black men shot by a police officer who makes up a story about being threated, nor of the middle-class professionals who told their stories at that APHA session. It is not the experience of the young woman who drove me to the Atlanta airport from the conference; in talking she said she had a 3-year old son and I asked if she feared for his safety not just from gangs but from police. In response she said she did, and pointed to a button hanging from her rear-view mirror and said “my uncle was killed by the police 3 years ago”. I don’t know what occurred with her uncle beyond what she told me, but I suspect it is not fate, coincidence, or Kismet that caused my driver to have her own story to tell, but rather the ubiquity of this experience among black people in America.
What about the police? Don’t we have to worry about the safety of the people who risk their lives each day to protect us? What about the fact that there are many (if not enough) minority police officers? To identify the current situation, not only the killings but the very real sense of most black people in this country that they do not have the same rights as whites, that they are, by definition, “suspicious” because of their color, does not require denigration of all police officers. Indeed, the families (especially male family members) of black police officers, and even the officers themselves when off-duty, experience the same indignities (and worse) as other black people.
It does mean that the idea that a police officer’s first loyalty is to other officers rather than to the community that they “protect and serve” must be very narrowly construed. Rather than a “thin blue line” of brothers (always, it seems, brothers, not sisters), it means that we should have tighter standards for police, excluding those who are overtly and viciously violent and racist. It means better training in identifying a situation in which you see through your prejudice and not through reality, and how to de-escalate. It means that when an officer kills a person innocent of a crime, it is not enough for other officers to have not “done it”; they must, if they were unable to prevent it, disclose it and discourage it and, yes, testify against the perpetrator. Police officers who do so are not “traitors”, they are heroes who allow the force to be thought of as we want to think of them.
The fact that even the most respectable and middle-class black people have to fear interactions with police (even when they are the ones who have called them!) is a societal scandal. The enormously disproportionate killing of black men by police is an epidemic, and like all epidemics we must identify it as such, find the cause, and treat it.
Even the APHA should be able to acknowledge that.

Status Syndrome: an important determinant of health

This is a guest post by Linda French, MD, who is Chair of the Department of Family Medicine at the University of Toledo School of Medicine.
In a recent blog (Keeping immigrants and all of us healthy is a social task), May 19, 2013), my good friend Josh Freeman wrote about the social determinants of health. When I commented that arguably the most important determinant was missing from his list he suggested that I write this book review blog as his guest. While I had long ago read quite a few papers on the topic of social determinants of health and health disparities that addressed the material that Josh covered in his blog, for me it was an eye-opening experience to read a book a few years ago by Michael Marmot (2004), The Status Syndrome: How Social Standing Affects Our Health and Longevity[1]. I found Professor Marmot’s explanations to provide a unifying idea that resonated with me.

Everyone knows that wealthier people are on average healthier than poorer people. However, it doesn’t follow that wealthier countries, including the United State (US), are necessarily healthier than poorer countries. For example, three countries that I am rather familiar with, Chile, Costa Rica, and Cuba, have life expectancies and other population health statistics that are as good or better than ours despite huge differences in average wealth.
Professor Marmot’s thesis is that, after a minimal threshold, it is not so much absolute differences in material means that makes wealthier people healthier, but rather their perceptions of their social status within their reference group. To quote him,
The remarkable finding is that among all of these people [i.e. the groups he studied], the higher the status in the pecking order, the healthier they are likely to be. In other words, health follows a social gradient. I call this the status syndrome.”

Professor Marmot is a British physician and epidemiologist from University College, London. His book carefully presents the evidence that it is the psychological experience of how much control you believe you have and your opportunities for full participation in society that is at the heart of social determinants of health.  He presents evidence from many countries and comparisons between them, and evidence related to individuals within different types of social hierarchies, and finally ends with evidence that countries with less inequality are healthier than those with more.
One example that he discusses in detail is that British office workers at the bottom of the office hierarchy have a higher risk of heart attacks than senior managers at the top, while just a generation ago popular wisdom was that highly successful “type A” personality people in stressful jobs were more prone to coronary artery disease.

Before reading his book I had seen some documentaries on primates that suggested that lower status animals had poorer health and reproductive outcomes and shorter lives on average compared with high status animals that was relatively unrelated to sufficient access to resources such as food. In addition I lived for a number of years in Chile as a young adult; my middle class income by Chilean standards was dire poverty by US standards. I was an American expatriate, a status  that was highly regarded in Chile, and also during some of those years I was a medical student. Despite the fact that I was really poor by US standards I was happy and healthy and my children also seemed as happy and healthy as US kids. After returning to the US I read some papers that included data to show that the generation of newly arrived Hispanic immigrants enjoy relatively good health outcomes, which deteriorate in subsequent generations despite the fact that the families have acquired more material wealth in absolute terms. No good explanations were included for the findings in those papers. After reading The Status Syndrome it made sense to me. The initial immigrants were probably using their country of origin as the social reference and subsequent generations had a US social frame of reference. I concluded that minority groups in this country have health disparities in large part due to the experiences of inequality and discrimination relatively more than due to absolute access to material means or even specific services – including health services.

In the latter part of his book Professor Marmot demonstrates that the countries with the best health statistics in the world are those that are both relatively wealthy and more equal. Examples of such countries are Sweden and Japan. On the other hand, countries at the other end of the spectrum present a reaffirming contrast. He spends the latter part of the book arguing for a political agenda in favor of reduction in social inequality.

If you haven’t figured it out by now, I highly recommend this book. It will transform how you think about the social determinants of health.



[1]Marmot, Michael. The Status Syndrome: How Social Standing Affects Our Health and Longevity. Owl Books. Henry Holt and Company. New York. 2004.

Battling for Biomedical Supremacy? How about improving the people’s health?

In an editorial on August 30, 2015, the New York Times discusses the “Battle for Biomedical Supremacy”, looking at the practice of what they call “poaching” of biomedical researchers by one state or university from another. Their main focus on the receiving end is Texas, because it has the highest profile of spending really big money to recruit researchers from universities in other states, and its main concern is (unsurprisingly) New York, which has more medical schools than any other state, and especially private medical schools with big endowments and big research programs to be “poached”. They raise the issue, but I am not (after reading it a few times) quite sure what their position is and I am afraid that they may not be either, since usually the position of the Times editorialist is clear. It seems to be saying “Well, New York needs to join this, but not spend too much public money on it.” But the editorial certainly does not condemn the practice.
I am not sure that I am wholly against it, either. Biomedical research is important. Researchers who can get better jobs (higher paying, more money to support their work) should not generally be criticized for accepting them. People have that right. On the other hand, from the point of view of the institutions that are being poached from, there can be not only feelings of sadness, betrayal, and anger, but in many cases financial losses that result from money they spent to recruit these “top researchers”, and now is down the drain, or so it seems. Sometimes these researchers are signed to contracts, just as physicians who bring in lots of money for a hospital are. These contracts for physicians may contain “non-compete” agreements, which (try to) restrict the area in which a physician leaving their employment can practice. They are more enforceable when they are more local, preventing them from going over to direct competitors, but not when someone is moving from NY to Texas. And the competition in biomedical research is much more national than the competition for direct medical care. On the other hand, if you hire mercenaries, you run the risk that someone will offer them more.
So it can increase the income and resources for the individual investigator (and his/her “team”) and can increase the status of the successful university, and might (in some cases) impact directly or indirectly on the economies of the local area, and thus state. Whether it is “worth it” from a direct financial return-on-investment (ROI) point of view probably depends upon the individual situation. It is almost never financially “worth it” directly; universities (medical especially) almost always lose money on their research endeavors even when you don’t factor in multi-million dollar recruitment packages; most “wet-lab” (biomedical) research (as opposed to say, community based or epidemiologic research) costs a lot more than even the sum of the “direct” dollars from the National Institutes of Health (NIH) and the indirect dollars (often 50% or more of the “direct”) that is supposed to help support the infrastructure. Add in another $5, $10, $20, $40 million more and you have a really hard time coming out anywhere close to break even.
But so what? The money for biomedical research has to come from somewhere; the usual source is NIH, but if states want to sweeten that, why not? After all, there are privately funded research institutes (the Stowers Institute in Kansas City is a local example); why not state, as well as federal. There are some concerns in that the federal (NIH) funds are the result of a competitive peer-review process, while these state funds are often just awarded to researchers based upon cachet. Still, if the state believes it has a chance for direct or indirect economic benefit, maybe it should “go for it”.
The bigger issue is not whether biomedical research should occur or who should support it, but why there should be competition for which university or state gets the big researchers. Does this facilitate biomedical researchers finding out more about how to treat or cure disease? I guess if more money is available, more progress could be made. But the bidding wars between universities and states seem to me to be more about local glory and (if lucky) economic development than real advances in biomedical research. It is similar to states and localities trying to lure employers by tax breaks, which may sometimes cost more than the economic benefit. Or, in the case of the Kansas City metropolitan area which straddles two states, luring companies back and forth across the state line (so that employees don’t even have to move) in what seems not-even-break-even mode (considering the cost of tax breaks). There may sometimes be benefit to science or the public good from relocating researchers and their laboratories but certainly not at the level and frequency it is occurring, and not enough to justify the huge expenditures. Often there is little or no new value being generated, but rather a shifting of resources from one place to another, maybe with a little loss in the process. However, this is how much of our economy works; the stock market and most of the financial industry – moving money around, skimming off profit (HUGE profit – the profiteers here are most of the richest of the billionaires) without creating any real value for the society.
Even more important is the implication that this is benefiting people’s health. If we wanted, as a society, to actually benefit people’s health, there are a lot more direct, effective, cost-effective and rational ways to do so. This, of course, could partly be providing financial access to health care for everyone regardless of their socioeconomic or other status, including those who have been left out of the ACA expansion because they life in states that have not expanded Medicaid, because they are undocumented, or because the level of health insurance that they can afford on the exchanges doesn’t meet all their health needs. A single-payer health system, Medicare for all. It also could mean enhancing geographic access, for those who are in rural areas or underserved urban areas, by using whatever is necessary (like financial incentives) to get doctors and hospitals to service these communities. It could also mean increasing the number and percentages of health care providers entering our most needed specialties, such as primary care, either by direct subsidy or by stopping the skewed and counterproductive reimbursement of subspecialists at much higher levels. (In Denmark, I discovered, general practitioners usually earn more than subspecialists! It is all about policy, not about the market.)
But, even more narrowly, talking about research, there is the question of getting out the therapies that research has already shown work, and are effective, and often cost-effective, to the people who need them. Continuing to do more research and find out more things is great, but actually having a national (or even state) system to ensure that the important discoveries are disseminated and implemented, is a greater priority. There are many common conditions, such as diabetes, for which we have treatments that are simply not available to many people, for many of the reasons above. Some of the unavailability of effective treatments are cost (the rapacious prices and profits charged by drug companies), but there are also treatments that are unavailable because – well, we don’t know why. While we continue to do more research on discovery, we need to do even more on efficacy, and fidelity, and finding out how to get our people to actually have improved health. Competition for researchers without increasing value is as wrong as it is in any arena.

The most effective treatments need to be available to all, the ineffective to none. We don’t need biomedical supremacy of Texas over New York, or California universities over those in Massachusetts, or even in the US over the rest of the world. We don’t need one university to “win” over another. We need better health for all our people.

Our health is going downhill: poor public health and poor attention to the social determinants

“Our health is going downhill” shouts a headline in the Kansas City Star, January 4, 2009. The local take of this article, by Alan Bavley, was the poor performance of Kansas and Missouri, the two states served by the Star, on the 2014 report on America’s Health Rankings, published by the United Health Foundation, the longest-running ranking of public health status in the nation, since 1990. Bavley emphasizes that both states have dropped significantly in those rankings; Kansas was 12th in 1990 and is now 27th; Missouri was 24th in 1990 and is now 36th.
This leads to a lengthy discussion of why both states have dropped, mainly attributed to a lack of investment in public health, and how there is a geographic disparity, with states on the coasts doing overall better than those in the Midwest: “What explains this dramatic difference between the coasts and the Midwest is broad investments on the coasts in things that make communities healthy,” Bavley quotes Patrick Remington of the University of Wisconsin. What this misses, however, is the even worse news that is hidden by “rankings” data. While in rankings of states there will always be a #1 (in this case, Hawaii) and a #50 (you guessed it, Mississippi) this hides the fact that, overall, states have gotten worse over this 25-year period. The graphs in the print edition of the Star (not included in the on-line edition) show the decrease in rankings noted above for the two states over time. However, on the “America’s Health Rankings” website one can not only look at the map showing relative state rankings but also click on each state and see how its absolute health ratings have changed over time.
Hawaii, ranked #1 in 2014 (Vermont is ranked #1 for the whole 25-year period), has nonetheless had its health status drop quite dramatically since 1990, while Mississippi, #50, has actually slightly improved. Locally, Kansas’ health status has dropped significantly consistent with its slippage in the rankings, but Missouri’s, after a big dip in the intervening years, is about the same as it was in the mid-1990s, despite its lower ranking. How can this happen? How can Missouri drop 12 places in the rankings despite having about the same health status if the top-ranked states are getting worse? The only explanation is that the gap was even greater in the past, and that some states in the middle, such as Illinois (#30) and Pennsylvania (#28) have gotten better while Missouri has stayed the same. Hawaii has dropped from a rating of +0.7 to +0.3, while Mississippi has gone from -0.4 to -0.3. Dr. Remington’s comments may be accurate, but they were more accurate in 1990, and since then states have seen a race to the middle, if not the bottom, in terms of public health.

The rankings above are the “all outcomes” rankings from the United Health Foundation studies. They are composed of several subcategories. One component lowering these overall outcomes is the obesity rates, which have risen nationally from 11.6% in 1990 to 29.4% in 2014 (!) as well as in every individual state. Diabetes has risen nationally from 4.4% to 9.6%. Physical inactivity has stayed relatively constant, but distressingly high, at nearly 75%. On the other hand, the last measure, smoking, has gone down nationally from 29.5% to 17.6%, but has tended to stay the same over many years more in lower-ranked states, such as Mississippi, Missouri, and even Kansas.  The study ranks senior health separately, but this tracks pretty well with overall health; Hawaii is the best, Kansas is 25, Missouri is 42, and Kentucky replaces Mississippi (#47) as the worst. The study also examines rankings for a variety of other characteristics, some of which are different for the overall population and for seniors. They include chronic drinking (seniors), binge drink (all adults), depression (seniors), etc., as well as societal measures which might impact or “confound” health status including education level, percent of “able bodied” (no disability) adults and percent of children in poverty.
The study also provides us with information on health disparities, obesity levels by different sub-populations, based on education, race/ethnicity, age, gender, urbanicity, and income. Two non-surprises: the South and South Central regions do the worst, and the problem is greater for those with lower education, non-white race/ethnicity, and lower income; urban status and age have less impact. In terms of educational impact on health disparity (the difference between the highest and lowest educated in terms of health status), things change: Hawaii is still #1 but Mississippi is #2, while California is #50! Unfortunately, for many of the states with both low overall health status and low disparity, it means that even the better-educated have poor health status.
So what do we learn? Yes, as Dr. Remington points out, some parts of the country generally do better than others (although identifying these as the Northeast , West, and North Central  regions is more accurate than saying “the coasts”), and the South and South Central regions tend to be worse. Yes, as Mr. Bavley highlights, both Kansas and Missouri have significantly slipped in the relative rankings. But we also see the whole country getting worse, particularly with regard to conditions such as obesity and diabetes. And we see the most dramatic drops in certain states, not only Kansas but Wisconsin (down from +.38 to barely positive at all, +.07). The people interviewed for the Bavley article in Kansas and Missouri, as noted above, cite inadequate, and decreasing, spending on public health as the reason.
It is certainly one of the big reasons, along with a consumer society that encourages consumption of high-calorie, low nutrition foods. And a car-based society that makes exercise a specialty activity, more available to some than others, rather than part of life. And a terrible economy where a shocking number of people don’t have jobs and others have to hold down two or more to make ends meet so have little time for exercise. The other huge reason are those “social determinants of health”; the impact of poverty, racism, poor education, inadequate housing and food. The social structure and social support for the most needy in the US has never been adequate, and is eroding, more in some states than in others, sometimes on purpose (because of political beliefs) and sometimes by a (possibly) more benign neglect.
Some of it is the chronic problem of public health, that its successes are the absence of disease and thus less obvious. It is easier to feel grateful for treatment of a disease we have contracted than, say (as I have often said before) to be grateful each morning that we don’t have cholera because we have clean water. It is, perhaps for some, easier to think we don’t need to vaccinate our children when diseases that the vaccines prevent are no longer in evidence. But it is a fatally flawed analysis. When a good has resulted from doing effective preventive efforts, the solution is to keep up our efforts, whether vaccination or public health.
And cutting back on our social safety net is a good prescription for worse health.

Why do students not choose primary care?

