Ebola, fate, and appropriately assessing risk.

There has been a lot written about Ebola lately, and lots of talk about it, and fear about it, in the halls of the hospital and clinics where I work, and I would guess lots of other places also. I don’t have any expertise in Ebola, and don’t claim to know what should have been done, or what “we” should be doing going forward, but it is clear that there have been mistakes, or at least major miscalculations, made by the WHO and the CDC and other government agencies. Some of this may be the result of cuts in funding over the last many years, some the result of emphasis on bioterrorism rather than the impact of infectious agents that get transmitted the regular way (“Failures of Competence”, Joe Nocera, October 18, 2014) but has been both sobering as well as a vehicle for administration opponents to attack it. Of course, the attacks may be justified, but there is no reason to think a previous administration would have done better.
First, it is critical to point out that the real problem, suffering, and crisis is in West Africa, in Liberia and Sierra Leone, and Guinea. In countries with little infrastructure and few resources and in the cases of the first two, relatively recent histories of devastating civil wars. The concern about Ebola in the US (so far two home-grown cases, both in nurses who cared for the Liberian man in Texas) needs to be seen in that context. Those countries that are severely affected need major resources, both human and financial, and need them fast. An excellent video analysis of the issues was recently done by Laurie Garrett on a webinar called “The Ebola crisis: the best and worst case scenarios from here”. Thankfully, there is some recognition of the need in these countries among those who are seeking to make political hay of this crisis; my own Senator Jerry Moran has joined others, particularly other Republicans, in calling for closing off flights from the affected countries, but proposes to exempt health workers. Of course, this misses the fact that it is easier to screen folks coming from those countries than people who first travel to other countries and then fly to the US.
What does interest me about the whole discussion in this country around Ebola is the degree to which it illustrates two common flaws in the way people think about problems. One, obviously at play in the case of Ebola, is the fear of the new, unfamiliar, and scary, especially when hyped up by the media. Thus, for example, the reluctance of both patients and staff (encouraged by their families) to come to work in our clinic during the period that a patient at our hospital was being ruled out for Ebola (he didn’t end up having it), even though it is in a separate building and the patient was three layers of isolation deep. This fear is stoked by events such as the revelation that the second nurse to come down with Ebola had been allowed to fly from Texas to Ohio and back on a commercial airliner (although it could just as well be cited as evidence that anyone,working in a hospital or not, might be at risk).
The second is that people often find it easier to worry about, to get worked up about, problems that they are at low risk for but that they cannot do anything about, even when they are not doing what they could do to prevent problems for which they are at much greater risk. I have written in the past about a prototypical patient obsessed by breast cancer, a condition for which she was in fact at no increased risk, who was not doing anything about problems she could act on such as uncontrolled hypertension, cigarette smoking, and unprotected sex with multiple partners. Indeed, my point was that if she was worried about those last three, people would expect her to dosomething about them since she could – she could take blood pressure medication, stop or cut down on her smoking, and use protection when having sex. But those might be hard. Worrying about breast cancer, something that there was nothing she herself could do to prevent (doctors could order mammograms, at too young an age and far too frequently, but she wouldn’t have to do anything) was, in this sense, easier. Both of these logical flaws were highlighted by comments from the chief medical officer of my hospital, early in the isolation of the possible Ebola patient: “If 20,000 people were dying of Ebola there would be riots in the streets. But every year an average of 22,000 Americans die of influenza, and people still don’t get their flu shots”.
This selective concern is a form of determinism, the topic addressed by Konika Banerjee and Paul Bloom in “Does everything happen for a reason?” in the NY Times, October 19, 2014. They discuss the idea of fate, that things happen that were destined to happen, that experiences of adversity which coincidentally lead to positive outcomes (the man hospitalized for injuries as a result of the 2013 Boston Marathon bombings who falls in love with and marries his nurse) are “meant to be”. They note that while this is most common in people who are religious and believe that God determines everything, it is still a very common belief among atheists. It is an attractive idea, but it is a mis-reading of chance. That is, people pay attention when things seem to fortuitously happen, or a coincidence facilitates something you wanted to happen. (E.g., yesterday morning I heard a part of a 1981 song on the oldies station but couldn’t remember its name; amazingly, when I turned the station back on in the evening, it was playing again! Fated? No, just Rick Springfield’s “Jesse’s Girl”.) We forget how often things do not happen, but remember when they do. Banerjee and Bloom write:
Not everyone would go as far as the atheist Richard Dawkins, who has written that the universe exhibits “precisely the properties we should expect if there is, at bottom, no design, no purpose, no evil, and no good, nothing but blind, pitiless indifference.”
Deists, like Thomas Jefferson I heard yesterday (also on the radio, but NPR this time), believed that the world was so ordered that there must be a creator, although they rejected the detailed instructions that many of their contemporaries took from the Bible or other religious texts. However, the random nature of events, as suggested by Dawkins or by Stephen Jay Gould (“Full House: The Spread of Excellence from Plato to Darwin”) accounts for these just as well.
The same issue of the Times contains a more medically related piece, “Why doctors need stories”, by Peter D. Kramer. I like stories, and I use them a lot (see above for a couple); they make things come alive, tie abstract events to actual lives, create examples in the experience of individual people of phenomena that are harder to understand when we look only at populations. But they can be misused; my story about the woman who was more worried about breast cancer than her smoking or high blood pressure is meant to be an example of how people can choose which facts they believe and which they ignore. It doesn’t prove anything, certainly not that most people act this way, or don’t. It does (I hope) get your attention. We have to be careful how stories are used; “I knew someone who had an abnormal Pap smear and she didn’t do anything and it went away”, while consistent with our most current knowledge about the early course of abnormal Pap smears in young women, is not a valid argument for you to not do anything. Stories tell what they tell; the lessons learned and conclusions reached are up to us.
Banerjee and Bloom end their piece:
If there is such a thing as divine justice or karmic retribution, the world we live in is not the place to find it. Instead, the events of human life unfold in a fair and just manner only when individuals and society work hard to make this happen. We should resist our natural urge to think otherwise.
And, no matter what we think about Ebola, we should get our flu shots.

Keeping immigrants and all of us healthy is a social task

The Health Toll of Immigration, by Sabrina Tavernise in the May 19 New York Times, documents the decreased life expectancy and worse overall health that accompany immigration to the United States. Focusing on Mexican immigrants in the border city of Brownsville, Texas, but drawing on data about other ethnicities and even time periods, the article provides convincing data that descendants of people who immigrate from Mexico and other, poorer, countries, have, in general, worse health, greater rates of obesity and diabetes, and shorter life expectancies than their parents or those who stayed. The numbers are impressive:  “A 2006 analysis by Gopal K. Singh, a researcher at the Department of Health and Human Services, and Robert A. Hiatt, a professor of epidemiology and biostatistics at the University of California, San Francisco, found that immigrants had at least a 20% lower overall cancer mortality rate than their American-born counterparts. Mortality rates from heart disease were about 16%  lower, for kidney disease 18%  lower, and for liver cirrhosis 24% lower.” It seems to get worse for later generations; “Elizabeth Arias, a demographer at the National Center for Health Statistics, has made exploratory estimates based on data from 2007 to 2009, which show that Hispanic immigrants live 2.9 years longer than American-born Hispanics.”
Some, perhaps most, of this is related to the prosperity of the US, and the easy availability of cheap, high fat, high sugar, high calorie food. One woman, who came to the US at 26 and has since developed diabetes, says she was amazed at seeing hamburgers as big as dinner plates; “I thought this really is a country of opportunity! Look at the size of the food!” Grueling work hours, both parents working (when both are here) make time for preparation of healthful food scarce, and more cash in their pockets allows the purchase of tasty-but-bad-for-you fast food. In addition, there is evidence of increased smoking and drinking as immigrants move into the US underclass, a group particularly targeted by marketing efforts for these substances of abuse.
Traditional diets for most people, including Mexicans, are based on food that is grown or found wild (vegetables, cactus) or bought in bulk (rice and beans). These are high fiber and low in empty calories. Robert Valdez, from the Department of Family and Community Medicine and Economics at the University of New Mexico, is quoted as saying “All the things we tell people to do from a clinical perspective today — a lot of fiber and less meat — were exactly the lifestyle habits that immigrants were normally keeping.” There is some evidence that there may be a genetic predisposition to diabetes in some Latinos, particularly Mexicans, as there is in American Indians; after all, Mexicans are largely a mestizo people with much Indian “blood”. Of course, these observations may be related; the natural diet of native peoples did not provide the environmental  factors (high calories, obesity) needed to trigger clinical diabetes, and so the genes for this did not “die out” as readily as in other groups. The same model is seen in South America; the remote Xingu Indians of the Amazon now have extremely high rates of diabetes where it never existed before the introduction of “white” food (used to refer to the color of the food as well as of the people who introduced it).
The other big factor is physical activity. While many immigrants work in physically demanding jobs, the prevalence of physical activity is not as great as for those living on farms in Mexico. One man talks about losing 75 pounds motivated by the image on the wall of his grandfather, who is 93 and still rides his bicycle every day. Yet, 4 of the 6 siblings of the grandson are obese and have diabetes. Another immigrant talks about walking in her early years in the US and feeling so conspicuous (“a bean in rice”) that she was afraid people would think she was here illegally. This has also been described in African-Americans moving from the agricultural (and very poor) South to a more prosperous, but sedentary, life in the North, and in most families a generation or two removed from farms, whatever their ethnicity. Concepts of what is “enough” food, what is a “good” breakfast or dinner for our children, did not change as quickly as lifestyles did. Our culture does not require physical activity as part of daily life the way farming, including subsistence farming, did, but we fed our children the same number of calories as we did (if we were prosperous farmers) or would have liked to, or more, because it is more easily available. Indeed, these changes are not limited to the US; things are changing for the worse (in terms of health) in Mexico as well; citing the fact that up to 40% of the rural diet in Mexico comes from packaged foods, “Researchers are beginning to wonder how long better numbers for the foreign-born will last.”
These are all factors in the “social determinants of health” – how we eat, how we exercise, how poverty grinds us down and how marketing of harmful substances like tobacco, alcohol, and high-sugar foods take their toll at even greater rates on the poor. This is not to romanticize rural poverty, of people, including children, having to do excessive physical labor in order to survive and thus burn up more calories than they consumed, or to minimize the difference between a rural/farming life which provided enough income to supply those calories and those in which malnutrition claimed lives and health. It is, rather, to point out that some of these terrible conditions ironically protected the health of its victims. This has been observed in the past; beri-beri occurred more in wealthy Chinese who ate hulled white rice than in the poor who ate the rice with hulls that contained the thiamine. In England in the early 20th century alcoholic cirrhosis was a disease of the rich who could afford highly-taxed spirits, while workers drank watered beer. The image of the wealthy many as obese – and suffering from gout, “The disease of kings1” (all that high-protein food) persists in cartoons.
Dr. Arias, cited above, observes that the health status of immigrant families “…may indeed improve as they rise in socioeconomic status, which in the United States is strongly correlated with better health.” Of course, there is no guarantee that longer time in this country will cause a rise in socioeconomic status; the last decade shows a persistent decrease in the socioeconomic status of most Americans, despite a “recovery” measured by Wall St. stock prices. The answer is not to regress to rural poverty, but it is to address these social determinants. It is to build towns that encourage walking and other physical activity. It should be to make fresh, healthful food widely available. It should involve education in schools about healthful eating, not undercut by junk food available in machines. It should limit advertising for poisons such as tobacco and alcohol. It should make clean air and water a priority, and ensure everyone has access to good health care.
 It should be a no-brainer, but in the politics of the US today, it may not be. Charles Blow in his May 18, 2013 column “Resonance Resistant”, notes that “We all know that anything with ‘social’ in its name activates the conservative gag reflex.” This is crazy; we are social beings. We can do better, and we should.

Tax policy, drug companies and the public’s health

Tax policy is complicated. You have to figure out who to tax and how much, and how much revenue it will bring in and what you (the government) needs to spend the money on and figure out how to match it up. People of different political stripes differ with regard to how much money to spend on what, and also who to tax. For example, is it better to have more graduated income tax (a “progressive” tax, where the more you make the higher percent you pay on the incremental amount), or more “regressive” tax where everyone, regardless of income pays the same amount, like a sales tax, or a “proportional tax” where everyone pays the same percent but not the same amount, like some variations of “flat tax”?
In Kansas, for example, our Governor and Legislature have made that decision. Faced with enormous budget deficits as a result of 2012 massive tax cuts on corporations and wealthy individuals, and unable to make it all up with one-time fixes such as raiding the state highway fund (hope those corporations don’t need to transport goods on our roads), they have gone for big sales tax increases. This is because, to them, the 2012 tax cuts are sacrosanct, because they believe that this will stimulate the economy and create jobs. They believe this even though such a strategy has not worked so far in Kansas and has in fact not worked anywhere. They even brought in Arthur Laffer, the trickle-down guru economist, to address the legislature. Nonetheless, owners of “S” corporations (usually small businesses, like lawyer’s offices, or the few remaining private practice doctors’ offices) do not pay state tax on the income they make from being the owners. Their employees — nurses and secretaries and legal assistants – do, along with the new higher sales taxes. The Governor and Legistlature have other plans as well; faced by a State Supreme Court decision to increase public school funding by a half-billion dollars or so that they don’t have (vide supra), they are thinking about not funding the State Supreme Court. Could be a solution, if they can get around the constitutional issue.
The Federal Government also has to deal with such issues. In the last 50 years our income tax policy has become less progressive, with a top rate of 35% rather than 90% when I was taking civics in junior high school. (Please note that this is not a flat tax of 90% on all of top-earners’ income, but on the marginal amount above the next lower tax rate; everyone paid the same percent on earnings up to each next bracket.) Also in that civics class, we saw that corporate income tax made up more income for the feds than personal tax. Not any more. Corporations are getting away with paying very low taxes, and with the new “global economy” taking more and more of their profits abroad, where they can avoid paying tax until they are re-patriated. To encourage them to do so, the Congress is considering legislation to create a “tax holiday”; this is where corporations are rewarded for bringing their profits home by paying a lower tax rate on them. This has been done before, and been amazingly unsuccessful. So let’s try it again. Like Kansas, why learn from experience? Why not, for example, tax those international earnings? After all, if they are creating jobs, it is not in the US.
Also like Kansas, the US has a problem with roads and other infrastructure, and the Federal Government funds much of the cost of repairs, which are unfortunately not being done. A study by the Center for Effective Government, “Burning our Bridges” notes that “To modernize our infrastructure, the American Society of Civil Engineers estimated it would cost $3.6 trillion by 2020. They warned that if we fail to make these investments, American citizens and businesses will face costs of $1.8 trillion a year in travel delays, water leaks, and power failures.” How has Congress responded? It’s slashed infrastructure spending to the lowest levels since the post-WWII era.
 
 But where could we get the money? Is the amount of money not being paid by US corporations on international earnings that big? Well, there is $2.1 trillion in untaxed international income, so that could be a chunk of change. About half of it is held by 26 corporations. Apple has the most, and GE is #2. The enormously profitable pharmaceutical industry (I have previously noted that it is, each year, either #1 or, well, #1 in profit among US industries) has about $82 billion among its 7 largest companies. Given that the report is called “Burning our Bridges”, it is of interest to note that this is enough money to pay for all US bridge repair and maintenance needs.
I guess this is where the public health and medical part of this post comes in. Let’s just think about that. We have drug companies charging “whatever the market will bear” for their products; for some of the recent recombinant DNA treatments for autoimmune diseases, Hepatitis C, and cancer this can range into 5 digits (beforethe decimal point) a month. They try every trick in the book to keep their prices high and patents in place to prevent generic competition. Some I have addressed before include changing the formulation of the drug — the FDA mandated elimination of fluorocarbons as propellants in inhalers was a bonanza because changing to non-fluorocarbon propellants was a “new formulation” allowing them to extend their patents. Or taking drugs used by, but not previously tested and approved for use by, children and testing them (when already, via practice, shown to be safe) in children, also extending their patents. Or in some the most offensive practices, testing drugs that have been used for generations and patenting them, thus jacking up their prices. The prime example is the gout treatment colchicine, formerly available for about 10 cents a pill and now available for $355 for 60 (about $5.20 a pill!).
In Canada, there are price controls on drugs, so they cost less. Thus pharmaceutical manufacturers try to block import (and Internet sale) of drugs from Canada. The Medicare drug benefit, (Part D) passed in the GW Bush administration, forbid Medicare from using its purchasing clout to negotiate lower prices. The new Trans-Pacific Partnership (TPP) pushed through by the Obama administration will offer more protections; corporations will be able to sue governments to ensure their profits, not in real courts but in specialized TPP pro-business “courts”. I wonder how long the price restrictions on drugs in Canada and elsewhere, not to mention the manufacture of affordable generic equivalents of high-priced HIV drugs in Brazil, India, and Thailand, will continue?
I personally am rooting for the success of the Brownback tax cuts to create jobs in Kansas. Not because I think they were good or even close to moral, or even because I think that they have a prayer of being successful, but as long as they are in place it would be nice to see some new jobs. It’s not going to happen with this state government. TPP passed, and there is no meaningful effort to either tax the international profits of pharmaceutical and other corporations, or to force drug manufacturers to make their products affordable in the US.
In their recent paper “Fantasy paradigms of health inequalities: Utopian thinking?”, Alex Scott-Samuel and Kathleen Smith note that “In a capitalist society, where liberal macroeconomic policies position virtually all economic activity – including unhealthy activity – as beneficial, there is an inbuilt incentive to ‘blame the victim’ rather than to tackle the corporate and economic causes of the problem.”[1] We prefer not to regulate unhealthy activity (when we have done so, such as with making cars safer and limiting smoking, it took intensive, long-term campaigns by public health advocates), and we allow corporations such as drug companies to profiteer from our trying to repair the damage to our health. And we also let them not pay taxes, which we really need.
It’s time to get serious, and hold them responsible and make them responsive.



[1] Scott-Samuel, A. & Smith, K. E. (2015).Fantasy paradigms of health inequalities: Utopian thinking? Social Theory & Health, advance online publication, 1 July 2015; doi: 10.1057/sth.2015.12

The social mission of medical education: Admit different students

In his JAMA “Viewpoint” article, “Social Mission in Health Professions Education: Beyond Flexner”,[1] June 17, 2017, Fitzhugh Mullan makes a convincing case for medical schools to be committed to their social mission. He takes his definition from the “Beyond Flexner” website (www.beyondflexner.org), which says “Social mission is about making health not only better but fairer—more just, reliable, and universal”. He details what this means in terms of commitment to reducing health disparities, increasing access to healthcare in both rural and urban underserved communities, increasing diversity within the health professions. These serious issues have been identified for decades, but in fact the trend may be toward getting worse instead of better.
Mullan cites some examples of medical schools, primarily newer and “community based” schools, that are working toward these goals. These include Morehouse and Mercer (founded in an earlier wave of medical school expansion in 1975 and 1982 respectively), those of a more recent expansion in the 2000s (Florida International University and the AT Still Mesa Campus), and those yet to come (the merger of Geisinger Health System and Commonwealth University, Kaiser Permanente School). But he also talks about “mainstreaming”, the need for consciousness about, and implementation of, social mission to be a characteristic of all medical schools.
I believe that the most important measures of a health professions school’s social mission are its outputs. Using the 3 criteria identified by Mullan and colleagues in their seminal 2010 Annals of Internal Medicine article “The social mission of medical education: ranking the schools”,[2] we need to look at whether its graduates are more diverse, whether they practice in underserved areas, and whether they are more likely to be in primary care specialties. The 2010 article showed that some schools do better — more often those that are public, newer, and not in the Northeast — but the fact is that none is doing all that well.
The number of students entering primary care is a critical indicator because, based on national and international comparisons, a well-functioning health system should have 40-50% of physicians should be in primary care; the US is well below 30% and going down. Family medicine match rates are the most sensitive indicators of primary care production, because unlike internal medicine virtually all family physicians practice primary care, so a choice of this specialty means a commitment to primary care. In addition, it is the specialty most suited for practice in rural areas. Even if all schools consistently produced 50% primary care physicians, it would take at least a generation to get to that number for all physicians in practice, and we are far, far from this.
In 2012 John Delzell and I looked at 10 years of data (2002-2011) published annually on the family medicine match by the American Academy of Family Physicians (AAFP) documenting the number and percent of students from each medical school entering family medicine.[3] We found only a few schools that were relatively high in both number and percent, with the University of Minnesota and the University of Kansas far ahead of the rest. And yet even those schools do not produce primary care physicians at the 50% rate. In the most recent AAFP report, on 2015 graduates,[4] even the “socially conscious” schools cited by Mullan did not have very high numbers matching in family medicine:  Morehouse 8 (12.9%), Mercer 13 (13.8%), FIU 4 (5%). Minnesota, at 42 (18.2%) had the largest number in the nation, but still had 20 fewer than it did in 1999! In 1994, the Association of American Medical Colleges (AAMC) announced Project 3000 by 2000, aiming for 3000 minority medical students into US schools by the year 2000[5]. It failed. Today, in 2016-17, we are not only far from that number, but the percent of many minorities (especially African-American men) continues to drop.[6]
As in any process, the results of medical (and all health professions) education are affected by 3 sets of variables. Input variables are the students enrolled,process variables include the curriculum and overall experience of students during their education, and output variables are the expectations of what the income and life experience of a graduate is likely to be. While the last is probably the most important determinant, especially given the degree of debt with which students are graduating and the fact that many specialists can earn 2-3 (or more) times as much as a primary care physician, it is also the area that schools have the least ability to influence. As Mullan and colleagues have emphasized, medical schools can influence the process variables, including the school’s vision and mission, the teaching of social mission, determinants of health, disparities, and other areas in their classrooms and clinics, experiences for students to serve such as free clinics, and mentoring and role modeling by faculty. However, making these changes seem to be insufficient to overcome the negative influence of the output variables in terms of students choosing primary care and practice in underserved areas. At least for most of the students currently in medical school.
Which brings us to the input variable: who is admitted? Clearly, from the data cited above, medical schools are not taking appreciable numbers of students from underrepresented minority groups, from rural areas, or from lower socioeconomic groups, at least not in anything close to the proportion in the population. They take, on the whole, white (and Asian) students from well-to-do suburbs of large cities who, not coincidentally, went to the “best” public and private schools and have the highest grades and Medical College Admissions Test (MCAT) scores. The problem for the health of the American people is that the strongest predictor of where a medical student will practice is where they come from; minority students are far more likely to practice in minority neighborhoods, rural students are far more likely to practice in rural areas, and white upper middle class students from the suburbs are more likely to practice in the suburbs. These are the areas that already have enough physicians (and sometimes too many). In a real sense, a physician who enters practice in a non-underserved area in a non-shortage specialty is contributing little marginal benefit to the health of the American people. The imbalance of physicians practicing in health professions shortage areas (HPSAs) vs other areas is demonstrated in the attached table from Zhang, et al.[7]

Yes, our society must urgently address the “output variables” to ensure that students who choose primary care can earn a reasonable proportion of what other specialists do (some studies indicate that 70% of mean specialist income would be sufficient to eliminate that as a reason for not choosing primary care). Indeed, medical schools need to address the “process variables” by having explicit curricula on health disparities, social determinants of health, and community and preventive health, and ensure there is not a “hidden curriculum” mitigating against primary care. But they also urgently need to ensure that most of their admissions, not a token number, are students whose characteristics mean they are more likely to meet America’s healthcare needs. These include demographic characteristics, such as rural or minority origin and lower socioeconomic status of their family, and individual characteristics identified by past performance (not sentiments in an essay). This is primarily significant volunteer service, especially major commitments like the Peace Corps, Americorps, Teach for America, etc.

