Sunday, August 2, 2015

Medicare and Medicaid at 50: Time to include “US” all

On Thursday, July 30, Medicare and Medicaid turned 50 years old. The anniversary was marked by an event held at the Truman Library in Independence, MO, which I attended. Why there? In 1965, President Lyndon Johnson signed those bills (officially Titles XVIII and XIX of the Social Security Act) there, in the presence of former President Truman and his wife Bess, who received cards #1 and #2. The location was chosen for its symbolism even in 1965, because Truman had fought for a national health insurance system and lost. Nearly 20 years later, Johnson honored his legacy by signing these two major bills (also opposed by the AMA) in his library. Both presidents thought that this was a down-payment on the national health insurance system that was sure to come soon. But it took another 45 years to pass the Affordable Care Act (ACA), and we still don’t have universal health insurance, and ACA and even Medicare are under constant attack. At least now it is not the AMA that is the active opposition.

This event was not the first held at the Truman Library to remember that day. Seven years ago, a group of single-payer activists organized a 43rd anniversary celebration there, both to commemorate the signing and to call for a universal health insurance system. That event was less “official” but more passionate, with talks by both local KC Congressman Emanuel Cleaver II and Rep. John Conyers of Michigan. Rep. Conyers’ first year in Congress was 1965, the year Medicare and Medicaid passed, and all those years later he was still vital and still in Congress and was the sponsor of HR 676, the national single payer bill. This year’s event had more of the feel of an administration press conference with several federal and Missouri bureaucrats speaking. Some of talks, including those by Truman’s grandson Clifton Truman Daniel and former Missouri state rep and insurance commissioner Scott Lakin, were good, but only one had any real passion. That was given by Bridget McCandless, MD, the CEO of the Health Care Foundation of Greater Kansas City (HCFGKC), which sponsored the event.

There is a reason for that. Before taking the reins of HCF, a “conversion” foundation established with the money that came from the sale of a group of not-for-profit hospitals to for-profit HCA, Dr. McCandless, a self-described “Independence girl”, was the medical director of the Jackson County Free Health Clinic in Independence, caring for the many people in that area who could not otherwise access excellent health service. She cared for people who had little, whose lives, in Dr. Camara Jones’ metaphor (most recently discussed in Racism and the Social Determinants of Equity: Camara Jones at Beyond Flexner 2015, April 19, 2015), were lived on the edge of the cliff before they even got sick. Dr. McCandless’ clinic provided a safety net that prevented many people from falling to the ground below. The “lucky” ones were those who were old enough (or disabled enough) to qualify for Medicare, and poor-plus-something enough to qualify for Medicaid. For those people, these federal programs, which now cover about 30% of Americans were indeed life savers.

Dr. McCandless, whose foundation is committed to funding programs that help the underserved and uninsured (the exceptional founding CEO, Steve Roling, was in the audience), talked, as did other speakers, about the difference that Medicare had made in the lives of seniors; before it they (and their families) lived their retirement years in financial fear of sickness. But her passion really showed when talking about Medicaid, originally seen as a means of providing access to health care for the poor. You certainly have to be poor to receive Medicaid, very poor in many states including Missouri, but that is not sufficient. She told us that you have to be “poor and”. Poor and pregnant, poor and the mother of small children, poor and disabled, poor and in a nursing home, poor and – and the tears rolled down her cheeks – a child. ACA was intended to expand this federal-state collaboration to encompass all the “just” poor (with the exception of those who are undocumented), but Missouri, and Kansas, the other state in the Kansas City metropolitan area, are among the states that have not done so.  Dr. McCandless eloquently expressed her hope that our states would rise to the need, that our legislators and leaders would rise to the decency, to remove the “and” by expanding Medicaid.

While it is possible that Missouri, and Kansas, and the other states that have taken advantage of the 2012 Supreme Court decision (National Federation of Independent Business v. Sebelius), that otherwise upheld the ACA, to not expand Medicaid will still do so, it is unconscionable that they have not yet, that they have left so many people who could now be accessing health care uncovered. It is a land-office business for the safety net clinics in the area, like Dr. McCandless’ former practice, but it is a volume that they can barely care for. When people get very sick, and show up in the Emergency Department and get admitted to the hospital, those hospitals bear the brunt of care without payment, but even their usually powerful lobbies have so far not been successful.

