.
On December 9 and 10, 2009, a massive “C.A.R.E.” clinic, sponsored by the National Association of Free Health Clinics occurred in Bartle Hall, the huge Convention Center in Kansas City. On the first day alone, with temperatures well below 20 degrees and the roads covered with ice from the snow that fell the night before, as many as 1,000 people showed up to receive health care from 1,600 volunteers, including 100 doctors, dentists, and nurse practitioners. It may end up seeing more people than similar events previous held in Houston, New Orleans and Little Rock. There is excellent coverage of the event in an article by Alan Bavley in the Kansas City Star, accompanied online by photos and videos by the Star’s Todd Feeback.
The purpose of these clinics is, of course, to provide some care to the people who attend – often the only care they have gotten in years. People were diagnosed and sometimes treated for acute conditions, such as pneumonia, or diagnosed with chronic diseases such as high blood pressure, high cholesterol, and diabetes. Indeed, most often they were really re-diagnosed; they knew they had these conditions but had been unable to afford medications or medical care. But another, even more important purpose, as Sherri Wood, Director of the Kansas City Free Clinic, says in the video, is to “put a face on the uninsured”. They are not only, or mostly, homeless, alcoholic, completely down-and-out, or even mostly unemployed. Rather, they are employed in low-wage jobs (not infrequently 2 or 3 jobs!) that do not offer health insurance, or they are employed part-time so that their employer does not have to buy their insurance. They are people, American people, our friends and families and neighbors. And they could be us; most Americans are a layoff away from uninsurance, and not too many paychecks away from dire financial straits and even homelessness.
The excellent accompanying editorial in the Star is titled “Massive free clinic at Bartle Hall a great event, but reform is still needed”. The editorial, along with the story, includes interviews with and comments from people who came for services (“Making three dollars an hour plus tips I can’t afford to see a doctor. When you have a house payment and your bills, it’s hard.”), but it also clearly states that “Although impressive, the free clinic clearly is no substitute for reliable medical care”. Yes, indeed. Or rather, No, indeed, it is certainly not. “Charity isn’t a good substitute for justice”, as I have quoted Jonathan Kozol before.
The Star editorial goes further, making the point that I have often made that a solution to the health care problem includes producing more primary care physicians. “Too many medical school graduates gravitate to high-paying specialties partly to pay off burdensome student loans.” We must, it says, “…encourage physicians to take up primary care.” It is appropriately critical of the fact that “The reform bills in Congress contain few incentives to set things right…Expanding access won’t work unless we start now to increase the supply of primary care physicians.”
So the problem is clear. And the solution is clear. Universal health coverage. Based on the principle that we need to ensure that people receive care, not that for profit companies make money. It has been figured out by every first-world (and some not quite first world) countries. It is not tricky, difficult, or even expensive (certainly not compared to what we are spending now). Not that it will happen, or happen easily, as the “debate” in Congress is currently demonstrating.
Maybe some of the opponents of real, meaningful, comprehensive health reform are just mean, evil, selfish people. I don’t rule that out. But more likely they are “blinkered”, like a horse, looking at only one aspect of the problem, such as the Kansas legislator who is proposing that our state refuse to participate in any health reform plan passed by Congress. (I am trying really hard to believe that this is his/her issue, being like the blind men of India with the elephant, not that s/he is mean, evil and selfish.) Plus the campaign contributions from the insurance companies and drug companies and health providers who are doing just fine, thank you, under the current system of literally leaving people out in the cold, help sway their beliefs.
It is time for the leaders of our country to stop compromising on a core need of our people, and ensure that everyone has access to quality health care. And they can do it in a responsible and cost effective manner through a single payer system, although there are other alternatives. The Star editorial says “A compassionate and cost-effective system would provide every American with a medical ‘home’ from which to receive preventive and needed care.”
I hope that most of our congressmen and other leaders are compassionate, and am certain that they wish to be cost-effective. But they need to abandon pandering to big contributors and keep this core value front and center: Quality health care for all.
.
Thursday, December 10, 2009
Sunday, December 6, 2009
Health Care Needs Should Guide Health Reform
.
As the debate over health care reform proceeds in the Senate, and in the nation, it is important to take stock of the key assumptions of those planning the changes. The Democrats have chosen to combine increased regulation and requirements for insurance companies with economic incentives, in an effort to cover more people and reduce skyrocketing costs. The Republicans have chosen to combine a core opposition to any proposal originating from the Administration or the Democratic leadership (articulated by New Hampshire Republican, and almost-Obama-cabinet-appointee, Judd Gregg) with cynical attempts to portray themselves as the defenders of currently-insured Americans by opposing cuts while criticizing the proposal for not saving enough money. The classic here is John McCain, who campaigned on a platform of quite draconian cuts in Medicare, screaming that the much more modest cuts in the Democratic proposal will, essentially, kill old people.
While the Democratic proposal does resemble an effort to patch the chinks in a leaky old house as winter approaches, leaving lots of holes and at cost greater than fixing the whole thing, the Republican scare tactics should be seen as what they are. Across the board cuts in Medicare would be a bad idea, as are almost all across-the-board cuts in any organization, but cuts which reduce the over- and unnecessary use of expensive tests and procedures, while increasing access to primary care, would save a lot of money. To be sure, the doctors and hospitals who provide those tests and procedures would take a financial hit, but it is unlikely to lead them to food stamps. A colleague who is in the health care field, but not a physician, told me that he had been at a meeting in which a Canadian doctor talked about the structure of their payment system, which pays subspecialists less than they make here, and observed that such change would be opposed by the specialists who would not welcome their income being reduced from, say, $600,000 to $400,000. What is there to say? Life is tough? It is hard to see the American people, worried about their jobs and future, increasingly (as I have recently discussed) on food stamps, fighting to prevent such losses. And, more important, I am sure that we will find doctors in those subspecialties who are willing to work for the $400,000.
The bigger problem with the Democratic proposal is that most of its solutions are based on creating business and economic incentives to try to get insurers to do the right thing, or at least a little more right and a little less evil. This is, I suppose, good insofar as it goes, and seems to be convincing even progressive economists such as Paul Krugman (“Reform or else”, New York Times December 4, 2009). But the idea of patching the house of health care using economics is intrinsically flawed, when the model should be based on social justice, morality, and doing the right thing for our nation and our people. Sophisticated businesses, whether Wall St. banks or health insurance companies, will always find ways to “game the system”, to find profit by reducing service, no matter how the economic incentives are structured (although surely they can be structured better than they are now). Even organizations that are intended to meet the health needs of the underserved can, because of the way incentives are structured, find that they can do better (or even simply survive) by caring for some needy in preference to others.
A case in point is one of our local Federally-Qualified Health Centers (FQHCs), also known as Community Health Centers (CHCs). I discussed these entities nearly a year ago, on December 30, 2008 (Community Health Centers, and more recently on September 3, 2009, Public/Private funding: We’re all in this together). These clinics are financially supported by the federal government largely because, in return for caring for the poor and meeting other federal service and reporting requirements, they receive cost-based reimbursement for Medicare and Medicaid patients, leading to Medicaid payments that are usually several times that paid to private doctors. They also usually receive a federal grant that helps support care provided to the uninsured. However, that money is never enough, and the additional funds from Medicaid and Medicare help subsidize that care for the uninsured.
One branch of the local FQHC located in northeast Wyandotte County, KS, where I live, served a desperately poor neighborhood. Indeed, most of the people are not on Medicare (because they are too young) or on Medicaid (because, while many are unemployed and others work for low wages at businesses that do not provide health insurance, either they are not families with young children or, if they are, they are often undocumented and ineligible). So the clinic was financially unable to support itself, and has solved its problem by moving to another part of the county, where the percentage of poor people with Medicaid is much higher. Still poor, to be sure, and in need of providers, but a good business move for the FQHC.
The problem, of course, is those people living in their old community. They did not go away, become more prosperous, or become more likely to be insured. They just lost their only source of health care. It’s hard to completely blame the FQHC, for all other providers left that community long ago, although the FQHC was specifically designed to fill these gaps. It is possible, and popular, to blame the “illegals” who make up much of this abandoned population, but while this works for propaganda, it is not so smart in reality. These people are here, and absent access to primary and preventive care they will continue to show up in emergency rooms to receive care for advanced disease that could have been treated more cost-effectively.*
Fortunately for this community, an independent, non-federally supported, safety net clinic (disclaimer: I am on its Board) has opened a small satellite in the basement of a church in that community. In doing so, it is not employing a traditional business plan; it is going where the need is, rather than where it can expect to make money. This will be a good thing for the people of that community, but it is no solution to the health care crisis, and cannot be expected to be replicated everywhere as a means of patching those chinks in our system. Not only does it depend upon funding from private foundations to exist, it depends upon enormous “in kind” contributions from its health care providers, doctors and dentists and nurses, who all receive the same wage as every other worker in the clinic, currently $12/hour.
But it could work on a national basis; not the part about doctors and dentists earning $12 an hour (we’re not talking here about $400,000 instead of $600,000!), but rather a national plan for a system that is predicated not on profit but on caring for people. A health care system which did not discriminate among people, but ensured that providers caring for everyone could survive and make a living, so that there would not be big parts of our population left out. Like a single-payer plan. Like Medicare for All.
Our system is upside down. Every other first world country has a health system built upon the idea that everyone is entitled to access to health care. Financial incentives to providers and insurers may work to fill some gaps. Ours uses financial incentives to provide care to a majority of our population, but it is a shrinking percent and even for them the coverage is decreasing and the cost is rising, and volunteerism and sacrifice are relied upon to fill the holes.
A health system for our country should start with ensuring access to high-quality health care for all our people. As I have discussed before, it may actually save money, but the reason to do it is that it is the right thing to do.
*This is not to mention that they work and pay taxes – often payroll, but certainly sales taxes – for low wages. What happens when they really leave – see “Arizona” – is there aren’t enough people to do these jobs, and aren’t enough people to rent housing – causing a major negative financial ripple effect.
.
As the debate over health care reform proceeds in the Senate, and in the nation, it is important to take stock of the key assumptions of those planning the changes. The Democrats have chosen to combine increased regulation and requirements for insurance companies with economic incentives, in an effort to cover more people and reduce skyrocketing costs. The Republicans have chosen to combine a core opposition to any proposal originating from the Administration or the Democratic leadership (articulated by New Hampshire Republican, and almost-Obama-cabinet-appointee, Judd Gregg) with cynical attempts to portray themselves as the defenders of currently-insured Americans by opposing cuts while criticizing the proposal for not saving enough money. The classic here is John McCain, who campaigned on a platform of quite draconian cuts in Medicare, screaming that the much more modest cuts in the Democratic proposal will, essentially, kill old people.
While the Democratic proposal does resemble an effort to patch the chinks in a leaky old house as winter approaches, leaving lots of holes and at cost greater than fixing the whole thing, the Republican scare tactics should be seen as what they are. Across the board cuts in Medicare would be a bad idea, as are almost all across-the-board cuts in any organization, but cuts which reduce the over- and unnecessary use of expensive tests and procedures, while increasing access to primary care, would save a lot of money. To be sure, the doctors and hospitals who provide those tests and procedures would take a financial hit, but it is unlikely to lead them to food stamps. A colleague who is in the health care field, but not a physician, told me that he had been at a meeting in which a Canadian doctor talked about the structure of their payment system, which pays subspecialists less than they make here, and observed that such change would be opposed by the specialists who would not welcome their income being reduced from, say, $600,000 to $400,000. What is there to say? Life is tough? It is hard to see the American people, worried about their jobs and future, increasingly (as I have recently discussed) on food stamps, fighting to prevent such losses. And, more important, I am sure that we will find doctors in those subspecialties who are willing to work for the $400,000.
The bigger problem with the Democratic proposal is that most of its solutions are based on creating business and economic incentives to try to get insurers to do the right thing, or at least a little more right and a little less evil. This is, I suppose, good insofar as it goes, and seems to be convincing even progressive economists such as Paul Krugman (“Reform or else”, New York Times December 4, 2009). But the idea of patching the house of health care using economics is intrinsically flawed, when the model should be based on social justice, morality, and doing the right thing for our nation and our people. Sophisticated businesses, whether Wall St. banks or health insurance companies, will always find ways to “game the system”, to find profit by reducing service, no matter how the economic incentives are structured (although surely they can be structured better than they are now). Even organizations that are intended to meet the health needs of the underserved can, because of the way incentives are structured, find that they can do better (or even simply survive) by caring for some needy in preference to others.
A case in point is one of our local Federally-Qualified Health Centers (FQHCs), also known as Community Health Centers (CHCs). I discussed these entities nearly a year ago, on December 30, 2008 (Community Health Centers, and more recently on September 3, 2009, Public/Private funding: We’re all in this together). These clinics are financially supported by the federal government largely because, in return for caring for the poor and meeting other federal service and reporting requirements, they receive cost-based reimbursement for Medicare and Medicaid patients, leading to Medicaid payments that are usually several times that paid to private doctors. They also usually receive a federal grant that helps support care provided to the uninsured. However, that money is never enough, and the additional funds from Medicaid and Medicare help subsidize that care for the uninsured.
One branch of the local FQHC located in northeast Wyandotte County, KS, where I live, served a desperately poor neighborhood. Indeed, most of the people are not on Medicare (because they are too young) or on Medicaid (because, while many are unemployed and others work for low wages at businesses that do not provide health insurance, either they are not families with young children or, if they are, they are often undocumented and ineligible). So the clinic was financially unable to support itself, and has solved its problem by moving to another part of the county, where the percentage of poor people with Medicaid is much higher. Still poor, to be sure, and in need of providers, but a good business move for the FQHC.
The problem, of course, is those people living in their old community. They did not go away, become more prosperous, or become more likely to be insured. They just lost their only source of health care. It’s hard to completely blame the FQHC, for all other providers left that community long ago, although the FQHC was specifically designed to fill these gaps. It is possible, and popular, to blame the “illegals” who make up much of this abandoned population, but while this works for propaganda, it is not so smart in reality. These people are here, and absent access to primary and preventive care they will continue to show up in emergency rooms to receive care for advanced disease that could have been treated more cost-effectively.*
Fortunately for this community, an independent, non-federally supported, safety net clinic (disclaimer: I am on its Board) has opened a small satellite in the basement of a church in that community. In doing so, it is not employing a traditional business plan; it is going where the need is, rather than where it can expect to make money. This will be a good thing for the people of that community, but it is no solution to the health care crisis, and cannot be expected to be replicated everywhere as a means of patching those chinks in our system. Not only does it depend upon funding from private foundations to exist, it depends upon enormous “in kind” contributions from its health care providers, doctors and dentists and nurses, who all receive the same wage as every other worker in the clinic, currently $12/hour.
But it could work on a national basis; not the part about doctors and dentists earning $12 an hour (we’re not talking here about $400,000 instead of $600,000!), but rather a national plan for a system that is predicated not on profit but on caring for people. A health care system which did not discriminate among people, but ensured that providers caring for everyone could survive and make a living, so that there would not be big parts of our population left out. Like a single-payer plan. Like Medicare for All.
Our system is upside down. Every other first world country has a health system built upon the idea that everyone is entitled to access to health care. Financial incentives to providers and insurers may work to fill some gaps. Ours uses financial incentives to provide care to a majority of our population, but it is a shrinking percent and even for them the coverage is decreasing and the cost is rising, and volunteerism and sacrifice are relied upon to fill the holes.
A health system for our country should start with ensuring access to high-quality health care for all our people. As I have discussed before, it may actually save money, but the reason to do it is that it is the right thing to do.
*This is not to mention that they work and pay taxes – often payroll, but certainly sales taxes – for low wages. What happens when they really leave – see “Arizona” – is there aren’t enough people to do these jobs, and aren’t enough people to rent housing – causing a major negative financial ripple effect.
.
Wednesday, December 2, 2009
Food stamp use increases: who should the government be working for?
.
The New York Times article “Food stamp use soars across US, and stigma fades” by Jason DeParle and Robert Gebeloff (November 29, 2009) details not only the dramatic increase in the number of people on food stamps across the country, but the fact that many people who would never have thought of themselves as candidates for “welfare” now (sometimes ruefully) avail themselves of this “Supplemental Nutrition Assistance Program” (SNAP). In two telling county-by-county maps we are shown, first, which counties have had the greatest increase in recipients of “nutritional assistance” (as food stamps are now called), and then which have the greatest percent of recipients.
The map showing percent increase, calls our attention to the West, Florida, and the North Central States, with Utah, Nevada, Arizona, California, Idaho, Washington, Wisconsin and Florida all darkly colored. As shown on the second map, these are mostly states that previously had relatively low percents of people on food stamps, and are even are now just catching up; they are still below the areas with the heaviest proportions – the Texas-Mexico border; the Appalachian strip through West Virginia, Kentucky, Tennessee, Arkansas, and Missouri; the Mississippi Delta; anywhere there is an Indian reservation. The South as a whole looks bad, but always has, because of the combination of low union penetration resulting in low wages, many people employed in marginal agriculture, and terrible social services. The interactive map feature is “cool” – you can hover over any county in the US and find out what percent of its population is on food stamps, and what the change (almost always “increase”) has been. The result is that “There are 239 counties in the United States where at least a quarter of the population receives food stamps…”, and do, nationally, one in four children.
While there are a number of smaller counties that have almost half (49%) of their population on food stamps, the two with the highest percents among counties with over a half-million people are Bronx County, NY, and Hidalgo County, TX, tied at 29%. Ironically, the last time Hidalgo County (county seat=McAllen) hit the national news it was when it was revealed, in Atul Gawande’s New Yorker piece, the “Cost Conundrum” (discussed in my post ‘Medicare Costs: ‘All Politics are Local’” on June 11, 2009), that it was the region that had the highest Medicare cost per person in the country.
This is pretty sad. It is sad that so many people in this country have to swallow their pride and take food stamps. “’It’s time for us to face up to the fact that in this country of plenty, there are hungry people,’” says SNAP’s director. “The program’s growing reach can be seen in a corner of southwestern Ohio where red state politics reign and blue-collar workers have often called food stamps a sign of laziness,” the Times tells us. But, of course, it is not “laziness” when it is you.
It is hard to think of this without thinking of the multi-billion dollar bailouts given to the bankers and financiers so that they could continue to give themselves huge bonuses. While it may be true that these companies were too big to fail, there is no reason that they had to use our tax money to pay their employees, each of whom is only a person, just like the people who are increasingly in need of food stamps. We are told that some statistics, such as that the rate of job losses are slowing, indicate that “we” as a country may be on our way out of the recession, but that still means that there are fewer people working each month than there were the month before; I don’t think such statistics mean as much to the more of “we” who are out of work each month as the statistics showing the increase in folks on food stamps. I don’t think that it makes the six people looking for each available job feel much better.
I am still marveling at the juxtaposition of the food stamp story with an advertisement in the program for a concern I recently went to. Under the photo of a sultry and glamorous beauty in a gown leaning against an elegant bar with a glass in one hand, the text says: “The glass is half full…of champagne. The more than 97 percent of KC consumers who spend $27,000 , or more, per month on personal luxuries subscribe to one necessity every month – KC Magazine.” I am sorry that it is not online and I can’t reproduce it. I had to read that several times to be sure I hadn’t read it wrong – it is, after all, a tortured sentence. Yes, $27,000. A month. That’s a lot of money. Over half the average annual household income in our region. But they’re not talking about income. They’re talking about luxuries. $27,000 a month on luxuries. $324,000 a year. Or more. In Kansas City, not even New York or LA. I am amazed at the audacity of it.
Paul Krugman’s recent column (“The Jobs Imperative”) calls for a new Works Progress Administration in which the government would directly create jobs. I don’t think this is going to happen because the Obama administration is not bold enough, and has never shown such boldness. It completely kowtowed to the financial sector, and is afraid to take on the right-wing bloviators in Congress who say they represent the American people when in fact all they want to do is to further screw the American people. Most of all it won’t happen because the Congress is owned by wealthy contributors, and doesn’t really work for the American people. It is a very sad situation, but at least we can be confident that few Congressmen, even when they retire, will require food stamps.
We as Americans seem, on so many fronts, to be unable to put ourselves in the position of others, even as we move toward that position. This is true in the area of reproductive rights, where younger women do not realize that if they don’t fight for it now, abortion could not be available when they need it (Sheryl Gay Stolberg, In Support of Abortion, It’s Personal vs. Political, New York Times November 29, 2009). It is true when we fail to realize that without a universal health insurance program, our access to health care can disappear with our jobs. It is also, clearly, true with regard to our basic human needs, such as food. In the Times story, the formerly-employed food stamp recipients of southeastern Ohio say “I always thought it was people trying to milk the system. But we just felt like we really needed the help right now,” and “I always thought people on public assistance were lazy, but it helps me know I can feed my kids.” So would “those people”. Maybe we need to start thinking about how what happens to some of us can happen to us all.
German Pastor Martin Niemöller wrote:
“First they came for the communists, and I did not speak out—because I was not a communist;
Then they came for the trade unionists, and I did not speak out—because I was not a trade unionist;
Then they came for the Jews, and I did not speak out—because I was not a Jew;
Then they came for me—and there was no one left to speak out for me.”
Most of us would agree with the woman in the Times article who said “I like to have a nice decent meal for dinner.” It’s not too much to ask that this be the goal of our national policies, and let the financiers and those people who are spending $27,000 a month – or more! – on “personal luxuries fend for themselves.
.
The New York Times article “Food stamp use soars across US, and stigma fades” by Jason DeParle and Robert Gebeloff (November 29, 2009) details not only the dramatic increase in the number of people on food stamps across the country, but the fact that many people who would never have thought of themselves as candidates for “welfare” now (sometimes ruefully) avail themselves of this “Supplemental Nutrition Assistance Program” (SNAP). In two telling county-by-county maps we are shown, first, which counties have had the greatest increase in recipients of “nutritional assistance” (as food stamps are now called), and then which have the greatest percent of recipients.
The map showing percent increase, calls our attention to the West, Florida, and the North Central States, with Utah, Nevada, Arizona, California, Idaho, Washington, Wisconsin and Florida all darkly colored. As shown on the second map, these are mostly states that previously had relatively low percents of people on food stamps, and are even are now just catching up; they are still below the areas with the heaviest proportions – the Texas-Mexico border; the Appalachian strip through West Virginia, Kentucky, Tennessee, Arkansas, and Missouri; the Mississippi Delta; anywhere there is an Indian reservation. The South as a whole looks bad, but always has, because of the combination of low union penetration resulting in low wages, many people employed in marginal agriculture, and terrible social services. The interactive map feature is “cool” – you can hover over any county in the US and find out what percent of its population is on food stamps, and what the change (almost always “increase”) has been. The result is that “There are 239 counties in the United States where at least a quarter of the population receives food stamps…”, and do, nationally, one in four children.
While there are a number of smaller counties that have almost half (49%) of their population on food stamps, the two with the highest percents among counties with over a half-million people are Bronx County, NY, and Hidalgo County, TX, tied at 29%. Ironically, the last time Hidalgo County (county seat=McAllen) hit the national news it was when it was revealed, in Atul Gawande’s New Yorker piece, the “Cost Conundrum” (discussed in my post ‘Medicare Costs: ‘All Politics are Local’” on June 11, 2009), that it was the region that had the highest Medicare cost per person in the country.
This is pretty sad. It is sad that so many people in this country have to swallow their pride and take food stamps. “’It’s time for us to face up to the fact that in this country of plenty, there are hungry people,’” says SNAP’s director. “The program’s growing reach can be seen in a corner of southwestern Ohio where red state politics reign and blue-collar workers have often called food stamps a sign of laziness,” the Times tells us. But, of course, it is not “laziness” when it is you.
It is hard to think of this without thinking of the multi-billion dollar bailouts given to the bankers and financiers so that they could continue to give themselves huge bonuses. While it may be true that these companies were too big to fail, there is no reason that they had to use our tax money to pay their employees, each of whom is only a person, just like the people who are increasingly in need of food stamps. We are told that some statistics, such as that the rate of job losses are slowing, indicate that “we” as a country may be on our way out of the recession, but that still means that there are fewer people working each month than there were the month before; I don’t think such statistics mean as much to the more of “we” who are out of work each month as the statistics showing the increase in folks on food stamps. I don’t think that it makes the six people looking for each available job feel much better.
I am still marveling at the juxtaposition of the food stamp story with an advertisement in the program for a concern I recently went to. Under the photo of a sultry and glamorous beauty in a gown leaning against an elegant bar with a glass in one hand, the text says: “The glass is half full…of champagne. The more than 97 percent of KC consumers who spend $27,000 , or more, per month on personal luxuries subscribe to one necessity every month – KC Magazine.” I am sorry that it is not online and I can’t reproduce it. I had to read that several times to be sure I hadn’t read it wrong – it is, after all, a tortured sentence. Yes, $27,000. A month. That’s a lot of money. Over half the average annual household income in our region. But they’re not talking about income. They’re talking about luxuries. $27,000 a month on luxuries. $324,000 a year. Or more. In Kansas City, not even New York or LA. I am amazed at the audacity of it.
Paul Krugman’s recent column (“The Jobs Imperative”) calls for a new Works Progress Administration in which the government would directly create jobs. I don’t think this is going to happen because the Obama administration is not bold enough, and has never shown such boldness. It completely kowtowed to the financial sector, and is afraid to take on the right-wing bloviators in Congress who say they represent the American people when in fact all they want to do is to further screw the American people. Most of all it won’t happen because the Congress is owned by wealthy contributors, and doesn’t really work for the American people. It is a very sad situation, but at least we can be confident that few Congressmen, even when they retire, will require food stamps.
We as Americans seem, on so many fronts, to be unable to put ourselves in the position of others, even as we move toward that position. This is true in the area of reproductive rights, where younger women do not realize that if they don’t fight for it now, abortion could not be available when they need it (Sheryl Gay Stolberg, In Support of Abortion, It’s Personal vs. Political, New York Times November 29, 2009). It is true when we fail to realize that without a universal health insurance program, our access to health care can disappear with our jobs. It is also, clearly, true with regard to our basic human needs, such as food. In the Times story, the formerly-employed food stamp recipients of southeastern Ohio say “I always thought it was people trying to milk the system. But we just felt like we really needed the help right now,” and “I always thought people on public assistance were lazy, but it helps me know I can feed my kids.” So would “those people”. Maybe we need to start thinking about how what happens to some of us can happen to us all.
German Pastor Martin Niemöller wrote:
“First they came for the communists, and I did not speak out—because I was not a communist;
Then they came for the trade unionists, and I did not speak out—because I was not a trade unionist;
Then they came for the Jews, and I did not speak out—because I was not a Jew;
Then they came for me—and there was no one left to speak out for me.”
Most of us would agree with the woman in the Times article who said “I like to have a nice decent meal for dinner.” It’s not too much to ask that this be the goal of our national policies, and let the financiers and those people who are spending $27,000 a month – or more! – on “personal luxuries fend for themselves.
.
Saturday, November 28, 2009
Medicine and Social Justice – the First Year: An Index
.
Thanksgiving weekend – today, November 28, specifically – marks the first anniversary of the Medicine and Social Justice blog. I thought I would review the topics I have covered, grouping them generally into several areas. This might enable anyone interested in a topic (particularly one that is not very time-sensitive) to go back and look at old ones that they might not have read. Also, of course, it gives me a way to organize my collected works book. Right! J
I have chosen the groupings: Health Reform and Funding (43), Primary Care (11), Social Justice (21), General Medical Topics (23), Medical Education (6), Other (4) (largely memorials). A few are “double-listed”, and I didn’t list a few small ones, so the total number of columns is 110.
Health Reform and Funding
Friday, November 28, 2008: Universal Health Coverage
Monday, December 1, 2008: Medicare "Advantage": Your Gift to the Insurance Industry
Friday, December 5, 2008: Not Getting What We Pay For
Thursday, December 25, 2008: A Rational Health Care System
Tuesday, January 6, 2009: Enthoven: Consumer Choice Health Plan -- Again
Thursday, January 8, 2009: Sanjay Gupta for Surgeon General?
Saturday, February 7, 2009: Universal Health Insurance or Universal Quality Health Care?
Tuesday, March 3, 2009: Kathleen Sebelius as Secretary of HHS
Sunday, March 15, 2009: Bargaining down the medical bills
Sunday, April 5, 2009: "Sick Around America": A little bit sickening
Friday, April 10, 2009: Does the nation need a clear policy on a right to basic health care?
Wednesday, April 22, 2009: The “Basic Law of Modern Health Care”
Saturday, April 25, 2009: The Social Ethic and Covering Everyone: Reinhardt and Himmelstein
Saturday, May 2, 2009: Health disadvantages of Americans compared to Europeans
Wednesday, May 6, 2009: Health Care Thought Experiments: Mile Long Questions Traveling at the Speed of Light (Guest column by Donald Frey, MD)
Friday, May 8, 2009: What is wrong with the idea of "Consumer Directed Health Care": A "Technical" Answer to the "Thought Experiment" (Guest column by Robert Ferrer, MD)
Saturday, May 16, 2009: Health Care Industry Pledge to Cut Costs: No News at All
Thursday, May 28, 2009: "The Nation"'s Health Care Bottom Line is Bottom of the Barrel
Friday, June 5, 2009: Health Insurers "Balk"
Thursday, June 11, 2009: Medicare Costs: "All Politics are Local"
Monday, June 15, 2009: Health Reform and the "Public Option"
Thursday, June 18, 2009: “No Single Payer”: Sebelius – making policy for the powerful
Monday, June 22, 2009: Government sponsored health coverage: The Good, the Cautionary, and the Ugly
Wednesday, June 24, 2009: Dear Senator Brownback: A letter my Kansas Senator
Saturday, June 27, 2009: Dear Senator Brownback, #2
Sunday, July 5, 2009: European vs. US Health Systems: Which one has the real drawbacks?
Wednesday, July 8, 2009: Proposals to Tax Health Benefits and Institute Individual Mandates
Saturday, July 25, 2009: Integrated Health Systems or Thinking Inside the Box?
Thursday, August 6, 2009: Doctors, their Patients, and Health Reform
Tuesday, August 11, 2009: Health Care Shoutdowns: Liars and Demagogues
Wednesday, August 19, 2009: Advance Directives, not "Death Panels"
Sunday, August 23, 2009: A Modest Proposal: Bribe the Insurance Companies
Wednesday, August 26, 2009: The "Super Rich" and Our Healthcare
Sunday, August 30, 2009: Senator Ted Kennedy, Social Justice, and Healthcare for the People
Thursday, September 3, 2009: Public / Private Funding: We're All in This Together
Tuesday, September 8, 2009: Will the President turn the “health reform” discussion around to real reform? Can he?
Monday, September 21, 2009: Medicare for All: Moran's logic, not the idea, is flawed
Wednesday, September 30, 2009: Some good, but a lot still wrong, in health reform bills
Sunday, October 4, 2009: Seniors and Medicare: Beware not simply "Scare Mongers" but lying hypocrites
Tuesday, October 20, 2009: Red, Blue, and Purple: The Math of Health Care Spending
Wednesday, November 4, 2009: Poverty and Uninsurance Diverge: So let’s solve the problem!
Sunday, November 8, 2009: Celebrating the Defeat of the Opponents of Health Reform
Thursday, November 12, 2009: HR 3962 is still a bad bill, and Stupak-Pitts is a scandal
Primary Care
Thursday, December 11, 2008: A Quality Health System Needs More Primary Care Physicians
Friday, January 2, 2009: Student Debt, Resident Hours, and Primary Care Redux
Thursday, January 15, 2009: Ten Biggest Myths Regarding Primary Care in the Future (Guest Column: Robert Bowman, MD)
Friday, April 3, 2009: More Primary Care Doctors or Just More Doctors?
Wednesday, April 29, 2009: Primary Care Shortage makes Times Front Page
Thursday, May 21, 2009: Primary Care, Pediatrics, and Physician Distribution
Sunday, July 12, 2009: The Primary Care Extension Service
Thursday, September 3, 2009: Public / Private Funding: We're All in This Together
Thursday, October 8, 2009: "Uncomplicated" Primary Care?
Wednesday, October 14, 2009: "War on Specialists?": Wall St. Journal defends the status quo!
Tuesday, November 17, 2009: Primary Care’s Image: A Problem?
Social Justice
Saturday, November 29, 2008: Mumbai, Valley Stream, and the Economic Meltdown
Wednesday, December 17, 2008: Notes on Diversity
Sunday, December 21, 2008:The financial sector, for a change…
Tuesday, January 27, 2009: Social Justice: Economic Stimulus and Bailout
Sunday, January 11, 2009:Mr. Bush’s Legacy: The Global Gag Rule
Friday, January 23, 2009: President Obama rescinds Global Gag Rule
Monday, January 19, 2009: Martin Luther King, Jr. Day and the Inauguration
Monday, February 9, 2009: Masters of the Universe: They need a long fall
Sunday, February 15, 2009: New Orleans: Have we still no shame?
Wednesday, March 4, 2009: Quote of the Day (with apologies to Don McCanne)
Tuesday, March 24, 2009: Mexican Murders and US Guns
Saturday, April 18, 2009: Medical Ethics and Social Justice
Wednesday, July 1, 2009: Stonewall: 40 years Later
Sunday, August 2, 2009: Not "Special Interests": The Wealthy and Powerful
Sunday, August 16, 2009: Should it be a crime to be poor, or, instead, to criminalize poverty?
Sunday, August 30, 2009: Senator Ted Kennedy, Social Justice, and Healthcare for the People
Wednesday, September 16, 2009: Joe Wilson: Racism in America rears its ugly head
Monday, October 12, 2009: Lessons from World War I
Saturday, October 17, 2009: The actions of criminal settlers in Israel cannot be allowed to define the Jewish people
Friday, October 23, 2009: "Wall St. Smarts"? Maybe the smart people should be doing something productive
Sunday, November 22, 2009: Health Workers and Our Wars (Guest column by Seiji Yamada, MD)
General Medical Topics
Thursday, December 4, 2008: Hospitalists
Monday, December 8, 2008: Physician Conflict of Interest
Tuesday, December 30, 2008: Community Health Centers
Thursday, January 22, 2009: The "Neurontin Legacy"
Monday, February 2, 2009: Prevention and Cost
Friday, February 13, 2009: Economics and Disease Prevention
Thursday, February 19, 2009: Performing procedures: Who is capable and how should we pay?
Tuesday, February 24, 2009: Quality and Chronic Disease Management
Thursday, February 26, 2009: Defining "Streetlight" Research
Saturday, March 7, 2009: “The Feminization of Medicine and Population Health…”
Wednesday, March 11, 2009: “Conservative” Drug Prescribing
Saturday, March 21, 2009: PSA Screening: What is the value?
Thursday, March 26, 2009: Medicare Costs in Rural America: A case of reaping what we haven't sown? (Guest column by Donald Frey, MD)
Monday, March 30, 2009: Immigrant and Refugee Health
Tuesday, April 14, 2009: Conscientious Objection in Medicine
Saturday, April 18, 2009: Medical Ethics and Social Justice
Tuesday, May 12, 2009: Clinical Guidelines and Technology Assessment
Wednesday, May 13, 2009: Addendum: Medtronic back in the news
Thursday, July 16, 2009: Fetal Monitoring: Why it will continue
Wednesday, July 29, 2009: Prevention and the “Trap of Meaning”
Tuesday, October 27, 2009: PSA Screening: “One of Medicine's Great Success Stories"? (Guest column by Robert Ferrer, MD MPH)
Saturday, October 31, 2009: Dietary Supplements can be Dangerous for your Health
Wednesday, November 25, 2009: Breast Cancer Screening and Evidence-based Medicine
Medical Education
Wednesday, December 3, 2008: Medical Resident Work Hours
Tuesday, December 9, 2008: Resident Work Hours: Addendum
Sunday, December 14, 2008: Medical Student Selection
Monday, May 25, 2009: Funding Graduate Medical Education
Saturday, September 12, 2009: Are we training physicians to be empathic? Apparently not.
Friday, September 25, 2009: Rankings of Medical Schools: Do they tell us anything?
Other
Sunday, November 30, 2008: Steven B. Tamarin, MD
Sunday, May 31, 2009: In Memoriam George Tiller
Monday, June 8, 2009: More on Dr. Tiller
Sunday, November 22, 2009: Health Workers and Our Wars (Guest column by Seiji Yamada, MD)
If you have been following Medicine and Social Justice since early on, or are a new follower, or an occasional visitor, you may want to see if there are any that you missed and are of interest to you.
And, in the spirit of the season, I thank you very much for your time and attention, and hope that it has been worth the investment.
.
Thanksgiving weekend – today, November 28, specifically – marks the first anniversary of the Medicine and Social Justice blog. I thought I would review the topics I have covered, grouping them generally into several areas. This might enable anyone interested in a topic (particularly one that is not very time-sensitive) to go back and look at old ones that they might not have read. Also, of course, it gives me a way to organize my collected works book. Right! J
I have chosen the groupings: Health Reform and Funding (43), Primary Care (11), Social Justice (21), General Medical Topics (23), Medical Education (6), Other (4) (largely memorials). A few are “double-listed”, and I didn’t list a few small ones, so the total number of columns is 110.
Health Reform and Funding
Friday, November 28, 2008: Universal Health Coverage
Monday, December 1, 2008: Medicare "Advantage": Your Gift to the Insurance Industry
Friday, December 5, 2008: Not Getting What We Pay For
Thursday, December 25, 2008: A Rational Health Care System
Tuesday, January 6, 2009: Enthoven: Consumer Choice Health Plan -- Again
Thursday, January 8, 2009: Sanjay Gupta for Surgeon General?
Saturday, February 7, 2009: Universal Health Insurance or Universal Quality Health Care?
Tuesday, March 3, 2009: Kathleen Sebelius as Secretary of HHS
Sunday, March 15, 2009: Bargaining down the medical bills
Sunday, April 5, 2009: "Sick Around America": A little bit sickening
Friday, April 10, 2009: Does the nation need a clear policy on a right to basic health care?
Wednesday, April 22, 2009: The “Basic Law of Modern Health Care”
Saturday, April 25, 2009: The Social Ethic and Covering Everyone: Reinhardt and Himmelstein
Saturday, May 2, 2009: Health disadvantages of Americans compared to Europeans
Wednesday, May 6, 2009: Health Care Thought Experiments: Mile Long Questions Traveling at the Speed of Light (Guest column by Donald Frey, MD)
Friday, May 8, 2009: What is wrong with the idea of "Consumer Directed Health Care": A "Technical" Answer to the "Thought Experiment" (Guest column by Robert Ferrer, MD)
Saturday, May 16, 2009: Health Care Industry Pledge to Cut Costs: No News at All
Thursday, May 28, 2009: "The Nation"'s Health Care Bottom Line is Bottom of the Barrel
Friday, June 5, 2009: Health Insurers "Balk"
Thursday, June 11, 2009: Medicare Costs: "All Politics are Local"
Monday, June 15, 2009: Health Reform and the "Public Option"
Thursday, June 18, 2009: “No Single Payer”: Sebelius – making policy for the powerful
Monday, June 22, 2009: Government sponsored health coverage: The Good, the Cautionary, and the Ugly
Wednesday, June 24, 2009: Dear Senator Brownback: A letter my Kansas Senator
Saturday, June 27, 2009: Dear Senator Brownback, #2
Sunday, July 5, 2009: European vs. US Health Systems: Which one has the real drawbacks?
Wednesday, July 8, 2009: Proposals to Tax Health Benefits and Institute Individual Mandates
Saturday, July 25, 2009: Integrated Health Systems or Thinking Inside the Box?
Thursday, August 6, 2009: Doctors, their Patients, and Health Reform
Tuesday, August 11, 2009: Health Care Shoutdowns: Liars and Demagogues
Wednesday, August 19, 2009: Advance Directives, not "Death Panels"
Sunday, August 23, 2009: A Modest Proposal: Bribe the Insurance Companies
Wednesday, August 26, 2009: The "Super Rich" and Our Healthcare
Sunday, August 30, 2009: Senator Ted Kennedy, Social Justice, and Healthcare for the People
Thursday, September 3, 2009: Public / Private Funding: We're All in This Together
Tuesday, September 8, 2009: Will the President turn the “health reform” discussion around to real reform? Can he?
Monday, September 21, 2009: Medicare for All: Moran's logic, not the idea, is flawed
Wednesday, September 30, 2009: Some good, but a lot still wrong, in health reform bills
Sunday, October 4, 2009: Seniors and Medicare: Beware not simply "Scare Mongers" but lying hypocrites
Tuesday, October 20, 2009: Red, Blue, and Purple: The Math of Health Care Spending
Wednesday, November 4, 2009: Poverty and Uninsurance Diverge: So let’s solve the problem!
Sunday, November 8, 2009: Celebrating the Defeat of the Opponents of Health Reform
Thursday, November 12, 2009: HR 3962 is still a bad bill, and Stupak-Pitts is a scandal
Primary Care
Thursday, December 11, 2008: A Quality Health System Needs More Primary Care Physicians
Friday, January 2, 2009: Student Debt, Resident Hours, and Primary Care Redux
Thursday, January 15, 2009: Ten Biggest Myths Regarding Primary Care in the Future (Guest Column: Robert Bowman, MD)
Friday, April 3, 2009: More Primary Care Doctors or Just More Doctors?
Wednesday, April 29, 2009: Primary Care Shortage makes Times Front Page
Thursday, May 21, 2009: Primary Care, Pediatrics, and Physician Distribution
Sunday, July 12, 2009: The Primary Care Extension Service
Thursday, September 3, 2009: Public / Private Funding: We're All in This Together
Thursday, October 8, 2009: "Uncomplicated" Primary Care?
Wednesday, October 14, 2009: "War on Specialists?": Wall St. Journal defends the status quo!
Tuesday, November 17, 2009: Primary Care’s Image: A Problem?
Social Justice
Saturday, November 29, 2008: Mumbai, Valley Stream, and the Economic Meltdown
Wednesday, December 17, 2008: Notes on Diversity
Sunday, December 21, 2008:The financial sector, for a change…
Tuesday, January 27, 2009: Social Justice: Economic Stimulus and Bailout
Sunday, January 11, 2009:Mr. Bush’s Legacy: The Global Gag Rule
Friday, January 23, 2009: President Obama rescinds Global Gag Rule
Monday, January 19, 2009: Martin Luther King, Jr. Day and the Inauguration
Monday, February 9, 2009: Masters of the Universe: They need a long fall
Sunday, February 15, 2009: New Orleans: Have we still no shame?
Wednesday, March 4, 2009: Quote of the Day (with apologies to Don McCanne)
Tuesday, March 24, 2009: Mexican Murders and US Guns
Saturday, April 18, 2009: Medical Ethics and Social Justice
Wednesday, July 1, 2009: Stonewall: 40 years Later
Sunday, August 2, 2009: Not "Special Interests": The Wealthy and Powerful
Sunday, August 16, 2009: Should it be a crime to be poor, or, instead, to criminalize poverty?
Sunday, August 30, 2009: Senator Ted Kennedy, Social Justice, and Healthcare for the People
Wednesday, September 16, 2009: Joe Wilson: Racism in America rears its ugly head
Monday, October 12, 2009: Lessons from World War I
Saturday, October 17, 2009: The actions of criminal settlers in Israel cannot be allowed to define the Jewish people
Friday, October 23, 2009: "Wall St. Smarts"? Maybe the smart people should be doing something productive
Sunday, November 22, 2009: Health Workers and Our Wars (Guest column by Seiji Yamada, MD)
General Medical Topics
Thursday, December 4, 2008: Hospitalists
Monday, December 8, 2008: Physician Conflict of Interest
Tuesday, December 30, 2008: Community Health Centers
Thursday, January 22, 2009: The "Neurontin Legacy"
Monday, February 2, 2009: Prevention and Cost
Friday, February 13, 2009: Economics and Disease Prevention
Thursday, February 19, 2009: Performing procedures: Who is capable and how should we pay?
Tuesday, February 24, 2009: Quality and Chronic Disease Management
Thursday, February 26, 2009: Defining "Streetlight" Research
Saturday, March 7, 2009: “The Feminization of Medicine and Population Health…”
Wednesday, March 11, 2009: “Conservative” Drug Prescribing
Saturday, March 21, 2009: PSA Screening: What is the value?