We need more primary care physicians. I have written about this often, and cited extensive references that support this contention, most recently in The role of Primary Care in improving health: In the US and around the world, October 13, 2013. Yet, although most studies from the US and around the world suggest that the optimum percent of primary care doctors should be 40-60%, the ratio in the US is under 30% and falling. A clear reason for this is that relative lack of interest of US medical students in entering primary care at the rates needed to maintain, not to mention increase, our current primary care ratio. In addition, the ratio of primary care to other specialty residency positions is too low. Here we confront the fact that the large majority of medical students completing Internal Medicine residencies enter subspecialty fellowships rather than practicing General Internal Medicine. At the Graduate Medical Education level, a simple way of estimating the future production of primary care doctors would be to add the number of residency positions in Internal Medicine (IM), Pediatrics (PD), Family Medicine (FM), and combined Internal Medicine-Pediatrics (IMPD) and subtract the number of fellowship positions they might enter. This still overestimates the number of general internists, however, since it does not account for doctors who practice as “hospitalists” after completing their residency because such a role does not currently require a fellowship (as does, say cardiology). Estimates are now that 50% or more of IM graduates who do not pursue fellowship training become hospitalists.
Thus, we welcome the research report from the Association of American Medical Colleges (AAMC) “The role of in medical school culture in primary care career choice”[1], by Erikson et al. that appears in the December 2013 issue of AAMC’s journal Academic Medicine. The authors surveyed all 4th-year medical students from a random sample of 20 medical schools to assess both student and school level characteristics that were associated with greater likelihood of entering primary care. The first, and arguably most important finding, was that only 13% of these final-year medical students were planning on primary care careers. This is despite the fact that 40% were planning to enter the “primary care” residencies of IM, PD, FM, and IMPD, with most of the fall-off in internal medicine and least in family medicine. This finding strongly supports my assertions above, and makes clear that the historically AAMC-encouraged practice of medical schools reporting “primary care” rates by entry into residencies in those fields is not valid. It also, even more important, shows the extent of our problem – a 13% production rate will not get us from 30% to 40% or 50% primary care no matter how long we wait; obviously it will take us in the other direction.
The primary outcome variable of the study was entry into primary care, and it specifically looked at two school level (but perceived by students, as reported in the survey) characteristics: badmouthing primary care (faculty, residents or other students saying it is a fall back or something that is a “waste of a mind”) and having greater than the average number of positive primary care experiences. It turns out that both were associated with primary care choice (in the case of badmouthing, students from schools with higher than average reported rates were less likely to be planning primary care careers, while students who were planning such careers reported higher rates of badmouthing), but, after controlling for individual student and school characteristics, accounted for only 8% of the difference in primary care choice. Characteristics of the student (demographics such as sex, minority status or rural origin, academic performance defined as the score on Step 1 of USMLE, as well as expectation of income and feeling of a personal “fit” with primary care) and of the school (research emphasis, private vs. public,  selectivity) accounted for the rest. Interestingly, debt was not a significant factor in this study.
I would argue that many of these individual and school characteristics are highly correlated. A school that prides itself on being selective (taking students with high scores) and producing subspecialists and research scientists does not have to badmouth primary care; the institutional culture intrinsically marginalizes it. On the other side, the students selected at those schools are more likely to have those characteristics (particularly high socioeconomic status and urban or suburban origin) not associated with primary care choice. It is worth noting that the measure of academic performance in this study was USMLE Step 1, usually taken after the first 2 years and focusing more on the basic science material covered in those years, rather than USMLE Step 2, which covers more clinical material (perhaps because not all 4th-year students studied have taken Step 2 yet). This biases the assessment of academic qualification; many studies have demonstrated high levels of association of pre-medical grades and scores on the Medical College Admissions Test (MCAT) with pre-clinical medical school course grades and USMLE Step 1 scores, but not with performance in any clinical activity, not to mention primary care. Perhaps most students improve their scores from Step 1 to Step 2, but it is particularly true for FM and primary care. A quick look at our KU students applying to our family medicine program shows an average increase of nearly 30 points in these scores.
So the problem is in the overall culture of medical schools, in their self-perception of their role (creating research scientists vs. clinicians, creating subspecialists vs. primary care doctors) and in their belief that taking students with the highest grades is equivalent to taking the best students. This culture, simply put, is bad, defined as “it has undesirable outcomes for the production of the doctors America needs”, and must change. Erikson and colleagues acknowledge that schools could do a better job of taking rural students, offer more opportunities to engage in public health and community outreach activities, and have more experiences in primary care, all of which were somewhat associated with primary care career choice. These are tepid, but coming from the AAMC, a reasonably significant set of recommendations. I say we need an immediate change in every single medical school to recruit at least half of every class with students whose demographic and personal characteristics are strongly associated with primary care choice, present a curriculum that has much less emphasis on “basic science” and more on clinical, especially public health, community health, and primary care. One of the primary bases for assessing the quality of a medical school should be its rate of primary care production, and this is going to require a major qualitative shift in their practices and the beliefs of many of their faculty and leaders.
I am NOT saying is that we don’t need subspecialists or research scientists. We do. I AM saying that the emphasis on production of these doctors compared to primary care doctors is out of whack, not just a little but tremendously so, and can only be addressed by a major sea change in attitudes and practices in all of our medical schools. I do not expect that all schools should produce the same percent of primary care physicians. Some might be at 70%, while others are “only” at 30%, but ALL need a huge increase, by whatever means it takes. Even if we produce 50% primary care physicians on average from all schools it will be a generation before we get to their being 50% of the workforce. At less than that it will take longer, and at less than 30% we will not even maintain where we are.
13% is not just “insufficient”, it is a scandalous abrogation of the responsibility of medical schools to provide for the health care of the American people. They should be ashamed, should be shamed, and must change.



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

The cost of health care: insurance companies, high-profit and low value care

We know that health care in the US is incredibly expensive. Those who read about health policy from a variety of sources (perhaps including this blog) know this in terms of data – our per capita cost is 50% more than the second highest-cost nation (Norway), twice what most comparable (rich) countries spend, and almost 3 times that of the United Kingdom. But you don’t have to be a policy wonk to know that health care is expensive; you just have to be a consumer who is trying to buy health insurance and is seeing their premiums go up – and their out-of-pocket costs (deductibles, co-pays, co-insurance) go up as well. All those other countries cover everyone, equitably, despite spending so much less money (and those that spend more, like Norway, have especially good coverage). Not so here.
“My premiums are more than $600 a month, which is more than our mortgage payment,” a cancer survivor quoted by the New York Timesin its August 14, 2016 article by Robert Pear “Health insurers use process intended to curb rate increases to justify them”, said. “I am grateful that the Affordable Care Act is here for my family, but I am disappointed by its limitations. All I want is a plan that makes our health care affordable, but it doesn’t exist.” She is likely to be disappointed, because this was not how the Affordable Care Act (ACA) was set up, and unless control of Congress changes dramatically, we probably will not see a fix. ACA passed because it guaranteed continued profit for insurance companies, and this has led to both the rate increases and out-of-pocket cost increases we have seen. Insurance companies can do this because the law allows them to ask for premium hikes when they are not making “enough” money. Essentially, ACA requires the American people (subsidized by the federal government if they are poor) to ensure private insurance companies are profitable. Because they believe that they have not been permitted to jack up rates “enough”, some companies (Humana, United, Ætna) are leaving the exchanges in many places.
While other counties make sure everyone is covered by some national health insurance (a national health service in the UK, a single-payer national health insurance system in Canada, and highly-regulated multi-payer systems in many other European countries such as France, Germany, and Switzerland), we have tried a patchwork that leaves many people out (e.g., the undocumented, poor people in the 19 states that haven’t expanded Medicaid), and encourages others to buy policies on the health insurance exchanges based solely on their cost. This is examined in a story by Reed Abelson in the Times from August 12, 2016, “Cost, not choice, is top concern of health insurance customers”. It notes that people who are healthy and young but don’t have employer-based health insurance are either buying the cheapest policies available on the exchanges or “particularly those not eligible for generous subsidies, are shunning plans altogether, finding all of the prices too high.” When they don’t buy insurance, it messes with the insurance company model of offsetting costs for sick people with the premiums paid by healthy people, the reason for increasing premiums. And many other people, neither young nor healthy, are also buying the cheapest policy they can find because they can’t afford the cost (and maybe can’t understand the details); for these folks, it is not the insurance companies that pay the financial price, but themselves, when they get hospitalized or otherwise need costly care and discover that their “insurance” is inadequate (the technical term here is “crap”).
And this is just the health insurance contribution to high health care cost. Also very important is the cost of the care itself, particularly high-tech, high-cost care, provided to many Americans (at least those with good insurance coverage). This is driven, at least currently, by the fact that in most places, where insurance companies pay providers by piecework (“fee-for-service”), high-cost is also high-profit for providers, both individual physicians and the large institutional providers (hospitals and health systems) that often employ them. This blog, and a variety of exposés in many news articles including in the Times (particularly the work of Elisabeth Rosenthal) have given example after example of such incentives driving both the kind of care delivered and the cost of that care. In the worst instances, this is the result of rapacious greed that provides unnecessary care at very high cost. In many other settings, the opportunity for profit subtly (I hope) tips the scales toward providing high-cost, high-profit services rather than just as good, or almost as good, alternatives. But there are even more insidious drivers of cost; these are in the “everyday tests”, such as those done for screening, that in themselves, one by one, don’t seem to be excessive but multiplied by the number of people receiving them cost a lot (and make a lot of money for providers). The practice of ordering such tests is often driven by advocacy groups, providers in certain specialties and relatively small numbers of people with a specific condition who think everyone needs to be tested for it.
A good example is screening for lipid disorders (basically, high cholesterol) in children. Yes, some children have a genetic disorder which means that they should be tested and treated, but the vast majority do not and screening them (barring a history of familial hyperlipidemia or very early heart attacks) should not be done. It is not recommended by either the US Preventive Services Task Force or the American Academy of Family Physicians (AAFP), nor by the UK National Screening Committee. This example is discussed in an outstanding editorial in JAMA Internal Medicine by Thomas B. Newman, Alan R. Schroeder, and Mark J. Pletcher published on August 9, 2016, titled “Lipid screening in children: Low-value care”, preceded by the tagline “Less is more.” The authors contrast the USPSTF and AAFP recommendations to those of the National Heart, Lung and Blood Institute of the NIH, endorsed by the American Academy of Pediatrics, which recommends it. The authors of the editorial demonstrate the amazing lack of cost-effectiveness for this screening test, and note that is only because USPSTF does not consider cost-effectiveness that it gave the test an “I” (insufficient evidence to recommend for or against”) and not a “D” (recommend against testing).
But the most important point made in the editorial is that our recommendations for testing – and how to spend our healthcare dollars – are individually focused, and virtually ignore (and thus dramatically underfund) those interventions in public health and the social determinants of health that would truly make a major difference in the health of millions of Americans. The authors say it extremely well:
Tackling major public health concerns such as climate change, poverty, obesity, and gun violence is likely to yield high-value solutions, and many advocate policy and community-level interventions that might achieve such solutions. Meanwhile, other segments of our health care establishment continue to try to solve health problems by doubling down on individual-level health care solutions that tend to be low in value…The need for clinicians and leaders to focus on sustainability and health care value has never been greater, and it is likely that policy and community-based interventions will get us there much more quickly than adding more clinic-based interventions that have low value and are wasteful of resources and clinicians’ time.

We need to take this advice to heart. It goes way beyond lipid screening in children. It means supporting interventions that actually  improve the health of the public on a large scale. And, as always, “support” is spelled M-O-N-E-Y.

Who is gaming the system? Surprise, it’s the corporations!

I recently participated in a panel discussion following a presentation on the impact of the Affordable Care Act (“Obamacare”) by UC-Berkeley economist J. Bradford DeLong. Unsurprisingly, Dr. DeLong, who worked in the federal government as Deputy Assistant Secretary of the Treasury for Economic Policy in the early years of the Clinton administration, during an earlier attempt to pass comprehensive health reform, took an economic point of view. He described the economic theories behind each of the approaches to health reform, how the ACA was put together, how it most resembled the “RomneyCare” model implemented in Massachusetts and endorsed by Hillary Clinton but abandoned by the Republicans; he also showed that the Obama administration miscalculated the near-unanimity of Republican opposition. He also looked at how the implementation of the ACA has been more successful than many feared (or hoped) and how the economic analysis behind it was distorted by the Supreme Court decision to allow states to not expand Medicaid, which has resulted in an enormous transfer of wealth from the “red” states that have not to the “blue” states that have done so. Apparently, the ideological commitment by many states (including my own, Kansas, and neighboring Missouri) to harm its people and give away money is puzzling from a purely economic, as well as a human, point of view.
One of the themes Dr. DeLong notes coming especially from “conservative” economists and Republican politicians (and we hear a lot) is the need for people to have “skin in the game”, by which they mean co-pays, deductibles, and other ways of people paying out of their pockets. As Dr. DeLong noted, the only large, well-designed, and meticulous study of the impact of such “skin in the game”, the 1983 RAND experiment (which I have previously discussed; see Insurance company profits up and patient care down, May 17, 2011*)  showed that even small out-of-pocket payments discourage people from seeking care for both minor and major conditions, ultimately cost much more to care for, and harm the health of those people. As noted by one of the audience, current requirements in many “high-deductible” plans for “skin in the game” cost-sharing are far greater than those studied by RAND (and can be 45% of a person’s income!) and are thus even more likely to have a major negative health impact.
Another common “game” meme, mentioned by one of the other panelists, is concern with people “gaming the system”. If this conjures up images of elegant gamblers in formal wear playing roulette with James Bond in a posh casino on the Riviera, that is the intent. Like Ronald Reagan’s “welfare queens” and Kansas Governor Sam Brownback’s “able-bodied adults who refuse to work”, it is meant to divide people by creating a “them” who are taking it easy while the hard-working “us” pay the price. Of course, this is nonsense; most of those individuals so “gaming the system” are merely trying their best not to break their budgets paying for health insurance until they get so sick that they need it. Yes, this is certainly contrary to the concept of insurance (everyone pays and only some people benefit, but you never know when it will be you), and is a big reason that most countries have gone to a “social insurance” system that just covers everyone.
In fact, despite all the fooforaw about it, there is no data suggesting that there is massive “gaming of the system” by regular people. Michael Hiltzik’s Los Angeles Times column of February 27, 2016 makes this clear, focusing on “Special Enrollment Periods” (SEPs), times when people can enroll in or change their insurance outside of the usual ACA annual period. Huge insurance companies like Aetna and Anthem have asserted, without much evidence, that people are using these SEPs (mostly designed to allow changes when you get married, divorced, have a baby, move to a different state where your current plan wouldn’t cover you) to “buy to use”, in Anthem’s words, meaning you wait until you’re sick to get insurance. Hiltzik presents data that shows this is not significantly the case, and that it is absurd; he writes “Aetna must think the entire country consists of people plotting how to get a quickie marriage or divorce or have a baby just in case they get sick. The vast majority of SEPs cover a relatively trivial number of cases, unless you think there are hordes of people applying to become members of a Native American tribe after they get sick.”
Of course, people do game the system. But the big gaming is by the insurance companies themselves and the providers of care. These corporations, big insurance companies, health systems, drug makers, who have the clout to “game the system” do so all the time as part of their core business models. It is convenient for them to divert our attention to regular people, middle-class people, and especially poor people, as the ones gaming the system. In fact these are of course the folks who suffer the most harm, whose health is most affected, whose access to care is most limited, and who are stuck with crummy health coverage because this is all they can afford.
The insurers work every legal angle (and perhaps some not-so-legal) to figure out how to mostly insure relatively healthy, low-cost people (after all, 5% of people account for 50% of health costs and 1% for 20%, see my Red, Blue, and Purple: The Math of Health Care Spending, October 20, 2009, and Kaiser Health News report 2013),  while the high-cost patients are covered by Someone Else. Providers, especially health systems and hospitals, figure out how they can “upcode” to get maximum reimbursement from insurers, attract people who have high-profit-margin conditions to themselves, and encourage high-cost, low-reimbursement poor and poorly-insured people to find their care from Someone Else. Insurers blame providers for charging too much, providers blame insurers for paying too little. One of the other panelists, a hospital executive, complained about how insurers seek transfer risk, which is part of the definition of insurance, to the providers. Neither is blameless, and the other big players, pharmaceutical companies (and device manufacturers) make out like bandits, with no major candidate having a real plan to address this according to a report by Julie Rovner of Kaiser Health, (cited hereby Medpage Today). Of course, this equates all plans to “negotiate prices” and it is obvious that a single-payer health plan, such as that advocated by Bernie Sanders, will have a lot more negotiating clout than the multiple-insurer mess that other candidates support and exists today.
What did I say as a panelist? Basically, that the goal of the system should be to maintain and improve the health of people, and that the economic design of the system should be designed to achieve that goal, rather than having competing economic theory be the driver, and people the incidental victims. I said that spending money on providing health care to people was not a bad thing, but spending huge amounts on “health care” when more than half was going to profit was. I said that all this spending on medical care (and profit) limited what was left to be spent on creating the conditions that allowed people to benefit from medical care – like housing, food, education – the social determinants of health.
I think that this resonates with people, both at the event and in the world. Or maybe I’m one of those “hopeless idealists”. If the alternative is being cynically corrupt, I wouldn’t want to be anything else.
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* Citations from that blog post: “RAND Health Insurance Experiment (as cited in Freedom abroad, health at home: experiments in preventive health care, February 13, 2011; the study was published in the New England Journal of Medicine in 1983[1]; and it is summarized in an article by Joseph P. Newhouse, “Free for all?:  lessons from the RAND Health Insurance Experiment“, RAND 1993.