The opposition to this expansion, the opposition to ACA, and even threats to Medicare are often said to be politically driven, but they are ideologically driven. They are driven by the agendas of billionaire elitists, most of whom have never known any hardship. They have been able to further expand their already-considerable influence as a result of the Supreme Court’s Citizens United decision, and blithely fund the election of their minions to state houses and legislatures.  The New York Times on Aug 2, 2015 documents that fewer than 400 families have contributed the almost have the money in this election cycleFormer Oklahoma football coach Barry Switzer once said that many of the privileged were “born on third base and think they’ve hit a triple” (although most of these billionaires were actually born within arm’s length of home plate!). Indeed, they have no empathy; they are selfish and mean. Their minions, who enjoy the power their sponsors’ money provides for them, must be (if they are not truly stupid) also mean, but actually are not fiscally prudent; not funding health care for our people costs us a lot. Medicare already covers our most costly ill (they are old; this is why raising the age for Medicare eligibility to 67 or 68 will save little money). It is way past time for it to cover the rest of us.

Rep Jim McDermott of Washington, a physician and long-time single-payer advocate, has introduced the American Health Security Act of 2015, which will authorize and provide federal funds to support single-payer programs developed by states. It should be passed, but it probably won’t be while we have a Congress bought and paid for by the rich mean selfish people. We have had single-payer bills in Congress before, Rep. Conyers’ and before that Rep. Ron Dellums’. It is time to pass them. We need to go beyond the ACA, we need to make sure states expand Medicaid and take the “and” out of the “poor and” for eligibility. But we need to go farther.


For 50 years Medicare has been literally a life-saver for our seniors. Now we need to expand it to include everyone. Everybody in, nobody out!

Sunday, July 26, 2015

Chemotherapy, Quality of Life, and Corporate Profit

“In reality, only 2 major reasons exist for administering chemotherapy to most patients with metastatic cancer: to help them live longer and/or to help them live better.”

So begins “Chemotherapy Near the End of Life: First—and Third and Fourth (Line)—Do No Harm”[1], an editorial by Charles D. Blanke and Erik K. Fromme in JAMA Oncology commenting on an important new study in the same issue by Prigerson and colleagues, Chemotherapy Use, Performance Status, and Quality of Life at the End of Life”.[2]  The study, a fairly large randomized controlled trial, discovered that giving last-ditch chemotherapy for “solid tumors” in patients estimated to have less than 6 months to live did neither. Not only was survival time not increased (although the editorialists note that this study was not designed to look at survival), but quality of life (QOL) was not improved. Indeed, and incredibly important, the group that had the best quality of life before receiving this final round of chemotherapy had the greatest drop in QOL, ending up pretty much as bad as the rest of the group. Blanke and Fromme observe that that this may be because they had “further to fall”. This is likely true, but surely the goal is not to give “treatment” that facilitates that fall.

So why do we do it? Were “we”, doctors especially, ignorant of this? Certainly the strength of the results – especially the fact that those whose pre-treatment QOL was the best were those who were most harmed – was a surprise in that it had never been published before, but that “palliative” chemotherapy at the end of life, intended entirely to improve QOL, often does the opposite – is something that every doctor who cares for patients with cancer, including but not limited to oncologists, has seen. Many of us, including many palliative care specialists, usually recommend against such treatment to patients and their families, often to have our voices drowned out by the encouragement from others (particularly some oncologists).

The truth is that the answer, as with so many things involving people, is complex. People do not usually want to die, and frequently grasp at any straw offered to them. Even when they themselves are not sure that they wish to go on, even when their disease makes them unable to make a decision, their family members often take on the role of demanding more treatment. This rarely if ever comes from a desire to cause more suffering for a loved one, but rather hoping that a miracle will occur. When this is encouraged by the physician who offers some sort of hope it is more likely to happen. The distinction between the outcomes of palliation and longer life is not always clear to patients or their families, and indeed “improvement” and “longer life” may mean different things to the doctor saying it (tumor gets smaller, life expectancy extended by weeks) and those hearing it.