Thursday, March 26, 2009: Medicare Costs in Rural America: A case of reaping what we haven't sown? (Guest column by Donald Frey, MD)
Monday, March 30, 2009: Immigrant and Refugee Health
Tuesday, April 14, 2009: Conscientious Objection in Medicine
Saturday, April 18, 2009: Medical Ethics and Social Justice
Tuesday, May 12, 2009: Clinical Guidelines and Technology Assessment
Wednesday, May 13, 2009: Addendum: Medtronic back in the news
Thursday, July 16, 2009: Fetal Monitoring: Why it will continue
Wednesday, July 29, 2009: Prevention and the “Trap of Meaning”
Tuesday, October 27, 2009: PSA Screening: “One of Medicine's Great Success Stories"? (Guest column by Robert Ferrer, MD MPH)
Saturday, October 31, 2009: Dietary Supplements can be Dangerous for your Health
Wednesday, November 25, 2009: Breast Cancer Screening and Evidence-based Medicine
Medical Education
Wednesday, December 3, 2008: Medical Resident Work Hours
Tuesday, December 9, 2008: Resident Work Hours: Addendum
Sunday, December 14, 2008: Medical Student Selection
Monday, May 25, 2009: Funding Graduate Medical Education
Saturday, September 12, 2009: Are we training physicians to be empathic? Apparently not.
Friday, September 25, 2009: Rankings of Medical Schools: Do they tell us anything?
Other
Sunday, November 30, 2008: Steven B. Tamarin, MD
Sunday, May 31, 2009: In Memoriam George Tiller
Monday, June 8, 2009: More on Dr. Tiller
Sunday, November 22, 2009: Health Workers and Our Wars (Guest column by Seiji Yamada, MD)
If you have been following Medicine and Social Justice since early on, or are a new follower, or an occasional visitor, you may want to see if there are any that you missed and are of interest to you.
And, in the spirit of the season, I thank you very much for your time and attention, and hope that it has been worth the investment.
.
Wednesday, November 25, 2009
Breast Cancer Screening and Evidence-based Medicine
.
In case you’ve been in a coma for a while, the US Preventive Services Task Force (USPSTF), a federally-funded-but-independent group of scientists who evaluates the evidence regarding preventive care, has announced new guidelines on screening for breast cancer. It has generated an amazing amount of comment, from physicians, patients, advocacy groups, politicians, and journalists. Every possible position on the issue, from thoughtful and balanced to alarmist and opportunist, has been taken and published by someone. For a quick review of articles just in the New York Times in the last few days we have:
November 17:
“Panel Urges Mammograms at 50, Not 40”
November 18:
“New Mammogram Advice Finds a Skeptical Audience”,
“Many Doctors to Stay Course on Breast Exams for Now”
November 19:
“Screening Policy Won’t Change, U.S. Officials Say“
Columnist Gail Collins: “Breast Brouhaha”
November 20:
Kevin Sack, News Analysis: “Medical Science and Practice in Conflict”
“Mammogram Debate Took Group by Surprise”
Therefore, the wise course might be for me to stop here, let you read everyone else, and not get involved. Of course, I won’t. Let me start by discussing the discovery, use, and application of evidence in medicine, and in particular with the USPSTF.
Disclaimer: I don’t work for, or have any relationship, financial or otherwise, with USPSTF, but I do believe that the responsible practice of medicine requires keeping up with the evidence and changing practices as new information becomes known; it should not be a “faith-based” effort.
Medical evidence for anything, including appropriate preventive services, gathers slowly. Studies are first done on high-risk populations, then later on average or low risk. Depending on the variables looked at, and the population studied, different information can emerge. Rarely (but sometimes) is the data from one good study on the same population directly opposite that of previous studies; more likely it will be similar, but might be of a greater or lesser degree of magnitude. Or just different enough to tip the risk/benefit balance. Because virtually never is anything – a treatment, a diagnostic test, a preventive activity – all good or all bad. There are benefits, real or potential, and risks, of varying degree. As new evidence accumulates, it tends to move the scales, or the seesaw, more down or up on one side or the other. Usually not enough to drop one end to the ground, but sometimes enough to tip the balance. And new studies are being done all the time, and it is not only hard to keep up, it is hard to assess the changes in risk. But it must be assessed, because it would be wrong to just keep doing what you were doing when the evidence changes.
That is the incredibly valuable service that the USPSTF has been providing since it was first convened in 1984. Evaluating, the existing studies and making recommendations – to clinicians – on what they should discuss with their patients. They are not really for patients, although this seems to be where much of the confusion is. Much of the coverage is about individual women trying to decide what to do – or reacting “against” the recommendations. The Times article cited above, “Many Doctors to Stay Course on Breast Exams for Now”, includes this: “Patients are already trying to figure out what the recommendations mean.” It means they should discuss them with their health care provider.
USPSTF assigns both a grade and a level of certainty to its recommendations. The grades are A, B, C, D, and I, and the levels of certainty are high, moderate, and low, and are described at the USPSTF website, at http://www.ahrq.gov/clinic/uspstf/grades.htm. When the grade is A or B, the procedure is recommended to clinicians in practice; when the grade is C it is generally not recommended, but there may be individuals or situations in which the benefit would exceed the risk; when it is D, it is not recommended. A grade of I means there is insufficient evidence to assess whether there is net benefit.
USPSTF is not the only group that makes recommendations. Many medical professional organizations and advocacy groups (such as the American Cancer Society and the American Heart Association) also make recommendations. However, the USPSTF is independent and has no “dog in the fight”, no financial or emotional attachment to an outcome. For example, after these recent recommendations were announced, suggesting most women start receiving mammograms later, and have them less often, the American College of Radiology (ACR) announced its disagreement with them. I’m sorry, but the fact that radiologists have an obvious financial stake in doing more mammograms has to make their opinion more suspect.
Certainly doing fewer mammograms will save money for insurers (including the government, for Medicare patients). In the current climate of our debate on health reform, some have seen these recommendations as an effort by these insurers to save money, and others have noted that, because of this, the timing of the announcement was “unfortunate”. However, unlike the ACR, the members of the USPSTF have no financial stake in their truly independent recommendations. I, for one, absolutely consider them to be the most valid source of independent analysis and advice.
What about these specific recommendations? They make sense to me, and are supported by the evidence. The recommendation that mammography begin at 40, rather than 50, only dates back to 2002, and was controversial at that time.
“In 2002…,” reports the Times in Panel Urges Mammograms at 50, Not 40, “When the group recommended mammograms for women in their 40s, some charged the report was politically motivated. But Dr. Alfred Berg of the University of Washington, who was the task force chairman at the time, said ‘there was absolutely zero political influence on what the task force did.’ It was still a tough call to make, Dr. Berg said, adding that ‘we pointed out that the benefit will be quite small.’ In fact, he added, even though mammograms are of greater benefit to older women, they still prevent only a small fraction of breast cancer deaths.” In the last 7 years more studies have come out, which have weakened the relative benefit to risk ratio for women between 40 and 50 who are at average risk for breast cancer.
In addition, the body of evidence does not suggest that there is significant additional benefit to screening every year rather than every two years. It also recommends against teaching self-breast examination (not against women doing it) – a “D” recommendation -- because there is good evidence from large population studies that it offers no advantage death or morbidity from breast cancer. Continuing screening of women over the age of 74, and doing clinical breast examination (by a physician or other clinician) in addition to mammography get “I” – insufficient evidence recommendations.
In the news analysis cited above, “Medical Science and Practice in Conflict”
“Mammogram Debate Took Group by Surprise”, Kevin Sack notes that “The backers of science-driven medicine, with its dual focus on risks and benefits, have cheered the elevation of data in the setting of standards. But many patients — and organizations of doctors and disease specialists — find themselves unready to accept the counterintuitive notion that more testing can be bad for your health.” But it certainly can be.
More, it should be obvious, is not always better, not only with fatty foods and salt, but with screening. The risks of unnecessary (read: too often for the risk level of the woman under consideration) mammograms is more than anxiety for false positives. It is also biopsy for false positives. And sometimes complications. And radiation exposure, which is not insignificant, and is, as we know, linked to causing cancer. Think: men get breast cancer also, but not at the rate that women do (about 1%). We do not screen men, because the risk/benefit ratio is way over to risk. Let me make clear that all of this discussion is about screening; by definition, someone who has NO symptoms. No lump, no discharge, no skin dimpling. They are not about diagnostic mammograms – examining someone with symptoms or physical findings, or a previous abnormal mammogram, and certainly do not apply to follow-up of people who have had breast cancer.
In “Many Doctors to Stay Course on Breast Exams for Now”, Dr. Annekathryn Goodman, director of the fellowship program in gynecological oncology at Massachusetts General Hospital, says “It’s kind of hard to suggest that we should stop examining our patients and screening them….I would be cautious about changing a practice that seems to work.” I hope that is not what she meant. What “seems to work”, while intuitively attractive, is not always correct. That is why we have independent bodies such as USPSTF continually examining the evidence.
.
In case you’ve been in a coma for a while, the US Preventive Services Task Force (USPSTF), a federally-funded-but-independent group of scientists who evaluates the evidence regarding preventive care, has announced new guidelines on screening for breast cancer. It has generated an amazing amount of comment, from physicians, patients, advocacy groups, politicians, and journalists. Every possible position on the issue, from thoughtful and balanced to alarmist and opportunist, has been taken and published by someone. For a quick review of articles just in the New York Times in the last few days we have:
November 17:
“Panel Urges Mammograms at 50, Not 40”
November 18:
“New Mammogram Advice Finds a Skeptical Audience”,
“Many Doctors to Stay Course on Breast Exams for Now”
November 19:
“Screening Policy Won’t Change, U.S. Officials Say“
Columnist Gail Collins: “Breast Brouhaha”
November 20:
Kevin Sack, News Analysis: “Medical Science and Practice in Conflict”
“Mammogram Debate Took Group by Surprise”
Therefore, the wise course might be for me to stop here, let you read everyone else, and not get involved. Of course, I won’t. Let me start by discussing the discovery, use, and application of evidence in medicine, and in particular with the USPSTF.
Disclaimer: I don’t work for, or have any relationship, financial or otherwise, with USPSTF, but I do believe that the responsible practice of medicine requires keeping up with the evidence and changing practices as new information becomes known; it should not be a “faith-based” effort.
Medical evidence for anything, including appropriate preventive services, gathers slowly. Studies are first done on high-risk populations, then later on average or low risk. Depending on the variables looked at, and the population studied, different information can emerge. Rarely (but sometimes) is the data from one good study on the same population directly opposite that of previous studies; more likely it will be similar, but might be of a greater or lesser degree of magnitude. Or just different enough to tip the risk/benefit balance. Because virtually never is anything – a treatment, a diagnostic test, a preventive activity – all good or all bad. There are benefits, real or potential, and risks, of varying degree. As new evidence accumulates, it tends to move the scales, or the seesaw, more down or up on one side or the other. Usually not enough to drop one end to the ground, but sometimes enough to tip the balance. And new studies are being done all the time, and it is not only hard to keep up, it is hard to assess the changes in risk. But it must be assessed, because it would be wrong to just keep doing what you were doing when the evidence changes.
That is the incredibly valuable service that the USPSTF has been providing since it was first convened in 1984. Evaluating, the existing studies and making recommendations – to clinicians – on what they should discuss with their patients. They are not really for patients, although this seems to be where much of the confusion is. Much of the coverage is about individual women trying to decide what to do – or reacting “against” the recommendations. The Times article cited above, “Many Doctors to Stay Course on Breast Exams for Now”, includes this: “Patients are already trying to figure out what the recommendations mean.” It means they should discuss them with their health care provider.
USPSTF assigns both a grade and a level of certainty to its recommendations. The grades are A, B, C, D, and I, and the levels of certainty are high, moderate, and low, and are described at the USPSTF website, at http://www.ahrq.gov/clinic/uspstf/grades.htm. When the grade is A or B, the procedure is recommended to clinicians in practice; when the grade is C it is generally not recommended, but there may be individuals or situations in which the benefit would exceed the risk; when it is D, it is not recommended. A grade of I means there is insufficient evidence to assess whether there is net benefit.
USPSTF is not the only group that makes recommendations. Many medical professional organizations and advocacy groups (such as the American Cancer Society and the American Heart Association) also make recommendations. However, the USPSTF is independent and has no “dog in the fight”, no financial or emotional attachment to an outcome. For example, after these recent recommendations were announced, suggesting most women start receiving mammograms later, and have them less often, the American College of Radiology (ACR) announced its disagreement with them. I’m sorry, but the fact that radiologists have an obvious financial stake in doing more mammograms has to make their opinion more suspect.
Certainly doing fewer mammograms will save money for insurers (including the government, for Medicare patients). In the current climate of our debate on health reform, some have seen these recommendations as an effort by these insurers to save money, and others have noted that, because of this, the timing of the announcement was “unfortunate”. However, unlike the ACR, the members of the USPSTF have no financial stake in their truly independent recommendations. I, for one, absolutely consider them to be the most valid source of independent analysis and advice.
What about these specific recommendations? They make sense to me, and are supported by the evidence. The recommendation that mammography begin at 40, rather than 50, only dates back to 2002, and was controversial at that time.
“In 2002…,” reports the Times in Panel Urges Mammograms at 50, Not 40, “When the group recommended mammograms for women in their 40s, some charged the report was politically motivated. But Dr. Alfred Berg of the University of Washington, who was the task force chairman at the time, said ‘there was absolutely zero political influence on what the task force did.’ It was still a tough call to make, Dr. Berg said, adding that ‘we pointed out that the benefit will be quite small.’ In fact, he added, even though mammograms are of greater benefit to older women, they still prevent only a small fraction of breast cancer deaths.” In the last 7 years more studies have come out, which have weakened the relative benefit to risk ratio for women between 40 and 50 who are at average risk for breast cancer.
In addition, the body of evidence does not suggest that there is significant additional benefit to screening every year rather than every two years. It also recommends against teaching self-breast examination (not against women doing it) – a “D” recommendation -- because there is good evidence from large population studies that it offers no advantage death or morbidity from breast cancer. Continuing screening of women over the age of 74, and doing clinical breast examination (by a physician or other clinician) in addition to mammography get “I” – insufficient evidence recommendations.
In the news analysis cited above, “Medical Science and Practice in Conflict”
“Mammogram Debate Took Group by Surprise”, Kevin Sack notes that “The backers of science-driven medicine, with its dual focus on risks and benefits, have cheered the elevation of data in the setting of standards. But many patients — and organizations of doctors and disease specialists — find themselves unready to accept the counterintuitive notion that more testing can be bad for your health.” But it certainly can be.
More, it should be obvious, is not always better, not only with fatty foods and salt, but with screening. The risks of unnecessary (read: too often for the risk level of the woman under consideration) mammograms is more than anxiety for false positives. It is also biopsy for false positives. And sometimes complications. And radiation exposure, which is not insignificant, and is, as we know, linked to causing cancer. Think: men get breast cancer also, but not at the rate that women do (about 1%). We do not screen men, because the risk/benefit ratio is way over to risk. Let me make clear that all of this discussion is about screening; by definition, someone who has NO symptoms. No lump, no discharge, no skin dimpling. They are not about diagnostic mammograms – examining someone with symptoms or physical findings, or a previous abnormal mammogram, and certainly do not apply to follow-up of people who have had breast cancer.
In “Many Doctors to Stay Course on Breast Exams for Now”, Dr. Annekathryn Goodman, director of the fellowship program in gynecological oncology at Massachusetts General Hospital, says “It’s kind of hard to suggest that we should stop examining our patients and screening them….I would be cautious about changing a practice that seems to work.” I hope that is not what she meant. What “seems to work”, while intuitively attractive, is not always correct. That is why we have independent bodies such as USPSTF continually examining the evidence.
.
Sunday, November 22, 2009
Health Workers and Our Wars
.
This guest column is by Seiji Yamada, MD, a family physician, Associate Professor of Complementary and Alternative Medicine at the University of Hawai’i John A. Burns School of Medicine, and one of my mentors. This essay is an expansion of the one that was published in the AAMC journal Academic Medicine, chosen as one of the five best responses to the question put forth by editor Steven Kanter “How can academic medicine respond to peace-building efforts worldwide?”. Dr. Yamada’s original essay, “Academic medicine should start at home”, is at http://journals.lww.com/academicmedicine/Fulltext/2009/11000/Academic_Medicine_Should_Start_at_Home.18.aspx
Health Workers and Our Wars
What is the responsibility of American health workers with regard to our nation’s wars in Iraq, Afghanistan, and Pakistan? As Americans, our primary responsibility should be to influence the actions of our own government. As health workers, our expertise is in the realm of morbidity and mortality, encompassing the direct effects of violence as well as the indirect effects arising from the collapse of health services, poor access to water and food, and damage to infrastructure, economies, and societies. Thus, we should monitor our government’s actions, apply the scientific methods at our disposal, apply the moral and ethical principles to which we subscribe, formulate and recommend policy, and disseminate our findings to the people. In a democracy, the citizenry would then determine the course of action.
During this decade, our nation has been responsible for invading and occupying two countries halfway around the globe—Afghanistan since 2001 and Iraq since 2003. In the case of Iraq, the invasion of 2003 was preceded by comprehensive economic sanctions, which hampered the rebuilding of its infrastructure after the Gulf War of 1991. The consequences included childhood deaths, mental illness, juvenile delinquency, begging and prostitution, as well as cultural and scientific impoverishment.[1]
In 2002-03, the American people were not convinced by the Bush administration that war on Iraq was justified. However, despite massive demonstrations against the war prior to its launch, the intellectual classes, the corporate media, and our elected representatives went along with the administration. Democracy failed us in this respect. Prior to the war, we health workers should have been recounting the health toll of the First Gulf War and the sanctions regime. With its onset, we should have been disseminating the images and recounting the narratives of casualties of the war.[2] As it progressed, we should have been acutely interested in the number of casualties caused by the war. The best estimates for deaths among Iraqis are those of the July 2006 epidemiological survey that reported 655,000 deaths as a consequence of war.[3] This study did not distinguish among civilians, military, and irregular combatants. While its authors have been criticized for breaches in the non-identification of participants, the study is nevertheless considered the most accurate estimate.[4]
Insofar as we have failed to pay attention to such findings, American health workers have failed its constituents.
At the mention of history or political economy, many health workers groan. We are not interested in politics, they say. But unreflective citizens repeat the blather that they are fed by the corporate media. We need advocate for the cause of health—in particular for the health of those whose voices are otherwise unheard, whose deaths are otherwise uncounted, unmourned, unopposed, and unorganized against. In order to do so, our analysis must be geographically broad and historically deep, as Paul Farmer urges us.
As the United States pulls its troops out of Iraq and sends them to Afghanistan, as our military wields drones called Predator and Reaper in Pakistan, we should concern ourselves with whether the cause of peace is thereby served by such acts. Our commander-in-chief is apparently now reflecting upon whether to double down (again) in Afghanistan and pursue counterinsurgency, as urged upon him by his general in the theater.[5]
Apparently, “counterinsurgency” no longer connotes Vietnam or Central America.[6] But the “clear and hold” strategy utilized late in the Vietnam War was characterized by indiscriminate shelling and bombing of villages[7] and ran concurrently with the Phoenix program of torture and assassination.[8] Extrajudicial killings in the Federally Administered Tribal Areas of Pakistan are now being carried out by the CIA by missile attacks by drones, with the deaths of many innocents.[9] Of 701 people killed in 60 attacks in FATA between January 2008 and April 2009, fourteen were suspected militants.[10]
The British and the Soviets failed in their attempts to militarily control Afghanistan, while inflicting untold casualties on the populace. The Soviet Union’s invasion of Afghanistan proved to be its Vietnam. One would think that our own country would not repeat its mistakes in Vietnam, but our wars in Iraq and Afghanistan’s go on. As American health workers, we must concern ourselves with the morbidity and mortality caused by our own government’s actions. Let us get to work.
References
[1] Save the Children UK. Iraq sanctions: humanitarian implications and options for the future. Available at: (http://www.globalpolicy.org/component/content/article/170/41947.html). Accessed July 21, 2009
[2] Yamada S, Fawzi MC, Maskarinec GG, Farmer PE. Casualties: narrative and images of the war on Iraq. Int J Health Serv. 2006; 36(2):401-15
[3] Burnham G, Lafta R, Doocey S, Roberts L. Mortality after the 2003 invasion of Iraq: a cross-sectional cluster sample survey. Lancet 2006; 368: 1421–28.
[4] Tapp C, Burkle FM, Wilson K, et al. Iraq War mortality estimates. Conflict & Health 2008;2:1-13.
[5] Filkins D. Stanley McChrystal’s long war. New York Times Magazine, Oct 18, 2009.
[6] Parry R. Bush’s death squads. In These Times, Jan 17, 2005. Available at (http://www.inthesetimes.com/site/main/article/1872/). Accessed Jan 23, 2005.
[7] Steinglass M. Vietnam and victory. Boston Globe, Dec 18, 2005. Available at (http://www.boston.com/news/globe/ideas/articles/2005/12/18/vietnam_and_victory/). Accessed Sep 27, 2009.
[8] Chomsky N, Herman ES. The Washington connection and third world fascism. Boston, MA: South End Press, 1979.
[9] Mayer J. The predator war. New Yorker, Oct 26, 2009. Available at (http://www.newyorker.com/reporting/2009/10/26/091026fa_fact_mayer). Accessed Nov 15, 2009.
[10] Ahmad MI. Pakistan creates its own enemy. Le Monde Diplomatique. Nov 2009. Available at (http://mondediplo.com/2009/11/02pakistan). Accessed Nov 5, 2009.
This guest column is by Seiji Yamada, MD, a family physician, Associate Professor of Complementary and Alternative Medicine at the University of Hawai’i John A. Burns School of Medicine, and one of my mentors. This essay is an expansion of the one that was published in the AAMC journal Academic Medicine, chosen as one of the five best responses to the question put forth by editor Steven Kanter “How can academic medicine respond to peace-building efforts worldwide?”. Dr. Yamada’s original essay, “Academic medicine should start at home”, is at http://journals.lww.com/academicmedicine/Fulltext/2009/11000/Academic_Medicine_Should_Start_at_Home.18.aspx
Health Workers and Our Wars
What is the responsibility of American health workers with regard to our nation’s wars in Iraq, Afghanistan, and Pakistan? As Americans, our primary responsibility should be to influence the actions of our own government. As health workers, our expertise is in the realm of morbidity and mortality, encompassing the direct effects of violence as well as the indirect effects arising from the collapse of health services, poor access to water and food, and damage to infrastructure, economies, and societies. Thus, we should monitor our government’s actions, apply the scientific methods at our disposal, apply the moral and ethical principles to which we subscribe, formulate and recommend policy, and disseminate our findings to the people. In a democracy, the citizenry would then determine the course of action.
During this decade, our nation has been responsible for invading and occupying two countries halfway around the globe—Afghanistan since 2001 and Iraq since 2003. In the case of Iraq, the invasion of 2003 was preceded by comprehensive economic sanctions, which hampered the rebuilding of its infrastructure after the Gulf War of 1991. The consequences included childhood deaths, mental illness, juvenile delinquency, begging and prostitution, as well as cultural and scientific impoverishment.[1]
In 2002-03, the American people were not convinced by the Bush administration that war on Iraq was justified. However, despite massive demonstrations against the war prior to its launch, the intellectual classes, the corporate media, and our elected representatives went along with the administration. Democracy failed us in this respect. Prior to the war, we health workers should have been recounting the health toll of the First Gulf War and the sanctions regime. With its onset, we should have been disseminating the images and recounting the narratives of casualties of the war.[2] As it progressed, we should have been acutely interested in the number of casualties caused by the war. The best estimates for deaths among Iraqis are those of the July 2006 epidemiological survey that reported 655,000 deaths as a consequence of war.[3] This study did not distinguish among civilians, military, and irregular combatants. While its authors have been criticized for breaches in the non-identification of participants, the study is nevertheless considered the most accurate estimate.[4]
Insofar as we have failed to pay attention to such findings, American health workers have failed its constituents.
At the mention of history or political economy, many health workers groan. We are not interested in politics, they say. But unreflective citizens repeat the blather that they are fed by the corporate media. We need advocate for the cause of health—in particular for the health of those whose voices are otherwise unheard, whose deaths are otherwise uncounted, unmourned, unopposed, and unorganized against. In order to do so, our analysis must be geographically broad and historically deep, as Paul Farmer urges us.
As the United States pulls its troops out of Iraq and sends them to Afghanistan, as our military wields drones called Predator and Reaper in Pakistan, we should concern ourselves with whether the cause of peace is thereby served by such acts. Our commander-in-chief is apparently now reflecting upon whether to double down (again) in Afghanistan and pursue counterinsurgency, as urged upon him by his general in the theater.[5]
Apparently, “counterinsurgency” no longer connotes Vietnam or Central America.[6] But the “clear and hold” strategy utilized late in the Vietnam War was characterized by indiscriminate shelling and bombing of villages[7] and ran concurrently with the Phoenix program of torture and assassination.[8] Extrajudicial killings in the Federally Administered Tribal Areas of Pakistan are now being carried out by the CIA by missile attacks by drones, with the deaths of many innocents.[9] Of 701 people killed in 60 attacks in FATA between January 2008 and April 2009, fourteen were suspected militants.[10]
The British and the Soviets failed in their attempts to militarily control Afghanistan, while inflicting untold casualties on the populace. The Soviet Union’s invasion of Afghanistan proved to be its Vietnam. One would think that our own country would not repeat its mistakes in Vietnam, but our wars in Iraq and Afghanistan’s go on. As American health workers, we must concern ourselves with the morbidity and mortality caused by our own government’s actions. Let us get to work.
References
[1] Save the Children UK. Iraq sanctions: humanitarian implications and options for the future. Available at: (http://www.globalpolicy.org/component/content/article/170/41947.html). Accessed July 21, 2009
[2] Yamada S, Fawzi MC, Maskarinec GG, Farmer PE. Casualties: narrative and images of the war on Iraq. Int J Health Serv. 2006; 36(2):401-15
[3] Burnham G, Lafta R, Doocey S, Roberts L. Mortality after the 2003 invasion of Iraq: a cross-sectional cluster sample survey. Lancet 2006; 368: 1421–28.
[4] Tapp C, Burkle FM, Wilson K, et al. Iraq War mortality estimates. Conflict & Health 2008;2:1-13.
[5] Filkins D. Stanley McChrystal’s long war. New York Times Magazine, Oct 18, 2009.
[6] Parry R. Bush’s death squads. In These Times, Jan 17, 2005. Available at (http://www.inthesetimes.com/site/main/article/1872/). Accessed Jan 23, 2005.
[7] Steinglass M. Vietnam and victory. Boston Globe, Dec 18, 2005. Available at (http://www.boston.com/news/globe/ideas/articles/2005/12/18/vietnam_and_victory/). Accessed Sep 27, 2009.
[8] Chomsky N, Herman ES. The Washington connection and third world fascism. Boston, MA: South End Press, 1979.
[9] Mayer J. The predator war. New Yorker, Oct 26, 2009. Available at (http://www.newyorker.com/reporting/2009/10/26/091026fa_fact_mayer). Accessed Nov 15, 2009.
[10] Ahmad MI. Pakistan creates its own enemy. Le Monde Diplomatique. Nov 2009. Available at (http://mondediplo.com/2009/11/02pakistan). Accessed Nov 5, 2009.
Tuesday, November 17, 2009
Primary Care’s Image: A Problem?
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Pauline Chen, a transplant surgeon and respected author of “Final Exam: A surgeon’s reflections on mortality” (Vintage Books) also write a “Doctor and Patient” column for the New York Times. On November 12, 2009, the topic was “Primary Care’s Image Problem”, in which she talks about the decreasing interest in primary care among medical students, and the perception among many, increased by many faculty members, that primary care was a backup to more “prestigious subspecialties…like dermatology, orthopedics, plastic surgery or radiology.” In particular, she talks of Kerry, one of her classmates, who wanted to (and did) enter primary care “despite” being at the top of her class, and how this amazed her friends. Dr. Chen addresses the attractions of the “ROAD” (radiology, ophthalmology, anesthesiology, and dermatology) to financial success as well as greater prestige, and the challenges it presents for having an adequate supply of primary care physicians.
While scarcely optimistic (“But even with current legislative efforts to address educational debt, payment discrepancies and lifestyle differences, many medical educators worry that the results will not be enough….Why? It is due to an issue deeper than money and paperwork. While the frisson of continually advancing treatments and approaches to patient care seem to envelope most other specialties, the image of primary care remains one of a vaguely anachronistic practice — a group of doctors who do not stand on the forefront of creative change and who are continually left holding the biggest bag of administrative expectations and clinical care coordination and demands.”), she also notes that “That image, however, may be changing”.
Dr. Chen attended a meeting of the Association of Deans and Directors for Primary Care, held in conjunction with the annual meeting of the Association of American Medical Colleges (AAMC) in Boston on November 9, 2009, where the discussion focused largely on changes in the type of practice, particularly in the creation of a “medical home” and a team approach to care. She quotes organization chair Bruce Gould, MD, of the University of Connecticut: “In a patient-centered medical home, I would not be the sole proprietor. Sometimes I would be the leader because of my specific skill set. But if we were dealing with adherence to diabetes care, the team’s social worker might be the leader….With a team approach each of us is freed up to practice at the top of our scope of training. And that leads to better patient outcomes and more job satisfaction.”
I admit that I found it somewhat frustrating, having been in the room, that the 3 physicians Dr. Chen quotes are all general internists, despite the fact that at least half the participants in the meeting and 2 of the 5 speakers were family doctors. I agree with the general theme expressed by many that it is important for primary care doctors to work together and not fight, but there are important differences in these specialties. In addition to the fact that family doctors care for adults and children and often pregnant women, the breadth of their practice makes them more suitable for rural practice, where there may be only a few doctors. While most family doctors do not practice in rural areas, about 20% do, which is comparable to the percent of the overall population; indeed, family medicine is the only specialty that “distributes” according to where people live.
More important for this discussion is that virtually all family physicians practice primary care, thus it is the primary care “bellwether”, going up more when student interest in primary care is up, and down more when it is down. Internal medicine, on the other hand, offers those who complete its 3-year residency the option of entering primary care / general internal medicine practice (or hospitalist practice, which is not primary care) or continuing into a subspecialty fellowship (cardiology, gastroenterology, pulmonary medicine, etc.); it is thus less sensitive to these ups and downs. As I have discussed previously (most recently in “Rankings of medical schools: do they tell us anything?” on September 25, 2009), the trend for general internal medicine is definitely down. General pediatrics, the third primary care specialty, has not seen a decrease, although the distribution and career trajectories are an issue, as I have discussed in “Primary care, pediatrics, and physician distribution” on May 21, 2009. Indeed, facing a shortage of pediatric subspecialists, many pediatrics groups are trying to encourage subspecialization.
Dr. Chen’s article ended with some guarded optimism, and an invitation to join the discussion on Tara Parker-Pope’s “Well blog”, “Giving primary care more respect”. With 180 responses (by November 16), it is clear that there are a lot of opinions out there, from physicians, medical students, other health professionals, and the general public. I admit to adding my comments, and “plugging” my October 8, 2009 blog piece “`Uncomplicated’ Primary Care?”, where I argue that primary care is anything but uncomplicated.
I thought that some comments on this from medical students on this issue might be welcome. The following comments are from students who spent 6 weeks with rural family physicians in Kansas between their first and second years of medical school, from quotes they gave to a reporter from the Kansas Family Physician, publication of the Kansas Academy of Family Physicians:
“This summer, I learned that people don’t choose family medicine because they want an easy profession. They choose it because they want to be life-long learners and truly want to help the community. Their knowledge base and diagnostic ability is no less than any specialist. The only difference they think ‘big picture’, and don’t focus on any one organ system.”
“A young man in his mid-30s came into the clinic. He was a partial quadriplegic of 15 years from a car accident. He was not there complaining of any acute symptoms or any problems; he was just there because he wanted to find a new doctor…Out of curiosity, I asked him what he was looking for in a physician. His only reply was: ‘I want someone who cares about me, not for me.’”
“I could not help but be impressed with the enormity of information family physicians are expected to ideally know. We are talking about working with every organ system of the body and also understanding the procedures and diagnostic tests that go along with these systems.”
“I learned family medicine is not simply caring for patients with chronic health issues or diagnosing and treating the common cold. While family physicians do both of those things almost every day, they also provide a variety of other care. They can deliver babies, provide women’s health, perform EGDs and colonoscopies, manage chronic pain, and diagnose extraordinarily well in the acute setting, just to list a small amount of what they do weekly.”
“Nothing compared to the feeling I got watching a family physician take care of the mother during delivery, perform an emergency C-section, and then treat the infant all within the same day. The ability of a family doctor to care for both mother and child simultaneously made me truly appreciate the rich complexity of family medicine.”
“A family physician should be held in the highest regard among physicians, for he or she must have the patience of a geriatrician, the gentleness of a pediatrician, the courage of an ER physician, the steady hand of a surgeon, and a knowledge base of every medical specialty.”
There are more, and many of them – which maybe I’ll post later – specifically talk to the role of the rural family doctor. Remember, these are not a random sample of students; they elected to do this experience. Many of them are from rural backgrounds and many are also planning careers in family medicine. All of them, having just finished their first year of medical school, have a long way to go before deciding on their specialty, and undoubtedly some will take some variant of the “ROAD”. We know from recent research that empathy takes a nose dive in the third year of medical school (“Are we training physicians to be empathic? Apparently not”, Sept 12, 2009).
However, it is great to hear these attitudes and know that at least among some students family medicine and primary care do not have an “image problem.” We can only hope that it persists in them, and in their peers. Hope, and do everything we can to foster it.
.
Pauline Chen, a transplant surgeon and respected author of “Final Exam: A surgeon’s reflections on mortality” (Vintage Books) also write a “Doctor and Patient” column for the New York Times. On November 12, 2009, the topic was “Primary Care’s Image Problem”, in which she talks about the decreasing interest in primary care among medical students, and the perception among many, increased by many faculty members, that primary care was a backup to more “prestigious subspecialties…like dermatology, orthopedics, plastic surgery or radiology.” In particular, she talks of Kerry, one of her classmates, who wanted to (and did) enter primary care “despite” being at the top of her class, and how this amazed her friends. Dr. Chen addresses the attractions of the “ROAD” (radiology, ophthalmology, anesthesiology, and dermatology) to financial success as well as greater prestige, and the challenges it presents for having an adequate supply of primary care physicians.
While scarcely optimistic (“But even with current legislative efforts to address educational debt, payment discrepancies and lifestyle differences, many medical educators worry that the results will not be enough….Why? It is due to an issue deeper than money and paperwork. While the frisson of continually advancing treatments and approaches to patient care seem to envelope most other specialties, the image of primary care remains one of a vaguely anachronistic practice — a group of doctors who do not stand on the forefront of creative change and who are continually left holding the biggest bag of administrative expectations and clinical care coordination and demands.”), she also notes that “That image, however, may be changing”.
Dr. Chen attended a meeting of the Association of Deans and Directors for Primary Care, held in conjunction with the annual meeting of the Association of American Medical Colleges (AAMC) in Boston on November 9, 2009, where the discussion focused largely on changes in the type of practice, particularly in the creation of a “medical home” and a team approach to care. She quotes organization chair Bruce Gould, MD, of the University of Connecticut: “In a patient-centered medical home, I would not be the sole proprietor. Sometimes I would be the leader because of my specific skill set. But if we were dealing with adherence to diabetes care, the team’s social worker might be the leader….With a team approach each of us is freed up to practice at the top of our scope of training. And that leads to better patient outcomes and more job satisfaction.”
I admit that I found it somewhat frustrating, having been in the room, that the 3 physicians Dr. Chen quotes are all general internists, despite the fact that at least half the participants in the meeting and 2 of the 5 speakers were family doctors. I agree with the general theme expressed by many that it is important for primary care doctors to work together and not fight, but there are important differences in these specialties. In addition to the fact that family doctors care for adults and children and often pregnant women, the breadth of their practice makes them more suitable for rural practice, where there may be only a few doctors. While most family doctors do not practice in rural areas, about 20% do, which is comparable to the percent of the overall population; indeed, family medicine is the only specialty that “distributes” according to where people live.
More important for this discussion is that virtually all family physicians practice primary care, thus it is the primary care “bellwether”, going up more when student interest in primary care is up, and down more when it is down. Internal medicine, on the other hand, offers those who complete its 3-year residency the option of entering primary care / general internal medicine practice (or hospitalist practice, which is not primary care) or continuing into a subspecialty fellowship (cardiology, gastroenterology, pulmonary medicine, etc.); it is thus less sensitive to these ups and downs. As I have discussed previously (most recently in “Rankings of medical schools: do they tell us anything?” on September 25, 2009), the trend for general internal medicine is definitely down. General pediatrics, the third primary care specialty, has not seen a decrease, although the distribution and career trajectories are an issue, as I have discussed in “Primary care, pediatrics, and physician distribution” on May 21, 2009. Indeed, facing a shortage of pediatric subspecialists, many pediatrics groups are trying to encourage subspecialization.
Dr. Chen’s article ended with some guarded optimism, and an invitation to join the discussion on Tara Parker-Pope’s “Well blog”, “Giving primary care more respect”. With 180 responses (by November 16), it is clear that there are a lot of opinions out there, from physicians, medical students, other health professionals, and the general public. I admit to adding my comments, and “plugging” my October 8, 2009 blog piece “`Uncomplicated’ Primary Care?”, where I argue that primary care is anything but uncomplicated.
I thought that some comments on this from medical students on this issue might be welcome. The following comments are from students who spent 6 weeks with rural family physicians in Kansas between their first and second years of medical school, from quotes they gave to a reporter from the Kansas Family Physician, publication of the Kansas Academy of Family Physicians:
“This summer, I learned that people don’t choose family medicine because they want an easy profession. They choose it because they want to be life-long learners and truly want to help the community. Their knowledge base and diagnostic ability is no less than any specialist. The only difference they think ‘big picture’, and don’t focus on any one organ system.”
“A young man in his mid-30s came into the clinic. He was a partial quadriplegic of 15 years from a car accident. He was not there complaining of any acute symptoms or any problems; he was just there because he wanted to find a new doctor…Out of curiosity, I asked him what he was looking for in a physician. His only reply was: ‘I want someone who cares about me, not for me.’”
“I could not help but be impressed with the enormity of information family physicians are expected to ideally know. We are talking about working with every organ system of the body and also understanding the procedures and diagnostic tests that go along with these systems.”
“I learned family medicine is not simply caring for patients with chronic health issues or diagnosing and treating the common cold. While family physicians do both of those things almost every day, they also provide a variety of other care. They can deliver babies, provide women’s health, perform EGDs and colonoscopies, manage chronic pain, and diagnose extraordinarily well in the acute setting, just to list a small amount of what they do weekly.”
“Nothing compared to the feeling I got watching a family physician take care of the mother during delivery, perform an emergency C-section, and then treat the infant all within the same day. The ability of a family doctor to care for both mother and child simultaneously made me truly appreciate the rich complexity of family medicine.”
“A family physician should be held in the highest regard among physicians, for he or she must have the patience of a geriatrician, the gentleness of a pediatrician, the courage of an ER physician, the steady hand of a surgeon, and a knowledge base of every medical specialty.”
There are more, and many of them – which maybe I’ll post later – specifically talk to the role of the rural family doctor. Remember, these are not a random sample of students; they elected to do this experience. Many of them are from rural backgrounds and many are also planning careers in family medicine. All of them, having just finished their first year of medical school, have a long way to go before deciding on their specialty, and undoubtedly some will take some variant of the “ROAD”. We know from recent research that empathy takes a nose dive in the third year of medical school (“Are we training physicians to be empathic? Apparently not”, Sept 12, 2009).
However, it is great to hear these attitudes and know that at least among some students family medicine and primary care do not have an “image problem.” We can only hope that it persists in them, and in their peers. Hope, and do everything we can to foster it.
.
Thursday, November 12, 2009
HR 3962 is still a bad bill, and Stupak-Pitts is a scandal
.
After the House of Representatives passed HR 3962 recently, I celebrated the defeat of the opponents of health reform. I tried to make it clear, and I will emphasize here below, that the bill is not only far from perfect, it is bad. I just think it would have been worse, a victory for those who wish to keep the status quo (for example, virtually all the Republicans). To my knowledge, Ohio congressman Dennis Kucinich is the only representative who voted against it from a progressive perspective, and I applaud him for that.
I was at a conference recently at which former Senator Tom Daschle spoke. He invited us to envision a huge stadium with the 300,000,000 Americans in it, and the President at the center asking “what should we do about health reform?”, and the huge multiplicity of opinions that would come. He then suggested that the Congress, with its 535 representatives and senators, was a microcosm of those people, expressing all their multiple beliefs. Well, maybe the multiple beliefs, but not in the same proportion. I feel quite certain that, while there would have been a lot of opponents, the 300,000,000 Americans would have been a lot more supportive of health reform, much more meaningful health reform, than the 535 representatives. This is because they don’t get huge contributions from lobbyists from the insurance industry, pharmaceutical industry, hospital industry, and other big corporations, as well as doctors and lawyers and other rich people. Congress does, and it definitely affects their way of seeing things.
HR 3962 is a bad bill that will finance insurance companies, not save money, and not cover all people. I think, I know, we can do better than that. A single-payer plan, for example, such as that proposed in the Medicare for All bill sponsored by Rep. John Conyers (D, MI), and almost voted on by the house in an amendment by Rep. Anthony Weiner (D, NY) to include single payer. This is actually quite a victory, that it came so close, given the efforts of both the Administration and the Congressional leadership to keep it “off the table” from the beginning of this debate. We can hope that, at least, the amendment sponsored by Rep. Kucinich permitting states to pilot single-payer plans, that passed out of committee with bipartisan support, will be considered. It would be a scandal to not allow those states that wished to to try to model a single-payer program.
Speaking of scandals, HR 3642 is further poisoned by the inclusion of the “Stupak-Pitts Amendment”, named after its sponsor, Michigan Democrat Bart Stupak, which not only continues the Hyde Amendment’s ban on the use of federal funds for abortions, it expands on it, by forbidding any plan that may have anyone getting a federal subsidy from offering coverage for abortion care. No “public option” can offer abortion coverage. This will mean that virtually no insurance policy will offer coverage for abortions, including the ones that do at the current time. Companies could offer two separate policies, so that portion of the population not getting subsidies (above 400% of poverty) could buy the other policy, but there is no evidence that they will do so. Under current state laws, five states offer the possibility of insurance companies offering “abortion riders”, allowed under Stupak-Pitts, but there is no evidence that any of them do. Women do not anticipate that they will need an abortion; like other medical care that may come unanticipated (such as the need for emergency surgery, or a diagnosis of cancer) it needs to be covered in the “regular” policy. See the excellent analysis by Jodi Jacobson, “The ‘Real Life’ Effects of Stupak-Pitts: An Analysis by Legal Experts at Planned Parenthood”, or at the Planned Parenthood site, http://plannedparenthoodaction.org/healthreform/668.htm.
The only exceptions allowed under Stupak-Pitts are for abortions resulting from rape, incest, or danger to the life of the mother. Note that this would not only include danger to the mental health of the mother, but would exclude terminations for fetal anomalies, even those incompatible with life. Thus, as is already the case in states such as Mississippi and Louisiana, which have such laws, women can get prenatal testing with ultrasound and amniocentesis, but have no legal access within their states for terminations if something is demonstrated to be wrong. They cannot even be referred. Luckily, at this time, they can go to other states. The Stupak amendment would make the current situation worse.
A group of at least 40 women in Congress, led by Diana DeGette of Colorado, have signed on to a letter demanding that Stupak-Pitts be removed from any final health reform bill. They deserve all the support that they can get, from other members of Congress, from their constituents, and from those who are residents in districts with representatives who voted for Stupak-Pitts. Note that this effort is led by women in Congress. This, obviously, is not a coincidence. Women are the people who get pregnant, including when it is not planned, including when the fetus has anomalies incompatible with life. There are many women, as well as men, who oppose abortion in the sense that they would not have one, that they might counsel friends and relatives not to have one, but also believe that the ultimate decision about what happens to a woman is hers, not theirs. There are also many women, as well as men, in Congress and in the public, who support the concept of Stupak-Pitts and Hyde and other restrictions on abortion, who believe it is their right to make decisions for other women. But none of the men will ever get pregnant themselves. There are many women who were strongly opposed to abortion who have had abortions because their circumstances were special. No men have had to. The role of men, including, obviously, the Catholic Bishops – who, amazingly, are all men! – in fighting for restrictions on abortion, is grossly immoral and offensive.
President Obama has indicated that he will seek some revision of Stupak-Pitts, as described in the New York Times article “Obama seeks revision of plan’s abortion limits”, but even his position would continue the Hyde Amendment restrictions. This has to stop. Women’s lives and health need to stop being the pawns of politicians.