And, most importantly, these changes and programs must happen at all medical schools and for the bulk of the classes. The time for experiments and pilot programs is done. These efforts must be scaled up, to be, in Mullan’s word, “mainstreamed”. And now is not too soon.

 


[1]Mullan, F, Social Mission in Health Professions Education: Beyond Flexner, JAMA published online June 26, 2017. doi:10.1001/jama.2017.7286
[2] Mullan  F, Chen  C, Petterson  S, Kolsky  G, Spagnola  M.  The social mission of medical education: ranking the schools.  Ann Intern Med. 2010;152(12):804-811
[3]  Freeman J, Delzell J, Medical School Graduates Entering Family Medicine: Increasing the Overall Number, Fam Med 2012;44(9):613-4.
[4]Kozakowski S, Travis A, Bentley A, Fetter G, Entry of US Medical School Graduates Into Family Medicine Residencies: 2015–2016, Fam Med 2016;48(9):688-95, (online Table A).
[5]Nickens HW, Ready TP, Petersdorf RG, Project 3000 by 2000 — Racial and Ethnic Diversity in U.S. Medical School, N Engl J Med 1994; 331:472-476August 18, 1994DOI: 10.1056/NEJM199408183310712
[7]Zhang X, Phillips RL, Bazemore AW, Dodoo MS, Petterson SM, Xierall I, Green LA, Physician Distribution and Access: Workforce Priorities, Am Fam Physician. 2008 May 15;77(10):1378.

Dead Man Walking: People still die from lack of health insurance

At the recent meeting of the Association of American Medical Colleges (AAMC) meeting in Philadelphia, Clese Erikson, Senior Director of the organization’s Center for Workforce Studies, gave the Annual State of the Workforce address. It had a great deal of information, and information is helpful, even if all of it is not good. She reported on a study that asked people whether they had always, sometimes or never seen a doctor when they felt they need to within the last year. On a positive note, 85% said “always”. Of course, that means 15% — a lot of people! – said “sometimes” (12%) or “never” (3%). Of those 15%, over half (56%) indicated the obstacle was financial, not having the money (or insurance). There are limitations to such a survey (it is self-report, so maybe people could have gone somewhere, like the ER; or maybe they asked your Uncle George who would have said always because he never wants to see a doctor even though you think he should for his high blood pressure, diabetes, and arthritis!) but it is not good news.
Of course, as former President George Bush famously said in July, 2007, “I mean, people have access to health care in America. After all, you just go to an emergency room.” Many of us do not think that this is a very good solution for a regular source of care in terms of quality. Also, if you have had to use the ER regularly for your care and already have a huge unpaid stack of bills from them, it can make you reluctant to return. This likely contributes to the “sometimes” responses, probably often meaning “sometimes I can ride it out but sometimes I am so sick that I have to go even though I dread the financial result.” Following this ER theme, another leading Republican, Mitt Romney, declared repeatedly during the 2012 Presidential campaign, that “No one dies for lack of health insurance,” despite many studies to the contrary. And despite the fact that as Governor of Massachusetts he presumably thought it was a big enough issue that he championed the passage of a model for the federal Affordable Care Act in his state.
People do, in fact, die for lack of health insurance. They may be able to go to the ER when they have symptoms, but the ER is for acute problems. Sometimes a person’s health problem is so far advanced by the time that they have symptoms severe enough to drive them to the ER that they will die, even though the problem might have been successfully treated if they had presented earlier. Or, the ER makes a diagnosis of a life-threatening problem, but the person’s lack of insurance means that they will not be able to find follow-up care, particularly if that care is going to cost a lot of money (say, the diagnosis and treatment of cancer). If you doubt this still, read “Dead Man Walking”[1], a Perspective in the October 12, 2013 New England Journal of Medicine, by Michael Stillman and Monalisa Tailor (grab a tissue first).

We met Tommy Davis in our hospital’s clinic for indigent persons in March 2013 (the name and date have been changed to protect the patient’s privacy). He and his wife had been chronically uninsured despite working full-time jobs and were now facing disastrous consequences.
The week before this appointment, Mr. Davis had come to our emergency department with abdominal pain and obstipation. His examination, laboratory tests, and CT scan had cost him $10,000 (his entire life savings), and at evening’s end he’d been sent home with a diagnosis of metastatic colon cancer.
Mr. Davis had had an inkling that something was awry, but he’d been unable to pay for an evaluation…“If we’d found it sooner,” he contended, “it would have made a difference. But now I’m just a dead man walking.”

The story gets worse. And it is only one story. And there are many, many others, just in the experience of these two physicians. “Seventy percent of our clinic patients have no health insurance, and they are all frighteningly vulnerable; their care is erratic.”  And the authors are just two doctors, in one state, a state which (like mine) starts with a “K” and (like mine) is taking advantage of the Supreme Court decision on the ACA to not expand Medicaid, and which (like mine) has two senators who are strong opponents of ACA, which means, de facto, that they are opposed to ensuring that fewer people are uninsured. I cannot get their thinking, but it really doesn’t matter, because it is ideology and they have no plan to improve health care coverage or access. So people like Mr. Davis will continue to die. This same theme is reflected in a front-page piece in the New York Times on November 9, 2013, “Cuts in hospital subsidies threaten safety-net care” by Sabrina Tavernise:

Late last month, Donna Atkins, a waitress at a barbecue restaurant, learned from Dr. Guy Petruzzelli, a surgeon here, that she has throat cancer. She does not have insurance and had a sore throat for a year before going to a doctor. She was advised to get a specialized image of her neck, but it would have cost $2,300, more than she makes in a month. ‘I didn’t have the money even to walk in the door of that office,’ said Ms. Atkins.
In a recent blog about the duration of medical education, I included a graphic from the Robert Graham Center which show the increased number of physicians that the US will need going forward, mostly as a result of population growth but also from the aging of that population, along with a one-time jump because of the increased numbers people who will be insured as a result of ACA (this will, I guess, have to be adjusted down because of the states that start with “K” and others that are not expanding Medicaid). Ms. Erikson included this graphic in her talk at AAMC, with numbers attached. Just from population growth and aging, we will require about 64,000 more physicians by 2025 (out of 250,000-270,000 total physicians).The one-time jump because of the ACA is about 27,000, bringing the number to 91,000.
But, of course, there is a big problem here. The projection that we will need more doctors because we have more people, or because our population is aging and older people need more medical care, is one thing. But the need for more doctors because more people will be insured? What is that about? Those people are here now, and they get sick, and they need care now, no less than they will when they are covered in the future. I do not mean to be critical of the Graham Center or Ms. Erikson for presenting those data. I do, however, think that we should emphasize how offensive is the idea that we will need more doctors just because more people will have coverage. They didn’t need doctors before, when they didn’t have insurance?
If there are people who cannot access care, we need to be able to provide that care. We will need more health care providers, including more doctors, especially more primary care doctors. We need health care teams, because there will not be enough doctors, especially primary care doctors. We need the skills of health workers who can go to people’s homes, and identify their real needs (see the work of Jeffrey Brenner and others (see Camden and you: the cost of health care to communities, February 18, 2012). We need to ensure that people have housing, and food, and heat, and education – to address the social determinants of health.
Decades ago, I heard from someone who visited Cuba a few years after the revolution. He said he mentioned to a cab driver the dearth of consumer goods, such as shoes, in the stores. The cab driver said “we used to have more shoes in the stores, but now we first make sure that they are on children’s feet before we put them in stores windows.” There was enough before the revolution, enough shoes and enough milk, as long as a lot of people were not getting any. The parallel is that now, in the US, if we seem to have enough health clinicians, it is because there are lots of people not getting health care.
This is not ok. It isn’t ok with the ACA, and it isn’t OK without it.



[1]Stillman M, Tailor M, “Dead Man Walking”, Michael Stillman, M.D., and Monalisa Tailor, M.D.
October 23, 2013DOI: 10.1056/NEJMp1312793

Drug prices and corporate greed: there may be limits to our gullibility

“A Huge Overnight Increase in a Drug’s Price Raises Protests”, by Andrew Pollack in the New York Times September 20, 2015, features the story of Daraprim, the brand name for pyrimethamine, a drug used to treat toxoplasmosis. “Toxo”, often associated with cat feces, is a protozoan and was an fairly rare infection prior to the HIV epidemic, when it became a significant cause of brain infections in those with very low CD4 counts. Luckily, pyrimethamine, a drug available for over 60 years, had reasonably good success. Now, rights to the drug have been acquired by Turing Pharmaceuticals and its price has been raised from $13.50 to $750 a pill. Turing’s founder and CEO, Martin Shkreli, is a former hedge fund manager who seems to know an opportunity to make a killing when he sees one. A few days later, the Times ran an AP story on a interview Shrkeli gave ABC news which reported that Turing would reduce the price, albeit to one that was unspecified. “’We’ve agreed to lower the price of Daraprim to a point that is more affordable and is able to allow the company to make a profit, but a very small profit,’ Shkreli told ABC.”
But this is, as the Pollack article points out, not the first or only time this has occurred. In the last few years new drugs, mainly those made in labs from recombinant DNA rather than from plant sources, for hepatitis C, high cholesterol, and various cancers have been criticized for their astronomical prices, but we are talking about old drugs here. One example is cycloserine, used to treat multi-drug resistant (MDR) TB, the price of which has been raised from the previously expensive $500 for a month’s supply to $10,800. (Please note that I am being careful with my decimal points; this is, indeed, over a 2000% increase.) The general manager of the manufacturer, Rodelis, “…said the company needed to invest to make sure the supply of the drug remained reliable.” And thus, of course, required the 2000% increase. Right.
And many more common, prosaic drugs have had the same increases. One I have previously written about several times is colchicine, an ancient treatment for gout derived from the autumn crocus (and I mean “ancient”, not like “20th century”; there are records of its use in Egyptian papyruses from 1500BC!). Dr. Stephen Griffith’s guest post “VISA and colchicine: maybe the banks and Pharma really ARE in it for the money!” said ”the FDA has encouraged pharmaceutical companies to study some of the older drugs for true effectiveness, and the company can then apply for a three year patent on the medication. URL Pharma, Inc. did the clinical trials on less than 1,000 patients, and proved that a drug everyone already knew worked, worked. Amazing! They received a three year patent, and now a pill that was $4 per month long before the $4 per month plans existed, is $5 per pill! Since it is usually given twice a day, the drug will now cost patients $10 per day when it formerly cost about a quarter.” What? The FDA is encouraging this?
The Times articles cites increases in other common drugs; two heart drugs, Nitropress and Isuprel, were acquired by Marathon Pharmaceuticals in 2013 and had their prices quintupled. Then this year, they were acquired by Valeant Pharmaceuticals which “…promptly raised their prices by 525 percent and 212 percent respectively.” The most depressing one for me is doxycycline, a form of the antibiotic tetracycline, which is broad-spectrum, effective, and, until recently, cheap. It is frequently used for pneumonia acquired in the community, as it is effective against both common bacterial and “atypical” causes of pneumonia, and generally effective against the very dangerous “methicillin-resistant Staphylococcus aureus”, or MRSA. It is used as a first or second-line drug for several sexually-transmitted infections (STIs), including syphilis, and is even effective for prevention and treatment of malaria. An altogether good drug. When I was a medical student, it had recently been introduced (under the brand name Vibramycin) and it was considered expensive compared to other tetracyclines, even if often more effective. So we were all very happy when it became generic and cheap. Indeed, the Wikipedia entry for doxycycline says “Doxycycline is available as a generic medicine and is not very expensive.[1][5] The wholesale cost is between 0.01 and 0.04 USD per pill.[6] In the United States 10 days of treatment is about 14 USD”.  Um,  that seems to be dated. The Times article tells us that “Doxycycline, an antibiotic, went from $20 a bottle in October 2013 to $1,849 by April 2014.” Oh. A 9200% increase. Kind of high for treating your bronchitis, or even your outpatient (or inpatient) pneumonia, or for your Lyme disease, or Chlamyidavaginitis, or for taking malaria prophylaxis.  Maybe you wouldn’t be very happy to have to pay that when you pick up your prescription, if you don’t have prescription drug coverage. And if you do, I’m sure that your insurer is not. The issue of how this price increase was allowed to happen is described as “murky” by David Lazarus in the Los Angeles Times. [Note: it seems that some of the generic forms of doxycycline have come back down, per a search on the valuable-for-health-care-providers-or-anyone-taking-prescriptions app, Goodrx.]
These price increases for long-standing generic drugs are outrageous, even more than the predatory prices of the new recombinant DNA drugs. It is blatant opportunism on the part of the drug manufacturers certainly, who could be considered to be cold-blooded profiteers on human misery (which of course they are, not to say evil, immoral, unconscionable and inhuman). But, hey, they are in business and are taking an opportunity to make more money, as does every cold-blood, profiteering business, in what is apparently a legal way. This, of course, raises the question of “how come it is legal? What the heck happened?”  Where is the FDA? Where is the Department of Health and Human Services? Where is the Executive Branch? Where is the Congress? Remember, we’re not talking small price increases. We’re not talking fair pricing. We’re talking thousands of percent increases in common drugs that people need, drugs that I, and other doctors, prescribe a lot.
People care a lot about the price of prescription drugs, and the amount that their co-pay is, because this affects them directly, in their pocketbook, regardless of what party they vote for. Margot Sanger-Katz of the Times, in “Prescription Drug Costs Are Rising as a Campaign Issue”, reports on a Kaiser Family Foundation survey that Americans identify costs for drugs for specific diseases and prescription drug costs overall as their #1 and #2 health concerns. “Americans have long paid the highest prices for drugs. Because the United States gives drug makers long periods of patent exclusivity and lets a multitude of insurers each negotiate with drugmakers on price, drug spending here is, on a per capita average, roughly double the amount spent in many developed countries.” (see figure)
I started out saying that these companies were making a killing, but the problem is that the ones being killed are the rest of us. Sounds like something Jim Hightower would say, and he’d be right. The real issue is why do we keep electing people who put our interests, our health, behind the rapacious profits of corporations. It is only because of the enormous coverage Turing’s increase in the price of Daraprim engendered, and the calls for investigations in Congress, that Shrkeli is planning to lower the price. It has nothing to do with his, or any other corporate leaders’, concern for the public (see, for example: Volkswagen diesels, poisoned peanuts).
By the way, you might want to write down the names of the two Congresspeople the Times article notes have called for an investigation of this: Representative Elijah Cummings of Maryland and Senator Bernard Sanders of Vermont. Yes, that Bernard Sanders; the one running for President. Hmm.

Medical futility and the responsibility of physicians…and patients

Ethics is a difficult area. Medical decision making is a difficult area. Both are fraught with ambiguities, conflicting priorities, differing values. Priorities shift with time, as our moral compass tacks back and forth, seeking to compensate for current problems and deficiencies, and sometimes overreaching, require new future shifts in direction. We will probably never get it exactly right, but need to keep working in the right direction.
Barron Lerner makes an excellent start in his NY Times  Op-Ed from September 18, 2014,”When Medicine is Futile”.  He talks about his father, who was a physician leader in “The medical futility movement, which argued that doctors should be able to withhold interventions that they believed would merely prolong the dying process…”.The father was an infectious disease specialist, whose early career was marked by the miracle of penicillin and drugs to treat tuberculosis. However, later his practice, as that of most infectious disease physicians in the US, was being called to consult on infections occurring in hospitalized patients who were otherwise severely ill, often in intensive care units, with terminal diseases and frequently advanced dementia, “…connected to machines and tubes he knew would not help them.”
The younger Dr. Lerner, author of this piece and a professor of medicine at a major medical school, notes that his father “..placed some of the blame for the situation at the feet of bioethics and patients’ rights, two movements that I, as a young physician, had fiercely advocated,” which put them in conflict. And yet, from a longer perspective, he can see a great deal of his father’s concerns. As he point out, the patient’s rights movement and to a lesser extent bioethics
…did not account for one thing: Patients often demanded interventions that had little or no chance of succeeding. And physicians, with ethicists and lawyers looking over their shoulders, and, at times, with substantial money to be made, provided them.
The stimulus for this article is a recent report by the Institute of Medicine (IOM) of the National Academy of Sciences, “Dying in America,” “…that argues that we subject dying patients to too many treatments, denying them a peaceful death.” This report begins the process of reconciling the physician’s responsibility to at least provide accurate information on treatments and the likelihood of their success with the autonomy of patients to make their own decisions about the treatment that they want. This is a welcome effort at reconciliation of these two apparently or potentially conflicted ethical principles, especially given, as Dr. Lerner points out, that “Physicians declaring things to be ‘futile’ sounded too much like the old system of medical paternalism, in which doctors had made life-and-death decisions for patients by themselves.” But any meaningful discussion of this  requires consideration of four powerful issues that always impact upon it.
First, there is trust. Can patients and their families trust the doctors to be advising them in their best interests? This is particularly true for many disenfranchised people who are not like the majority of doctors in background, ethnicity, and certainly income. For the poor and members of minority groups that have in fact in the past been victims of outrageous abuses, there may remain a suspicion of any effort to suggest that further interventions would be futile. People may think “you are only saying this because I (or my family member) is …” and would recommend intervention for a member of your own family, or someone more like you.
Second is the issue touched on above about the “likelihood of success”. Success at what? For patients and/or their families to make intelligent decisions, the parameters of success, or similar words like “help”, “improve”, “make better”, need to be clearly defined in words and concepts that lay people can understand and that physicians are willing to use. I have written in the past about a woman whose daughter worked with me who was dying in the intensive care unit (ICU) of the hospital I worked at. I came to visit and met her 5 children trying to decide whether to approve the use of an intervention in their unconscious, uncomprehending, and terminally ill mother that they were told “would help”. As I was not the treating physician, I went to the ICU doctor and inquired, on their behalf, what the intervention was and how it was expected that it might help. I then cautiously returned to the family to feel them out regarding their understanding of “help”. They thought it meant it would make her “better”. What, I asked, did “better” mean to them? When they appeared confused, I went further, asking if it meant that she would wake up, be able to talk to them, be able to go home, perhaps be able to say goodbye? Yes, they said, that is what it meant to them. I tried to gently say that this would not happen, that this intervention would, perhaps, correct a laboratory value, but would not have any of the outcomes they hoped for. They opted to not have it.
These are not easy discussions, and lead to the third issue. Most people do not have the training and background to understand the ramifications of the decisions that they are asked to make under the rubric of “patient autonomy”. I feel that I am knowledgeable about many areas, particularly medical ones, but it would be ridiculous to ask me how a bridge should be built. You wouldn’t want to drive over it, and I wouldn’t either. Simply citing “patient autonomy” and presenting incomprehensible data and decisions about whether to do something that even the words for make no sense to a regular person is not ethical; it is equivalent to abandonment. Sometimes a doctor or nurse or other health professional with patience can spend the time and effort necessary to help a patient or their family really understand what is going on, what likely outcomes of any intervention or –equally validly – non-interventions might be, so that they can make an informed decision based upon that information and on their own values and priorities. Most of the time the healthcare providers are too busy, and do not have the time and may not have the inclination, and are not paid well, or at all, for that time.
Which leads to the final issue, money. In a quote from Dr. Lerner above regarding procedures that will not be effective, I include “the substantial money to be made from them”. The money to be made by providing them is a profoundly important issue, potentially corrupting any discussion of ethic versus futility. Dr. Lerner notes that the IOM report “…advocates that Medicare and other insurers pay physicians to talk to their patients about end-of-life care”. This is a great idea, but it doesn’t currently happen often, and even the proposal that physicians do it (not to mention be paid for it) was grossly misrepresented as “death panels” when included in the Affordable Care Act (ACA). Even if this time is paid for, it would never approach the amount of money that would come from doing the procedure, or certainly not the money a busy surgeon, for example, might make from operating on someone else.
All people know, intellectually, that everyone dies. What may be harder for many to accept is that they must die, particularly when their time comes. It may be even harder for family members, who are not the actual patient, to accept, and to demand that “everything” be done. For Dr. Barron the elder, as described by his son, “Infections were the way that such frail individuals were supposed to die, the ‘final straw’ in the deterioration of so many of the body’s vital organs and functions.” Yet somehow they had become things that needed to be treated.” 

Everyone dies; what we can only hope for is a death unaccompanied by pain and unpleasantness. Infections like pneumonia which should be treated in an otherwise healthy person in whom a return to health is likely probably should not be in a person who is terminally ill, bed bound, demented. They are nature’s exit door. The same could be said for starvation, a relatively benign way to go, and almost always better than the alternatives of feeding tubes or intravenous nutrition, which carry high risks of complications of aspiration and infection and discomfort.
There must be a real understanding that patient autonomy does not include the right to demand any treatment. We would not assume a person could request a Corvette or a lifetime pension, and yet the latter would probably do more to improve health than any medical intervention, and the former would cost less than many.
Dealing with and overcoming the barriers presented by the first three issues will be difficult but can be done. To really do so means eliminating the fourth issue, the perverse economic conflict of interest that can cloud judgment, decrease trust, and pollute the entire process.

“Good enough for Government Work”: Quality, cost, and gaming the system, Part 2 (of 4 parts)

This is part two of the Charles Odegaard Lecture, delivered at the 27th National Conference on Primary Health Care Access, April 6, 2016
 
We have all heard the business mantra “do more with less”, which, on the face of it, is either absurd or, perhaps, a very cynical indictment of how much is currently being “wasted”, waste being differently defined depending upon the point the user wishes to make. I, for example, would consider “waste” to be money designated as “health care dollars” going to excessive profits for private corporations rather than actually being spent delivering health care; others, perhaps in the insurance industry, might consider “waste” to be an excessive “medical loss ratio”, their quaint term for the money that they actually have to spend delivering health care and don’t get to pocket. Politicians, of course, are more malleable; “waste” is whatever is being spent on what they don’t like, provided of course, it doesn’t get them into trouble with their constituents (like the VA scandal), in which case switching definitions is always an option.
What might be waste in the provision of health care? One is providing, and charging for, services that are unnecessary or possibly even harmful. A current example is the performance of pelvic examinations (as distinct from collecting Pap smears) in asymptomatic women (without pain, discharge, or bleeding) just to see what we can find. The American College of Physicians (ACP), the internists’ group, recommends against them. ACOG, the American College of Obstetricians and Gynecologists, recommends doing them, or at least leaving it up to the physician. Guess which group stands to lose more financially? ACOG’s position includes the statement that “…the College continues to firmly believe in the clinical value of pelvic examinations, through which gynecologists can recognize issues such as incontinence and sexual dysfunction. While not evidence-based, the use of pelvic exams is supported by the clinical experiences of gynecologists treating their patients.”![1]Hm. Maybe the best way to discover issues like incontinence or sexual dysfunction is not to put one’s hands inside a woman, but, perhaps, to ask her!
The US Preventive Services Task Force (USPSTF), of course, makes no recommendations on whether to do a particular exam or procedure, as its recommendations are for or against screening for particular diseases (with, in that context, exams or procedures discussed). It recommends against (“D” recommendation) screening for ovarian cancer, a major “benefit” cited by some ob-gyns, because it is inadequately sensitive and specific and doesn’t save lives. In a recent survey of ACOG members, the “potential benefits” of pelvic examination in asymptomatic women were cited, but not the costs – in dollars or to patients in terms of discomfort and morbidity. 
This is relevant here because when costs, both potential for harm as well as dollars, are not considered, everything could be potentially of benefit. Another recent study showing mild benefit from the use of the diabetes drug pioglitazone to prevent strokes or TIAs in people who have previously had them shows some benefit, but at the cost of an increase in the number of fractures requiring surgery or hospitalization; the editorialist in Journal Watch General Medicine emphasizes the benefit rather than the risk of harm, but is a neurologist, not an orthopedist. Should we do an MRI on everyone every week, just to see what we can find? Certainly there could be some things found! What about CT scans for screening for lung cancer (USPSTF “B” rating)? The best study, from the US, shows absolute risk reduction for death in 6.5 years of 0.33%; some smaller recent studies from Italy and Denmark show no benefit for mortality, and even in the US the frequency being recommended is moving to less than annually.  Should we be on track to weekly MRIs?
So, I just wanted to be clear that it is not true that I am for anything that could improve quality whatever the cost. That is ridiculous. But there is a baseline of quality which not only can, but regularly is, compromised when there is a potential for financial benefit from doing so. 
More recently, and wildly popular in health care, is the Triple Aim. The idea is to improve quality, improve patient satisfaction, and cut costs, all at once. It is difficult to find anyone, regardless of political affiliation or medical specialty, politician, provider, or consumer advocate, who doesn’t think that this is a good idea. To some degree, even I think this is a good idea, but I also believe that, like a lot of good ideas, the devil is in the details, the proof is in the pudding, where the rubber meets the road, or whichever is your favorite saying. While I am certain that many well-meaning pundits and providers, such as the leaders of family medicine, the experts at the Institute for Healthcare Improvement (IHI) and others are serious about improving quality, the reality, as M. Gregg Bloche notes in his NEJM piece (see Part 1, ref #3), is that almost all of the rewards are for cost-cutting. Yes, ACA has given us some modest revenue enhancements for meeting quality goals, although in general they are either very broad or very precise, and in either case poor measures of actual quality, and thus of limited impact. But almost all of the rewards, on either side of the Atlantic, in the NHS, or the VA, or for the ACOs created by the ACA, are for reducing costs. And it is almost always in the public sector that the impact is the greatest.
For example, outside the VA, we have our RACs, the bounty hunters licensed by Medicare to come into hospitals to find “fraud and abuse”. This usually manifests as discovering that some Medicare patients have been “admitted” to the hospital, rather than placed on “observation” status, which costs Medicare less. We have been well-socialized by our institutions, prompted by Medicare, into ensuring that we have reason to believe a patient will be in for “two midnights” (a bizarre conception with regard to health, much easier to achieve when a patient is admitted at 11pm than at 1am!), but how many of us realize that it is our patients who pay, literally with dollars? The excess cost is because “observation” is officially outpatient and paid by Medicare Part B, which requires much higher co-pays than the Medicare Part A that covers admissions. I have to admit that it was only relatively recently, when I heard a cousin being admonished by a friend to “make sure that your mom is admitted, not put on observation, or she’ll go bankrupt”, that I realized this.
 