The results of this study showing the decrease in QOL for those who were “best off” prior to treatment should be sobering and decrease the use of end-of-life chemotherapy, but there continue to be critics of the work. Some oncologists, typified by the one quoted by Pam Belluck in the New York Times article on the study (“Benefit of End-Stage Chemotherapy Is Questioned”, July 23, 2015) who “noted that patients were seen between 2002 and 2008, before some newer chemotherapy drugs with fewer side effects or the ability to directly target certain tumors or cancer-causing mutations,” still hold out hope. He may be right, but, of course, all studies are done in the past, and the “things are better now than then” refrain is almost always the one we hear from people unhappy with the results; in all probability, things, for end-of-life cancer patients, are not really better now.

The one clearly unacceptable reason for doing such therapy is the financial benefit to the manufacturers of these chemotherapeutic agents, but also to a lesser degree the providers – mainly the hospitals but also sometimes the doctors – who administer them. This is a major consideration, not generally addressed in the articles about this study. “Costs aside,” Blanke and Fromme write, “we feel the last 6 months of life are not best spent in an oncology treatment unit or at home suffering the toxic effects of largely ineffectual therapies for the majority of patients.” The costs that they are holding aside are the costs of the drugs, the implication is that it is the cost to the patient (or their insurer), a negative to be weighed against the potential benefit (or not) of the therapy. In this sense, it is one item on the scale. But the cost to the patient or insurer is the source of enormous profits to the pharmaceutical companies that make these incredibly expensive drugs, and they are heavily marketed to physicians by those multi-billion-dollar corporations. Their marketing campaigns push the slightest, least-convincingly-demonstrated-by-research potential benefits, and almost never talk (audibly) about the possible, probable, likely negative effects of treatment. 

While these companies are the greatest financial beneficiaries, so are the hospitals and cancer centers that administer them. The reason that there are so many cancer centers is only in part because cancer is a bad disease; it is largely because it is a very profitable disease to treat because the markup paid by insurers (led by Medicare) for administering chemotherapy is very high. Doctors (particularly oncologists) benefit most directly when they are owners of such cancer centers, but to a lesser degree when they receive high salaries from their employer that are made possible by the huge profits on cancer treatment.

It is an ugly thought that your receiving cancer drugs may be in large part because the manufacturers stand to make a lot of money from it, but there it is. And it is not just cancer treatment; a recent article in the Business section of the NY Times from July 24, 2015 by Andrew Pollack, “New Drug Sharply Lowers Cholesterol, but It’s Costly”,  describes the introduction of a new “recombinant DNA” drug called alirocumab (Praluent) that dramatically lowers cholesterol levels, but will cost $14,600 a year! This may be a wonder drug for the relatively small number of people who have familial hypercholesterolemia, but the indications will unquestionably be pushed by physicians with encouragement from the manufacturer. Every time there is the least evidence that a drug, initially intended for the most severely affected patient, can be used for a larger group, there is more potential for enormous profit.  The evidence that just lowering cholesterol as much as can be done is linearly linked to reducing heart attack and stroke is limited. “’This is treating a lab value,’ said Dr. Rita Redberg, a cardiologist at the University of California, San Francisco, referring to lowering cholesterol for its own sake. ‘I don’t think we should rush into it.’

“’We came to a price that is reflective of value, not what the market will bear,’ said Elias Zerhouni, head of research and development at Sanofi [one of the two companies that make alirocumab], who said his own brother had suffered three heart attacks and needed new options to control cholesterol.” I am sorry about his brother, but if you believe that, I’ve got a bridge to sell you. It is absolutely about the price that the market will bear. The sad part is that there may be some who are more willing to believe this because Dr. Zerhouni used to be the head of the National Institutes of Health (NIH), a higher-profile but undoubtedly less well-paid position. Revolving door, anyone?

Alirocumab is likely to be beneficial to some patients but will undoubtedly be used in many more and is unconscionably priced. It’s fine for a company to make profit on its drugs, but predatory pricing and rapacious profit is not. Most disturbing is the thought that people who do not need and will not benefit from a drug, and may even be harmed by it, may receive it mainly so these companies can profit.

The line I quote from Blanke and Fromme at the start of this piece refers to chemotherapy for metastatic cancer, but in fact can be applied far more generally: 

In reality, only 2 reasons exist for administering therapy to patients: to help them live longer and/or to help them live better.

Let’s keep that, and not corporate profit, as our touchstone.