After the House of Representatives passed HR 3962 recently, I celebrated the defeat of the opponents of health reform. I tried to make it clear, and I will emphasize here below, that the bill is not only far from perfect, it is bad. I just think it would have been worse, a victory for those who wish to keep the status quo (for example, virtually all the Republicans). To my knowledge, Ohio congressman Dennis Kucinich is the only representative who voted against it from a progressive perspective, and I applaud him for that.
I was at a conference recently at which former Senator Tom Daschle spoke. He invited us to envision a huge stadium with the 300,000,000 Americans in it, and the President at the center asking “what should we do about health reform?”, and the huge multiplicity of opinions that would come. He then suggested that the Congress, with its 535 representatives and senators, was a microcosm of those people, expressing all their multiple beliefs. Well, maybe the multiple beliefs, but not in the same proportion. I feel quite certain that, while there would have been a lot of opponents, the 300,000,000 Americans would have been a lot more supportive of health reform, much more meaningful health reform, than the 535 representatives. This is because they don’t get huge contributions from lobbyists from the insurance industry, pharmaceutical industry, hospital industry, and other big corporations, as well as doctors and lawyers and other rich people. Congress does, and it definitely affects their way of seeing things.
HR 3962 is a bad bill that will finance insurance companies, not save money, and not cover all people. I think, I know, we can do better than that. A single-payer plan, for example, such as that proposed in the Medicare for All bill sponsored by Rep. John Conyers (D, MI), and almost voted on by the house in an amendment by Rep. Anthony Weiner (D, NY) to include single payer. This is actually quite a victory, that it came so close, given the efforts of both the Administration and the Congressional leadership to keep it “off the table” from the beginning of this debate. We can hope that, at least, the amendment sponsored by Rep. Kucinich permitting states to pilot single-payer plans, that passed out of committee with bipartisan support, will be considered. It would be a scandal to not allow those states that wished to to try to model a single-payer program.
Speaking of scandals, HR 3642 is further poisoned by the inclusion of the “Stupak-Pitts Amendment”, named after its sponsor, Michigan Democrat Bart Stupak, which not only continues the Hyde Amendment’s ban on the use of federal funds for abortions, it expands on it, by forbidding any plan that may have anyone getting a federal subsidy from offering coverage for abortion care. No “public option” can offer abortion coverage. This will mean that virtually no insurance policy will offer coverage for abortions, including the ones that do at the current time. Companies could offer two separate policies, so that portion of the population not getting subsidies (above 400% of poverty) could buy the other policy, but there is no evidence that they will do so. Under current state laws, five states offer the possibility of insurance companies offering “abortion riders”, allowed under Stupak-Pitts, but there is no evidence that any of them do. Women do not anticipate that they will need an abortion; like other medical care that may come unanticipated (such as the need for emergency surgery, or a diagnosis of cancer) it needs to be covered in the “regular” policy. See the excellent analysis by Jodi Jacobson, “The ‘Real Life’ Effects of Stupak-Pitts: An Analysis by Legal Experts at Planned Parenthood”, or at the Planned Parenthood site, http://plannedparenthoodaction.org/healthreform/668.htm.
The only exceptions allowed under Stupak-Pitts are for abortions resulting from rape, incest, or danger to the life of the mother. Note that this would not only include danger to the mental health of the mother, but would exclude terminations for fetal anomalies, even those incompatible with life. Thus, as is already the case in states such as Mississippi and Louisiana, which have such laws, women can get prenatal testing with ultrasound and amniocentesis, but have no legal access within their states for terminations if something is demonstrated to be wrong. They cannot even be referred. Luckily, at this time, they can go to other states. The Stupak amendment would make the current situation worse.
A group of at least 40 women in Congress, led by Diana DeGette of Colorado, have signed on to a letter demanding that Stupak-Pitts be removed from any final health reform bill. They deserve all the support that they can get, from other members of Congress, from their constituents, and from those who are residents in districts with representatives who voted for Stupak-Pitts. Note that this effort is led by women in Congress. This, obviously, is not a coincidence. Women are the people who get pregnant, including when it is not planned, including when the fetus has anomalies incompatible with life. There are many women, as well as men, who oppose abortion in the sense that they would not have one, that they might counsel friends and relatives not to have one, but also believe that the ultimate decision about what happens to a woman is hers, not theirs. There are also many women, as well as men, in Congress and in the public, who support the concept of Stupak-Pitts and Hyde and other restrictions on abortion, who believe it is their right to make decisions for other women. But none of the men will ever get pregnant themselves. There are many women who were strongly opposed to abortion who have had abortions because their circumstances were special. No men have had to. The role of men, including, obviously, the Catholic Bishops – who, amazingly, are all men! – in fighting for restrictions on abortion, is grossly immoral and offensive.
President Obama has indicated that he will seek some revision of Stupak-Pitts, as described in the New York Times article “Obama seeks revision of plan’s abortion limits”, but even his position would continue the Hyde Amendment restrictions. This has to stop. Women’s lives and health need to stop being the pawns of politicians.
Sunday, November 8, 2009
Celebrating the Defeat of the Opponents of Health Reform
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Last night, late on November 7, 2009, HR 3962, the health reform bill jointly worked out by 3 House committees, passed the House by the narrow margin of 220-215. All Republicans but one (Anh "Joseph" Cao of Louisiana) plus 39 Democrats voted against it. This is reason enough to be glad that it passed, despite the limitations of the bill itself. It did not come so close because of progressives concerned about those limitations voting against it; it came so close because there are so many in Congress who are opposed to any improvement in the access to health care for the American people. It is important that they were defeated, even if by a slim margin, because they are voices for an untenable and unjust status quo.
The bill that passed the House is not a good health reform plan on the face of it. It will leave millions of Americans uninsured. It will not provide a significant limit on the ability of insurance companies to profit from the health problems of our people. A wise and clear analysis of the limitations of the bill is provided by John Geyman, MD, Professor and Chair Emeritus of Family Medicine at the University of Washington and author of the official blog of Physicians for a National Health Program (PNHP). In his piece Health Care Reform 2009: No Bill is Better than a Bad Bill, he makes the case that it should not pass. PNHP’s official position before the vote was: “We have been asked how to tell members to vote on the House bill. Our response is that the bill is ‘like aspirin for breast cancer’.” I agree with their analysis of the bill, and still hope (but am not optimistic) that a better bill will eventually emerge from conference, but have to disagree that it would have been better for it to have been defeated, because that would not have been seen as a victory for progressives, but rather have been a victory for the forces of darkness.
Herb Freeman, a long-time social activist and observer (and a close relative), writes:
“Because of the tenor of the health bill discussion in the House today [November 7] on C-span, and after receiving an e-mail showing what cost of living and earnings were in the US 100 years ago, I started to Google how and when other changes were made. In looking up information on other federally-mandated social modifications (or improvements), such as abolition of child labor (1938), compulsory public education (early 1900s), fair labor standards (especially the 40-hour week, 1938) and food standards and examination, I came across some surprising things:
Wikipedia mostly quotes libertarian approaches to public education as destructive to the "educable" and wasteful to the "others."
The impact of the 40-hour week is largely negated by 12-hour work days, elimination of overtime after an 8-hour day, partially because of the lack of a national health plan, which makes insurance too expensive for employers and partially from lost vacations to compensate from static wages.
I reviewed the arguments made, both at the time of passage and to this day, against 68 or more laws that protect people from gross exploitation as workers, and they are exactly what I heard today on C-Span for several hours on the health bill from these dinosaurs from Texas, Mississippi, Wisconsin and Utah, etc.”
The cruel and vicious racist and classist arguments that were made against child labor laws and a 40-hour week and fair wages, that were based in ideas that some people were “educable” and others were not, that exploitation was ok, are the same ones we heard in the health care debate. They were evil and wrong back then, and they are evil and wrong now. The laws that Mr. Freeman refers to, which offer some protection for workers, have indeed been eroded, but to the extent that they exist, and that there is a strong belief on the part of most people that they are good things, help to protect against the worst of exploitation. Many of them also passed, in their day, by narrow margins. I think that the importance of passing HR 3962 was that, by a narrow majority in the House (representing, of course, a much larger majority in the country, that of the people who are not rich or corporations to give money to congresspeople), is that it rejected the narrow-minded selfishness and toadying-to-their-wealthy-benefactors of its opponents
I am not optimistic that the Senate bill will be better (Professor Leonard Rodberg, PhD, Chair of Urban Studies at Queens College/CUNY, describes in Don McCanne’s Quote of the Day how the current plan is bad (he calls it a DOG, but I like my dogs!) or that there will be much improvement in the bill that comes out of conference. It is very unfortunate that there is not a single-payer plan, and that Rep. Anthony Weiner’s single-payer plan was not brought to a vote. I still hope that the proposal by Rep. Dennis Kucinich to allow states to pilot single-payer programs (which passed the committee with support from even some Republicans) may yet happen. Single payer got much further along in the debate than the administration and leadership, which tried to kill it at the beginning of the debate, hoped.
But the most important point is that, whatever, the content of the bill, on this one night, by a narrow margin, a bill passed that says the American people should have access to health care, whatever its limitations in actually providing for it, passed, and it passed over the opposition of those who only support legislation that benefits the privileged minority, and opposed, as they have always opposed, programs that benefit all of our people. I celebrate their defeat.
Last night, late on November 7, 2009, HR 3962, the health reform bill jointly worked out by 3 House committees, passed the House by the narrow margin of 220-215. All Republicans but one (Anh "Joseph" Cao of Louisiana) plus 39 Democrats voted against it. This is reason enough to be glad that it passed, despite the limitations of the bill itself. It did not come so close because of progressives concerned about those limitations voting against it; it came so close because there are so many in Congress who are opposed to any improvement in the access to health care for the American people. It is important that they were defeated, even if by a slim margin, because they are voices for an untenable and unjust status quo.
The bill that passed the House is not a good health reform plan on the face of it. It will leave millions of Americans uninsured. It will not provide a significant limit on the ability of insurance companies to profit from the health problems of our people. A wise and clear analysis of the limitations of the bill is provided by John Geyman, MD, Professor and Chair Emeritus of Family Medicine at the University of Washington and author of the official blog of Physicians for a National Health Program (PNHP). In his piece Health Care Reform 2009: No Bill is Better than a Bad Bill, he makes the case that it should not pass. PNHP’s official position before the vote was: “We have been asked how to tell members to vote on the House bill. Our response is that the bill is ‘like aspirin for breast cancer’.” I agree with their analysis of the bill, and still hope (but am not optimistic) that a better bill will eventually emerge from conference, but have to disagree that it would have been better for it to have been defeated, because that would not have been seen as a victory for progressives, but rather have been a victory for the forces of darkness.
Herb Freeman, a long-time social activist and observer (and a close relative), writes:
“Because of the tenor of the health bill discussion in the House today [November 7] on C-span, and after receiving an e-mail showing what cost of living and earnings were in the US 100 years ago, I started to Google how and when other changes were made. In looking up information on other federally-mandated social modifications (or improvements), such as abolition of child labor (1938), compulsory public education (early 1900s), fair labor standards (especially the 40-hour week, 1938) and food standards and examination, I came across some surprising things:
Wikipedia mostly quotes libertarian approaches to public education as destructive to the "educable" and wasteful to the "others."
The impact of the 40-hour week is largely negated by 12-hour work days, elimination of overtime after an 8-hour day, partially because of the lack of a national health plan, which makes insurance too expensive for employers and partially from lost vacations to compensate from static wages.
I reviewed the arguments made, both at the time of passage and to this day, against 68 or more laws that protect people from gross exploitation as workers, and they are exactly what I heard today on C-Span for several hours on the health bill from these dinosaurs from Texas, Mississippi, Wisconsin and Utah, etc.”
The cruel and vicious racist and classist arguments that were made against child labor laws and a 40-hour week and fair wages, that were based in ideas that some people were “educable” and others were not, that exploitation was ok, are the same ones we heard in the health care debate. They were evil and wrong back then, and they are evil and wrong now. The laws that Mr. Freeman refers to, which offer some protection for workers, have indeed been eroded, but to the extent that they exist, and that there is a strong belief on the part of most people that they are good things, help to protect against the worst of exploitation. Many of them also passed, in their day, by narrow margins. I think that the importance of passing HR 3962 was that, by a narrow majority in the House (representing, of course, a much larger majority in the country, that of the people who are not rich or corporations to give money to congresspeople), is that it rejected the narrow-minded selfishness and toadying-to-their-wealthy-benefactors of its opponents
I am not optimistic that the Senate bill will be better (Professor Leonard Rodberg, PhD, Chair of Urban Studies at Queens College/CUNY, describes in Don McCanne’s Quote of the Day how the current plan is bad (he calls it a DOG, but I like my dogs!) or that there will be much improvement in the bill that comes out of conference. It is very unfortunate that there is not a single-payer plan, and that Rep. Anthony Weiner’s single-payer plan was not brought to a vote. I still hope that the proposal by Rep. Dennis Kucinich to allow states to pilot single-payer programs (which passed the committee with support from even some Republicans) may yet happen. Single payer got much further along in the debate than the administration and leadership, which tried to kill it at the beginning of the debate, hoped.
But the most important point is that, whatever, the content of the bill, on this one night, by a narrow margin, a bill passed that says the American people should have access to health care, whatever its limitations in actually providing for it, passed, and it passed over the opposition of those who only support legislation that benefits the privileged minority, and opposed, as they have always opposed, programs that benefit all of our people. I celebrate their defeat.
Wednesday, November 4, 2009
Poverty and Uninsurance Diverge: So let’s solve the problem!
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Wyandotte and Johnson counties form the Kansas side of the Kansas City metropolitan area. Wyandotte, mainly Kansas City, KS, where I live, is an old “rust-belt” inner city, packing-house industrial city, and is the poorest county in Kansas. Johnson, to its south, consists of older inner suburbs and newer, were-recently-farmland suburbs, and is the richest and most populous Kansas county, with more than 3 times the population of Wyandotte. In Johnson County, only 14% of the population is below 200% of the poverty level, compared to Wyandotte County’s 44%, but it actually a slightly larger absolute number (73,200 to 67,400) because of Johnson County’s larger population. More interesting is the uninsured rate; while it has fewer than 10% more people under 200% of poverty, Johnson County has 2.5 times as many uninsured people as does Wyandotte County.
Wyandotte and Johnson counties form the Kansas side of the Kansas City metropolitan area. Wyandotte, mainly Kansas City, KS, where I live, is an old “rust-belt” inner city, packing-house industrial city, and is the poorest county in Kansas. Johnson, to its south, consists of older inner suburbs and newer, were-recently-farmland suburbs, and is the richest and most populous Kansas county, with more than 3 times the population of Wyandotte. In Johnson County, only 14% of the population is below 200% of the poverty level, compared to Wyandotte County’s 44%, but it actually a slightly larger absolute number (73,200 to 67,400) because of Johnson County’s larger population. More interesting is the uninsured rate; while it has fewer than 10% more people under 200% of poverty, Johnson County has 2.5 times as many uninsured people as does Wyandotte County.
This means, obviously, that there are many non-poor uninsured people, and this is a national phenomenon. For most of this century, poverty and uninsurance rates tracked together. But in the late 1990s, with poverty rates decreasing, uninsurance rates continued to rise. With the recent recession, both have climbed, but uninsurance is rising at a higher rate. (See graph).
This dissociation between poverty and uninsurance is a very troubling phenomenon; while it is bad enough for poor people to not have financial access to health care, more and more of the uninsured are not poor.
Thus the case for health reform: let’s do something about this. Let’s dissociate the “privilege” of having health insurance from being employed by an entity large enough to afford to provide it, and make sure everyone has financial access to high quality care. Unfortunately, the current plans in the Congress will not do so. The recent assurance by Senate Majority Leader Reid that the Senate bill will contain a “public option”, as will the House bill, obscures the fact that the public option it contains will be weak; in an ostensible effort to not give the public option an “unfair advantage” over private insurance plans, it has been given an unfair disadvantage – it will not be able to use its public status to set rates for provider compensation, as does Medicare, or for drug prices, as Medicare (under the bad restrictions of Part D) also does not.
This is, of course, bizarre: why should anyone, other than the insurance companies themselves, care that they can continue to make money hand over fist while providing inadequate coverage, and not be held accountable by having to compete with a public option that provides comprehensive coverage and does not have to make a profit? Oh yes, the senators and congressmen who get contributions from those insurance companies, yes, but the rest of us? Why should we care? And why should we not insist that our representatives represent our interests, and not those of the insurance companies?
Much of the opposition – not only to single payer, but to a “public option” has been based on, not to put too fine a point on it, lies spread by opponents who are mostly on the payroll of insurance companies. These lies have led people to think that they will lose the excellent medical care, and extensive freedom of choice that they have under the current system (oh, whoops, forgot, they don’t!) if we have a government program. Writing in the Oct 28, 2009 issue of JAMA, Joseph S. Ross and Allan S. Detsky look at “Health care choices and decisions in the United States and Canada”[1], choosing Canada specifically “…because the Canadian health system, with much greater government involvement, is often publicly portrayed in the United States as limiting choice.” They review the restraints on choice of insurance plans, hospitals and doctors, and diagnostic testing and treatments, and conclude, modestly that “…there is clear evidence that for Canada’s health care system, less choice in insurance coverage (although guaranteed) has not resulted in less choice of hospitals, physicians, and diagnostic testing and treatments compared with the United States. In fact, there is arguably more choice.” More than “arguably”, I’d say, based on the evidence provided in their piece.
The fewer obstacles that are placed in the way of services to people, the more efficient they are, the more they are appreciated, and the less they affront the dignity of the people receiving them. When comprehensive services are provided to everyone, there is no need to put people through rigorous screening to see if they are poor enough, or don’t have other insurance, or are deserving enough to receive them.
Ironically, or maybe not, the same legislators who decry government bureaucracy are those who demand that bureaucracy through establishing restrictions on programs that help people. This includes, of course, income and citizenship verification for those seeking help with health care; after all we wouldn’t want people to “cheat” and avail themselves of public services when they didn’t “need” them, when their incomes exceeded the 200% of poverty, or 100% of poverty, or 38% of poverty* that we require. If there were one program for everyone, a single-payer or Medicare-for-all program, then all this bureaucracy could be eliminated. We wouldn’t have to screen people, because everyone would be eligible. It would be everyone’s program.
I have written before about the enormous administrative cost involved in both insurance companies (payers) and providers having huge teams of people to try to deny payment or get paid; in one more way, a single-payer plan would eliminate administrative waste and bureaucracy. Funny that those anti-government-bureaucracy folks can’t – or won’t – see it this way.
*38% of poverty was what one's income used to have to be to get financial assistance in Kansas if you were a childless adult -- and it was $100/month. Now it is not available at all.
[1] Ross JS, Detsky AS, “Health care choices and decisions in the United States and Canada”, JAMA, Oct 28, 2009;302(16):1803-4.
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This is, of course, bizarre: why should anyone, other than the insurance companies themselves, care that they can continue to make money hand over fist while providing inadequate coverage, and not be held accountable by having to compete with a public option that provides comprehensive coverage and does not have to make a profit? Oh yes, the senators and congressmen who get contributions from those insurance companies, yes, but the rest of us? Why should we care? And why should we not insist that our representatives represent our interests, and not those of the insurance companies?
Much of the opposition – not only to single payer, but to a “public option” has been based on, not to put too fine a point on it, lies spread by opponents who are mostly on the payroll of insurance companies. These lies have led people to think that they will lose the excellent medical care, and extensive freedom of choice that they have under the current system (oh, whoops, forgot, they don’t!) if we have a government program. Writing in the Oct 28, 2009 issue of JAMA, Joseph S. Ross and Allan S. Detsky look at “Health care choices and decisions in the United States and Canada”[1], choosing Canada specifically “…because the Canadian health system, with much greater government involvement, is often publicly portrayed in the United States as limiting choice.” They review the restraints on choice of insurance plans, hospitals and doctors, and diagnostic testing and treatments, and conclude, modestly that “…there is clear evidence that for Canada’s health care system, less choice in insurance coverage (although guaranteed) has not resulted in less choice of hospitals, physicians, and diagnostic testing and treatments compared with the United States. In fact, there is arguably more choice.” More than “arguably”, I’d say, based on the evidence provided in their piece.
The fewer obstacles that are placed in the way of services to people, the more efficient they are, the more they are appreciated, and the less they affront the dignity of the people receiving them. When comprehensive services are provided to everyone, there is no need to put people through rigorous screening to see if they are poor enough, or don’t have other insurance, or are deserving enough to receive them.
Ironically, or maybe not, the same legislators who decry government bureaucracy are those who demand that bureaucracy through establishing restrictions on programs that help people. This includes, of course, income and citizenship verification for those seeking help with health care; after all we wouldn’t want people to “cheat” and avail themselves of public services when they didn’t “need” them, when their incomes exceeded the 200% of poverty, or 100% of poverty, or 38% of poverty* that we require. If there were one program for everyone, a single-payer or Medicare-for-all program, then all this bureaucracy could be eliminated. We wouldn’t have to screen people, because everyone would be eligible. It would be everyone’s program.
I have written before about the enormous administrative cost involved in both insurance companies (payers) and providers having huge teams of people to try to deny payment or get paid; in one more way, a single-payer plan would eliminate administrative waste and bureaucracy. Funny that those anti-government-bureaucracy folks can’t – or won’t – see it this way.
*38% of poverty was what one's income used to have to be to get financial assistance in Kansas if you were a childless adult -- and it was $100/month. Now it is not available at all.
[1] Ross JS, Detsky AS, “Health care choices and decisions in the United States and Canada”, JAMA, Oct 28, 2009;302(16):1803-4.
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Saturday, October 31, 2009
Dietary Supplements can be Dangerous for your Health
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Lots of people take non-prescription “food supplements”, nutritional additives, “vitamins”, “energy tonics”, etc. These are particularly attractive if they are labeled “natural” or “organic”. For some folks, the goal is “general health” – the vitamins, minerals, herbs and other preparations, the herbs that. Many of the users of these substances, whether bought from retail outlets or over the internet are precisely those who disdain prescription medications, who don’t like to “take drugs” but take these “natural” substances. Others are taking them for a specific purpose – weight loss, muscle building, pain relief, energy – often when their doctors have refused to prescribe them, because they are dangerous, or illegal, or both.
Thus, we might conceive of two groups of the 114 million of us who take these medications. “Group 1” are those who believe in “natural” and are trying to “naturally” get healthier. “Group 2” wants magic drugs to help them achieve a goal, would be happy to take them if they could find a doctor to prescribe them, but can’t. Unfortunately, this is much a more hypothetical than real distinction, as there is considerable overlap. Many people in the first group can find their way into the other when they develop symptoms. Especially if the treatments are ostensibly “natural”.
A “Perspective” article in the New England Journal of Medicine, October 15, 2009, by Pieter A. Cohen, MD, titled “American Roulette – Contaminated Dietary Supplements”, discusses these issues. Cohen starts by discussing a police sergeant who lost his job after random drug tests found him positive for amphetamines – an unlabeled ingredient present in the weight-loss supplement he had been taking. It goes on to discuss contaminants found in many such over the counter supplements, both imported and made in USA, sold in retail stores and over the Internet. He notes that the 140 contaminated supplements that the FDA has identified are only a small percentage of those on the market; recently 75 weight-loss drugs were found to be contaminated. And “contamination” is not always the correct word. It implies inadvertent (although perhaps through inadequate quality control) substances present that are not on the label – such as rodent hairs or lead or other heavy metals (beryllium, cadmium, arsenic, etc., which are all poisons that accumulate in the body), bacteria, and plant molds. However, frequently the “off-label” ingredients are there on purpose – they are the drugs that are actually having the desired effect – amphetamines for weight loss or energy, anabolic steroids for muscle building, corticosteroids for arthritis relief, opiates for pain. And these are drugs that are illegal to sell without a prescription (and often heavily restricted even with a prescription!) so they are left off the label. And, in part because the FDA has had its budget gutted and has too few inspectors, are undetected.
There are other reasons that the FDA does not detect such accidental or purposeful adulteration. One is the Dietary Supplement Health and Education Act (DSHEA) of 1994, that limited the ability of the FDA to regulate them. The DSHEA was pushed by the supplement manufacturers, with support of many ordinary people who feared that increased FDA regulation would lead to loss of free access to these substances. Before 1994, Cohen writes, “These supplements, which include botanical products, vitamins and minerals, amino acids, and tissue extracts…were considered food additives, and their manufacturers were required to show proof of safety before marketing them. Since the passage of the DSHEA, dietary supplements are presumed to be safe and can be marketed with very little oversight.” And American consumers, looking for magic potions, pay the price in their health.
There are a few things to remember when considering purchasing and taking dietary supplements, even ones you have long taken. They include:
--“Natural” does not mean “good” or even “safe”. There are plenty of natural poisons, and most substances, taken in excessive amounts can have adverse effects. Similarly, “made in a pharmaceutical laboratory” does not mean “bad”; usually, if it is a reputable and inspected lab (including the pharmaceutical manufacturers I often criticize) it means that there is much more quality control.
--If a substance actually has “good” effects, it can also have “side effects”. Substances only have effects. They don’t know what you want and don’t want. If a substance is actually having biological effects on your body (as opposed to psychological placebo effects), it doesn’t matter if it is “natural” or manufactured, from a plant or a chemical. If, for example, the estrogens in plants “work” just as well as those from animals (mare urine) or chemically produced, they will have the same sort of risks.
--Unregulated or under-regulated substances are often “contaminated”, and this is particularly true for those made in other countries and often bought over the Internet. In this case I mean truly “contaminated”, with the lead, bacteria, molds, and toxins I mention above.
--Plants vary in potency. Thus “1 leaf” or “1 ounce” of a plant may have very different amounts of active ingredient depending upon where and what season it was grown in, and just in terms of random variation. If you buy the actual plants – and if you are a skilled enough botanist to be sure of what you are buying – the variable potency needs to be considered. If, however, you are buying capsules said to contain a specific plant, you are, as described above, shooting craps with your health, because these are subject to much less regulation than “standard” pharmaceuticals.
--If it seems too good to be true, it almost certainly is. If a substance you buy, over the Internet or from a retailer, works amazingly well, it is likely that it contains, probably unlabeled, a very potent drug such as steroids, amphetamines, or opiates. Maybe you knew that and wanted it because your mean doctor would not prescribe them. Maybe that makes you unwise. However, if you bought them under the impression that they were “natural” and “safe”, you may be in for a big surprise. And this is likely to be in terms of the serious adverse effects that led them to be highly regulated in the first place.
Finally, the people manufacturing and selling these “supplements” are profit-making companies. Calling themselves “organic” or “natural” does not make them automatically nice, safe, good guys. As in any other industry, as we have seen so often over the last year, there are opportunists who will lie, cheat, steal, and poison you to make a buck. Strong regulation, well-funded regulation, is the only thing we have on our side to protect us. Limiting regulations of substances that can affect our health is almost always wrong. The DSHEA was a mistake, and well-meaning people who supported it made a mistake in doing so. They now need to demand that their legislators protect them at least as much from over-the-counter dietary supplements as they do from prescription drugs!
.
Lots of people take non-prescription “food supplements”, nutritional additives, “vitamins”, “energy tonics”, etc. These are particularly attractive if they are labeled “natural” or “organic”. For some folks, the goal is “general health” – the vitamins, minerals, herbs and other preparations, the herbs that. Many of the users of these substances, whether bought from retail outlets or over the internet are precisely those who disdain prescription medications, who don’t like to “take drugs” but take these “natural” substances. Others are taking them for a specific purpose – weight loss, muscle building, pain relief, energy – often when their doctors have refused to prescribe them, because they are dangerous, or illegal, or both.
Thus, we might conceive of two groups of the 114 million of us who take these medications. “Group 1” are those who believe in “natural” and are trying to “naturally” get healthier. “Group 2” wants magic drugs to help them achieve a goal, would be happy to take them if they could find a doctor to prescribe them, but can’t. Unfortunately, this is much a more hypothetical than real distinction, as there is considerable overlap. Many people in the first group can find their way into the other when they develop symptoms. Especially if the treatments are ostensibly “natural”.
A “Perspective” article in the New England Journal of Medicine, October 15, 2009, by Pieter A. Cohen, MD, titled “American Roulette – Contaminated Dietary Supplements”, discusses these issues. Cohen starts by discussing a police sergeant who lost his job after random drug tests found him positive for amphetamines – an unlabeled ingredient present in the weight-loss supplement he had been taking. It goes on to discuss contaminants found in many such over the counter supplements, both imported and made in USA, sold in retail stores and over the Internet. He notes that the 140 contaminated supplements that the FDA has identified are only a small percentage of those on the market; recently 75 weight-loss drugs were found to be contaminated. And “contamination” is not always the correct word. It implies inadvertent (although perhaps through inadequate quality control) substances present that are not on the label – such as rodent hairs or lead or other heavy metals (beryllium, cadmium, arsenic, etc., which are all poisons that accumulate in the body), bacteria, and plant molds. However, frequently the “off-label” ingredients are there on purpose – they are the drugs that are actually having the desired effect – amphetamines for weight loss or energy, anabolic steroids for muscle building, corticosteroids for arthritis relief, opiates for pain. And these are drugs that are illegal to sell without a prescription (and often heavily restricted even with a prescription!) so they are left off the label. And, in part because the FDA has had its budget gutted and has too few inspectors, are undetected.
There are other reasons that the FDA does not detect such accidental or purposeful adulteration. One is the Dietary Supplement Health and Education Act (DSHEA) of 1994, that limited the ability of the FDA to regulate them. The DSHEA was pushed by the supplement manufacturers, with support of many ordinary people who feared that increased FDA regulation would lead to loss of free access to these substances. Before 1994, Cohen writes, “These supplements, which include botanical products, vitamins and minerals, amino acids, and tissue extracts…were considered food additives, and their manufacturers were required to show proof of safety before marketing them. Since the passage of the DSHEA, dietary supplements are presumed to be safe and can be marketed with very little oversight.” And American consumers, looking for magic potions, pay the price in their health.
There are a few things to remember when considering purchasing and taking dietary supplements, even ones you have long taken. They include:
--“Natural” does not mean “good” or even “safe”. There are plenty of natural poisons, and most substances, taken in excessive amounts can have adverse effects. Similarly, “made in a pharmaceutical laboratory” does not mean “bad”; usually, if it is a reputable and inspected lab (including the pharmaceutical manufacturers I often criticize) it means that there is much more quality control.
--If a substance actually has “good” effects, it can also have “side effects”. Substances only have effects. They don’t know what you want and don’t want. If a substance is actually having biological effects on your body (as opposed to psychological placebo effects), it doesn’t matter if it is “natural” or manufactured, from a plant or a chemical. If, for example, the estrogens in plants “work” just as well as those from animals (mare urine) or chemically produced, they will have the same sort of risks.
--Unregulated or under-regulated substances are often “contaminated”, and this is particularly true for those made in other countries and often bought over the Internet. In this case I mean truly “contaminated”, with the lead, bacteria, molds, and toxins I mention above.
--Plants vary in potency. Thus “1 leaf” or “1 ounce” of a plant may have very different amounts of active ingredient depending upon where and what season it was grown in, and just in terms of random variation. If you buy the actual plants – and if you are a skilled enough botanist to be sure of what you are buying – the variable potency needs to be considered. If, however, you are buying capsules said to contain a specific plant, you are, as described above, shooting craps with your health, because these are subject to much less regulation than “standard” pharmaceuticals.
--If it seems too good to be true, it almost certainly is. If a substance you buy, over the Internet or from a retailer, works amazingly well, it is likely that it contains, probably unlabeled, a very potent drug such as steroids, amphetamines, or opiates. Maybe you knew that and wanted it because your mean doctor would not prescribe them. Maybe that makes you unwise. However, if you bought them under the impression that they were “natural” and “safe”, you may be in for a big surprise. And this is likely to be in terms of the serious adverse effects that led them to be highly regulated in the first place.
Finally, the people manufacturing and selling these “supplements” are profit-making companies. Calling themselves “organic” or “natural” does not make them automatically nice, safe, good guys. As in any other industry, as we have seen so often over the last year, there are opportunists who will lie, cheat, steal, and poison you to make a buck. Strong regulation, well-funded regulation, is the only thing we have on our side to protect us. Limiting regulations of substances that can affect our health is almost always wrong. The DSHEA was a mistake, and well-meaning people who supported it made a mistake in doing so. They now need to demand that their legislators protect them at least as much from over-the-counter dietary supplements as they do from prescription drugs!
.
Tuesday, October 27, 2009
PSA Screening: “One of Medicine's Great Success Stories"?
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Guest blog by Robert Ferrer, MD MPH
I spent 2 days at home recently with the H1N1 flu and caught up on some of my newspaper reading. In the Oct 11, 2009 New York Times Magazine, (p.38) was an advertising supplement, "Health and Wellness Outlook Special Report: Cancer Treatment Options," paid for by some of our finest cancer centers. [1] In the prostate cancer section, I found this interesting assertion, in big capital letters: "The PSA test for prostate cancer detection and management is one of medicine's great success stories." It goes on to say that 90% of prostate ca is now diagnosed when curable and that the death rate has declined by 40% since the PSA test began to be widely used in the 1980's. The source is the chair of urology and senior vice president for translational research at Roswell Park Cancer Institute in Buffalo, where the the PSA test was developed.
I found the assertion curious because this past March the New England Journal of Medicine published 2 long-awaited studies[2],[3] on whether PSA testing was effective: one found a modest benefit and the other virtually none. Both noted that a very large number of men had to be screened and treated for every one who benefited. These articles received extensive press coverage. And just as I was going to my laptop today to assemble this and other maybe-not-such-a-great-success-story evidence for PSA screening, this week's JAMA showed up with a terrific paper by Esserman, Shieh, and Thompson.[4] They have this to say about PSA screening:
"After 2 1/2 decades of screening for [breast and] prostate cancer, conclusions are troubling: Overall cancer rates are higher, many more patients are being treated, and the absolute incidence of aggressive or later-stage disease has not been significantly decreased. Screening has some effect, but it comes at significant cost, including over-diagnosis, overtreatment, and complications of therapy."
So how do we get from "great success story" to "troubling"? How can diagnosing cancer early not be a good thing? The answer lies in the kind of cancers we can detect with screening. Slow growing cancers, the kind unlikely to kill you, grow... slowly and so are around for a long time to be detected by screening. On the other hand, fast growing cancers can go from undetectable to lethal even in the year between cancer screenings. So the cancers we detect through screening are more likely to be the non-lethal kind. Well, isn't that still a good thing? Can't cancer harm without killing?
Yes, but the issue here is what we call "cancer." Our screening tests can detect collections of cells that are, by pathologists' standards, "cancer" when viewed under the microscope, yet not every collection of such cells is destined act like cancer; that is, to grow or spread (metastasize) to other parts of the body. Some are destined to remain dormant until the person eventually dies of something else. And therein lies the problem with PSA screening. It detects many of the ones destined to be dormant or slow growing for every one destined to be lethal. The exact number is uncertain, but the large European study in the NEJM this March estimated 1410 men needed to be screened and 48 cases of prostate cancer treated to prevent 1 death. [2] The American study released in parallel found the benefits to be even smaller. [3]
What this means, is that the consequence of PSA testing for many men is adding 6-12 years of life diagnosed -- and often treated -- as a cancer patient, without actually living any longer.
Just how much over-diagnosis can we attribute to PSA? In the August 2009 issue of the Journal of the National Cancer Institute, H. Gilbert Welch and Peter Alberson calculate than in the first 19 years of the PSA era, 1987 to 2005, about 1.3 million additional cases were diagnosed and 1 million more men treated.[5] They estimate that about half of these extra cases represent over-diagnosis, meaning that the diagnosed man was very unlikely to die from prostate cancer. So of the roughly 4 million men diagnosed from 1985 to 2005, half a million were over-diagnosed.
What about the fact that, as the Roswell Park urologists note, mortality rates have fallen since PSA testing began in the mid-80's? Doesn't that suggest that PSA is helping? The authors in this week's JAMA paper address this in their analysis. For that claim to be credible, we should be seeing a sharp fall in number of advanced stage prostate cancers, which is what would happen if screening was finding the "bad" cancers early, before they could reach an advanced stage. Although we have indeed seen a fall in advanced cancers it has been nowhere near as sharp as we would expect, given the many more cancers we are finding in the PSA era. We should thus probably look elsewhere to explain the fall in prostate cancer mortality, likely improvements in treatment.
So, given what we know about how well PSA testing performs as a screening test, how can it be advertised as one of medicine's great success stories? As potential explanations, I offer two themes that I believe also offer some larger lessons for why health care is less effective and more expensive than it should be.
Theme 1: Thinking about organs rather than people: If your focus is the prostate, then finding and removing cancerous prostates is the goal. This works well at the level of prostates, but not so well for whole men. With a test as imperfect as the PSA, a small or nonexistent reduction in the risk of dying from prostate cancer is sometimes traded for diminished quality of life, most commonly the incontinence and impotence that affect about 1/4 of men treated for prostate cancer.
Theme 2: Economic incentives favoring procedures. As the numbers above demonstrate, PSA has expanded the number of prostate cancer patients by about a third. The professional urology association has long recommended PSA screening even when the US Preventive Services Task Force, tasked with providing rigorous assessments for screening procedures, has consistently recommended against routine PSA screening.
Themes 1 and 2 intertwine. Greed is not what drives PSA testing. When a urologist can make a prostate cancer diagnosis and provide a "cure," doctor and patient alike perceive it as a valuable service. A life-saving intervention. That the service is well reimbursed appears justified when the stakes seem so high. It is only from the application of healthy skepticism and careful analysis -- of outcomes for people, not organs -- that we can reach better conclusions about the value of what we do.
The topic of PSA screening was previously addressed (if less well) in PSA Screening: What is the Value? March 21, 2009
[1] Anonymous. Health and Wellness Outlook Special Report: Cancer Treatment Options [advertising supplement]. New York Times Magazine, 11 October 2009. p. 33-46
[2] Schroder FH, Hugosson J, Roobol MJ, et al. Screening and prostate-cancer mortality in a randomized European study. New England Journal of Medicine. 2009a;360:1320.
[3] Andriole GL, Crawford ED, Grubb III RL, et al. Mortality results from a randomized prostate-cancer screening trial. N Engl J Med. 2009b;360:1310.
[4] Esserman L, Shieh Y, Thompson I. Rethinking screening for breast cancer and prostate cancer. JAMA. c;302:1686-1692.
[5] Welch HG, Albertsen PC. Prostate cancer diagnosis and treatment after the introduction of prostate-specific antigen screening: 1986-2005. J Natl Cancer Inst. 2009c;101:1325-1329
This topic was also addressed previously in PSA Screening: What is the Value? March 21, 2009
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Guest blog by Robert Ferrer, MD MPH
I spent 2 days at home recently with the H1N1 flu and caught up on some of my newspaper reading. In the Oct 11, 2009 New York Times Magazine, (p.38) was an advertising supplement, "Health and Wellness Outlook Special Report: Cancer Treatment Options," paid for by some of our finest cancer centers. [1] In the prostate cancer section, I found this interesting assertion, in big capital letters: "The PSA test for prostate cancer detection and management is one of medicine's great success stories." It goes on to say that 90% of prostate ca is now diagnosed when curable and that the death rate has declined by 40% since the PSA test began to be widely used in the 1980's. The source is the chair of urology and senior vice president for translational research at Roswell Park Cancer Institute in Buffalo, where the the PSA test was developed.
I found the assertion curious because this past March the New England Journal of Medicine published 2 long-awaited studies[2],[3] on whether PSA testing was effective: one found a modest benefit and the other virtually none. Both noted that a very large number of men had to be screened and treated for every one who benefited. These articles received extensive press coverage. And just as I was going to my laptop today to assemble this and other maybe-not-such-a-great-success-story evidence for PSA screening, this week's JAMA showed up with a terrific paper by Esserman, Shieh, and Thompson.[4] They have this to say about PSA screening:
"After 2 1/2 decades of screening for [breast and] prostate cancer, conclusions are troubling: Overall cancer rates are higher, many more patients are being treated, and the absolute incidence of aggressive or later-stage disease has not been significantly decreased. Screening has some effect, but it comes at significant cost, including over-diagnosis, overtreatment, and complications of therapy."
So how do we get from "great success story" to "troubling"? How can diagnosing cancer early not be a good thing? The answer lies in the kind of cancers we can detect with screening. Slow growing cancers, the kind unlikely to kill you, grow... slowly and so are around for a long time to be detected by screening. On the other hand, fast growing cancers can go from undetectable to lethal even in the year between cancer screenings. So the cancers we detect through screening are more likely to be the non-lethal kind. Well, isn't that still a good thing? Can't cancer harm without killing?
Yes, but the issue here is what we call "cancer." Our screening tests can detect collections of cells that are, by pathologists' standards, "cancer" when viewed under the microscope, yet not every collection of such cells is destined act like cancer; that is, to grow or spread (metastasize) to other parts of the body. Some are destined to remain dormant until the person eventually dies of something else. And therein lies the problem with PSA screening. It detects many of the ones destined to be dormant or slow growing for every one destined to be lethal. The exact number is uncertain, but the large European study in the NEJM this March estimated 1410 men needed to be screened and 48 cases of prostate cancer treated to prevent 1 death. [2] The American study released in parallel found the benefits to be even smaller. [3]
What this means, is that the consequence of PSA testing for many men is adding 6-12 years of life diagnosed -- and often treated -- as a cancer patient, without actually living any longer.
Just how much over-diagnosis can we attribute to PSA? In the August 2009 issue of the Journal of the National Cancer Institute, H. Gilbert Welch and Peter Alberson calculate than in the first 19 years of the PSA era, 1987 to 2005, about 1.3 million additional cases were diagnosed and 1 million more men treated.[5] They estimate that about half of these extra cases represent over-diagnosis, meaning that the diagnosed man was very unlikely to die from prostate cancer. So of the roughly 4 million men diagnosed from 1985 to 2005, half a million were over-diagnosed.
What about the fact that, as the Roswell Park urologists note, mortality rates have fallen since PSA testing began in the mid-80's? Doesn't that suggest that PSA is helping? The authors in this week's JAMA paper address this in their analysis. For that claim to be credible, we should be seeing a sharp fall in number of advanced stage prostate cancers, which is what would happen if screening was finding the "bad" cancers early, before they could reach an advanced stage. Although we have indeed seen a fall in advanced cancers it has been nowhere near as sharp as we would expect, given the many more cancers we are finding in the PSA era. We should thus probably look elsewhere to explain the fall in prostate cancer mortality, likely improvements in treatment.
So, given what we know about how well PSA testing performs as a screening test, how can it be advertised as one of medicine's great success stories? As potential explanations, I offer two themes that I believe also offer some larger lessons for why health care is less effective and more expensive than it should be.
Theme 1: Thinking about organs rather than people: If your focus is the prostate, then finding and removing cancerous prostates is the goal. This works well at the level of prostates, but not so well for whole men. With a test as imperfect as the PSA, a small or nonexistent reduction in the risk of dying from prostate cancer is sometimes traded for diminished quality of life, most commonly the incontinence and impotence that affect about 1/4 of men treated for prostate cancer.
Theme 2: Economic incentives favoring procedures. As the numbers above demonstrate, PSA has expanded the number of prostate cancer patients by about a third. The professional urology association has long recommended PSA screening even when the US Preventive Services Task Force, tasked with providing rigorous assessments for screening procedures, has consistently recommended against routine PSA screening.
Themes 1 and 2 intertwine. Greed is not what drives PSA testing. When a urologist can make a prostate cancer diagnosis and provide a "cure," doctor and patient alike perceive it as a valuable service. A life-saving intervention. That the service is well reimbursed appears justified when the stakes seem so high. It is only from the application of healthy skepticism and careful analysis -- of outcomes for people, not organs -- that we can reach better conclusions about the value of what we do.
The topic of PSA screening was previously addressed (if less well) in PSA Screening: What is the Value? March 21, 2009
[1] Anonymous. Health and Wellness Outlook Special Report: Cancer Treatment Options [advertising supplement]. New York Times Magazine, 11 October 2009. p. 33-46
[2] Schroder FH, Hugosson J, Roobol MJ, et al. Screening and prostate-cancer mortality in a randomized European study. New England Journal of Medicine. 2009a;360:1320.
[3] Andriole GL, Crawford ED, Grubb III RL, et al. Mortality results from a randomized prostate-cancer screening trial. N Engl J Med. 2009b;360:1310.