Rand Paul on health policy: small brain and no heart

While politicians are rarely elected to office because of their profession (I seem to remember that when in elementary school we learned that the second most common profession in the NY state legislature, after attorneys, was undertakers!), the fact is that often fellow legislators often turn to their colleagues with expertise in a certain area to understand bills with technical implications. Legislators who are physicians, nurses and pharmacists, for example, may have influence on bills related to health care. (This is provided, of course, that they don’t involve touchstone ideological issues like abortion where facts are routinely ignored and new ones, such as “abortion causes breast cancer”, are invented.) Thus, physicians like former US Senate Majority Leader Bill Frist, a cardiac surgeon (and member of the family that founded and controlled HCA, the nation’s largest for-profit hospital chain) had great influence on medical matters.
So it is relevant to look at statements by Sen. Rand Paul (R, KY) about healthcare. Primarily known as a prominent libertarian conservative and Tea Party favorite, as well as a probable Republican presidential contender, Paul is an ophthalmologist, an eye surgeon, and thus probably is presumed to have credibility on healthcare issues. This does not seem to be diminished by the fact that he has not been Board-Certified by the mainstream American Board of Ophthalmology since 2005, being rather certified by the National Board of Ophthalmology, which, coincidentally, he founded and is president of (the Louisville Courier-Journal link is no longer live, but it is referenced in TPM). Perhaps this appeals to his libertarian base; perhaps it even is honorable if it is truly based (as he states) on “…a principled stand in response to the ABO’s ‘decision to grandfather in the older ophthalmologists and not require them to recertify….I thought this was hypocritical and unjust for the older ophthalmologists to exempt themselves from the recertification exam.’
So what does Sen. Paul have to say about important health policy issues? Unsurprisingly he is a strong opponent of “Obamacare” and, for that matter, any universal healthcare system. He apparently has a fair amount to say about this it in his book, “Government Bullies”, which I have not read. I did, however, hear him discuss it at some length with John Oliver on a “Daily Show” appearance on August 12, 2013. His main point is that, unlike “most legislators” who have “dinosaur syndrome — small brains and big hearts” (news to me about politicians, at least the “big heart” part. And, by the way, where does he get the idea that dinosaurs had big “hearts” other than in the physical sense?), he can help solve problems because he is not in that mold (I think he was referring to the “small brain” part, but I’m not sure!). He called upon his experience as an eye surgeon to demonstrate how the “market” controls costs by referring to how it led to big price drops for two major procedures in his specialty, Lasik® surgery and contact lenses. With regard to the former, he notes that competition among ophthalmologists has led to dramatic decreases in charges (and costs) from over $2000 an eye to less than $500. The competition for contact lenses was with large retailers like Wal-Mart, which forced him to drop his charges in order to compete. Neither was covered by insurance, so he uses them as examples of how this could work for all the other things that are covered by insurance and to which people are price-insensitive.
All but the last of these assertions are true as far as they go. The cost of both Lasik® and contact lenses have indeed dropped. So, will this work for all health costs? No, absolutely not. There is a reason that these two procedures are not covered by insurance; they are both elective procedures and thus (like cosmetic surgery and many consumer items) can be reasonably subject to market forces. One has a much cheaper and effective option that works for the medical problem: wear glasses. If you are considering Lasik or contact lenses, you can choose to not buy them now and wait until prices come down. However, most of healthcare is not elective (thus more like food and housing). Emergencies are emergencies and need to be addressed now, by the most available provider (see The high cost of US health care: it’s not the colonoscopies, it’s the profit, July 28, 2013, for a discussion about how hospitals like Bayonne Medical Center have turned this into a profit-making strategy).
Mark Ebell, MD, a family physician and expert in evidence-based medicine, notes a more apt comparison: “If you have a stick in your eye, I doubt that you are price shopping or waiting for ads on the radio to advertise a special for removal of sticks in the eye.” No doubt; and while not all necessary healthcare is about emergencies, most of it is not about elective procedures. Chronic diseases like hypertension and diabetes need to be treated in order to prevent their progression to serious outcomes. Preventive care like screening for cancer and immunizations are only of value if they happen before the onset of disease. Neither Lasik nor contact lenses prevent either disease or its progression. 
Dr. Ebell is unhappy that Mr. Oliver, usually quite clever, completely missed this point, and it is an extremely important one. While I do not know if Sen. Paul is aware of this and is dissembling in using this inappropriate and simplistic example as a justification for his anti-government ideology, or is he actually believes it, the fact is that it is not at all a valid argument for a market-based health system. The empiric evidence is there, both in comparisons to other developed countries and in internal comparisons between state and local experimental government and insurance programs in the US: providing comprehensive health care at costs that do not discourage or make it impossible for people to access it improves health status. Conversely, there is excellent evidence that obstacles to healthcare access do discourage people from seeking it and do result in worse health outcomes, for individuals, populations and nations.
The danger in an argument such as Sen. Paul’s is two-fold. One is that, coming from the Republicans’ most prominent physician, it will reinforce the beliefs of those who already think that the market will solve the healthcare crisis. The other is that people who are not such ideologues but whose exposure to the health system, because of a fortunate combination of relative youth, good health, and economic security, is largely for such elective, minor or episodic care, may say “yeah, that seems right”. But it isn’t; it’s wrong. A recent NPR “Marketplace” show focused on the ACA’s requirements for individual health insurance policies that preclude many low-coverage, high-deductible options currently available.[1] It featured a self-employed Californian who noted that he was having to pay much more for insurance now, even though he was never sick and, in the last 14 years, had visited a doctor only a few times. It didn’t give his age, but whatever it was he will, in the future, be older; this is a certainty. And, as we get older the probability of needing health care increases. The old maxim about the stock market – that past performance is not a guarantee of future performance – is even more true for one’s health. It is at best risky and at worst foolhardy; the more apt comparison may be to the person who falls off a 20-story building and is heard by people as he passes each floor saying “so far, so good”. Making public policy on such a basis is nonsensical.

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


[1] For a good discussion of the insurance exchanges, see Harvey Matoren’s blog The Patient’s Advocate” for August 21, 2013, and for a state-by-state portrayal of federal/state involvement in the exchanges, the Commonwealth Fund website,

Outliers, Hotspotting, and the Social Determinants of Health

We all have, or will have, our personal health problems, and the health problems that confront those close to us in our family and among our friends. Some are relatively minor like colds, or are temporary like injuries from which we will heal. Some are big but acute and will eventually get all better, like emergency surgery for appendicitis, and others are big and may kill us or leave us debilitated and suffering from chronic disease. Some of us have more resources to help us deal with these problems and others fewer. Those resources obviously include things like how much money we have and how good our health insurance is, but also a variety of other things that have a great impact in our ability to cope with illness, survive when survival is possible, and make the most of our lives even when afflicted with chronic disease. 

These other things are often grouped under the heading of “social determinants of health”. They include factors clearly related to money, such as having safe, stable and warm housing, having enough to eat, and otherwise having our basic needs met. They also include support systems – having a family and friends that is supportive and helpful, or alternatively not having one or having family and friends whose influence is destructive. It includes having a community that is safe and livable and nurtures and protects us and insulates us from some potential harm. This concept, “social capital”, is most well-described in Robert Putnam’s “Bowling Alone”[1]and its health consequences in Eric Klinenberg’s “Heat Wave”[2], discussed in my post “Capability: understanding why people may not adopt healthful behaviors”, September 14, 2010.
How this affects communities is a focus of the work of Dr. Jeffrey Brenner, a family physician who practiced in one of the nation’s poorest, sickest, and most dangerous cities, Camden, NJ, and is a founder of the “Camden Coalition”. I have written about him and his work before (“Camden and you: the cost of health care to communities”, February 18, 2012); his work drew national attention in the New Yorker article by Dr. Atul Gawande in January, 2011, “The Hot Spotters”. Brenner and his colleagues have taken on that name to describe the work that they do, and have collaborated with the Association of American Medical Colleges (AAMC) to focus on “hotspotting” (www.aamc.org/hotspotter) and produce a downloadable guide to help health professionals become “hot spotters” in their own communities in ten not-easy steps. The focus of this work is on identifying outliers, people who stand out by their exceptionally high use of health care services, and develop systems for intervening by identifying the causes of their high use and addressing them to the extent possible, activities for which traditional medical providers are often ill-suited and health care systems are ill-designed.
The essential starting point in this process, emphasized by Brenner in two talks that he gave at the recent Annual Meeting of the AAMC in Philadelphia (his home town) in early November, 2013, is identifying “outliers”.  The concept of recognizing outliers was the topic of a major best seller by Malcolm Gladwell a few years ago (called “Outliers”[3]), and Brenner notes that they are the “gems” that help us figure out where the flaws, and the costs, in our system are. As described in Gawande’s article, Brenner was stimulated by looking at work done by the NYC Police Department to identify which communities, which street corners, and which individuals were centers of crime; rather than developing a police presence (and, hopefully, pro-active community intervention) for the “average” community, they were able to concentrate their work on “hot spots”. Moving out of a crime-prevention and policing model, Brenner and his colleagues were able to link to hospital admissions data that was tied to people and performed a “utilization EKG” of their community, looking at who had the highest rates of admissions, ER visits, 911 calls and sought to determine what the reasons were.
Unsurprisingly, the individuals identified most often had the combination of multiple chronic diseases, poverty, and a lack of social supports – pictures of the impact of poor social determinants of health. Sometimes there were individual, specific issues – like the person who called 911 multiple times a day and was found to both live alone and have early Alzheimer’s so that he couldn’t remember that he already had called. Often, there were predictable community and poverty related issues, related to inadequate housing , food, transportation, and poor understanding of the instructions given them by the health care providers that they had seen.
One example of such an effort is “medicine reconciliation”, in which (usually) pharmacists review the medications that a patient entering the hospital, clinic or ER is supposed to be on (per their records) and what they say they are taking. It sounds like a good idea, and it has received a great deal of emphasis in the last several years, but it is one that Brenner calls a “fantasy” because it doesn’t involve going into people’s homes and (with them) searching through their medicine cabinets and drawers to find the piles of medications they have, and often have no idea of how to take, which ones are expired, which ones have been replaced by others, which ones are duplicated (maybe brand vs. generic names or from samples). He showed a slide of a kitchen table piled high with medicines found in one house, and says that his group has collected $50,000 in medicines found in people’s houses that their current providers did not know they were taking or wanted them to take.
Brenner notes that continuous ongoing stress weakens the body and the immune system, enhancing production of cortisol (a stress hormone) that has effects like taking long-term steroids, increasing the probability of developing “metabolic syndrome” and a variety of other physical conditions. He also cites the work of Vincent Felitti[4]and his colleagues that have identified Adverse Childhood Events (ACEs), such as abuse, neglect, etc., being associated with the presence of being a high-utilizer sick person in middle age (and, if they reach it, old age). This is, he indicates, exactly what they have found doing life histories of these “outliers”. It suggests that while interventions at the time of being identified as a high utilizer can be helpful for the individual patient, for the cost to the health system, and even to the community; but it also reinforces what we should already know – that the interventions need to occur much earlier and be community-wide, ensuring safe housing and streets, effective education, and adequate nurturance for our children and their families.
We need, Brenner says, half as many doctors, twice as many nurses, and three times as many health coaches, the intensively trained community-based workers who do go out and visit and work with people at home. I do not know if those numbers are true, but it is clear that we need to have comprehensive interventions, both to meet the needs of those who are sickest now and to prevent them from developing in the future. We are not doing it now; Brenner says “Like any market system, if you pay too much for something you’ll get too much of it, and if you pay too little you’ll get too little.”
We need to have a system that pays the right amount for what it is that we need.


[1] Putnam, Robert D. Bowling Alone: The Collapse and Revival of American Community.Simon & Schuster, New York, NY. 2000.
[2] Klinenberg, Eric. Heat Wave: A Social Autopsy of a Disaster in Chicago. University of Chicago Press, Chicago. 2002.
[3] Gladwell, Malcolm. Outliers: the story of success. Little Brown. New York. 2008.
[4] Felitti, V et al., “Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults The Adverse Childhood Experiences (ACE) Study”, Am J Prev Med 1998;14(4) (and many subsequent publications).

Trump, Price, and Verma: Bad news for the health of Americans, including Trump voters

The election of Donald Trump as President continues to be extensively analyzed. It demonstrates major divisions among our populace. One of those that has been discussed a lot is that the “white working class” that voted for him by a 2:1 margin will suffer a lot from the policies likely to be implemented by his administration. Not more, and probably less, than minority people, but a lot.

Healthcare and health insurance is one of those areas, as discussed by me in several recent posts and by Paul Krugman in the New York Times, December 2, 2016, “Seduced and betrayed by Donald Trump”. He notes that anger about their health care coverage, and in particular the dramatic increases in premiums under the ACA exchanges, drove many people to choose Mr. Trump’s promise to replace it with “something terrific”. Of course, he never specified what that would be, for the same reason that the Republicans in Congress have never been specific, which is that any replacement plan that does not move “left” toward a more universal coverage plan such as the single-payer advocated by Senator Bernie Sanders (and me) will be much worse for most people, including most Trump voters, who will either lose or have to pay a lot more (if they can!) for their health insurance coverage. Repealing Obamacare means that many of the 13 million newly insured (a majority white, for the record) who received insurance under the exchange will not get rate cuts, but rather they will get no coverage. Certainly not those who need the insurance most, because they have pre-existing conditions that insurance companies were mandated by ACA to cover. As Krugman puts it, “we’re probably looking at more than five million Trump supporters, many of whom have chronic health problems and recently got health insurance for the first time, who just voted to make their lives nastier, more brutish, and shorter.” This is made clear in the Times article on December 3, 2016 “GOP plans immediate repeal of health law, then a delay” by Robert Pear, Jennifer Steinhauer and Thomas Kaplan. The reason is because the only plan they have will yank health insurance coverage for so many people, and despite their vociferous opposition and multiple votes to repeal ACA, they do not want to do that, at least right away.
The best evidence for their long term plan to, basically, remove health insurance coverage from many Americans including their base of support is the appointment of Rep. Tom Price (R, GA) as HHS Secretary. Mr. Price has been a leader of the Tea Party movement and a major Congressional figure calling for the repeal of Obamacare. His solution is not completely fleshed out, but does include eliminating guaranteed issue, community rating, and federal support for the exchanges. He is a fan of vouchers, an idea advocated for decades by conservative think tanks, and which, I guarantee (and this is far more of a certainty than Mr. Trump’s promises), can NEVER work, especially over the long term. Vouchers will never cover the cost of a decent insurance policy; people with health problems will naturally be the first to seek coverage, and faced by the adverse selection insurers will raise the premiums, co-pays, and deductibles for them. If there are problems with this under Obamacare, vouchers will make those look pale by comparison. And by getting out of the running-the-infrastructure business, the government will ensure that it never gets better.
Price, a wealthy orthopedist from suburban Atlanta, does not really care. He represents rich doctors who want to be able to charge whatever they want to be able to charge, and care only for the people who have insurance good enough to pay it. Sorry, Trump voters with not much money, chronic disease, and difficulty paying even ACA premiums, that isn’t you. And when you get to an age that you can get Medicare, finally having federally-supported coverage, Mr. Price has another answer for you – privatize Medicare! Make it subject to the same market forces that have made health care and health insurance so unaffordable and unavailable to younger folks affect the elderly too! The ACA has modified the egregiously negative impact of private sector health insurance for the under-65 group; the crumbum Price wants to both reverse that benefit and extend the damage to seniors too.
When Lyndon Johnson signed the Medicare law at the Truman Library in 1965, presenting Harry and Bess Truman with cards #1 and #2, he quoted the former President from nearly 20 years earlier: “Millions of our citizens do not now have a full measure of opportunity to achieve and to enjoy good health. Millions do not now have protection or security against the economic effects of sickness. And the time has now arrived for action to help them attain that opportunity and to help them get that protection.”LBJ then added that “There are more than 18 million Americans [in 1965; way more now] over the age of 65. Most of them have low incomes. Most of them are threatened by illness and medical expenses that they cannot afford. And through this new law, Mr. President [referring to Mr. Truman], every citizen will be able, in his productive years when he is earning, to insure himself against the ravages of illness in his old age.”
This is what Tom Price and his colleagues want to reverse. The AMA, with its shameful history of actually having blocked Truman’s health plan, and unsuccessful opposition to Medicare, is endorsing him. The Association of American Medical Colleges (AAMC) is endorsing him as well. The American Academy of Family Physicians (AAFP) more tepidly expresses optimism. Presumably these are political decisions, to maintain access. After all, in the ongoing battles between insurers and providers (patients are rarely a real player), at least he is a provider. But many others, including Physicians for a National Health Program (PNHP)and Common Dreams, as well as the medical students of Future Docs, have appropriately condemned Price and these organizations endorsing him.
Mr. Price will be joined by Seema Verma, who will head the Center for Medicare and Medicaid Services (CMS). Verma helped Mike Pence design the Indiana version of Medicaid expansion. On the plus side, that state did expand Medicaid, helping people more than those states that did not. On the minus side, the requirement that everyone covered has to pay meant at least 1/3 of those who would have been eligible did not sign up. I guess she is the moderate!
Mr. Trump’s cabinet picks are, so far, a panoply of people who are either right-wing ideologues who wish to destroy everything that has been done to help the American people at least back to the Great Society and maybe to the New Deal, or are billionaires who speak for the corporate financial ruling class that he attacked so effectively during his campaign, or both. An example of the latter is anti-public education billionaire Betsy DeVos to head the Department of Education. Myron Ebell, a noted climate-change denier, will head EPA. Steven Mnuchin, a leading Goldman Sachs banker, will be Treasury Secretary. Senator Jeff Sessions (R, AL), denied a judgeship because of his racist beliefs and practices will be Attorney General. Trump’s nominee for Commerce Secretary, Wilbur Ross, according to Money, alone has 10 times the net worth of the entire cabinet of President George W. Bush. Talk about foxes guarding the henhouse! Compared to these folks, naming El Chapo to head the DEA, as suggested in a New Yorker satire by Andy Borowitz,would be a moderate pick.
The future of not only public health, but also your individual private health, now and when you get to retirement age, is in great jeopardy. But, then, so is everything else that helps people. Not to mention the earth, since global warming is likely to accelerate during a Trump administration. There is an endless string of battles before us.

And we must join every one.

Racism, classism, and who we take into medical school: Who will care for the people?