[1] Blanke CD, Fromme EK, “Chemotherapy Near the End of Life: First—and Third and Fourth (Line)—Do No Harm”, JAMA Oncology, published online 7/23/15, doi: 10.1001/jamaoncol.2015.2379
[2] Prigerson HG, et al., “Chemotherapy Use, Performance Status, and Quality of Life at the End of Life”, JAMA Oncol. Published online July 23, 2015. doi:10.1001/jamaoncol.2015.2378

Sunday, July 19, 2015

Tax policy, drug companies and the public's health


Tax policy is complicated. You have to figure out who to tax and how much, and how much revenue it will bring in and what you (the government) needs to spend the money on and figure out how to match it up. People of different political stripes differ with regard to how much money to spend on what, and also who to tax. For example, is it better to have more graduated income tax (a “progressive” tax, where the more you make the higher percent you pay on the incremental amount), or more “regressive” tax where everyone, regardless of income pays the same amount, like a sales tax, or a “proportional tax” where everyone pays the same percent but not the same amount, like some variations of “flat tax”?

In Kansas, for example, our Governor and Legislature have made that decision. Faced with enormous budget deficits as a result of 2012 massive tax cuts on corporations and wealthy individuals, and unable to make it all up with one-time fixes such as raiding the state highway fund (hope those corporations don’t need to transport goods on our roads), they have gone for big sales tax increases. This is because, to them, the 2012 tax cuts are sacrosanct, because they believe that this will stimulate the economy and create jobs. They believe this even though such a strategy has not worked so far in Kansas and has in fact not worked anywhere. They even brought in Arthur Laffer, the trickle-down guru economist, to address the legislature. Nonetheless, owners of “S” corporations (usually small businesses, like lawyer’s offices, or the few remaining private practice doctors’ offices) do not pay state tax on the income they make from being the owners. Their employees -- nurses and secretaries and legal assistants – do, along with the new higher sales taxes. The Governor and Legistlature have other plans as well; faced by a State Supreme Court decision to increase public school funding by a half-billion dollars or so that they don’t have (vide supra), they are thinking about not funding the State Supreme Court. Could be a solution, if they can get around the constitutional issue.

The Federal Government also has to deal with such issues. In the last 50 years our income tax policy has become less progressive, with a top rate of 35% rather than 90% when I was taking civics in junior high school. (Please note that this is not a flat tax of 90% on all of top-earners’ income, but on the marginal amount above the next lower tax rate; everyone paid the same percent on earnings up to each next bracket.) Also in that civics class, we saw that corporate income tax made up more income for the feds than personal tax. Not any more. Corporations are getting away with paying very low taxes, and with the new “global economy” taking more and more of their profits abroad, where they can avoid paying tax until they are re-patriated. To encourage them to do so, the Congress is considering legislation to create a “tax holiday”; this is where corporations are rewarded for bringing their profits home by paying a lower tax rate on them. This has been done before, and been amazingly unsuccessful. So let’s try it again. Like Kansas, why learn from experience? Why not, for example, tax those international earnings? After all, if they are creating jobs, it is not in the US.

Also like Kansas, the US has a problem with roads and other infrastructure, and the Federal Government funds much of the cost of repairs, which are unfortunately not being done. A study by the Center for Effective Government, “Burning our Bridges” notes that “To modernize our infrastructure, the American Society of Civil Engineers estimated it would cost $3.6 trillion by 2020. They warned that if we fail to make these investments, American citizens and businesses will face costs of $1.8 trillion a year in travel delays, water leaks, and power failures.” How has Congress responded? It's slashed infrastructure spending to the lowest levels since the post-WWII era.
 
 But where could we get the money? Is the amount of money not being paid by US corporations on international earnings that big? Well, there is $2.1 trillion in untaxed international income, so that could be a chunk of change. About half of it is held by 26 corporations. Apple has the most, and GE is #2. The enormously profitable pharmaceutical industry (I have previously noted that it is, each year, either #1 or, well, #1 in profit among US industries) has about $82 billion among its 7 largest companies. Given that the report is called “Burning our Bridges”, it is of interest to note that this is enough money to pay for all US bridge repair and maintenance needs.