[part 3 next week: The VA, the private and public sector, and the profit motive]

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

At the Family Medicine Midwest conference held recently in Milwaukee, the first day’s plenary speaker was Richard Roberts, MD, from the University of Wisconsin. Dr. Roberts has a distinguished history as a health services researcher and leader in Family Medicine, having been president of both the American Academy of Family Physicians (AAFP) and the World Organization of Family Doctors (WONCA). He has extensive experience in international health, and is knowledgeable about the health systems – and their results – in countries around the world. And he continues to practice family medicine.
Some of the issues that Dr. Roberts discussed involve the health care system, and, drawing from the important work of the late Dr. Barbara Starfield, emphasize the importance of primary care to improving the health of a population. I have written about the disproportionate emphasis of medical education on hospital care, advanced disease, and high-cost rescue interventions which often fail to rescue and frequently cause complications, rather than on primary care, prevention, and early diagnosis and treatment. Dr. Roberts reminds us of the “Ecology of Medical Care” (referring to the

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

In 2005, there were 34 million hospital admissions in the US, but almost 1 billion office visits. Of those, about 53% were to primary care physicians. While much is made of the increase in emergency department usage, from 1995 to 2005 ER visits were up 8% while primary care visits increased 22%. As Roberts notes (medical students should cover their ears!) primary care doctors comprise about ¼ of the physician workforce but see more than ½ of all patient visits and earn about ½ the income of subspecialists (and this is average; a much smaller fraction of the income of the most highly paid subspecialists).
Internationally, the same trends are noted. Countries with a higher “primary care score” (which largely measures the percent of the medical workforce in primary care) had lower rates of premature deaths than those with low PC scores in 1970, and over the last 4 decades, while the rate has gone down in both groups, the gap between them has widened. In an unintended “natural experiment”, the Asian economic boom of the early 1990s allowed Indonesia to greatly increased health spending, mostly in primary care; that nation saw a 70% improvement in health status in all provinces. With the collapse of that “bubble” in the late 1990s, spending on primary care went down, but not on hospital care in the big cities. This was a result not of Indonesian government decisions, but rather of the international community through organizations such as the World Bank saying “your economy is worse, but you need health care – here’s money … to build hospitals”. But health status dropped in most provinces. Not the best use of resources!
In the 1990s, Shi studied socioeconomic, environmental, and health system characteristics of US states and their relationship to health status (mortality, lifespan, deaths due to heart disease and cancer, neonatal mortality, and low birthweight). Access to primary care was the strongest predictor of greater lifespan and was second (to living in an urban area) for lower mortality rates, even ahead of education. Number of specialists and number of hospital beds were far down the list – indeed they were negative predictors![3] None of the changes in the health system since that time are likely to change this; indeed, the increase in specialists, technology, and hospitalizations have probably increased it.
What is it about primary care? Why does it make so much difference. Starfield’s work identified the fact that nations and regions with high levels of primary care have greater self-reported health status and fewer health disparities, and that the presence of primary care tends to mitigate the negative impact of income inequality.[4] This group also demonstrated that an increase of primary care physicians of 1 per 10,000 (20%) physicians decreases mortality by 40 per 100,000 (5% fewer deaths), and 1 per 10,000 (33%) more family physicians decreases mortality by 70 per 100,000 (9% fewer deaths), while an increase in specialists of 1 per 10,000 (8%) increases mortality by 16 per 100,000 (2% more deaths). [5] Dr. Roberts notes 4 features of systems with higher primary care to specialist ratios that might affect this: 1) when there are too many specialist and not enough primary care doctors, specialists may try to manage conditions outside their specialty in which they are not knowledgeable; 2) prevention and early detection save more lives and extend life more than intervention late in the disease process; 3) there is excessive utilization of procedures when there are too many specialists (supply drives demand rather than vice versa) and these often have risks; 4) the more “handoffs” there are between doctors caring for a patient, the more that care begins to resemble an elementary school game of “telephone”, where the final message heard is very different from that which began the communication.
The fact that family physicians specifically seem to improve population health status more than primary care physicians taken as a whole is apparent in the data, but the reason has not yet been identified by studies. Dr. Roberts postulates that it has to do with caring for multiple family members, and using that information to improve their care, such as when a mother’s issues are addressed at a visit ostensibly limited to caring for her child. Primary care (and possibly especially family physicians) acts to achieve all aspects of what has been identified as the “Triple Aim” of health care: greater access, lower cost and higher quality.
Primary care doctors, and especially family physicians, are doctors of “first and last resort”. They care for pregnant women and deliver their babies and care for their children as well as the other adults in the family. They tend to the “grandparents”, older adults, and manage the often complex interplay of multiple chronic diseases. They provide acute care and preventive care and are aware of the individual’s beliefs and preferences and those of the family, and the dynamics that exist between them. They care for people at the end of life, right through the end, not just until “there is no more to do”, and they remain there for the survivors.
The US could do a lot better. We need a health system that is more grounded in primary care, and we need a health system that provides access to everyone. What we don’t need is folks in Congress are committed so committed to preventing that access they will shut the government down!  Another conference speaker, Dr. Cynthia Haq of the University of Wisconsin, quoted the Ethiopian Minister of Health, with whom she had recently met. “Only in the United States,” the Minister said, “could there be discussion about whether access to health care was a human right or not.”
Oh, my. He’s right. I sure wish he were not.


[1]White KL, Williams TF, Greenberg BG. The ecology of medical care. N Engl J Med 1961;265:885–892.
[2] Green, LA et al., “The ecology of medical care revisited”, N Engl J Med 2001; 344:2021-2025June 28, 2001DOI: 10.1056/NEJM200106283442611
[3]Shi L, “Primary care, specialty care, and life change”, Intl J of Health Service,1994; 24(3):431-58
[4]Starfield BA, Shi L, Macinko J, “Contribution of Primary Care to Health Systems and Health”, Milbank Quarterly Sept2005; 83(3):457-502. DOI: 10.1111/j.1468-0009.2005.00409.x
[5]Shi L, et al., “The Relationship Between Primary Care, Income Inequality, and Mortality in US States, 1980–1995”, J Am Bd Fam Med, 1Sep2003;16(5)412-422. doi: 10.3122/jabfm.16.5.412.

Making contraception easy and available: we are going in the wrong direction!

It is 2017. It is more than 100 years since Margaret Sanger advocated for contraception, and more than 50 years since the oral contraceptive pill became available. The last two generations of women – and men – have never known a world where there was no effective form of contraception. They probably do not recall when even condoms, although “over the counter” (in that no prescription was required) were stocked “behind the counter” and required requesting them from the pharmacist often with (if you were young) a disapproving glare, and maybe worse, a raft of questions.
The verbal and physical indignations and worse, including even murder committed on unmarried women who got pregnant and were unable, of course, to have access to abortion should be things of the past. They are, horrifically documented in Dan Barry’s New York Times piece “The Lost Children of Tuam”. The film “The Magdalene Sisters” shows the intolerable treatment of girls who may not have even gotten pregnant but were, perhaps, just a little too familiar with boys. Both the Magdalene laundries and the mother-baby home in Tuam were in Ireland, which was perhaps extreme in the poverty, ignorance, and fast ties to the Roman Catholic Church, but the treatment of women in England and the US were also inexcusably harsh. The British drama “Call the Midwife” tells the story of an unmarried teacher who gets pregnant in the early 1960s and is fired from her job (morally unfit to care for children!), tries to self-induce abortion with a coat hanger, and almost dies. Finally, post-hysterectomy so that she will never be able to have children, she is driven out of town. The most sympathetic characters in the show see it as sad, but none indicate it is horrific, immoral, and inhuman. And this was commonplace, even in the 1960s and beyond.
We should not, in 2017, even be discussing the availability of contraception, not to mention whether it works. Amazingly, we are. Teresa  Manning, appointed by President Trump in May to be the director of the Office of Population Affairs, the main family planning arm of the federal government, is not only a former employee of two anti-abortion groups, but has expressed skepticism of the effectiveness of contraception itself! Manning, a lawyer and not a health professional (although this is not an excuse), is completely wrong. The data is in. Contraception dramatically decreases unplanned pregnancy (regardless of marital status). Time recently ran an article accurately describing the science titled “No, birth control doesn’t make you have riskier sex”. That is the truth, but in fact, even if it is was associated with riskier sex for some people, that would be no reason to restrict access to it. The more contraception is available, the lower the rate of bad outcomes of virtually all kinds. It even, of course, reduces the rate of abortion; in fact, the only two things ever to have been shown to significantly reduce the rate of abortion are comprehensive and accurate sex education and easy and cheap availability of contraception. Indeed, the degree to which contraception is effective in decreasing the incidence of unplanned and undesired pregnancy is directly related to the ease of its availability, including financial availability. Unsurprisingly, reducing the cost of and increasing the ease of access to contraception has the greatest impact on teens and on the poor.
So it is amazing that, in what The Atlantic refers to as “one of its boldest moves yet” (I don’t think that they meant it was positive, but “cowardly”, as well as “stupid” and “reactionary” come to mind as better adjectives) has reversed the ACA’s requirements that employers and insurers provide contraception at no cost to women. Politically, it is part of the administration’s efforts to dismantle the ACA piece by piece, since they were unsuccessful in doing it as a whole. Morally, it is an imposition of a minority’s religious values on the rest of us, and is particularly ironic being spearheaded by Donald Trump. It will cause great harm to individual women (and men) and to the society as a whole. Arguments that the cost of contraception is “only” $50 a month may wash with those in the middle class and up, but for poor women and teens, $50 a month is a lot. The most effective methods of contraception, IUDs and implants (collectively referred to as LARC, long-acting reversible contraception) may have a lower amortized cost over the use period but a high upfront cost that is unaffordable, without subsidies, for many women. (The reason, lack of cash on hand, is the same one that leads many poor families, as described by Barbara Ehrenreich in her wonderful and depressing book “Nickel and Dimed”,  to live in expensive weekly motel rentals – the overall cost may be more than an apartment, but the upfront cost, including deposits, rent in advance, etc., is prohibitive for them.) The impact on the teens who will be denied free access is described movingly by a pediatrician in Vox.
The other important impact of such a policy would – and perhaps will — be on the economy. This is articulately addressed in a column by Bryce Covert in the NY Times, October 29, 2017. The reasons start with individual women, and the cost of purchasing birth control, money which will not be available for them to spend on other goods – with more than 57 million women using contraception, in one year that is $1.3 billion. But the larger impact is societal – women who cannot control their own reproduction, who do not know when and if they will get pregnant – are in a poorer position to contribute to the workforce and to the economy. Again, going back to the history I address at the start of this piece, we know this empirically, not just theoretically:
… a raft of evidence has definitively found that when women gained greater access to the pill in the late 1960s and early ’70s, they were able to delay marriage and childbirth and invest in careers through education, job training and staying in paid work….Legal access to the pill transformed the economy in that era. It increased young women’s labor force participation by 7 percent….about a third of the increase in how many women attained careers in fields like law and business was due to birth control. Women with earlier access to the pill also made 8 percent more than their peers, and the pill was responsible for about a third of the decrease in the gender wage gap by 1990.
And it is still critical. Perhaps Trump himself is just cynically pandering to his base, and probably much of that base depends upon contraception, women directly but men just as much. Opposition to contraception cannot be justified except by the small minority of religious purists (and of course they are welcome to not use it); opposition to making contraception easily and freely available is almost as bad, as it is completely discriminatory. It is still, as Covert describes,
…still playing the economic role that it did in the 1970s. About half of women who use it say they do so to complete education or to get and keep a job. Contraception is still increasing the share of women who get educated and get paid work, particularly prestigious jobs.
Easy and affordable (affordable for all those who need to use it, not just billionaires or even the upper middle class!) is not a “women’s issue”, it is not a “special interest” issue. It is a core need for people. People with the views of Teresa Manning should not be given center stage, and certainly not given authority over contraception. We need to guarantee permanent access to contraception for all, and for accurate sex education. 

Now.

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

One of the recurrent themes of this blog has been the importance of everyone having access to necessary medical care, and how the US compares poorly to other developed countries in that it does not cover everyone. Another recurrent theme has been that many medical procedures are unnecessary, sometimes even harmful, but are nonetheless provided to people who have the money or insurance to pay for them. This is not to say that greed is always the motivator; there is a powerful, if often incorrect, belief that to do something is better than to do nothing.
In this context, it is interesting to read “President Bush’s unnecessary heart surgery”, a Washington Post “Viewpoint” by Vinay Prasad and Adam Cifu published August 9, 2013. As part of his “annual physical”, the former President  (who is “…widely regarded as a model of physical fitness”), received, in addition to (presumably) the screening tests and immunizations recommended by the evidence, a cardiac stress test. Discovering an abnormality on that test led to his having a CT angiogram and finally placement of a cardiac stent.
One interpretation of this story might be “he’s lucky they did the test; they found something wrong and fixed it”. I’m afraid, along with Prasad and Cifu, that this might be the lesson taken from it by many people, and the result could be more people requesting such a test because, “hey, they found something wrong with President Bush – could I also have such a problem?” This would be unfortunate, because it is incorrect. President Bush – based on the information provided – should not have had the stress test and not have had the stent placed.
The key point is in understanding that he was (by all reports) asymptomatic. “Before he underwent his annual physical, Mr. Bush reportedly had no symptoms. Quite the opposite: His exercise tolerance was astonishing for his age, 67. He rode more than 30 miles in the heat on a bike ride for veterans injured in the wars in Iraq and Afghanistan.” While the definition of screening tests is that they are done on asymptomatic people, there are a number of criteria that have to also be present, among them that the test should detect a condition before it is symptomatic, and there should be an intervention that will prevent progression if disease is discovered. So, isn’t that true in this case? He did have the disease, a narrowing in one of his coronary arteries, right? So isn’t it good that it was discovered.
As Prasad and Cifu discuss, however, there is no evidence that stenting a coronary artery prolongs life.  It is worth noting that at least two large randomized trialsshow that stenting these sorts of lesions does not improve survival.” Even for higher risk patients than Mr. Bush, survival is not increased. However, if people have symptoms of chest pain that appears cardiac in origin, for whom stress testing may be indicated (not a screening test now; they are symptomatic), treatment by angioplasty, stenting, or even bypass surgery can ease or relieve the pain. That is a good thing. But for Mr. Bush, who had no pain, there can, by definition, be no pain relief. There was some additional risk, however; in addition to the inherent low risk of doing the procedure (such as bleeding and stroke, and even, rarely, death), he now has to take anti-platelet drugs, which also confer some risk. And a stent only holds open the spot it is in; it does not prevent progression of coronary artery disease elsewhere.
The larger issue of the “annual physical” (which I have addressed previously in “ The “Annual Physical”: Screening, equity, and evidence”, July 4, 2012, citing Elizabeth Rosenthal’s NY Times article “Let’s (not) get physicals”) was again the subject of a popular article, “The case against the annual checkup” by Brian Palmer on Slate.com on August 20, 2013, which states: “There are two kinds of arguments against the adult annual health checkup. The first has to do with the health care system overall, and the second has to do with you personally.” Palmer does add that
“It’s important to separate preventive care from annual checkups. Only one-half of annual checkups actually include a preventive health procedure such as a mammogram, cholesterol testing, or a check for prostate cancer. (Annual gynecological visits are excluded from these numbers, although the evidence supporting those is not particularly overwhelming either.) More importantly, only 20 percent of the preventive health services provided in the United States are delivered at annual checkups.”
He has a pretty good point, although he includes prostate cancer screening, which is not recommended or beneficial, in his list, something Prasad and Cifu do not. But I would take issue with his suggestion that you only visit the doctor when you are sick, which is in fact when doctors tend to work in the preventive services the other 80% of the time.
There are a couple of reasons for this, but the main one is that there are a lot of people (even older people at higher risk) who do not get sick, or at least sick enough to decide to come to the doctor, or at least sick enough to decide to take off from work and maybe lose income to come to the doctor. And they could benefit from preventive care as well. The list of preventive services changes from time to time, which it should as new evidence emerges, but includes immunizations, screening, and education. The list of conditions for which screening is effective and recommended by the evidence is relatively short (despite our natural desire to have more, more effective, tests) and does not include prostate cancer or ovarian cancer (thus, no reason for an asymptomatic woman to have a “routine” bimanual pelvic exam), but does include Pap smear for cervical cancer, colorectal cancer screening (which can be done with colonoscopy or regular stool screening for occult blood), bone density screening for certain age groups, and mammography. There are also recommended screening for other conditions: hyperlipidemia (mainly cholesterol), abdominal aortic aneurysm (once, in men over 60 who have smoked), HIV and Hepatitis C, as well as some screens for people who are themselves asymptomatic but whose family history places them at higher risk for a condition (e.g., diabetes). (See theGuide to Preventive Services 2012, Recommendations of the US Preventive Services Task Force, on the website of the Agency for Healthcare Research and Policy.)
Immunizations include not only annual influenza shots, but also less-frequent pneumococcal vaccine and tetanus/diphtheria/pertussis boosters, which are often not up-to-date in adults.Education may be the most important: counseling on diet, exercise, smoking, alcohol, drugs, and risk behaviors, as well as identifying victims of violence (domestic or otherwise) should not wait until these conditions have resulted in symptomatic disease.
Perhaps these preventive services should not be “annual”; there is no magic to this number, but it was chosen because it is easy to remember. Certainly many of these preventive services (now including Pap smears, bone density and mammograms) are recommended less frequently than yearly. Perhaps they can be as well delivered by other health professionals as by physicians. But there is benefit to preventive care even for asymptomatic people, and not the least is noted by Palmer: “They build relationships between doctor and patient, and open lines of communication are important in medicine.”  Yes, there are certainly many risks, which I have often pointed out, to over-testing and over-medicalization. But there are also risks to not having preventive care. And, of course, the key point here is equity: those most at risk of “too much” care and too many interventions are the more well-to-do, well-educated, and well-insured. Those most at risk of too little care, too little screening and immunization and education about how to reduce their risks and early identification of disease are the poorer, less educated, and uninsured.

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

Primary Care Contributes More than Money….

I have often written about why the US needs a comprehensive national health system to cover all of its people, and my preference for a single-payer system similar to that in place in Canada. I believe that this is necessary for our country to address its poor health statistics. You can’t have lots of people without financial access to health care and have a healthy country.  When financial obstacles exist, we have artificial and unnecessary suffering, pain, and death.

But having financial access to care is, although necessary, not sufficient. We need other changes in our health care system. For starters, we more primary care doctors and other providers, for another we need systems that encourage and reward quality of care, and we need to have everyone receive care that is need, no one receive care that is not needed, and have health, not profit, drive the system.
Unfortunately, this is not what we have. While a sensible health care system, such as that in most countries with better health outcomes than our own, is built on a broad base of primary care, with a much smaller number of subspecialists, and even less hospital (and even less tertiary care). Our system, or non-system as I have called it, is skewed toward high-technology, high intervention care, aimed at the top of the pyramid. Most of the resources are allocated there, and balanced on a relatively small number of primary care providers. As should be obvious, inverted pyramids are inherently unstable.
One reason for this inversion is the demand of people in the US, particularly those with good health insurance or lots of money, for more and more expensive, high-tech care. This follows from the general assumption that “if some is good, more is better”, and “if it costs more it must be better, and if it is better it is what I want” that pervades much of our culture. Unfortunately, those old saws are not true when it comes to health care. Frequently, less is better, and more is worse. This has increasingly been demonstrated with a number of ostensibly-preventive interventions that have been showed to both increase morbidity (because of false-positive tests that lead to dangerous but unnecessary intervention) and cost. These include PSA testing for prostate cancer (even the American Urological Association has come on board by not recommending this test for most men – AUA guidance cited inAAFP Smart Brief May 15, 2013; it should actually be for no men), mammography for breast cancer screening, and the never-had-any-justification-as-a-screening-test-in-asymptomatic-women pelvic exam (the part where the provider puts hands inside, as distinct from the Pap smear screening test for cancer of the cervix, Questioning the pelvic exam, by Jane Brody, New York Times, April 29, 2013).
Farther down the spectrum of health care interventions are the incredibly costly things we do to people at the end of their lives. Heroic things done that ultimately don’t make any positive difference, and often end up extending a poor quality of life, or have someone end their lives enduring continuous interventions, needle sticks, and harassment. Why do we do this? Maybe because we want it? Some of us do. A colleague relocated from Kansas to DC says that people in the East don’t seem to accept  that people die; she feels it is less of an issue in the Midwest, where farmers are used to animals dying, but I don’t know. I see it here. And, indeed, it is an extension of the observation by Marion Stone, the fictional hero of Abraham Verghese’s “Cutting for Stone”, that, in comparison to Ethiopia where he grew up and went to medical school, Americans seem to think of death as optional. But, of course, it is not.  Many Americans have come to realize that, and have advance directives limiting what is done to them. But some, or their families, keep bringing people whose bodies are trying to die, into the hospital where our interventional technology saves them – for the moment. Until the next admission, a month or a week or a day later. “We have created,” says an intensivist colleague, “a group of people who can only live in the ICU.
But there is more. And that is that such high-tech, high-intervention, high-cost medicine makes money, for the doctors who do it and the hospitals that it takes place in. And, of course for the manufacturers of the devices that are used. This is why, in large part, we have a primary care/subspecialist imbalance, why the pyramid of health care is balanced on that knife-edge. If cardiac care makes the institution money, if cancer care or neurosurgery or orthopedics does, this is what those institutions want. These are the specialists that they will subsidize to be on their hospital staffs. These are the specialties in which teaching hospitals will voluntarily support residents and fellows, even if that creates an inappropriate mix of specialists for the community at large. I have often said that in medicine, unlike classical economics, supply drives demand as opposed to vice versa. But I have also said that, as insurers move to prospective payment, the former money-maker product lines become cost centers, and that primary care providers who can care for things themselves without lots of referrals will become profit centers.
There is already evidence that this financial situation is shifting. Health Leaders Media reports in a story by John Commins on May 20, 2013 that “A survey of hospital CFOs shows primary care physicians generated a combined average of $1,566,165 for their affiliated hospitals in the last year. Other specialties generated a combined annual average of $1,424,917, the lowest average in five years, data shows. Primary care physicians have emerged as key money makers for their affiliated hospitals and for the first time are generating more revenues on average than their specialist colleagues, a survey data from Merritt Hawkins (PDF) shows.” This has to be good for primary care doctors, and has to get the attention of both hospital administrators and subspecialists.
However, it may not necessarily be good for people’s health. I say this cautiously, because, as I think I have made clear above, I do not think that it is better to have more subspecialists doing more interventional procedures which do not improve the quality of life. But simply showing that primary care doctors generate more revenue for hospitals does not mean that things are that different; it may only mean that primary care doctors are referring more patients into hospitals for procedures. This is, in itself, not the goal.
There is a goal. The goal is improved health for the American (and all) people. The goal is everyone getting the care that they need that will benefit them, and no one getting care that will not benefit or might even harm them. The goal is the medical ethics principle of justice: that everyone has the same options for diagnosis and treatment open to them, based upon their disease and condition, and not their wealth. The goal is a society that provides the necessary basis for good health – food, housing, education.
We can achieve that goal. We have the resources. We just need the will.