[4] Esserman L, Shieh Y, Thompson I. Rethinking screening for breast cancer and prostate cancer. JAMA. c;302:1686-1692.
[5] Welch HG, Albertsen PC. Prostate cancer diagnosis and treatment after the introduction of prostate-specific antigen screening: 1986-2005. J Natl Cancer Inst. 2009c;101:1325-1329
This topic was also addressed previously in PSA Screening: What is the Value? March 21, 2009
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Friday, October 23, 2009
"Wall St. Smarts"? Maybe the smart people should be doing something productive
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The humorist Calvin Trillin had a recent column in the NY Times advancing his theory as to what changed on Wall St. that led to the orgy of greed that both came close to destroying our economy and continues to this day. Because he is a humorist, “Wall Street Smarts” is funny, but its premise is probably, sadly, true. He argues that in his day the smart kids became relatively-low paid professors, judges, etc., while the kids who went on to enter Wall St. careers were from the lower end of his college class, often from families that had long histories of such work and such money (perhaps that is why they didn’t feel they had to work so hard in school). They expected to be rich, but more in the “big house in Greenwich and a sailboat” than the “second oceangoing yacht” rich. But when the “smart kids” entered Wall St. they no longer worked “bankers’ hours” nor were satisfied with the “products” that financiers had long purveyed. They lobbied successfully for changes in laws and regulations and developed new products such as derivatives that nobody understood[1] and made, well, oodles.
And now they are still doing it. We stood at the precipice of global financial collapse and were pulled back only by massive public investment into the finance and banking system. Even “progressives” argued that these institutions, like Goldman Sachs, were “too big to fail”. So we bailed them out and they are now back to making billions of dollars (like Goldman’s most recent quarterly profit) while too many Americans are out of work, and out of hope. The fault lies squarely at the feet of Congress, who is, as on healthcare, totally influenced by the contributions of the wealthy corporations that they continue to do their bidding, and on the administration of President Obama, which has appointed so many insiders that we can’t tell who is actually going to regulate them. The “revolving door” is certainly not new; it has characterized every recent administration, both Republican and Democratic, but we had hoped it would change with this new president.
It hasn’t. Treasury Secretary Timothy Geithner spends all his time on the phone with the executives of Goldman and CitiBank. Chief economic advisor Lawrence Summers comes from Goldman via Harvard. Goldman chief and former Clinton Treasury Secretary Robert Rubin is the current “guru” of financial advice to the President. We keep hoping that the President will, on this issue, on health care, on Afghanistan, take a bold leadership position, but we keep being disappointed. Sunday, Oct 18, 2009’s papers are full of depressing insights. In the NY Times, Maureen Dowd describes in depressing detail President Obama’s history of compromising so much that the baby is lost and the bath water leaks away (“Fie, fatal flaw!”). Frank Rich has a detailed column on the excesses of Goldman Sachs (“Goldman, can you spare a dime?”), comparing them unfavorably to JD Rockefeller’s Standard Oil and the administration’s attempts at regulation unfavorably to Teddy Roosevelt’s. Steve Breen, in his syndicated cartoon in the Kansas City Star, depicts Wall St. at a bar drinking from a bottle labeled “Risk” and saying “I keep drinking ‘cause I have a designated driver”, while a car with the license plate “Bailouts” and Uncle Sam at the wheel idles outside.
This has to stop. The administration needs to fire all the Summerses, Rubins, and Geithners, and get some hard-nosed prosecutors with no sympathy for these folks, like the legendary Ferdinand Pecora of the 1930s, in to reign in these folks. And Congress, with the urging of the administration, needs to pass laws that take these stolen profits away through both a windfall profits tax and limitations on executive income. How much should they be allowed to make? $50,000? $500,000? $2 million? Some amount, and take the rest.
And do what with it? I have said many times that we – represented by the government that is supposed to be ours – should take all that money so that these Wall St. financiers are reduced to living in surplus FEMA trailers. The President has taken some flak because he just made his first trip to New Orleans since taking office (although he traveled there several times since Katrina as a Senator and a candidate) for a visit that lasted only a few hours (and had to end so he could make a fund-raising event in San Francisco). Let’s use the money to rebuild New Orleans. Then this wealth would be used for a good purpose, channeling it back to the people from whom it was stolen.
We are told by Wall St. that limitations on the income of financiers would make it difficult or impossible for them to lure the “best and the brightest”. Maybe Calvin Trillin is right, and having the “best and the brightest” working on Wall St. is part of the etiology of the problem. Maybe they should go back to being professors, judges, doctors, scientists. Solving real problems that the world faces in the environment, human rights, and health. I can’t see any downside.
[1] That’s because they don’t really exist. They are a Ponzi scheme which, through repackaging, sells the same stuff over and over again. And, like a Ponzi scheme, customers who don’t understand it are happy as long as they are making money, but it always collapses. However our new Wall St. tyros learned one thing from traditional brokers – whether the customer is winning or losing, you always take your cut!
The humorist Calvin Trillin had a recent column in the NY Times advancing his theory as to what changed on Wall St. that led to the orgy of greed that both came close to destroying our economy and continues to this day. Because he is a humorist, “Wall Street Smarts” is funny, but its premise is probably, sadly, true. He argues that in his day the smart kids became relatively-low paid professors, judges, etc., while the kids who went on to enter Wall St. careers were from the lower end of his college class, often from families that had long histories of such work and such money (perhaps that is why they didn’t feel they had to work so hard in school). They expected to be rich, but more in the “big house in Greenwich and a sailboat” than the “second oceangoing yacht” rich. But when the “smart kids” entered Wall St. they no longer worked “bankers’ hours” nor were satisfied with the “products” that financiers had long purveyed. They lobbied successfully for changes in laws and regulations and developed new products such as derivatives that nobody understood[1] and made, well, oodles.
And now they are still doing it. We stood at the precipice of global financial collapse and were pulled back only by massive public investment into the finance and banking system. Even “progressives” argued that these institutions, like Goldman Sachs, were “too big to fail”. So we bailed them out and they are now back to making billions of dollars (like Goldman’s most recent quarterly profit) while too many Americans are out of work, and out of hope. The fault lies squarely at the feet of Congress, who is, as on healthcare, totally influenced by the contributions of the wealthy corporations that they continue to do their bidding, and on the administration of President Obama, which has appointed so many insiders that we can’t tell who is actually going to regulate them. The “revolving door” is certainly not new; it has characterized every recent administration, both Republican and Democratic, but we had hoped it would change with this new president.
It hasn’t. Treasury Secretary Timothy Geithner spends all his time on the phone with the executives of Goldman and CitiBank. Chief economic advisor Lawrence Summers comes from Goldman via Harvard. Goldman chief and former Clinton Treasury Secretary Robert Rubin is the current “guru” of financial advice to the President. We keep hoping that the President will, on this issue, on health care, on Afghanistan, take a bold leadership position, but we keep being disappointed. Sunday, Oct 18, 2009’s papers are full of depressing insights. In the NY Times, Maureen Dowd describes in depressing detail President Obama’s history of compromising so much that the baby is lost and the bath water leaks away (“Fie, fatal flaw!”). Frank Rich has a detailed column on the excesses of Goldman Sachs (“Goldman, can you spare a dime?”), comparing them unfavorably to JD Rockefeller’s Standard Oil and the administration’s attempts at regulation unfavorably to Teddy Roosevelt’s. Steve Breen, in his syndicated cartoon in the Kansas City Star, depicts Wall St. at a bar drinking from a bottle labeled “Risk” and saying “I keep drinking ‘cause I have a designated driver”, while a car with the license plate “Bailouts” and Uncle Sam at the wheel idles outside.
This has to stop. The administration needs to fire all the Summerses, Rubins, and Geithners, and get some hard-nosed prosecutors with no sympathy for these folks, like the legendary Ferdinand Pecora of the 1930s, in to reign in these folks. And Congress, with the urging of the administration, needs to pass laws that take these stolen profits away through both a windfall profits tax and limitations on executive income. How much should they be allowed to make? $50,000? $500,000? $2 million? Some amount, and take the rest.
And do what with it? I have said many times that we – represented by the government that is supposed to be ours – should take all that money so that these Wall St. financiers are reduced to living in surplus FEMA trailers. The President has taken some flak because he just made his first trip to New Orleans since taking office (although he traveled there several times since Katrina as a Senator and a candidate) for a visit that lasted only a few hours (and had to end so he could make a fund-raising event in San Francisco). Let’s use the money to rebuild New Orleans. Then this wealth would be used for a good purpose, channeling it back to the people from whom it was stolen.
We are told by Wall St. that limitations on the income of financiers would make it difficult or impossible for them to lure the “best and the brightest”. Maybe Calvin Trillin is right, and having the “best and the brightest” working on Wall St. is part of the etiology of the problem. Maybe they should go back to being professors, judges, doctors, scientists. Solving real problems that the world faces in the environment, human rights, and health. I can’t see any downside.
[1] That’s because they don’t really exist. They are a Ponzi scheme which, through repackaging, sells the same stuff over and over again. And, like a Ponzi scheme, customers who don’t understand it are happy as long as they are making money, but it always collapses. However our new Wall St. tyros learned one thing from traditional brokers – whether the customer is winning or losing, you always take your cut!
Tuesday, October 20, 2009
Red, Blue, and Purple: The Math of Health Care Spending
.
The Business section of the New York Times on October 10, 2009, had a small article by Floyd Norris called “The Divided State of Health Care”. It looks at which states and, within those states, Congressional districts, have the highest number of uninsured. In a neat series of graphics, states are divided into “blue” (voted for Obama, have 2 Democratic senators), “red” (voted for McCain, have 2 Republican senators) and “purple” (some other combination). The red states had the highest percent of uninsured, led by my former state, Texas, with 26.5% of those under 65, including 17.8% of children under 18, uninsured. While not linear (the second highest percentage of uninsured is in Florida, a “purple” state, and third is New Mexico, a “blue” state), the association is strong. My home state of Kansas, which has only one (of 4) Democratic congressional districts, and only 2 of 105 counties that voted for the President, is the "best” of the red states. However, its 13.8% uninsured is worse than 14 of the 21 blue states and 7 of the 17 purple states.
From an ideological point of view, this is not surprising, given the vicious opposition of the Republican Party to any type of meaningful health reform. From a practical point of view, it might be surprising – why are the leaders of those states, where there is such great need, not interested in addressing that need? Or, at least, why do the people in the states that have such great need keep re-electing folks who oppose meeting their need? Part of the explanation may come from the second half of the analysis, which shows that it is the blue (Democratic) congressional districts within the red states that have the highest number of uninsured people. This is because these districts have a lot of poor and minority people and vote Democratic, but to the majority of people in the rest of those states, are the “other”: “Of the 10 Congressional districts with the least health insurance,” writes Norris, “seven are in Texas, two in California and one in Florida. Nine of those districts are largely black or Hispanic, and are represented by Democrats who faced little if any Republican opposition in the last election.” Whether this is explained mostly by classism, racism, or something else is an interesting question, but the result is that if you are a poor or minority person in a conservative state, you are in particularly bad straits.
Of course, it is not only the poor minority inner-city people who are left out. In Kansas, while Wyandotte County (Kansas City), one of the “blue” counties, is the poorest county, and also has a high percent of minorities, the next 6 poorest are in rural, white southeast Kansas. Why do these folks vote against their self-interest for Republicans? (Well, they don’t always.[1]) Some of it is that there are other issues that attract their attention, and some of it is that they believe shamelessly propagated lies.
But some of it, as for so many Americans, is misunderstanding how health care costs work. Most of the money is not spent on most of the people. Journalists, living in their middle-class, young-to-middle aged worlds, are among the worst perpetrators of misunderstanding healthcare usage, writing about their rotator cuff surgery or their neighbor’s strep throat. 50% of people account for only 3% of health care costs; thus half of us are essentially “rounding error”. 5% of people account for 50% of costs. The other 45% are using about “their share”, or 47% of health dollars. If we look at this graphically, using (for fun) red, blue, and purple, we see:
The 45% of people who are using about “their share” are those who have chronic health problems and have to go to doctors more frequently, and get more tests, but don’t have frequent hospitalizations. It also includes the folks who have, in a given year, surgery or physical therapy – like for those rotator cuffs – but usually are in the low use group. This portion of the population includes a disproportionate % of seniors, who have more chronic disease and use more health care services.
Another way to look at it would be for $100 spent on 100 people (whose costs are distributed as per the whole population), 45 people would cost about “their share”, just over $1 each, 50 people would cost $0.06 (6 cents) each, and 5 people would cost $10 each.
Seniors, because they are also more likely to have multiple chronic health problems that require multiple hospitalizations, and because they are more likely to have cancer, which costs a lot to treat, are also disproportionately represented in the high cost group. However, they are still the minority of that group. These high-cost users are the “outliers”, and also include other people with cancer, people with trauma, as from auto accidents, requiring multiple surgeries, and premature and sick babies requiring incredibly expensive care in neonatal intensive care units.
This is an extremely important concept, because it is the reason that insurance exchanges have gone bankrupt in every state that has tried it, and will not work at the federal level. While it is acknowledged that insurance companies “game the system” and “cherry pick” healthier people, the efforts in the current legislation to try to prevent that will not be sufficient, because, given the above data, they don’t have to enroll only people in the “low cost” group (although I’m sure they’d like that!), they just have to find subtle ways to get rid of one or two of those 5 high-cost people. For each one of those people they can avoid, they save the same amount as their cost for 10 “mid-user” people or 167 “low users”. None of the current legislation will be rigorous enough to force each insurance company to enroll 5% of the high users (in part because we don’t always know who they’re going to be – see below – which is also why they can’t have none of them). The insurance “exchanges” for uninsurables will then, soon, just as they have in each state that has tried it, become unsustainably expensive while the insurance companies continue to make big profits. See the amazing report in the Washington Times “Insurer ends health program rather than pay out big” to get a sense of what we can expect from insurance companies. (And note that this is from a very conservative newspaper!)
So if everyone looks at it from the point of view of their current self-interest, those in that “low use, low cost” group wouldn’t want to pay more for all those high-cost, high-use folks. This year, today, it wouldn’t be in our self-interest. Except…
…we don’t know when we, or our teenage children, will be in a car accident that rockets them from the low-cost to the high-cost group. And we don’t know when we’ll have a premature baby, or be diagnosed with cancer, or have us or our parents move from the mid-cost, have-chronic-conditions-and-see-the-doctor-but-rarely-be-hospitalized group to the high-cost be-hospitalized-a-lot-including-in-intensive-care group.
So we are all in it together. And the only system that prevents “gaming”, “cherry picking” and adverse selection is having one system. And that is what we need to adopt.
With profound thanks to Robert Ferrer, MD, MPH
[1] In 2006, the Kansas 2nd Congressional district that includes SE KS, but also the city of Topeka, elected a Democratic Congresswoman, Nancy Boyda, to replace reactionary Jim Ryun, remembered mostly as a KU mile champion. But in 2008, she was defeated by a Republican. SE Kansas also has a populist history, with Crawford County being one of 3 counties in the nation to vote for Gene Debs in 1920.
The Business section of the New York Times on October 10, 2009, had a small article by Floyd Norris called “The Divided State of Health Care”. It looks at which states and, within those states, Congressional districts, have the highest number of uninsured. In a neat series of graphics, states are divided into “blue” (voted for Obama, have 2 Democratic senators), “red” (voted for McCain, have 2 Republican senators) and “purple” (some other combination). The red states had the highest percent of uninsured, led by my former state, Texas, with 26.5% of those under 65, including 17.8% of children under 18, uninsured. While not linear (the second highest percentage of uninsured is in Florida, a “purple” state, and third is New Mexico, a “blue” state), the association is strong. My home state of Kansas, which has only one (of 4) Democratic congressional districts, and only 2 of 105 counties that voted for the President, is the "best” of the red states. However, its 13.8% uninsured is worse than 14 of the 21 blue states and 7 of the 17 purple states.
From an ideological point of view, this is not surprising, given the vicious opposition of the Republican Party to any type of meaningful health reform. From a practical point of view, it might be surprising – why are the leaders of those states, where there is such great need, not interested in addressing that need? Or, at least, why do the people in the states that have such great need keep re-electing folks who oppose meeting their need? Part of the explanation may come from the second half of the analysis, which shows that it is the blue (Democratic) congressional districts within the red states that have the highest number of uninsured people. This is because these districts have a lot of poor and minority people and vote Democratic, but to the majority of people in the rest of those states, are the “other”: “Of the 10 Congressional districts with the least health insurance,” writes Norris, “seven are in Texas, two in California and one in Florida. Nine of those districts are largely black or Hispanic, and are represented by Democrats who faced little if any Republican opposition in the last election.” Whether this is explained mostly by classism, racism, or something else is an interesting question, but the result is that if you are a poor or minority person in a conservative state, you are in particularly bad straits.
Of course, it is not only the poor minority inner-city people who are left out. In Kansas, while Wyandotte County (Kansas City), one of the “blue” counties, is the poorest county, and also has a high percent of minorities, the next 6 poorest are in rural, white southeast Kansas. Why do these folks vote against their self-interest for Republicans? (Well, they don’t always.[1]) Some of it is that there are other issues that attract their attention, and some of it is that they believe shamelessly propagated lies.
But some of it, as for so many Americans, is misunderstanding how health care costs work. Most of the money is not spent on most of the people. Journalists, living in their middle-class, young-to-middle aged worlds, are among the worst perpetrators of misunderstanding healthcare usage, writing about their rotator cuff surgery or their neighbor’s strep throat. 50% of people account for only 3% of health care costs; thus half of us are essentially “rounding error”. 5% of people account for 50% of costs. The other 45% are using about “their share”, or 47% of health dollars. If we look at this graphically, using (for fun) red, blue, and purple, we see:
The 45% of people who are using about “their share” are those who have chronic health problems and have to go to doctors more frequently, and get more tests, but don’t have frequent hospitalizations. It also includes the folks who have, in a given year, surgery or physical therapy – like for those rotator cuffs – but usually are in the low use group. This portion of the population includes a disproportionate % of seniors, who have more chronic disease and use more health care services.
Another way to look at it would be for $100 spent on 100 people (whose costs are distributed as per the whole population), 45 people would cost about “their share”, just over $1 each, 50 people would cost $0.06 (6 cents) each, and 5 people would cost $10 each.
Seniors, because they are also more likely to have multiple chronic health problems that require multiple hospitalizations, and because they are more likely to have cancer, which costs a lot to treat, are also disproportionately represented in the high cost group. However, they are still the minority of that group. These high-cost users are the “outliers”, and also include other people with cancer, people with trauma, as from auto accidents, requiring multiple surgeries, and premature and sick babies requiring incredibly expensive care in neonatal intensive care units.
This is an extremely important concept, because it is the reason that insurance exchanges have gone bankrupt in every state that has tried it, and will not work at the federal level. While it is acknowledged that insurance companies “game the system” and “cherry pick” healthier people, the efforts in the current legislation to try to prevent that will not be sufficient, because, given the above data, they don’t have to enroll only people in the “low cost” group (although I’m sure they’d like that!), they just have to find subtle ways to get rid of one or two of those 5 high-cost people. For each one of those people they can avoid, they save the same amount as their cost for 10 “mid-user” people or 167 “low users”. None of the current legislation will be rigorous enough to force each insurance company to enroll 5% of the high users (in part because we don’t always know who they’re going to be – see below – which is also why they can’t have none of them). The insurance “exchanges” for uninsurables will then, soon, just as they have in each state that has tried it, become unsustainably expensive while the insurance companies continue to make big profits. See the amazing report in the Washington Times “Insurer ends health program rather than pay out big” to get a sense of what we can expect from insurance companies. (And note that this is from a very conservative newspaper!)
So if everyone looks at it from the point of view of their current self-interest, those in that “low use, low cost” group wouldn’t want to pay more for all those high-cost, high-use folks. This year, today, it wouldn’t be in our self-interest. Except…
…we don’t know when we, or our teenage children, will be in a car accident that rockets them from the low-cost to the high-cost group. And we don’t know when we’ll have a premature baby, or be diagnosed with cancer, or have us or our parents move from the mid-cost, have-chronic-conditions-and-see-the-doctor-but-rarely-be-hospitalized group to the high-cost be-hospitalized-a-lot-including-in-intensive-care group.
So we are all in it together. And the only system that prevents “gaming”, “cherry picking” and adverse selection is having one system. And that is what we need to adopt.
With profound thanks to Robert Ferrer, MD, MPH
[1] In 2006, the Kansas 2nd Congressional district that includes SE KS, but also the city of Topeka, elected a Democratic Congresswoman, Nancy Boyda, to replace reactionary Jim Ryun, remembered mostly as a KU mile champion. But in 2008, she was defeated by a Republican. SE Kansas also has a populist history, with Crawford County being one of 3 counties in the nation to vote for Gene Debs in 1920.
Saturday, October 17, 2009
The actions of criminal settlers in Israel cannot be allowed to define the Jewish people
.
NPR recently covered a story about the response of Jewish settlers on the West Bank to the Israeli army tearing down illegal “outpost” settlements, in response to court order (“Evicted Israeli settlers attack Palestinian land”). The settlers are, apparently, responding by burning down the olive groves and other property, belonging to nearby Palestinian farmers.
Let’s get this straight: Jewish settlers, in Palestinian territory, establish illegal “satellite” settlements in an absolutely purposeful aggressive gesture against their own government, the Palestinian people, and the rest of the world. Israeli courts declare them illegal, and send in Israeli security forces to tear them down. In response, the settlers destroy the property of nearby Palestinians. This they call the “price tag”.
So I waited, as they interviewed the Arab farmer whose groves were burned, the attorney who had brought the issue to the court, and a settler who asserted their right to act because the “Jews have a right to all this territory”. I waited to hear how the settlers who committed this atrocity, identified after an intensive police investigation, had been jailed and were awaiting trial.
Didn’t hear it. Did hear that the courts are now more reluctant to issue such orders. So they are not arresting and prosecuting the thugs who perpetrate these acts, but rather awarding them victory. This is not ok.
I was going to say that the settlers who destroyed the lands of their Arab neighbors were nothing more than common criminals, to be arrested, prosecuted, and imprisoned. But they are more than common criminals. They are hate criminals. I do not know Israeli law, but in the US these would be clearly hate crimes, and treated much more harshly than common crimes.
The settlers, as a movement, are wrong, but this sort of tactic is execrable. These are bad people because they are doing bad things, very bad things, and the failure of the Israeli government to immediately, enthusiastically, and harshly punish this behavior is intolerable. These people, these bad people, give the Jewish people a bad name.
Jews, as a people, probably because of their own history of oppression, have always been in the forefront of progressive social movements. They are and have been very active in movements for social justice, including the civil rights movement in the United States, including the war against fascism (by some estimates 80% of US volunteers who fought with the Lincoln Battalion in Spain were Jewish). In South Africa, a very high proportion of the white participants in and leaders of the anti-apartheid movement were Jewish. Across the US and the world, where there are any Jews, they are disproportionately represented in fights for human rights. Even in Israel; while even progressive Jews in the US are reluctant to criticize Israel, in that country there are many who stand for human rights.
The perpetrators of these acts, and their supporters, are acting to reverse the Jewish people’s tradition of empathy and support for the oppressed, becoming oppressors themselves. Just as most Muslim people do not wish to be defined by Al Qaeda, these criminals cannot be permitted to define what it means to be Jewish. They are the Jewish Taliban, and deserve no support or sympathy.
NPR recently covered a story about the response of Jewish settlers on the West Bank to the Israeli army tearing down illegal “outpost” settlements, in response to court order (“Evicted Israeli settlers attack Palestinian land”). The settlers are, apparently, responding by burning down the olive groves and other property, belonging to nearby Palestinian farmers.
Let’s get this straight: Jewish settlers, in Palestinian territory, establish illegal “satellite” settlements in an absolutely purposeful aggressive gesture against their own government, the Palestinian people, and the rest of the world. Israeli courts declare them illegal, and send in Israeli security forces to tear them down. In response, the settlers destroy the property of nearby Palestinians. This they call the “price tag”.
So I waited, as they interviewed the Arab farmer whose groves were burned, the attorney who had brought the issue to the court, and a settler who asserted their right to act because the “Jews have a right to all this territory”. I waited to hear how the settlers who committed this atrocity, identified after an intensive police investigation, had been jailed and were awaiting trial.
Didn’t hear it. Did hear that the courts are now more reluctant to issue such orders. So they are not arresting and prosecuting the thugs who perpetrate these acts, but rather awarding them victory. This is not ok.
I was going to say that the settlers who destroyed the lands of their Arab neighbors were nothing more than common criminals, to be arrested, prosecuted, and imprisoned. But they are more than common criminals. They are hate criminals. I do not know Israeli law, but in the US these would be clearly hate crimes, and treated much more harshly than common crimes.
The settlers, as a movement, are wrong, but this sort of tactic is execrable. These are bad people because they are doing bad things, very bad things, and the failure of the Israeli government to immediately, enthusiastically, and harshly punish this behavior is intolerable. These people, these bad people, give the Jewish people a bad name.
Jews, as a people, probably because of their own history of oppression, have always been in the forefront of progressive social movements. They are and have been very active in movements for social justice, including the civil rights movement in the United States, including the war against fascism (by some estimates 80% of US volunteers who fought with the Lincoln Battalion in Spain were Jewish). In South Africa, a very high proportion of the white participants in and leaders of the anti-apartheid movement were Jewish. Across the US and the world, where there are any Jews, they are disproportionately represented in fights for human rights. Even in Israel; while even progressive Jews in the US are reluctant to criticize Israel, in that country there are many who stand for human rights.
The perpetrators of these acts, and their supporters, are acting to reverse the Jewish people’s tradition of empathy and support for the oppressed, becoming oppressors themselves. Just as most Muslim people do not wish to be defined by Al Qaeda, these criminals cannot be permitted to define what it means to be Jewish. They are the Jewish Taliban, and deserve no support or sympathy.
Wednesday, October 14, 2009
"War on Specialists?": Wall St. Journal defends the status quo!
.
The Wall St. Journal, October 13, 2009, contains a “Review and Outlook” piece (editorial) titled “The War on Specialists”. The opinion piece decries the way that “ObamaCare” is going to try to save money by reallocating funds from subspecialists to primary care doctors. As an example, they talk about the proposed cuts to some of the “basic tools of heart specialists”, echocardiograms and cardiac catheterizations. They quote American College of Cardiology CEO Jack Lewin, MD, as saying that it will cause a “horrible disruption” that may make senior patients wait days for tests and services, because staff will have to be laid off. (Of course, it could lead to SHORTER waits if the cardiologists do more procedures per day to try to make up that income!) The WSJ correctly points out that the cuts don’t necessarily cut any spending; “…the RVUs merely redistribute it from one medical bucket to another.” That is, the cap on spending on medical care (called the Sustainable Growth Rate, or SGR, which I have previously addressed) would increase primary care doctors’ reimbursements while it cuts those of subspecialists.
But would these predicted disasters actually come to pass? Hard to know; but what we do know is that the reimbursement for subspecialists is many times that of primary care physicians, so much so that it is more and more difficult to convince medical students, graduating with large debt, to enter primary care. The assertions of the WSJ, and Dr. Lewin (who used to be director of Public Health for the state of Hawai’i, and an advocate for the public’s health, before taking this more highly-paid job) are simply assertions. Following the same pattern as the paper I discussed recently by Dr. Cooper (“’Uncomplicated’ Primary Care?”), and others, they ignore data that shows that there needs to be a balance between primary care and subspecialty care in order to achieve the best outcomes in the public’s health, and that the current ratio is way out of balance. I have cited, over and over again, the literature, from many places and many times, that demonstrates this. And is conveniently ignored in this piece, attacking this consistent data as “based on a flimsy survey” that HHS has done and that Secretary Sebelius and budget director Orszag will not discuss with poor Dr. Lewin. Why bother to look at the data when you can simply assert your beliefs?
The WSJ article ignores the fact that much of the care provided by, for example, cardiologists, is excessive; that supply generates demand. The work of the researchers at the Dartmouth Health Atlas show the dramatic differences in costs of care and frequency of expensive procedures by region – often based on the density of subspecialists – without appreciable differences in health outcomes. (Or, when there are differences, that the outcomes are better where there is less use of expensive technology!) It makes the key mistake of conflating “health” with “preventing death”. Of course, we all want to prevent our deaths when we see meaningful life ahead, but the extraordinary expenditures that often prevent death only by weeks, days or hours, would often be better spent on having a sufficient number of primary care doctors to be able to maintain health, control chronic disease, and do preventive care. [1]
“Markets,” the WSJ asserts, “are supposed to determine the composition of the workforce, not a command medical economy run out of Washington.” Perhaps, but the situation that exists today is far from a “free market”. In addition to the almost-unique ability of medical specialists to generate demand based on supply, as discussed above, the simple fact is that it is the “command economy”, not the market, that accounts for the current, inequitable state of reimbursement. The assignment of RVU values grossly overvalues procedures in comparison to time spent with the patient discussing their health, managing medical problems and planning treatment. It is the fact that Medicare (and thus other insurers, whose reimbursements are almost always tied to multiples of Medicare rates) and its current method of reimbursing fee-for-service by RVU values that have created this inequity. What is needed is to correct it, and this cause is not served by blatantly false assertions that it is a free market, rather than a stacked system, that has created the problem.
While Jack Lewin has become an embarrassment to public health, he is doing his job. The WSJ can advocate for “markets” but should not imply that the status quo is a result of the operation of free markets, rather than a reflection of the way the deck is currently stacked. The WSJ provides no service whatever when it tries to make a discussion about what best serves the health needs of the American people a partisan cause. It can disagree with me on the issues, it can even choose to trumpet its disregard for facts, but this is not, and should not be a Democratic / Republican issue. The health of our people is too important.
[1] For example, the most common outpatient medical visit, code 99213, taking about 20-30 minutes, in which I can address multiple chronic health problems as well as preventive services, is valued at 0.92 work RVUs. If I then clean the wax out of the person’s ear, I get another 0.61.
The Wall St. Journal, October 13, 2009, contains a “Review and Outlook” piece (editorial) titled “The War on Specialists”. The opinion piece decries the way that “ObamaCare” is going to try to save money by reallocating funds from subspecialists to primary care doctors. As an example, they talk about the proposed cuts to some of the “basic tools of heart specialists”, echocardiograms and cardiac catheterizations. They quote American College of Cardiology CEO Jack Lewin, MD, as saying that it will cause a “horrible disruption” that may make senior patients wait days for tests and services, because staff will have to be laid off. (Of course, it could lead to SHORTER waits if the cardiologists do more procedures per day to try to make up that income!) The WSJ correctly points out that the cuts don’t necessarily cut any spending; “…the RVUs merely redistribute it from one medical bucket to another.” That is, the cap on spending on medical care (called the Sustainable Growth Rate, or SGR, which I have previously addressed) would increase primary care doctors’ reimbursements while it cuts those of subspecialists.
But would these predicted disasters actually come to pass? Hard to know; but what we do know is that the reimbursement for subspecialists is many times that of primary care physicians, so much so that it is more and more difficult to convince medical students, graduating with large debt, to enter primary care. The assertions of the WSJ, and Dr. Lewin (who used to be director of Public Health for the state of Hawai’i, and an advocate for the public’s health, before taking this more highly-paid job) are simply assertions. Following the same pattern as the paper I discussed recently by Dr. Cooper (“’Uncomplicated’ Primary Care?”), and others, they ignore data that shows that there needs to be a balance between primary care and subspecialty care in order to achieve the best outcomes in the public’s health, and that the current ratio is way out of balance. I have cited, over and over again, the literature, from many places and many times, that demonstrates this. And is conveniently ignored in this piece, attacking this consistent data as “based on a flimsy survey” that HHS has done and that Secretary Sebelius and budget director Orszag will not discuss with poor Dr. Lewin. Why bother to look at the data when you can simply assert your beliefs?
The WSJ article ignores the fact that much of the care provided by, for example, cardiologists, is excessive; that supply generates demand. The work of the researchers at the Dartmouth Health Atlas show the dramatic differences in costs of care and frequency of expensive procedures by region – often based on the density of subspecialists – without appreciable differences in health outcomes. (Or, when there are differences, that the outcomes are better where there is less use of expensive technology!) It makes the key mistake of conflating “health” with “preventing death”. Of course, we all want to prevent our deaths when we see meaningful life ahead, but the extraordinary expenditures that often prevent death only by weeks, days or hours, would often be better spent on having a sufficient number of primary care doctors to be able to maintain health, control chronic disease, and do preventive care. [1]
“Markets,” the WSJ asserts, “are supposed to determine the composition of the workforce, not a command medical economy run out of Washington.” Perhaps, but the situation that exists today is far from a “free market”. In addition to the almost-unique ability of medical specialists to generate demand based on supply, as discussed above, the simple fact is that it is the “command economy”, not the market, that accounts for the current, inequitable state of reimbursement. The assignment of RVU values grossly overvalues procedures in comparison to time spent with the patient discussing their health, managing medical problems and planning treatment. It is the fact that Medicare (and thus other insurers, whose reimbursements are almost always tied to multiples of Medicare rates) and its current method of reimbursing fee-for-service by RVU values that have created this inequity. What is needed is to correct it, and this cause is not served by blatantly false assertions that it is a free market, rather than a stacked system, that has created the problem.
While Jack Lewin has become an embarrassment to public health, he is doing his job. The WSJ can advocate for “markets” but should not imply that the status quo is a result of the operation of free markets, rather than a reflection of the way the deck is currently stacked. The WSJ provides no service whatever when it tries to make a discussion about what best serves the health needs of the American people a partisan cause. It can disagree with me on the issues, it can even choose to trumpet its disregard for facts, but this is not, and should not be a Democratic / Republican issue. The health of our people is too important.
[1] For example, the most common outpatient medical visit, code 99213, taking about 20-30 minutes, in which I can address multiple chronic health problems as well as preventive services, is valued at 0.92 work RVUs. If I then clean the wax out of the person’s ear, I get another 0.61.
Monday, October 12, 2009
Lessons from World War I
.
Kansas City has the largest World War I memorial in the nation, Liberty Memorial, associated with the incredibly impressive National World War I Museum. It is a must-see for a visitor to Kansas City, and even worth a special trip. It is impossible to tour the museum and not be impressed by the enormity of this almost-forgotten war, the enormity of death and destruction, the virtual wiping out of an entire generation of young men in Europe, and the wanton disregard for people that led to an entirely unnecessary war being fought. The trenches must have been unbelievably awful; the image of men firing at each other across a no-man’s land difficult to envision.
WWI brought in its wake many writings that should be remembered and re-read, including the remarkable All Quiet on the Western Front by Erich Maria Remarque, and the heart-rending poems of the “World War I poets”, many of whom lost their lives, such as Rupert Brooke, Wilfred Owen, John McCrae, Isaac Rosenberg and others. One cannot read these works without tears and regret and wondering what it was that led to, in England alone, the loss to death or wounds of 8% of its population. If you prefer your tears to musical accompaniment, I recommend “Battlefields of Green”[1] by Scottish-Canadian singer John McDermott; while it includes lovely renditions of standards such as “Danny Boy”, most of the songs are about WWI, including a powerful performance of Australian Eric Bogle’s anti-anthem, “And the Band Played Waltzing Matilda”.
World War I was not fought because Gavrilo Princip assassinated the Archduke Ferdinand of Austria, although that may have been a spark. What was it that led these countries of Europe, many of them (such as England and Germany) ruled by cousins, to enter this horrific conflagration? At its base it was a mercantile war, about whose merchants and manufacturers would control markets and be able to make money (and, of course, the war munitions makers, who did extremely well). For their economic self-interest, for the greater wealth of a small number of plutocrats, millions of young men were killed and wounded, Europe was decimated, and the seeds of WW II were sown. But boy, did those plutocrats do well! Not only did those in Europe do well, so did those in the US, which entered the war late, had (relatively) fewer casualties, and had no battles on its territory. The literature of this time is “The Great Gatsby”, the profligate 1920s, ending in the crash of ’29, the Great Depression, and the rise of Nazism and Fascism in Europe. (required reading is Howard Zinn's classic "People's History of the United States", Ch. 14, "War is the Health of the State". Interesting to note this in a "health" blog.)
Why talk about WWI now, here, in this blog? I suppose that I could tie it to the pointless wars in Iraq and Afghanistan that continue to claim lives, and there would be validity to that, although now our wars are fought in other people’s countries, in the third world, and not by all of our children but predominantly working class children. However, I am more struck by the parallels to today in that policy continues to be made, and young lives sacrificed in the cause of increasing the “abundance of those who have much”. Not a year since the “crash” of 2008, our bankers and financiers are back to the same practices of excess in their personal lives and excessive risk-taking in their public actions that put the entire world economy into a recession and continues to cause amazing pain to millions. We are told that the economy is improving, which means that the bankers and financiers are doing well. We are told that the number of new job losses is less this month than last. Not that jobs are being created, understand, but that the rate of loss is less. There are 6 people for every available job. This is not improvement. This is bad. It is bad for the real people who live in this country. It is intolerable. We did not think that the Bush administration cared for regular people, but had hoped that the Obama administration did. No such luck. The predators are feasting over the spoils of the economy and the regular people still suffer.
People are angry. They are angry because they do not have jobs, because more jobs are being eliminated than created, because they do not see the government doing anything for them. On the heels of the Great Depression, FDR instituted the New Deal, including Social Security, banking reform, and a massive jobs program. On the heels of the current depression we bailed out the banks. Something is wrong with this picture.
In the 1930s, anger led to massive movements on the left and on the right. The right is always funded by the wealthy and led by ideologues, but requires regular people for a mass movement. These people are convinced that, somehow, their interests will be met by policies that are entirely directed at benefiting the wealthiest and the corporations they own; racism, jingoism, and mainly lying are popular and effective methods. The young Englishmen who died in WWI for the profits of the mercantile sector were sent to die for “King and country".
It is not only in war, and in the economy, that our government is doing the bidding of the super-rich and corporations and ignoring the people; it is happening on every front. Michael Moss, in the New York Times, on October 4, 2009, reported on the poisoning of our ground beef supply with pathogenic E. coli bacteria, E. Coli Path Shows Flaws in Beef Inspection, because of inadequate testing by the slaughterhouses, grinders and processers, and government. The story of the effects on people were horrifying, but more horrifying is the quotation from “Dr. Kenneth Petersen, an assistant administrator with the department’s Food Safety and Inspection Service” who “said that the department could mandate testing, but that it needed to consider the impact on companies as well as consumers. ‘I have to look at the entire industry, not just what is best for public health,’ Dr. Petersen said.” This does not help us to gain faith in our government and feel that, in Lincoln’s words, it is acting “of the people, by the people, and for the people.”
World War I was an unmitigated disaster, fought for terrible reasons and leading to tremendous devastation. Well, maybe a little mitigated. A lot of arms manufacturers made a lot of money, and the corporations from the victorious companies gained markets. But it was, and is, inexcusable; and as inexcusable are the ways we continue to attract young men to die for markets, as they did in WWI. Wilfred Owen’s poem “Disabled”,
…One time he liked a blood- smear down his leg,
After the matches, carried shoulder-high.
It was after football, when he'd drunk a peg,
He thought he'd better join. - He wonders why.
Someone had said he'd look a god in kilts,
That's why; and maybe, too, to please his Meg,
Aye, that was it, to please the giddy jilts
He asked to join. He didn't have to beg;
Smiling they wrote his lie: aged nineteen years.
Germans he scarcely thought of; all their guilt,
And Austria's, did not move him. And no fears
Of Fear came yet.
He thought of jewelled hilts
For daggers in plaid socks; of smart salutes;
And care of arms; and leave; and pay arrears;
Esprit de corps; and hints for young recruits.
And soon, he was drafted out with drums and cheers.
Some cheered him home, but not as crowds cheer Goal.
Only a solemn man who brought him fruits
Thanked him; and then enquired about his soul.
Now, he will spend a few sick years in institutes,
And do what things the rules consider wise,
And take whatever pity they may dole….
characterizes too many veterans today.
Yes, something is wrong. We need more than wars to send our young people to. We need jobs for them to do. And since the corporations we bail out won’t create them, we need the government to do it; a massive works program to rebuild our infrastructure for all of us. We need health care for all of us. We need a government that works for all of us. I hope, and I worry, and I fear that even under this President it will not.
[1] Hyperlink to one of many sites it can be purchased at.
Kansas City has the largest World War I memorial in the nation, Liberty Memorial, associated with the incredibly impressive National World War I Museum. It is a must-see for a visitor to Kansas City, and even worth a special trip. It is impossible to tour the museum and not be impressed by the enormity of this almost-forgotten war, the enormity of death and destruction, the virtual wiping out of an entire generation of young men in Europe, and the wanton disregard for people that led to an entirely unnecessary war being fought. The trenches must have been unbelievably awful; the image of men firing at each other across a no-man’s land difficult to envision.
WWI brought in its wake many writings that should be remembered and re-read, including the remarkable All Quiet on the Western Front by Erich Maria Remarque, and the heart-rending poems of the “World War I poets”, many of whom lost their lives, such as Rupert Brooke, Wilfred Owen, John McCrae, Isaac Rosenberg and others. One cannot read these works without tears and regret and wondering what it was that led to, in England alone, the loss to death or wounds of 8% of its population. If you prefer your tears to musical accompaniment, I recommend “Battlefields of Green”[1] by Scottish-Canadian singer John McDermott; while it includes lovely renditions of standards such as “Danny Boy”, most of the songs are about WWI, including a powerful performance of Australian Eric Bogle’s anti-anthem, “And the Band Played Waltzing Matilda”.
World War I was not fought because Gavrilo Princip assassinated the Archduke Ferdinand of Austria, although that may have been a spark. What was it that led these countries of Europe, many of them (such as England and Germany) ruled by cousins, to enter this horrific conflagration? At its base it was a mercantile war, about whose merchants and manufacturers would control markets and be able to make money (and, of course, the war munitions makers, who did extremely well). For their economic self-interest, for the greater wealth of a small number of plutocrats, millions of young men were killed and wounded, Europe was decimated, and the seeds of WW II were sown. But boy, did those plutocrats do well! Not only did those in Europe do well, so did those in the US, which entered the war late, had (relatively) fewer casualties, and had no battles on its territory. The literature of this time is “The Great Gatsby”, the profligate 1920s, ending in the crash of ’29, the Great Depression, and the rise of Nazism and Fascism in Europe. (required reading is Howard Zinn's classic "People's History of the United States", Ch. 14, "War is the Health of the State". Interesting to note this in a "health" blog.)
Why talk about WWI now, here, in this blog? I suppose that I could tie it to the pointless wars in Iraq and Afghanistan that continue to claim lives, and there would be validity to that, although now our wars are fought in other people’s countries, in the third world, and not by all of our children but predominantly working class children. However, I am more struck by the parallels to today in that policy continues to be made, and young lives sacrificed in the cause of increasing the “abundance of those who have much”. Not a year since the “crash” of 2008, our bankers and financiers are back to the same practices of excess in their personal lives and excessive risk-taking in their public actions that put the entire world economy into a recession and continues to cause amazing pain to millions. We are told that the economy is improving, which means that the bankers and financiers are doing well. We are told that the number of new job losses is less this month than last. Not that jobs are being created, understand, but that the rate of loss is less. There are 6 people for every available job. This is not improvement. This is bad. It is bad for the real people who live in this country. It is intolerable. We did not think that the Bush administration cared for regular people, but had hoped that the Obama administration did. No such luck. The predators are feasting over the spoils of the economy and the regular people still suffer.
People are angry. They are angry because they do not have jobs, because more jobs are being eliminated than created, because they do not see the government doing anything for them. On the heels of the Great Depression, FDR instituted the New Deal, including Social Security, banking reform, and a massive jobs program. On the heels of the current depression we bailed out the banks. Something is wrong with this picture.
In the 1930s, anger led to massive movements on the left and on the right. The right is always funded by the wealthy and led by ideologues, but requires regular people for a mass movement. These people are convinced that, somehow, their interests will be met by policies that are entirely directed at benefiting the wealthiest and the corporations they own; racism, jingoism, and mainly lying are popular and effective methods. The young Englishmen who died in WWI for the profits of the mercantile sector were sent to die for “King and country".