I guess this is where the public health and medical part of this post comes in. Let’s just think about that. We have drug companies charging “whatever the market will bear” for their products; for some of the recent recombinant DNA treatments for autoimmune diseases, Hepatitis C, and cancer this can range into 5 digits (before the decimal point) a month. They try every trick in the book to keep their prices high and patents in place to prevent generic competition. Some I have addressed before include changing the formulation of the drug -- the FDA mandated elimination of fluorocarbons as propellants in inhalers was a bonanza because changing to non-fluorocarbon propellants was a “new formulation” allowing them to extend their patents. Or taking drugs used by, but not previously tested and approved for use by, children and testing them (when already, via practice, shown to be safe) in children, also extending their patents. Or in some the most offensive practices, testing drugs that have been used for generations and patenting them, thus jacking up their prices. The prime example is the gout treatment colchicine, formerly available for about 10 cents a pill and now available for $355 for 60 (about $5.20 a pill!).

In Canada, there are price controls on drugs, so they cost less. Thus pharmaceutical manufacturers try to block import (and Internet sale) of drugs from Canada. The Medicare drug benefit, (Part D) passed in the GW Bush administration, forbid Medicare from using its purchasing clout to negotiate lower prices. The new Trans-Pacific Partnership (TPP) pushed through by the Obama administration will offer more protections; corporations will be able to sue governments to ensure their profits, not in real courts but in specialized TPP pro-business “courts”. I wonder how long the price restrictions on drugs in Canada and elsewhere, not to mention the manufacture of affordable generic equivalents of high-priced HIV drugs in Brazil, India, and Thailand, will continue?

I personally am rooting for the success of the Brownback tax cuts to create jobs in Kansas. Not because I think they were good or even close to moral, or even because I think that they have a prayer of being successful, but as long as they are in place it would be nice to see some new jobs. It’s not going to happen with this state government. TPP passed, and there is no meaningful effort to either tax the international profits of pharmaceutical and other corporations, or to force drug manufacturers to make their products affordable in the US.

In their recent paper “Fantasy paradigms of health inequalities: Utopian thinking?”, Alex Scott-Samuel and Kathleen Smith note that "In a capitalist society, where liberal macroeconomic policies position virtually all economic activity – including unhealthy activity – as beneficial, there is an inbuilt incentive to ‘blame the victim’ rather than to tackle the corporate and economic causes of the problem."[1] We prefer not to regulate unhealthy activity (when we have done so, such as with making cars safer and limiting smoking, it took intensive, long-term campaigns by public health advocates), and we allow corporations such as drug companies to profiteer from our trying to repair the damage to our health. And we also let them not pay taxes, which we really need.

It's time to get serious, and hold them responsible and make them responsive.





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

Sunday, July 12, 2015

Prostate Screening and the Public’s Health


For the first time in several years, I am writing about prostate cancer screening. I had hoped that this was sufficiently covered in 2009, with PSA Screening: What is the value? (March 21) and the excellent guest piece by Robert Ferrer, PSA Screening: “One of Medicine's Great Success Stories"? (October 27), and finally a bit of celebration in 2011 with PSA redux: The USPSTF finally recommends NOT getting it! (October 14). However, like the proverbial bad penny (or to use a more au courant analogy, zombie), this issue continues to return from the dead. The most recent effort is “Bring Back Prostate Screening”, a NY Times op-ed piece by Deepak A. Kapoor on July 6, 2015.

What Dr. Kapoor is suggesting is obvious from the title, but the question is “is there some new information, some new research, that now makes such screening more reasonable or appropriate?" The answer, unfortunately (because it makes more work for the zombie hunters) is “no”. Dr. Kapoor suggests that there is. He notes research is this field is “... now paying off.” He says that the decision to recommend against prostate screening by the US Preventive Services Task Force “…didn’t take into account adaptations that urologists have made to help better identify patients likely to develop deadly prostate cancers.” He cites the increased sensitivity of PSA screening, the individualization of it to the risks of different men, and the use of PSA trajectory (its rate of increase, or not), as well as new methods of assessing cancer like MRI. However, his assertion is incorrect; all of this information was available to the USPSTF when it made its recommendations, and was taken into account. It is not new.

“At the time,” Dr. Kapoor notes, “I and many other urologists warned of public health repercussions. Our fears have materialized. Since 2010, fewer biopsies have been performed and fewer prostate cancers found. But studies show an increase in the risk that a cancer, when found, will be more aggressive.” This sounds scary, but it is to be expected; when you stop screening everyone you won’t find the cancers early. A big part of recommending against PSA screening was that so many of the cancers it identified were indolent and not going anywhere; the aggressive cancers will be the ones that eventually show up. Indeed, he actually acknowledges that “No increase in cancer mortality has been observed,” but continues to raise the alarm with “…that may be a matter of time; aggressive cancers are less treatable.” So maybe we should be scared.