Cancer, cost, hope, and the responsibility of physicians

The headline on a recent article by Marilynn Marchione of the Associated Press, as featured in the Arizona Daily Star, is “Few doctors discuss cancer costs with patients, study finds”, and that about covers it. The actual study previewed in the article, which will be presented at the American Society for Clinical Oncology (ASCO) conference in Chicago in June, was led by Dr. Rahma Warsame of Mayo Clinic. It recorded clinical encounters at three cancer sites (Mayo, USC, and LA County) and discovered that the often extraordinarily high cost of cancer care was not usually discussed; discussion happened in just 151 of 529 visits, and in only 45 of those cases, less than 1/3, was the issue brought up by the doctor rather than the patient.
The article suggested several reasons for this. One was that the visits were short, 15 minutes at USC and LA County (about typical, though, across the country), and 30 minutes at Mayo. Another was that doctors are trained to diagnose and recommend treatment rather than to focus on the cost. A third is that the doctors themselves might not know the costs of the treatment. And, for a combination of both of those reasons, they might be uncomfortable talking about the cost. Given that these treatments can easily cost $100,000 a year or more, this is not fair to patients. While good insurance might cover the cost, not everyone has good insurance. In addition to the uninsured, many more people have crappy insurance plans with poor benefits and lifetime caps that are easily exceeded with the cost of cancer care. For most of these folks, the answer is go broke and bankrupt, or die without treatment. From a health point of view, this is not a desirable state of affairs. From a medical point of view of trying to do the best for a patient, it is an abrogation of the obligation to provide the best care. From a moral point of view, it is reprehensible. From some points of view, however, it must be ok, because this is the situation we are in, and it is not by accident. And that is tremendously distressing.
But who would have such a despicable point of view? We can start with the organizations that make money from such care. Of course, this includes the very clinical oncologists who are the members of the ASCO, but they are the least of the beneficiaries. Indeed, I feel comfortable saying that most oncologists would enthusiastically welcome lower costs for chemotherapy. The biggest winners are the drug manufacturers, who charge fantastic amounts for these drugs, and the hospitals and “cancer centers” that provide them. A large part of this profit comes from the reimbursement from insurance companies, which, in addition to paying the cost of the drug, also pay an fee to the hospital for administering the drug that is, frankly, exorbitant and far more than is paid for comparable work in provision of most other care. Indeed, this is why there is such an apparent explosion of cancer centers. It is not because of the explosion of cancer; it is because they are big profit centers and every hospital wants their own to try to lure cancer patients (those who are well-insured, it goes without saying) away from their competitors. And, in a step back from my confidence in the patient-centeredness of oncologists, those groups of oncologists who own independent cancer centers outside of hospitals, and make lots of money on it.
Why would insurers pay such high prices? Medicare pays a pretty high “administration fee”, and most private insurers reimburse at multiples of Medicare. Also, insurers can just raise their rates to cover these costs, especially if they value (as in “appreciate the clout because of the number of patients they control”) the relationship with a particular hospital, cancer center, or health system as described in Elisabeth Rosenthal’s “An American Sickness” and discussed in my blog post “United Airlines, health care, and a system designed to privilege the powerful” (April 15, 2017).
Students learn very little about the cost of care in medical school. There are beginning to be some courses that introduce cost-consciousness, but they are uncommon and limited, although even residents and students have access to smartphone information, through apps such as ePocrates®, that provides information about drugs, and often cost.  But is true that these doctors do not know the cost of the care that they are providing? Certainly while the clinical oncologist may not know the exact dollar amount, they know that it is a lot. And it is irresponsible to not discuss this with patients, to help them understand what they are getting into when they start treatment.
Drugs are only one component of the cost of care; a huge one in cancer, but radiation therapy can be even more. As I have discussed before, the real problem is that no one knows what anything actually costs. Yes, hospitals have “charge masters”, but they are not only dense and hard to find (especially for patients) but not that relevant; these charges are adjusted dramatically depending upon insurance. Medicare is unique in that it sets the amounts that it will pay (a lot for chemotherapy), but other insurers pay varying amounts depending upon the contracts that they have arranged with the hospital. Thus we have the irony (which I discussed in “Integrated Health Systems and Cost: The Price is the thing!”,December 20, 2015) that smaller cities with large integrated health systems have some of the lowest costs for Medicare (because they can create efficiencies) but some of the highest costs for private insurers (because they “own” the market and can charge more).
The real issue is that people should be able to get the care that they need and is medically indicated and has evidence to back its effectiveness without going broke. Physicians can no longer hide behind the first half of that sentence, saying “I recommended the care that they need and is evidence-based” (although certainly their recommendations should always be evidence-based!) without considering the cost. On the other hand, the health system of the US should ensure that everyone is covered for necessary care. One way of having enough money to do this is not providing unnecessary, evidence-free care to some people just because they or their insurance will pay for it.
This also means that people should not expect it. As horrific as it is for you or a loved one to be dying of cancer, it is unreasonable to expect that experimental, hopeful, or completely wishful-thinking treatments would or should be paid for by someone else, and it is generally a bad idea to try to pay for them yourself since they won’t work. Some years back, my friend was dying of an aggressive cancer. A bone marrow transplant failed. The genetics of his cancer were such that it was destined to fail. The cancer center (arguably the “best” place in the US for his type of cancer) offered him the opportunity for a second transplant, but the insurance company rightly refused to pay. His family cashed in his entire retirement to pay. Predictably, the transplant failed, and his family was left without any savings. The doctors knew that it would almost certainly fail, and should have known what it would cost, and thus not recommended it. An agnostic stance on cost is unacceptable.
The media coverage of the ACA and the Republican repeal plan makes clear that there are many people who do not want to pay for insurance coverage when they are healthy, but want everything taken care of when they or their family are sick. Then they get desperate and might spend the last of their savings on treatments that will not work, whether quack drugs like laetrile or futile attempts offered by the medical community, such as happened to my friend. It is the responsibility of doctors to know the cost of treatments they recommend and discuss this with their patients, and to not offer ineffective treatments. It is wise for patients also to ask for this, although many are unempowered and intimidated by the medical system.

But if we all pay in when we can and benefit when we need it, the system would work. It’s called single payer, or Medicare for all. Unfortunately, our system, with or without ACA, is nowhere close.

Suicide: What can we say?

On Sunday, September 8, 2013, we participated in the annual Suicide Remembrance Walk in Kansas City’s Loose Park, organized by Suicide Awareness Survivor Support of Missouri and Kansas (SASS/Mo-Kan). An article previewing the walk and interviewing Bonnie and Mickey Swade, our friends who established SASS/Mo-Kan, ran in the Kansas City Star on September 7: “What to say, and not, to those left behind by suicide”. Bonnie and Mickey became our friends because we are members of a club none of us would wish to be in: suicide survivors. Their son Brett completed suicide about a year after our son Matt did, and we were in a support group together before the Swades started their own. Matt’s suicide was on December 13, 2002, which I never thought of as being “Friday the 13th” until I realized that because of the vagaries of leap years, this year, 11 years later, is the first Friday December 13thsince then. Thus, this post several months later.

The Remembrance Walk around Loose Park in Kansas City was well-attended on a hot morning, and culminated in all of us standing in a very large circle holding long-stemmed flowers as a distressingly long list of names was read. We counted 7 times when two (and in one case 3) last names were repeated; the list was not in alphabetical order, so this was not coincidence. As much pain it is to have one person you love having committed suicide, two or more is unfathomable. Finally, white doves were released, and the ceremony ended to the strains of “Somewhere over the rainbow”.
I have written about suicide before (July 29, 2009, “Prevention and the “Trap of Meaning”), in which I discussed an article that had recently appeared in JAMA by by Constantine Lyketsos and Margaret Chisholm titled “The trap of meaning: a public health tragedy”[1] ). The thrust of that piece was that people — families, lay persons, psychiatrists, psychologists, philosophers, and others — search for “meaning”, “reasons” for suicide, and that this is, essentially, pointless at best and, devastating at worst. Suicide is the fatal result of the disease of depression, a disease which is very common and not usually fatal, but can be. It may often be precipitated by a specific event or set of events (as the final episode of chronic heart or lung disease is often preceded by a viral infection) but those are not the cause. The strongest prima facie evidence is that most people in the same circumstances (whether victims or perpetrators of bad things) do not kill themselves. But enough do to have made a long list to have read at the ceremony in Loose Park.
Like everyone else, each person who kills themselves is unique, and their histories differ. Some have made previous attempts, often many times; others gave no clue. Some have been hospitalized, often many times; others never. Some have family who were sitting on the edge, awaiting the suicidal act, trying their best to help to prevent it but helpless to really do so. The families and friends of others had no idea it might happen. While those who attempt or complete suicide are depressed, some very overtly manifest that depression and some not so much. While many people who have depression never attempt suicide, some complete suicide when things are looking, to others, good. Overall, access to effective weapons increases the probability of “success”; the “lethality” (the probability that you will die from an attempt) is about 95% from guns, and only 3% from pills. Therefore, easy access to guns is associated with a higher successful suicide rate; in young men 16-24 the success rate is nearly 10 times higher in low gun control states than in high. I doubt these young men are more depressed, but they have quick and effective methods of turning what may have been relatively transient suicidal thoughts into permanent death. Of course, not all suicides are classified as such; while it is often obvious, sometime it is not: how many one-car accidents, for example, are really suicides? And, because “unsuccessful” suicide attempts are grossly under-reported, the lack of an accurate denominator makes “success” rates very hard pin down.
On one hand, the fact that most suicide attempts are not hospitalized and given intensive treatment seems to me to be a bad idea. Since the greatest predictor of a suicide attempt is a previous suicide attempt, if there is any likelihood that a suicide can be prevented it would be best to intervene at that time and try to treat the depression. On the other hand, I am not sure that there is any good evidence that treatment is terribly effective in preventing suicide. Yes, there are many people who have attempted suicide once and never again, but this may be a result of treatment or the natural history of their disease. There are people who are under intensive treatment when they complete suicide, often when least expected. Indeed, there is evidence that treatment of depression may sometimes paradoxically increase the risk of suicide by getting a person whose depression was so severe that they were unable to act better enough that they can. And, conversely, there is no way of knowing how many times, before a suicide is completed, a planned attempt was put off by an intervention that may not have even been intended, by demonstrating love and letting the person know they were needed.
It doesn’t always work. If the person is unwilling to share their symptoms and is determined to complete suicide, there is no prevention that is effective. My son was 24, deeply loved, lived in a state with strict gun control laws and probably never held a gun before. But he was able to drive to a low gun-control state, buy a carbine and bullets, and complete his suicide. He took his time and planned it, and it is unlikely to have been preventable. But many suicide attempts are not as well planned, are more impulsive, and efforts to prevent these might be successful in many cases. In a classic 1975 article in the Western Journal of Medicine[2] David Rosen interviewed 6 survivors of jumps from the Golden Gate bridge. The emphasis in these interviews is on transcendence and “spiritual rebirth”, but all agreed that putting a “suicide fence” in place might have deterred them and might deter others.
For all of us who wish mightily to prevent disease and death, suicide may be seen as the greatest affront because the death is seen as “unnecessary” and often involves people who were “healthy” (except for their depression), young, and had a future before them – sometimes (as I like to think of Matt’s) a truly promising future. But too often we, in our desire to prevent death and disease, choose to focus on the least effective interventions to do so. We will take unproven drugs (especially if they are “natural” or non-prescription), and clamor for our “right” to have marginally useful or even ineffective screening tests, but there is a vocal movement against immunizations, one of the few preventive interventions that are known to be effective. We decry mass murders in school after school, and bemoan the loss of our young people to both suicide and homicide, but resist regulation of the most effective instruments of death, guns. We all take our shoes off each time we fly because of one failed “shoe-bomber”, but ignore the thousands of deaths on our city streets.
I wish my son had not killed himself. I wish I knew how to have prevented it. I wish I could tell those of you who worry about a loved one how you can prevent it. I wish even more that I could tell those of you who don’t suspect it that you can be secure because in the absence of definite warning signs you can feel safe. I can’t do that. When there are warning signs, take whatever action you can, but the reality is that it may not be effective. When there are no signs, hope that it is because there is no risk.
As individuals, we hope and do what we can. As a society, we should decide on our priorities, and we should be guided by the evidence, not by our fantasies, hopes, or magical thinking.


[1]Lyketsos CG, Chishom MS, “The Trap of Meaning: A Public Health Tragedy”, JAMA. 2009;302(4):432-433. doi:10.1001/jama.2009.1059.
[2] Rosen DH, “Suicide Survivors: A Follow-up Study of Persons Who Survived Jumping from the Golden Gate and San Francisco-Oakland Bay Bridges, West J Med. 1975 April; 122(4): 289–294. PMCID: PMC1129714

ACA: Where are we? And where should we go?

I am finished writing the book, as yet untitled, that I have been working on during my sabbatical, which accounts for the sparse number of blog posts. This is not to say that the book is anywhere near ready to be published; I am sure it will need more revisions.
However, it does mean that I am likely to be posting to the blog more frequently, as I find things that inspire me to write.
Thanks for your patience!
Josh
The Affordable Care Act (ACA) has been law since 2010, and was supposed to have been fully implemented this year in 2014, although as is clear many of its provisions have not yet been. The most important has been the failure of about half our states to implement the expansion of Medicaid, which was the mechanism through which the law intended to cover all those poor (incomes under 133% of the federal poverty level) who are currently ineligible for Medicaid (most of those now receiving it are poor children and their mothers, although the majority of dollars are spent on nursing home care). This is legal as a result of the Supreme Court decision that was important because it made the rest of the law legal; this is, I think, of faint solace to those poor people who live in my state of Kansas and the others who have failed to expand Medicaid despite the fact that the federal government would have paid 100% of the cost for 4 years, then 90%.
The newest court actions that affect ACA are two Court of Appeals decisions which say, basically, opposite things about the subsidies that support the premiums of people making above 133% of poverty but less than allows them to pay the full amount.[1]One court decided that people living in states that ran their own exchanges were eligible for the subsidies, but that those who were in federally-administered exchanges were not. The other appeals court decided that both were. Of course, those states that have federally-administered exchanges are those with governors and legislatures who oppose ACA completely; they include all those who did not expand Medicaid plus many more (about 36 altogether). This suggests some political agenda; the interpretation of Congressional intent rather than parsing the words, has historically been the basis for such court decisions. It also will mean that the cases will go to the Supreme Court, sometimes known as SCOTUS, but now appropriately called COCUHL (Court of Citizens United and Hobby Lobby), where it will be amazing if a conscious, careful, legal approach supersedes politics. The decision to basically gut the Hobby Lobby decisions one remaining protection only a day after it was announced bodes ill. The Republicans in Congress have decided to sue President Obama for not implementing portions of the ACA, which, as Timothy Egan of the NY Times points out, “…they have tried to repeal more than 50 times.”[2]
What has the Republicans so flustered that they have taken to self-contradictory actions is, in fact, the success of the ACA at achieving many of its goals. These are summarized in another NY Times op-ed, by Paul Krugman, titled “Obamacare fails to fail”.[3]There has been a huge surge in enrollment, and while indeed some people are paying more (largely healthy young people who are low risk for high-cost illness, thus previously had lower premiums), most people (including 74% of Republicans) are happy with their current premiums. In addition to the early wins (preventing insurance companies from not covering those with pre-existing conditions, allowing young people to stay on their parents’ insurance until they are 26), we now add over 6 million people who are newly covered, and can access health care. Despite decisions such as Hobby Lobby, most women will now get contraceptive coverage without a copayment. It is a good thing. This is why opponents (mainly ideological) are trying any trick that they can to limit its effectiveness, including the two biggest addressed above—not expanding Medicare and trying to block subsidies for those on the federal exchanges. That is to say, trying to limit health insurance coverage to our less-affluent citizens.
But ACA, even if it came through all the court decisions unscathed, is not a solution. It doesn’t cover those who are not citizens, even though they live here. It is a gift to insurance companies, who still get to charge high rates and make enormous profits, but now have the federal government paying the premiums. Therefore, it will not really save cost. Don’t get me wrong – I am not advocating that we provide less of the health care people need to save money (although I do advocating not providing “health care” that will not help or even harm people just because someone can make money on it). I am saying that the huge profits guaranteed for insurers, and other components of our system who make profit, make it excessively costly. It costs us way more per capita, for poorer health outcomes, than do the healthcare systems of other developed countries. The latest edition of “Mirror, Mirror on the Wall”, published in 2014 by the Commonwealth Fund demonstrates this clearly; in comparing 11 wealthy countries the US ranks #11 overall, and #11 in 3 of the 5 areas examined (Efficiency, Equity), and Healthy Lives), #5 in Quality, and #9 in Access. It achieves this less-than-mediocre performance by spending (2011) $8508 per capita, while the other 10 countries spent from $3182 (New Zealand) to $5669 (Norway).[4]
 

The problem is not that our system is not working, but that it is. Paul Batalden is famous for saying “every system is perfectly designed to get the results that it gets”, and ours is. The results that we get are relatively poor health outcomes on a population basis, large numbers of people excluded from health care coverage (even after ACA), many people getting unnecessary care because someone can make a profit on it, and the bizarre concept that there are not only people who are preferable to provide care for (because of their wealth or insurance status) but even diseases that it is preferable to provide care for (because the profit margin is better). Our system is not designed for people’s health; it is designed so that some (providers, insurers, drug companies, etc.) can make profit. It gets the results it is designed to get.

But that is unacceptable. We need a health system designed to maximize the health of our people. All our people. And we need it yesterday.

 



[1]Goodnough A, Ruling on Health Care Subsidies Puts Coverage at Risk, NY Times 7/23/14, 
[2]Egan, T, “Ambulance Chaser in the House”, NY Times, 7/26/14, 
[3] Krugman P, “Obamacare fails to fail”, NY Times, 7/13/14. 
[4] Karen Davis, Kristof Stremikis, David Squires, and Cathy Schoen, Mirror, Mirror on the Wall: How the Performance of the U.S. Health Care System Compares Internationally, 2014 Update, The Commonwealth Fund, June 2014. 

Doctors’ incomes and patient coverage: both need to be more equal

On Sunday, January 18, 2014, the New York Times ran another stellar front-page piece by Elisabeth Rosenthal addressing the fact that, as the title states clearly, Patients’ Costs Skyrocket; Specialists’ Incomes Soar. It continues, with detailed documentation, her explanation of how providers – in this case doctors, and in particular the most highly paid subspecialists — game the system of insurance reimbursement to maximize their income, and how patients pay the price. She focuses particularly on dermatologists, whose combination of high income and low workload makes them the exemplar of what medical students call the “ROAD”, the specialties of radiology, ophthalmology, anesthesiology, and dermatology, all of which are known for having high income/work-hours ratios.
Rosenthal addresses in particular a kind of dermatologic surgery called Mohs surgery, which commands a high price. Mohs surgery is very good for its ability to identify margins of a skin cancer and leave less of a scar, but it can be, and often is, overused at high cost. She cites a particular case of a woman who had a small basal cell cancer (the kind that almost never metastasizes and is often simply excised) removed from over her cheekbone and had a bill of over $25,000. “Her bills included $1,833 for the Mohs surgery, $14,407 for the plastic surgeon, $1,000 for the anesthesiologist, and $8,774 for the hospital charges.” The plastic surgeon, by the way, was called in – along with the anesthesiologist – to close the small lesion from the excision that the dermatologist was unwilling to do.
The cases that Rosenthal documents are typical enough that they cannot be  called “abuses” because they are the norm; it is, of course, the entire system that is the abuse. It would be absurd if it were not so real, if it didn’t skew the entire health care system away from primary care and toward specialties where enormous incomes are made by billing – and collecting – for each single activity. Rosenthal describes the RUC, the AMA-convened body that makes “recommendations” to Medicare about the relative value (and thus payment) for procedures, as well as for other forms of patient care — such as listening to you, examining you, thinking about your problem, making a diagnosis, and recommending treatment — which are well undervalued compared to procedures. I discussed the RUC, and what I consider its outrageous behavior, in Changes in the RUC: None.. How come we let a bunch of self-interested doctors decide what they get paid?, July 21, 2013, and earlier in  Outing the RUC: Medicare reimbursement and Primary Care, February 2, 2011, but Rosenthal does an excellent job of describing its perverse incentives. Given that Medicare takes the RUC’s recommendations 95% of the time, and that most insurers base their payments on Medicare’s, the RUC, which is heavily stacked against primary care, essentially sets doctors’ reimbursement. And this is not to the benefit of patients, either financially or medically.
In another article, Rules for Equal Coverage by Employers Remain Elusive Under Health Law, buried much farther inside the paper but also very important, Robert Pear describes the fact that the Obama administration has chosen to not (yet) enforce rules which allow companies to offer discriminatory levels of coverage to some employees than to others; generally, “better” coverage to executives than to line workers. There is already a ban on such discrimination in companies that are self-insured, but the Affordable Care Act (ACA) extended this to those who purchase coverage from insurance companies. The possibilities for discrimination are illustrated by the things that are forbidden; for example, covering only executives and not others, paying the full cost of executives’ premiums while making lower-paid workers pay for a portion of their benefits, or offering different terms for coverage of the dependents of executives and other workers.
Of course, the companies (read: the executives who run the companies and stand to benefit from discriminatory practices) disagree. Pear quotes Kathryn Wilber, from the American Benefits Council “which represents many Fortune 500 companies” as saying “Employers should be permitted to provide lower-cost coverage to employees who may not be able to afford the comprehensive coverage being provided to other employee groups,” which, of course, would not be an issue if the company paid for comprehensive coverage for all employees. The one “benefit” that may be excluded from the non-discrimination rules are “certain types of executive physicals”, which is ironic because there is no data that these benefit most people, including executives, but rather increase both the cost of care and the risk (in follow-up tests for false positives) to the patient. Certainly there are some occupations where the risk of something going wrong is high enough that it exceeds the risk of harm, changing the harm/benefit ratio — airplane pilots for example, or possibly those who drive buses full of school children. But virtually no corporate executives are in this group.
The reason companies want differential benefits is primarily to save money by not offering good coverage to the majority of their employees, and also as a “perk” that they can offer to their executives. It is presented as parallel to other market goods, the difference between “serviceable” and “excellent”. This is even carried over in the metaphor to describe the low-copay plans that the ACA was going to tax, “Cadillac” plans, when everyone knows that a Chevy is just as good at getting you where you want to go, just not in such luxurious circumstances. But this is a lousy metaphor for health care, and confuses two benefits. One, which is the intent of the “Cadillac policy” tax, is whether individuals have to make co-pays or have co-insurance, or have limits on their benefits, or not. This is financial, and is very important. The other, however, is whether some people have coverage that gets them better health care. This is not OK. Obviously, they come together at some point since health care that is unaffordable to a person is unavailable to them, even when it is necessary. Conversely, for those executive physicals, providing a “benefit” that the individual does not have to pay for encourages them to seek unnecessary, and sometimes potentially harmful, care.
It may be that there are certain kinds of “health care” that are in fact reasonable to treat as elective consumer goods which a company might offer to some employees and not others; cosmetic surgery is the classic example (or non-medically-necessary contact lenses or radial keratotomy [Lasik®]; see Rand Paul on health policy: small brain and no heart, September 1, 2013). There also may be some employees for whom the harm/benefit ratio makes certain services of value when it does not for others (the comprehensive exams, “physicals”, for pilots, or Pap smears for women but not men). But, overall, coverage that does not include all necessary care for everyone is inappropriate. In addition, coverage of unnecessary care is as well. It is not Cadillacs vs. Chevies, or Volkwagens vs. Mercedes; it is making sure that everyone is covered for their health care needs. Like every other OECD country does. Like we could do if everyone was in Medicare.
Then instead of buying their executives “Cadillac health plans” to demonstrate how important they are, these companies can just buy them Cadillacs. 