I work in a medical school. I see and teach medical students. They are a smart group. When measured by grades and scores on standardized exams, they are even smarter. Some of them – but not nearly enough – are members of socioeconomic and ethnic groups or geographic areas under-represented in medicine. Sometimes, these students struggle with grades in medical school. Occasionally, this elicits comments, sometimes smug, sometimes rueful, that this is the result of affirmative action, as if this were a negative thing. Given the alternative, the default of taking all people who look alike, who come from the same background, who want to do the same things – in brief, to stereotype, white 22 year old men who come from economically privileged and professional families (many of them medical) who want to be subspecialists in the suburbs – this is pretty scary.
It is affectively, intellectually, and morally scary, yes, to think that we could accept this kind of regression to an archaic, not to say racist and classist past where becoming a doctor was a privilege limited to only a few. It is also scary in very practical terms, because the people who need health care the most are those least likely to be served by the “default” group. Indeed, in fulfilling their personal goals, the result will be to “serve” already overserved communities, largely in specialties in oversupply. There is good data that shows that students from rural areas are more likely to serve rural communities, that students from underrepresented minority groups are more likely to serve members of those groups, that students from less-privileged backgrounds are more likely to serve needier communities. And that all these groups are more likely to enter primary care specialties, those in most short supply. This is what we want. But they represent a small percentage of our medical students. Why? Because we still, despite all the data showing what predicts service to people most in need, stay wedded to incorrect and outdated ideas of “qualified” for medical school that overwhelmingly bring us the same old same old.
Many (although clearly, given the above, not most) of medical students, from all backgrounds, have some difficulty with the first two years of medical school despite being not only smart but are well-educated from top small liberal arts colleges. There is a relationship here; these colleges emphasize thinking and creativity and problem solving, exactly the skills needed to be an effective physician. They teach largely in small and interactive classes, fostering self-confidence and independence and thoughtfulness and sometimes non-conformity, exactly the temperament needed for an effective physician. They grade largely on the basis of essay tests, requiring integration of information, literacy, and demonstrating an ability to think, not on multiple-choice tests, just what we want from physicians. Unfortunately, this is not the best preparation for the first two years of medical school, overwhelmingly consisting of large lectures characterized by a presentation of a huge number of facts, and designed to reward memorization of those facts using massive multiple-choice tests. Good preparation for this: being a science major at a large university whose courses overwhelmingly consisted of large lectures characterized by a litany of factoids and rewarding successful regurgitation of those factoids on massive multiple choice tests. QED.
Not, of course, the best preparation for being a curious, open-minded, thinking, problem-solving doctor. But this is what we get. Yes, it is certainly true that some of our students from large universities, or from professional or high socioeconomic status, or majority ethnic groups, or suburbs, or all, are incredibly committed to making a difference. Many want to enter primary care, many more want to serve humanity’s neediest, in our country and abroad. They are humble, and caring, and smart. We are lucky to have them in our schools and entering medicine. But they, along with those who are from less-well-off families, and ethnic minority groups, and rural communities, remain a minority among all the sameness. And remain more or less in the same proportions over time. We continue to do the same thing, and have the audacity to wonder why we do not get different results. This is Einstein’s definition of insanity.
On November 16, 2014, Nicholas Kristof published his column “When Whites Just Don’t Get It, Part IV” in the New York Times. He discusses the continuing racism in this country, the legacy of slavery, the fact that “For example, counties in America that had a higher proportion of slaves in 1860 are still more unequal today, according to a scholarly paper published in 2010.” And, of course, he discusses the responses he received (from white people) to Parts I-III, saying it is all in the past, stop beating that drum, it is not my fault, I work hard and don’t get the special privileges that “they” do, and why don’t they take personal responsibility, and our President is Black, isn’t that proof that the problem is gone? I won’t begin to get into the question of how much of the vicious attacks on our President are in fact the result of the fact that he is Black; rather while I observe that the fact that he was elected says “Yes, we have made incredible progress,” I note that this does not eliminate “Yes, we still have lots of racism and it has major negative effects on people as individuals and society as a whole.”
Kristof talks about the fact that he and his Times colleague, Charles Blow, are both promoting books. He notes that while he (Kristof) is white and from a middle-class background, Blow is black and was raised largely in poverty by a single mother. But he also makes clear that this doesn’t prove that the playing field is even, but rather that Blow was very talented, very hard working, and also lucky. That some members of minority groups, or people with very disadvantaged backgrounds (or both) succeed is a testimony to them, to their drive and intelligence and talent and luck, and the support that they have had from others such as family or friends which, while obviously not financial, was significant. It absolutely doesn’t prove that those who are from such backgrounds who have not succeeded are at fault. Indeed, the converse is true; how many of those who are from well-to-do, educated, privileged and white backgrounds, who have had all the financial and educational supports all their lives, who are now in medical school or doctors or professors or leaders of industry would have gotten there if they had started as far down the ladder as, say, Charles Blow, or some of our medical students? Some, for sure, but not most. They are folks born on second, or even third, base, who make it home and look at those who started from home and made it around all four bases, and say “why can’t they all do that”? Most of you, starting in the same place, would, like those who actually did start there, never have had a prayer.
It is common for classes of medical students to develop a “personality”, more self-centered or more volunteering, more intellectually curious or more grinding, more open or more closed. I suspect that this probably has to do with a few highly visible people, because most of the students don’t vary that much. I have heard faculty complain about the inappropriate behavior, the lack of professionalism (especially when they get to the parts of school that involve caring for patients), the sense of “entitlement” that many students have. But this is not true (overwhelmingly) of those who are the first in their families to go to college, who are grateful for the opportunity and hard-working, and committed to making a difference in the world. If we think that entitled, unprofessional students are not desirable, why are we accepting those who fit that mold?

We can do better. We can scale up programs to accept caring, humble, committed, smart people instead of self-centered, arrogant, and entitled ones. Indeed, if we hope to improve the health of our people, we must.

More guns and less education is a prescription for poor health

Within the span of one week, my state of Kansas was headlined in two pieces in the New York Times, unusual for a small state. Unfortunately, neither was meant to be complimentary. “What’s the matter with Kansas Schools?” by David Sciarra and Wade Henderson appeared as an op-ed on January 8, 2014, and “Keeping Public Buildings Free of Guns Proves Too Costly for Kansas Towns”, by Steve Yaccino, was a news article (middle of the main section but top of the web page!) on January 12. Both are political and social issues; for example, the thrust of the “guns” article is that Kansas municipalities (like Wichita) that want to keep guns out of public buildings (like the library) are financially stymied by the cost of the security requirements the legislature has put in place in areas where carrying guns is not permitted. Like abortion (and neither of these pieces addresses Kansas’ virulent anti-abortion laws), guns are a very hot-button issue that inflames deep-seated passion in places like Kansas, and so is (sometimes) education. I will, however, focus my comments on the health impacts of these laws.
First, guns. Guns are, very simply, bad for people’s health. (Obviously, even when used as “intended”, for hunting, they are bad for some animals’ health, but this is not my focus.) Having guns around increases the risk of death or injury from them. Having guns intended for hunting stored locked and unloaded is the safest, but this doesn’t work for guns intended for self-defense since that renders them less available for that purpose. Carrying guns on your person, in your car, in public, on the street, and into businesses, public buildings, schools, and health care settings increases the risk. This is not what gun advocates, and concealed-carry advocates believe. Their idea is that there are bad guys out there carrying guns, either criminals who might want to rob you or crazy people who might want to shoot up your school or post office, and that carrying a gun allows one to protect oneself, and possibly others, by shooting down the perpetrator before more damage can be done. Thus, it protects your health, and that of others.
Nice idea, but completely unsupported by the facts.  Guns kill lots of people, injure many more, and virtually never save lives. This is the case even when used by police, and even more true when use of guns by police officers is excluded. It is true despite the widely-publicized, often repeated on the internet, and frequently invented stories about a virtuous homeowner shooting an armed robber. I have no doubt that such cases occur, but with such rarity as to be smaller than rounding error on the number of deaths and serious injuries inflicted by guns.  Suicides and homicides are among the leading causes of death in the US, most are caused by guns, and almost none of the homicides are “justifiable manslaughter” from a person protecting him/herself from an armed invader. The mere presence of easy-to-access guns in the environment increases dramatically the risk of successful suicide (see my blog, Suicide: What can we say?, December 12, 2013, with data from David Hemenway’s “Private Guns, Public Health”[1]). In addition, the number of “accidental” deaths (where someone other than the intended victim was shot, or someone was shot when the intent was “just” to threaten or show off, or by complete accident, sometimes when an unintended user – say a child – gets hold of a loaded gun) from guns is way ahead of any other method of harm (knives, bats, etc.)
When we go beyond having guns to carrying guns in public places, the data is less well collected. However, the trope of the heroic law-abiding, gun-carrying citizen drawing down on the evildoer in a public place, like say a movie theater or the waiting room of your clinic, is a terrifying thought. First of all, almost none of them are Bat Masterson or Wyatt Earp or Annie Oakley (except maybe in their own minds) and the idea that they will hit who they are aiming at is wishful thinking; the rest of the folks are caught in a gunfight. It is scary enough when this involves police officers, but if half the waiting room pulls out pieces, the results will be, um, chaotic. Harmful. Not to mention what happens when the police show and don’t know who to shoot at (maybe if you are a gun-toting good guy you can wear a white hat…).
So, having guns around, and the more easily they are available, is absolutely harmful to the health of the population, and generally you as an individual. If people, including legislators, and Kansas legislators in particular, want to encourage gun carrying for other reasons, they should at least be aware of and acknowledge the health risks. But what about education? The cuts in state education will, quite likely, harm the education of children (or if, as the article notes, the state Supreme Court forces the legislature to fund K-12, the education of young adults since the money will likely come from higher education), but what about health?
There is a remarkable relationship. More education leads to better health. Better educated people are healthier. The relationship is undoubtedly complex, because better educated people also have better jobs and higher incomes, which is also associated with health. This is addressed with great force in a recent policy brief “Education: It Matters More to Health than Ever Before”, by the Virginia Commonwealth University Center for Society and Health sponsored by the Robert Wood Johnson Foundation; for example, while lifespan overall in the US continues to increase, for white women with less than 12 years of education, it is currently decreasing! The RWJ site also includes an important interview with Steven Woolf, MD MPH, Director of the Center. “I don’t think most Americans know that children with less education are destined to live sicker and die sooner,” Dr. Woolf says. He discusses both the “downstream” benefits of education: “getting good jobs, jobs that have better benefits including health insurance coverage, and higher earnings that allow people to afford a healthier lifestyle and to live in healthier neighborhood,”and the “upstream” issues, “factors before children ever reach school age, which may be important root causes for the relationship between education and health. Imagine a child growing up in a stressful environment,” that increase the risk of unhealthy habits, poor coping skills and violent injuries.
In several previous blogs I have cited earlier work by Dr. Woolf, one of the nation’s most important researchers on society and health, notably in “Health in All” policies to eliminate health disparities are a real answer, August 18, 2011. I included this graph, in which the small blue bars indicate the deaths averted by medical advances (liberally interpreted) and the purple bars represent the potential deaths that could be averted if all Americans had the death rates of the most educated. I also included a link to the incredible County Health Calculator which allows you to look at any state or county, find out how the education or income level compares to others, and use an interactive slider to find out how mortality and other health indicators would change if the income or education level were higher or lower.
In the US, the quality of one’s education is very much tied to the neighborhood you live in, since much of school funding is from local tax districts and wealthier communities have, simply, better schools. (This last is completely obvious to Americans, but not necessarily to foreigners. A friend from Taiwan was looking at houses and was told by the realtor that a particular house was a good value because it was in a good school district. She called us an asked what that meant; “In Taiwan, all schools are the same; they are funded by the government. No one would choose where to live based on the school.”) This difference could be partially compensated for by state funding for education, which is why cuts in this area are particularly harmful, including to our people’s health. In fact the most effective investment that a society can make in the health of its people is in the education of its young.
An educated population is healthier. Wide availability and carrying of guns decreases a population’s health. Unfortunately, the public’s health seems to carry little weight in these political decisions.

 



[1]Hemenway, David. Private Guns, Public Health. University of Michigan Press. Ann Arbor. 2007.

Fake news, fake facts, and fake science: making stuff up to justify hurting people and the planet

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 accessis 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.  

Caribbean medical schools: “second chance” or serving a real need?

“Second chance med school”, by Anemona Harticollis in the New York Times July 31, 2014, is the most recent treatment of the topic of for-profit Caribbean medical schools that train American students who, in most cases, were unable to gain admission to traditional US-based schools. This is not the first time Ms. Harticollis has covered the story; they are also the subject of her article in the Times from December 22, 2010, “Medical schools in region fight Caribbean flow”, which focused on the fear of US schools that these Caribbean schools are willing to pay for the use of clinical teaching spots in hospitals that these US-based schools have been using for free. This most recent piece focuses on St. George’s University in Grenada, one of the more established and better-regarded Caribbean schools. It was briefly famous when protection of its students was one of the justifications for President Ronald Reagan’s invasion of that country in 1983. The article also mentions the other three schools that have been approved for US loans by the Department of Education. However, beyond this, and despite Harticollis’ efforts, the discussion gets murky on two counts: which Caribbean schools are under discussion, and what are the issues of concern.

 Harticollis notes that
There are more than 70 medical schools across the Caribbean, about half of them catering to Americans. A handful — including St. George’s, Saba University, Ross University in Dominica and American University of the Caribbean in St. Maarten, all of which are for-profit — have qualified for federal financial aid programs by demonstrating that their standards are comparable to those in the United States. And they report that high numbers of their test-takers — 95 percent or more — pass the United States Medical Licensing Exam Step 1, a basic science test.
But quality is all over the map in the Caribbean. A 2008 study in the journal Academic Medicine looked at 14 schools and found that the first-time pass rate on the exam ranged from 19 percent to 84 percent. Countries whose schools performed lowest were the Cayman Islands, Haiti, Cuba, Aruba, Dominican Republic, Antigua and Barbuda and, the lowest, St. Lucia, which hosted four medical schools at the time. High performers were in Jamaica, Barbados, Dominica and, the highest, Grenada.
It is irrelevant to the discussion of American medical students going to the Caribbean to look at the national medical schools in Caribbean (or any other) countries; it is only relevant to look at those which were created to educate Americans, and for the purpose of this discussion to limit it to the four that have Department of Education approval. The next thing is to understand that what is “good” or “bad” about any of these schools, or whether they should exist altogether, depends on who is looking and what their interests are. From the point of view of the individuals or companies that own these schools, the motivation is profit, but having a high-quality product increases their enrollment. From the point of view of students enrolling, the motivation is a chance to become physicians and practice in the US. From the point of view of those who are responsible for the academics of the schools themselves, it is to support students, provide a good education, and help them to be successful. From the point of view of many American medical schools, it may be to limit competition, whether that is for clinical teaching spots in hospitals such as those of the New York City public hospitals or for good students.
Most US allopathic medical schools, and their trade association, the Association of American Medical Colleges (AAMC), disparage the Caribbean medical schools in terms of quality of the students that they accept, since the majority of those attending such schools have failed to gain admission to AAMC member schools. However, since most of these AAMC schools have recently or are in the process of expanding their own classes, they must believe that there are well-qualified students who are not currently being admitted, and many of these have ended up in Caribbean schools. When AAMC campaigns to disparage the Caribbean schools, they tend to lump them all together, rather than looking at individual schools or only the 4 listed above. Unquestionably, students even at these four schools have, on average, lower grade-point averages (GPAs) and Medical College Admissions Test (MCAT) scores, and may, on average, not do as well on the USMLE exams as those from US allopathic schools, but there is great overlap. On the other hand, what is perhaps the most concerning part of education at the Caribbean schools is their clinical training – where they learn clinical medicine in the last two years of school. Are the doctors teaching them and the institutions in which they practice of high quality? Is there a well-defined curriculum? Is there standardization of the curriculum so that they can be confident that students are learning what they need to whether they are doing, say, a surgery clerkship in a NYC public hospital or a community hospital in Michigan? However, when AAMC schools are fighting with them about whether they should be able to have spots at the same places US medical schools use – say, NYC public hospitals – this point is also moot.
The most important perspective, of course, is not that of the students, the owners or faculty of the Caribbean schools, or that of the US schools and the AAMC. It is that of the American people and whether they will have access to physicians who will provide excellent care for them. The measures that are usually used for assessing the “quality” of applicants and students – MCAT and GPA and USMLE Step 1 scores – are at best peripheral, since, as I have often argued, they are scarcely relevant to being a good doctor. Does it matter that a doctor didn’t focus when they were a freshman in college and so got C’s, and so even after doing well for 3 years had a lower GPA than another? Should the chance to become a doctor be a reward for having your nose to the academic grindstone your whole life without surcease, or an opportunity for those with skill, passion, and commitment? I have often argued that the way to judge a medical school is by what its graduates do with their lives, and that the percent that enter primary care and practice in underserved areas is a major criterion. It is fine to have some of your graduates doing laboratory research or entering narrow subspecialties, but a school should be judged on its overall output and how well it provides for the needs of our nation.
There is some concern that because of recent agreements between the Accreditation Council for Graduate Medical Education (ACGME), which accredits allopathic (MD) residencies and the American Osteopathic Association (AOA), which accredits DO residencies, that osteopathic graduates will be more welcome in allopathic residencies, tending to crowd out Caribbean graduates. I would doubt that this will be an issue in the Midwest, where osteopathy is strong and most residencies already tend to prefer DOs to Caribbean grads, but it might have an impact in the East, where osteopathy is less present, and where I hear that information pre-med students get from peers (and perhaps sometimes pre-med advisors) is that Caribbean schools are preferable to US-based osteopathic schools.
Like osteopathic schools, Caribbean medical schools, including the 4 DOE-certified schools, place a much higher percentage of their graduates into primary care than do US-based allopathic schools. Is this just a result of the fact that primary care residencies are less competitive than many other specialties, so easier for students from Caribbean schools to get into? Unquestionably, this is part of the explanation, but there is also more encouragement for primary care in these schools, which do not boast a huge research enterprise or maintain tertiary-care hospitals. It also doesn’t change the fact that graduates of these schools, like many international graduates who were not US citizens, are serving the needs of our country because the US schools are not stepping up to the plate. US medical schools are very selective about taking students with high grades, and putting most of them into oversupplied specialties.
The education at Caribbean schools varies, and it would be a mistake to say that they are doing a better job than US allopathic schools. However, US schools are doing a poor job of training the doctors America needs, of ensuring that all people have equal access to quality health care, and the students graduating from Caribbean schools are often filling the holes that they leave.

Those who live in glass houses… 

Serving others or self-serving? All generations have both kinds of people

The current generation of young adults, commonly called “millennials”, is often criticized for being self-centered, “spoiled”, the product of “helicopter parents”, showing the signs of having grown up in a culture where “everyone was a winner”. On the other hand, studies also show them to be the most socially conscious, idealistic, and optimistic generation in a long time (despite the evidence that things are not going so well for them, and little reason to think they’ll improve soon). They, as a group, have become politically involved, shocking the established political order with their enthusiasm for the presidential candidacy of an old Jewish socialist from New York City via Vermont, making Sen. Sanders a viable contender
This generation includes most medical students, as well as most residents, so I get to see them a lot. I can say that there are many in this group who are committed, hard-working, idealistic and self-sacrificing. And there are a lot who are not. In short, they are people. Yes, there are those who, for whatever reasons in their personality or upbringing, are “all about me”, argue their grades, have no time for giving to others, seem to have no sense of the collective good, and sometimes make me wonder why they want to be doctors. But you know what? We had those people back in my generation. I was in college in the 1960s, and not pre-med, and there were pre-meds around who had the reputation as narrow, grade-grubbing, and not socially involved. There were also pre-meds who were very involved in the major struggles of the day, anti-war, civil rights, racism. I was in a post-baccalaureate premedical program in the early 1970s, when the Vietnam War, with its extension into Cambodia, was peaking. Many of my fellow students, going to night classes after working all day, could not be seen as privileged, but many, including veterans, were active in those movements. And many were not.
I was in medical school in the mid-1970s, and there were many who were all about themselves and their futures. And many whose futures turned out to be very distinguished and productive. There was also a lot of social involvement. Chicago had a number of medical schools, and students knew each other across schools, even sometimes roomed together. When a physician researcher at one school was discovered to be doing research that targeted poor black women, students there protested; when he planned to leave for a job at another school, students there made an issue of it. I was involved in some of these struggles, and some in medical school. When, at a forum of the whole school to discuss the impact of our 3-year curriculum, the Chairman of Surgery announced he thought our 3rd-year medical students were ill-prepared because he had heard some of them asking nurses for advice on skills such as starting an IV (“in my day, we would never have asked nurses for advice!”), I stood up and spoke on how we were glad to not be like that, that we wanted to be able to learn from anyone. Maybe not my smartest hour (the chair of another department tried to get my year-old grade in his clerkship changed), but I bring it up because there appeared to be generational differences then, as now. I am not an expert on generational trends (for this I recommend the outstanding book by Paul Taylor, “The Next America”[1]), but looking back I also remember senior faculty who were very supportive of progressive efforts; I think that then, as now, it is people who are different, not really generations.
Our current and recent medical students at KU created and continue to staff and work hard for the Jaydoc Student-run Free Clinic, which provides care for folks with little or no money or insurance in the evenings; succeeding classes, if not generations, have expanded the scope and impact of the clinic. Students frequently volunteer for, and self-fund, trips to provide care in poorer countries – and even sometimes in our own, for those left out of our non-system of health care. (These trips are generically called “mission trips” even when there is no explicit evangelical religious component; however, many are indeed organized by religious organizations, and personed by students, doctors and others motivated by their religious beliefs. I may not be a big fan of religious evangelism, but I am a big fan of people doing good work!) Many of our students are active in the community, in local as well as national programs. They regularly volunteer for the school-based health clinic at a local high school, named the Bulldoc for the school’s teams, the Bulldogs, by the high school’s students (post-milennials?). The clinic itself was created by a collaboration between the school, school district, community groups (particularly pastors), medical school faculty, and students – in particular one medical student, without whose efforts it would never have come to pass.
When I was young, and even in earlier generations, many students, like other people, worked for the interests of others as well as themselves. Many do so now. Others, it is sad (to me) to say, are indeed self-absorbed, and all about themselves. Like other people, like doctors – and nurses and accountants and steelworkers and retail clerks and unemployed people. We can only laud those whose work demonstrates the “better angels” of human nature, and hope that narrow, selfish behaviors will extinguish.
To those who are in medical school, I want to say “No, it is not about you. It is about the people for whom you will be caring. And let’s not forget what ‘caring’ means.” Sometimes I actually do. Maybe we should all say, or at least think, that more often.