It is not only in war, and in the economy, that our government is doing the bidding of the super-rich and corporations and ignoring the people; it is happening on every front. Michael Moss, in the New York Times, on October 4, 2009, reported on the poisoning of our ground beef supply with pathogenic E. coli bacteria, E. Coli Path Shows Flaws in Beef Inspection, because of inadequate testing by the slaughterhouses, grinders and processers, and government. The story of the effects on people were horrifying, but more horrifying is the quotation from “Dr. Kenneth Petersen, an assistant administrator with the department’s Food Safety and Inspection Service” who “said that the department could mandate testing, but that it needed to consider the impact on companies as well as consumers. ‘I have to look at the entire industry, not just what is best for public health,’ Dr. Petersen said.” This does not help us to gain faith in our government and feel that, in Lincoln’s words, it is acting “of the people, by the people, and for the people.”
World War I was an unmitigated disaster, fought for terrible reasons and leading to tremendous devastation. Well, maybe a little mitigated. A lot of arms manufacturers made a lot of money, and the corporations from the victorious companies gained markets. But it was, and is, inexcusable; and as inexcusable are the ways we continue to attract young men to die for markets, as they did in WWI. Wilfred Owen’s poem “Disabled”,
…One time he liked a blood- smear down his leg,
After the matches, carried shoulder-high.
It was after football, when he'd drunk a peg,
He thought he'd better join. - He wonders why.
Someone had said he'd look a god in kilts,
That's why; and maybe, too, to please his Meg,
Aye, that was it, to please the giddy jilts
He asked to join. He didn't have to beg;
Smiling they wrote his lie: aged nineteen years.
Germans he scarcely thought of; all their guilt,
And Austria's, did not move him. And no fears
Of Fear came yet.
He thought of jewelled hilts
For daggers in plaid socks; of smart salutes;
And care of arms; and leave; and pay arrears;
Esprit de corps; and hints for young recruits.
And soon, he was drafted out with drums and cheers.
Some cheered him home, but not as crowds cheer Goal.
Only a solemn man who brought him fruits
Thanked him; and then enquired about his soul.
Now, he will spend a few sick years in institutes,
And do what things the rules consider wise,
And take whatever pity they may dole….
characterizes too many veterans today.
Yes, something is wrong. We need more than wars to send our young people to. We need jobs for them to do. And since the corporations we bail out won’t create them, we need the government to do it; a massive works program to rebuild our infrastructure for all of us. We need health care for all of us. We need a government that works for all of us. I hope, and I worry, and I fear that even under this President it will not.
[1] Hyperlink to one of many sites it can be purchased at.
Thursday, October 8, 2009
"Uncomplicated" Primary Care?
.
I have often written about the importance of primary care, the shortage of primary care physicians, and the fact that fewer medical students are choosing primary care careers, which will exacerbate the problem. A key part of this analysis is the large number of studies, by researchers from a variety of settings, that show that the presence of a higher proportion of primary care doctors decreases cost and increases quality.[1],[2],[3],[4],[5] Indeed, there are studies that show that health disparities in infant mortality and low birthweight can be virtually eliminated by a greater presence of primary care.[6]
However, not everybody agrees. In an earlier post, More Primary Care Doctors or Just More Doctors?, I discussed the position taken by Dr. Richard Cooper, former Executive Vice President and Dean of the Medical College of Wisconsin and currently Professor of Medicine and Senior Fellow, Leonard Davis Institute of Health Economics, University of Pennsylvania, who argues against this position, as well as rebuttals from some of those he has criticized. In a recent publication supported by the Physician’s Foundation, a group comprised primarily of state and local medical societies, “Physicians and their practices under health care reform: a report to the president and the congress”, Dr. Cooper and a group of equally distinguished colleagues restate this position; in particular that the value of primary care is overstated. In an excerpt from the Executive Summary they note:
"Primary care has been a central focus of health care reform. In modeling the future workforce, the Project Team acknowledged the critical importance of primary care services and the role of generalist physicians in providing them. However, the Team rejected the claim by Starfield and others of lower mortality in regions with more family practitioners as a statistical anomaly, and it questioned the wisdom of deploying generalist physicians to take responsibility for the proposed medical homes. Indeed, faced with deep and prolonged physician shortages, it saw no need for physicians to expend effort on uncomplicated primary care"
This is quite a strong statement in opposition to what I, and many others, have been saying in support of the importance of primary care to the health of the public, so of course one looks for the supporting data, especially for the striking dismissal of the work of Starfield and others as “a statistical anomaly”; however the data isn’t there. Presumably, when people are so distinguished and feel their positions so strongly, such data is unnecessary. One distinguished colleague put forward this definition:
Statistical anomaly: A consistent finding, in multiple nations and health systems that disagrees with my current self-interest and bias.
That says it very well. If you have no data to justify publication in peer-reviewed journals, you can continue to perpetrate your ideas in foundation-sponsored opinion pieces.
Several organizations, including the American Academy of Family Physicians (AAFP) and the Association of Departments of Family Medicine (ADFM) have protested this publication to the sponsors, the Physicians Foundation. The Foundation took the position that it commissioned the study but did not endorse it; that it was supportive of primary care, and chose to focus on other findings of the report (such as that socioeconomic differences make a difference in geographic variation, which the Dartmouth Atlas researchers are purported to have ignored in their analysis). The PF states its unequivocal support of primary care in a letter to the President of ADFM: “As for the Physicians Foundation (PF), it would never do anything to damage primary care.” Nonetheless, the AAFP found this inadequate; its formal response to the PF includes the following:
“This report is an attack on decades of sophisticated research that validly supports the value and need for improving access to robust primary care using a thin vein of research that has been publicly demonstrated to be oversimplified and wrong. The authors’ perspectives and opinions are welcome in the debate about how to reform the health system and physician workforce, but this report is largely opinion richly dressed in discredited, unsophisticated research.
This study is largely a recapitulation of the primary author’s paper in Health Affairs in January of this year[7]. In that same issue, several researchers pointed out the fundamental flaws in this simplistic research showing that important basic adjustments showed this work to strongly support the prior studies it criticized. It continues to claim that population differences explain past findings for the value of primary care and variance in spending, when these were fully accounted for in these studies. This report does not repair those flaws. It labels several well-validated and valued studies as “anomalous” and “simple frameworks” without supporting evidence from other sources. We feel that such claims carry an obligation to point out specific errors of methodology or data, not just recapitulation of personal belief. The burden of proof is still overwhelmingly against the evidence upon which this reports rests. Its foundation is flimsy.”
Enough said about the lack of intellectual rigor, and essentially incorrectness about this piece. More important, I believe, the other assertion in the quote from Cooper’s paper, above, neatly packaged in the sentence “Indeed, faced with deep and prolonged physician shortages, it saw no need for physicians to expend effort on uncomplicated primary care". What is this “uncomplicated primary care” of which you speak? The idea that provision of primary care is simple, unchallenging intellectually, not worthy of the training of a physician, and could be done by someone with much less training, is a position put forward by other specialists and subspecialists that is:
· Common, especially in speaking to medical students,
· Derogatory, and offensive,
· Self-serving, since obviously the services provided by the subspecialists are much more rigorous and difficult, and
· Wrong.
The myth is that primary care is about patients with colds and high blood pressure checks. The reality is that it is about people with multiple chronic diseases who need management of those conditions as well as coordination with whatever other specialists they are seeing; preventive services delivered; counseling and “asking for trouble” (“are you safe at home?”); discussion of whatever the other specialist may have recommended; and, of course, caring for acute complaints. This is hard, complex, time consuming and difficult. Yarnall, et. al, in the American Journal of Public Health, identified that it would take 7.4 hours a day for a primary care physician to just provide the preventive services, not to mention all the other services above, especially chronic disease management.[8] One of my residents recently returned from a rotation on cardiology; on her first day she was sent to see a patient and returned in 7 minutes. “That was fast,” said the cardiologist. “You just wanted me to address their heart problem,” the resident, used to caring for many different problems in a family medicine visit, replied. Perhaps this is cognitive dissonance for the subspecialist (or “partialist”), who has to believe that their in-depth knowledge of one particular set of conditions is at a higher level than managing the whole person with all of their complex medical, psychological, and social and economic issues.
Another wise colleague, who believes that “The question of what is intellectually challenging and worthy of training and intellect is a classic example of hubris perpetuated by subspecialists and academic health centers,” asks the following question of his medical students:
“What is more intellectually challenging?
Performing your 2000th knee arthroscopy
Performing your 3000th laparascopic cholestectomy
Performing your 4000th bronchoscopy
Performing your 5000th colonoscopy
Performing your 6000th intubation
Performing your 7000th breast augmentation
Performing your 8000th cataract removal
Reading your 10000th MRI
Seeing you 15000th case of acne (achievable in 7 years seeing 10 case a day 20 days a month 45 weeks a year)
OR
Taking care of a 55 yo with diabetes, hyperlipidemia, hypertension, coronary artery disease, chronic renal insufficiency, who is depressed, has a rash, erectile dysfunction, esophageal reflux and who is taking care of his elder mother with Alzheimer's dementia.”
I just had the opportunity to review the charts of the patients seen by one of my first-year family medicine residents in one clinic session recently. They included:
· Woman with uncontrolled Diabetes, recently discharged from the hospital with diabetic ketoacidosis; marked edema of legs.
· Woman with anhedonia who feels “fat and alone”; no “physical abuse” – boyfriend just pushes her and she feels safe when she locks the door.
· Woman for “well-woman exam”, who came for Pap smear and prevention, with uncontrolled hypertension, very stressed from working her two jobs, having difficulty with her medication.
All had, in addition, other medical problems.
“Uncomplicated” primary care”? Perhaps you would like to take over the comprehensive management of her patient panel, Dr. Cooper?
[1] Baicker K & Chandra A, “Medicare Spending, The Physician Workforce, And Beneficiaries’ Quality Of Care”, Health Affairs, 7 Apr 2004;W4.184
[2] [3] Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83:457–502
[3] Ferrer RL, Hambridge SJ, Maly RC, “The essential role of generalists in health care systems”, Annals of Internal Medicine 2005;142:691-699.
[4] . Ferrer RL. Pursuing equity: contact with primary care and specialist clinicians by demographics, insurance, and health status. Ann Fam Med. Nov-Dec 2007;5(6):492-502.
[5] Goodman DC, Grumbach K. Does having more physicians lead to better health system performance? JAMA. 2008;299(3):335-337.
[6] Shi L, Macinko J, Starfield B, Xu J, Regan J, Politzer R and Wulu J, “Primary care, infant mortality, and low birthweight in the states of the USA”,J Epidemiol Community Health 2004;58;374-380
[7] Cooper RA, “States with More Physicians Have Better-Quality Health Care,” Health Affairs 28, no. 1 (2009): w91–w102
[8] Yarnall KS, Pollak KI, Østbye T, Krause KM, Michener JL., Primary care: is there enough time for prevention?, Am J Pub Health, 2003 Apr;93(4):635-41.
I have often written about the importance of primary care, the shortage of primary care physicians, and the fact that fewer medical students are choosing primary care careers, which will exacerbate the problem. A key part of this analysis is the large number of studies, by researchers from a variety of settings, that show that the presence of a higher proportion of primary care doctors decreases cost and increases quality.[1],[2],[3],[4],[5] Indeed, there are studies that show that health disparities in infant mortality and low birthweight can be virtually eliminated by a greater presence of primary care.[6]
However, not everybody agrees. In an earlier post, More Primary Care Doctors or Just More Doctors?, I discussed the position taken by Dr. Richard Cooper, former Executive Vice President and Dean of the Medical College of Wisconsin and currently Professor of Medicine and Senior Fellow, Leonard Davis Institute of Health Economics, University of Pennsylvania, who argues against this position, as well as rebuttals from some of those he has criticized. In a recent publication supported by the Physician’s Foundation, a group comprised primarily of state and local medical societies, “Physicians and their practices under health care reform: a report to the president and the congress”, Dr. Cooper and a group of equally distinguished colleagues restate this position; in particular that the value of primary care is overstated. In an excerpt from the Executive Summary they note:
"Primary care has been a central focus of health care reform. In modeling the future workforce, the Project Team acknowledged the critical importance of primary care services and the role of generalist physicians in providing them. However, the Team rejected the claim by Starfield and others of lower mortality in regions with more family practitioners as a statistical anomaly, and it questioned the wisdom of deploying generalist physicians to take responsibility for the proposed medical homes. Indeed, faced with deep and prolonged physician shortages, it saw no need for physicians to expend effort on uncomplicated primary care"
This is quite a strong statement in opposition to what I, and many others, have been saying in support of the importance of primary care to the health of the public, so of course one looks for the supporting data, especially for the striking dismissal of the work of Starfield and others as “a statistical anomaly”; however the data isn’t there. Presumably, when people are so distinguished and feel their positions so strongly, such data is unnecessary. One distinguished colleague put forward this definition:
Statistical anomaly: A consistent finding, in multiple nations and health systems that disagrees with my current self-interest and bias.
That says it very well. If you have no data to justify publication in peer-reviewed journals, you can continue to perpetrate your ideas in foundation-sponsored opinion pieces.
Several organizations, including the American Academy of Family Physicians (AAFP) and the Association of Departments of Family Medicine (ADFM) have protested this publication to the sponsors, the Physicians Foundation. The Foundation took the position that it commissioned the study but did not endorse it; that it was supportive of primary care, and chose to focus on other findings of the report (such as that socioeconomic differences make a difference in geographic variation, which the Dartmouth Atlas researchers are purported to have ignored in their analysis). The PF states its unequivocal support of primary care in a letter to the President of ADFM: “As for the Physicians Foundation (PF), it would never do anything to damage primary care.” Nonetheless, the AAFP found this inadequate; its formal response to the PF includes the following:
“This report is an attack on decades of sophisticated research that validly supports the value and need for improving access to robust primary care using a thin vein of research that has been publicly demonstrated to be oversimplified and wrong. The authors’ perspectives and opinions are welcome in the debate about how to reform the health system and physician workforce, but this report is largely opinion richly dressed in discredited, unsophisticated research.
This study is largely a recapitulation of the primary author’s paper in Health Affairs in January of this year[7]. In that same issue, several researchers pointed out the fundamental flaws in this simplistic research showing that important basic adjustments showed this work to strongly support the prior studies it criticized. It continues to claim that population differences explain past findings for the value of primary care and variance in spending, when these were fully accounted for in these studies. This report does not repair those flaws. It labels several well-validated and valued studies as “anomalous” and “simple frameworks” without supporting evidence from other sources. We feel that such claims carry an obligation to point out specific errors of methodology or data, not just recapitulation of personal belief. The burden of proof is still overwhelmingly against the evidence upon which this reports rests. Its foundation is flimsy.”
Enough said about the lack of intellectual rigor, and essentially incorrectness about this piece. More important, I believe, the other assertion in the quote from Cooper’s paper, above, neatly packaged in the sentence “Indeed, faced with deep and prolonged physician shortages, it saw no need for physicians to expend effort on uncomplicated primary care". What is this “uncomplicated primary care” of which you speak? The idea that provision of primary care is simple, unchallenging intellectually, not worthy of the training of a physician, and could be done by someone with much less training, is a position put forward by other specialists and subspecialists that is:
· Common, especially in speaking to medical students,
· Derogatory, and offensive,
· Self-serving, since obviously the services provided by the subspecialists are much more rigorous and difficult, and
· Wrong.
The myth is that primary care is about patients with colds and high blood pressure checks. The reality is that it is about people with multiple chronic diseases who need management of those conditions as well as coordination with whatever other specialists they are seeing; preventive services delivered; counseling and “asking for trouble” (“are you safe at home?”); discussion of whatever the other specialist may have recommended; and, of course, caring for acute complaints. This is hard, complex, time consuming and difficult. Yarnall, et. al, in the American Journal of Public Health, identified that it would take 7.4 hours a day for a primary care physician to just provide the preventive services, not to mention all the other services above, especially chronic disease management.[8] One of my residents recently returned from a rotation on cardiology; on her first day she was sent to see a patient and returned in 7 minutes. “That was fast,” said the cardiologist. “You just wanted me to address their heart problem,” the resident, used to caring for many different problems in a family medicine visit, replied. Perhaps this is cognitive dissonance for the subspecialist (or “partialist”), who has to believe that their in-depth knowledge of one particular set of conditions is at a higher level than managing the whole person with all of their complex medical, psychological, and social and economic issues.
Another wise colleague, who believes that “The question of what is intellectually challenging and worthy of training and intellect is a classic example of hubris perpetuated by subspecialists and academic health centers,” asks the following question of his medical students:
“What is more intellectually challenging?
Performing your 2000th knee arthroscopy
Performing your 3000th laparascopic cholestectomy
Performing your 4000th bronchoscopy
Performing your 5000th colonoscopy
Performing your 6000th intubation
Performing your 7000th breast augmentation
Performing your 8000th cataract removal
Reading your 10000th MRI
Seeing you 15000th case of acne (achievable in 7 years seeing 10 case a day 20 days a month 45 weeks a year)
OR
Taking care of a 55 yo with diabetes, hyperlipidemia, hypertension, coronary artery disease, chronic renal insufficiency, who is depressed, has a rash, erectile dysfunction, esophageal reflux and who is taking care of his elder mother with Alzheimer's dementia.”
I just had the opportunity to review the charts of the patients seen by one of my first-year family medicine residents in one clinic session recently. They included:
· Woman with uncontrolled Diabetes, recently discharged from the hospital with diabetic ketoacidosis; marked edema of legs.
· Woman with anhedonia who feels “fat and alone”; no “physical abuse” – boyfriend just pushes her and she feels safe when she locks the door.
· Woman for “well-woman exam”, who came for Pap smear and prevention, with uncontrolled hypertension, very stressed from working her two jobs, having difficulty with her medication.
All had, in addition, other medical problems.
“Uncomplicated” primary care”? Perhaps you would like to take over the comprehensive management of her patient panel, Dr. Cooper?
[1] Baicker K & Chandra A, “Medicare Spending, The Physician Workforce, And Beneficiaries’ Quality Of Care”, Health Affairs, 7 Apr 2004;W4.184
[2] [3] Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83:457–502
[3] Ferrer RL, Hambridge SJ, Maly RC, “The essential role of generalists in health care systems”, Annals of Internal Medicine 2005;142:691-699.
[4] . Ferrer RL. Pursuing equity: contact with primary care and specialist clinicians by demographics, insurance, and health status. Ann Fam Med. Nov-Dec 2007;5(6):492-502.
[5] Goodman DC, Grumbach K. Does having more physicians lead to better health system performance? JAMA. 2008;299(3):335-337.
[6] Shi L, Macinko J, Starfield B, Xu J, Regan J, Politzer R and Wulu J, “Primary care, infant mortality, and low birthweight in the states of the USA”,J Epidemiol Community Health 2004;58;374-380
[7] Cooper RA, “States with More Physicians Have Better-Quality Health Care,” Health Affairs 28, no. 1 (2009): w91–w102
[8] Yarnall KS, Pollak KI, Østbye T, Krause KM, Michener JL., Primary care: is there enough time for prevention?, Am J Pub Health, 2003 Apr;93(4):635-41.
Sunday, October 4, 2009
Seniors and Medicare: Beware not simply "Scare Mongers" but lying hypocrites
.
Old age, at whatever chronologic age it happens to one, is not an easy time. The body loses its resilience, often strength, and resistance to disease. Seniors account for the bulk of medical spending because chronic disease is so much more common. It is a time of vulnerability, both physical and socioeconomic; most seniors are living on fixed incomes and, after children, they are the demographic group most likely to be living in poverty. So it is quite understandable that many seniors would be worried about threats to the few things that they feel that they can count on to support their lives, especially Medicare and Social Security. It is also understandable, and completely unconscionable, that reactionary politicians and blowhards in the media would play upon those fears for their own political ends, which are usually about supporting the greater amassment of wealth for the already rich and powerful.
We already know about “death panels”. Hopefully, most people know, by now, that they do not exist, they never existed, and nobody was proposing that they exist. It was a falsehood made up of whole cloth, an insidious perversion of the idea that our government (which supports most of the research as well as much of the care already) support research into what medical interventions work and what don’t, and assess the cost:benefit ratio for those procedures. All of us, seniors and non-seniors alike, want to have what will benefit us, and do not want, particularly when we are most vulnerable, interventions that will not help and only cause discomfort, false hope, and cost us money besides.
I, along with many others, have made fun of the comment, unfortunately often heard, “Keep the government’s hands off my Medicare!” This seems like a joke – doesn’t everyone know that Medicare is a government program? But I guess not. Medicare, in 1965, and Social Security, in the 1930s, were progressive programs that have become the most valued and hallowed institutions in our society. They help to ease the pain and insecurity of old age. And – and let me be absolutely clear on this – they were completely opposed, in the 1930s and 1960s, by the political ancestors of those who are opposing government health reform now.
Let me say this again. The McConnells, McCains, Grassleys, Boehners, and Cantors, the Limbaughs, O’Reillys, Becks, and Hannitys, the AMA and the AHA and manufacturers’ associations of those periods, absolutely opposed the government intervention that created Social Security and Medicare. Their ideological heirs today are charlatans, liars and cheats to pretend that they are defending it now.
The latest scare tactic is to imply that those receiving Medicare would have their coverage watered down because all these other people would now be covered. To even imply this is an immoral and egregious crime. The best system, as I have often advocated, is Medicare for All. The additional money it would cost would not be equivalent to multiplying the percent now receiving Medicare by everyone else, because those receiving Medicare, the aged, blind and disabled, are the population already requiring the most care. The savings, not simply on insurance company profits but on the huge administrative infrastructure both insurers and providers have to protect those profits, would be enormous. Even in the tepid, inadequate reforms being proposed by the Senate Finance Committee, the additional funds appropriated would address this need. Medicare recipients would not lose quality care; savings being proposed are those that would come from no longer paying for worthless but expensive procedures, and from eliminating Medicare fraud.[1]
Nonetheless, unsigned and unattributed inflammatory emails continue to arise unsolicited, as this one recently forwarded by a friend:
Subject: Info For Seniors
Congress vote themselves cost of living adjustments (hefty ones at that)....what's wrong with this picture?
For the first time in history, Congress will not allow an increase in
the social security COLA (cost of living adjustment). In fact, the
Henry J. Kaiser Family Foundation predicts there may not be any COLA
for the next three years. However, the per person monthly Medicare
insurance premium will be increased from the 2009 premium of $96.40 to
$104.20 in 2010 and to $ 120.20 for the year 2011.
Let's send this to all seniors that you know. Remind them not to vote
for the incumbent senators and congressmen in the 2010 and the 2012
elections.
Sounds pretty bad. But I strongly recommend looking at the actual website of the Kaiser foundation, which has a superb paper on the topic, http://www.kff.org/medicare/upload/7912.pdf.
The reason there will be no cost of living adjustment (COLA) for 2 (not 3) years is that the Consumer Price Index (CPI), to which it is tied, went down. Remember the recession? Part B Medicare payments (this is what pays doctors, and is paid by individuals, not the Medicare trust fund; the latter, to which we contribute from every paycheck, funds only Part A, hospital costs) will still go up, because medical costs rose despite the recession.
75% of Medicare recipients will not see an increase in their Part B payments because the law contains a "hold harmless" provision that prevents the total from decreasing from one year to the next. That is, it prevents the increase in payment for Part B from exceeding the increase in income from Social Security. Of the other 25% of Medicare recipients, 17% are "dual-eligibles" who also get Medicaid because they are poor; their Part B premiums go up, but Medicaid already pays them and will continue to do so. 3% are folks who just retired this year and thus aren’t covered by the “hold harmless” provision because they payments can’t "go down" (they are receiving SS for the first time). The last 5% are higher income seniors -- those with a modified adjusted growth income of $85,000 for individuals and $170,000 for couples who are (absolutely correctly in my opinion) presumed to be able to pick up the few extra dollars a month. (Part D, the drug program, is not covered by the Hold Harmless Provision, so its premiums will go up.)[2]
Another target has been cuts to the Medicare Advantage (formerly Medicare-Plus-Choice) program (which is Medicare Part C.) I have criticized this program as one more give-away to the insurance companies in a previous blog. To understand the issue here, you need to understand the difference between fee-for-service and capitation (as in HMOs). In fee-for-service care, which is what most insured people, as well as most Medicare recipients have, providers (doctors, hospitals, equipment providers) are paid per-service or per-item. In an HMO, the provider (the HMO) receives money in advance and then provides all covered care to the beneficiary. Medicare Advantage plans have the same plusses and minuses as other HMOs – which is to say that they vary tremendously by HMO. Most provide (relatively low cost, but valued) “extra” services, such as glasses and hearing aids. They may or may not provide the actual services that one needs when one is sick. Remember – they already have the money, and anything they spend on you is loss of profit (the “medical loss ratio”). Unsurprisingly, the HMOs (and Medicare Advantage) programs that are owned by for-profit insurance companies are usually meaner (in the sense of “cheaper” and well as the more common definition) than are the few remaining “consumer cooperatives” such as Group Health of Puget Sound and HIP in NYC, or Kaiser Permanente (somewhat different in that it was initially founded by a corporation for its employees). Some recipients of Medicare Advantage are angry that it may be cut back, but the fact is that most of these programs restrict access to care more than traditional Medicare. Both of these points of view are expressed in letters to the editor of the New York Times, Sept 30, 2009; I commend especially the data-driven, rather than solely opinion, letters of Barbara Kennelly and Samuel Brooks.
These letters are in response to a New York Times editorial (“Medicare Scare Mongering”, Sept 27, 2009), which, among other things, calls for changes in this program. Acknowledging the extra benefits that Medicare Advantage offers, it correctly points out that it is unfair and unreasonable for Medicare to pay more to these insurers than it pays for other recipients. Some Medicare recipients pay additional money out of their own pockets to be covered by an HMO; this is their choice and if it is a good HMO, may well be a wise decision. But it is wrong for Medicare to subsidize, as it has, the insurance company providers by paying more for Medicare Part C (most of which goes to profit, not patient care, or, excuse me, “medical loss”!), and the Times is correct to call for such change.
The original Social Security, as we all know, was championed and pushed through by President Franklin D. Roosevelt -- against the opposition of conservatives who called him a “socialist”. All seniors, and all of the rest of us who will hopefully become seniors, owe him thanks. The following words are carved on his memorial:
“THE TEST OF OUR PROGRESS IS NOT WHETHER WE ADD MORE TO THE ABUNDANCE OF THOSE WHO HAVE MUCH; IT IS WHETHER WE PROVIDE ENOUGH TO THOSE WHO HAVE TOO LITTLE".
We need to keep these words in mind, live by them and make policy by them. We must resolutely oppose those in Congress or the private sector whose goal is to “add more to the abundance of those who have much”, often because those who have much share some of it with them, especially when they deviously seek to achieve their ends through vicious scare tactics. They are immoral and wrong.
[1] As I have indicated, I believe that the government way overstates Medicare “fraud”. The regulations are complex and ever-changing, and the vast majority of this is not fraud at all, but simple mistakes. One can liken this to the IRS. But I am certain that there is some true Medicare fraud, just as there is income tax fraud.
[2] Also note that it is fine to call for voting out those in Congress, but, but the ones who voted this in are largely dead, as the linking of SS and Medicare to the CPI was done in 1973.
Old age, at whatever chronologic age it happens to one, is not an easy time. The body loses its resilience, often strength, and resistance to disease. Seniors account for the bulk of medical spending because chronic disease is so much more common. It is a time of vulnerability, both physical and socioeconomic; most seniors are living on fixed incomes and, after children, they are the demographic group most likely to be living in poverty. So it is quite understandable that many seniors would be worried about threats to the few things that they feel that they can count on to support their lives, especially Medicare and Social Security. It is also understandable, and completely unconscionable, that reactionary politicians and blowhards in the media would play upon those fears for their own political ends, which are usually about supporting the greater amassment of wealth for the already rich and powerful.
We already know about “death panels”. Hopefully, most people know, by now, that they do not exist, they never existed, and nobody was proposing that they exist. It was a falsehood made up of whole cloth, an insidious perversion of the idea that our government (which supports most of the research as well as much of the care already) support research into what medical interventions work and what don’t, and assess the cost:benefit ratio for those procedures. All of us, seniors and non-seniors alike, want to have what will benefit us, and do not want, particularly when we are most vulnerable, interventions that will not help and only cause discomfort, false hope, and cost us money besides.
I, along with many others, have made fun of the comment, unfortunately often heard, “Keep the government’s hands off my Medicare!” This seems like a joke – doesn’t everyone know that Medicare is a government program? But I guess not. Medicare, in 1965, and Social Security, in the 1930s, were progressive programs that have become the most valued and hallowed institutions in our society. They help to ease the pain and insecurity of old age. And – and let me be absolutely clear on this – they were completely opposed, in the 1930s and 1960s, by the political ancestors of those who are opposing government health reform now.
Let me say this again. The McConnells, McCains, Grassleys, Boehners, and Cantors, the Limbaughs, O’Reillys, Becks, and Hannitys, the AMA and the AHA and manufacturers’ associations of those periods, absolutely opposed the government intervention that created Social Security and Medicare. Their ideological heirs today are charlatans, liars and cheats to pretend that they are defending it now.
The latest scare tactic is to imply that those receiving Medicare would have their coverage watered down because all these other people would now be covered. To even imply this is an immoral and egregious crime. The best system, as I have often advocated, is Medicare for All. The additional money it would cost would not be equivalent to multiplying the percent now receiving Medicare by everyone else, because those receiving Medicare, the aged, blind and disabled, are the population already requiring the most care. The savings, not simply on insurance company profits but on the huge administrative infrastructure both insurers and providers have to protect those profits, would be enormous. Even in the tepid, inadequate reforms being proposed by the Senate Finance Committee, the additional funds appropriated would address this need. Medicare recipients would not lose quality care; savings being proposed are those that would come from no longer paying for worthless but expensive procedures, and from eliminating Medicare fraud.[1]
Nonetheless, unsigned and unattributed inflammatory emails continue to arise unsolicited, as this one recently forwarded by a friend:
Subject: Info For Seniors
Congress vote themselves cost of living adjustments (hefty ones at that)....what's wrong with this picture?
For the first time in history, Congress will not allow an increase in
the social security COLA (cost of living adjustment). In fact, the
Henry J. Kaiser Family Foundation predicts there may not be any COLA
for the next three years. However, the per person monthly Medicare
insurance premium will be increased from the 2009 premium of $96.40 to
$104.20 in 2010 and to $ 120.20 for the year 2011.
Let's send this to all seniors that you know. Remind them not to vote
for the incumbent senators and congressmen in the 2010 and the 2012
elections.
Sounds pretty bad. But I strongly recommend looking at the actual website of the Kaiser foundation, which has a superb paper on the topic, http://www.kff.org/medicare/upload/7912.pdf.
The reason there will be no cost of living adjustment (COLA) for 2 (not 3) years is that the Consumer Price Index (CPI), to which it is tied, went down. Remember the recession? Part B Medicare payments (this is what pays doctors, and is paid by individuals, not the Medicare trust fund; the latter, to which we contribute from every paycheck, funds only Part A, hospital costs) will still go up, because medical costs rose despite the recession.
75% of Medicare recipients will not see an increase in their Part B payments because the law contains a "hold harmless" provision that prevents the total from decreasing from one year to the next. That is, it prevents the increase in payment for Part B from exceeding the increase in income from Social Security. Of the other 25% of Medicare recipients, 17% are "dual-eligibles" who also get Medicaid because they are poor; their Part B premiums go up, but Medicaid already pays them and will continue to do so. 3% are folks who just retired this year and thus aren’t covered by the “hold harmless” provision because they payments can’t "go down" (they are receiving SS for the first time). The last 5% are higher income seniors -- those with a modified adjusted growth income of $85,000 for individuals and $170,000 for couples who are (absolutely correctly in my opinion) presumed to be able to pick up the few extra dollars a month. (Part D, the drug program, is not covered by the Hold Harmless Provision, so its premiums will go up.)[2]
Another target has been cuts to the Medicare Advantage (formerly Medicare-Plus-Choice) program (which is Medicare Part C.) I have criticized this program as one more give-away to the insurance companies in a previous blog. To understand the issue here, you need to understand the difference between fee-for-service and capitation (as in HMOs). In fee-for-service care, which is what most insured people, as well as most Medicare recipients have, providers (doctors, hospitals, equipment providers) are paid per-service or per-item. In an HMO, the provider (the HMO) receives money in advance and then provides all covered care to the beneficiary. Medicare Advantage plans have the same plusses and minuses as other HMOs – which is to say that they vary tremendously by HMO. Most provide (relatively low cost, but valued) “extra” services, such as glasses and hearing aids. They may or may not provide the actual services that one needs when one is sick. Remember – they already have the money, and anything they spend on you is loss of profit (the “medical loss ratio”). Unsurprisingly, the HMOs (and Medicare Advantage) programs that are owned by for-profit insurance companies are usually meaner (in the sense of “cheaper” and well as the more common definition) than are the few remaining “consumer cooperatives” such as Group Health of Puget Sound and HIP in NYC, or Kaiser Permanente (somewhat different in that it was initially founded by a corporation for its employees). Some recipients of Medicare Advantage are angry that it may be cut back, but the fact is that most of these programs restrict access to care more than traditional Medicare. Both of these points of view are expressed in letters to the editor of the New York Times, Sept 30, 2009; I commend especially the data-driven, rather than solely opinion, letters of Barbara Kennelly and Samuel Brooks.
These letters are in response to a New York Times editorial (“Medicare Scare Mongering”, Sept 27, 2009), which, among other things, calls for changes in this program. Acknowledging the extra benefits that Medicare Advantage offers, it correctly points out that it is unfair and unreasonable for Medicare to pay more to these insurers than it pays for other recipients. Some Medicare recipients pay additional money out of their own pockets to be covered by an HMO; this is their choice and if it is a good HMO, may well be a wise decision. But it is wrong for Medicare to subsidize, as it has, the insurance company providers by paying more for Medicare Part C (most of which goes to profit, not patient care, or, excuse me, “medical loss”!), and the Times is correct to call for such change.
The original Social Security, as we all know, was championed and pushed through by President Franklin D. Roosevelt -- against the opposition of conservatives who called him a “socialist”. All seniors, and all of the rest of us who will hopefully become seniors, owe him thanks. The following words are carved on his memorial:
“THE TEST OF OUR PROGRESS IS NOT WHETHER WE ADD MORE TO THE ABUNDANCE OF THOSE WHO HAVE MUCH; IT IS WHETHER WE PROVIDE ENOUGH TO THOSE WHO HAVE TOO LITTLE".
We need to keep these words in mind, live by them and make policy by them. We must resolutely oppose those in Congress or the private sector whose goal is to “add more to the abundance of those who have much”, often because those who have much share some of it with them, especially when they deviously seek to achieve their ends through vicious scare tactics. They are immoral and wrong.
[1] As I have indicated, I believe that the government way overstates Medicare “fraud”. The regulations are complex and ever-changing, and the vast majority of this is not fraud at all, but simple mistakes. One can liken this to the IRS. But I am certain that there is some true Medicare fraud, just as there is income tax fraud.
[2] Also note that it is fine to call for voting out those in Congress, but, but the ones who voted this in are largely dead, as the linking of SS and Medicare to the CPI was done in 1973.
Wednesday, September 30, 2009
Some good, but a lot still wrong, in health reform bills
.
The recent release of the “Chairman’s Mark” of the Senate Finance Committee bill (Max Baucus, Chairman), the “America’s Healthy Futures Act” has brought to 3 the number of plans to be reconciled by Congress. The “Chairman’s Mark” is not legislative language, which is good; it is actually comprehensible – if you can get through the 273 pages. Or find a good summary. There are several. Not a summary, but useful, is the Congressional Budget Office (CBO)’s evaluation This joins the previously produced Senate Health, Education, Labor and Pensions (HELP) Committee (the Kennedy Committee) bill, and the 3 merged House bills, mostly modeled on the Energy and Commerce (Rep. Waxman) Committee’s bill, HR3200.
There is actually a lot of good stuff in these bills, things that will help address many of the issues that I have raised. Both the House and the Senate Finance bills shift GME slots to primary care, and address many vexing issues of graduate medical education funding, such as support for time spent outside the hospital, time spent in required didactic conferences, and allowing doctors in private practice to actually volunteer their time to be “preceptors” for residents.[1],[2] (The Senate HELP Committee bill doesn’t address this, as Medicare is not part of their charge; similarly there will be other areas where the Senate Finance committee is silent because they don’t have authority.) The House and Senate HELP bills provide excellent funding for “Title VII” Primary Care cluster for educational grants for primary care, fund the National Health Service Corps at good levels, and the House bill provides demonstration projects for funding GME directly to non-hospitals, especially Community Health Centers and Rural Health clinics. The various bills also creates committees or commission and provide funding for demonstration projects for actual workforce analysis and development.[3] The Senate HELP bill provides funding for Primary Care extension services.[4] The House bill and the Finance bill provide some funding for the Medical Home. All bills provide significant funding for Comparative Effectiveness Research.[5]
That’s the good stuff, and there is more. The biggest problem in these bills, especially the Senate Finance bill, is that they do not cover everyone, and won’t. John Iglehart, writing in the New England Journal of Medicine[6], notes that “The Congressional Budget Office (CBO) has estimated the measure’s net cost at $774 billion over 10 years and projected that it would provide health insurance to 94% of Americans by 2019, leaving about 25 million people — one third of them illegal immigrants — without coverage.”
Excuse me? We now have 47 million uninsured in this country, and this is the greatest health threat. Ten years after implementation of this major overhaul of the health system, this bill promises us a reduction to – 25 million uninsured?? That 1/3 of them are undocumented is irrelevant; in addition to the fact that this leaves 2/3 (nearly 17 million people) who are legal residents uninsured, the fact that people are undocumented does not mean that they do not get sick, or cause a burden on our health system and taxpayers when they appear in emergency rooms with far advanced disease requiring expensive care because they were not eligible for prevention and early treatment. Nor does it change the fact that most of them are working, and when they get sick it has significant negative impacts on their employers, communities, and our economy. This is a fatal flaw. Health reform must cover everyone. (I feel like a broken record, but I will never stop saying it!).
The House, and Senate HELP bills, do provide potentially for covering everyone through a public option and/or requiring people to buy health insurance, but despite the intrinsic limitations to such systems (mainly cost) in comparison to a rational, sensible, cost-effective single payer system, the Obama administration, according to Iglehart (and others), “…considers Baucus’s bill the most promising vehicle for crafting a compromise, because it is less costly than the alternatives approved by four other congressional committees and is the most palatable to influential private stakeholders (large employers, health plans, and hospitals).”
This becomes even more concerning with the defeat of two proposals to re-introduce a public option into the Senate Finance bill on Sept 29, 2009 . Although the Democrats have a 13-10 majority on the committee, five Democrats opposed an amendment by Sen. Jay Rockefeller (D-WV), and 3 a second proposed by Sen. Charles Schumer (D-NY); Baucus voted against both as did his Democratic colleague from the “Group of Six”, Kent Conrad (D-ND). The water for the Republicans was carried by Sen. Charles Grassley (R-IA), who attacked the public option as a step toward “socialized medicine” and “government run health care” and sidestepped Sen. Schumer’s questions about why he didn’t oppose the government-run Medicare program.
So, by being the most likely to appease and please the huge private industries paying the lobbying bills, we will get no public option. Even though, as noted by Jacob Hacker in the NEJM [7], “According to a recent survey, a majority of U.S. physicians support health care reform that includes a new national public health insurance plan, which would compete with private plans[8]” and that “Polls have shown that a substantial majority of Americans support the public option as well.” What care we for what the people think?
The Senate Finance bill, in lieu of a public option, proposes “co-ops”, where people would get together and buy health insurance as a group. Co-ops are a good idea, if vaguely socialistic (I mean that as a joke, but others certainly do not!). They have served farmers well. The original “HMOs” were (other than Kaiser) consumer cooperatives (before most were bought out by large insurance companies and perverted from their original goals – getting more care for the same money, or the same care for less money, for their member/owners – to the corporate ones of making more money by spending less on the actual provision of health care). However, co-ops will not address the lack of a public option, which is the main point of the Hacker article. Hacker quotes the Sept 16 CBO report: “The proposed co-ops had very little effect on the estimates of total enrollment in the exchanges or federal costs...they seem unlikely to establish a significant market presence in many areas of the country or to noticeably affect federal subsidy payments." Hacker concludes:“In short, neither the cooperative nor the trigger[9] represents an acceptable substitute for the immediate creation of a national public plan. Rather than developing fig leaves to provide political cover, congressional leaders and the President should push for a national public plan that competes on a level playing field with private insurance to provide coverage to people who are uninsured and workers in the smallest firms. Such competition is the key to creating greater choice and accountability in increasingly consolidated insurance markets.”
This is starting to be nonsense. We need to cover everyone, and they need to be covered by a comprehensive, high-quality, affordable health plan. What we are getting is a lot of carrots (even, as I indicated, tasty ones for me!) to get buy in to a plan that contains the one core flaw. Folks will be left out. This is not OK, no matter what the lobbying efforts of insurance companies, pharma, hospitals, doctors, etc. All of us – including senior on Medicare – must avoid falling into these pits, so fearful we will endorse an immoral solution. “Give me everything, save money by not caring for you!” is not only immoral, it is untenable.
.
[1] see “Funding Graduate Medical Education”, May 25, 2009,
[2] Yes, indeed. CMS (Medicare) has been rigid in saying that community doctors have to be paid (or more likely, really are being paid but the sneaky residencies don’t tell us how much) to have residents in their offices from time to time. That is, that they don’t believe doctors would and do volunteer. They do, and it is honorable and good, and this legislation finally tells CMS that it is ok.
[3] Until now, most of medical workforce planning has been based upon the perceived short-term self-interest of a group of 25 year olds: that is, medical students decide what specialties to enter based on what they think will be best for them. There has been no national health workforce planning.
[4] See “The Primary Care Extension Service”, July 12, 2009,
[5] See “Clinical Guidelines and Technology Assessment”, May 12, 2009,
[6] Iglehart, J, Baucus’s Bill and the Long Road to Reform, NEJM 9/23/09
[7] Hacker, J, Poor Substitutes — Why Cooperatives and Triggers Can’t Achieve the Goals of a Public Option, NEJM 9/23/09,
[8] Keyhani S, Federman A. Doctors on coverage — physicians’ views on a new public insurance option and Medicare expansion. N Engl J Med 2009;361:e24-e24.
[9] The “trigger” is Sen Olympia Snowe’s (R-ME), the most likely Republican to support the plan. She opposes a public option “only in the event that private health plans failed to offer affordable coverage in a particular region, ‘triggering’ the creation of a public option.” (quote from Hacker). This is probably a more progressive position than Sen Baucus has taken!
.
The recent release of the “Chairman’s Mark” of the Senate Finance Committee bill (Max Baucus, Chairman), the “America’s Healthy Futures Act” has brought to 3 the number of plans to be reconciled by Congress. The “Chairman’s Mark” is not legislative language, which is good; it is actually comprehensible – if you can get through the 273 pages. Or find a good summary. There are several. Not a summary, but useful, is the Congressional Budget Office (CBO)’s evaluation This joins the previously produced Senate Health, Education, Labor and Pensions (HELP) Committee (the Kennedy Committee) bill, and the 3 merged House bills, mostly modeled on the Energy and Commerce (Rep. Waxman) Committee’s bill, HR3200.
There is actually a lot of good stuff in these bills, things that will help address many of the issues that I have raised. Both the House and the Senate Finance bills shift GME slots to primary care, and address many vexing issues of graduate medical education funding, such as support for time spent outside the hospital, time spent in required didactic conferences, and allowing doctors in private practice to actually volunteer their time to be “preceptors” for residents.[1],[2] (The Senate HELP Committee bill doesn’t address this, as Medicare is not part of their charge; similarly there will be other areas where the Senate Finance committee is silent because they don’t have authority.) The House and Senate HELP bills provide excellent funding for “Title VII” Primary Care cluster for educational grants for primary care, fund the National Health Service Corps at good levels, and the House bill provides demonstration projects for funding GME directly to non-hospitals, especially Community Health Centers and Rural Health clinics. The various bills also creates committees or commission and provide funding for demonstration projects for actual workforce analysis and development.[3] The Senate HELP bill provides funding for Primary Care extension services.[4] The House bill and the Finance bill provide some funding for the Medical Home. All bills provide significant funding for Comparative Effectiveness Research.[5]
That’s the good stuff, and there is more. The biggest problem in these bills, especially the Senate Finance bill, is that they do not cover everyone, and won’t. John Iglehart, writing in the New England Journal of Medicine[6], notes that “The Congressional Budget Office (CBO) has estimated the measure’s net cost at $774 billion over 10 years and projected that it would provide health insurance to 94% of Americans by 2019, leaving about 25 million people — one third of them illegal immigrants — without coverage.”