Killing our children: Guns, mortality and morality

There is really nothing to write about at this time other than the ongoing carnage in our nation as a result of angry young men (always men!) shooting up their schools, most recently (at least at the time of this writing) with the death of 17 students and teachers at Marjory Stoneman Douglas HS in Parkland, FL. It is hard to write through the tears. This should not be going on. Many people have written pieces on the subject — sad, or angry, or articulate, or all of these. One of the most moving appeared in the New York Times on February 18, 2018, by a man named Gregory Gibson whose son was killed in a school shooting 25 years ago. The online headline, “A message from the club no one wants to join”, is different from, and in this case is much weaker than, the print headline: “Why wasn’t my son the last victim?”
Why indeed? Twenty-five years ago. And since then, countless school shootings, and other mass murders (such as, if we needed reminders, the Las Vegas country music concert, the Pulse nightclub in Orlando and the First Baptist Church of Sutherland Springs, TX) have occurred, and every parent, every family member, wants to know why the most recent prior child to die was not the last, instead of their child. People are terrified; a friend, a rational physician, embarrassedly admits to looking online for Kevlar backpacks for his children. He does international “mission” work and is taking his 14-year old daughter to Africa; when people ask him if he is worried about her safety there, he says “no”, but he is worried about her safety attending school two miles from his home in an affluent suburban community in the US. His day job includes being a leader for the quality program in his hospital, where he searches the actual data for root and contributing causes to problems; he wonders why this country cannot do the same for gun violence. Arizona Star columnist Dave Fitzsimmons expresses similar fears for his children.
This country could, but so far it shows no sign of doing so. Gibson quotes the author Chester Himes commenting on the lynching of 14-year old Emmett Till in 1955 that “The real horror comes when your dead brain must face the fact that we as a nation don’t want it to stop.” Himes was talking about lynching, but it is clear that the same can be said today, more than 60 years later, about school shootings. We don’t want it to stop. Because, if we did, we would do something about it.
Of course, we do, most of us. Various surveys, asking the question in different ways, find different percentages, but always large majorities, of Americans want stricter gun laws, often up to 90%. Even most people who are members of the NRA and/or are registered Republicans want limitations on who can buy guns based on mental illness and other criteria (always “me, and people like me”, but not the people like you) and some kinds of guns or gun modifiers (like “bump stocks”, used by the Las Vegas shooter to turn his AR-15 semi-automatic – and by the way almost all these shootings involve AR-15s) and armor-piercing bullets. No, the “we” who don’t want to stop it, in this case is, beyond a small minority of zealots, the even smaller minority of those who are politicians, in Congress, in the Executive Branch, and in our statehouses.
Why would they do this? Or, rather, not do anything about gun violence? Well, there is a small minority of this small minority who are, themselves, zealots whose interpretation of the Second Amendment is such that our dead children are just collateral damage in pursuit of the higher cause of unrestricted gun ownership. But, for most, opposition to even the most rational restrictions is tied to money, specifically to money from the NRA. A staffer for Jimmy Kimmel, Bess Kalb, looked at how much each of the Senators and Congresspeople tweeting their sadness and condolences took from the NRA, noting that “In the 2015-2016 election cycle alone, GOP candidates took $17,385,437 from the NRA,” (quoting a tweet from Republican National Convention chairwoman Ronna Romney McDaniel), and that “This is NOT counting the $21 million given to President Trump.” Another article documents the individual contributions, led by $4.4 million to Thom Tillis (R-NC, or, excuse me, R-NRA).

These legislators, and sadly even the President, when not crying their hypocritical crocodile tears and then voting with the NRA to kill any sort of gun reform, talk instead about the need to focus on mental health. This, by the way, is a good idea; the mental health system in this country is terrible; insurance companies cover it inadequately, those who are not insured and need public facilities find them cut back yearly, and there is no shortage of news stories focusing on a poor mentally-ill person pushed out of a treatment facility found wandering the street, or worse. Our jails and prisons have become our new mental hospitals, documented, for example, in this comprehensive Atlantic article from 2015, “America’s largest mental hospital is a jail”. However, it is not the diagnosed mentally ill who commit these murders and mass murders. Most such murderers do not have a diagnosis, although they probably suffer from “anger management disorder” (not in the current Diagnostic and Statistical Manual for Mental Disorders (DSM-IV),but “intermittent explosive disorder“ will be in DSM-V). This is important because it is the angry who commit these murders. An article in Slate by Laura L. Hayes from 2014,”How to Stop Violence; Mentally ill people aren’t killers. Angry people are”, contains this persuasive data:
80 to 90 percent of murderers had prior police records, in contrast to 15 percent of American adults overall. In a study of domestic murderers, 46 percent of the perpetrators had had a restraining order against them at some time. Family murders are preceded by prior domestic violence more than 90 percent of the time.
Hayes concludes that “Violent crimes are committed by people who lack the skills to modulate anger, express it constructively, and move beyond it.” Sadly, this also describes many of the most virulent opponents of gun control.
If anything could be even more sad than the fact that the mass killing of our children is tacitly endorsed through inaction by our political leaders, it is that it is only one face of the epidemic that is child mortality in the US. This January, Ashish P. Thrakar and colleagues published “Child Mortality In The US and 19 OECD Comparator Nations: A 50-Year Time-Trend Analysis” in the journal Health Affairs. The picture was bleak. The first sentence of their Abstract summarizes their findings: “The United States has poorer child health outcomes than other wealthy nations despite greater per capita spending on health care for children.” Guns are part of it, and the “social determinants of health”, a sanitized way of saying that in the richest country in the world there are millions of children with inadequate food, housing, warmth, safety, healthcare, and educational opportunities, are ultimately the other causes. We may be the richest country in the world, but we are also the most unequal in the developed world, and the increases in the wealth of the top 0.1% does not “trickle down” to those in need.
Indeed, even the outrageous and disproportionate child mortality rates in this country are not the whole story. As I have noted before (Rising white midlife mortality: what are the real causes and solutions?, November 14, 2015; Tom Petty, the opioid epidemic and changing structural inequities in the US, January 23, 2018) the US is the only wealthy country in which mortality rates are rising, a completely shocking finding since, of course, it didn’t used to be true. And this rising mortality is driven by the white non-Hispanic population (although, it must continue to be said, that the absolute mortality rate of minorities, and especially African-Americans, still exceeds that of whites), and more particularly, poor whites.

In a terrific effort to try to explain to the international community what is happening in the US, Steven Woolf recently wrote an editorial for the BMJ, Failing Health of the United States. He notes the causes of the increases in mortality (more than opioids, more than guns, although these are major contributors), provides data, and proposes solutions. “In theory,” he says,
…policy makers would promote education, boost support for children and families, increase wages and economic opportunity for the working class, invest in distressed communities, and strengthen healthcare and behavioral health systems.
Politicians need to address these issues, and they need to be made to do so. By us, the people they are supposed to work for, not the huge money contributors like the NRA. But we can only do this if we stay angry, and stay organized. We cannot heed calls to “not talk about this now” while families are grieving, because it will, based on history, not be very long before it happens again.
It is our job and we must take it on. 

Guidelines, bias, and your health

One of the challenges in educating health-care professionals is the massive – and growing — amount of information about diseases, diagnosis, and especially treatments that are available. This is not only an issue for students and residents, but for continuing education; if a doctor or nurse or pharmacist knows only what they learned in school, it will be outdated in a very few years. Thus, the health professions have committed to the concept of “life-long learning”, but how this happens, and how effective and accurate it is, is the challenge.
With the development of the Internet, information is extraordinarily widely shared very quickly. It makes information available not only to health professionals, but to everyone; in the “old days”, perhaps someone with symptoms, or a new diagnosis, might go to the library, or find an outdated copy of Morris Fishbein’s “Handy Home Medical Encyclopedia” or a similar book. Now they go to the internet and are overwhelmed with information. The problem is that this information may be correct, partially correct, or wrong; it may be complete, incomplete, or valueless. There is a difference between information and truth, and certainly between information and wisdom. Wisdom, and truth, require information, but much  of the information is chaff or worse.
If keeping up with information and sifting through it to discover what is true, relevant, and important is hard for a person who wants to find out about their one condition, it is truly daunting for health professionals who need to keep up on many. There are so many drugs! And new ones all the time! And they are all better, improved, more effective (and certainly more expensive!) than the old ones. Until, of course, we find out that they are not. Or, worse, dangerous. Sometimes so dangerous that they have to be pulled from the market.
In his Op-Ed piece in the New York Times on June 12, 2013, “Healing the overwhelmed physician”, Dr. Jerry Avorn of Harvard Medical School calls this the “Stendhal syndrome”, after the French author who, on an 1817 visit to Florence, “…was seized by palpitations, dizziness and a feeling of being overwhelmed by the abundance of great art surrounding him”; the over-abundance of information, too much to grasp, integrate, and categorize, not to mention utilize effectively.  How can doctors and other health professionals get through this to “truth”? To be able to most effectively help, and, primum non nocere,  not hurt you?
One traditional method, adopted by our friends in the drug industry, has been “detailing”. Pharmaceutical representatives (called, regardless of gender, “detailmen”) fanned out, visiting physicians, giving out free samples of their wares as well as food and pens and sticky-note pads and clocks and calendars and little scale models of whatever organ their drug worked on, along with information about the drug. The information might have been accurate and complete, but often was skewed, and almost always was research funded by the manufacturer. The detailpersons were easily identifiable, even when not pushing a cart full of pizza for “grand rounds” because they were all good-looking and so much more well-dressed than run of the mill health care workers. What a great system! You get information about new drugs, direct from the person selling them, and little scale models of the urinary system and donuts too! Isn’t that how we all hoped our doctors were keeping up with the field of caring for our health?
Well, ethics rules have limited the ubiquity of detailpersons, and free gifts, and even samples; the “educational cruises” to the Caribbean just for being a high-utilizer of a company’s drugs are all but gone. A resident asking a drug rep to fly their whole residency class to Las Vegas for graduation is so last millennium! But an incredibly wealthy industry like the pharmaceutical industry will not give up there. This is the real thrust of Avorn’s op-ed piece. He discusses the influence that these companies have on the development of “clinical guidelines” by groups of experts in a particular medical field.
Clinical guidelines can be really good and helpful. The information glut is real, sifting through all the data is almost impossible for all the conditions that exist, especially ones that are seen rarely by a particular practitioner. It makes sense that a group of experts in the field review all the evidence in that narrow area and make recommendations that we can count on as accurate and can utilize effectively. But we may be reaching a point where there are too many guidelines, often with conflicting recommendations. Avorn focuses on recent recommendations from the American Association of Clinical Endocrinologists (AACE) on caring for patients with diabetes:
The A.A.C.E.’s latest guidelines elevate many second- or third-line drugs to more prominent positions in the prescribing hierarchy, rivaling once uncontested go-to medications like metformin, an inexpensive generic. They also emphasize the riskiness of established treatments like insulin and glipizide, which now carry yellow warning labels in the A.A.C.E. summary. Several of the now promoted drugs are expensive newcomers that lack the track records of clinical effectiveness and safety held by the older, potentially displaced treatments. The changes were made, ostensibly, to give physicians more treatment choices for their patients. But there is also concern that they could have been influenced by another factor: the manufacturers of some of these new drugs financially supported the development of the guidelines, and many of the authors are paid consultants to some of those companies.”
Avorn goes on to cite previous examples of expert-generated and industry-sponsored guidelines that have led to overuse of drugs with very bad outcomes for patients. He also cites reliable sources of clinical guidelines, which are based solely on review of the evidence, not the opinions (possibly influenced by money) of experts, “…including the Institute of Medicine, the American College of Physicians and the Cochrane Collaboration, an international network of experts that evaluates clinical research.” He also refers to the practice of “academic detailing”, which he helped to develop[1] [2], in which academic physicians and pharmacists try to counter the impact of drug-industry detailpersons by going out to practicing physicians and presenting evidence-based recommendations.
There are at least two other sources of bias in addition to any direct influence exerted by drug company funding of research, guidelines development, and individual experts. One is the fact that many treatments, particularly when they involve procedures, can increase the income of the individual physicians doing them. Unfortunately, we have seen (and continue to see) the persistence of many procedures for which there is weak evidence overall or for as broad a population as it is being used on, presumably for this reason. The other, less overtly money-driven and thus more insidious, is that many experts are, almost by definition, specialists (well described in this context by the more pejorative “partialists”) who are focused on the impact of a treatment on “their” disease and may miss the potential for negative impact on the patient. An example may be very tight control of blood sugar in people with diabetes; it may improve the outcomes from diabetes, but if it also leads to potentially dangerous episodes of low blood sugar, it may not be a good idea.
Guidelines issued by different organizations also may be in conflict. An excellent example is mammographic screening for breast cancer, discussed in two outstanding “Viewpoint” articles in a recent JAMA. Michael Marmot addresses potential benefits and harms from different guidelines, focusing on UK recommendations[3], and Kachalia and Mello look at the differing US recommendations from the US Preventive Services Task Force (USPSTF), American Cancer Society (ACS), and American College of Radiology (ACR).[4]If a radiologist reads a mammogram as normal, but, following ACR guidelines recommends another in one year, while the clinician is following USPSTF guidelines for less frequent screening, does that place the clinician at increased legal risk? They argue at least for consistent guidelines to be utilized within a single institution.
Finally, there is the potential for unintended outcomes. One of the most reliable evidence-based sources of recommendations is the USPSTF. Its recommendations are based solely on review of the science, which has generated controversy before when those recommendations were unpopular with powerful groups (see mammography guidelines). Their reliability led them to be written into the health reform law, ACA, which mandates insurers pay for preventive services with an “A” or “B” recommendation from USPSTF. However, as articulately described by USPSTF members Steven Woolf and Doug Campos-Outcalt in another recent JAMA[5], this creates the unintended consequence of turning USPSTF into a group that decides whether companies and doctors will make money; you can imagine the lobbying by a company to try to prove that its product deserves a “B” rating!
You sure can imagine it. It is not what we need. Essentially, as long as potential for big profit exists in health care, for providers, drug companies, device manufacturers, insurers, and others, there will be plenty of opportunities — and actual occurrences – of this, not scientific evidence, guiding medical practice.
And I doubt that this is what you want for your health.



[1] Soumerai SB, Avorn J,  “Principles of educational outreach (‘academic detailing’) to improve clinical decision making.”, JAMA. 1990 Jan 26;263(4):549-56. PMID: 2104640
[2] Fischer MA, Avorn J, “Academic detailing can play a key role in assessing and implementing comparative effectiveness research findings,” Health Aff (Millwood). 2012 Oct;31(10):2206-12. doi: 10.1377/hlthaff.2012.0817.
[3] Marmot M, “Sorting through the arguments on breast screening” JAMA. 2013;309(24):2553-2554. doi:10.1001/jama.2013.6822
[4]Kachalia A, Mello MM, “Breast cancer screening: conflicting guidelines and medio-legal risk”, JAMA. 2013;309(24):2555-2556. doi:10.1001/jama.2013.7100
[5] Woolf SH, Campos-Outcalt D, “Severing the link between coverage policy and the US Preventive Services Task Force”, JAMA. 2013 May 8;309(18):1899-900. doi: 10.1001/jama.2013.3448. 

“Good enough for Government Work”: Quality, cost, and gaming the system, Part 1 (of 4 parts)

This is part one of the Charles Odegaard Lecture, delivered at the 27th National Conference on Primary Health Care Access, April 6, 2016
 
The dream of reason did not take power into account”.
–Paul Starr, “The Social Transformation of American Medicine”, 1982
 
In 2008, the British Healthcare Commission began an investigation into conditions at Stafford Hospital, run by the Mid-Staffordshire Health Trust.[1]The investigation was prompted by patient complaints and a higher-than-expected death rate, and it and subsequent[2]investigations uncovered a pattern of both poor quality care and cover-ups by those running the hospital. It became a major national scandal. In 2014, whistleblowers began to reveal the extent of problems in the Phoenix Veterans Administration system, with long delays for appointments, inadequate care, and even excess deaths. The investigation revealed enormous cuts in services, as well as efforts to cover up the problems, similar to those in Stafford. Moreover, it turned out that the problem was far more extensive across the VA than just Phoenix.
These two events are discussed by M. Gregg Bloche in his NEJM Perspective “Scandal as a Sentinel Event — Recognizing Hidden Cost–Quality Trade-offs[3]. The details of the two scandals differ, as do the health systems of the two countries in which they occurred, but there are disturbing similarities.
“As with the VA scandal,” Bloche writes, talking about Staffordshire, “politicians blamed individual perpetrators and one another, and the prevailing narrative highlighted lapses of character and culture…In both cases, performance standards often proved incompatible with resource constraints….The fakery was discovered, and perpetrators were punished. But the truth that trade-offs between quality and cost were embedded in budget constraints remained submerged.”
So, while more rigorous standards were being set for performance, budgets were being cut. These cuts made it difficult or impossible to meet those standards, and administrators in both systems covered up the problems. They lied about their compliance with the standards — and, not coincidentally, often got financial bonuses for doing so (or at least got to keep their jobs). In addition to the probably unnecessary deaths, outcomes were more generally poor care for all patients. In the British case, the excess deaths were pretty well documented, as were the stories of patients lying in urine and excrement, inadequate food, and unavailable nursing care. In the US, at the VA, proving excess deaths was more difficult, but excessively long waits, particularly for specialty services, may well have contributed to unnecessary or premature mortality, and falsifications by the administrators were very clear.
In both cases, heads rolled – local administrators, the head of the Mid-Staffordshire NHS Trust, and in the US eventually the head of the VA.  The politicians, in the US Congress and the British Parliament, who had been responsible for the funding cuts in the first place, took no responsibility and indeed used these scandals to act in a self-righteous manner, denouncing “those responsible”, while being clear that this did not include themselves. Nowhere in the discourse in the media are the budget constraints and cutbacks acknowledged as a major cause of the problem.
And, yet, the politicians were surely responsible, because it was the budget cuts that they imposed, along with the potential they built in to these systems for financial gain on the part of those directly tasked with running the operations, that led to these problems, certainly along with the collusion of the people directly in charge. The process has had two steps  – first, we are going to cut your funding and you are going to have to figure out how to cut in a way that doesn’t, at least obviously and in a manner that reflects on us, cut services. Second, we are going to tie rewards – institutional and personal (direct financial bonuses, or at least keeping your jobs) – to the degree that you can cut costs. We are also going, to a greater or lesser degree, “privatize” operations on the assumption that this will, with the motivation of profit, increase the efficiency (and lower the cost). And if we cannot privatize them, we will use “motivators” characteristic of private enterprise – again see financial bonuses. And now a right-wing group of Koch-funded consultants and legislators is creating a proposal to essentially privatize the VHA, covered by Suzanne Gordon,
The proposal they have crafted is an exercise in incoherence, denial, and magical thinking. he group believes that private sector hospitals would be willing and able to recreate VHA Centers of Excellence and other programs like the San Francisco VAHCS’s Center of Excellence in Epilepsy or Primary Care Education or Palo Alto’s polytrauma, blind or spinal cord injury rehabilitation programs. It also believes the private sector could fulfill the VHA’s research and teaching missions. As one San Francisco VAHCS researcher told me, “Can you see my eyes rolling?” 
It is of more than passing interest that both of these events occurred in government agencies that were established to provide necessary care to people. In Britain, the National Health Service, established in 1948 to expand upon the National Health Insurance program that had existed since prior to WW I, is enormously popular because it provides care to everyone. Let’s think about this for a minute. 1948 was soon after the war. Britain, as most of Europe (but not the US) was in shambles, its population of young men decimated, its economy and industrial capacity largely destroyed, its streets covered with rubble from the Blitz (think the street scenes of East London in Call the Midwife from over a decade later), and the last thing that they had was “extra money”.

But the National Health Service was established, not as largesse in a time of plenty, but as a way of meeting the needs of the British people. In the US, a different story unfolded; with its industrial capacity intact and the need to shift from war to consumer production, the demand for labor exceeded the number of workers. Prevented from increasing wages because of wage and price controls, large companies found offering health insurance (non-taxable) a significant inducement, and found common cause with labor unions who could then offer these benefits to their members; a win-win that led to the employer-based health system that has characterized the US since.

In Britain, the Mid-Staffordshire scandal broke under a Labor government, but the seeds were sown when the Conservatives were in control. Recognizing that the NHS was far too popular to be dismantled, the Tories, seeking to emulate the US, both cut funding and established “NHS Foundation Trusts”, like Mid-Staffordshire, which were in a sense semi-privatized and incented to save money by being offered an opportunity to keep some of the savings, which could be used both for reinvestment in the hospitals and health system and to bonus those in charge. In the US, our services to veterans have almost never (as documented by Bloche) kept up with our rhetoric about the heroism of the men and women who serve in our military, and the VA scandal was tightly linked to cuts in funding. Indeed, some of the “solutions” offered by the same Congressmen who were responsible for the cuts involved privatization; this is often proposed as a solution to not having enough money, and almost never works, at least if the goal is improving quality.
As Suzanne Gordon says in her piece on the growing efforts in Washington to privatize the VA:
‘In their document, the Strawmen [the group working on this] justify their position on total privatization by pointing to the fact that the VHA is having trouble hiring new recruits to fill many staff vacancies because of the “stigma” attached to working at the VHA.  They also argue that the current VHA workforce suffers from “poor morale” and a “culture of fear.” Of course, VHA management practices could be significantly improved.  But if there is now a “stigma” attached to working at the VHA, a “culture of fear” within it, or demoralization among its current employees, that is, in great part, due to the bashing conservatives have unleashed in the media and Congress.
 
But we’ll get back to that.
 
(to be continued)

 

Moving to Recovery By Design

The following is a guest post by Robert Bowman, MD, of the A.T. Still College of Osteopathic Medicine in Mesa, Arizona. He welcomes your comments and feedback.