[1]Taylor, P and the Pew Research Center, “The Next America: Boomers, Millennials, and the Looming Generational Showdown”, 2014.

Critical access hospitals: Worth subsidizing to help save rural America

If you live in a sparsely populated area, you may find it difficult to obtain medical care because doctors and hospitals are far away. The issue of geographic isolation is independent of insurance status; it is a problem that plagues Canada, where everyone has health insurance through its single payer system (coincidentally called “Medicare”), but most of the people are concentrated within a short distance of the US border, and there are vast stretches of empty (or, more to the point in this case, almost empty) land. The situation is exacerbated further by the fact that many people living in rural areas work in jobs that have a higher risk of injury which might need care (e.g., farming, ranching, logging), and by the fact that a greater percentage of people living in rural areas are older, and thus more likely to have chronic disease. However, hospitals serving rural areas are small, and may not bring in enough revenue to support their fixed costs, so hundreds of rural hospitals closed in the 1980s and 1990s.
In response, Congress created the Critical Access Hospitals (CAH) designation in 1997, allowing hospitals that meet certain criteria (initially being greater than 35 miles apart) to receive increased reimbursement from Medicare at 101% of their costs. This was very successful, not only permitting the survival of many existing rural hospitals, but the creation of new ones, particularly when states were allowed to add other criteria to the designation, creating “Necessary Provider” Critical Access Hospitals, NP-CAH. The existence of these hospitals has been seen as a top priority for many rural communities, and for the states that they are located in. However, a recent report (OEI-05-12-00080) by the Department of Health and Human Services’ Office of the Inspector General (HHS-OIG) suggests that a stricter application of the distance criterion (even 15 miles, not 35) would mean that many of these hospitals would no longer receive 101% of their costs, and that this would result in the saving of $449 million to Medicare. They provide us with a sample map of Missouri, showing which hospitals would be affected.
As reported by Mike Shields of the Kansas Health Institute (KHI) in “Inspector general’s report has rural hospitals worried”, this has the National Rural Health Association raising the alarm. It is of special interest in the middle of the country. Kansas, where former governor and current HHS Secretary Kathleen Sebelius certified 31 additional hospitals under the NP-CAH criteria, leads the nation with 83 CAHs; Iowa is second with 82. According to the OIG, “There are more than 1,300 CAHs in the United States. CAHs are located in every State except Connecticut, Delaware, Maryland, New Jersey, and Rhode Island. CAHs provided care for approximately 2.3 million beneficiaries in 2011. Medicare and beneficiaries paid approximately $8.5 billion for this care.” So it is not surprising that these hospitals, their trade association, and the states in which they are located, are very concerned; many of them would likely close if they didn’t receive the excess payments from Medicare. The question is: would it be a good idea?
Essentially, the key part of that question is not whether it would save money for Medicare; clearly it would. The question is “would it harm the access of rural people to necessary medical care”? I don’t know the answer to that; or, rather, I know the answer is that it would but I don’t know how much. Could people drive 15 miles farther to the next hospital? Probably. Many of them are already driving a number of miles. Would this be inconvenient? Probably. After all, a large percentage of the users of these hospitals (most of which are also the locations of the doctors’ or other health providers’ practices) are older, thus Medicare’s interest in them. Would people be less likely to get necessary preventive and treatment care for none emergencies? Possibly. Distance is a big issue, especially if you have to be picked up and driven by someone else. Would there be disparities in which rural residents see decreased access? Almost certainly. Many rural people with high incomes often go to larger facilities in bigger cities, or to “destination” centers, like the Mayo Clinic, for their regular care. Obviously, the poor will have less access.
But would it save sufficient money to justify this? What is the cost/benefit to saving $449 million to Medicare against the – what? Lives? Convenience? of a bunch of rural Americans? Very hard to measure, although I again (see “Why poor people choose ERs: we need a system designed to meet everyone’s needs”, August 4, 2013) call attention to the fact that “convenience” is a loaded word that does not convey the full impact of time, transportation, and competing demands that affect the lives of the most needy. It is probably a matter of priorities, and of course, who you are. Are you the majority of people, including Medicare recipients, who live in major metropolitan areas, and for whom the sheer distance to a hospital is not among the many problems that you have accessing care (although transportation might well be) or the 20% or so who live in these rural areas?

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

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

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

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

Is the US health system about “health” or “profit”?

There are two forces at work in the system of health care delivery in the US which are essentially incompatible. One, which might be called the “health” approach, is focused on improving the health of the people. This could, should, and does include efforts to control costs, because this makes it possible to maximize the number of people who can benefit. This approach, which is codified in almost all international and most national health goals, seeks to use whatever resources exist (financial, structural, institutional, and human) to have the greatest health benefit for the most people. The World Health Organization (WHO) defines health as “…a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”. A cornerstone of this is understanding that public health measures, which benefits populations, are generally of greater urgency and wider benefit than individual medical interventions.
While the need for a public health approach is perhaps more obvious for poor countries which lack, for example, clean water, it is no less important for wealthy nations such as the US; we just don’t usually think of the fact that we usually have clean water as a “health benefit”. As with many things, we are less likely to notice things that are good than those that are problems, and we relegate them to the background of our consciousness. We don’t wake up each morning saying “I’m glad I don’t have cholera because I have access to clean water!” Indeed, it is only when we travel abroad and have to use only bottled water, or when a crisis like the lead pollution of the water supply in Flint, MI grabs our attention, that we give this any thought at all. The result is that public health efforts pay the price; less than 6% of our US health expenditures are on public health, with the bulk spent on direct individual medical care, and the profit that insurers, providers and middlemen skim. In addition, our country spends much less, proportionally, on efforts that impact upon the social determinants of health, those characteristics of people’s lives (housing, food, safety, education) that affect people’s lives much more than health care.
Still, when we – or those we love – are sick and in need of medical care we are grateful that it is there. But for many or most of us, it is often hard to pay for it. When we cannot, when the incredible amount of money we have to pay for medical care (often even when we are insured) threatens our families’ well-being, our ability to pay for shelter, food, education, it is a different story. And we know that access to and use of such individual medical care is neither randomly distributed among the American people nor allocated based on the greatest need; no one is shocked to discover that rich people get more medical services. (What may be shocking to learn, however, is that this does not always lead to better health. Services are often delivered — to those who can pay — whether they are really necessary or not, and sometimes this leads to complications and worse health!)
It is in this context that a new study in the journal Health Affairs by Dickman, et al., “Health spending for low-, middle-, and high-income Americans, 1963–2012”[1]is very revealing. The authors provide data on both the amount health spending among the American people over that 50 years, and how it has been distributed by quintiles of income. To summarize the findings: in 1963, before Medicare and Medicaid, spending was heavily skewed toward wealthier populations, but after those programs were implemented spending became more equal among the quintiles (although, adjusted for disease burden, which is higher in low-income populations, it was still not equitable). Then, over the last decade studied, the spending gaps returned, with much more being spent on the upper than lower quintiles (despite the generally better hea

lth of those who are better off), for the population under 65 (presumably because those over 65 all have Medicare). The authors state that “The rising income-based disparity in spending suggests a shift from allocation of health care according to need to allocation by willingness (and ability) to pay,” and it clearly does. They add that “It is unclear whether this shift arises from the underuse of needed care among the poor or overuse of unnecessary care by the wealthy,” but I am going to go out on a limb and suggest that it is both.

The reason for this is the prominence of the second force at work in health care systems (you were wondering if I would ever get to this!), which I will call the “profit” approach. This approach looks at health care as a commodity to be purchased and marketed. Unsurprisingly, those taking this approach choose to preferentially market both certain services over others (those for which the reimbursement is much higher than the cost of providing them, called even in non-profit institutions the “profit margin”), and market them to certain populations over others (those with money or insurance, and relatively good health so there are less likely to be costly complications). While this approach tends to favor the wealthy, leading to the data presented by Dickman et al., it also favors the less sick. Since older people tend to be sicker than younger (and are covered by Medicare, which pays less well than private insurance), this may in part explain why the quintile-of-income differences are less for the elderly. In summary, health care providers (mainly hospitals and physicians, but also others), want to market the services on which they can make the most money to the people who, arguably, need them the least. You can have greater difficulty accessing care because you are the wrong person (too poor, too sick) or have the wrong condition (one for which treatment has a low profit margin).
Dickman and colleagues present their data fairly dispassionately, without hammering home the obvious conclusion that it reflects a society more driven by the “profit” than the “health” approach to health care delivery. Essentially, it is a story of half-hearted (called “practical” by its advocates) efforts to introduce greater equity into our health care system being overcome by the tactics that smart and well-paid insurers and providers employ to “game the system”. In his regularly outstanding “Quote of the Day” commentary on the Dickman article, titled “Redistribution of health care from the poor to the wealthy”, Dr. Don McCanne takes the discussion a little farther, noting that a single-payer health care system, in which everyone had the same coverage and which could regulate the marketplace, decreasing the profit incentive, would improve the population’s health.
When I wrote to Dr. McCanne that the effort to find ways to preferentially deliver high-profit care to well-insured high-income folks rather than those who needed it most upset me (OK, I said it made me want to puke), he wisely responded that it “seems like our health care system has excelled at creating ‘work arounds’ for those measures that health care justice advocates keep attempting to advance.”Usually when people use the term “work arounds” they are referring to finding ways to do what needs to be done in the face of bureaucracy or inefficiency. In this case, however, it means propagating inequity in order to make money.
The two different approaches, putting “health” or “profit” as the primary impetus to our health care system, get different results. Personally, I favor “health”. Sadly, though, the other is often more prominent.



[1] Dickman SL, Woolhandler S, Bor J, McCormick D, Bor DH, Himmelstein DU, “Health Spending For Low-, Middle-, And High-Income Americans, 1963–2012”, Health Affairs 35(7):1189

Medicaid expansion: Is there something the matter with Kansas?

One of the key parts of the Affordable Care Act’s (ACA) effort to cover most Americans was the expansion of Medicaid to cover everyone under 138% of the federal poverty level (FPL). The Supreme Court decision in 2012 (National Federation of Independent Business v. Sebelius) found in favor of the “individual mandate”, allowing the law to go forward, but found against the ability of the federal government to withhold all Medicaid funding from states that did not expand Medicaid. This decision did not prevent the federal government from creating an incentivefor states to expand Medicaid, which it did; for the first 4 years the federal share of cost of expansion would be 100%, dropping to 90% thereafter. This is quite a financial incentive, and as of December 15, 2015, 31 states have expanded Medicaid, 4 are considering it, and 16 are not, depicted on this map from the Kaiser Family Foundation (KFF).

Neither of the Kansas City area states, Kansas and Missouri, are in the expansion group, and thus a significant portion of their population remains uncovered. Like the other 14, control of their legislatures (and in Kansas, of the governor’s office) is in the hands of very conservative Republicans ideologically hostile to ACA. However, this is a problem not only for the poor people left without insurance and their advocates (like many of the healthcare foundations), but also the states’ hospitals, who continue to have to provide care for these people without reimbursement. To some degree it is also a problem for the state’s business community because more than half of the this group of people are employed, mainly in small businesses that cannot afford to buy private health insurance. It also decreases, in the opinion of many Chambers of Commerce, the state’s ability to attract new business and jobs.
On January 5, 2016, I attended a forum on expanding KanCare (Kansas’ privatized Medicaid program) sponsored by many of these business organizations (6 Chambers of Commerce), hospitals, physician provider organizations, and healthcare foundations (see list of sponsors on KC COC site). The event, held in Overland Park in the Kansas City area, followed a similar one held in Wichita in November, 2015.  It began with a presentation by Dave Kerr, a Republican former president of the Kansas State Senate, detailing how Medicaid expansion would bring in at least 10 times what the state would have to spend. After this were two panels, one consisting of 5 KS legislators (3 Republican, 2 Democratic; 3 senators, 2 representatives), and the other of 5 healthcare experts.
Prominently included in the second group was the president of the Indiana Hospital Association, Doug Leonard, who presented how his state had effectively expanded Medicaid. The presumption of the sponsors of the event was that this would resonate in Kansas, because Indiana is also a conservative state with a very conservative governor (Mike Pence) who had mandated the expansion based on certain principles of individual responsibility and fiscal neutrality. Indiana’s plan is one of 4 (those with asterisks on the map) that were developed with federal waivers. In its first year, it has enrolled 220,000 people into its Medicaid program, and, largely because it is paying providers at Medicare rates, increased by 1,000 those who accept Medicaid. It is paid for by a combination of increased cigarette taxes and levies on hospitals.
Unsurprisingly, this resonated well with most of the attendees and speakers, although support was not universal. Sen. Jim Denning (R., Overland Park), who is considered a health policy leader in the state senate (apparently he works for a group of private ophthalmologists), indicated that Indiana’s program would not pay for itself after the first year and would have to tap into the state general fund. The moderator asked Mr. Leonard, who drily indicated that perhaps Sen. Denning had information that Indiana did not have. When the moderator asked Sen. Denning the source of his information, he indicated “the Forbes article”. Mr. Leonard responded that, first of all, it was not an article but a blog post in Forbes, and second that the state had responded point-by-point to its incorrect assertions.  
Sen. Denning’s credibility as a source of facts was already questionable, as he had previously asserted that Medicaid expansion would affect only those between 100% and 138% of the FPL as those below 100% were already eligible for KanCare (not true; in Kansas, adults actually must be actual below about 33% of FPL, in addition to being a a special group like mothers of dependent children or disabled, to be eligible for KanCare) and that those between 100% and 138% of FPL could buy subsidized “silver” plan coverage on the exchanges for about $2.50 a month (not true; those below 138% of FPL are not eligible to buy coverage on the exchanges at all). I do not know if he misspoke or whether he believes those assertions to be true. If the latter, it is not clear whether whether those misconceptions in part inform his opposition to KanCare expansion (and thus could be changed by the facts) or if his ideological opposition informs his willingness to believe such incorrect information. However, he is a leader in the state senate, and so he is probably accurate when he asserts that the KS legislature will not expand KanCare. Other legislators on the panel, including the Republicans, indicated that such expansion would require leadership from KS Governor Sam Brownback, which the governor has not indicated will be forthcoming. One, Sen. Jeff King (R., Independence) is from the town whose hospital recently closed, at least in part because it could not count on KanCare expansion; he indicated that his father, who had had 2 heart attacks, was now 25 miles, not ¾ of a mile, from the closest hospital.
Beyond Sen. Denning, there were other concerns about the forum. Every panel member was white, and other than one state senator, Laura Kelly (D., Topeka), every one was man. Women gave the opening and closing remarks, but there were no people of color who spoke. This was obvious, but not the only important way in which the speakers (at least) and probably audience differed from the average person. One reason was that there were a lot of business leaders, because they have clout. They do, however, have a limited – and not always accurate – view of the rest of the people in this country. They seem to think that support for expansion of KanCare (and other social programs) is important until people get good jobs and get these benefits from their work (they referred a lot, disparagingly, to the “able bodied unemployed”). But where are the jobs? Job creation is supposed to be a high priority of the governor and legislature, and is the stated reason for the dramatic tax cuts of 2012 (indeed, rich people are now renamed “job creators”) but not only has job growth been slow, but it is mostly in lousy jobs – poorly paid and without benefits (eg., health insurance!). There was a great deal of talk about “retraining”, but there simply are not enough “good” jobs to employ everyone no matter how retrained they are. Their myopia may be because many well-to-do people have contact with others who are like them; in their neighborhoods, work, and country clubs. They have little insight into the real issues confronting those in the bottom 80%, not to mention 50% or 10%. I doubt they even know what the numbers are, but this article from CNN Money, with its neat interactive graph, should help; the median household (not individual) income in the US is $52,000.
I see lots of both poor and “regular” people as a doctor in the clinic and in the hospital. I live in a neighborhood that is mostly, well, working class. I see my neighbors, adults and children, on the streets when I walk my dogs. They’re trying, but it is not easy for them. Jobs are scarce, and many of those  that  they can get involve the sort of physical labor that takes its toll on their bodies and leaves them prematurely disabled. Lack of health insurance exacerbates their problems. A major recent NY Times/Kaiser Family Foundation study, reported by the NY Times, finds “Even Insured can face crushing medical debt”. Those business leaders who may think that $200K a year (for a household, most with two earners) is “middle class” should know it puts that household in the top 5% (and, for goodness sakes, in many parts of the country households making $200K are still struggling!). It would be good for them to meet with some regular folks and find out about their lives. I applaud the work that the various healthcare foundations in Kansas, many of whom co-sponsored this event, are doing. But our leaders, political, business, and otherwise, need a little reality check to leaven the ideology.
There are a lot of things that impact on whether a person is healthy besides access to health care (the social determinants of health: housing, warmth, food, education, safety, etc.). But access to health care helps. 