Excuse me? We now have 47 million uninsured in this country, and this is the greatest health threat. Ten years after implementation of this major overhaul of the health system, this bill promises us a reduction to – 25 million uninsured?? That 1/3 of them are undocumented is irrelevant; in addition to the fact that this leaves 2/3 (nearly 17 million people) who are legal residents uninsured, the fact that people are undocumented does not mean that they do not get sick, or cause a burden on our health system and taxpayers when they appear in emergency rooms with far advanced disease requiring expensive care because they were not eligible for prevention and early treatment. Nor does it change the fact that most of them are working, and when they get sick it has significant negative impacts on their employers, communities, and our economy. This is a fatal flaw. Health reform must cover everyone. (I feel like a broken record, but I will never stop saying it!).
The House, and Senate HELP bills, do provide potentially for covering everyone through a public option and/or requiring people to buy health insurance, but despite the intrinsic limitations to such systems (mainly cost) in comparison to a rational, sensible, cost-effective single payer system, the Obama administration, according to Iglehart (and others), “…considers Baucus’s bill the most promising vehicle for crafting a compromise, because it is less costly than the alternatives approved by four other congressional committees and is the most palatable to influential private stakeholders (large employers, health plans, and hospitals).”
This becomes even more concerning with the defeat of two proposals to re-introduce a public option into the Senate Finance bill on Sept 29, 2009 . Although the Democrats have a 13-10 majority on the committee, five Democrats opposed an amendment by Sen. Jay Rockefeller (D-WV), and 3 a second proposed by Sen. Charles Schumer (D-NY); Baucus voted against both as did his Democratic colleague from the “Group of Six”, Kent Conrad (D-ND). The water for the Republicans was carried by Sen. Charles Grassley (R-IA), who attacked the public option as a step toward “socialized medicine” and “government run health care” and sidestepped Sen. Schumer’s questions about why he didn’t oppose the government-run Medicare program.
So, by being the most likely to appease and please the huge private industries paying the lobbying bills, we will get no public option. Even though, as noted by Jacob Hacker in the NEJM [7], “According to a recent survey, a majority of U.S. physicians support health care reform that includes a new national public health insurance plan, which would compete with private plans[8]” and that “Polls have shown that a substantial majority of Americans support the public option as well.” What care we for what the people think?
The Senate Finance bill, in lieu of a public option, proposes “co-ops”, where people would get together and buy health insurance as a group. Co-ops are a good idea, if vaguely socialistic (I mean that as a joke, but others certainly do not!). They have served farmers well. The original “HMOs” were (other than Kaiser) consumer cooperatives (before most were bought out by large insurance companies and perverted from their original goals – getting more care for the same money, or the same care for less money, for their member/owners – to the corporate ones of making more money by spending less on the actual provision of health care). However, co-ops will not address the lack of a public option, which is the main point of the Hacker article. Hacker quotes the Sept 16 CBO report: “The proposed co-ops had very little effect on the estimates of total enrollment in the exchanges or federal costs...they seem unlikely to establish a significant market presence in many areas of the country or to noticeably affect federal subsidy payments." Hacker concludes:“In short, neither the cooperative nor the trigger[9] represents an acceptable substitute for the immediate creation of a national public plan. Rather than developing fig leaves to provide political cover, congressional leaders and the President should push for a national public plan that competes on a level playing field with private insurance to provide coverage to people who are uninsured and workers in the smallest firms. Such competition is the key to creating greater choice and accountability in increasingly consolidated insurance markets.”
This is starting to be nonsense. We need to cover everyone, and they need to be covered by a comprehensive, high-quality, affordable health plan. What we are getting is a lot of carrots (even, as I indicated, tasty ones for me!) to get buy in to a plan that contains the one core flaw. Folks will be left out. This is not OK, no matter what the lobbying efforts of insurance companies, pharma, hospitals, doctors, etc. All of us – including senior on Medicare – must avoid falling into these pits, so fearful we will endorse an immoral solution. “Give me everything, save money by not caring for you!” is not only immoral, it is untenable.
.
[1] see “Funding Graduate Medical Education”, May 25, 2009,
[2] Yes, indeed. CMS (Medicare) has been rigid in saying that community doctors have to be paid (or more likely, really are being paid but the sneaky residencies don’t tell us how much) to have residents in their offices from time to time. That is, that they don’t believe doctors would and do volunteer. They do, and it is honorable and good, and this legislation finally tells CMS that it is ok.
[3] Until now, most of medical workforce planning has been based upon the perceived short-term self-interest of a group of 25 year olds: that is, medical students decide what specialties to enter based on what they think will be best for them. There has been no national health workforce planning.
[4] See “The Primary Care Extension Service”, July 12, 2009,
[5] See “Clinical Guidelines and Technology Assessment”, May 12, 2009,
[6] Iglehart, J, Baucus’s Bill and the Long Road to Reform, NEJM 9/23/09
[7] Hacker, J, Poor Substitutes — Why Cooperatives and Triggers Can’t Achieve the Goals of a Public Option, NEJM 9/23/09,
[8] Keyhani S, Federman A. Doctors on coverage — physicians’ views on a new public insurance option and Medicare expansion. N Engl J Med 2009;361:e24-e24.
[9] The “trigger” is Sen Olympia Snowe’s (R-ME), the most likely Republican to support the plan. She opposes a public option “only in the event that private health plans failed to offer affordable coverage in a particular region, ‘triggering’ the creation of a public option.” (quote from Hacker). This is probably a more progressive position than Sen Baucus has taken!
.
Friday, September 25, 2009
Rankings of Medical Schools: Do they tell us anything?
.
Often it appears that Americans are obsessed by “rankings”. I am not talking about which is the best: car, TV, stereo, video game, and all the other consumer products we buy, and which are evaluated and often ranked by various organizations such as Consumers’ Union, based upon explicitly stated criteria. I am talking about the more subtle and subjective of rankings of various organizations and providers of services, particularly universities. More specifically, I will address the rankings of schools of medicine, and most specifically use as examples those in primary care and family medicine.
The US News and World Report rankings of colleges, and graduate schools in a wide variety of areas, including medicine, are the most well-known and “respected” (in the sense of “paid attention to”[1]) of the national rankers. The question is, what do the rankings mean? How are they derived? What do they reflect about the “product” being evaluated? Are they using criteria that are accurately assessing what I am looking for in a school? Are these down-to-earth, utilitarian, “Consumers Report”-type evaluations or are they more James Bond-like brand-name dropping[2]? Of course, if what I am looking for in a school is indeed cachet -- its status, fame and brand-name recognition -- then there is no difference. If, however, I am looking for outcomes – what is the success of that school in educating people in the area in which I wish to be educated, it is important to look at the criteria being used and the degree to which they accurately predict outcomes.
In general, most educators do not feel that US News rankings accurately reflect what they purport to be ranking – quality of the school in a particular area. These criticisms probably are more vocal from those who believe that they are ranked lower than they should be, but even those ranked highly will usually acknowledge, sotto voce, that they are not completely accurate – although they are pleased to be ranked highly. Recently, probably in response to ongoing criticism from the higher education community, US News has begun to publish the criteria that they use for ranking, the weight that they give to each criterion, and the method that they use to gather the information. This helps us to assess the validity of those criteria. (Validity is a concept that is used in research to evaluate the quality of a tool being used – how well does it actually measure what it is that I am using it to measure?).[3]
Medical schools are comprehensively ranked by US News in Research and in Primary Care. For Research the criteria include “peer assessment” (by other Deans, Chairs and Residency Directors), selectivity (how high were the pre-admission grades and scores on the Medical College Admissions Test of its students, percent of applicants accepted – low is ‘good’), faculty:student ratio, # and $ amount of research grants. For Primary Care, peer assessment and selectivity are again considered but rather than measuring research grants, they look at the total number (#) and percentage (%) of graduates entering primary care residency training. In addition, US News reports top-ranked schools in a variety of program areas (AIDS, Family Medicine, Geriatrics, Internal Medicine, Pediatrics, Rural Health, Women’s Health); in these areas the rankings are done entirely by peer assessment.
The Peer Assessment counts for about 40% of the weight of the rankings for primary care (and 100% for the program areas listed above). Deans of medical schools, department chairs in the “primary care” specialties, and directors of residencies in those primary care specialties are asked to list the top schools, in their opinion. These are then cumulated and weighted. Selectivity accounts for about 15%, faculty:student ratio another 15%, and is the same as measured for Research. The final 30% consists of the schools self-report of the % of students graduating who enter the primary care specialties, defined by US News as family medicine, general internal medicine, and general pediatrics. Let us deconstruct those three sets of criteria.
Percent of students actually entering the primary care specialties might seem to be the most objective, outcome-based criterion, and thus the most important. However, there are some problems in the data. What is, for example, the definition of entering a “general internal medicine” residency? Virtually all schools count everyone entering an internal medicine residency because, after all, the first 3 years, the residency they matched in, is indeed general medicine. The problem, of course, is that after completing that residency a percentage of graduates will enter medicine sub-specialty training (to become cardiologist, gastroenterologists, endocrinologists, etc.) and not practice primary care. And, as detailed in previous entries (“A Quality Health System Needs More Primary Care Physicians” December 11, 2008, Ten Biggest Myths Regarding Primary Care in the Future” by Dr. Robert Bowman January 15, 2009, “More Primary Care Doctors or Just More Doctors? April 3, 2009, and others) in recent years the percent entering subspecialty fellowships on completing their residencies has been increasing so much that the number of students entering internal medicine residencies who actually become primary care/general internists is becoming vanishingly small.[4] [5] So measuring those entering internal medicine residencies dramatically overstates the actual production of primary care doctors. But at least everyone does it.
Arguably, the most sensitive indicator is entry into family medicine; the reason is that virtually all family medicine residents become primary care doctors, so when the number of students entering family medicine is up, it means that interest in primary care is up, and it is likely that the percent of students entering internal medicine who will become general internists is also up. When, as now, the number entering family medicine is down, so is the number of internists entering general internal medicine.4,5
Peer assessment may be good, but it also has flaws. These include: people’s memories are dated (they may remember that a place was good and so assume it still is), they may assume that a place that is good in many things is good in everything (e.g., Harvard gets votes for great family medicine, even though there is no family medicine at Harvard!), and the ratings (especially from deans and chairs) may reflect the prominence of the faculty in primary care rather than the school’s success in producing primary care physicians. This is not to minimize the latter; “Best” primary care school does not equal “most students entering primary care”; it also includes the scholarship and prominence of the faculty on the national and international stage. Finally, because the chairs and residency directors surveyed are from all three specialties, the degree to which one or more is particularly strong or weak (or perceived as particularly strong or weak) can color the assessment.
Selectivity is an ironic criterion. The simple fact is that the more selective a school is the lower the primary care production. This is explained in many of the previous posts; in brief, students from medical families in upper class suburbs who had great schools and thus the likelihood of the highest grades are the least likely to enter primary care, while those from rural and inner-city backgrounds, as well as those from minority and lower income backgrounds are more likely to. High faculty:student ratio sounds good, but probably doesn’t matter to students unless they are teaching. In fact, schools with higher faculty:student ratios don’t usually have more teachers; the additional faculty are either doing research (good for the research criterion, less obviously so for primary care) or providing clinical care in a variety of settings that have little or nothing to do with educating students.
So what is the correlation between high US News primary care rankings and entry of students into primary care? I have only the data on family medicine, but given, as above, that this is the most sensitive indicator of primary care, it is probably worth using. Here it is:
Of the US News’ “Top 50” schools in Primary Care:
· -Only 10 were among the top 15 in either percent or total number of students entering family medicine.
· -Fully half (26) of these “Top 50” primary care schools were below the national average of 8.2% of students entering family medicine. Thirteen had 5 of fewer students entering family medicine, and 7 had 2, 1, or 0!
Conversely, only 6 of the top 15 schools in percent of students entering family medicine, and only 9 of the top 16 (4 way tie for 13) schools ranked by number of students entering FM, made US News’ “Top 50” for primary care.
What about US News’ “Top 10” for Family Medicine (remember, these are ranked only by “peer assessment”)?
Only 3 of these medical schools were in the top 15 for students entering FM by percent, and 3 by total number of students entering FM residencies. Two schools were both, so a total of 4 of US News’ “Top 10” medical schools for family medicine were in the top 15 in either category. And of these 4, the highest rank for percent of students was #11, and for total number, the highest rank was #4.
Among that group of “Top 10 Family Medicine” schools, 3 (30%) were below the national average for percent of students entering FM, and 3 of them were quite low: 7 students (4.1%); 6 students (4%); and 2 students (2.2%)!
Again, conversely, only 3 of the top 15 schools by number of students, and only 4 of the top 15 by percent of students, entering family medicine residencies made US News’ Family Medicine top 10.
So how valuable are these rankings? The answer is: it depends. If you want high status, they are “it”. If you want a school that is actually successful at producing graduates who enter primary care, don’t count on them.
[1] Also as in “you’re not respecting me – but you will now that I’m pointing this gun at you!”
[2] I presume there is some newer name-brand dropper, but Ian Fleming was the master at one time.
[3] Not always so obvious; I could ask people if they smoke, but the answers might have limited validity if people don’t tell the truth. A blood test for a nicotine breakdown product might, e.g., be a more valid test.
[4] Garibaldi, RA, Popkave C, Bylsma W, “Career plans for trainees in internal medicine residency programs”, Acad Med 2005 May;80(5):507-12
[5] Hauer KE, Durning SJ, Kernan WN et al., “Factors associated with medical students’ career choices regarding internal medicine”. JAMA 2008;300(10):1154-64
Often it appears that Americans are obsessed by “rankings”. I am not talking about which is the best: car, TV, stereo, video game, and all the other consumer products we buy, and which are evaluated and often ranked by various organizations such as Consumers’ Union, based upon explicitly stated criteria. I am talking about the more subtle and subjective of rankings of various organizations and providers of services, particularly universities. More specifically, I will address the rankings of schools of medicine, and most specifically use as examples those in primary care and family medicine.
The US News and World Report rankings of colleges, and graduate schools in a wide variety of areas, including medicine, are the most well-known and “respected” (in the sense of “paid attention to”[1]) of the national rankers. The question is, what do the rankings mean? How are they derived? What do they reflect about the “product” being evaluated? Are they using criteria that are accurately assessing what I am looking for in a school? Are these down-to-earth, utilitarian, “Consumers Report”-type evaluations or are they more James Bond-like brand-name dropping[2]? Of course, if what I am looking for in a school is indeed cachet -- its status, fame and brand-name recognition -- then there is no difference. If, however, I am looking for outcomes – what is the success of that school in educating people in the area in which I wish to be educated, it is important to look at the criteria being used and the degree to which they accurately predict outcomes.
In general, most educators do not feel that US News rankings accurately reflect what they purport to be ranking – quality of the school in a particular area. These criticisms probably are more vocal from those who believe that they are ranked lower than they should be, but even those ranked highly will usually acknowledge, sotto voce, that they are not completely accurate – although they are pleased to be ranked highly. Recently, probably in response to ongoing criticism from the higher education community, US News has begun to publish the criteria that they use for ranking, the weight that they give to each criterion, and the method that they use to gather the information. This helps us to assess the validity of those criteria. (Validity is a concept that is used in research to evaluate the quality of a tool being used – how well does it actually measure what it is that I am using it to measure?).[3]
Medical schools are comprehensively ranked by US News in Research and in Primary Care. For Research the criteria include “peer assessment” (by other Deans, Chairs and Residency Directors), selectivity (how high were the pre-admission grades and scores on the Medical College Admissions Test of its students, percent of applicants accepted – low is ‘good’), faculty:student ratio, # and $ amount of research grants. For Primary Care, peer assessment and selectivity are again considered but rather than measuring research grants, they look at the total number (#) and percentage (%) of graduates entering primary care residency training. In addition, US News reports top-ranked schools in a variety of program areas (AIDS, Family Medicine, Geriatrics, Internal Medicine, Pediatrics, Rural Health, Women’s Health); in these areas the rankings are done entirely by peer assessment.
The Peer Assessment counts for about 40% of the weight of the rankings for primary care (and 100% for the program areas listed above). Deans of medical schools, department chairs in the “primary care” specialties, and directors of residencies in those primary care specialties are asked to list the top schools, in their opinion. These are then cumulated and weighted. Selectivity accounts for about 15%, faculty:student ratio another 15%, and is the same as measured for Research. The final 30% consists of the schools self-report of the % of students graduating who enter the primary care specialties, defined by US News as family medicine, general internal medicine, and general pediatrics. Let us deconstruct those three sets of criteria.
Percent of students actually entering the primary care specialties might seem to be the most objective, outcome-based criterion, and thus the most important. However, there are some problems in the data. What is, for example, the definition of entering a “general internal medicine” residency? Virtually all schools count everyone entering an internal medicine residency because, after all, the first 3 years, the residency they matched in, is indeed general medicine. The problem, of course, is that after completing that residency a percentage of graduates will enter medicine sub-specialty training (to become cardiologist, gastroenterologists, endocrinologists, etc.) and not practice primary care. And, as detailed in previous entries (“A Quality Health System Needs More Primary Care Physicians” December 11, 2008, Ten Biggest Myths Regarding Primary Care in the Future” by Dr. Robert Bowman January 15, 2009, “More Primary Care Doctors or Just More Doctors? April 3, 2009, and others) in recent years the percent entering subspecialty fellowships on completing their residencies has been increasing so much that the number of students entering internal medicine residencies who actually become primary care/general internists is becoming vanishingly small.[4] [5] So measuring those entering internal medicine residencies dramatically overstates the actual production of primary care doctors. But at least everyone does it.
Arguably, the most sensitive indicator is entry into family medicine; the reason is that virtually all family medicine residents become primary care doctors, so when the number of students entering family medicine is up, it means that interest in primary care is up, and it is likely that the percent of students entering internal medicine who will become general internists is also up. When, as now, the number entering family medicine is down, so is the number of internists entering general internal medicine.4,5
Peer assessment may be good, but it also has flaws. These include: people’s memories are dated (they may remember that a place was good and so assume it still is), they may assume that a place that is good in many things is good in everything (e.g., Harvard gets votes for great family medicine, even though there is no family medicine at Harvard!), and the ratings (especially from deans and chairs) may reflect the prominence of the faculty in primary care rather than the school’s success in producing primary care physicians. This is not to minimize the latter; “Best” primary care school does not equal “most students entering primary care”; it also includes the scholarship and prominence of the faculty on the national and international stage. Finally, because the chairs and residency directors surveyed are from all three specialties, the degree to which one or more is particularly strong or weak (or perceived as particularly strong or weak) can color the assessment.
Selectivity is an ironic criterion. The simple fact is that the more selective a school is the lower the primary care production. This is explained in many of the previous posts; in brief, students from medical families in upper class suburbs who had great schools and thus the likelihood of the highest grades are the least likely to enter primary care, while those from rural and inner-city backgrounds, as well as those from minority and lower income backgrounds are more likely to. High faculty:student ratio sounds good, but probably doesn’t matter to students unless they are teaching. In fact, schools with higher faculty:student ratios don’t usually have more teachers; the additional faculty are either doing research (good for the research criterion, less obviously so for primary care) or providing clinical care in a variety of settings that have little or nothing to do with educating students.
So what is the correlation between high US News primary care rankings and entry of students into primary care? I have only the data on family medicine, but given, as above, that this is the most sensitive indicator of primary care, it is probably worth using. Here it is:
Of the US News’ “Top 50” schools in Primary Care:
· -Only 10 were among the top 15 in either percent or total number of students entering family medicine.
· -Fully half (26) of these “Top 50” primary care schools were below the national average of 8.2% of students entering family medicine. Thirteen had 5 of fewer students entering family medicine, and 7 had 2, 1, or 0!
Conversely, only 6 of the top 15 schools in percent of students entering family medicine, and only 9 of the top 16 (4 way tie for 13) schools ranked by number of students entering FM, made US News’ “Top 50” for primary care.
What about US News’ “Top 10” for Family Medicine (remember, these are ranked only by “peer assessment”)?
Only 3 of these medical schools were in the top 15 for students entering FM by percent, and 3 by total number of students entering FM residencies. Two schools were both, so a total of 4 of US News’ “Top 10” medical schools for family medicine were in the top 15 in either category. And of these 4, the highest rank for percent of students was #11, and for total number, the highest rank was #4.
Among that group of “Top 10 Family Medicine” schools, 3 (30%) were below the national average for percent of students entering FM, and 3 of them were quite low: 7 students (4.1%); 6 students (4%); and 2 students (2.2%)!
Again, conversely, only 3 of the top 15 schools by number of students, and only 4 of the top 15 by percent of students, entering family medicine residencies made US News’ Family Medicine top 10.
So how valuable are these rankings? The answer is: it depends. If you want high status, they are “it”. If you want a school that is actually successful at producing graduates who enter primary care, don’t count on them.
[1] Also as in “you’re not respecting me – but you will now that I’m pointing this gun at you!”
[2] I presume there is some newer name-brand dropper, but Ian Fleming was the master at one time.
[3] Not always so obvious; I could ask people if they smoke, but the answers might have limited validity if people don’t tell the truth. A blood test for a nicotine breakdown product might, e.g., be a more valid test.
[4] Garibaldi, RA, Popkave C, Bylsma W, “Career plans for trainees in internal medicine residency programs”, Acad Med 2005 May;80(5):507-12
[5] Hauer KE, Durning SJ, Kernan WN et al., “Factors associated with medical students’ career choices regarding internal medicine”. JAMA 2008;300(10):1154-64
Monday, September 21, 2009
Medicare for All: Moran's logic, not the idea, is flawed
.
I recently received an email from one of our Kansas Congressmen, Jerry Moran, Republican from the First District that covers essentially the western 2/3 of the state. (He is not my congressman, who is Blue Dog Democrat Dennis Moore, but we are a small state in terms of population with only 4 congressmen, and I get emails from many of them. Plus Rep. Moran is one of two Republican congressmen from Kansas running to succeed Sen. Sam Brownback who is resigning to become – the result is foreordained – our next Governor.) The email contained the text of an editorial that Rep. Moran posted on his website http://www.jerrymoran.house.gov/index.php?option=com_content&task=view&id=1524&Itemid=103 to explain why he did not think that expanding Medicare to cover everyone, as has been advocated by many, including myself, was a good plan for health reform. Unsurprisingly, the title was “A Medicare-Type Public Option Does Not Make Sense”.
Rep. Moran acknowledges that “This idea is supported by some in Washington and, at first glance, may appear appealing to many. Certainly, this idea seems easier to understand than other proposals that are being pushed in our nation’s capital and in the media.” He is a thoughtful man, not a reflex yahoo. He then goes on to give four reasons why it is a bad idea, and that he does “…not see how this plan will protect and enhance care for Kansans.” His four points are:
“Medicare is going bankrupt – The Medicare trust fund that pays for inpatient hospital stays is currently paying out more in benefits than it is collecting through payroll taxes. As a result, this fund is expected to go bankrupt in 2017, just eight years from now. Additionally, Medicare faces overall shortfalls of nearly $38 trillion, nearly three times current GDP levels…
Providers suffer major losses treating Medicare patients – Kansas health care providers and hospitals operate on razor-thin margins because they are drastically underpaid by Medicare. When Medicare underpays doctors and hospitals, the cost is shifted to private insurers. The average family in a private PPO health plan pays an additional $1,788 a year to compensate for Medicare underpayments. If these rates were expanded to those who currently have private insurance, many Kansas hospitals would be forced to close their doors and access to doctors and nurses in the state would be further limited.
Current Medicare fraud is staggering – According to the FBI, Medicare and Medicaid lose an estimated $60 billion or more annually to fraud. This amount equals 10% of all health spending in the U.S. Congress needs to address this problem in Medicare and Medicaid before creating a massive new program that would be susceptible to the same fraud.
Medicare regulations are a mess – The morass of regulations governing Medicare prevents progress and impedes doctors, nurses, and other providers from efficiently caring for patients...Bureaucrats in Washington set Medicare payment rates for providers and hospitals and these rates are so low that many doctors refuse to see Medicare patients. An expansion of this regulatory mess will lead to fewer providers and diminished health care access for Kansans.”
I had to write back and comment that these arguments, too, have pretty major flaws. They fall into three major categories:
First, misunderstanding (or misrepresenting) the source of the high cost of health care.
It is sick people who cost money. This is why, as I have pointed out, the key issues of health reform is so difficult to "sell" to most people, who are not (currently) really sick. The cost of what is perceived as “health problems” by the young, healthy journalists and Congressional aides -- colds, checkups, rotator cuffs, meniscuses, blood pressure checks – is essentially rounding error in the cost of health care. What costs money are the sick people -- the elderly who have multiple diseases and require mutliple hospitalizations, people with cancer, babies in neonatal intensive care, multiple trauma victims from car accidents. 5% of the people account for 55% of health costs; 10% for 70%. More than 50% of the people all together are about 3%. That is why insurance companies make money by underwriting -- insuring the healthy, disenrolling (or excluding, or sending to Medicare) the sick. Most of the people who cost the most are already in Medicare. The rest of us would cost much less per capita.
If everyone was in Medicare, we'd have one system to pay our health bills, and Moran’s first issue could be addressed because all health care $ now spent by employers would go into the pool, while the sickest people are already in the pool, so the marginal cost of putting everyone else in would be must less than the income.
The second flaw is that his argument, in both his second and fourth point, is that providers are unhappy with how much (or little) Medicare pays and how complex their regulations are. On the other hand, his third point attacks providers (presumably the same group) because of the massive amount of “fraud” they are perpetrating on the Medicare system. You can’t have it both ways unless you can be sure that the “fraud-meisters” (presuming there really is extensive fraud) are not the same ones, doctors and hospitals, who are making the complaints you validate in points two and four. And there is no way to do that. The answer for these two points is the same as for #1 – with everyone in the same system we could increase our payments for certain services in Medicare. And, of course, not pay more, or even pay less, for certain other services. By having the one payer, we could make policy that says we are going to pay for what we value (e.g., primary care) and not for excessive technological interventions that are not needed.
The third issue, fraud, mentioned above, is arguable. Much of what the government calls fraud is unintentional incorrect billing. To the extent that there are providers -- the same providers the Congressman worries about underpaying in the second point – who are committing fraud, this needs to be addressed, and would be able to be more thoroughly address with a single source of payment. Does Rep. Moran think no one commits fraud against private insurers? Certainly those private insurers would not agree!
The third flaw is in Rep. Moran’s fourth point regarding complex Medicare regulations. Boy, are they ever! But so are – even more so – those of private insurers. And the problem is made many times worse because of the plethora of different insurers, all with their own rules and regulations, and indeed with the same insurer having different rules for different people in different plans or employed by different companies. Cleaning up the Medicare regulatory complexity is important, but could be done by the government. If we had everyone in Medicare, it would be all cleaned up. If we continue to have multiple private insurers, it will stay a mess anyway. And blaming “bureaucrats” for low Medicare payments is at best disingenuous; Medicare pays what Congress will support. If Congress wants to pay more, they can appropriate more, at least for Part B and D. And this argument runs absolutely counter to the first, which is that Medicare is going broke. It sure isn’t from lack of parsimonious administration.
Rep. Moran concludes by saying “Medicare guarantees health care for seniors. But, what good does it do to have an insurance card if there is no doctor, nurse, or hospital to provide care? Instead of expanding Medicare, Congress should address Medicare’s current challenges and consider common-sense reforms to make quality coverage more affordable and more accessible for Americans. Medicare cannot pay all of its bills now and the problems will be exponentially magnified if it is expanded to include an additional 114 million Americans.”
Congress should address Medicare’s current challenges, and the most effective way to do so would be to put the other (?114 million) Americans into it. This would dilute the number of sick people already in the program with the younger and healthier, support the program financially with the current employer contributions now going to private insurers, and, most importantly, put all of us in the same plan together, all of us concerned about how well it works and how it spends its money.
Because, Congressman, we really are all in it together.
.
I recently received an email from one of our Kansas Congressmen, Jerry Moran, Republican from the First District that covers essentially the western 2/3 of the state. (He is not my congressman, who is Blue Dog Democrat Dennis Moore, but we are a small state in terms of population with only 4 congressmen, and I get emails from many of them. Plus Rep. Moran is one of two Republican congressmen from Kansas running to succeed Sen. Sam Brownback who is resigning to become – the result is foreordained – our next Governor.) The email contained the text of an editorial that Rep. Moran posted on his website http://www.jerrymoran.house.gov/index.php?option=com_content&task=view&id=1524&Itemid=103 to explain why he did not think that expanding Medicare to cover everyone, as has been advocated by many, including myself, was a good plan for health reform. Unsurprisingly, the title was “A Medicare-Type Public Option Does Not Make Sense”.
Rep. Moran acknowledges that “This idea is supported by some in Washington and, at first glance, may appear appealing to many. Certainly, this idea seems easier to understand than other proposals that are being pushed in our nation’s capital and in the media.” He is a thoughtful man, not a reflex yahoo. He then goes on to give four reasons why it is a bad idea, and that he does “…not see how this plan will protect and enhance care for Kansans.” His four points are:
“Medicare is going bankrupt – The Medicare trust fund that pays for inpatient hospital stays is currently paying out more in benefits than it is collecting through payroll taxes. As a result, this fund is expected to go bankrupt in 2017, just eight years from now. Additionally, Medicare faces overall shortfalls of nearly $38 trillion, nearly three times current GDP levels…
Providers suffer major losses treating Medicare patients – Kansas health care providers and hospitals operate on razor-thin margins because they are drastically underpaid by Medicare. When Medicare underpays doctors and hospitals, the cost is shifted to private insurers. The average family in a private PPO health plan pays an additional $1,788 a year to compensate for Medicare underpayments. If these rates were expanded to those who currently have private insurance, many Kansas hospitals would be forced to close their doors and access to doctors and nurses in the state would be further limited.
Current Medicare fraud is staggering – According to the FBI, Medicare and Medicaid lose an estimated $60 billion or more annually to fraud. This amount equals 10% of all health spending in the U.S. Congress needs to address this problem in Medicare and Medicaid before creating a massive new program that would be susceptible to the same fraud.
Medicare regulations are a mess – The morass of regulations governing Medicare prevents progress and impedes doctors, nurses, and other providers from efficiently caring for patients...Bureaucrats in Washington set Medicare payment rates for providers and hospitals and these rates are so low that many doctors refuse to see Medicare patients. An expansion of this regulatory mess will lead to fewer providers and diminished health care access for Kansans.”
I had to write back and comment that these arguments, too, have pretty major flaws. They fall into three major categories:
First, misunderstanding (or misrepresenting) the source of the high cost of health care.
It is sick people who cost money. This is why, as I have pointed out, the key issues of health reform is so difficult to "sell" to most people, who are not (currently) really sick. The cost of what is perceived as “health problems” by the young, healthy journalists and Congressional aides -- colds, checkups, rotator cuffs, meniscuses, blood pressure checks – is essentially rounding error in the cost of health care. What costs money are the sick people -- the elderly who have multiple diseases and require mutliple hospitalizations, people with cancer, babies in neonatal intensive care, multiple trauma victims from car accidents. 5% of the people account for 55% of health costs; 10% for 70%. More than 50% of the people all together are about 3%. That is why insurance companies make money by underwriting -- insuring the healthy, disenrolling (or excluding, or sending to Medicare) the sick. Most of the people who cost the most are already in Medicare. The rest of us would cost much less per capita.
If everyone was in Medicare, we'd have one system to pay our health bills, and Moran’s first issue could be addressed because all health care $ now spent by employers would go into the pool, while the sickest people are already in the pool, so the marginal cost of putting everyone else in would be must less than the income.
The second flaw is that his argument, in both his second and fourth point, is that providers are unhappy with how much (or little) Medicare pays and how complex their regulations are. On the other hand, his third point attacks providers (presumably the same group) because of the massive amount of “fraud” they are perpetrating on the Medicare system. You can’t have it both ways unless you can be sure that the “fraud-meisters” (presuming there really is extensive fraud) are not the same ones, doctors and hospitals, who are making the complaints you validate in points two and four. And there is no way to do that. The answer for these two points is the same as for #1 – with everyone in the same system we could increase our payments for certain services in Medicare. And, of course, not pay more, or even pay less, for certain other services. By having the one payer, we could make policy that says we are going to pay for what we value (e.g., primary care) and not for excessive technological interventions that are not needed.
The third issue, fraud, mentioned above, is arguable. Much of what the government calls fraud is unintentional incorrect billing. To the extent that there are providers -- the same providers the Congressman worries about underpaying in the second point – who are committing fraud, this needs to be addressed, and would be able to be more thoroughly address with a single source of payment. Does Rep. Moran think no one commits fraud against private insurers? Certainly those private insurers would not agree!
The third flaw is in Rep. Moran’s fourth point regarding complex Medicare regulations. Boy, are they ever! But so are – even more so – those of private insurers. And the problem is made many times worse because of the plethora of different insurers, all with their own rules and regulations, and indeed with the same insurer having different rules for different people in different plans or employed by different companies. Cleaning up the Medicare regulatory complexity is important, but could be done by the government. If we had everyone in Medicare, it would be all cleaned up. If we continue to have multiple private insurers, it will stay a mess anyway. And blaming “bureaucrats” for low Medicare payments is at best disingenuous; Medicare pays what Congress will support. If Congress wants to pay more, they can appropriate more, at least for Part B and D. And this argument runs absolutely counter to the first, which is that Medicare is going broke. It sure isn’t from lack of parsimonious administration.
Rep. Moran concludes by saying “Medicare guarantees health care for seniors. But, what good does it do to have an insurance card if there is no doctor, nurse, or hospital to provide care? Instead of expanding Medicare, Congress should address Medicare’s current challenges and consider common-sense reforms to make quality coverage more affordable and more accessible for Americans. Medicare cannot pay all of its bills now and the problems will be exponentially magnified if it is expanded to include an additional 114 million Americans.”
Congress should address Medicare’s current challenges, and the most effective way to do so would be to put the other (?114 million) Americans into it. This would dilute the number of sick people already in the program with the younger and healthier, support the program financially with the current employer contributions now going to private insurers, and, most importantly, put all of us in the same plan together, all of us concerned about how well it works and how it spends its money.
Because, Congressman, we really are all in it together.
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Wednesday, September 16, 2009
Joe Wilson: Racism in America rears its ugly head
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I am not a huge believer in protocol and quietly and respectfully listening to what you consider to be evil lies. I kind of enjoy the spectacle of the British Parliament where opposition members get to boo at the Prime Minister. So maybe, to that degree, I should be less upset about Rep. Joe Wilson’s “You lie!” outburst during the President’s speech on health care. Washington Post columnist Kathleen Parker http://www.kansascity.com/273/story/1442853.html condemns such impropriety while also minimizing and lumping it with hecklers from the galleries (“Although heckling by individuals usually emanates from the public gallery, group histrionics are a time-honored tradition in American political theater.”) it is different because it has never been done before when a President has addressed a Joint Session of Congress. The real question is “Why did this representative do it at this time with this President?” That is the question that Maureen Dowd supplies with some information to consider: her point, in her op-ed piece “Boy, oh Boy!”, is that it was racism, an extremely racist act performed by an extremely racist man because he cannot accept that a black man is the President of the United States and needs to be accorded the respect due that office. (http://www.nytimes.com/2009/09/13/opinion/13dowd.html) There is a better than even chance that she is right.
Now, I don’t know that Joe Wilson is a racist, in the sense that I cannot look into his heart, or his brain, to know what he really feels or believes. But he absolutely has long manifested racist behaviors and provided racist leadership. He, Ms. Dowd informs us “…belonged to the Sons of Confederate Veterans, led a 2000 campaign to keep the Confederate flag waving above South Carolina’s state Capitol and denounced as a ‘smear’ the true claim of a black woman that she was the daughter of Strom Thurmond, the ’48 segregationist candidate for president.” That is all racist, and remains so no matter how many sons of the South want to tell us that the Confederacy was about everything but slavery. Even to the extent that it might have been, the only reason to remember it and keep it up is to be racist, if in a thinly-veiled way. Mr. Thurmond, Mr. Wilson’s mentor, and all the racist, segregationist colleagues of his era, deserve to be remembered – as wrong. As perpetuators of an inhumanly evil system that derives from slavery. Not, in any way, shape or form, to be emulated. Let us instead award accolades to the Southern Senator and President Lyndon Johnson, who may or may not have been racist inside, but outside, where it mattered, pushed through the landmark Civil Rights and Voting Rights Act. There can be no quarter given, ever, in any sense, to racism in public policy.
I do not know if Mr. Wilson and his Republican colleagues are cynically using racist references to push their anti-people policies, perpetuating the ultimate reason for people in power to push such issues, divide and conquer, or if he really thinks this way; if, as Ms. Dowd says, he “…clearly did not like being lectured and even rebuked by the brainy black president presiding over the majestic chamber.” In any case, he must be soundly and unequivocally castigated and repudiated, not for interrupting, but for thinking he, as a white guy, could do it because this President was not a white guy.
And let us remember that the other nonsense being propagated by either honest or opportunistic racists are wrong, are lies. Having a black President is great, but it does not reverse the tide of history or put racism behind us. Saying that “white men are discriminated against” by affirmative action is only true to the extent that “when you’ve had the wind at your back for your whole life, a calm day seems unfair.” (I wish I could get the attribution for that great quote!) On the same day that Ms. Dowd’s column appeared, Barbara Ehrenreich and Dedrick Muhammed had a guest op-ed in the NY Times , “The Recession’s Racial Divide”, http://www.nytimes.com/2009/09/13/opinion/13ehrenreich.html?_r=1&ref=opinion, in which they carefully and systematically demonstrate how much worse this recession has been for black people than white – because, despite lies widely propagated by the right wing, they started so much farther behind. “In fact,” they write, “you could say that for African-Americans the recession is over. It occurred from 2000 to 2007, as black employment decreased by 2.4 percent and incomes declined by 2.9 percent. During those seven years, one-third of black children lived in poverty, and black unemployment — even among college graduates — consistently ran at about twice the level of white unemployment.
That was the black recession. What’s happening now is more like a depression.”
They assert that “Thanks to a legacy of discrimination in both hiring and lending, they’re less likely than whites to be cushioned against the blows by wealthy relatives or well-stocked savings accounts.”
For those continuing doubters, here are some more facts that support their assertion:
--“In 2008, on the cusp of the recession, the typical African-American family had only a dime for every dollar of wealth possessed by the typical white family.
--Only 18 percent of blacks and Latinos had retirement accounts, compared with 43.4 percent of whites.
--…even high-income blacks were almost twice as likely to end up with subprime home-purchase loans as low-income whites — even when they qualified for prime mortgages, even when they offered down payments.”
Ehrenreich and Muhammad do attribute some blame to the individuals caught in this situation, and to those who encourage it. Specifically, they cite a “cultural factor” that is “…widely shared with whites — a penchant for ‘positive thinking’ and unwarranted optimism.” They note that this has taken on a “…theological form of the ‘prosperity gospel.’ Since ‘God wants to prosper you’ all you have to do to get something is ‘name it and claim it,’” and name both the black evangelist Creflo Dollar and white megachurch pastor Joel Osteen as propagators of this “gospel”. They do not, interestingly, mention Oprah Winfrey in this article, although Ehrenreich has cited her before as one of the leading figures purveying the “positive thinking” mantra to both blacks and whites (“The Power of Negative Thinking”, NY Times Sept 24, 2008, http://www.nytimes.com/2008/09/24/opinion/24ehrenreich.html?_r=1&scp=5&sq=ehrenreich&st=cse). Although not talking about racism, David Brooks (NY Times Sept 15, 2009, http://www.nytimes.com/2009/09/15/opinion/15brooks.html?_r=1&ref=opinion, does address this issue of “me”-ness, comparing the humility of Americans – soldiers, politicians, celebrities, and the rest of us, at the end of World War II. “When you look from today back to 1945, you are looking into a different cultural epoch, across a sort of narcissism line. Humility, the sense that nobody is that different from anybody else, was a large part of the culture then….Everything that starts out as a cultural revolution ends up as capitalist routine....Today, immodesty is as ubiquitous as advertising, and for the same reasons.”
“’I did not take a racial connotation from Mr. Wilson’s remarks,’ said Representative Steny H. Hoyer of Maryland, the majority leader, who introduced the resolution” to “rebuke” Mr. Wilson (House Rebukes Wilson for Shouting ‘You Lie, NY Times Sept 15, 2009, ’http://www.nytimes.com/2009/09/16/us/politics/16wilson.html?ref=us, but he added “I do believe that there are expressions throughout the country being made that are unusually harsh. I think the attacks being made on Mr. Obama are unusually vitriolic.” Yeah, racist.
Ehrenreich and Muhammad conclude: “So despite the right-wing perception of black power grabs, this recession is on track to leave blacks even more economically disadvantaged than they were. Does a black president who is inclined toward bipartisanship dare address this destruction of the black middle class? Probably not. But if Americans of all races don’t get some economic relief soon, the pain will only increase and with it, perversely, the unfounded sense of white racial grievance.”
Of course, this would require us, as a society, to actually deal with truth, to actually look at what is happening to actual people. When we have “jobless recoveries”, in which Wall Street has “recovered” while we celebrate the loss of more jobs because it is fewer than last month (and we are 9.4 million jobs down from before the “recession”), it is not surprising that reactionary populists will take this as an opportunity to try to garner support for their agendas by spreading racist lies. But we have to take responsibility for calling them what they are, not letting them happen, fighting back against deceit and shameful pandering.
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Saturday, September 12, 2009
Are we training physicians to be empathic? Apparently not.
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Three articles in the September issue of Academic Medicine, the journal of the Association of American Medical Colleges (AAMC) address the issue of development – or more concerning, the erosion -- of empathy among medical students and doctors. All three used the Jefferson Scale of Physician Empathy (JSPE), developed at the Jefferson Medical College in Philadelphia, and all included Jefferson faculty who developed the JSPE as authors. Two were done in collaboration with authors from other countries, one examining doctors in Italy and the other medical students in Japan. However, the most important one for us looked at US medical students, at Jefferson Medical College.[1] The authors administered the JSPE to students entering medical school in 2002 and 2004, and then administered it again to each of them 4 more times, at the end of each of their years of medical school. The results, while unfortunately not surprising to those of us who teach in medical schools, should be very concerning for everyone else in the country. The empathy scores were pretty much unchanged from entry to the end of the second year, but dropped significantly by the end of the third year for both classes. They stayed down, picking up slightly, by graduation at the end of the fourth year.
For those of you who don’t know, the third year of medical school in the US is when the main “clinical” portion of the education of students begins. In most schools, the first two years are largely dedicated to learning “basic science”, although increasing amounts of clinical material have been added in more recent years. But in the third year, students do their “core” clinical rotations (usually internal medicine, surgery, pediatrics, psychiatry, family medicine, obstetrics/gynecology, sometimes neurology and geriatrics). They spend this time largely working in the hospital, on hospital services with faculty members and residents, who are medical school graduates training in the particular specialty. This is the main time of “clinician formation”, when the student, who has been spending the bulk of his/her time in a classroom, works, under close supervision, in the actual care of actual people. One would hope (at least this one would hope) that working with actual people (called “patients” in the medical jargon) would provide students an opportunity to become more empathic, seeing the pain and suffering and hopes and expectations and fears and prayers of the people with whom they work. That it has the opposite effect is scary.
Students were given the opportunity to identify themselves so that data could be analyzed over time for individuals or groups of individuals as well as the whole group. Unfortunately, only 25% did so, so looking at trends among sub-groups, which could only be done on this smaller group, provides less robust data. However, within this “matched” group, women started with higher empathy scores than did men and dropped less, although still significantly. In addition, students who planned to enter “technology-oriented” specialties (anesthesiology pathology, radiology, surgery, orthopedics, etc.) not only had greater drops in their empathy scores than those entering “people oriented” specialties (family medicine, internal medicine, pediatrics, emergency medicine, psychiatry, obstetrics and gynecology), but had lower scores to begin with. This means that (at least among the 25% who allowed themselves to be tracked, among these two classes at Jefferson) there is a difference in empathy levels even at baseline, at entry, between those entering the different types of specialties (when taken as a group). It may also be worth noting that Japanese students did not demonstrate this decline; the reasons are presumably cultural.[2]
Why? All medical educators have their theories, but this research only can contribute information gleaned from the elective, open-ended comments students were invited to make. Themes that arose included exhaustion (working so hard and so many hours makes it difficult to care so much about others), victim blaming (it is hard to feel for someone whose behaviors brought their illness on themselves), and negative role models (the residents and teaching physicians were not empathic):
“Reflecting on the nature of the training environment, one student stated ‘I was constantly reminded of the hierarchy of medicine and how it was not the student’s job to speak up even in defense of the patient’s best interest. The bureaucratic side of medicine overshadowed the human, empathic side.’ When students perceive from their training experiences that the ‘’humanistic side of medicine is too soft and a waste of time…I worry that over time I will be “molded by the system” into this idea””, they are correct. The study shows that they are.