Well, in fact all prostate cancer is treatable. All cancer is; in fact all conditions are. The question is how effective is the treatment? Does it cure? Does it prolong life? Does it improve the quality of remaining life? This is the area that Dr. Kapoor and his colleagues do not address, because, for prostate cancer, the answer is basically no. If you have the more common kind of prostate cancer, it is slow-growing (indolent) and may even disappear itself; you will die with it, rather than from it. If you have the less-common aggressive form, you may well die from it, and unpleasantly; prostate cancer metastases go to bone and cause a lot of pain. Sadly, however, treatment does not seem to impact this. The “cures” from treatment of prostate cancer are of the ones that would have “cured” themselves, or at least not have manifested with symptoms. The mortality from aggressive deadly cancers is not changed by treatment. This is the critical point that discussions of the sensitivity and specificity of PSA or any other kind of screening often ignores. Not only can they not reliably distinguish between the indolent and aggressive types of cancer well, even if they could and we had a test to reliably tell which one you had, it is only of importance if treatment can make a difference. And in terms of mortality, it doesn’t. What about the other results from treatment? Improved quality of life? Well, here even Dr. Kapoor notes that “cancer treatment can reduce quality of life.” If you consider impotence, urinary incontinence, and the many unpleasant and painful effects of radiation on the rectum to lower quality of life, you betcha.

We can dismiss Dr. Kapoor’s comments by saying he is a urologist, and they make their money treating prostate cancer; can you imagine the impact on their income if we didn’t treat it? But this misses the far bigger issue, which is that we are enamored with – and, more important, spend huge amounts of money on-- high-technology interventions rather than the prosaic, low-tech interventions that have actually been demonstrated to improve the public’s health. Screening for prostate cancer, and overuse and reliance on mammographic screening for breast cancer, are huge industries which (even in breast cancer) have had relatively little impact on mortality. Providing good prenatal care and preventing unwanted pregnancy, ensuring treatment of common diseases like hypertension and diabetes, ensuring that children are not only immunized against infectious disease but are well-fed, well-housed, and well-educated, and free from poisoning by environmental toxins (including bullets) – the basic components of public health and primary care -- may seem less sexy and stimulate our collective psyches less, but they are the things that actually increase population health.

One of the newer fascinations is genomics, the identification of each person’s sequence of DNA. The promise of “precision medicine” is that we will find out who has the risk gene for which disease, and treat it directly and appropriately; treatment for cancer will be based on the genes you have just as treatment for bacterial infections is based on the organism identified by culturing it in a microbiology laboratory. It is so exciting! It is so “sci-fi today”! The American Board of Family Medicine, for example, is planning to create a new self-assessment module (“SAM”, tests that family doctors have to complete one of each year to maintain their Board certification) on genomics. On the other hand, it doesn’t think we need one on contraception, which is too small an area (isn’t it just part of “women’s health”? Oh, do men have a role in contraception also?), unlike genomics, which could affect EVERYTHING!

Except, so far, it hasn’t and there is little evidence to suggest that it will anytime soon. I wrote a blog on the topic on February 1, 2015 (“Precision medicine, trade policy and the cost of drugs: benefiting people or profit for business?) after the appearance of a Times op-ed by Mayo Clinic cancer expert Michael Joyner (“’Moonshot’ medicine will let us down”, January 15, 2015); Dr. Joyner has more recently contributed more comprehensive articles on the topic to JAMA (“Seven questions for personalized medicine[1]) and The Lancet (“Is precision medicine the route to a healthy world?”[2]) in which he makes the important point that most disease is not the result of a single gene, but rather the result of a complex interplay of different genes and the environment. Indeed, the only cancer-specific genes that have been identified so far are the breast cancer genes BRCA1 and BRCA2, and no treatment has emerged; we simply say “get mammograms more often and consider prophylactic mastectomy”.