Josh Freeman recently linked to the Charles Blow column in the NY Times, “These Children are our future” (June 14, 2013)  about the past, present, and likely future of the HS Graduating class of 2013 – and those missing from any high school graduation. We were both up into  the wee hours as I also reacted to this with the following:

A classic story taught in most introductory public health classes is of the person who finds the body floating in the river, and pulls it out. Then there are more, and he pulls them out. Then more and more and he gets friends. Then so many that the whole town gets involved, developing a highly efficient system for removing bodies from the river, moving them up and out to the graveyard. Until someone says: “Maybe we should go upstream, and try to find out what is causing all these people to die and fall into the river. And maybe do something about it.”

“Upstreamers”, then, are those who try to find out why the bodies are getting into the river as compared to those who are focused on addressing problems much later; often too late. Upstreamers recognize social determinant and other barriers that can shape outcomes. For the bottom 30 to 40% of Americans, the outcomes can be shaped substantially by various determinants and not by school, teacher, physician, nurse practitioner, etc. Most of the studies regularly promoted in major journals or reports fail to understand social determinants and patient situations.

Upstream thinking is broken in our nation. Nations with effective social systems have people serving on the front line for health and other social services, who stabilize and support the people of the nation, anticipate their needs, and translate these to national leaders. The role of national leaders is to listen to the people and their translators while acting in the best interest of the nation to make the entire nation more efficient and more effective. When the stabilizing front-liners can no longer support the leadership of a nation, chaos reigns – as we should understand from numerous current examples.

Our leaders are not listening to the upstreamer family physicians, teachers, public health, military, nurses, and front line public servants. Leaders need to listen to those who have the perspectives that can help to better understand normal Americans and those facing numerous dimensions of challenges. This perspective is often shaped because front liners tend to arise from lower and middle income and upper middle income Americans, rather than the top of the socioeconomic heap. Our top leaders, on the other hand, tend to come more from the exclusive sector, and such upbringing  makes it difficult to understand the daily lives of most Americans.
Falling Behind By Design

We are clearly falling behind as a nation. A greater proportion of or nation is falling behind in ways that make recovery more difficult. How we progress as a nation (or not) is about whether we can wake ourselves up to recognize the things that are required. Nations do not recover by economic development, defense, too much spending, or too little spending. Nations recover by investing in the earliest years of life. With progress made year to year or generation to generation, we can recover.

Few want to take responsibility for poor child well being, failures of investment in child development, numerous errors in the production and retention of important health care workforce, health costs that are too high for the outcomes, and other broken designs such as school funding mechanisms. It is easier to blame teachers or physicians rather than to make the investments that can make a difference. It is hard to see how these increasing costs and distractions prevent the investments that we need to make in our children – and our future.

Our education focus is downstream and works for those who do well without any intervention. Designs for school funding and standardized testing and high school and college focus do not work for most children left behind — almost a tautology. Investments focused downstream insure that school districts in communities with high property values have good outcomes, those with middle property value less, and that even the high performing children from lower property value school districts do less well than those in the bottom portions of the higher property value school districts. Advantages for the advantaged also may retard the needed development of the advantaged children, because they are never challenged by the majority of the population who, if offered the same advantages and opportunity, might spur real competition that pushes all of them further ahead. The result is the lack of social class mobility that worsens in our nation.

How Do Declining Opportunities for Most Americans Shape Lack of Health Access?


Resolution of health access has two multiplier factors – origin shared with the population in need of health access and family medicine choice. Frankly, as Rabinowitz[1] has demonstrated, the effect of origin to help distribute physicians is negated when rural origin candidates do not choose family medicine. This is because their practice location is dictated by their specialty rather than their origin. FM choice facilitates the influence of origin. Social determinants can greatly limit access to medical school, but FM choice is 2 to 5 times as potent a marker for rural choice than medical school training and origins. Only FM physicians, and family NP and Pas, have population-based distribution – the opposite of all other specialties which are more concentrated where health care workforce is concentrated already.

Access to health care is mostly limited by lack of front line health access family medicine. We have insufficient MD, DO, NP, and PA family practice positions supported, offered, and filled.  This is the failed health policy determinant. It fails even more when “flexible” potential sources of family providers can easily choose other specialties; this is seen in NP and PA training programs, which are adding both more specialties and more trainees in each specialty, as well as internal medicine training for physicians.

What I have learned in two decades about family physician origins confirms social determinants and social situations that shape the proportion of providers in family medicine. The same social determinants shape medical school admission and performance as a medical student. After all, those who take — and in particular do well on — the tests are more likely to be highest income, most urban, and children of professionals. The standard population for scoring for tests such as MCAT and board exams are the subjects that take the test. Those students whose language, culture, parents, or other origin factors are different will have different scores. Normal origins are associated with different scores because they are normal. Exclusive origin students have exclusive scores. Scores shape opportunity, type of medical school, and even subspecialty. A normal distribution of career choice types is different because it is normal. Normal origins, normal types of medical schools, normal distributions of health spending, and normal career choices such as FM are the recovery vehicles for health access. This is not what our national design dictates. Origins, training, health spending, and career choices favor the concentrated or exclusive.

FM docs arise at 1 per 100,000 people across various types of counties or types of populations. In the populations associated with lower income and other social determinants that have lesser opportunity, about 4 per 100,000 are admitted to medical school per class year (1970 county pop, AMA Masterfile with 90% birth origins). This is 25% family medicine result. In the populations of advantage, about 14 – 20 per 100,000 per class year are admitted. These are areas around DC or NYC or other major metro areas with the highest income, most urban locations with top concentrations of professionals.  When you map concentrations of physician origins it is the same as where physicists, engineers, research and development, colleges, and other concentrations of professionals are found. In these areas most associated with concentrations or combinations of concentrations of high-income professionals, about 14–20 per 100,000 become a physician – about 2 to 3 times higher than average. However, for these populations associated with such concentrations, there is still only 1 per 100,000 found in family medicine per class year. Only 1 in 14 to 1 in 20 enter family medicine (about 5 – 7%). Moreoer, this was data from 20 years ago, at the peak of FM choice. FM choice in all types of origins has declined since this time.

Access is more than FM docs. When I look at rural docs or docs for underserved locations and map them to their birth county, the same 1 per 100,000 applies. Higher proportions of FM doctors arise from locations associated with lower concentrations of people. When there are higher concentrations, the proportions of rural or underserved docs decline. Meanwhile the most subspecialized docs most dense areas (metropolitan) with higher and higher concentrations from origins associated with higher concentrations. A doctor with a sub-specialty such as gastroenterology is 6-8 times more likely to come from a county in the top tier of population concentration as compared to those with lowest quartile income or population density.

Only FM has equitable population based origins and the same 1 per 100,000 per class year distribution, or about 30 FM docs per 100,000, for the current past 30 years of FM graduates. FM will actually decline slightly with population growth as FM is locked at 90,000 due to just 3000 annual graduates dating since 1980.

 
Declining Middle Class and FM
Populations vary in higher education and medical school admission. In the lower income segments, few arise for admission at all. Carnevale[2]and the Century Foundation have demonstrated that only 3% from the bottom quartile were found in the top 146 colleges – the same ones that feed the same types of students to medical schools. About 74% arose from the top income quartile. In the US middle income populations are disappearing, groups that used to be able to access higher education and they also had reasonable FM probability and distribution probability. The highest income segments are lowest FM probability. For example, at the University of Nebraska Medical School, those whose hometown is Omaha and Lincoln and other metro areas have 2% family medicine while those from the rest of the state have 15 – 30% FM choice (4 years of data). Out of state and foreign born components have been increasing and are typically highest income, most urban, children of professionals.

Asian Indian choice of FM was 2% for the 1990s – the population segment most representative of highest income, most urban, children of professionals in census and in AAMC data. All such populations are 3 – 10 times more likely to gain medical school admission in the US compared to the average. Advantages of child well being from the start of life are evident.

It is not about artificial markers of race or ethnicity – it is about highest income, most urban, highest property value, and other characteristics associated with advantage (or concentrations). Those more normal and representative are falling behind of all races and ethnicities. The same is true in studies of college students. Asian and white populations are populations of advantage and as Barr[3] demonstrated at Stanford, for students who planned to go to medical school when they were freshmen, these students of advantage had 100 – 110% actually apply to medical school, while the rate for underrepresented minorities, even in a select school such as Stanford, was only 50% remaining to apply for medical school. Advantage involves concentrations or combinations of concentrations as compared to normal. Those left behind are no small segment of the United States. Most Americans do not have the concentrations or combinations of concentrations needed for better opportunity, better cost of living, better health care quality, or easy health access.

Recovering Health Care Cost, Quality, and Access

The states doing best in health care quality consistently have the best child well being, the best markers of middle class, and the least divisions between rich and poor. Health care quality, access, and to some degree costs are related to child well being as expressed birth to admission in a student or as expressed birth until health care encounter in a patient. Downstream focus, and ever more dollars invested at the high school or college downstream level will not help. Research that attempts to claim better quality without changing Upstream tends to represent distractions from real improvements.
We have models such as Southcentral Foundation in Alaska and Grand Junction that illustrate what can be done – and these are just a start. These are models that recovered from poor designs to optimal designs. As a nation we can also recover from poor designs, by designing well from the earliest months and years of life. Who would deprive a 2 year old or a 3 year old of an opportunity to rise above?

We cannot do better as a nation with so many left behind from the earliest ages by design.

Health professionals such as family physicians can do Upstream work at the community level.

We need similar professionals working entire careers like we do to improve child development.

We need primary care and public health nurses that were trained specifically for primary care and public health – and who remain in such careers.

How we invest in our children and work locally in teams will determine our future.


[1] Rabinowitz HK, Diamond JJ, Markham FW, Hazelwood CE. ”A program to increase the number of family physicians in rural and underserved areas: impact after 22 years.” JAMA. 1999 Jan 20;281(3):255-60.

[2] Anthony P. Carnevale and Stephen J. Rose, “Socio-economic Status, Race/Ethnicity, and Selective College
Admissions,” in Richard D. Kahlenberg, ed.,America’s Untapped Resource: Low-Income Students in Higher
Education. (New York: Century Foundation Press, 2004),
[3] Barr DA, Gonzalez ME, Wanat SF, “The leaky pipeline: factors associated with early decline in interest in premedical studies among underrepresented minority undergraduate students,” Acad Med. 2008 May;83(5):503-11. doi: 10.1097/ACM.0b013e31816bda16.

The screening pelvic examination: not annual, not ever

The Dispute Over Annual Pelvic Exams, an editorial in the New York Times July 3, 2014, highlights an issue about which I have written before, including Primary Care Contributes More than Money…., June 2, 2013 and President Bush’s stent: inappropriate screening and care for the rich, nothing for the poor, September 7, 2013. The Times has also had articles on the same subject, notably Questioning the pelvic exam, by Jane BrodyApril 29, 2013. The impetus was a recent guideline recommendation from the American College of Physicians (ACP), the specialty society for internal medicine physicians, that recommended against doing this test on an annual basis.[1]
 
This examination is not to be confused  with the Pap smear screening test for cervical cancer (although it regularly is). The Pap smear involves obtaining cells for cytological examination from the cervix by means of a spatula and/or small brush. The Pap smear is not perfect, but it is probably the best of the cancer screening tests available to us; the US Preventive Services Task Force (USPSTF) recommends them in women 21-65 years of age every 3 years. The pelvic exam, the part where the doctor puts her/his hands inside a woman and feels around, is often done in conjunction with the collection of the Pap, thus the basis for the confusion among many women. It is not recommended by USPSTF at all, at any frequency[2], but the American College of Obstetricians and Gynecologists (ACOG) recommends it on an annual basis.
 
I have long been a teacher of family medicine, and for many years have told my students and residents that there was no indication for this examination, at any frequency, for screening. I do this despite the fact that I know they are taught to do so on their OB-Gyn clerkships and rotations, and not because I believe I am more experienced in providing women’s reproductive health care than are the OB-Gyns. I can, however, read the evidence. By definition screening occurs in asymptomatic people; should a woman present with symptoms referable to the pelvic region (for example, pain, bleeding or discharge) the examination may be indicated. However, in the absence of symptoms it is a screening test, and should not be done because there is nothing that it can screen for. Years ago, an argument for doing it was screening for ovarian cancer, but many studies have demonstrated that it is not effective for this purpose, because by the time an ovarian cancer can be felt by the examiner, it is very far gone. These are essentially the same reasons that USPSTFand ACP recommend against it.
And, yet, ACOG, as noted, continues to recommend it (”Annual pelvic examination of patients 21 years of age or older is recommended by the College.”). The Times editorial notes that
…the gynecologists group argues that the “clinical experiences” of gynecologists, while not “evidence-based,” demonstrate that annual pelvic exams are useful in detecting problems like incontinence and sexual dysfunction and in establishing a dialogue with patients about a wide range of health issues.
 
This defense ranges from the indefensible (that it is not evidence based) to the absurd (that it is the way to find problems like incontinence and sexual dysfunction). If a woman has incontinence or sexual dysfunction, she knows it and the way to discover it is not by a pelvic exam, but by asking her. Clearly, the same is true of “establishing a dialogue with patients about a wide range of health issues.” I strongly doubt that most women would feel that having the doctor put his/her hands inside her vagina is the best way to open such a dialogue!
Why, then, would ACOG continue to recommend it? Long ago, when I was in medical school and residency, almost all OB-Gyns were men, and lack of empathy could be a possibility, but this is far from the case now or in recent decades. There is also the fact that such an examination, as a procedure, is reimbursed at a much higher rate than simply talking to a patient. This is true also for family physicians and other primary care providers (such as general internists, which explains the ACP’s interest in the issue), but for OB-Gyns it is a much greater percentage of their practice and thus their income. It is hard to break with tradition, to change the way that you have always been taught, and it is probably harder when there is a concrete disincentive (loss of income) for changing.
But women, and all people, need to be able to trust that their doctors are recommending and doing procedures, particularly invasive and uncomfortable procedures like the pelvic examination, only when they are indicated by the evidence. They need to have confidence that those physicians are not motivated, consciously or not, by a conflict of interest (e.g., financial gain). One step is for physicians to honestly look at the evidence, and avoid prioritizing their anecdotal experience over that evidence.
More profoundly, however, our society, our health care system, needs to eliminate perverse incentives for doing “more” even when it is not indicated, still less when it is also unpleasant for the patient (like a pelvic exam), and least of all when it is also dangerous (as other procedures are). Physicians should be paid for maintaining and increasing the health of their patients, not for “doing things”. If talking to the patient about “a wide range of health issues”, including but not limited to incontinence and sexual dysfunction, is the right way to find out about these problems, and if it takes a long time, then this is what needs to be reimbursed, not a procedure.
We are currently a long way from this sort of reimbursement, for spending the time needed to provide the best health care for a person. It is good that ACP has added its voice to recommending against screening pelvic examinations, but it is unsurprising that doctors do what they are paid to do. We need system change.


[1]Qaseem A, et al, “Screening Pelvic Examination in Adult Women: A Clinical Practice Guideline From the American College of Physicians”, Annals of Internal Medicine 2014;161(1):67-72. doi:10.7326/M14-0701.

 

Health system woes, or whose benefit should we be focusing on anyway?

It’s not easy to be a big healthcare system these days, what with all the new rules and incentives for spending less money and providing less unnecessary care. Medicare is leading this charge, with a variety of efforts, mostly recently contained in the 2015 Medicare Access and CHIP Reauthorization Act, fondly known as MACRA. This law extends previous efforts by Medicare to encourage consolidation and “shared savings” (spend less and you get to keep some) through the creation of “alternative payment models” (APMs), most of which emphasize increasing prospective payment (paying in advance for a basket of services to be delivered to a population) rather than fee-for-service (paying for each service provided).
In some ways, and particularly in some places, such large health systems are well-positioned for these changes; because they are big and provide the whole range of healthcare services (or most of it), and because many of them employ physicians, they should be able to take advantage of the efficiencies of scale, as well as understand their comprehensive costs. Many of them are; Kaiser, especially on the West Coast, and other early-adopters of this comprehensive model. Other payers are following Medicare’s lead, such as Blue Cross/Blue Shield of Massachusetts.
Still, it’s hard to change your business model. When your health system has been designed for decades to maximize income from fee-for-service by hiring lots of specialists who provide services (often procedures) that bring in a lot of money and supplying them with the expensive facilities and equipment to do them, it is scary to think that this entire investment could move from being a profit center to a cost center, where each of these procedures just chips off money already received in capitation rather than generating new revenue. Plus APMs create incentives to spend less overall, and you have spent decades gearing up to spend more – with the expectation and assumption that reimbursement would more than cover this investment.
And if you are not on a coast, but in the part of the country where such changes are happening more slowly, and in fact are mostly still in the future and you’re still making money the old way, it is a very scary and risky proposition to change your business model completely. The analogy of when it is time to put your second foot in a canoe is an apt one. The dock is a stable place to be, comfortable and familiar, but the canoe can take you off to new, and maybe wonderful, places. But there is only a limited amount of time that you can keep one foot on the dock and one in the canoe before the canoe moves off and you end up falling in the lake.
One of the big concerns confronting such health systems is the degree to which they should invest in expanding primary care capacity. The argument for doing so, put forward by most consultants and experts, is that it ensures a patient base loyal to their system and referring in to their hospital(s) and specialists and providing a more comprehensive ability to manage the spectrum of care. The other option is to “double down” and be providers of only high-end, high-cost (and hopefully high-profit) care, with the assumption that the community’s primary and secondary care providers will see you as a beacon for their complex problems and refer their patients to you. This latter position is especially popular among academic medical centers, hospitals tied to a medical school and a faculty practice group, and is much closer to the advice given by the University Health Consortium, the organization of such hospitals.
Along with this is the question of how income might be distributed. Most of the incentives in MACRA and prospective payment are for primary care; in addition to direct reimbursements for primary care providers, the shared savings come from a higher percent of conditions being managed by primary care and not subspecialists, fewer hospitalizations resulting from greater continuity of care, and fewer referrals for imaging (x-rays and the like) of questionable necessity but easy availability (because the capacity for doing them has been overbuilt). Kocher and Chigurupati discuss these issues in their July 14 piece in the New England Journal of Medicine, “The Coming Battle over Shared Savings — Primary Care: Physicians versus Specialists”.[1]The main point of the piece is how specialty physicians will respond to their incomes decreasing – they suggest the options are defensive (fight it and keep doing what they are doing) or offensive (sell themselves as more able to contain costs especially for certain disease conditions). Of course, what works for some specialists may harm others; if, say, a pulmonologist caring for chronic obstructive lung disease is very efficient and their patients need less imaging and fewer admissions, it can hurt others.
The average American is not going to have great sympathy for loss of income for such specialists. The authors cite the mean income for primary care doctors as $195,000, about 4 times the average US household income, and average for specialists $284,000, significantly more but deceptive in that many specialist make 2, 3, or more times that. Thus a $35,000 reduction in income, which is what the authors use in their example, is likely to mostly concern these doctors. The authors also note that primary care physicians “…account directly for a small percentage of health care costs. Yet they substantially influence the total cost of care through referrals and directing of their patients’ subsequent care.” They are, or could be, cost effective, provided that there is not pressure from the system to increase referrals – something that has usually been the norm, and even touted by primary care physician groups who talk about “downstream revenue” generated.
Of course, nowhere in these discussions is the question of what is best for the health of the American people. Implicitly, MACRA and the ACA before it (with its creation of accountable care organizations or ACOs), are intended to increase both access to care and its quality (two legs of the “triple aim”), but arguably have been put forward by both the federal government (Medicare) and adopted by other insurers to achieve the third leg – lower cost. And for insurers, including Medicare, the concern is lower cost to them. The issues addressed heretofore in this piece and by Kocher and Chigurupati and by consultants such as the Advisory Board and organizations like UHS, are how healthcare providers (healthcare systems, academic and otherwise, physicians and other individual providers) can most effectively respond to keep from losing money, from having the cost savings for insurers come at a big cost to them.
The health of the people should be the measure. And it needs to be the health of all the people, the poorest and sickest and most vulnerable and most easily left off, not just the high-yield, high-profit generally healthy, well-insured person who needs a single procedure and has no complicating conditions. Indirect incentives that seek to modify behavior by not demanding that all necessary health needs be provided to all people and no unnecessary care be provided to anyone are all bound to fail. Societies are, or should be judged, not by how they care for their most privileged but by how they care for their most needy (see the FDR epigram at the top right of this page).
And nowhere is this more true than when it comes to the people’s health.



[1] Kocher R, Chigurupati A, The Coming Battle over Shared Savings — Primary Care Physicians versus Specialists, NEJM 375(2):104-106, July 14, 2016

Beyond Flexner 2016: Medical schools still need to up their social mission

The “Beyond Flexner 2016”Conference was held in Miami September 19-21, 2016. It was the third in this series of conferences, originally stimulated by the 2010 Annals of Internal Medicine article “The social mission of medical education: ranking the schools”[1]. The first conference, held in Tulsa in 2012, featured the authors of the article and leaders from many “community-based” medical schools founded in 2 rounds of medical school expansion, the 1970s and the 2000s, discussing their real or proposed innovations (Beyond Flexner: Taking the Social Mission of Medical Schools to the next level, June 1, 2012). The second, held in Albuquerque in 2015, had major growth in attendance, and a group of national speakers who powerfully addressed the failures of both medical schools and our medical system to address the health needs of the American people, especially through (lack of) diversity in our health care workforce, equity (especially racial) in the care provided, and the inadequate numbers of primary care doctors being produced (Beyond Flexner: It is time to stop shoring up the bridge and figure out how to cross the river!, April 7, 2015). The metaphor for that blog’s title came from a talk by Don Berwick, in which he compared the US health system to the sturdily-built Choluteca Bridge in Honduras that withstood Hurricane Mitch only to be useless because the hurricane moved the river. (Such a great picture I’m posting it again here!)
The Miami conference, again sponsored by the Josiah Macy, Jr. Foundation along with Florida International University, was very good, although it had some disappointing aspects, notably the attendance, about 350, which was a little less than that in Albuquerque. The speakers were again excellent, with several standouts:  Mona Hanna-Attisha, the pediatrician who exposed the Flint lead poisoning crisis, gave a powerful talk in which she observed that despite being in Michigan, the “mitten state” surrounded by the largest collection of fresh water in the world, Flint’s water even today is still not safe. Robert H. Brook, of the RAND Corporation and UCLA gave a talk where he challenged the “rights” of medical schools, suggesting that hospitals (especially academic medical centers, AHCs) that do not care for their fair share of Medicaid and uninsured patients should not be allowed to have residency training programs, and that, more than allowing community service to count toward promotion and tenure, we should not allow anyone to be promoted without community service. Julio Frenk, the President of the University of Miami, a public health physician who served as Secretary of Health in Mexico, spoke about the need for building social capital that did not just “bond” communities but created “bridges” between them. He also noted that education had to move from the “informative” (providing the knowledge to become a professional) to the “formative” (creating the character and roles that define a professional) to the “transformative”, where professionals could truly create change both in their professions and in society.
One of the new events was the presentation of the First Annual Josiah Macy, Jr. Foundation Awards for Social Mission in Medical Education. The Institutional Award went to Morehouse School of Medicine, the Individual Award to Thomas Curtin, MD of Massachusetts and a leader in establishing Teaching Health Centers, and the program award to the University of Florida for its “Putting Families First” interprofessional education program. The highlight was the presentation of the Lifetime Achievement Award to H. Jack Geiger, whose achievements, from establishing the first Community Health Centers in the US, Physicians for Social Responsibility, Physicians for Human Rights, to serving as Dean of the Sophie Davis School of Biomedical Sciences at CCNY, are enough for several such lifetime awards. Dr. Geiger, who spoke eloquently at the 2015 conference, again addressed the group. He is nearly blind but as powerful and articulate a speaker as ever; he noted that “I have lost most of my eyesight, but it turns out you don’t need good eyesight to hang on to a vision!”
In my 2012 blog on the Tulsa Conference, I noted 4 areas I felt were important for focus, and reiterated them writing about the 2015 Albuquerque Conference. They were:
·         Diversity: How does the school produce a health workforce that looks more like American by enrolling, and supporting, a group of students that is truly diverse in ethnicity, gender, socioeconomic status, and geographic origin?
·         Social Determinants of Health: How does the school teach about and train students in, and carry out programs aimed at addressing, the social determinants of health? How does its curriculum and work invert that of the traditional medical school, which focused most on tertiary hospital-care, and emphasize instead ambulatory  primary care, community based interventions, and interventions on the most important health determinants including housing, safety, education, food, and warmth?
·         Disparities: How does the school, through its programs of education and community intervention, and its research agenda and practices, work to reduce disparities in health care and health among populations?
·         Community Engagement: How does the school identify the community(ies) it serves and how does it involve them in determining the location of training, kinds of programs it carries out, and in identifying the questions that need to be answered by research?
There was more emphasis on interprofessional diversity at this conference, with panels including two national nursing leaders (Divina Grossman and Randy Rausch), and a panel including a community (and FQHC) based Dental School Dean (Jack Dillenberg). There was great ethnic and racial diversity in the speakers and moderators, but somewhat less emphasis on diversity in the content of the talks than in 2015. Primary care was still emphasized, but I remain concerned that the conference still features relatively small programs in medical or health professions schools aimed at increasing diversity, primary care, and community engagement. This is, of course, because most such programs are small within their AHCs, and nowhere near as important as the provision of tertiary and quaternary medical care and obtaining NIH research grants. Until these can be scaled up, until producing a majority of graduates entering primary care, enrolling and graduate underrepresented minority and low-income students at leastin proportion to their percentages in the population, and working in the community becomes the highest priority of an AHC, the movement is stalled.
It is sometimes tempting to think that AHCs are incorrigible, that they are set in their ways – and in the way that they are financed – and that achieving the goals I have outlined above, or even more modest improvements in social mission – are not going to happen, at least any time soon. The Association of American Medical Colleges (AAMC) supports in word – and to a limited extent in deed – the goals of diversity and community engagement, but not enough to change the core focus of their members. Indeed, tellingly, they continue to call for increasing the number of residency positions, but not on targeting them to primary care, as does the American Academy of Family Physicians (AAFP). The largest specialty in medicine, Internal Medicine, opposes AAFP’s proposal to fund only “first certification” residencypositions, as this would not fund their subspecialty fellowships.[2]Thus, they put self-interest (having funded fellows in their subspecialties) ahead of the need for America to have more primary care doctors.
Yes, it can get frustrating to work with medical schools and their entrenched anti-social values. But this is where the medical students are, where they are trained, and where they get their ideas of what might be the most appropriate specialties to enter and what th

e professional role of a physician is – e.g., working in the community or not. They need both individual and institutional role models.