Premature babies and informed consent: we need to do it right

The New York Times reported April 10, 2013 that an investigation by the Department of Health and Human Services “has found that a number of prestigious universities failed to tell more than a thousand families in a government-financed study of oxygen levels for extremely premature babies that the risks could include increased chances of blindness or death.”  “Study of Babies Did Not Disclose Risks, U.S. Finds”, by Barbara Tavernise reports that the study of the use of oxygen in 1,300 infants born at 24-27 weeks of gestation during 2004-2009 and published in the  New England Journal of Medicine in 2010, “did have an effect on which infants died and which developed blindness, and that those risks were not properly communicated to the parents, depriving them of information needed to decide whether to participate,” and that these  “…conclusions were listed in great detail in a letter last month to the University of Alabama at Birmingham [UAB], the lead site in the study,” which included 23 academic institutions, including Stanford, Duke and Yale.
The science is complex. Very premature infants such as those studied are at high risk of death and other complications, including blindness. It has long been known that the use of very high concentrations of oxygen, near 100% (room air is 21% oxygen), causes them to have an increased risk of blindness. The Times notes that “Clinical treatment of premature infants has a troubled history. Attempts to treat them with higher oxygen levels that were thought to improve their odds of survival led to many cases of blindness. Premature babies need oxygen because their lungs are underdeveloped and they often need help breathing.” The study under investigation was using lower concentrations, 85-95%, in an effort to find a level that was most beneficial for survival without having an increased risk of serious outcomes, such as blindness. The response letter from the lead investigator at UAB argues that a similar (but not formal control group) of infants had a higher mortality rate than those in the study group; this is criticized by others who note that it is not valid science to retrospectively attempt to create a comparison group because they may be different in important ways. Usually, participants are randomly assigned to either receive the intervention or not, because this means that any differences that may exist, known or not, are likely to be equally present in both groups. In fact, one critic, Michael Carome of Public Citizen’s Group on Health, points to a study published in the journal Pediatrics in 2012 that noted the babies in the other group were sicker and thus more prone to die.
But what is of concern to the HHS investigators, and to me, is that the parents of the babies in the study were apparently not informed of the risk of blindness that is known to accompany high-level oxygen therapy, despite the study (and its consent form) having been approved by the Institutional Review Boards (IRBs) of all 23 participant institutions. This is shocking on the face of it, but is even more surprising given that consent forms have largely become, as the Times article quotes Arthur Caplan, head of the division of medical ethics at New York University Langone Medical Center, “…captured by worries about legal liability, so risks tend to come billowing forward like a huge fog… It’s a truth dump, so they are covered should something go wrong.” He is absolutely correct; consent forms commonly include a list of potential negative outcomes so long as to obfuscate what is important, e.g., “rash, fever, nausea, vomiting, headaches, bleeding, seizures and death”. (NOTE: This is MY rendition of what I think is typical; it is NOT the list contained on the premature infant oxygen study.) What is a patient or parent of a patient to think? How bad are these outcomes? How likely are they to occur? How can I make a decision? And, perhaps most important, how can I give a well-thought-out response, giving or withholding consent, when I am – or my baby is – terribly sick and at high risk. What usually happens, as Dr. Caplan notes, is that “…often in such emergency medical situations, parents often rely more on what doctors say in deciding whether to participate than on the fine print of a consent form.“
Much, if not most, research, even medical research, is done with people who are not at high or immediate risk; much early clinical research, as well as that in the social sciences, specifically looks at “normal volunteers” or at regular people in the community. All require informed consent by participants. There are (at least) 3 different sets of interests in any research. The researcher is interested in finding out the answer to a question, which in clinical research is usually about whether one type of treatment is better than another. The patient (or guardian), whose motivation, according to the urgency of the situation, may be to contribute to expanding medical knowledge, to earn some money (if there is an honorarium involved), to help others in the future who may confront the same problem, or, especially when the situation is very urgent and the patient very sick (as in this study) to hopefully get immediate benefit for themselves or their child. The institution in which the study is conducted (represented by their legal department) is interested in guarding, to the extent possible, against risk of lawsuits.
Interestingly, the allegation in this current study is the failure to mention the potential outcome of blindness, more a typical failing of the “bad old days” when patients were not informed at all of risks (e.g., the Tuskegee syphilis studies) than of the “bad new days” where the risk aversion of universities’ legal departments has created the type of laundry list of bad outcomes noted above. But both are bad. Consent cannot be “informed” if typical, regular, non-lawyer people cannot understand the consent form because the language is so abstruse, or if the list of potential outcomes is a jumble of serious and minor ones. This is particularly true when a patient  is critically ill, and they or their guardian is under incredible stress. This is when, as Dr. Caplan notes, they rely on what the doctors say; unfortunately this puts the doctor in the position of trying to dispassionately provide a recommendation as to whether or not to participate in a study that s/he usually feels passionately about. This is not a setting conducive to true informed consent.
The literature on informed consent is enormous, and it is a major focus of the field of medical ethics. But the key principle must be that participants be adequately informed of the risks that may exist, in language that they can easily understand. The risks must be presented with the most serious ones highlighted, along with the probability that they will occur. They must be presented openly and dispassionately, and study leaders must be available to honestly and completely answer questions. There is, unfortunately, an inverse relationship between the comprehensibility of a consent document and the degree to which it is written in legal language (as anyone who has ever tried to read anything written in legal language can believe).
Consents must be appropriate to the situation. Researchers who wish to, say, interview people outside a local supermarket to find out what they think are health problems in their community, should not have to have those people sign a 3-page consent to participate or no one would do it. Researchers who wish to study clinical interventions in high-risk patients in urgent circumstances need to provide adequate information about risks and benefits in a way that patients can understand, and not use their role as the “doctor” to “sell” a study because they believe the intervention will be beneficial even though the results are not yet in. IRBs need to take their responsibility to protect participants’ interests and be truly informed, while facilitating the conduct of research seriously. It’s not easy. Lawyers need to learn how to write in a way that folks can understand.
Clearly, leaving out a major potential complication like blindness from a consent form is wrong, but there is much more to getting true informed consent than a simple fix. But it has to happen if we are to continue to be able to conduct research in order to have new knowledge.

Rising white midlife mortality: what are the real causes and solutions?

 A widely covered and important health research study was recently published by Princeton economists Anne Case and Angus Deaton in the Proceedings of the National Academy of Sciences, “Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century”. The main message is contained in the title – mortality rates for white middle-aged Americans are going up – but there are three other important findings that emphasize its significance.
The first is that mortality rates are going down for every other age and ethnic group, as well as for whites of the same age in other developed countries (see graphic). This means something special is happening to this population group in the US. The second is that this increasing mortality rate is not evenly distributed across class, but is concentrated in the lower-income, high-school-educated or less, group of people. This begins to suggest what is special about this group: that they are being hit hard by societal changes that particularly affect them. The third is that the mortality rates for African-Americans, while decreasing, still significantly exceed those of this group of midlife whites. All of these bear further examination.
That these death rates are rising was apparently surprising to the study’s authors, according to the New York Times article “Death Rates Rising for Middle-Aged White Americans, Study Finds” by Gina Kolata on November 2, 2015, which begins with the sentence “Something startling is happening to middle-aged white Americans.” It surprises not only Case and Deaton, but also numerous commentators quoted in the article and in subsequent coverage. An example cited by Kolata is Dr. Samuel Preston, professor of sociology at the University of Pennsylvania and an expert on mortality trends and the health of populations, whose comment was “Wow.”  I guess this is an appropriate comment about an increase in mortality rates of 134 more deaths per 100,000 people from 1999 to 2014, which Dr. Deaton says is only matched by HIV/AIDS in current time.
But the findings are not too surprising to me. After all, Deaton and Case are economists, not physicians or health researchers, and they came upon this data almost serendipitously while studying other issues (such as whether areas where people are happy have lower suicide rates). But others, those who are physicians and health researchers, should know better. Maybe the doctors expressing surprise are those who don’t take care of lower-income people. And the health researchers are those who have not been reading. In a blog piece  from January 14, 2014 (“More guns and less education is a prescription for poor health”) I cite  Education: It Matters More to Health than Ever Before, published on the Robert Wood Johnson Foundation website by researchers from the Virginia Commonwealth University Center for Society and Health, which notes that “since the 1990s, life expectancy has fallen for people without a high school education, a decrease that is especially pronounced among White women.” This was reported over a year and a half ago, and discusses a trend in place for two decades!
Or maybe I am not surprised because I am a doctor, and see these patients both in the clinic and in the hospital. We do take care of lots of lower income people – those not in the 1%, or the 20% or even the top 50%. Yes, the bottom half of the population by income do exist, and many of them are white, and they are not doing well. The study by Case and Deaton indicates that the causes of death that are increasing the mortality rates in this group of people are not increases in the “traditional” chronic diseases such as diabetes, heart disease, and cancer, but are rather due to substance abuse (illegal drugs, prescription narcotics, and alcohol) and suicide. This is not to say that we don’t see much illness and many deaths from those other chronic diseases in this population; we do, and they account for the high baseline mortality among this group, but these other causes are the reasons for the rising mortality rate.
We have seen the explosion of prescription opiate use in people who (like Dr. Case, as it happens) have chronic musculoskeletal pain (despite increasing evidence that opiates are not very effective for such pain). This often results from their work as manual laborers, either from a specific accident or from the toll wreaked by chronic lifting, bending, twisting, and straining. We also see increased use of alcohol, that traditional intoxicant. While sometimes it seems that we hear more about studies touting the benefits of a couple of glasses of wine a day, the reality is that millions of lives are destroyed directly and indirectly by alcohol use: those of the drinkers, those of their families, those of the people they hit when driving drunk. And in both urban and rural areas (people in rural areas were particularly affected by the mortality increase in Case and Deaton’s study) the use of methamphetamine. And as the drop in standard of living for people who used to make their living with their bodies doing jobs that have disappeared or they can no longer physically do becomes clearly irreversible and leads to serious depression, often compounded by chronic pain and substance use, increasing rates of suicide.
What is only alluded to in some of the coverage of this study is the most important point: this is about our society failing its people. It is about the “social determinants of health” writ large. Yes, the direct causes of the increased death rate in this population are alcohol and drug use and depression leading to suicide, and we do need better treatment for these conditions. But to leave it there would be like looking at deaths from lung cancer and chronic lung disease and concluding only that we need better drugs to treat these conditions without considering tobacco. Our society has, for at least four decades, been somewhere between uncaring and hostile to a huge proportion of its people. Where once we were a land of rising expectations, where people who worked hard could expect to have a reasonably good life, this changed beginning in the 1970s. Jobs for those with high school educations started to become rarer, and in the Reagan 1980s, “Great Society” programs that supported the most needy were decimated. (For the record, the “War on Poverty” actually worked; poverty rates went down!)
In the 1990s, economic growth hid the concomitant growth in income disparities. With the crashes of the tech and housing bubbles leading to severe recession in the mid-2000s, the impact of these disparities became apparent. While there were protests in response (e.g., the “Occupy” movement), the banks were bailed out, the wealthy continued to grow wealthier, and working people have seen their jobs, incomes, standards of living, health, and ultimately lives disappear. Only the blind or willfully ignorant could have not seen this coming.
To a large extent, then, this is an issue of class, however much “important people” decry the use of that word. It is also an issue of race, since, as noted, mortality rates for African-Americans (although not for Latino/Hispanics) continue to exceed those of whites; even as they begin to converge, there is still great disparity. Camara Jones, MD, the new president of the American Public Health Association (APHA) uses the term “social determinants of equity” to describe why African-Americans are so over-represented in the lower class.  The current data showing that lower-income whites are moving toward the long-term disadvantaged should not obscure this fact, but rather remind us that white people have had a privilege that is now, for the lowest income, being eroded.
The irony is that many of the people in the groups reported on, and their friends and relatives and neighbors, voted for those in Congress and their states who pursue policies that make their situations worse. That the 1%, or 0.1%, or 0.001% (after all, 153 families have contributed 50% of all campaign donations this year!) like these policies is understandable provided that they are not only rich but selfish, but they alone don’t have many votes. That their money controls votes, both by buying advertising and directly buying politicians, is undeniable. Maybe poor people cannot contribute as much as rich people, but they can vote (most of the time) and there are so many more of them. If we must reject “trickle down”, we must also reject appeals for votes that are implicitly or explicitly racist; lower income white people are not benefiting by voting for the racists.  The lives and health of Americans will be improved by improving the conditions in which they live, by an economy whose growth is marked by more well-paying jobs, not money socked away by the wealthiest corporations and individuals. People, of all races and ethnicities and genders and geographical regions need dignity and opportunity and hope that is based in reality, not false promises.
We need to treat the diseases that affect people and cause rising mortality, but we need to treat the conditions that lead to them even more urgently.

“Good enough for Government Work”: Quality, cost, and gaming the system, Part 3 (of 4 parts)

This is part three of the Charles Odegaard Lecture, delivered at the 27th National Conference on Primary Health Care Access, April 6, 2016

The VA is an example of how quality can be and is compromised when public sector funding is cut. In the area of public health, it can have an even greater impact, and no fewer apologists. When, under cost-cutting mandates from the state of Michigan the city of Flint changed its water supply from treated Lake Huron water to the industrially-polluted Flint River, the complaints of citizens were ignored. When concerned health care providers, like Dr. Mona Hanna-Atisha (pictured), raised warnings about rising lead levels in the children of that city, she was attacked and vilified. But she was right and they were wrong, or, perhaps worse, lying. Poisoning our children to save money. If individual health care is jeopardized when those responsible are being rewarded for cost-cutting, we can do a truly impressive job of harm when we destroy the public health infrastructure. And let us not forget that a major reason this was able to happen was Racism; that they were not “our” children, at least not those of the state authorities.
We need more emphasis on quality. Indeed, quality, not cost-cutting, needs to be our primary metric. Spending less should only be acceptable when quality is not negatively impacted. I realize that this is also subject to interpretation; “quality” has almost as many different interpretations as “waste”, and is frequently (if, hopefully, usually unconsciously) associated with “what benefits me”. I am talking about health care that is of benefit to most people, and is considered basic – keeping patients clean and out of their own filth, feeding them, treating the diseases that we know how to treat, doing surgery when it is of clear benefit, not having excessive waits for specialty care that compromise outcomes. And, most importantly, not providing financial incentives for limiting care. From a cost-cutting point of view, money is fungible, whether it comes from ‘cutting the fat’ or cutting needed care; but from a healthcare point of view, there is a big difference. (I refer to healthcare here as “caring for people’s health”, not the industry of the same name!)
This is the big issue, and it is amazing to me that it sometimes seems like such a mystery. If most of our incentives are to cut costs, to keep our jobs or to make bonuses or to keep our agency functioning, costs will be cut. Even when those cuts negatively affect quality, in real and dramatic ways. The argument for privatization goes something like “the private sector can do it better because, motivated by the opportunity to make profit, they will discover efficiencies that government employees do not, and run a ‘leaner ship’”. The problem is that, while there may be some examples of this happening, what usually happens is that costs are cut by cutting services, and making off with the profit, or bonus. The ship is made lean by cannibalizing its parts, and the only thing which is certain to be maintained in fine working order is the lifeboat in which the parties responsible hope to escape in while the rest sinks. This scenario is repeated over and over again, whether services are actually provided by private and for-profit organizations (think drug companies, insurance companies, nursing homes, and increasingly hospitals) or whether “private sector incentives” are built into publicly provided services, as in England at Mid-Staffordshire, or, increasingly, in the US in Medicare.
Profit may not be a great incentive to provide better health care, and is an uncertain to very poor guarantee of quality, but it is an excellent incentive to generating profit. Think of drug companies like Turing and its former CEO, Martin Shkreli, the poster child for unfettered greed, and his 5000% increase in the price of pyrimethamine, or of Valeant, the Canadian pharmaceutical company that recently doubled the price of secobarbital, an 80 year old barbiturate, in anticipation of California’s assisted suicide law. Think of the increase in price of colchicine, a drug that was used (in its plant form) to treat gout in ancient Egypt 3500 years ago, from 10 cents to $5 a pill when the FDA “encouraged” its manufacturer to conduct new studies and banned the generic (finally reversed last year, with generic colchicine again available.) Think of the insurance companies whose profit was baked into the ACA, making it costly and still not covering everyone. The ACP has recently called for government controls on drug pricing. The fact is that you can’t count on private for-profits to provide quality, unless you really trust Martin Shkreli.
Interestingly, in contrast to the Triple Aim advocates, critics of Sen. Bernie Sanders’ proposal for National Health Insurance system, Medicare for All, assert his math must be wrong, that we couldn’t both save money and deliver quality health care to everyone. (The Chicago Tribune editorial endorsing no one in the Democratic primary says: “Sanders first amused Americans who know their fiscal math with proposals for free college tuition, expanded Social Security, $1 trillion in infrastructure spending, “Medicare for all” …. The nonpartisan Committee for a Responsible Federal Budget calculates that his economic plans would push the top federal tax rate to about 77 percent”).[1](By the way, they really mean the topmarginal federal tax rate, which was, for the record, 90% when I took civics in junior high.) I don’t know if they are disingenuous or purposely befogging the issue, since it is clear that every other developed country delivers care to all its people for, usually, 1/3-1/2 of what we spend per capita in the US, with much better outcomes by most or nearly all measures.
So why are cost estimates in the US so high, when other developed countries do it for so much less? A great deal of it is that profit is built into the system. When we read about the problems of our system, we hear from insurers, who think providers charge too much, and providers, who think insurers pays too little, and each with an army to try to get what it wants. It is not because we care too much about patients. In Canada, there is a single payer national health insurance program (called “Medicare”) where the government pays the bills for largely privately-delivered care. The fact that it is private delivered is part of why their costs have risen second only to ours, but there is some central control. In Switzerland, there are multiple payers, insurance companies that are, however, forced to charge the same amount and provide the same basket of services, and be non-profit. How do they compete then? Why, on service to their patients! What an incredible idea! If you call your company to complain and can’t get through, you switch to another! As long as our system is predicated on building in excessive profit for providers, insurers, and drug companies, it will be fantastically expensive, albeit a full-employment program for those people trained to try to get bills paid and, on the other side, to deny payment. And it will be about cutting costs, not improving quality.