The authors spend a fair amount of time distinguishing between empathy, which they are trying to measure, which they feel more of is always good for the practice of medicine, and sympathy, a less cognitive (thinking) and more affective (feeling) characteristic which they feels helps at some level but at too high a level can impede the practice of high-quality medicine. Empathy is less innate, more subject to learning and thinking, requires more effort, and is more likely to be accurate. The behavioral motivation is altruistic, while sympathy is egoistic; that is “I feel your pain” (sympathy) is instinctive but also is about the “feeler” (the student or doctor) rather than the patient. It is different from “I understand your suffering”. This latter not only is more likely to lead to helping, but is more likely to be “energy conserving” and lead to growth; the former to burnout.
This suggests a few things to me. The first is, obviously, that we need to change our medical education system, and the way patient care is role modeled. This may seem easy, but it is not; societies (and medicine is a micro-society) do not change easily, because new apprentices are taught by those in power. However, they do change, and the difference between medical education today and twenty or forty or sixty years ago is enormous. There is, for starters, teaching about these issues. Small group discussions, reflection papers, support networks exist where they never existed in the past. And students come from much more varied backgrounds – there are more women, and people from different class and geographic backgrounds and even pre-medical majors (music and English as well as biology and chemistry). And student are increasingly often older, second career – with prior life experiences in other professions, in business, in the workplace, and have had more experiences with healthcare as consumers either first-hand or in their families. But old traditions die hard; when biochemistry is valued more than ethics (and of course it is, because this is what you are tested on and your grades are based on both in school and your National Board exams); when being knowledgeable about the lab tests and x-rays is valued more than knowing the patient (and it often is by clinical teachers); when getting the work done is more important than understanding what work the patient wants done (and it very frequently is), it is hard to change.
What about experiences in medical school? The NY Times, September 9, 2009, “Summer of work exposes medical students to system’s ills” (http://www.nytimes.com/2009/09/09/health/policy/09medschool.html?ref=health) describes the experiences of medical students at the University of Washington working with rural, therefore mostly primary care, doctors in the 5 states the school serves (Alaska, Idaho, Montana, Washington, Wyoming). Many schools do similar programs, either required like Washington’s (e.g., New Mexico) or elective, like at the University of Kansas. The feedback seems to be similar – many students really like it and learn a lot and find it incredibly valuable pointing them to a future of service, and others find it frustrating to see inefficient systems, poor reimbursement to primary care, overwork of physicians, and thus plan (or are reinforced in their original plan) to be urban-based subspecialists. Like the Jefferson work on empathy, exposure to actual people and actual practice can reinforce either positive or negative attitudes; the sad part is when it introduces negatives to those who came in thinking more positively.
Thus, as I have written before, input variables matter. If we want more empathic physicians, the best strategy is to recruit more empathic students to medical school, and to provide them with role models who demonstrate empathy and learning settings in which having greater empathy is more valued and is considered a core quality. Medical educators are working hard on this; the public needs to demand it.
[1] Hojat M, Vergare MJ, Maxwell K, et al, “The Devil is in the Third Year: A Longitudinal Study of Erosion of Empathy in Medical School”, Academic Medicine, Sept 2009;84(2):1182-91.
[2] Kataoka HU, Koide N, Ochi K, Hojat M, Gonnella JS, “Measurement of empathy among Japanese medical students: psychometrics and score differences by gender and level of medical education,” Academic Medicine Sept09;84(9):1192-7.
Three articles in the September issue of Academic Medicine, the journal of the Association of American Medical Colleges (AAMC) address the issue of development – or more concerning, the erosion -- of empathy among medical students and doctors. All three used the Jefferson Scale of Physician Empathy (JSPE), developed at the Jefferson Medical College in Philadelphia, and all included Jefferson faculty who developed the JSPE as authors. Two were done in collaboration with authors from other countries, one examining doctors in Italy and the other medical students in Japan. However, the most important one for us looked at US medical students, at Jefferson Medical College.[1] The authors administered the JSPE to students entering medical school in 2002 and 2004, and then administered it again to each of them 4 more times, at the end of each of their years of medical school. The results, while unfortunately not surprising to those of us who teach in medical schools, should be very concerning for everyone else in the country. The empathy scores were pretty much unchanged from entry to the end of the second year, but dropped significantly by the end of the third year for both classes. They stayed down, picking up slightly, by graduation at the end of the fourth year.
For those of you who don’t know, the third year of medical school in the US is when the main “clinical” portion of the education of students begins. In most schools, the first two years are largely dedicated to learning “basic science”, although increasing amounts of clinical material have been added in more recent years. But in the third year, students do their “core” clinical rotations (usually internal medicine, surgery, pediatrics, psychiatry, family medicine, obstetrics/gynecology, sometimes neurology and geriatrics). They spend this time largely working in the hospital, on hospital services with faculty members and residents, who are medical school graduates training in the particular specialty. This is the main time of “clinician formation”, when the student, who has been spending the bulk of his/her time in a classroom, works, under close supervision, in the actual care of actual people. One would hope (at least this one would hope) that working with actual people (called “patients” in the medical jargon) would provide students an opportunity to become more empathic, seeing the pain and suffering and hopes and expectations and fears and prayers of the people with whom they work. That it has the opposite effect is scary.
Students were given the opportunity to identify themselves so that data could be analyzed over time for individuals or groups of individuals as well as the whole group. Unfortunately, only 25% did so, so looking at trends among sub-groups, which could only be done on this smaller group, provides less robust data. However, within this “matched” group, women started with higher empathy scores than did men and dropped less, although still significantly. In addition, students who planned to enter “technology-oriented” specialties (anesthesiology pathology, radiology, surgery, orthopedics, etc.) not only had greater drops in their empathy scores than those entering “people oriented” specialties (family medicine, internal medicine, pediatrics, emergency medicine, psychiatry, obstetrics and gynecology), but had lower scores to begin with. This means that (at least among the 25% who allowed themselves to be tracked, among these two classes at Jefferson) there is a difference in empathy levels even at baseline, at entry, between those entering the different types of specialties (when taken as a group). It may also be worth noting that Japanese students did not demonstrate this decline; the reasons are presumably cultural.[2]
Why? All medical educators have their theories, but this research only can contribute information gleaned from the elective, open-ended comments students were invited to make. Themes that arose included exhaustion (working so hard and so many hours makes it difficult to care so much about others), victim blaming (it is hard to feel for someone whose behaviors brought their illness on themselves), and negative role models (the residents and teaching physicians were not empathic):
“Reflecting on the nature of the training environment, one student stated ‘I was constantly reminded of the hierarchy of medicine and how it was not the student’s job to speak up even in defense of the patient’s best interest. The bureaucratic side of medicine overshadowed the human, empathic side.’ When students perceive from their training experiences that the ‘’humanistic side of medicine is too soft and a waste of time…I worry that over time I will be “molded by the system” into this idea””, they are correct. The study shows that they are.
The authors spend a fair amount of time distinguishing between empathy, which they are trying to measure, which they feel more of is always good for the practice of medicine, and sympathy, a less cognitive (thinking) and more affective (feeling) characteristic which they feels helps at some level but at too high a level can impede the practice of high-quality medicine. Empathy is less innate, more subject to learning and thinking, requires more effort, and is more likely to be accurate. The behavioral motivation is altruistic, while sympathy is egoistic; that is “I feel your pain” (sympathy) is instinctive but also is about the “feeler” (the student or doctor) rather than the patient. It is different from “I understand your suffering”. This latter not only is more likely to lead to helping, but is more likely to be “energy conserving” and lead to growth; the former to burnout.
This suggests a few things to me. The first is, obviously, that we need to change our medical education system, and the way patient care is role modeled. This may seem easy, but it is not; societies (and medicine is a micro-society) do not change easily, because new apprentices are taught by those in power. However, they do change, and the difference between medical education today and twenty or forty or sixty years ago is enormous. There is, for starters, teaching about these issues. Small group discussions, reflection papers, support networks exist where they never existed in the past. And students come from much more varied backgrounds – there are more women, and people from different class and geographic backgrounds and even pre-medical majors (music and English as well as biology and chemistry). And student are increasingly often older, second career – with prior life experiences in other professions, in business, in the workplace, and have had more experiences with healthcare as consumers either first-hand or in their families. But old traditions die hard; when biochemistry is valued more than ethics (and of course it is, because this is what you are tested on and your grades are based on both in school and your National Board exams); when being knowledgeable about the lab tests and x-rays is valued more than knowing the patient (and it often is by clinical teachers); when getting the work done is more important than understanding what work the patient wants done (and it very frequently is), it is hard to change.
What about experiences in medical school? The NY Times, September 9, 2009, “Summer of work exposes medical students to system’s ills” (http://www.nytimes.com/2009/09/09/health/policy/09medschool.html?ref=health) describes the experiences of medical students at the University of Washington working with rural, therefore mostly primary care, doctors in the 5 states the school serves (Alaska, Idaho, Montana, Washington, Wyoming). Many schools do similar programs, either required like Washington’s (e.g., New Mexico) or elective, like at the University of Kansas. The feedback seems to be similar – many students really like it and learn a lot and find it incredibly valuable pointing them to a future of service, and others find it frustrating to see inefficient systems, poor reimbursement to primary care, overwork of physicians, and thus plan (or are reinforced in their original plan) to be urban-based subspecialists. Like the Jefferson work on empathy, exposure to actual people and actual practice can reinforce either positive or negative attitudes; the sad part is when it introduces negatives to those who came in thinking more positively.
Thus, as I have written before, input variables matter. If we want more empathic physicians, the best strategy is to recruit more empathic students to medical school, and to provide them with role models who demonstrate empathy and learning settings in which having greater empathy is more valued and is considered a core quality. Medical educators are working hard on this; the public needs to demand it.
[1] Hojat M, Vergare MJ, Maxwell K, et al, “The Devil is in the Third Year: A Longitudinal Study of Erosion of Empathy in Medical School”, Academic Medicine, Sept 2009;84(2):1182-91.
[2] Kataoka HU, Koide N, Ochi K, Hojat M, Gonnella JS, “Measurement of empathy among Japanese medical students: psychometrics and score differences by gender and level of medical education,” Academic Medicine Sept09;84(9):1192-7.
Tuesday, September 8, 2009
Will the President turn the “health reform” discussion around to real reform? Can he?
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Like many progressives in the United States, I’m wondering what it was all about. “It”, in this case, being the election of a President who cared about people, who was committed to health reform, who believed that single payer was the best idea for health reform, and that government existed not only, as Rousseau and Thomas Jefferson said, by the consent of the governed, but for the interests of the governed. And, to help him out, we threw out bunches of no-nothing Bush supporters and gave him almost (now, with Specter and Franken, actually) 60 votes in the Senate and an overwhelming majority in the House. So, what has happened? Not much. The painful story is detailed by Matt Taibbi in Rolling Stone, "Sick and Wrong", September 3, 2009, http://www.rollingstone.com/politics/story/29988909/sick_and_wrong/. Sit down and keep your fist away from glass tables when you read it, but read it.
The President and the congressional Democrats we elected seem to have wasted the goodwill, enthusiasm, and hope for the future that we gave them, and mired it in a sea of legislative inertia, with the President not leading but watching, without apparent pain, as the rest of us face great pain. Taibbi writes: “The more the Republicans and Blue Dogs fidgeted and f****d around, the easier it would be for them to kill the public option. Democrats, who on the morning after Election Day could have passed a single-payer system without opposition, were now in a desperate hurry to make a deal.” He is of course, correct. The President and most of the “progressives” in Congress have moved away from the “left” and such “leftist” ideas as, first, single payer, and now probably the public option, and soon, it seems from even employer mandates or minimum requirements for what insurance companies have to offer us in the way of coverage. They have done this, ostensibly, to become more acceptable to Republicans, but without an ounce of chance of success. Every “compromise”, every give-back of a promise to actually provide the all the American people with the health care that they need at a price that they can afford and with a system that has at least some possibility of controlling costs has been given away with absolutely zero acceptance, gratitude or compromise from the MINORITY, the right-wing cabal currently called the Republican party. They and their supporters have had nothing at all positive to say. They continue to call the President a socialist or a communist, they object to his talking to students in school, and they get away with it.
The leadership of this movement, which seems to be mainly Rush Limbaugh and Bill O’Reilly and Glenn Beck (sorry, Sarah) is truly Neanderthal, truly anti-people. Many people have written about the why of this, of how all these White Men fear that they are becoming less than completely powerful, that the history that always gave preference to them and any old thing that they believe may have to be compromised with – well, everyone else – and that is the reason for their venom. The New York Times article on the proposed creation of a “day of special significance” on Harvey Milk’s birthday, http://www.nytimes.com/2009/09/05/us/05milk.html?_r=2&ref=us, quotes opponent Randy Thomassen of SaveCalifornia.com as saying “The bill is so broad it could encompass all kinds of things. Remembering the life of Harvey Milk could allow for gay pride parades on campus or mock gay weddings or cross-dressing. There is no prohibition of what the bill calls ‘suitable commemorative exercises.’ The sky’s the limit.”
Let’s look at that. Thomassen is worried that what? That other people might do things that he doesn’t like? Things that won’t (except I suppose psychically) hurt him. Those people won’t make him do any of those things, but he doesn’t want anyone else to be able to do them either. He could just say he is opposed to the bill, which of course doesn’t call for any of these things, without sounding like a finger-wagging scold. Does Thomassen, and do his friends, really think it is ok to make people do, or not do, things just because he doesn’t like it or it offends him? If so, maybe they could come here to Kansas and tell the other folks on the lake here to stop using their speedboats and jet-skis so I can have more quiet and be able to use my kayak without all that wake threatening to topple me. Hey, I am much more affected, limited in my choice of activities, by those power boats than he is by a Harvey Milk day or any of the bugbears he calls out. Why do people think they can – or should – tell other folks what they can do, as long as it doesn’t hurt them? How can we honestly condemn the fanatics in the Mideast who want to do the same thing?
But it is not funny. Thomassen may or may not be only a finger wagging scold, but these same ideas, these same limits, are often imposed on others, sometimes violently. And certainly this is not new, the reason Thomassen and his friends are worried. It is the same reason that it was in the 1920s and 30s. In his mystery novel “The Redbreast”, Norwegian writer Jo Nesbø has a character talk about the old men from Norway who volunteered to fight with the Nazis on the Eastern Front: “Oh yes, they’re still angry. At Third World aid, cuts in the defence budget, women priests, marriages for homosexuals, our new countrymen, all the things you would guess would upset these old boys. In their hearts, they’re still fascists.” [1] At least in the book the old men who believed these things had once been acknowledged fascists and Nazis. If you were to accuse the folks – the O’Reillys and Limbaughs and Becks and Thomassens who say these same things now, of being fascists, you would be attacked. But you’d be a whole lot closer to the truth than those who accuse Obama of communism are. George Bush is no longer President, and Dick Cheney is no longer – whatever he was – but the venom of the “we’re going to tell you – make you – do what we want” crowd is, probably as a result, more overt.
Meanwhile, regular people have a lot bigger issues; the Times (Sept 4, 2009) reports on the “Jobless recovery”, whatever that is. What I see is that people are still losing their jobs, just at a slower rate, but not getting jobs. So who is recovering? The bankers and Wall Street folks? If you can’t pay your mortgage and feed your family, if you don’t have a job, it is not a recovery. And let’s get this straight: Unless we’re going to go for big-time socialism and pay everybody a living wage even there is no work for them to do, the only purpose of the economy is to create jobs. This is actual people we’re talking about. They need work, and they need health coverage, and they need to know that they won’t lose their health coverage if they, again, lose their job.
The folks who are so worried about losing their coverage now are those who are, like the vast majority of Americans, not sick – yet. As Dr. Ferrer wrote as a guest in this blog on May 8, 2009 :
“The healthiest half of Americans accounts for only 3% of health care expenditures. Conversely, the sickest 5% account for 55% of expenditures and the sickest 10% for 70% of expenditures. So most health spending isn't folks with a cold or twisted ankle who run to the doctor. Most health spending is NICU babies and 20 year-olds with massive trauma from car accidents and cancer patients and old folks with congestive heart failure and 5 hospitalizations in the last year. None of those is engaging in discretionary spending or likely to 'value shop' for health care or to direct their own spending.”
Should they become seriously ill, it will be a sad time to find out what is NOT covered in their policies.
It may be too late for the President to do something. The Times doesn’t think so. Their very strong and atypically long editorial from September 4, 2009, “President Obama’s Health Choices” (http://www.nytimes.com/2009/09/06/opinion/06sun1.html?_r=1) gives very clear advice on what they think President Obama should say in his Wednesday talk to a Joint Session of Congress.
“Given the raucous, often ill-informed attacks on Democratic proposals over the past month, and the clear aim of most Republicans to oppose any bill, no matter how much he compromises, Mr. Obama now needs to spell out in some detail what he wants and how it would benefit both the uninsured and most other Americans as well.”
The Times takes on the Republicans and the “Blue Dog” Democrats, who are supposed to be deficit hawks but have distinguished themselves in this debate mostly by opposing any reform that will pour less government money into the pockets of insurance companies:
“The Bush administration and a Republican-controlled Congress enacted a Medicare prescription drug benefit that will cost the government almost $1 trillion over the next decade without raising or saving a penny to pay for it. They also passed tax cuts for wealthy Americans that will cost more than $1.7 trillion over 10 years, again without making provisions to offset the costs. Now they are complaining that $1 trillion for health care reform — fully paid for over the next 10 years — is too much to spend on a problem that has been festering for decades.”
And the Times has a suggestion for the President: “Rather than yield to Republican intransigence, the Democrats ought to resort to a parliamentary maneuver known as 'budget reconciliation,' which would allow them to push through most reforms by majority vote.” I don’t know about parliamentary process. Maybe President Obama can still say, “OK, this is the way it is going to go. We are going to have health care for the people,” and make it pass the Democratic majorities in Congress. I don’t know if he still can; worse, I don’t know whether, even if he can, he will. If he is going to really lead on making sure we get real, comprehensive, health reform, this is the time to do it. I hope he does, and hope it is not too late.
[1] Nesbø, Jo. The Redbreast. US paperback edition. Harper. New York. 2009. P. 257.
.
Like many progressives in the United States, I’m wondering what it was all about. “It”, in this case, being the election of a President who cared about people, who was committed to health reform, who believed that single payer was the best idea for health reform, and that government existed not only, as Rousseau and Thomas Jefferson said, by the consent of the governed, but for the interests of the governed. And, to help him out, we threw out bunches of no-nothing Bush supporters and gave him almost (now, with Specter and Franken, actually) 60 votes in the Senate and an overwhelming majority in the House. So, what has happened? Not much. The painful story is detailed by Matt Taibbi in Rolling Stone, "Sick and Wrong", September 3, 2009, http://www.rollingstone.com/politics/story/29988909/sick_and_wrong/. Sit down and keep your fist away from glass tables when you read it, but read it.
The President and the congressional Democrats we elected seem to have wasted the goodwill, enthusiasm, and hope for the future that we gave them, and mired it in a sea of legislative inertia, with the President not leading but watching, without apparent pain, as the rest of us face great pain. Taibbi writes: “The more the Republicans and Blue Dogs fidgeted and f****d around, the easier it would be for them to kill the public option. Democrats, who on the morning after Election Day could have passed a single-payer system without opposition, were now in a desperate hurry to make a deal.” He is of course, correct. The President and most of the “progressives” in Congress have moved away from the “left” and such “leftist” ideas as, first, single payer, and now probably the public option, and soon, it seems from even employer mandates or minimum requirements for what insurance companies have to offer us in the way of coverage. They have done this, ostensibly, to become more acceptable to Republicans, but without an ounce of chance of success. Every “compromise”, every give-back of a promise to actually provide the all the American people with the health care that they need at a price that they can afford and with a system that has at least some possibility of controlling costs has been given away with absolutely zero acceptance, gratitude or compromise from the MINORITY, the right-wing cabal currently called the Republican party. They and their supporters have had nothing at all positive to say. They continue to call the President a socialist or a communist, they object to his talking to students in school, and they get away with it.
The leadership of this movement, which seems to be mainly Rush Limbaugh and Bill O’Reilly and Glenn Beck (sorry, Sarah) is truly Neanderthal, truly anti-people. Many people have written about the why of this, of how all these White Men fear that they are becoming less than completely powerful, that the history that always gave preference to them and any old thing that they believe may have to be compromised with – well, everyone else – and that is the reason for their venom. The New York Times article on the proposed creation of a “day of special significance” on Harvey Milk’s birthday, http://www.nytimes.com/2009/09/05/us/05milk.html?_r=2&ref=us, quotes opponent Randy Thomassen of SaveCalifornia.com as saying “The bill is so broad it could encompass all kinds of things. Remembering the life of Harvey Milk could allow for gay pride parades on campus or mock gay weddings or cross-dressing. There is no prohibition of what the bill calls ‘suitable commemorative exercises.’ The sky’s the limit.”
Let’s look at that. Thomassen is worried that what? That other people might do things that he doesn’t like? Things that won’t (except I suppose psychically) hurt him. Those people won’t make him do any of those things, but he doesn’t want anyone else to be able to do them either. He could just say he is opposed to the bill, which of course doesn’t call for any of these things, without sounding like a finger-wagging scold. Does Thomassen, and do his friends, really think it is ok to make people do, or not do, things just because he doesn’t like it or it offends him? If so, maybe they could come here to Kansas and tell the other folks on the lake here to stop using their speedboats and jet-skis so I can have more quiet and be able to use my kayak without all that wake threatening to topple me. Hey, I am much more affected, limited in my choice of activities, by those power boats than he is by a Harvey Milk day or any of the bugbears he calls out. Why do people think they can – or should – tell other folks what they can do, as long as it doesn’t hurt them? How can we honestly condemn the fanatics in the Mideast who want to do the same thing?
But it is not funny. Thomassen may or may not be only a finger wagging scold, but these same ideas, these same limits, are often imposed on others, sometimes violently. And certainly this is not new, the reason Thomassen and his friends are worried. It is the same reason that it was in the 1920s and 30s. In his mystery novel “The Redbreast”, Norwegian writer Jo Nesbø has a character talk about the old men from Norway who volunteered to fight with the Nazis on the Eastern Front: “Oh yes, they’re still angry. At Third World aid, cuts in the defence budget, women priests, marriages for homosexuals, our new countrymen, all the things you would guess would upset these old boys. In their hearts, they’re still fascists.” [1] At least in the book the old men who believed these things had once been acknowledged fascists and Nazis. If you were to accuse the folks – the O’Reillys and Limbaughs and Becks and Thomassens who say these same things now, of being fascists, you would be attacked. But you’d be a whole lot closer to the truth than those who accuse Obama of communism are. George Bush is no longer President, and Dick Cheney is no longer – whatever he was – but the venom of the “we’re going to tell you – make you – do what we want” crowd is, probably as a result, more overt.
Meanwhile, regular people have a lot bigger issues; the Times (Sept 4, 2009) reports on the “Jobless recovery”, whatever that is. What I see is that people are still losing their jobs, just at a slower rate, but not getting jobs. So who is recovering? The bankers and Wall Street folks? If you can’t pay your mortgage and feed your family, if you don’t have a job, it is not a recovery. And let’s get this straight: Unless we’re going to go for big-time socialism and pay everybody a living wage even there is no work for them to do, the only purpose of the economy is to create jobs. This is actual people we’re talking about. They need work, and they need health coverage, and they need to know that they won’t lose their health coverage if they, again, lose their job.
The folks who are so worried about losing their coverage now are those who are, like the vast majority of Americans, not sick – yet. As Dr. Ferrer wrote as a guest in this blog on May 8, 2009 :
“The healthiest half of Americans accounts for only 3% of health care expenditures. Conversely, the sickest 5% account for 55% of expenditures and the sickest 10% for 70% of expenditures. So most health spending isn't folks with a cold or twisted ankle who run to the doctor. Most health spending is NICU babies and 20 year-olds with massive trauma from car accidents and cancer patients and old folks with congestive heart failure and 5 hospitalizations in the last year. None of those is engaging in discretionary spending or likely to 'value shop' for health care or to direct their own spending.”
Should they become seriously ill, it will be a sad time to find out what is NOT covered in their policies.
It may be too late for the President to do something. The Times doesn’t think so. Their very strong and atypically long editorial from September 4, 2009, “President Obama’s Health Choices” (http://www.nytimes.com/2009/09/06/opinion/06sun1.html?_r=1) gives very clear advice on what they think President Obama should say in his Wednesday talk to a Joint Session of Congress.
“Given the raucous, often ill-informed attacks on Democratic proposals over the past month, and the clear aim of most Republicans to oppose any bill, no matter how much he compromises, Mr. Obama now needs to spell out in some detail what he wants and how it would benefit both the uninsured and most other Americans as well.”
The Times takes on the Republicans and the “Blue Dog” Democrats, who are supposed to be deficit hawks but have distinguished themselves in this debate mostly by opposing any reform that will pour less government money into the pockets of insurance companies:
“The Bush administration and a Republican-controlled Congress enacted a Medicare prescription drug benefit that will cost the government almost $1 trillion over the next decade without raising or saving a penny to pay for it. They also passed tax cuts for wealthy Americans that will cost more than $1.7 trillion over 10 years, again without making provisions to offset the costs. Now they are complaining that $1 trillion for health care reform — fully paid for over the next 10 years — is too much to spend on a problem that has been festering for decades.”
And the Times has a suggestion for the President: “Rather than yield to Republican intransigence, the Democrats ought to resort to a parliamentary maneuver known as 'budget reconciliation,' which would allow them to push through most reforms by majority vote.” I don’t know about parliamentary process. Maybe President Obama can still say, “OK, this is the way it is going to go. We are going to have health care for the people,” and make it pass the Democratic majorities in Congress. I don’t know if he still can; worse, I don’t know whether, even if he can, he will. If he is going to really lead on making sure we get real, comprehensive, health reform, this is the time to do it. I hope he does, and hope it is not too late.
[1] Nesbø, Jo. The Redbreast. US paperback edition. Harper. New York. 2009. P. 257.
.
Thursday, September 3, 2009
Public / Private Funding: We're All in This Together
.
I have written a great deal about the shortage of primary care physicians in the US, both at present and probably worsening in the future. One of the main reasons is that they make less (much less!) money than many other specialists. This has led to a true shortage of physicians in many Migrant Health Centers, Indian Health Service Clinics, public (e.g., county owned) clinics and other safety net providers, and can even affect Community Health Centers (especially those serving rural areas), although they are in a special category[1]. Another reason that these clinics have difficulty in recruitment of primary care doctors is that their salaries, and these days most primary care doctors are salaried, are lower than those of “private” for-profit (a typical medical practice) or non-profit (when a medical practice is owned by a non-profit hospital, for example) groups. Thus, there are fewer doctors to serve the underserved.
There are also fewer nurse practitioners and nurses. The salaries offered at most of these public settings are much lower than can be earned in private practices or hospital based practices caring for the patients in a particular sub-specialty. County health clinics, which often provide prenatal care, children’s care, family planning, and treatment for sexually-transmitted infections (STIs), as well as other highly infectious diseases which can put the entire community at risk (e.g., tuberculosis) are grossly underfunded, pay low salaries, and thus usually have open positions or people operating above their level of training. Because these nurses and others are not independent practitioners, they often operate under very rigid protocols that can limit care when referrals are not available.
In addition, such clinics (county, public health, etc.) have inadequate non-staff resources, so that their patients get second-class treatment. For example, a county family planning clinic may be able to offer intrauterine devices (a very effective and appropriate method of contraception for many women) only if the company making one of the two brands available in the US approves them for a free IUD. And if the clinic has not exceeded its “allotment”. Very different from a patient in a private office whose insurance will pay for the IUD. And this is just one of many, many examples of patients in public clinics getting inferior care.
Well, you may say, what did you expect? These are after all, public clinics, funded by tax revenue. They can’t expect to have high salaries competitive with the private sector, to have all the equipment and drugs that they need. Governments, both state and local, have always underfunded these operations, and it is obvious that it will get worse in economically hard times. After all, the people who come to these clinics are poor people, without insurance, without money. What do you expect? This is the free market at work: doctors, practices, and hospitals that can be private and take only insured patients will make more money; those at the mercy of our public generosity have to take what they can get. Maybe some of us think it would be nice to do better, but, hey, these are hard times. Taxing the middle-class to be able to provide all these nice services for poor people simply won’t fly. This is the way of the market and the way of the world.
Except, simply, this is a lie. Pretty much we all pay for everyone’s health care. We just choose to do it in different ways, to segregate the market, so that more middle and upper class people have access to more services and better paid doctors and nurses (and thus, obviously, more doctors and nurses!) and poor people have to make do (or not) with what we have left over and choose to devote to this cause.
First of all, there are a lot of health care dollars spent directly by government, federal state and local. This was discussed in the last posting (“Senator Kennedy…, August 30, 2009). Medicare, Medicaid, VA, military, Indian Health service. Then there are the public dollars filtered through private insurance companies – the Federal Employees Health Benefits Plan and the various state and local governments that pay the premiums for their employees. Then there are the tax subsidies for employer contributions to health insurance – the money that the government would get if your employer paid you higher wages, but doesn’t get because, instead of higher wages, you get health insurance, which is tax-deductible to the employer. Of course, even with the availability of this tax break, you may not get health insurance; it depends upon your employer. Not, mainly, whether they are nice or caring, but whether they are big enough to negotiate a good rate with an insurer, and also pay enough in tax to get the break. So your neighbor, the machinist working for Ford, may have a good health plan while you, the just-as-skilled machinist working for a small company may not. But your income taxes are subsidizing his (or her) health insurance. And if you are the insured worker and are healthy, your premiums subsidize the costs of those who are not. That is the way of both insurance and, more important, a society that functions together.
Of course, the reimbursement received by providers for particular episodes of care is higher from some payers, mainly those large companies that insure employees, than it is from other payers, such as Medicare and particularly Medicaid. This is because those costs are paid directly with tax dollars and thus subject to more scrutiny than those filtered (laundered?) through insurance companies. Therefore providers, doctors and hospitals, prefer to care for privately insured patients because they get more money. But, as noted above, a significant part of that cost is paid by government funds. And, of course, the costs are higher because the insurance companies do not provide their laundry service for free; the taxpayer is paying more, the recipient patient is often getting less, and the middleman, the insurance companies, are making the profit.
Thus, the financial justification for provided more limited services to patients (there is no moral justification!) who have to access public or other safety net clinics for their care, is very weak when the entire picture is considered. Obviously, those individual clinics, public hospitals and other safety net providers face limited resources to provide care. But that is because so many dollars, that could be used to provide such care, are being siphoned off for subsidies to “privately insured”, insurance company profit, and administrative waste. The system, as all systems, is “perfectly designed to get the results it gets.” Huge administrative waste, huge insurance company profits, 47 million uninsured, and enormous numbers of underinsured who find out when they get sick what their insurance doesn’t, or won’t, cover.
And a system, noted at the beginning of this piece, that perversely incents the production of high-intervention subspecialists rather than the prevention-and-chronic-disease-management primary care doctors that we need more of. There are also not enough nurse practitioners, physician’s assistants, and nurses working in these areas, because they too can make much more money in high-tech, high-intervention areas. Not as a result of the market, but simply federal government policy decisions. The relative reimbursement for any medical activity (office visit, procedure, hospitalization) is basically set by federal policy. The actual amount will vary depending upon the insurer, but they are virtually all tied to Medicare reimbursement. That is, Blue Cross, or Aetna, or CIGNA will pay 120% of Medicare or 150% of Medicare, or whatever rate the provider (usually based on their power as market share) can negotiate, but always tied to Medicare rates. So, if intervention is paid higher than prevention, if subspecialists are paid higher than generalists, if certain drugs are paid with big markups (like chemotherapy), this is not the market at work, it is simply government policy – it is set by Medicare. This is succinctly and well explained in a recent Slate.com article by Darshak Sanghavi, “The Fix Is In: The hidden public-private cartel that sets health care prices.” http://www.slate.com/id/2227082/pagenum/all/#p2.
And, again, the system is perfectly designed to get the results it gets.
We get it. But it is not what we want or need.
[1] Community Health Centers, CHCs, get significantly higher reimbursement from Medicare and Medicaid – often 3 times higher than do non CHC providers. Therefore they have an incentive to see Medicare and Medicaid recipients, but not uninsured people.
I have written a great deal about the shortage of primary care physicians in the US, both at present and probably worsening in the future. One of the main reasons is that they make less (much less!) money than many other specialists. This has led to a true shortage of physicians in many Migrant Health Centers, Indian Health Service Clinics, public (e.g., county owned) clinics and other safety net providers, and can even affect Community Health Centers (especially those serving rural areas), although they are in a special category[1]. Another reason that these clinics have difficulty in recruitment of primary care doctors is that their salaries, and these days most primary care doctors are salaried, are lower than those of “private” for-profit (a typical medical practice) or non-profit (when a medical practice is owned by a non-profit hospital, for example) groups. Thus, there are fewer doctors to serve the underserved.
There are also fewer nurse practitioners and nurses. The salaries offered at most of these public settings are much lower than can be earned in private practices or hospital based practices caring for the patients in a particular sub-specialty. County health clinics, which often provide prenatal care, children’s care, family planning, and treatment for sexually-transmitted infections (STIs), as well as other highly infectious diseases which can put the entire community at risk (e.g., tuberculosis) are grossly underfunded, pay low salaries, and thus usually have open positions or people operating above their level of training. Because these nurses and others are not independent practitioners, they often operate under very rigid protocols that can limit care when referrals are not available.
In addition, such clinics (county, public health, etc.) have inadequate non-staff resources, so that their patients get second-class treatment. For example, a county family planning clinic may be able to offer intrauterine devices (a very effective and appropriate method of contraception for many women) only if the company making one of the two brands available in the US approves them for a free IUD. And if the clinic has not exceeded its “allotment”. Very different from a patient in a private office whose insurance will pay for the IUD. And this is just one of many, many examples of patients in public clinics getting inferior care.
Well, you may say, what did you expect? These are after all, public clinics, funded by tax revenue. They can’t expect to have high salaries competitive with the private sector, to have all the equipment and drugs that they need. Governments, both state and local, have always underfunded these operations, and it is obvious that it will get worse in economically hard times. After all, the people who come to these clinics are poor people, without insurance, without money. What do you expect? This is the free market at work: doctors, practices, and hospitals that can be private and take only insured patients will make more money; those at the mercy of our public generosity have to take what they can get. Maybe some of us think it would be nice to do better, but, hey, these are hard times. Taxing the middle-class to be able to provide all these nice services for poor people simply won’t fly. This is the way of the market and the way of the world.
Except, simply, this is a lie. Pretty much we all pay for everyone’s health care. We just choose to do it in different ways, to segregate the market, so that more middle and upper class people have access to more services and better paid doctors and nurses (and thus, obviously, more doctors and nurses!) and poor people have to make do (or not) with what we have left over and choose to devote to this cause.
First of all, there are a lot of health care dollars spent directly by government, federal state and local. This was discussed in the last posting (“Senator Kennedy…, August 30, 2009). Medicare, Medicaid, VA, military, Indian Health service. Then there are the public dollars filtered through private insurance companies – the Federal Employees Health Benefits Plan and the various state and local governments that pay the premiums for their employees. Then there are the tax subsidies for employer contributions to health insurance – the money that the government would get if your employer paid you higher wages, but doesn’t get because, instead of higher wages, you get health insurance, which is tax-deductible to the employer. Of course, even with the availability of this tax break, you may not get health insurance; it depends upon your employer. Not, mainly, whether they are nice or caring, but whether they are big enough to negotiate a good rate with an insurer, and also pay enough in tax to get the break. So your neighbor, the machinist working for Ford, may have a good health plan while you, the just-as-skilled machinist working for a small company may not. But your income taxes are subsidizing his (or her) health insurance. And if you are the insured worker and are healthy, your premiums subsidize the costs of those who are not. That is the way of both insurance and, more important, a society that functions together.
Of course, the reimbursement received by providers for particular episodes of care is higher from some payers, mainly those large companies that insure employees, than it is from other payers, such as Medicare and particularly Medicaid. This is because those costs are paid directly with tax dollars and thus subject to more scrutiny than those filtered (laundered?) through insurance companies. Therefore providers, doctors and hospitals, prefer to care for privately insured patients because they get more money. But, as noted above, a significant part of that cost is paid by government funds. And, of course, the costs are higher because the insurance companies do not provide their laundry service for free; the taxpayer is paying more, the recipient patient is often getting less, and the middleman, the insurance companies, are making the profit.
Thus, the financial justification for provided more limited services to patients (there is no moral justification!) who have to access public or other safety net clinics for their care, is very weak when the entire picture is considered. Obviously, those individual clinics, public hospitals and other safety net providers face limited resources to provide care. But that is because so many dollars, that could be used to provide such care, are being siphoned off for subsidies to “privately insured”, insurance company profit, and administrative waste. The system, as all systems, is “perfectly designed to get the results it gets.” Huge administrative waste, huge insurance company profits, 47 million uninsured, and enormous numbers of underinsured who find out when they get sick what their insurance doesn’t, or won’t, cover.
And a system, noted at the beginning of this piece, that perversely incents the production of high-intervention subspecialists rather than the prevention-and-chronic-disease-management primary care doctors that we need more of. There are also not enough nurse practitioners, physician’s assistants, and nurses working in these areas, because they too can make much more money in high-tech, high-intervention areas. Not as a result of the market, but simply federal government policy decisions. The relative reimbursement for any medical activity (office visit, procedure, hospitalization) is basically set by federal policy. The actual amount will vary depending upon the insurer, but they are virtually all tied to Medicare reimbursement. That is, Blue Cross, or Aetna, or CIGNA will pay 120% of Medicare or 150% of Medicare, or whatever rate the provider (usually based on their power as market share) can negotiate, but always tied to Medicare rates. So, if intervention is paid higher than prevention, if subspecialists are paid higher than generalists, if certain drugs are paid with big markups (like chemotherapy), this is not the market at work, it is simply government policy – it is set by Medicare. This is succinctly and well explained in a recent Slate.com article by Darshak Sanghavi, “The Fix Is In: The hidden public-private cartel that sets health care prices.” http://www.slate.com/id/2227082/pagenum/all/#p2.
And, again, the system is perfectly designed to get the results it gets.
We get it. But it is not what we want or need.
[1] Community Health Centers, CHCs, get significantly higher reimbursement from Medicare and Medicaid – often 3 times higher than do non CHC providers. Therefore they have an incentive to see Medicare and Medicaid recipients, but not uninsured people.
Sunday, August 30, 2009
Senator Ted Kennedy, Social Justice, and Healthcare for the People
.
The death of Senator Edward Kennedy this week was sad and sobering. Even this longest-lived of the Kennedy brothers, the only one to not die by a bullet in war or from an assassin’s gun, the one who served 47 years in the US Senate, still experienced tragedy at the end of his life. When someone dies, there is a natural tendency, in eulogies, to talk only about their positive attributes. In Senator Kennedy’s case, these are not only well-deserved, but important. I am not talking about his personal life, or things that happened long ago; I am talking about his public life as a leader.
On August 27, 2009, NPR Morning Edition ‘s Pam Fessler spoke with former Kennedy political advisor Bob Schrum http://www.npr.org/templates/story/story.php?storyId=112281174&ft=1&f=112268401.:
“FESSLER: Political consultant Bob Shrum recalls how he almost got his head bitten off during Kennedy's reelection campaign in 1994 against Republican Mitt Romney. Shrum had given this political advice: Don't oppose Romney's plan to stop welfare for women who have children out of wedlock.
Mr. BOB SHRUM (Political Consultant): And he said I'm not going to do that. I'm not going to get reelected by taking food out of the mouths of poor kids. I don't need the job that much. They need the food. He was genuinely angry.
FESSLER: Shrum says it was part of Kennedy's deep philosophical belief.
Mr. SHRUM: I think Ted Kennedy always had a very strong feeling that government existed for people who didn't have power and didn't have privilege and didn't have influence, that it somehow or other was a balancing mechanism to achieve a measure of social justice and opportunity and equality.”
I didn’t know this story, before, and I can’t say that I always thought that the Senator was doing everything I thought he could to advance healthcare for all, but I can say that this pretty much seems like the right definition of the purpose of government. And this should define what our government, representing our people, should be doing to reform health care.
Of course, not everyone believes that this is the purpose of government, but I do. I am not talking about the national defense, or the building of federal highways but in its core approach to domestic spending. Small business loans should help small businesses, people who are starting up or trying to get through hard times to achieve the American dream, not big companies. Farm support, to the extent we have it, should protect and help the family farmer, not giant agribusiness companies. We need to protect our nation’s natural resources and public lands so that they will be there for future generations, not destroy them to create more enormous wealth for multi-national corporations. Huge multinational corporations (and make no mistake, all of these large ventures from farming to mining to manufacturing to finance are controlled by large multinational corporations) and the extremely wealthy people who control them are doing just fine, thank you. If some of them are doing a little less fine than they were a year ago, that is fine also, and no one should shed a tear even if they are forced to move into public housing (hah!) – see my entry on the “Super Rich”, August 27.
But there are lots of people who do need help. They include the children that Senator Kennedy knew needed food, and who also need education. Nicholas Kristof, writing in the New York Times on August 19, 2009 (http://www.nytimes.com/2009/08/20/opinion/20kristof.html?scp=16&sq=&st=nyt), notes that while the Oakland, CA schools spend $8,000 per year to educate each of its students, the state of California spends $216,000 per year for each inmate in its juvenile justice system. If these children had a little more spent on their eduation, perhaps they won’t be in the same situation as another man described by Kristof, who, having had two minor convictions at 19, landed in jail for life for stealing a $2.50 pair of socks, under California’s 3 strikes law! Prison for life for stealing $2.50! While the bankers and financiers who were true bandits get government bailouts! Um, wrong use of taxpayer money.
And we need healthcare for all, which Senator Kennedy long fought for. By the end of his life, with the greatest possibility of achieving this goal on the horizon, he was unfortunately willing to give up on the plan he knew would work best, single payer, but would never give up on the need for a public plan, because he would not give up on the idea that everyone needed to be covered, and there are only 3 ways to do this: single payer, a public plan (more costly, as I have discussed previously), and a system using not-for-profit private insurance companies that are highly regulated, forcing them to cover everyone and not gouge them with his premiums (which has less chance of happening than single payer!) We need to do this he, and I, belive, because that should be the role of government: to be a balance, to help those who need the help to meet have the basic requirements for a good life, and to spend not a penny padding the accounts of the least needy in a manner that is often believed to be characteristic only of backward, corrupt, third-world dictatorships.
Not everyone agrees that government should be involved in health care reform. “The federal government has absolutely no business in any way, shape or form addressing health care,” an attendee at a town hall held by Sen Claire McCaskill of MO was quoted as saying by the Kansas City Star on August 24 (http://www.kansascity.com/news/politics/story/1403874.html). “Not pro, not con. Zero. Zip.” The article did not contain more information explaining this position, but I’m certain it was coherent as well as cogent. I'm sure that this person would be happy to eliminate the benefits offered by taxpayers not only for Medicare and Medicaid, but also the Veteran’s Administration, and the military and all federal employees. Not to mention the benefits supplied by all the state and local governments for their employees. Or the tax revenue foregone (thus a cost) by the federal government for making employer health contributions (perhaps including the employer of the person making this comment) tax-deductible. While the Center for Medicare and Medicaid Services (CMS) estimates the federal contribution to be 45% of healthcare spending, this doesn’t include the benefits for federal employees, state and local employees, or the tax breaks. When they are, appropriately, included, it brings the taxpayer-supported contribution to healthcare to nearly 60%.[1] In absolute per capita dollars, the US taxpayer spends more than the TOTAL per capita healthcare spending of every country save Switzerland, while having 47 million uninsured! We pay for national health care, but do not get it.
Go out, all of you covered by government funds, and get your own private health insurance!