So the need to work for a social mission for medical – and health professions – education is still an important goal.



[1] Mullan F, Chen C, Petterson S, Kolsky G, Spagnola M,“The social mission of medical education: ranking the schools”, Ann Int Med 15 June 2010, Vol 152, No. 12,
[2]Butkus R, et al. Ann Intern Med. 2016;doi:10.7326/M15-2917.

High spending, poor outcomes: the health results of inequality in the US

A recent article in JAMA, “Health care spending in the United States and other high-income countries”, by Irene Papanicolas, Liana Woskie, and Ashish Jha, is the latest in the almost continuous series of articles on this topic that have been appearing for decades. The dramatic difference between how much we in the US spend (per this paper, the US spends 17.8% of GDP on “health care” compared to 9.6-124% for the other 10 highest-income countries—United Kingdom, Canada, Germany, Australia, Japan, Sweden, France, the Netherlands, Switzerland, and Denmark) and our health outcomes (e.g., lowest life expectancy and highest infant mortality) continues to be striking. This information appears regularly, in one form or another, from reliable sources such as the Commonwealth Fund, the Kaiser Family Foundation and its Kaiser Health News. It is the subject of many academic studies and books by experts, such as “An American Sickness: How Healthcare Became Big Business and How You Can Take It Back”, the 2017 book by Elisabeth Rosenthal, now editor of KHN. I have addressed this topic extensively both in my book, “Health, Medicine, and Justice: Designing a fair and equitable healthcare system” (Copernicus Healthcare, 2015) and in many of my blogs (e.g., US Health Rankings remain low and #Trumpcare will make them worse!, June 18, 2017).
So what is new in this current study? Why is it important? As best as I can tell, it is the spin being put on it by a variety of commentators, and in articles that point out those aspects that seem to be different from what has been published before, such as in “Why Is U.S. Health Care So Expensive? Some of the Reasons You’ve Heard Turn Out to Be Myths” by Margot Sanger-Katz in the New York Times March 13, 2018. The original title of that article, preserved in the hyperlink URL, was “United States healthcare resembles rest of world”, an amazingly hard claim to make given the data that the study itself presents. The Sanger-Katz piece manages to do this by both cherry-picking some data points, including that “…the United States sends people to the hospital less often, it has a smaller share of specialist physicians, and it gives people about the same number of hospitalizations and doctors’ visits… while its spending on social services outside of health care, like housing and education, looked fairly typical.” Maybe, but the important findings, even mentioned in the Times article, are not suggested by the headline, such as “The nation did rank near the top in its use of certain medical services, including expensive imaging tests and specific surgical procedures, like knee replacements and C-sections.”
The article in JAMA is accompanied by four editorial commentaries, taking different approaches; they are well and accurately analyzed by Don McCanne in the “Quote of the Day” piece he wrote on it. The most important is that by Howard Bauchner and Phil B. Fontanarosa, “Health Care Spending in the United States Compared With 10 Other High-Income Countries: What Uwe Reinhardt Might Have Said” (JAMA. 2018;319(10):990-992. doi:10.1001/jama.2018.1879, full text requires subscription). Reinhardt died a few months ago, but the authors do an excellent job of pointing out the important issues that he had already called attention to in previous articles, and would likely emphasize regarding this one.
Importantly, the article by Sanger-Katz goes on to say
There were two areas where the United States really was quite different: We pay substantially higher prices for medical services, including hospitalization, doctors’ visits and prescription drugs. And our complex payment system causes us to spend far more on administrative costs. The United States also has a higher rate of poverty and more obesity than any of the other countries, possible contributors to lower life expectancy that may not be explained by differences in health care delivery systems.
Let us look separately at these two, higher prices and high administrative costs, and high rates of poverty and obesity. Higher prices and higher administrative costs are, shock, a major reason that our medical care costs so much! The higher administrative costs, which the study estimates at 8% compared to 1-3% for other countries, are a huge driver; so are prescription drug expenses, $1443 per capita in the US vs a range of $466 to $939 in the other countries. What all this is about is profit.It is the elephant in the room in all these discussions. In the US, “healthcare” spending includes the enormous profits made by insurance companies, pharmaceutical companies, device makers, and providers (especially hospitals and health systems, as well as some very expensive specialists). This is money being taken out of the system, and is not about providing medical care, not to mention “health” care or certainly “health”. And while the study shows that US physicians (even primary care physicians, although this is very variable country to country) make more, this important graphic, recently updated, shows how much of this cost is related to the increase in the number of “administrative” personnel compared to doctors in the US over the last few decades. I first saw this graph in about 1995, and while the relative increase was huge

it is dwarfed by the phenomenal increase since then, as shown in the full graphic:

(Note that after the ACA went into effect, the uptick was even steeper.)
The other point identified by Sanger-Katz is that the US has a “higher rate of poverty and more obesity than any of the other countries”. These go hand in hand to some degree (the easy and cheap availability of calorie-dense low nutrition foods to poor people), but both are about blaming the victims. The higher rate of poverty is most important. The damning fact is that the US tolerates this and does not have, like other rich countries, social service programs in place to both decrease the rate of poverty and to mitigate its most malignant effects on health such as lack of food, housing, warmth and education. And, of course, health care, which is available either free or at prices people at different income levels can afford (much less for poor people) in those other nations. The US is very unequal economically; the growth in wealth has been so disproportionately to the top <0.1% that the three richest Americans now have as much wealth as the bottom half of our population. Our inequality-adjusted Human Development Index (HDI) is lower than most of the wealthiest nations of the world (#19).
Arguing that the fault in our cost and quality of healthcare is the result of higher poverty levels (and for the record, I don’t think that this is what either the study’s authors or Sanger-Katz is doing) is somewhat parallel to saying we have worse health because of our ethnic and racial diversity (which has been done). The important 2015 Case and Deaton study, which I have previously discussed (Rising white midlife mortality: what are the real causes and solutions?, November 14, 2015), showed increasing mortality for poor white non-Hispanic people. This was shocking, but it would be shocking even if it included Hispanics, or Blacks, or Native Americans. There is an old joke about the person who murders his parents and pleads for mercy because he is an orphan; this is pretty analogous to the issue of poverty and health.
Bauchner and Fontanarosa note that Uwe Reinhardt was very critical of insurance companies for having, on top of nearly 3% profit, 18% “operating costs” (only 79% was spent on actual health care) that included, among other things, “…marketing, determining eligibility, utilization controls (e.g., prior authorization of particular procedures), claims processing, and negotiating fees with each and every physician, hospital, and other health care workers and facilities. These operating costs are about twice as high as are the overhead costs of insurers in simpler health insurance systems in other countries.”
To say we have worse health status because we have more poor people is an indicting tautology; we should identify and address the causes of poor health which are mostly “upstream”, the social determinants, and very tied to poverty. Our healthcare dollars should be spent on delivering healthcare and not profits; our overall dollars should be spent on decreasing the impact of the tremendous economic and social inequities that exist in the US.
This is the way to both a more healthy and more just society.

“Inconvenient truth”, science, politics and USPSTF

There are a lot of things that we can expect to be different in a Trump administration, not only than in the Obama administration but even compared to that of G.W. Bush (my previous gold standard for irrational and right-wing policies). Many of these are important, and dangerous, but are arguably political, such as the change in our relationships with other countries (Russia, China, Europe, Israel). However disastrous these policies will be for people in the world (say, Syria) and even possibly destroy the world (nuclear weapons), they proceed from a different political perspective. Also arguably political will be the domestic changes, in the rights of LGBT citizens (such as marriage, use of restrooms), and access to reproductive health services for women, not only abortion but even contraception. The impact on people will be horrific, but it derives from a different perspective (admittedly one that completely devalues huge numbers of people; majorities in the case of women and non-wealthy people).
There will be other changes, however, that proceed from a rejection of science, or of what Al Gore calls “inconvenient truth”. Clearly the biggest one is the one that Mr. Gore was speaking of, global warming, because this will eventually destroy the planet. Maybe later, as we have already been so slow in implementing limits on warming. Maybe sooner, if his climate change deniers have their way. The title of Mr. Gore’s film has several meanings; it is “inconvenient” for all of us to try to find ways to use fossil fuels less rapaciously, but it is a financial issue for others. I am not talking about the coal miners who will lose their jobs; that is going to happen anyway. I am talking about the Captains of Industry, who, unlike the miners, will never be anywhere close to poor but have the possibility of making fewer billions if we seriously address global warming. Oh, the horror!
While of course the destruction of the environment is a health issue, there are also more prosaic health results from those who will try to make policies, or pass legislation, that benefits themselves or their friends and contributors at the expense of truth. Certainly we have seen this regarding reproductive health for years, especially at the state level, where laws restricting women’s access to abortion (targeted regulation of abortion providers, or TRAP, laws) have been based on what might be generously called phony science, or, more correctly, lies. These have included fetal pain syndrome, need for facilities appropriate for major surgery, need for admitting privileges for doctors doing abortions, excessive waiting periods,  and other made-up justifications for doing what legislators really wanted to do – restrict access to abortion. In Florida, a law was passed forbidding doctors from asking their patients if they had a gun in the home, meaning they couldn’t even have a discussion about how to keep them safe from their children accessing them.
So now we have the probability that Congress will be restructuring the membership of the US Preventive Services Task Force (USPSTF) to include more specialists on a body largely made up of primary care doctors and epidemiologists. The goal of the USPSTF is to dispassionately and objectively evaluate the evidence for the effectiveness of tests and procedures aimed at preventing disease. It gives ratings in easy to understand letters (A,B,C,D,I ) that are not based upon the opinions of the task force members but on the actual data. Unfortunately, this doesn’t always make providers happy; if you provide a service (say, mammography for breast cancer screening) on which you make money, then a recommendation that says it doesn’t need to be done quite so often hits you where it hurts – in the pocketbook. So you might come out against it. And while advocacy groups may not have the same direct financial interest (although if you are such an advocacy group, contributions are usually closely related to how serious how many people think a problem is), it may challenge your long-held beliefs. And then, if you find some doctors who agree with you (for example, those whose income may be decreased) you are more confident you were right.
But the goals of USPSTF recommendations is to synthesize the existing data and base their recommendations on that, not to reach “compromise” between those who want something done more (because they are “true believers” and/or have a financial stake in it) and those who believe it is unnecessary cost with little or no benefit and potential risk. This is why it is not necessary to include specialists on these panels because of their “expertise”. Other scientists can interpret the data accurately; a panel reviewing the data on, say, the frequency with which mammography should be performed in a particular population does not need mammography radiologists and breast surgeons to understand the research. This is not to say that such specialists are inherently biased and shouldn’t be on USPSTF; they could be as objectively good scientists as others. But it is to say that the reason being put forward for them being added to the panel – that they are ‘experts’ in the topic – is wrong. They should not bring their experiences and expertise to ‘balance’ the data. They should be guided by it.
It is not necessarily true that expert specialists are purposely obtuse, that they will advocate for recommendations that will make them more money. It is also true that their perspective is skewed by the populations that they see. Specialists see people with a disease, which is a selected population. Screening is, by definition, testing people who are asymptomatic and are statistically unlikely to have the disease. Therefore different standards are applied for screening asymptomatic people (say, all adult women between 50-75 by mammography) and for following up people previously diagnosed with breasts cancer, or those who are at higher risk (defined as a first-degree relative, mother or sister, with breast cancer, not a great-aunt). And, of course, doctors are not necessarily above advocating for laws to keep their incomes up. When, about 20 years ago, the federal Agency for Health Research and Quality (AHRQ) recommended against a specific type of spine surgery because it didn’t help, was risky, and cost a lot, groups of spine surgeons tried to get that agency defunded! Oh, yes, and AHRQ continues to be threatened with funding cuts because special interest groups don’t like their findings!  With the ACA requiring insurers pay for any USPSTF recommendation with an “A” or “B” rating, the political pressure is on to get such recommendations, whether the data supports them or not. On the positive side, the American Academy of Family Physicians (AAFP) has come out against such stacking of the USPSTF.
Once, when I lived in a good-sized condominium, I was one of the few families with children, and it seemed like they and their friends were often harassed for violation of (sometimes) condo rules and (more often) an individual’s belief of what should be a rule. Even the rules, however, were often, in my opinion, unreasonable; I thought the condo association rules should protect our investment and our safety, but should not be just anything 51% of the owners wanted. On the positive side, while they may have inconvenienced me and my family, they did not try to overrule natural law or science. The same cannot be said for current federal, state, and local efforts to make a law about anything they want to be true. They cannot make global warming disappear by a law, but they can make it illegal! And they can violate the rights and human dignity of our people. And stack federal agencies with anti-science people or at least turn what should be scientifically-driven decisions into a political negotiation.

This is going to be a long battle. Those with money and power are entitled and feel that it is their right to stack the deck. Happy New Year!

The State of US Health: improved over 20 years, but not nearly enough

An enormous, and enormously important, study was recently published online-ahead-of-print in JAMA describing the state of health in the US and comparing it that in other 33 “developed” countries in the Organization for Economic Cooperation and Development (OECD). “The State of US Health, 1990-2010: Burden of Diseases, Injuries, and Risk Factors[1]was written by the members of the US Burden of Disease Collaboration, an enormous group of population-health scholars from institutions across the country and a few from other parts of the world. The methods used are incredibly complex; indeed editorialist and President of the Institute of Medicine (IOM) Harvey V. Fineberg, MD PhD (“The State of Health in the United States”)[2]calls it “…an arcane and complex process, and despite the authors’ best efforts to explain their methods and make data available, few readers will fully understand how the results are derived.” Nonetheless, the findings are incredibly important.
Here are the main results:
Since 1990, the health status of the US has improved in most areas.
·         Average life expectancy has increased, from 75.2 to 78.2 years;
·         Healthy life expectancy (HALE) has increased, from 65.8 to 68.1 years;
These are good things; that is, they are moving in the right direction. However, they are moving in the right direction more slowly than in the other OECD countries, so that, since 1990, the US rank for life expectancy (at birth) has dropped from 20th to 27th among these 34 countries, and the HALE has dropped from 14th to 26th!
A few more terms, not that hard to understand: Life expectancy is decreased by the years of life lost through premature (age-standardized) death due to disease or injury (YLL). The difference between absolute life expectancy and HALE is the number of years lived with disability (YLD). The sum of YLL and YLD is expressed as disability-adjusted life years (DALY), kind of the complement of HALE. That is, the lower the DALY, the fewer years of life have been either lost to premature death or lived with disability. From 1990, the US rank among the OECD countries has dropped in all these areas:
·         From 18th to 27th in age-standardized death rate;
·         From 23rd to 28th in YLL;
·         From 5th to 6th in age-standardized YLD.
These are not good things. The table indicates, for each of the 34 countries, the rank for YLL for each of 25 conditions: green means significantly better than the mean, yellow about the mean, and red significantly worse. The US is green in only one (stroke), and is red in 15!
The other important thing done by the study’s authors was to look at risk factors for YLL and YLD in the US. As Fineberg explains, this is a complicated and difficult task,”…attempting to estimate the contribution of each risk factor to premature death.” It is easier to measure mortality (death) than morbidity (disability), but it is important because, as noted in the abstract, “As the US population has aged, YLDs have comprised a larger share of DALYs than YLLs.” That is, years lived with disability exceeds years of life lost from treatable disease. This makes sense; as we have developed increasingly sophisticated (and costly) high-tech interventions to prevent death (discussed by me, for example, in Primary Care Contributes More than Money…, June 2, 2013), we have increased the number of years that people are kept alive but suffering from the symptoms and complications of their diseases. The article’s abstract contains 4 sentences that describe this:
  • The diseases and injuries with the largest number of YLLs in 2010 were ischemic heart disease, lung cancer, stroke, chronic obstructive pulmonary disease, and road injury.
  • Age-standardized YLL rates increased for Alzheimer disease, drug use disorders, chronic kidney disease, kidney cancer, and falls.
  • The diseases with the largest number of YLDs in 2010 were low back pain, major depressive disorder, other musculoskeletal disorders, neck pain, and anxiety disorders….
  • The leading risk factors related to DALYs were dietary risks, tobacco smoking, high body mass index, high blood pressure, high fasting plasma glucose, physical inactivity, and alcohol use.”

The largest number of YLLs were caused by the “traditional” chronic diseases, while most of the conditions that increased YLL over the last 20 years were those that one would expect to increase as we keep people alive longer, particularly Alzheimer’s disease, chronic kidney disease, falls, and drug use disorders (which includes not just “illicit” or “illegal” drug use, but those taking prescription drugs, in particular for chronic pain – which comprise a large proportion of the diseases that have the largest number of YLDs — back pain, other musculoskeletal disorders, neck pain).
These findings should guide our population/public health interventions. And the leading risk factors for DALYs are not surprising; they are the ones that we hear about all the time: dietary risks, tobacco smoking, high body mass index, high blood pressure, high fasting plasma glucose, physical inactivity, and alcohol use. These are the very areas, in fact, where most population/public health programs are currently focused. However, when it comes to public policy, laws, and spending money to try to solve the problems, we are woefully deficient in the US. There has been some success in regulation of smoking in public places although not without significant resistance from those who profit from tobacco, including the tobacco industry, tobacco retailers, and clubs and casinos; indeed the public smoking ban passed in my state of Kansas a few years ago is being threatened with repeal. Public interventions in the other areas have had much greater opposition (see New York City’s efforts to limit portion size of sugar-filled soft drinks) or non-existent.
What is popular is victim-blaming, telling people who are overweight, inactive, smokers, drinkers, and victims of diabetes or hypertension to “clean up their acts”, to stop, to lose weight, to adopt healthy habits. Of course, these would be good, and we see increasing numbers of individuals doing so. However, the success rate is much higher among groups with higher income and higher educational levels, which must mean something. It could be that they know that smoking, obesity, inactivity, drinking, drugs, and not taking medicine for diabetes and high blood pressure are bad for you, while poorer people don’t. That, however, is hard to imagine. It is more likely due to their greater level of resources to try to address these problems, social support for healthful behaviors (including jobs), and access to health care. In addition, the same interests that lobby against regulation of smoking, unhealthy foods and alcohol are heavily advertising these same substances in the least-advantaged communities.
The “social determinants of health” are at play here; not only access to health care, but safe communities, stable housing, education, and prospects for jobs – the very things that national and often state policymakers seem to be least willing to fund, and the areas that other OECD countries often do fund. As discussed by Bradley and Taylor  in their book and NY Times Op-ed “To fix health care, help the poor” and by me in my post from December 18, 2011, “To improve health the US must spend more on social services”, the US stands out among OECD countries in that the vast majority of its combined health and social services spending is on medical care. This helps explain both our decrease in YLL from treatable but essentially end-stage medical conditions and our increase in YLD and in risk factors for chronic disease, because, as Bob Bowman described so well in “Moving to Recovery By Design”, June 22, 2013,we do not treat the “upstream” circumstances of people’s lives that lead to “downstream” disability and death. Even the US Burden of Diseases Collaborators have left out discussion of the social issues, which is perhaps on purpose but did not escape Fineberg’s notice: “The most glaring omission in the assessment of risk factors, as the authors acknowledge, is the role of social factors such as income and inequality as a risk of premature death and disability.” It is, as he acknowledges, harder to measure, but that scarcely decreases its relevance.
It is not about the money. We have the money. It is, as I have said before, about the will. About the will of politicians, who are ideologically committed to the principle that the only ones who really deserve government assistance are the largest corporations and wealthiest individuals and have, as Charles Blow has said (“Resonance Resistant”, May 18, 2013), a gag reflex to the word “social”, but also the will of the American people who often seem to value high-cost, high-tech care at the end of life more than healthful nurturing of people at its beginning.
27thin age-standardized death rate? 28th in years of life lost? Come on! Where is that old American competitive spirit? We can do it. We know that. Now, we must do it! 



[1] US Burden of Disease Collaborators, “The state of US health 1990-2010”,  JAMA. 2013;():.  doi:10.1001/jama.2013.13805.  Published online July 10, 2013.
[2]Fineberg HV, “The State of health in the United States”, JAMA. 2013;():-. doi:10.1001/jama.2013.13809, published  online July 10, 2013.

Will the GOP “solve” access to health care? No, unless you can redefine “access”!