Medicare payments to doctors: the big issue is the underpayment for primary care

The Center for Medicare and Medicaid Services (CMS) just published how much money individual doctors get paid from Medicare. This initial version is without names, but undoubtedly the names will eventually be revealed. Enough information is available for Reed Abelson and Sarah Cohen, who wrote the article for the New York Times on April 9, 2014Sliver of Medicare Doctors Get Big Share of Payouts”,   to identify many of the specialties and locations. About ¼ of all Medicare payments, the article tells us, go to about 2% of all doctors. “In 2012, 100 doctors received a total of $610 million, ranging from a Florida ophthalmologist who was paid $21 million by Medicare to dozens of doctors, eye and cancer specialists chief among them, who received more than $4 million each that year.” The largest amount of money was accounted for by office visits, $12B, but this was for 214M visits, with an average reimbursement of $57, in contrast to the Florida ophthalmologist, or to the “Fewer than 1,000 radiation oncologists, for example, received payments totaling $1.1 billion.”

Much of the discussion in the article, and in the comments attached, relates to why so few doctors get so much of the $77B Medicare pays out each year. There are, obviously, concerns about fraud; not only is Medicare seemingly fixated on looking for fraud everywhere but there is good evidence that it has occurred, at least historically. For example a highly paid (by Medicare) Florida ophthalmologist is apparently linked to a previous Medicare fraud scandal in which there was some implication of New Jersey Senator Robert Menendez. “The Office of Inspector General for the Department of Health and Human Services, which serves as a federal watchdog on fraud and abuse for the agency, released a report in December recommending greater scrutiny of those physicians who were Medicare’s highest billers.” I would have to say that this is a much wiser, fairer, and probably more productive strategy than simply trying to find largely unintentional errors in coding for outpatient visits, or checking each hospital admission to see if it could have been an “observation”, which is reimbursed less because it is considered outpatient status, as is done by Medicare’s Recovery Audit Contractors (RACs, or as I have called them, bounty hunters). Also, as I have previously discussed, these efforts are harmful to the patient in a direct financial way; as an “outpatient”, a Medicare recipient in the hospital has much higher out-of-pocket costs than if they are admitted as an inpatient. This is, of course, why CMS wishes to limit some stays, but if a person medically needs to be in the hospital, Medicare should pay for a hospitalization, and not play these games that not only financially penalize the hospital and doctors but more importantly the patient.
The other big area discussed is whether, if not exactly fraud, there is substantial difference in practice (e.g., getting CTs before each procedure, using more expensive drugs, etc.) that some specialists who are highly reimbursed by Medicare are doing more of than others. In addition, the question is “are they doing more procedures” or doing procedures with less strict indications? It is worth looking at; there is no guarantee that, even if some doctors are doing more procedures, having looser criteria for them, using more expensive drugs and tests, that this is not the better way to practice, but there is no guarantee that it is the better way to practice. If some doctors are outliers in their specialty, and their practice characteristics “happen” to end up making them a LOT more money than others, then this is certainly a reasonable basis on which to look more closely at how they are practicing, and what is the evidence basis of appropriate practice.
A third issue is that many of the recipients of the most money from Medicare, particularly oncologists (cancer doctors) and ophthalmologists are using very expensive drugs, which they have to buy first and which Medicare reimburses them for. Thus, this skews their reimbursement upward even though the money (or most of it) does not go to the doctor, but rather to the pharmaceutical company. The article refers to a drug called ranibizumab, injected into the eye by ophthalmologists monthly for age-related macular degeneration. It is very expensive, as are many drugs which are made through recombinant DNA (a lot end in “-ab”) used by oncologists, neurologists, rheumatologists, and gastroenterologists as well. One comment notes that he as a physician only makes 3% on the drug. While it can be argued that this is a significant markup (for example, making $3000 on a $100,000 drug), and that this doesn’t include the doctor’s fee for administering it (substantial), it is unfair to count the full cost of the drug as income for the doctor. Of course, it is income for someone (the pharmaceutical company) which suggests there needs to be substantial investigation into pricing of these drugs. And, of course, if a physician is found to be using a lot of a drug where he (or she) makes a 3% markup rather than prescribing an equally effective drug (if there is one) where there is no markup profit, this would be a bad thing.
However, the most important thing revealed by this data, I believe, is the enormously skewed reimbursement by specialty. It is an excellent window into the incredible differences in reimbursement for different specialties, with the ophthalmologists, radiation oncologists, etc. making huge incomes while primary care doctors (and nurse practitioners) are making $57 for an office visit. This is major. The fact that Medicare pays so fantastically much more for procedures (and, as a note, it is likely that all of the doctors, including the 202 family doctors in the highest-paid 2%, are getting it for doing a lot of procedures) leads to private insurers paying similarly more. And makes these specialties very attractive to medical students because they are lucrative (and often, though not in the case of many surgical specialties, involve fewer hours of work). Which leads to fewer primary care doctors, and a dramatic shortage in this country.
Medicare could change this. It could dramatically, not a little bit, change the reimbursement for cognitive visits to be closer to the payment for these procedures. If it did, so would private insurers. If the income of primary care doctors was 70% of that of specialists (instead of say, 30%) data from Altarum researchers and from Canada suggest that the influence of income on specialty choice would largely disappear. More students would enter primary care, and in time we would begin to see a physician workforce that would be closer to what this country needs, about 50% doctors actually practicing primary care.
It is fine if CMS and the OIG look at these highest billing doctors to make sure that they are not committing overt fraud. It is also fine to look at them and see if they are using criteria for procedures that are not supported by current evidence, or doing too many other tests, or taking kickbacks. It is also a good idea to look at the cost of drugs, especially the portion going to the drug company, as well as the markup for physicians, and to re-present the data excluding that portion of the money the doctor does not get (goes to the pharmaceutical company) from their income.
But the most important result of this report should be to be shocked at the way Medicare enables the continued practice of reimbursing for procedures at such high levels, and to kickstart a complete revision of the Medicare fee schedule to bring reimbursement for different specialties into better balance.
That would be a great outcome!

Perception of problems in the health care system: will the mighty fall or is there a chance to save it for all of us?

[This is a particularly long post, but I haven’t posted for some time. I have been working on a book, and if it ever comes together, this will be part of it.]
 
There are a lot of problems with our health care system in the US. Undoubtedly, there are problems with all health care systems, but ours has the distinction of being – by far – the most expensive in the world, and yielding health outcomes that are shocking low, especially for the cost. Our outcomes are much worse than those in comparable advanced capitalist democracies, and often follow behind other generally less wealthy countries. There are those who persist in saying “the US has the best healthcare in the world” but to the extent that they are not completely ignorant, or, worse, purposely dissembling for political reasons, they are talking about a narrow portion of health care. First of all, medical care. Second of all, medical care that is accessible, and therefore only for some individuals. Thirdly, mostly rescue care – high intensity, highly-specialized, high-tech, high-cost interventions for individuals with some conditions.
 
Even within these parameters, the claim is not entirely true. Many of the interventions that are available do not actually prolong life or the quality of life. They exist as goods which can be purchased by those with sufficient resources and sufficient motivation (presumably, ill health that is not responding to other treatment) but do not always (or even most of the time) create benefit that is “patient-important” – elimination of unnecessary death, or increased quality of life. For overall health care, even those with money, access, and insurance do not always get higher quality care; frequently, they have things done to them both diagnostically and therapeutically which they are led to believe may be of benefit to them, but often is not. In fact, these interventions can lead to further interventions, at greater cost in both dollars and discomfort or morbidity to the person, as abnormalities that turn out to be unimportant are chased down. Sometimes, these interventions, available mostly to the best off of us, are actually harmful. The costs are so high, we are seeing a new enterprise, “medical tourism”, in which Americans who need or want more-or-less elective surgery travel to other parts of the world, where the outcomes are as good and the cost is often (even with airfare and hotel!) less than the deductible would be in this country.
 
When we look at population health, rather than the individual health issues of people in the middle and upper class, the problems are even starker. By virtually every measure, health status in the US lags beyond other wealthy countries, and many less wealthy, in markers such as infant mortality, years of life lost to treatable conditions, disability adjusted life years, and even age of death. Our “between groups” contrasts are very stark in the US, mirroring those of many developing economies, not other “first world” countries. The fortunate among us may get the “best” care for some conditions at the expense (both financial and personal) of over-intervention, but many of us get what is frankly poor care or no care at all.
 
Finally, most of the negative determinants of health are outside of and before interaction with the medical care, or even any aspect of the health care, system. They are the social determinants of health, the economic status of your family (and of your family of origin; wealthy people born poor, while admirable “Horatio Alger” role models, have worse health status as a group than wealthy people born rich). They include housing, food, education, warmth, discrimination, environmental pollution (much worse in poor communities than in wealthier) and a host of other negative impacts that, in Dr. Camara Jones’ analogy[1], put you closer to the cliff face, more likely to fall off and then be at the mercy of whatever the medical care system does or does not provide.
 
However, even when people acknowledge that these disparities, inequalities and inequities exist, and that our health system is sorely lacking, there is not agreement on what the most important problems actually are. Even when we eliminate overtly political posturing and consider only the honestly conceived beliefs of different players in the system, there is lack of consensus because there are many different perspectives from which to view the elephant of health care. In addition to the differences in perspective, there are differences in incentives, in the fact that what may be good for some part of the system is bad for others. Physicians and other individual providers, hospitals and health systems, politicians, policy makers and pundit – and of course patients – have different perspectives. And, certainly, there is plenty of blame to go around, and no shortage of others that any of us can point fingers at as the “real” problem.
 
For a physician who is interested in caring for patients, the regulatory burdens can be the real problem. Days are spent with less and less time providing care to patients, and more and more completing the record (and the evidence is that, whatever the benefits, electronic health records take more time to complete), filling out forms, complying with regulations. Increasingly employed by hospitals and health systems, they are driven to “be productive”, which in a fee-for-service system translates into “see more patients and spend less time with each”.  The number of people who need care is increasing, not just from the one-time bolus of people getting health coverage under ACA, but more from the increase and aging of the population. There are exceptions, systems where care is capitated, where physicians and other providers (especially those in primary care) are organized into teams and paid on the basis of providing comprehensive care for populations rather than for face-to-face encounters, but these are far from the norm. From the perspective of these providers, most of the efforts to increase access have increased their workload, decreased their job satisfaction, and, possibly most important, decreased their sense that they are providing quality health care to their patients.
 
For hospitals and health systems, which have built enormous physical plants and infrastructures based upon “product lines” that are highly reimbursed (and, more important, have a high return on investment, or high reimbursement-to-cost-of-providing-the-service ratio), the challenge is also regulation, but in a different way, and of changing what is reimbursed. Like physicians, hospitals would like the public to think that they are in the business of delivering quality health care, but the emphasis, whether for-profit or non-profit, is often on the business part. Hospitals and health systems are sometimes run by physicians or other health providers (often with MBA degrees) but are frequently run by accountants. They may do well by their metrics, making (or not losing) money, but this may be a result of providing a particular market segment, or product line, or service to a particular (insured) patient population, rather than providing the most-need healthcare to those who need it most. If policy changes begin to financially reward doing something different than the hospitals have been doing (for example, keeping people out of the hospital) they can restructure, acquire ambulatory practices, fight it and hope it will go away, or go bankrupt. They can adopt collaborative arrangements with their physicians, and sometimes restrict referrals to keep them within the system. Changes in policies and regulations are very challenging, because there is such an enormous capital investment.
 
Policy makers, politicians, and pundits have different challenges. Politicians want to be re-elected, and so need to satisfy voters, or at least likely voters, or at least those with the most money who will finance their campaigns. Pundits have few restrictions other than their beliefs. Policy makers, who may be politicians or work for them, or may have been or later become pundits, have to implement goals. But sometimes the goals are in conflict. To restrict the potentially inappropriate admission of patients by hospitals in order to collect more money from Medicare, puts policies and practices into place which encourage classifying patients as outpatients (“observation” status). But this then does not eliminate the cost; it both decreases the reimbursement of the hospital and increases the amount that the patient, the Medicare beneficiary, has to pay out of pocket.
 
Of course, there is the patient, who is ostensibly the focus of all the attention, for whom the entire health system exists, but who is usually the least powerful player in the entire equation. More important, there is not a patient, there are many people with different sets of needs and preferences. Yes, most would like to stay healthy if they are, or get healthy if they can. They may be willing to put a lot of work into it or may have a more passive approach, wanting to be made healthy. They may have very different understandings of health, and different degrees of belief in and trust in physicians or other providers, and indeed in science. Even if they want to trust science and medicine, they are very likely to be confused by the complex way in which new medical knowledge is developed and found to be accurate, scarcely in a linear “this is good for everyone, this is bad for everyone” manner. Their lives may be very busy and have little time to spend at the doctor, or they may see visits to the doctor as one of the more positive and fulfilling experiences that they have. They may “know” what is wrong and what is to be done, and find the doctor to be just a particularly uncooperative store clerk who will not provide them with it, even when the doctor believes that it would be of little or no use, unnecessary and expensive, or even dangerous. They may have the sense of invulnerability that often accompanies youth, or the frailty and fear of old age. They may have cultural beliefs that make it difficult or impossible to understand or accept medical recommendations, and lead to frustration in interactions with the medical system. Even positive developments, such as the “Patient-centered Medical Home” (PCMH), are challenged by the fact that not all patients are the same, and what makes one comfortable, at ease, and feel healed may be a negative for another.
 
In his sensitive and thoughtful essay on the Health Affairs blog, Matthew Anderson provides us with 9 questions that he has about the PCMH, in the form in which he finds himself working and in the projections for the future.[2]He is certainly not opposed to a conversion of practice to being more patient-centered and less provider-centered, but raises questions about the degree to which the processes that have been put in place in the name of PCMH have actually done this, and whether they have increased or decreased not just his satisfaction as a provider but the quality of care that is provided to patients. Dr. Anderson is neither a Luddite nor a malcontent, but rather is trying to raise his eyes above instrument panel at which he is working to see if the direction in which the ship is sailing is the one we want to go in. He is, above all, focused on the values that we are trying to achieve, and concerned that our over-emphasis on the process, on the plan we have put in place rather than the goal, will not get us where we want to go.
 
In his book “How the Mighty Fall”[3]business professor Jim Collins puts forward 5 stages of decline in once-great companies. Stage 1 is “Hubris born of success”, Stage 2 is “Undisciplined pursuit of more”, Stage 3 is “Denial of Risk and Peril, Stage 4 is “Grasping for Salvation”, and Stage 5 is “Capitulation to irrelevance or death”. Which stage is your organization in?
 
Luckily, Collins’ work suggests that turnarounds can happen even in Stage 4. The key is staying true to the key principles and practices of our work. Dr. Anderson’s 9 questions can be a start to guiding us.

 


[1]Jones CJ, et al., “Addressing the social determinants of children’s health: a cliff analogy”, J Health Care Poor Underserved. 2009;20(4 Suppl):1-12. doi: 10.1353/hpu.0.0228.
[2]Anderson, M, “Nine questions about my new medical home”, Health Affairs blog, March 17 , 
[3]Collins J. How the might fall: and why some companies never give in.Collins Business Essentials. New York. 2009.

The Future of ACA and Health Care for Americans: We need Medicare for ALL!

It’s a new year. 2017 ended with the GOP passing a landmark tax bill that will provide huge long-term windfalls to corporations and the very, very rich, but little and time-limited benefit most folks. “Most”, in this case, being the vast majority. The “99%” probably underestimates it. Hey, how about I give you $10 once and you support my getting $1,000 a year in perpetuity? Well, why not? At least I get my $10. Except, whoops, you’ve raised prices on me by $20 a year.
The Republicans just missed out on their repeal of the Affordable Care Act in 2017, but there is a strong possibility they’ll try again in 2018. The decision will certainly be made on political grounds; maybe they’ll want to do it while they have a one-vote majority in the Senate if they think they might lose it. On the other hand, maybe doing it will increase the likelihood of them losing even more Senate seats. Tough one; you know the American people will stand for a lot of screwing-over, but it may be possible for you to push it too far.
In the meantime, however, the Trumpenik administration has slashed subsidies for people getting coverage on the federal exchanges. The President himself tweeted on December 26, 2017 that the “Tax Cut Bill…essentially Repeals (over time) ObamaCare”. It didn’t, but it did make it much more difficult for many Americans to obtain health insurance, and most of them are in states that voted for Trump and the GOP. As CBS reported on the same day, 80% of the 8.8 million newly covered are in these states. The four states with the highest enrollment, totaling 3.9 million, were Florida, Texas, North Carolina and Georgia. While these are states all went for Trump in 2016, all but Texas are in danger of going Democratic in the future. Florida has long been a swing state (remember the hanging chads of 2000!), NC is probably flippable in a presidential election (although, barring a court ruling overturning it, amazing gerrymandering will protect Republican House seats there), and Georgia is changing quickly. Of the 11 states with the biggest increases in enrollment, 8 voted Republican (Iowa, Kansas, Kentucky, Missouri, Nebraska, North Dakota, South Dakota and Wyoming). So cutting subsidies for buying insurance on the exchanges is a great way to punish your base.
There is even a school of thought that believes the cutbacks in funding for purchase of private insurance, along with the dramatic expansion of Medicaid (in the states that have done so), creates the opposite of GOP intentions, a more publicly-funded health insurance system. This topic is addressed in the NY Times article “Years of Attack Leave Obamacare a More Government-Focused Health Law” by Robert Pear, also on December 26. While only about 10 million have gotten coverage by private insurers through the exchanges, and this will drop as both the individual mandate and subsidies are eliminated, over 75 million people have benefited from Medicaid expansion. The “Medicare for All” movement advocated by Sen. Bernie Sanders is gaining increased momentum in many states (for example, Maine, where it may be pushed over the resistance of the Republican governor), as people increasingly realize that this is their only protection. Eliminating the mandate means healthy people will not buy insurance that they can no longer afford without subsidies, so that the cost of insurance for sick people will become truly unaffordable. If they do not qualify for Medicaid, they will be plumb out of luck, unless Medicare is expanded to cover everyone.
Some advocate for gradual expansion of Medicare, rather than going straight for Medicare for All, by extending it to those over 50 or 55 first. This is most often heard from “mainstream” (“centrist”) Democrats (the Republicans care about the health of the American people not at all), who have been most remarkable for their tentativeness and cautious incrementalism when in power, as opposed to the Republicans’ aggressiveness. And, while expanding Medicare to cover everyone is the simplest and most straightforward route to a single-payer insurance system, it must be an “improved and expanded” Medicare for all, as advocated and detailed by groups such as Physicians for a National Health Program (PNHP).Without this improvement people may legitimately fear an underfunded health system that requires major out-of-pocket expenses, that restricts access to certain procedures and specialties even when medically indicated, and that is more focused on cost-cutting than on health care.
Incremental efforts, such as gradually ratcheting down the age of Medicare eligibility, may seem to be tactically good ideas, but in fact they are silly and likely to cost more both in dollars and in worse health outcomes. Medicare, despite its limitations in funding, has made a phenomenal difference in the health of those eligible since its introduction in 1965. Those who receive Medicare now, the aged, blind and disabled, are the population with the greatest health care needs and costs. However, as physicians we regularly see those just under the age of 65 but with chronic illness suffering serious health outcomes and costs until they become eligible. While lowering the age to, say, 55 would enroll many of those with greatest need, there would always be people with need just below the age cutoff. More important, as the age of eligibility goes down, the marginal cost per covered life also goes down, because younger people are healthier. What makes sense is to simply wrap everyone together, getting both the benefit of an overall healthier younger population paying in and using little care and not excluding individuals of any age who (from chronic or acute illness or accident) do need care.
The day after all these appeared, December 27, a British physician named Rachel Clarke (@doctor_oxford), author of the current [British] Sunday Times bestseller “Your Life in My Hands”, posted a note on Twitter about her father dying of cancer after a long illness. “One major surgery,” she wrote, “countless chemotherapies, & a small army of community and palliative nurses so that he could be at home with us.”  She continued: “The bill? £zero. Grief, pain, emptiness – but not bankruptcy. Thank you, #NHS.”  How many of us could say the same in the US? Some, perhaps many, of us; those with money and good insurance, which is becoming increasingly rare. But MOST of us could not.