Perhaps the commenter at the McCaskill event meant that he believed that he and everyone else should pay for their health insurance themselves in after-tax dollars. Or maybe he, or others who might be tempted to agree with him, are victims of the “Craig T. Nelson Fallacy”. This fallacy, of which “keep the government’s hands off my Medicare!” is an example, is named for the actor who, after an extensive anti-government rant on Fox’s Glenn Beck show, declared “I've been on food stamps and welfare. Anybody help me out? No. No.” (May 28, 2009, http://www.foxnews.com/story/0,2933,522939,00.html).
While many may dismiss Mr. Nelson as an ignorant blowhard who doesn’t know what he is talking about (which he is and is true), the real issue is that so many other people are missing the key point: how much they, personally, benefit from the government, and how helping them, and others in need, is a completely appropriate thing for the government to do. The “government” after all should be representing all of us, and helping us when we have need, not stuffing the pockets of the privileged (who, in turn, stuff the pockets of our representatives).
On MSNBC’s “The Morning Grind” on August 25, 2009, Rep. Anthony Weiner (D., NY), a single-payer advocate, left host Joe Scarborough “speechless” (many links all over the web; here is one:
http://click.icptrack.com/icp/relay.php?r=4798182&msgid=254377&act=0LH3&c=196437&admin=0&destination=http%3A%2F%2Fwww.pnhp.org%2Fmultimedia%2Fanthony_weiner_leaves_scarborogh_speechless.php) by his simple logic that said, essentially (paraphrase) “why should we pay insurance companies such a big cut of our health care dollar? When did an insurance company ever operate on someone or make a diagnosis?” Scarborough could not believe that the Congressman was urging that insurance companies be eliminated, but all he could basically say was “I believe in private enterprise, and you want the government to run healthcare!”, unable, of course, to respond to the content. Weiner noted that if private insurance companies could really do a better, more cost-effective job, they wouldn't be concerned about competing with a public option.
Apparently Joe Scarborough, and many others, have an ideological belief different from that of Senator Kennedy. They believe that government should support rich corporations rather than existing “…for people who didn't have power and didn't have privilege and didn't have influence,” and being “a balancing mechanism to achieve a measure of social justice and opportunity and equality.” I believe that it was largely in agreement with this purpose that so many people became activated in the campaign of Barack Obama and elected him President. The President would be doing us all a great favor if he could ignore the advice of the (pre-reconstructed) Bob Shrums who advise him to abandon that belief, and provide the leadership that he can to create a health reform that is truly reform, that will truly cover all the people of the United States, and that willing truly be a fitting tribute to Senator Kennedy.
[1] Woolhandler S and Himmelstein DU, “Paying for national health insurance – and not getting it!” Health Affairs, July-August 2002, pp. 88-98.
The death of Senator Edward Kennedy this week was sad and sobering. Even this longest-lived of the Kennedy brothers, the only one to not die by a bullet in war or from an assassin’s gun, the one who served 47 years in the US Senate, still experienced tragedy at the end of his life. When someone dies, there is a natural tendency, in eulogies, to talk only about their positive attributes. In Senator Kennedy’s case, these are not only well-deserved, but important. I am not talking about his personal life, or things that happened long ago; I am talking about his public life as a leader.
On August 27, 2009, NPR Morning Edition ‘s Pam Fessler spoke with former Kennedy political advisor Bob Schrum http://www.npr.org/templates/story/story.php?storyId=112281174&ft=1&f=112268401.:
“FESSLER: Political consultant Bob Shrum recalls how he almost got his head bitten off during Kennedy's reelection campaign in 1994 against Republican Mitt Romney. Shrum had given this political advice: Don't oppose Romney's plan to stop welfare for women who have children out of wedlock.
Mr. BOB SHRUM (Political Consultant): And he said I'm not going to do that. I'm not going to get reelected by taking food out of the mouths of poor kids. I don't need the job that much. They need the food. He was genuinely angry.
FESSLER: Shrum says it was part of Kennedy's deep philosophical belief.
Mr. SHRUM: I think Ted Kennedy always had a very strong feeling that government existed for people who didn't have power and didn't have privilege and didn't have influence, that it somehow or other was a balancing mechanism to achieve a measure of social justice and opportunity and equality.”
I didn’t know this story, before, and I can’t say that I always thought that the Senator was doing everything I thought he could to advance healthcare for all, but I can say that this pretty much seems like the right definition of the purpose of government. And this should define what our government, representing our people, should be doing to reform health care.
Of course, not everyone believes that this is the purpose of government, but I do. I am not talking about the national defense, or the building of federal highways but in its core approach to domestic spending. Small business loans should help small businesses, people who are starting up or trying to get through hard times to achieve the American dream, not big companies. Farm support, to the extent we have it, should protect and help the family farmer, not giant agribusiness companies. We need to protect our nation’s natural resources and public lands so that they will be there for future generations, not destroy them to create more enormous wealth for multi-national corporations. Huge multinational corporations (and make no mistake, all of these large ventures from farming to mining to manufacturing to finance are controlled by large multinational corporations) and the extremely wealthy people who control them are doing just fine, thank you. If some of them are doing a little less fine than they were a year ago, that is fine also, and no one should shed a tear even if they are forced to move into public housing (hah!) – see my entry on the “Super Rich”, August 27.
But there are lots of people who do need help. They include the children that Senator Kennedy knew needed food, and who also need education. Nicholas Kristof, writing in the New York Times on August 19, 2009 (http://www.nytimes.com/2009/08/20/opinion/20kristof.html?scp=16&sq=&st=nyt), notes that while the Oakland, CA schools spend $8,000 per year to educate each of its students, the state of California spends $216,000 per year for each inmate in its juvenile justice system. If these children had a little more spent on their eduation, perhaps they won’t be in the same situation as another man described by Kristof, who, having had two minor convictions at 19, landed in jail for life for stealing a $2.50 pair of socks, under California’s 3 strikes law! Prison for life for stealing $2.50! While the bankers and financiers who were true bandits get government bailouts! Um, wrong use of taxpayer money.
And we need healthcare for all, which Senator Kennedy long fought for. By the end of his life, with the greatest possibility of achieving this goal on the horizon, he was unfortunately willing to give up on the plan he knew would work best, single payer, but would never give up on the need for a public plan, because he would not give up on the idea that everyone needed to be covered, and there are only 3 ways to do this: single payer, a public plan (more costly, as I have discussed previously), and a system using not-for-profit private insurance companies that are highly regulated, forcing them to cover everyone and not gouge them with his premiums (which has less chance of happening than single payer!) We need to do this he, and I, belive, because that should be the role of government: to be a balance, to help those who need the help to meet have the basic requirements for a good life, and to spend not a penny padding the accounts of the least needy in a manner that is often believed to be characteristic only of backward, corrupt, third-world dictatorships.
Not everyone agrees that government should be involved in health care reform. “The federal government has absolutely no business in any way, shape or form addressing health care,” an attendee at a town hall held by Sen Claire McCaskill of MO was quoted as saying by the Kansas City Star on August 24 (http://www.kansascity.com/news/politics/story/1403874.html). “Not pro, not con. Zero. Zip.” The article did not contain more information explaining this position, but I’m certain it was coherent as well as cogent. I'm sure that this person would be happy to eliminate the benefits offered by taxpayers not only for Medicare and Medicaid, but also the Veteran’s Administration, and the military and all federal employees. Not to mention the benefits supplied by all the state and local governments for their employees. Or the tax revenue foregone (thus a cost) by the federal government for making employer health contributions (perhaps including the employer of the person making this comment) tax-deductible. While the Center for Medicare and Medicaid Services (CMS) estimates the federal contribution to be 45% of healthcare spending, this doesn’t include the benefits for federal employees, state and local employees, or the tax breaks. When they are, appropriately, included, it brings the taxpayer-supported contribution to healthcare to nearly 60%.[1] In absolute per capita dollars, the US taxpayer spends more than the TOTAL per capita healthcare spending of every country save Switzerland, while having 47 million uninsured! We pay for national health care, but do not get it.
Go out, all of you covered by government funds, and get your own private health insurance!
Perhaps the commenter at the McCaskill event meant that he believed that he and everyone else should pay for their health insurance themselves in after-tax dollars. Or maybe he, or others who might be tempted to agree with him, are victims of the “Craig T. Nelson Fallacy”. This fallacy, of which “keep the government’s hands off my Medicare!” is an example, is named for the actor who, after an extensive anti-government rant on Fox’s Glenn Beck show, declared “I've been on food stamps and welfare. Anybody help me out? No. No.” (May 28, 2009, http://www.foxnews.com/story/0,2933,522939,00.html).
While many may dismiss Mr. Nelson as an ignorant blowhard who doesn’t know what he is talking about (which he is and is true), the real issue is that so many other people are missing the key point: how much they, personally, benefit from the government, and how helping them, and others in need, is a completely appropriate thing for the government to do. The “government” after all should be representing all of us, and helping us when we have need, not stuffing the pockets of the privileged (who, in turn, stuff the pockets of our representatives).
On MSNBC’s “The Morning Grind” on August 25, 2009, Rep. Anthony Weiner (D., NY), a single-payer advocate, left host Joe Scarborough “speechless” (many links all over the web; here is one:
http://click.icptrack.com/icp/relay.php?r=4798182&msgid=254377&act=0LH3&c=196437&admin=0&destination=http%3A%2F%2Fwww.pnhp.org%2Fmultimedia%2Fanthony_weiner_leaves_scarborogh_speechless.php) by his simple logic that said, essentially (paraphrase) “why should we pay insurance companies such a big cut of our health care dollar? When did an insurance company ever operate on someone or make a diagnosis?” Scarborough could not believe that the Congressman was urging that insurance companies be eliminated, but all he could basically say was “I believe in private enterprise, and you want the government to run healthcare!”, unable, of course, to respond to the content. Weiner noted that if private insurance companies could really do a better, more cost-effective job, they wouldn't be concerned about competing with a public option.
Apparently Joe Scarborough, and many others, have an ideological belief different from that of Senator Kennedy. They believe that government should support rich corporations rather than existing “…for people who didn't have power and didn't have privilege and didn't have influence,” and being “a balancing mechanism to achieve a measure of social justice and opportunity and equality.” I believe that it was largely in agreement with this purpose that so many people became activated in the campaign of Barack Obama and elected him President. The President would be doing us all a great favor if he could ignore the advice of the (pre-reconstructed) Bob Shrums who advise him to abandon that belief, and provide the leadership that he can to create a health reform that is truly reform, that will truly cover all the people of the United States, and that willing truly be a fitting tribute to Senator Kennedy.
[1] Woolhandler S and Himmelstein DU, “Paying for national health insurance – and not getting it!” Health Affairs, July-August 2002, pp. 88-98.
Wednesday, August 26, 2009
The "Super Rich" and Our Healthcare
.
The New York Times, August 21, 2009, has a front-page article by David Leonhart and Geraldine Fabrikant titled “After 30-year run, rise of the super-rich hits a sobering wall” (http://www.nytimes.com/2009/08/21/business/economy/21inequality.html?_r=1&scp=1&sq=super%20rich&st=cse). My heart bleeds. Not. Not at all. Couldn’t happen to more deserving people.
I do not mean to say that all super-rich folks are bad people. Some worked hard, got lucky, had a product or an idea that no one else had, and were able to turn it into great wealth. Others inherited it – ok, they did nothing to earn the wealth, but maybe they are spending it in very socially-conscious ways, supporting the movement for the environment and limiting climate change, working for peace, helping feed the hungry and house the homeless in this country and abroad.
But the “30-year run” is largely a story of greed gone wild. It is a story of the society that was among the most middle-class in world history, with poor people and rich people and some very rich people, to a society with lots of poor people, a declining role for the middle and upper middle class, and a relatively large (though still tiny) group of super-rich. It is a story of policies begun in the Reagan administration and carried through the subsequent administrations, both Republican and Democratic, of limiting restrictions and regulations that helped to keep business relatively honest. It encouraged lying, cheating and racketeering by making so much of it legal that some folks weren’t even sure where the line was. (Of course, some purposely stepped over the line.) It is a story that came to a head this last year with the near-collapse of the economy of the US and the world. It is good to hear that many of these people are losing their money, it is sad to hear that so many are not; they are getting money from the government (you and me) and spending it on bonuses for themselves. They have no humility.
I am looking forward to the creation of a memorial for these 30 years. Perhaps it can be prominently displayed in the broom closet of one of the surplus FEMA trailers that I have been advocating selling to these people after all their money is forfeit.
So what does this have to do with medicine? It has to do with social justice and with health reform. The current backtracking by the administration on the “public option” is shameful and inappropriate. The concept that co-ops could somehow cover everyone is flawed. Perhaps if they were true consumer-owned cooperatives, like most of the original groups (later called HMOs), such as Group Health of Seattle (one of the few remaining), Ross-Loos of Los Angeles, HIP of NY. But most of the consumer-cooperative HMOs, created by believers in cooperatives who felt that by cutting out the middleman – the insurance company – they could get more care for the same money or the same care for less money – were taken over, beginning in the 80’s, by – Insurance Companies! One of the threats that they faced, which made them susceptible to takeover, was increased costs without a willingness (or ability) to have increased premiums as their membership aged. It is strangely parallel to the history of the Israeli kibbutz – young idealists could do a lot when they were young and healthy, but as they aged, without replacement young workers, they found it difficult to survive. So a “co-op” owned by the insurance company would be the HMO that we have grown to know and hate over the last 20+ years, the one that makes money by denying us coverage. A true co-op movement would be neat for those who are in it, but would do nothing to help cover the uninsured. Whoops, let that cat out of the bag!
The whole concept misses the key, #1, worthless-if-it-isn’t-included, issue of health reform: It must cover everyone. Not like the economic “growth” we had when all those super-rich were created which left so many people out, and left out even more when we look at health coverage. Every year corporations, including the many controlled by these super-rich, cut benefits, cut coverage, increased co-pays, and even dropped health insurance altogether for dependents and sometimes for the workers themselves. The unions, whose job it should have been to protect the interests of their members, the workers, were greatly weakened by the same government policies that protected the super-rich and encouraged the financial-speculators-who-produce-nothing-but-steal-from-us-all crowd. And those unions who still had good health insurance had no interest in fighting for the rest of workers; they were too busy trying to hold on to their own. Like, for example, the UAW. Whoops, there went GM and “Cadillac” health benefits!
No, the only thing that will allow everyone to be covered is a public plan. As I have said often, the best public plan is one that covers everyone in one plan. But no “reform” absent a public plan will cover everyone. The objections to the “government” takeover of health care are, with the exceptions of those voiced by right-wing ideologues who are in the pay of the big “super-rich” corporations, misguided. Let’s look at some public plans. Medicare. No one who has it wants to lose it. At a recent town hall meeting, US Senator Claire McCaskill (D-MO) asked the audience how many had Medicare. About a third of those in attendance raised their hands. Then she asked (and I paraphrase) “how many of you want to give up your government-controlled public health insurance?” All hands went down.
Arguably, the only program as popular as Medicare is Social Security itself. A government plan. Like Medicare, it is government run, but the expenditure of funds is up to the individual. Remember the Republican plan, the Bush plan, to “privatize” Social Security? To invest the funds “in the market”? To take advantage of the huge growth of the stock market? I bet a bunch of current and soon-to-be seniors are breathing a big sigh of relief that that didn’t happen, but Republicans and other conservatives (what are they conserving? Not your retirement!) are still touting the same ideas! And the objections that they have brought up to health reform, such as the “death panels”, are completely spurious. But they are tenacious ideas, because of the big lie (as I addressed on August 11, “Should it be a crime to be poor – or instead to criminalize poverty”) and because of the psychology of stories and narrative, as addressed by George Lakoff in the Huffington Post (http://www.huffingtonpost.com/george-lakoff/the-policyspeak-disaster_b_264043.html#postComment)
In the Kansas City Star on August 20, 2009, Providence Journal columnist Froma Harrop wrote that “Health insurers have their own death panels” (http://www.kansascity.com/273/story/1395629.html). In it she describes the pain that she and her husband went through with their insurance company, United Health Care (the one that gave CEO William McGuire a more than $1 Billion bonus in 2006 http://money.cnn.com/magazines/fortune/fortune_archive/2006/07/10/8380799/index.htm; yes, that United Health Care) trying to get treatment for his liver cancer. I do not have access to his medical records and cannot comment on the appropriateness of the care or not, but she makes it absolutely clear that there ARE “death panels” now, and they are operated by private insurance companies.
The basis of the opposition to a public option, to single-payer, is opposition to what will be good for Americans in pursuit of corporate profit and political gain. In his op-ed in the Times August 24, 2009, “All the President’s Zombies”, (http://www.nytimes.com/2009/08/24/opinion/24krugman.html?ref=opinion), Paul Krugman makes this point very clearly; in echoes of Reaganism opponents of health reform keep trumpeting “government” when it is entirely clear, if you think about it, that it is only government programs that are likely to work, to cover everyone. He notes that DEMOCRATIC Sen. Ben Nelson of Colorado has “…warned ominously that if the option were available, Americans would choose it over private insurance — which he treats as a self-evidently bad thing, rather than as what should happen if the government plan was, in fact, better than what private insurers offer.” What is this, the Twilight Zone?
Commenting on the Democrats’ need to have A BILL, Cokie Roberts, on NPR Morning Edition August 24, 2009, that the Republicans will not vote for any health bill because they don’t want the Democrats to be able to take credit for it, as they have for years for Social Security and Medicare. She is probably correct. She also said that they have to have a bill that will not pass narrowly. I disagree. If a good bill, that will cover everyone with access to quality health, leave free choice of providers, eliminating prejudice against pre-existing conditions, and limits profit passes, the results will be wonderful and folks will love it more than they love Social Security and Medicare. Remember in TR Reid’s “Sick Around the World” (http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/), the Swiss plan barely passed with just over 50% of people supporting it in the early ‘90s, but now no one would give it up.
This is what the opponents of health reform fear; real change. We need to keep up the pressure to get it.
.
The New York Times, August 21, 2009, has a front-page article by David Leonhart and Geraldine Fabrikant titled “After 30-year run, rise of the super-rich hits a sobering wall” (http://www.nytimes.com/2009/08/21/business/economy/21inequality.html?_r=1&scp=1&sq=super%20rich&st=cse). My heart bleeds. Not. Not at all. Couldn’t happen to more deserving people.
I do not mean to say that all super-rich folks are bad people. Some worked hard, got lucky, had a product or an idea that no one else had, and were able to turn it into great wealth. Others inherited it – ok, they did nothing to earn the wealth, but maybe they are spending it in very socially-conscious ways, supporting the movement for the environment and limiting climate change, working for peace, helping feed the hungry and house the homeless in this country and abroad.
But the “30-year run” is largely a story of greed gone wild. It is a story of the society that was among the most middle-class in world history, with poor people and rich people and some very rich people, to a society with lots of poor people, a declining role for the middle and upper middle class, and a relatively large (though still tiny) group of super-rich. It is a story of policies begun in the Reagan administration and carried through the subsequent administrations, both Republican and Democratic, of limiting restrictions and regulations that helped to keep business relatively honest. It encouraged lying, cheating and racketeering by making so much of it legal that some folks weren’t even sure where the line was. (Of course, some purposely stepped over the line.) It is a story that came to a head this last year with the near-collapse of the economy of the US and the world. It is good to hear that many of these people are losing their money, it is sad to hear that so many are not; they are getting money from the government (you and me) and spending it on bonuses for themselves. They have no humility.
I am looking forward to the creation of a memorial for these 30 years. Perhaps it can be prominently displayed in the broom closet of one of the surplus FEMA trailers that I have been advocating selling to these people after all their money is forfeit.
So what does this have to do with medicine? It has to do with social justice and with health reform. The current backtracking by the administration on the “public option” is shameful and inappropriate. The concept that co-ops could somehow cover everyone is flawed. Perhaps if they were true consumer-owned cooperatives, like most of the original groups (later called HMOs), such as Group Health of Seattle (one of the few remaining), Ross-Loos of Los Angeles, HIP of NY. But most of the consumer-cooperative HMOs, created by believers in cooperatives who felt that by cutting out the middleman – the insurance company – they could get more care for the same money or the same care for less money – were taken over, beginning in the 80’s, by – Insurance Companies! One of the threats that they faced, which made them susceptible to takeover, was increased costs without a willingness (or ability) to have increased premiums as their membership aged. It is strangely parallel to the history of the Israeli kibbutz – young idealists could do a lot when they were young and healthy, but as they aged, without replacement young workers, they found it difficult to survive. So a “co-op” owned by the insurance company would be the HMO that we have grown to know and hate over the last 20+ years, the one that makes money by denying us coverage. A true co-op movement would be neat for those who are in it, but would do nothing to help cover the uninsured. Whoops, let that cat out of the bag!
The whole concept misses the key, #1, worthless-if-it-isn’t-included, issue of health reform: It must cover everyone. Not like the economic “growth” we had when all those super-rich were created which left so many people out, and left out even more when we look at health coverage. Every year corporations, including the many controlled by these super-rich, cut benefits, cut coverage, increased co-pays, and even dropped health insurance altogether for dependents and sometimes for the workers themselves. The unions, whose job it should have been to protect the interests of their members, the workers, were greatly weakened by the same government policies that protected the super-rich and encouraged the financial-speculators-who-produce-nothing-but-steal-from-us-all crowd. And those unions who still had good health insurance had no interest in fighting for the rest of workers; they were too busy trying to hold on to their own. Like, for example, the UAW. Whoops, there went GM and “Cadillac” health benefits!
No, the only thing that will allow everyone to be covered is a public plan. As I have said often, the best public plan is one that covers everyone in one plan. But no “reform” absent a public plan will cover everyone. The objections to the “government” takeover of health care are, with the exceptions of those voiced by right-wing ideologues who are in the pay of the big “super-rich” corporations, misguided. Let’s look at some public plans. Medicare. No one who has it wants to lose it. At a recent town hall meeting, US Senator Claire McCaskill (D-MO) asked the audience how many had Medicare. About a third of those in attendance raised their hands. Then she asked (and I paraphrase) “how many of you want to give up your government-controlled public health insurance?” All hands went down.
Arguably, the only program as popular as Medicare is Social Security itself. A government plan. Like Medicare, it is government run, but the expenditure of funds is up to the individual. Remember the Republican plan, the Bush plan, to “privatize” Social Security? To invest the funds “in the market”? To take advantage of the huge growth of the stock market? I bet a bunch of current and soon-to-be seniors are breathing a big sigh of relief that that didn’t happen, but Republicans and other conservatives (what are they conserving? Not your retirement!) are still touting the same ideas! And the objections that they have brought up to health reform, such as the “death panels”, are completely spurious. But they are tenacious ideas, because of the big lie (as I addressed on August 11, “Should it be a crime to be poor – or instead to criminalize poverty”) and because of the psychology of stories and narrative, as addressed by George Lakoff in the Huffington Post (http://www.huffingtonpost.com/george-lakoff/the-policyspeak-disaster_b_264043.html#postComment)
In the Kansas City Star on August 20, 2009, Providence Journal columnist Froma Harrop wrote that “Health insurers have their own death panels” (http://www.kansascity.com/273/story/1395629.html). In it she describes the pain that she and her husband went through with their insurance company, United Health Care (the one that gave CEO William McGuire a more than $1 Billion bonus in 2006 http://money.cnn.com/magazines/fortune/fortune_archive/2006/07/10/8380799/index.htm; yes, that United Health Care) trying to get treatment for his liver cancer. I do not have access to his medical records and cannot comment on the appropriateness of the care or not, but she makes it absolutely clear that there ARE “death panels” now, and they are operated by private insurance companies.
The basis of the opposition to a public option, to single-payer, is opposition to what will be good for Americans in pursuit of corporate profit and political gain. In his op-ed in the Times August 24, 2009, “All the President’s Zombies”, (http://www.nytimes.com/2009/08/24/opinion/24krugman.html?ref=opinion), Paul Krugman makes this point very clearly; in echoes of Reaganism opponents of health reform keep trumpeting “government” when it is entirely clear, if you think about it, that it is only government programs that are likely to work, to cover everyone. He notes that DEMOCRATIC Sen. Ben Nelson of Colorado has “…warned ominously that if the option were available, Americans would choose it over private insurance — which he treats as a self-evidently bad thing, rather than as what should happen if the government plan was, in fact, better than what private insurers offer.” What is this, the Twilight Zone?
Commenting on the Democrats’ need to have A BILL, Cokie Roberts, on NPR Morning Edition August 24, 2009, that the Republicans will not vote for any health bill because they don’t want the Democrats to be able to take credit for it, as they have for years for Social Security and Medicare. She is probably correct. She also said that they have to have a bill that will not pass narrowly. I disagree. If a good bill, that will cover everyone with access to quality health, leave free choice of providers, eliminating prejudice against pre-existing conditions, and limits profit passes, the results will be wonderful and folks will love it more than they love Social Security and Medicare. Remember in TR Reid’s “Sick Around the World” (http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/), the Swiss plan barely passed with just over 50% of people supporting it in the early ‘90s, but now no one would give it up.
This is what the opponents of health reform fear; real change. We need to keep up the pressure to get it.
.
Sunday, August 23, 2009
A Modest Proposal: Bribe the Insurance Companies
(apologies to Mr. Swift)
Extensive research done by the Physicians for a National Health Program (PNHP), particularly by Steffie Woolhandler and David Himmelstein, have identified at least $400 BILLION in annual “waste” from our current system of health insurance (and, of course, lack of insurance for tens of millions of Americans). Drs. Woolhandler and Himmelstein are major advocates of a single-payer system, as am I (OK, I’m not so major!) and I have used much of their research in supporting single payer and in pointing out the limitations of a “public option”. Himmelstein, in his testimony to Congress (http://www.pnhp.org/news/2009/april/testimony_of_david_u.php) and in more detail on his PNHP blog (http://www.pnhp.org/campaign/materials/Refuting%20the%20Public%20Option.pdf) notes that a public option “…foregoes at least 84% of the administrative savings available through single payer. The public plan option would do nothing to streamline the administrative tasks (and costs) of hospitals, physicians offices, and nursing homes. They would still contend with multiple payers, and hence still need the complex cost tracking and billing apparatus that drives administrative costs. These unnecessary provider administrative costs account for the vast majority of bureaucratic waste. Hence, even if 95% of Americans who are currently privately insured were to join a public plan (and it had overhead costs at current Medicare levels), the savings on insurance overhead would amount to only 16% of the roughly $400 billion annually achievable through single payer.”
More than that, only a part of that 16% is actual insurance company profit, as noted in a letter to the New York Times (June 21, 2009) by Dr. Woolhandler: “Moreover, the savings on overhead from a public plan option are far smaller than you suggest. While it might cut insurers’ profits (which is why they hate it), that’s only 3 percent of the roughly $400 billion squandered on health bureaucracy annually.” (http://pnhp.org/blog/2009/06/25/paul-starr-and-steffie-woolhandler-on-the-public-option/).
Let’s think about that. We waste $400 billion a year in administrative overhead so that the insurance companies can make 3% of that, or about $10-15 billion. That is a lot of money, but it is also a high waste:profit ratio. We could just pay the insurance companies their $15 billion a year, maybe for a limited time (5-10 years, perhaps decreasing 10% per year, so they could get into some other business, perhaps cleaning up the environment or rebuilding infrastructure or teaching underserved inner-city children), and tell them to disappear, leave the debate, get out; then we do single-payer and save the other $385 billion.
Sounds like a good deal to me. And not so bad for the insurance companies, since they won’t have to work or bribe Congressmen! Sure, it is lacking in morality, but so was the bank bailout, and this is a lot cheaper. And it would get us a plan a lot better than any of those being tossed around by the administration and congressional committees.
Maybe we should go for it!
.
Extensive research done by the Physicians for a National Health Program (PNHP), particularly by Steffie Woolhandler and David Himmelstein, have identified at least $400 BILLION in annual “waste” from our current system of health insurance (and, of course, lack of insurance for tens of millions of Americans). Drs. Woolhandler and Himmelstein are major advocates of a single-payer system, as am I (OK, I’m not so major!) and I have used much of their research in supporting single payer and in pointing out the limitations of a “public option”. Himmelstein, in his testimony to Congress (http://www.pnhp.org/news/2009/april/testimony_of_david_u.php) and in more detail on his PNHP blog (http://www.pnhp.org/campaign/materials/Refuting%20the%20Public%20Option.pdf) notes that a public option “…foregoes at least 84% of the administrative savings available through single payer. The public plan option would do nothing to streamline the administrative tasks (and costs) of hospitals, physicians offices, and nursing homes. They would still contend with multiple payers, and hence still need the complex cost tracking and billing apparatus that drives administrative costs. These unnecessary provider administrative costs account for the vast majority of bureaucratic waste. Hence, even if 95% of Americans who are currently privately insured were to join a public plan (and it had overhead costs at current Medicare levels), the savings on insurance overhead would amount to only 16% of the roughly $400 billion annually achievable through single payer.”
More than that, only a part of that 16% is actual insurance company profit, as noted in a letter to the New York Times (June 21, 2009) by Dr. Woolhandler: “Moreover, the savings on overhead from a public plan option are far smaller than you suggest. While it might cut insurers’ profits (which is why they hate it), that’s only 3 percent of the roughly $400 billion squandered on health bureaucracy annually.” (http://pnhp.org/blog/2009/06/25/paul-starr-and-steffie-woolhandler-on-the-public-option/).
Let’s think about that. We waste $400 billion a year in administrative overhead so that the insurance companies can make 3% of that, or about $10-15 billion. That is a lot of money, but it is also a high waste:profit ratio. We could just pay the insurance companies their $15 billion a year, maybe for a limited time (5-10 years, perhaps decreasing 10% per year, so they could get into some other business, perhaps cleaning up the environment or rebuilding infrastructure or teaching underserved inner-city children), and tell them to disappear, leave the debate, get out; then we do single-payer and save the other $385 billion.
Sounds like a good deal to me. And not so bad for the insurance companies, since they won’t have to work or bribe Congressmen! Sure, it is lacking in morality, but so was the bank bailout, and this is a lot cheaper. And it would get us a plan a lot better than any of those being tossed around by the administration and congressional committees.
Maybe we should go for it!
.
Wednesday, August 19, 2009
Advance Directives, not "Death Panels"
.
The Sunday New York Times, August 16, 2009, has a plethora of health-reform-related articles and opinion pieces, including an op-ed by President Obama himself (ok, signed by himself), which articulately makes the case for health reform, (“Why we need health care reform”, http://www.nytimes.com/2009/08/16/opinion/16obama.html). It includes a re-statement of his most important, and correct, point: “…what’s truly scary — truly risky — is the prospect of doing nothing.” This point is driven home by the lead editorial, “Lining up for help”, http://www.nytimes.com/2009/08/16/opinion/16sun1.html?ref=opinion , which itself is a commentary on the article from August 13, 2009, “Thousands line up for promise of free health care”, http://www.nytimes.com/2009/08/13/health/13clinic.html?ref=opinion. It describes the efforts of Remote Area Medical, “…which was formed to deliver care to Indians living in remote areas of the Amazon basin…” to deliver care to thousands of people at the Forum in Inglewood in Los Angeles. Not to Indians in the Amazon, not to refugees swarming in from abroad, but to Americans living in one of our great cities.
And Los Angeles, of course, is not alone, not by any means. Barbara Shelly writes in my local Kansas City Star (http://www.kansascity.com/277/story/1381919.html), about the story about thousands of people waiting to be seen in a traveling clinic in Wise, Virginia. She talks about the Southwest Boulevard Family Health Care clinic here in Kansas City, KS, where the medical director, my friend and colleague “Dr. Sharon Lee telephones friendly specialists and pleads with them to treat her uninsured patients with potentially life-threatening conditions.” To not recognize that such situations are not only daily occurrences all over the country, but that the number of people being affected by them grows daily, that President Obama’s assertion that the worst outcome would be to keep our current non-system , is irresponsible, wrong, and when done knowingly for political gain, evil. I addressed this in a recent blog entry, “Health Care Shoutdowns: Liars and Demagogues” (August 11, 2009), and the inflammatory lies continue even as the facts show them to be such.
“In the coming weeks, the cynics and the naysayers will continue to exploit fear and concerns for political gain,” the President writes, but they already are. Sarah Lyall of the Times reports from London (“Health Care in Britain: Expat Goes for a Checkup”, Sarah Lyall, http://www.nytimes.com/2009/08/16/weekinreview/16lyall.html?scp=1&sq=ex-pat&st=cse
on the efforts of Investor’s Business Daily to disparage the health reform movement by comparing it to the British National Health Service, and stating that famed physicist Stephen Hawking, who suffers from amyotrophic lateral sclerosis (ALS, “Lou Gehrig’s Disease”) would not be able to get care if he lived in the UK. Of course, the problem is that Dr. Hawking does live in the UK, and has issued a statement saying that the NHS has kept him alive! (You can look at the link provided by Ms. Lyall, http://www.ibdeditorials.com/IBDArticles.aspx?id=333933006516877, but you won’t find IBD’s assertion there as they have pulled it from their article.)
One of the most irritating lies to me is that of the “death panels” that are called for in the administration and congressional health reform bills. Despite the fact that no such panel was ever called for in the bill, a point explicitly made by senior Republican Senator Charles Grassley when he noted that the end-of-life discussions provision had been dropped by the negotiators because of the misinterpretation of it, the liars and demagogues continue to press the point, led by former vice-presidential candidate and now-former Alaska governor, Sarah Palin: “Palin stands by ‘death panel’ claim”, (Matthew Daly, Associated Press, http://hosted.ap.org/dynamic/stories/U/US_HEALTH_CARE_END_OF_LIFE?SITE=CACRU&SECTION=HOME&TEMPLATE=DEFAULT ). Why I am particularly irritated about this is that it misrepresents a really important health care issue, one that we all need to think about: end-of-life care. It also misrepresents how decisions on limiting access to unproven treatments would be made. I have previously addressed the latter at some length (May 12, 2009, July 5, 2009), and probably will again, but today want to talk about the former.
The legislation under consideration (specifically HR 3200) said that the plan would pay for voluntary consultation with a physician about end-of-life care. We should all be thinking about end-of-life care. If and when we are diagnosed with a terminal disease, or are in extremis at the end of our lives, what do we want done? Treatments that will cure us and have us back to playing tennis? Most of us would say “You betcha!”, but this is not what we are talking about. We are talking about interventions that are done to maintain life, in its literal sense, and are sometimes successful (for a while; no one lives forever) ranging from the seemingly benign administration of nutrition in an atypical way (fluid through a vein, or liquid through a tube in the nose into the stomach or directly into the stomach), to maintaining breathing on a ventilator when there is no hope of ever being able to come off of it, to having electroshocks and chest compressions applied when your heart stops. Contrary to the portrayal on television shows, very few such cardiac resuscitations are done on relatively healthy, relatively young people who go on to survive to live normal lives. The vast, vast majority are done on terminally ill people, most do not survive the intervention, very few survive in a meaningful way – to hospital discharge, and hardly any return to their previous state of pre-hospital function.
Nonetheless, it may be that we choose to have such interventions at the end of our lives. While many of us would choose not to, might choose palliative care (the kind of care given by hospice) where we get everything we can possibly get to keep us comfortable and pain-free but not vain attempts at treatment, many of us might not. We might choose a “Living Will” that delineates what treatments we want and what treatments we don’t want, or we might not, asking for all treatments. But we should think about it, discuss it with our families and the others whose opinions we care about, including our doctors and other health care providers. We are much better off making those kinds of decisions when we are sentient, and able, than when we are unable to speak or are disoriented or in a coma.
And all of us should have a “Durable Power of Attorney for Health Care” (DPOA-HC), even those of us who are young and healthy, because, unfortunately, accidents happen. The DPOA-HC designates a specific person to make healthcare decisions for us when we are unable to do so for ourselves. This is a particularly wise idea for two reasons. One is that, while the law in most states designates an order of relations to make decisions (beginning with the legal spouse and continuing to adult children and then to adult parents) this can be a problem. The spouse may not, him or herself, be able or willing to make decisions. The children may disagree, and there is no law that says, for example, that the oldest has precedence, or that there is a vote. So it is best to designate one person, although we all hope that all of those we care for will agree. Perhaps the person you want to make the decision is a friend, a pastor, or an unmarried life partner.
The second reason is that it requires you to think about what you would want to happen in a situation where you cannot make your own decisions and to share these thoughts and discuss them with your designee (DPOA) and with others who will be involved. The DPOA is supposed to make decisions based on their understanding of what you would want, even if it is different from what they would want, and the way they understand this is for you to discuss it with them. It is also important to note that the DPOA cannot make decisions for you when you are able to make them for yourself, that it (and the Living Will, or any other “advance directives”) can be revoked by you at any time, and that it only covers health care decisions (not, for example, financial decisions).
All hospitals currently are required to ask patients when admitted if they have advance directives. This makes sense; if you’ve made these decisions, and you’re being admitted to a hospital where you hope good things will happen but they might not, you want them to know about them. Sarah Palin, as governor of Alaska, “signed a proclamation making April 16, 2008, Healthcare Decision Day with the goal to have health care professionals and others participate in a statewide effort to provide clear and consistent information about advance directives”. Most insurance companies pay for consultations with physicians about end-of-life care. Although Medicare does not, most primary care physicians do it anyway. This is altogether a good thing.
The current effort to portray advance directives as something they are not, as something bad, as euthanasia, is not only a scurrilous tactic to oppose health reform legislation, it is a terrible, terrible attack on good health care, on something we should all want to do.
.
The Sunday New York Times, August 16, 2009, has a plethora of health-reform-related articles and opinion pieces, including an op-ed by President Obama himself (ok, signed by himself), which articulately makes the case for health reform, (“Why we need health care reform”, http://www.nytimes.com/2009/08/16/opinion/16obama.html). It includes a re-statement of his most important, and correct, point: “…what’s truly scary — truly risky — is the prospect of doing nothing.” This point is driven home by the lead editorial, “Lining up for help”, http://www.nytimes.com/2009/08/16/opinion/16sun1.html?ref=opinion , which itself is a commentary on the article from August 13, 2009, “Thousands line up for promise of free health care”, http://www.nytimes.com/2009/08/13/health/13clinic.html?ref=opinion. It describes the efforts of Remote Area Medical, “…which was formed to deliver care to Indians living in remote areas of the Amazon basin…” to deliver care to thousands of people at the Forum in Inglewood in Los Angeles. Not to Indians in the Amazon, not to refugees swarming in from abroad, but to Americans living in one of our great cities.
And Los Angeles, of course, is not alone, not by any means. Barbara Shelly writes in my local Kansas City Star (http://www.kansascity.com/277/story/1381919.html), about the story about thousands of people waiting to be seen in a traveling clinic in Wise, Virginia. She talks about the Southwest Boulevard Family Health Care clinic here in Kansas City, KS, where the medical director, my friend and colleague “Dr. Sharon Lee telephones friendly specialists and pleads with them to treat her uninsured patients with potentially life-threatening conditions.” To not recognize that such situations are not only daily occurrences all over the country, but that the number of people being affected by them grows daily, that President Obama’s assertion that the worst outcome would be to keep our current non-system , is irresponsible, wrong, and when done knowingly for political gain, evil. I addressed this in a recent blog entry, “Health Care Shoutdowns: Liars and Demagogues” (August 11, 2009), and the inflammatory lies continue even as the facts show them to be such.
“In the coming weeks, the cynics and the naysayers will continue to exploit fear and concerns for political gain,” the President writes, but they already are. Sarah Lyall of the Times reports from London (“Health Care in Britain: Expat Goes for a Checkup”, Sarah Lyall, http://www.nytimes.com/2009/08/16/weekinreview/16lyall.html?scp=1&sq=ex-pat&st=cse
on the efforts of Investor’s Business Daily to disparage the health reform movement by comparing it to the British National Health Service, and stating that famed physicist Stephen Hawking, who suffers from amyotrophic lateral sclerosis (ALS, “Lou Gehrig’s Disease”) would not be able to get care if he lived in the UK. Of course, the problem is that Dr. Hawking does live in the UK, and has issued a statement saying that the NHS has kept him alive! (You can look at the link provided by Ms. Lyall, http://www.ibdeditorials.com/IBDArticles.aspx?id=333933006516877, but you won’t find IBD’s assertion there as they have pulled it from their article.)
One of the most irritating lies to me is that of the “death panels” that are called for in the administration and congressional health reform bills. Despite the fact that no such panel was ever called for in the bill, a point explicitly made by senior Republican Senator Charles Grassley when he noted that the end-of-life discussions provision had been dropped by the negotiators because of the misinterpretation of it, the liars and demagogues continue to press the point, led by former vice-presidential candidate and now-former Alaska governor, Sarah Palin: “Palin stands by ‘death panel’ claim”, (Matthew Daly, Associated Press, http://hosted.ap.org/dynamic/stories/U/US_HEALTH_CARE_END_OF_LIFE?SITE=CACRU&SECTION=HOME&TEMPLATE=DEFAULT ). Why I am particularly irritated about this is that it misrepresents a really important health care issue, one that we all need to think about: end-of-life care. It also misrepresents how decisions on limiting access to unproven treatments would be made. I have previously addressed the latter at some length (May 12, 2009, July 5, 2009), and probably will again, but today want to talk about the former.
The legislation under consideration (specifically HR 3200) said that the plan would pay for voluntary consultation with a physician about end-of-life care. We should all be thinking about end-of-life care. If and when we are diagnosed with a terminal disease, or are in extremis at the end of our lives, what do we want done? Treatments that will cure us and have us back to playing tennis? Most of us would say “You betcha!”, but this is not what we are talking about. We are talking about interventions that are done to maintain life, in its literal sense, and are sometimes successful (for a while; no one lives forever) ranging from the seemingly benign administration of nutrition in an atypical way (fluid through a vein, or liquid through a tube in the nose into the stomach or directly into the stomach), to maintaining breathing on a ventilator when there is no hope of ever being able to come off of it, to having electroshocks and chest compressions applied when your heart stops. Contrary to the portrayal on television shows, very few such cardiac resuscitations are done on relatively healthy, relatively young people who go on to survive to live normal lives. The vast, vast majority are done on terminally ill people, most do not survive the intervention, very few survive in a meaningful way – to hospital discharge, and hardly any return to their previous state of pre-hospital function.
Nonetheless, it may be that we choose to have such interventions at the end of our lives. While many of us would choose not to, might choose palliative care (the kind of care given by hospice) where we get everything we can possibly get to keep us comfortable and pain-free but not vain attempts at treatment, many of us might not. We might choose a “Living Will” that delineates what treatments we want and what treatments we don’t want, or we might not, asking for all treatments. But we should think about it, discuss it with our families and the others whose opinions we care about, including our doctors and other health care providers. We are much better off making those kinds of decisions when we are sentient, and able, than when we are unable to speak or are disoriented or in a coma.
And all of us should have a “Durable Power of Attorney for Health Care” (DPOA-HC), even those of us who are young and healthy, because, unfortunately, accidents happen. The DPOA-HC designates a specific person to make healthcare decisions for us when we are unable to do so for ourselves. This is a particularly wise idea for two reasons. One is that, while the law in most states designates an order of relations to make decisions (beginning with the legal spouse and continuing to adult children and then to adult parents) this can be a problem. The spouse may not, him or herself, be able or willing to make decisions. The children may disagree, and there is no law that says, for example, that the oldest has precedence, or that there is a vote. So it is best to designate one person, although we all hope that all of those we care for will agree. Perhaps the person you want to make the decision is a friend, a pastor, or an unmarried life partner.
The second reason is that it requires you to think about what you would want to happen in a situation where you cannot make your own decisions and to share these thoughts and discuss them with your designee (DPOA) and with others who will be involved. The DPOA is supposed to make decisions based on their understanding of what you would want, even if it is different from what they would want, and the way they understand this is for you to discuss it with them. It is also important to note that the DPOA cannot make decisions for you when you are able to make them for yourself, that it (and the Living Will, or any other “advance directives”) can be revoked by you at any time, and that it only covers health care decisions (not, for example, financial decisions).
All hospitals currently are required to ask patients when admitted if they have advance directives. This makes sense; if you’ve made these decisions, and you’re being admitted to a hospital where you hope good things will happen but they might not, you want them to know about them. Sarah Palin, as governor of Alaska, “signed a proclamation making April 16, 2008, Healthcare Decision Day with the goal to have health care professionals and others participate in a statewide effort to provide clear and consistent information about advance directives”. Most insurance companies pay for consultations with physicians about end-of-life care. Although Medicare does not, most primary care physicians do it anyway. This is altogether a good thing.
The current effort to portray advance directives as something they are not, as something bad, as euthanasia, is not only a scurrilous tactic to oppose health reform legislation, it is a terrible, terrible attack on good health care, on something we should all want to do.
.
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