An editorial in the New York Times on February 20, 2017 (“Ryancare: You can pay more for less!”) does a very good job of concisely demonstrating what the new Republican plan is likely to do to access to health care, the cost of health insurance, and what it covers. The key to House Speaker Paul Ryan’s plan for replacement of Obamacare involves “…flat tax credits unrelated to income, that could be applied to the purchase of insurance” (Paul Krugman, “Death and tax cuts”, NY Times February 24, 2016). As Krugman makes clear, the credits would be insufficient for low and middle income families to buy insurance, but would be a small benefit to high income households. The obvious result would be the loss of health insurance for millions of Americans who gained it through either the ACA exchanges and accompanying subsidies or through Medicaid expansion.
Giving tax credits or deductions is a long-standing Republican strategy that pretends to be equitable but in reality always benefits the financially better off. Ivanka Trump (the President’s daughter who is not, it should be observed, elected or even appointed to anything) has her pet project, tax deductions for childcare. Again, this sounds good, especially to the more well-off, two-income couples who would benefit (but don’t get your hopes up; the $500 billion tab makes it unlikely to pass even with the First Daughter’s support), but would be of less benefit to the poor. The one thing that is certain about Republican and Trump policy is that it will benefit the better-off; the problem with such deductions, from their point of view, is that it is costly and doesn’t benefit a narrow enough slice of the highest income individuals and corporations (sorry, Ivanka).
As summarized in MedPage’s Washington Watch Policy Papers on ACA Repeal: Many Question, Few Answers, no one, outside the Republicans pushing it, has any belief that the Ryan plan will provide coverage for most of the people who gained coverage from the components of the ACA, not to mention those who remained uninsured even with ACA in place, mostly poor people in states that did not expand Medicaid and undocumented people, as well as those who risked the penalties for violating the individual mandate rather than buy health insurance that they felt they could not afford. The first two groups are completely left out of any “replacement” plan (and of course undocumented people were never part of Obamacare). None of these plans will in any way benefit the middle and lower income people who voted for Trump in part because they wanted to get rid of Obamacare, which was costing them too much, and get the terrific, affordable health care coverage that the President promised them in the campaign. It is not going to happen, and people are beginning to understand that; CNBC reports that Obamacare is getting more popular in the first month of Trump’s presidency.
All that has been revealed so far about the content of a Republican “plan” indicates that it will cover fewer people than the ACA currently does. Some of this has to do with the mechanism of funding, with “tax credits” replacing direct subsidies for lower-income people. There is even a debate among Republican lawmakers about whether those tax credits should be “refundable” or not; if they are, then people will get the amount designated for the tax credit even if that amount is greater than the amount they would have owed in Federal income tax. Thus, it would be a subsidy, and thus many “conservative” (their word) Republicans oppose it. For a very large percentage of those who would be buying insurance and need help, the amount would likely be greater than the amount of Federal tax they owe. Of course, this depends upon how much the tax credit is determined to be; one thing, however, is that there is essentially no chance that it will be enough to actually purchase insurance.
Which brings up another big part of the way Republicans talk about health coverage. They use the term “access” rather than coverage, and have defined it in such a way that it is different from coverage; people, they say, will have the option of buying health coverage, not be forced to, the way that the ACA’s individual mandate did. This requires a conscious effort to ignore the crucial “ability to pay for it” as part of access, and makes the idea of “option” insincere. Something is not an option if you cannot afford it. Sen. Bernie Sanders said, in a good takedown of this use of “access”, that he had access to purchase a $10 million house; he just didn’t have the money to do it!
Insurance companies are a big part of the problem for ACA. The absence of a “public option”, not to mention a single-payer plan, meant that the law had to build in a way for insurance companies to be able to make money. To be able to profit, they have to either be able to charge a lot for coverage (or deny it altogether) for sick people, which was the pre-ACA status quo, or have a large pool of healthy low-cost people buying insurance. Thus, especially given ACA’s elimination of their ability to refuse insurance to people with pre-existing conditions, the individual mandate, requiring everyone to buy insurance, was needed. Despite the mandate, though, not enough healthy people bought insurance, and there was no rate cap, so it quickly has become unaffordable for many. Of course, we could have done what other developed countries do – have either a single-payer system where we have everyone automatically in the risk pool and everyone is actually covered, or have a highly regulated system, where benefit packages and rates are set by the government and insurance companies are non-profit, so compete on customer service. We actually have examples of both in the US. Medicare is a single payer plan (and while Medicare Part A, hospital, is paid for by the Medicare trust fund, Part B, doctor and outpatient bills, require individuals to pay, with high-income  people paying a supplement), as is the military health care system and the VA. Medicare supplement (Medigap) plans are regulated with regard to benefits; there are a number of plans lettered Type A to Type N (except there is no E, H, or I) with different benefit packages. The degree of comprehensiveness does not follow the alphabet (F is the best, K probably the worst) but at least they are standardized so all Type A, C, F, or K plans offer the same benefits regardless of which company you buy from, and so you can shop based on price.
I do not think that we are going to have such a simple situation as a highly-regulated marketplace, and certainly not single payer. We are likely going to back as far away from comprehensive coverage and affordable health care as the Republican Congress and President can get away with, which means as far as the American people will allow. Of course, the American people (other than the small number of, but incredibly powerful, wealthy ideological conservatives) do not want to lose their health coverage; they just want to pay less. Or not pay until they are sick. For them, and maybe for their families. For others, maybe not so much; some studies have found that as many as 2/3 of Americans support Medicare for All, while for Dr. Paul Gordon on his “Bike Listening Tour” across the US in 2016, one of his most upsetting findings (at least among the mostly white, rural, northern people he interviewed) was people’s lack of concern for others. Or at least “the other”, folks not like them.
It’s a real shame. We could have comprehensive quality care for everyone, at a more reasonable cost. Too bad the ideologues and the greedy are in control.

“There’s a sucker born every minute”: False and inflated health claims

There is,” in a phrase rightly or wrongly attributed to P.T. Barnum, “a sucker born every minute.” To Barnum, and to countless others before and since, this was a business opportunity. They can get rich off us because we want stuff to be true even when every input from our senses should show us that it isn’t; we want magical, easy cures and money-making schemes, even when we know that they only work for the scheme’s designers, not the suckers who take the bait. Betsy DeVos, the recently approved Secretary of Education, who knows nothing about education and devalues public education (I could go on, but that’s another story…) is the beneficiary of such desires. She is in the position that she is in because of her great wealth which has bought her great influence, and that great wealth, at least the portion from her husband’s side, derives from the Ponzi scheme known as Amway. It is clear that Amway was in fact the path to wealth that it was claimed to be, for the DeVoses anyway.
The persistent and widespread greed of people despite evidence that the odds are stacked way against them is testimony to either optimism or stupidity, or some of both. It is one of the oldest memes in literature, from the alchemists who would turn lead into gold (or Rumpelstiltskin who would weave it) to Faust who would sell his soul to the devil (and maybe so did guitarist Robert Johnson) to Ralph Kramden (and his cartoon successor Fred Flintstone) and George “Kingfish” Stevens, doubly oppressed and vulnerable, being poor and black. And the outcome is always the same, the little guy gets screwed.
We could go on and on with this theme. The temptation to tie it to the election and reign of Donald Trump is enormous; people want something to be true (that they’ll get good jobs back, that their streets will be safe, that they can have all the health care they want and need without paying for it when they don’t need it, whatever) and Trump promised it all, and of course he is not and will not deliver, but many still love him. If you want a good article about this, try Matt Taibbi in Rolling Stone, “The end of facts in the Trump era”. But, after all, this blog is about public health and medicine, and there is no shortage of examples in those fields. After all, con men and grifters, whether low level hucksters, Amway merchants, or Wall Street bankers are all regularly called “snake oil salesmen”, and what was snake oil but a promise of better health? And the liniment sold by these folks might have worked a bit since it had red pepper, a bit like current capsaicin. When they were convicted it was because their oil did not come from snakes, not because it was a fraudulent cure.
You’d think that people would wonder why, if there is a miracle easy (and sometimes even relatively cheap) cure for all their ills that everyone else hasn’t benefited from it. Ah, but that is part of the attraction – being in the know about something everyone else isn’t. Is that not the way that inside traders work? Isn’t that how they fix sporting events, how your brother-in-law knows that this 100-1 shot will come in at Santa Anita? Is that not how Arnold Rothstein got rich? So, sure, it’s done in health. Watch daytime television sometime. It is mostly about medicine, from Dr. Oz (a font of misinformation), to an electric scooter you can get FREE (or at no cost to you, other than as a taxpayer paying into Medicare), or a miracle drug that will allow you to have even better relief from your arthritis or asthma or will keep your blood from clotting even better than warfarin, at only 1000 times the price, and at great potential risk to your immune system.
The hucksters present not only misinformation about individual medical care, but also public health. The most obvious, and likely most serious, current issue is that of vaccines. Despite there being no evidence linking vaccines to autism, and strong evidence showing there is no link, the myth persists. The price will likely be serious outbreaks of vaccine-preventable diseases, especially measles, as discussed by Peter J. Hoetz in his NY Times Op-Ed “How the anti-vaxxers are winning”, February 7, 2017. Water fluoridation suffers from similar myths. Public health may be even more susceptible to such hype than medical care, since so many of its benefits are things (like measles, or tooth decay) that don’t happen, rather than those that do. We rarely wake up saying “Gee, I’m glad I don’t have cholera today because we have clean water”; indeed, we mostly worry about water quality when something specifically bad is happening, like lead poisoning in Flint. People are susceptible to liars and charlatans who tell them things that they want to believe, as well as things that seem to make sense, but as I tell students, something that seems to make sense is called a research question; only when the study is done will we know if it is true.
But it is not only the more obvious (to the discerning, anyway) scams. Mainstream medicine does it often. Every new discovery, every potential ameliorant (if not cure) is trumpeted by both the companies that manufacture it and, at an earlier stage, the university for which they work. Of course, most of these discoveries are scarcely the magic breakthroughs that they are initially claimed to be. That is the nature of science; things are learned and knowledge grows incrementally. But a new discovery by a scientist at your university is worth a lot of publicity! Maybe it is a cure for Alzheimers! Or at least a step in that direction! Certainly worth millions of dollars more in NIH funding! There is nothing wrong in incremental discoveries; the problem is when they are hyped as the Holy Grail. Indeed, on July 16, 2010, I wrote about Rosiglitazone and the “Holy Grail”, and how disappointed diabetes advocates were that Avandia® was being taken off the market just because it caused heart disease, because it did lower blood sugar! (A diabetes advocate noted that lowering blood sugar was the “Holy Grail”.) This story is a terrific example of the peskiness caused by the human body being an integral organism; something that is very good for one condition may still cause big problems. And so, maybe we should wait before we hype it too much. On the other hand, what an opportunitywe have to get big publicity before that happens…
A recent example involves using low-dose CT screening for lung cancer. The US Preventive Services Task Force recommends it (as a “B” recommendation) for men 55-80 years old with a history of smoking. This “B” recommendation is worth a lot to the CT manufacturers and radiologists who read them, since the ACA requires insurers to cover USPSTF “A” and “B” recommendations. But a big Veterans Administration study just published in JAMA shows that it is not quite as good as previously thought. “Of the 2106 patients screened, 1257 (59.7%) had nodules; 1184 of these patients (56.2%) required tracking, 42 (2.0%) required further evaluation but the findings were not cancer, and 31 (1.5%) had lung cancer.” Does this mean that it is a bad idea to get screened? Not necessarily; if I had a patient with a significant smoking history, I would discuss the risks inherent in getting this procedure but prepare them for the probability that even a positive test would likely not mean they had cancer, and that they might have to undergo more procedures with some risk to find out. The point is not that this is a bad idea, but it is not some amazing breakthrough, as touted.

Just because you want to get rich quick, or avoid needle sticks, or find the magic cure for your arthritis or cancer that has been denied you, and someone is selling something that claims to do it, doesn’t make it true. If you think so, I’ve got a couple of bridges to sell you.

Life expectancy, socialism, and the determinants of health

Socialism,”writes Washington Post columnist Kathleen Parker on February 9, “has always appealed to the young, the cure for which isn’t age but responsibility. This usually comes in the form of taxes and children, both of which involve working and sacrificing for the benefit of others, the extent of which forms the axis upon which all politics turns.” Parker is discussing the brouhaha around comments about the need for women to support Hillary Clinton’s presidential bid, particularly those by Gloria Steinem that young women are supporting Bernie Sanders because, essentially, that’s where the boys are. Her logic seems a little contradictory to me, because socialism is all about being part of a society that we are all in together, where we work and sometimes sacrifice for the benefit of others.
Parker really means that we become more selfish, that the “others” narrows from our whole society to that small group, presumably our nuclear family, for whom we work and sacrifice. Of course, she is only talking about some people. Some people never have children. Others of us realize that there are benefits that we all want as a society – transportation and police and schools and even a social safety net – that makes us more than willing to pay our taxes. And a few people, very wealthy, accumulate much more money than they or their children could ever use and pay very little in taxes. They, to be sure, are big fans of the popular narrative endorsed by Parker: that the rest of us need to buckle down and take care of our kids and not make a fuss and be socialist and threaten their gravy train. And for sure keep paying taxes, so that when they need to be bailed out the government has the funds.
It is a deeply flawed narrative, but it holds a lot of sway, and is used to justify policies that have facilitated the greatest transfer of wealth, from most of us to a few of them, in a century. More and more Americans are on a treadmill, working harder and harder to discharge their responsibilities to their families and pay their taxes, because their real wages are stagnant or decreasing. Our economy increasingly is one where little is manufactured but we all tithe to the kitty (or is it a lion?) of the financial services sector; its “players” compete for that money taken from the rest of us (anyone seen “The Big Short”?) and it bothers them not one bit. That it bothers a lot of young people enough to support Senator Sanders (who Parker says “never outgrew his own socialist-rebellious tendencies”) should make all of us happy and optimistic, since what is happening now is not good for most individuals, their families, America, or the world.
It’s also not good for a lot of people’s health. The New York Times’ Sabrina Tavernise reports on February 12, 2016 that the “Disparity in Life Spans of the Rich and the Poor Is Growing”. “Experts have long known that rich people generally live longer than poor people,” she begins, but how much longer is increasing. This was most recently demonstrated by a study conducted for the Brookings Institute by Barry Bosworth, Gary Burtless, and Kan Zhang (“What growing life expectancy gaps mean for the promise of Social Security”). Men in the bottom 10% of income born in 1920 lived 6 years less than those in the top 10%; for those born in 1950 it will be 14 years. For women the increase is as great, from 4.7 to 13 years, and for women in the bottom 30%, life expectancy has actually decreased. This is not a good trend, and it is not limited to the outliers in the top and bottom deciles. As illustrated by the accompanying graph, the more you make the longer you can expect to live. Tavernise makes clear that this is despite the advances that have occurred in medicine and technology; indeed those have relatively little impact upon longevity or health, despite the amount that we as a society spend upon them; most estimates of the contribution of all medical care to health status are in the 10-15% range. This is, nonetheless, where most of our health expenditures (now over 17% of GDP) are, and of course to the extent that they are of benefit to individuals they are far more available to those who have more money. Per Tavernise: “The Social Security Administration found, for example, that life expectancy for the wealthiest American men at age 60 was just below the rates in Iceland and Japan, two countries where people live the longest. Americans in the bottom quarter of the wage scale, however, ranked much further down — one notch above Poland and the Czech Republic.”
The Times article quotes the usual sources to tell us that lower income people are likely to have more negative health behaviors, like smoking and prescription opioid use (but, somewhat surprisingly, not that much more obesity – 37% in the lowest and 31% in the highest income group). Health behaviors are important; they may be as significant as medical care in determining our health. So is biology, our individual genetics. But even smoking only accounted for a fifth to a third of the difference.
The real causes of the difference in life expectancy are the “social determinants of health” (SDH). These include having a place to live, having enough to eat, having warmth in the winter, living in a neighborhood with lower rates of both interpersonal (muggings, homicide) and institutional (environmental pollution, lack of access to basic resources like stores, transportation, sidewalks) violence. They also include the occupational risks accompanying many lower-income jobs that involve physical labor and the toll it takes on the body (and increase the probability of living with chronic pain and using opioids). The SDH are tied to other risk behaviors, such as smoking. And, since socioeconomic status is highly correlated with that of one’s family of origin, people with higher incomes were likely to be born and raised in families with higher incomes, which confers a lifelong health benefit. Of course, this negative impact of SDH would be expected to be greatest in the lowest socioeconomic groups, which it is, but above them surely people have those basic needs met? Why are they living less long than the really rich?
A big part of the reason is misperception by the well-off, which includes most policymakers, politicians, pundits, and even journalists of how much money people make, and thus how many people are well-off. The median household income in 2014 (US Census Bureau report) was about $53,000. Half the households made less, and half more. The bottom 80% of income earners account for about 50% of all income, with the top 20% having the other 50% and the top 5% over 20%.  An individual with an income of $100,000 is in the top decile on that table, and so it is less surprising that folks making less have some deficit in their health and life expectancy.
From the Timesarticle: “At the heart of the disparity, said Elizabeth H. Bradley, a professor of public health at Yale, are economic and social inequities, ‘and those are things that high-tech medicine cannot fix.’”. I have cited Bradley before (To improve health the US must spend more on social services, December 18, 2011), and her point, that in the US we spend far more on medical care than other social services, is still right on. We spend huge amounts on high-tech and variably effective care that benefits a relatively small number of people (and, disproportionately, those with higher income) and much less than other OECD nations on other social services that actually improve health and life expectancy. Oh, but those countries spending that money are those “social democracies” that Bernie Sanders goes on about. You know, socialist. The ones where people are healthier and live longer.

Now, why would we expect, or want, our young people to “grow out” of the idea that this is a good thing?

Belief vs. “truth”: how people often make medical decisions

In a fascinating article in the “Medicine and Society” section of the New England Journal of Medicine, “Beyond belief—how people feel about taking medication for heart disease”[1], Lisa Rosenbaum discusses some of the reasons that people do not take medicines prescribed for them by doctors, really for any condition, not just heart disease. These reasons go beyond the obvious ones of personally experiencing side effects and not being able to afford them; indeed, she starts out discussing the fact that folks don’t use aspirin, a very cheap drug, even after having been diagnosed with coronary heart disease, for which the evidence of benefit is very strong.
Rosenbaum addresses a number of reasons, beginning with simple belief. A friend tells her that “My parents [whom Rosenbaum describes as “brilliant and worldly”] are totally against taking any medication”. Another person she meets, prescribed a “statin” (an anti-cholesterol drug), has no intention of taking it and indeed expresses disdain that is “raw and bitter” (the disdain, not the pill). For him, it is tied to the suffering he saw his sister endure when taking toxic anti-cancer drugs. Her hairdresser suggests another reason: taking medication means acknowledging that you are sick, and people don’t want to acknowledge that. He says that he gives his grandmother her nightly medication by telling her they are vitamins—after all, vitamins are to make you healthier, not treat your sickness.

Rosenbaum tells more stories, relating more reasons, but most come down to a belief, almost to an unchangeable worldview. Some of the issues seem to be semantic. People do not want to take “chemicals”, but will take vitamins. Connotation, and the “frame” that people put around words and concepts (sickness, drugs, natural, chemical, etc.) are very important. Of course, they’re all chemicals, and of course anything (“natural” or produced in a laboratory) that can have a biologic effect (good or bad) can have other effects (good or bad).  People sometimes cite the side effects of drugs even when they haven’t experienced them but have read or heard about them, and credit them with more importance than the beneficial effects. While some people have always made decisions based on creating a parallel to what happened to someone they know, the Internet has probably magnified the universe of people they “know” and stories that they “hear”.
Perhaps the scariest reason Rosenbaum points out is that the success of medical treatment has led people to minimize, in some cases,  the seriousness of the disease. As a cardiologist, she points to acute myocardial infarction (heart attack), which used to require 4-6 weeks of hospitalization, and now often has people out of the hospital in 24 hours. She talks to a person who contrasts it to the flu, which “can knock you down for days or a week or two, [while]the heart attack, once they do the thing, you’re in good shape.” And yet, “once they do the thing”, whatever it is, stents or clot lysing (presumably not yet bypass, which does require a longer hospitalization) and you feel better, you still have the disease; only the use of certain drugs along with diet and lifestyle changes can modify the trajectory of the disease. But the latter are hard, and maybe we don’t want to take drugs. Because, you know, we are feeling better.
I admit to initially feeling anger, hostility, as I read the “reasons” that these people would not take medicine, feeling that they were stupid. I don’t mean that I was angry that they don’t take medicine; this is their decision. In addition, there are lots of important reasons to be wary of taking medicines that go beyond personal experience with side effects. Not the least of these is the fact that they are heavily marketed by drug manufacturers, who are in business solely to make a profit, and regularly invent new “diseases” that “need” treatment in order to market their drugs and make money. In addition, “indication creep” (which I have discussed before, The cost of health care: Prevention and Indication “creep”, drugs, and the Sanders plan, June 25, 2011, particularly citing a piece by  Djulbegovic and Paul, “From efficacy to effectiveness in the face of uncertainty: indication creep and prevention creep”).[2]This means that a drug, which is found to be effective and relatively safe for a certain condition, at a certain severity level, in certain people, starts to be used by physicians (often encouraged by the manufacturers) for other people with less severe levels of conditions, and sometimes for other indications for which efficacy has not been proven. For example, starting drugs for cholesterol at levels below which treatment has been shown to reduce mortality, or putting younger (or older) people on treatments only shown to benefit older (or younger) people, or men or women.
Indeed, this appeals to another system of beliefs common in people (including doctors), that if a little is good, more is better; if reducing cholesterol in people whose level is above “X” is good, why not in people whose cholesterol is a little below “X”; if getting your average blood sugar below “Y” is good, why not a little lower still; if aspirin is good prevention and reduces death in men who have coronary heart disease, why not use it in men who don’t but otherwise look a lot like men who do? This sort of belief may lead to behavior opposite of that described by Rosenbaum (that is, taking medication when it is not of value rather than not taking medication that is likely to be of value) but it stems from same root—making decisions based on beliefs rather than evidence. And it is not uncommon to see both behaviors manifested in the same people: someone who would “never” take “artificial chemicals” (regulated drugs) into their body who ingests large amounts of unregulated chemicals (labeled as “natural”). The apparent contradiction is non-rational to me but makes sense to them.
I often—maybe usually—agree with those who say “less is better”, such as Ezekiel Emanuel in his New York Times op-ed “Skip your annual physical”.[3]But I hope that I do this when, as in the case of the annual physical, the evidence does not demonstrate benefit, and the cost is high, as it is for many heavily-marketed drugs. And, of course, my anger subsides as I realize that I often feel the same things, and maybe even sometimes act on them. I don’t want to be a sick person, certainly not one with a chronic disease (it’s bad enough to have the flu!) and taking a medicine for a condition labels me as such. I don’t want to take medicines just because they “might” help (prescription or over-the-counter, made by traditional pharmaceutical manufacturers or “natural” companies) if there is not good evidence, and I don’t want to experience unpleasant side effects. But I do take the medicines that have been shown to benefit people like me, with the same or similar risk factors, and even put up with some side effects (e.g., mild myopathy from the statin).
I am not going to change anyone’s worldview, no more than Dr. Rosenbaum is likely to change that of the “brilliant and worldly” friends of her parents. And I am certainly not going to become an advocate for treating for the sake of treatment, or being a flak for drug companies. But if there is strong evidence that taking a drug (in the lowest effective dose) for a condition that I in fact have (denial or not) is likely to have a “patient-important” (meaning lower risk of premature death or better quality of life) outcome, and I personally do not experience serious side effects, I will take the drug.
The key issue here is not making decisions to do, or not do something (have a physical or take a drug) because of a general belief that such things are good or bad for you, but rather to evaluate the evidence of how it might benefit or harm you, and to make a decision that balances these filtered through your own value system, how much you value the potential benefit or harm that might come.
To me, this is a rational approach.



[1] Rosenbaum L, “Beyond belief—how people feel about taking medications for heart disease”, NEJM 8 Jan 2015;372(2):183-87
[2] Djulbegovic B, Paul A., From efficacy to effectiveness in the face of uncertainty: indication creep and prevention creep”, JAMA. 2011 May 18;305(19):2005-6..
[3]Emanuel E, “Skip your annual physical”, New York Times, January 9, 2015.