The lives of all of us, the health of all of us, and the commitment of society and government to the health of all of us, is what is at issue here. The Republican Party and its leader have demonstrated their clear and persistent opposition to it. And it is all of us, including their voters, who are suffering and will continue to suffer for it.

Medicaid expansion and uncovered lives: are people meaner in the South?

I have lived in a number of places, from New York City to Texas, Illinois to Kansas. Politically and socially there are very different norms that prevail, which are demonstrated by the difference in who we elect and what policies we choose to legislate. And, yet, in all of these places people are people. They can be kind and generous or mean and selfish. As individuals, they love and care for their children, or sometimes don’t. They are respectful of others, or not. In all places. And yet it is clear that there are major regional tendencies to policy that must reflect the local and regional values even though people are not necessarily nicer or meaner. I think that my blog posts have made clear my positions on many issues, particularly those related to health and to social justice.
Obviously, self-interest has a lot to do with what people believe, what policies they support, and which politicians they vote for to implement those policies. To a large degree, it is economic – what is good for me and my family, as illustrated in the old Clinton campaign mantra “It’s the economy [stupid]”. Of course there is more than that. If people voted mostly for their economic self-interest, we would have a very different set of national policies because there are so many more poor and middle-class people than rich, and in the last decade especially so many more middle-class people descending toward poor than ascending toward rich. Many of the policies we have would only be supported by those who are both rich and selfish, the latter being only a portion of the rich. And yet, so many of our policies only benefit the very richest. When it is “the economy”, it is usually good for the wealthy and big business, but not necessarily for all of us. And it is more so in some states and regions. We are, not individually but as a group, meaner some parts of the country than in others.
Access to health care and the means to be healthy (having the opportunity to have a home, and good food and a job and a reasonable opportunity to care for the needs of yourself and your family) is one important arena in which we are meaner in some places than others. We know, for example, that expansion of Medicaid under the Affordable Care Act has varied not only by state but largely by region. Since the ACA intended people under 133% of poverty to be covered by this expanded Medicaid (paid by the federal government, 100% for 4 years and then 90%), they are not eligible for health insurance exchanges. Thus, if their state did not expand Medicaid, they are unable to get coverage. This is the map of states that have expanded Medicaid; clearly, it there is a strong regional difference:

This figure from the Kaiser Family Foundation, showing the regional focus of non-expansion of Medicaid in the Southeast, South Central, Plains and Mountain states, is included in a very interesting piece in the Huffington Post by Harold Pollack of the University of Chicago, “Martin Luther King wouldn’t be very happy with this map”, posted on King’s Birthday holiday, January 19, this year. What he is referring to is that the South, the area King was from and spent most of his time working in (much of which is shown in the movie “Selma”) is one of the areas most affected. But Pollack makes the point that it is actually much worse, and that the South has the vast majority of uncovered people because some of those geographically-large Mountain and Plains states haven’t got very many people. Other states that have not expanded Medicaid, like Wisconsin, have other programs covering a large number of those who would be eligible for an expanded Medicaid. We have seen maps of the US re-drawn to make the size of states proportional to their population, where California and Texas and Florida and New York are huge, and Mountain states tiny. Pollack asked Harvard researcher Laura Yasaitas to show the states re-drawn to have their size proportional to the number of uncovered people. The results are even more amazing:
Because of their larger population, Southern states now obviously account for the vast majority of uncovered people, with the most populous states – Texas, Florida, Georgia, and North Carolina seeming huge. The two states Kansas City borders, Kansas and Missouri, are pretty big (Missouri is the one above Arkansas, the blue keystone in the middle, and Kansas is to its west, over Oklahoma which is recognizable because of its panhandle). Montana, Wyoming, and Utah fade not because they are covering people but because of their small populations. California and New York only show up because the mapmakers artificially pretended there were a couple of thousand uncovered people so they wouldn’t drop off the map altogether.
As Pollack points out, the two states that have benefited the most in terms of fewer people being uninsured are Arkansas, the keystone mentioned above, and Kentucky, the dark blue state above and to its east. This is because these two, southern/border states, had very large proportions of uninsured as did the rest of the South, so showed the greatest increase in covered people when they expanded Medicaid. Arkansas’ expansion created poignant stories in places like Texarkana where the poor folks in the Arkansas half were now able to get coverage, while those in the Texas half were not (see the NY Times “In Texarkana, uninsured and on the wrong side of the state line”, June 8, 2014). The lesson is that Medicaid expansion could benefit even more people if it were implemented in these large-population states, with real significant changes in the actual and potential health status of lower-income people there.
But they haven’t done it and are unlikely to. The political will is not present. There are anti-ACA crusaders in many states, but they are particularly prominent in the South, which already has the highest proportion of poor and needy people and the lowest levels of social services. Clearly, this has a lot to do with race – that historically and in the present many of the poorest people in the South are African-American (and, especially in Texas, Latino). This makes Dr. Pollack’s invocation of Dr. King particularly relevant. And particularly poignant. Racism has been one of the dominant themes in America, and while it certainly exists in all parts of the country, it has never been as institutionalized as in the South (remember slavery? Jim Crow?). And to those who say it is not like that anymore, we don’t have Bull Connor, or the bridge in Selma anymore, we are the New South, look at the map above.
I really don’t think that the people in the South, any more than in Kansas or Missouri—or Montana and Wyoming—are meaner than they are in other parts of the country. So why do they elect people who institute policies to make it look like they are?

Payments for surgical complications: With a scalpel or a meat ax?

When you bring your car to a mechanic and there is a complication, when something goes wrong with the procedure they say they are going to do, you don’t expect to pay for it, at least if it is their fault, and if you know it. Say that in repairing one part of the engine, they cut a hose in another part; you wouldn’t expect to be financially responsible for fixing it. You’d think that they should absorb the cost, but of course it might unlikely that you would know whether the complication was their fault (sloppy work) or unpredictable, maybe a pre-existing problem that they hadn’t anticipated. On the other hand, if they fix your brakes or transmission and a few days later they fail, you do expect them to repair it for no cost to you.
The relationship between payment and surgical procedures done on your body in the hospital is more complex. First of all, just as with your car, complications happen. Sometime they are the result of “operator error”, whether mechanic or surgeon, but most of the time they occur with a predictable (but hopefully low) frequency. And, like with your car, some people have higher risk of complications because they are in worse shape. And one of (although certainly not the only) the predictors of being worse shape is, just as with cars, the age of the patient. Therefore, it is important to consider the risk (and potential seriousness) of complications and weigh it against the potential benefit from the surgery.
Secondly, payment for surgery (as for all hospital activities, and to some degree all medical activities) is bewildering and incomprehensible to health economists, not to mention doctors and regular people. With your car, you get a bill for “parts” and for “labor”; if you think you’re overcharged, you go somewhere else next time. In medicine, and particularly in hospitals, “charges” for procedures are a largely mythical but definitely inflated number that bears only a little relationship to the costs the hospital incurs, and is almost never the amount that is paid. Different insurers (private, Medicare, Medicaid, “self-pay”) pay different amounts; big insurance companies can bargain down the rates that they pay, government programs such as Medicare and Medicaid set their rates, and the uninsured are the only ones who get a bill for the whole set of charges (of course, they can rarely pay them, but are often bankrupted or have their credit ruined in the process). (See Bargaining down the medical bills, March 15, 2009, or the experience of health journalist Frank Lalli trying to find out what his medicine would cost, “A health insurance detective story”, NY Times December 2, 2012, and covered in my blog post “Medicare: Consumer choice or choosing your poison? How about coverage for everyone?”, December 15, 2012.)

So, do hospitals make or lose money when there are complications to surgery? The answer is “it depends on who’s paying”. In a recent JAMA, Relationship Between Occurrence of Surgical Complications and Hospital Finances[1], Sunil Eappen and colleagues from the Harvard School of Public Health (including, as last and corresponding author, Atul A. Gawande, the surgeon whose New Yorker essays I have discussed several times) examined this question in a large hospital system in the southeast US whose “inpatient surgical payer mix (Medicare, 45%; private, 40%; Medicaid, 4%; and self-pay, 6%) was comparable to that of an average US hospital in 2010 (Medicare, 40%; private, 41%; Medicaid, 9%; and self-pay, 5%)”. Their study found that “…The financial effects of surgical complications varied considerably by payer type. Complications were associated with more than $30,000 greater contribution margin per privately insured patient ($16,936 vs $55,953) compared with less than $2000 per Medicare patient ($1880 vs $3629). In contrast, for Medicaid and self-pay procedures, those with complications were associated with significantly lower contribution margins than those without complications. As a result, the payer mix will determine the overall economics of surgical complications for a given hospital.”

Definitions  of Costs and Margins  (from Eappen, et al.)
Variable costs: Costs that vary with patient  volume (ie, supplies and nurse staffing).
Fixed costs: Costs that do not vary with patient volume (ie, costs for the hospital building, utilities, and maintenance).
Total margin: Revenue minus variable costs and fixed costs.
Contribution margin: Revenue minus variable costs. These are revenues available to offset fixed costs.


This absolutely does not mean that in these hospitals, or any hospital, surgical complications are seen as desirable. It does mean that, when the complications happen, the hospitals make money (their “contribution margin” toward fixed costs goes up – see the box which I have reproduced from the article for explanations of terms) if the patients are privately insured or covered by Medicare and lose money if the patients are covered by Medicaid or self-pay. It provides another example of why hospitals see some patients as “more desirable” based upon their insurance coverage, and illustrates how flawed this system is.

The study by Eappen was done on data from 2010, and there have been some changes since then. Medicare no longer pays for the treatment of complications (surgical or medical) that it has identified as preventable and that did not exist on admission (such as new bed sores or blood clots). It will soon go further and not pay for readmissions to the hospital within a certain period of time, whether or not the readmission is for the same problem. So, to carry on the car analogy, not only will they not pay again if your brakes fail after they’ve been “fixed”, they also won’t pay if you have to bring your car back because it needs transmission work. The latter may be as inappropriate for people as for cars; with time multiple things break down, not always related. With a car, we may sell or junk it; with a person we usually try to treat it. Our high-tech medical system can often get a person from the brink of death to “well enough” to go home or a skilled-care facility, but the same problem or another recurs and requires readmission. And, of course, since this is Medicare, all of our patients over 65 covered by this program now become “less desirable”; it means that, even more than before, hospitals will compete for patients with private insurance coverage.

This is no way to fix the problem. The first step has to be to put everyone in the same boat, to have a universal health insurance system, so that no patient is “more” or “less” desirable from a financial standpoint based upon their insurance coverage. Second, hospitals should not be paid on a “per case” basis or have a charge structure that no one understands. They should not have to seek out “well-insured” patients to cover their actual costs (fixed and variable) or put aside money for purchase of new capital equipment. In Canada, hospitals receive a global yearly payment for operating costs (and capital expenses are considered separately), and can thus make treatment decisions based on best meeting the needs of the patient, rather than “readmissions good” (we make money) or “readmissions bad” (we lose money. It is rather parallel to capitated payments for physicians, which I have discussed (recently, for example, Gaming the system: Integration of healthcare services can just raise costs, not quality, December 1, 2012), allowing physicians to treat patients in person, by phone or email, with long visits or short, depending upon what is most appropriate rather than which has the greatest reimbursement.

Of course, like capitated payments to physicians, hospital global budgets need to be adequate to cover costs and incent efficient but effective performance. A well-designed structure for payment that minimizes “gaming” the system no longer works when it is grossly underfunded. An open and transparent system of funding is most likely to permit cost savings where appropriate and not “across the board” (which is almost always wrong); it encourages the use of a scalpel rather than a meat ax.


[1] Eappen S, Relationship Between Occurrence of Surgical Complications and Hospital Finances, JAMA 2013;309(15):1599-1606.

Are primary care practices prepared for complex patients? Is this even the right question?

The goal for our national policy should be that every person have the best health status that they can. One component of this, although certainly not all of it, is access to high-quality appropriate health care services. This means that people can receive the care that they need, when they need it, and do not receive unnecessary or harmful care. Access includes both financial and physical (geographic) access, and also access to high-quality care (see, for example, “Et qui vendit pellucidum“, a recent blog post by my friend Dr. Allen Perkins).
One part of having access is that there need to be sufficient numbers of providers, appropriately trained and distributed to meet those health needs. It also means that those providers should have no reason or incentive to preferentially provide certain types of care rather than others, or care to certain people rather than others. Unfortunately, the profit motive skews this in the US; we have redundancy of profitable services like “cancer centers” and “heart centers” in major metropolitan areas, with hospitals competing for the same pool of patients, while in other areas even primary care is unavailable. We have excess capacity in some areas (every hospital, for example, needs an MRI or patients might go somewhere else, even if the number of MRI scans the population needs doesn’t justify it; providers prefer to take care of less-complex patients – a single joint replacement in an otherwise-healthy 45 year old with an athletic injury is more profitable than, and thus preferable to, doing a joint replacement in an 80 year old with multiple medical problems).
A recent survey of primary care providers in 10 countries by the by Robin Osborn and colleagues from the Commonwealth Fund, “Primary Care Physicians In Ten Countries Report Challenges Caring For Patients With Complex Health Needs”[1], published in the December 2015 issue of Health Affairs (only the abstract is available free on line) sought to determine whether primary care physicians (there are, at least in the US, other providers like NPs and PAs who are not physicians) feel competent to provide various types of care. The 10 countries were all wealthy and highly developed (Australia, Canada, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States). All but the US have some form of universal health care, although the way that it is organized (e.g., single-payer government health insurance in Canada, a national health service in the UK, multiple non-profit insurers in several others) varies from country to country. In most countries, “primary care” meant family physicians or GPs, but in others (including the US), it also included general internists and general pediatricians.
The researchers found both similarities and differences by country in the percent of primary care practices that had confidence in their ability to adequately address population health needs, especially those that are increasing because of the aging of the population. For example, the confidence of these practices in managing patients with multiple chronic conditions was generally high (from 70% in Canada to 88% in Germany and the Netherlands; the US was at 76%). Fewer practices were confident in other areas, and there was greater variance. For example, 92% of practices in the Netherlands and 81% in the UK had high confidence in providing palliative care, while Sweden (25%), the US (41%), and Canada (42%) were much lower. Similar variations existed for other services (see table); for example, confidence in dealing with patients with substance use related issues were much lower (from 16% in the US to 41% in the UK).


The authors also surveyed whether practices had a number of characteristics that many experts think are important for being able to effectively and efficiently manage complex patients. These included use of electronic health records (European countries were ahead, but the US and Canada, late adopters, are catching up), team based care, after hours care not requiring visiting the ER (the US is very low), access of patients to their medical records (the US is very high as this is one of the criteria for “meaningful use” payments from the federal government), communication between different hospitals, specialists, and ERs with the primary providers (all over the board including in the US), and many other areas.
Of course, these surveys reflect the experiences of physicians in different countries, and are thus subjective rather than compared to some iconic “gold standard”. People do not know what they do not know, or haven’t experienced, or cannot even imagine; their experiences are context-dependent, and so cannot be directly compared. For example, the survey asked whether physicians thought that (their) “system works well; only minor changes needed”.  Only 16% of US doctors answered positively, with the high being in Norway, 67%. However, in the UK the number was also very low – 22%. How can we interpret that? In all of these countries, save the US, including the UK, everyone is covered. 78% of UK physicians may not believe that their “system works well; only minor changes needed”, but what would they think if the alternative was a non-system like the US where there are large numbers of uninsured people? Would they think that a better system? Probably not, but can’t tell from this data.
Finally, and perhaps most important, the survey does not look at whether there are a sufficient number and appropriate distribution of primary care providers to meet a country’s needs even when the practices are well-organized. It is my impression that the answer to this question is closer to “enough” in most of these other countries; I am certain it is not in the US. In our country, the financial rewards for subspecialization and the “lifestyle” (and sometimes financial) rewards for urban location are major determinants in our distribution of providers across specialties and geography. There are far too few primary care providers as a percentage of all physicians, and while family physicians are far more equitably distributed than other specialists, there are still big geographic disparities. Among the many “solutions” that have been suggested, I believe that only one will work: eliminate, or at least dramatically decrease, the income differential between primary care and subspecialties. This is not as far-fetched as it seems; as I have discussed before, high income for some specialists and procedures are not market-drive but are set by policy; Medicare sets these rates.
As far as geographic disparity is concerned, this is an issue that most effects primary care and a few other specialties (psychiatry, general surgery) since most subspecialists practice only in urban areas where there are sufficient populations to use their services. This also can be addressed by money: pay providers differentially more for more rural practice. We also need to provide financial resources to support these practices not only for income, but for wrap-around care. Support must be provided to these practices so that they can afford the capacity to care for the complex problems addressed in the survey.
A general practitioner from Denmark (not one of the 10 countries surveyed) told me about how his anesthesiologist son-in-law really liked his work. I chuckled about how much he must make. He told me no, actually in Denmark GPs make more. This is a good illustration of how our assumptions are context bound.
It is also the way we need to go in the US.


[1]Osborn R, Moulds D, Schneider EC, et al., “Primary Care Physicians In Ten Countries Report Challenges Caring For Patients With Complex Health Needs”, Health Affairs 34, no.12 (2015):2104-2112, doi: 10.1377/hlthaff.2015.1018