Spending all this money on precision medicine, on high-tech interventions, expensive drugs and devices is like blowing your house budget on art for the walls before you have built it. Some art is great, some is mediocre, and some is poor, but none will hang well on a jerry-rigged house made poorly of shoddy materials because there was no money left. Some high-tech, expensive interventions are worthwhile but what we really need to increase the population’s health is public health nurses making home visits to pregnant and recently delivered women, and their children; public health nurses or community health workers or even doctors making visits to people’s homes to assess the real risk factors to their health and reasons that they might not be able to comply with treatment plans. We need more primary care, not more interventionalists. But most important, we need to apply what we know works, what we know how to do, to everyone.

That is how we move the needle on population health.





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

Sunday, June 28, 2015

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

In the context of the historic and momentous Supreme Court decision legalizing gay marriage across the US, and its affirmation of the Fair Housing Act, the third of the “trifecta” of progressive decisions announced this week, the ruling against those who argued that the ACA forbid federal financial support of federally-sponsored rather than state-sponsored insurance exchanges, seems rather pedestrian. After all, it just decided that the intent of the ACA was to achieve what its intent was – greater insurance coverage for the American people – and this would not be invalidated by 4 poorly-chosen words in a 1,000 page bill. What is more worthy of note is that there were three Supreme Court Justices who voted against it, when it was clearly not a real issue of law but an end-run to get it invalidated on a technicality. The low point of the dissent was Justice Scalia’s juvenile characterization of the majority decision as “jiggery-pokery”, an archaic expression most recently used in the public domain in a Harry Potter movie. Of course, Scalia could make a fair Harry Potter villain; not the potent evil of Lord Voldemort, but more of a scowling, snarling Severus Snape.

But the decision has real meaning. It means that millions of Americans in the 34 states that elected to not establish state-based exchanges and thus depend upon federal ones will not lose their health insurance. That is a good thing for those people, and it is a good thing for America. It does nothing for those people who were excluded by the SCOTUS decision 3 years ago (also written by Chief Justice Roberts) that, while validating ACA, precluded requiring states to expand Medicaid. This left millions more in the states that have not done so (like mine, Kansas) without insurance.  It certainly does nothing for the millions of those without legal documentation who live here, or the many others who fall between the cracks of the law. It still leaves us without the moral, medical, social, and economic advantages that come from a truly universal health system such as any of those adopted by every other wealthy nation, which achieve better health for less cost (see graphic). But it does make us seem slightly less cruel and benighted.

Not that this will end the discussion. A small article in the New York Times of June 27, 2015 notes that “Legal challenges remain for health law”.  These include a lawsuit by House Republicans led by Speaker John Boehner maintaining ACA is invalid because it spends money not appropriated by Congress, and a series of suits by religious organizations about the law’s requirement that they cover contraception. Indeed, the whole opposition to the law has becoming akin to a religion itself; according to its opponents (obviously also including all the Republican candidates for President) it is bad as a matter of faith, even though it does so much good. Yes, it does good in costly ways, ensuring that insurance companies make their profit; it does it in arcane ways; it does it in ways which in fact cost some people more than they might have otherwise paid. But it provides several million people the opportunity to not be the Donna Atkins or Tommy Davis of the future (see Dead Man Walking: People still die from lack of health insurance, November 17, 2013).

In response to a blog in which I posted a map that shows that the vast majority of those remaining uninsured are in the states of the former Confederacy and suggested that while Southern people might not be meaner than others, the impact of their policies was (Medicaid expansion and uncovered lives: are people meaner in the South?, February 8, 2015), Bobby Cohen wrote in a comment “If meanness doesn't explain the rejection of Medicaid expansion by Southern states, what does?” Well, for many people, I suppose, it is ignorance, of the sort demonstrated by “Keep the government’s hands off my Medicare!” or what I have called the “Craig T. Nelson fallacy” (“I've been on food stamps and welfare. Anybody help me out? No. No.”!!). Or the beliefs of some of the people in southeast Kansas interviewed for Kai Wright’s excellent article “Life and Death in Brownback’s Kansas”, published in the June 22/29 issue of The Nation where it seems that “Everyone is convinced that someone else is getting a better deal, that somewhere a horde of Kansans are gaming the system and preventing the truly needy from getting help.” In a true “What’s the Matter with Kansas”[1] illustration, even the doctor at the community health clinic who is fighting hard to get care for her impoverished patients who would have otherwise had Medicaid is conflicted; Brownback, after all, is a strong anti-abortion advocate, as is she.

All of these may explain some of the position of the leaders of this movement, but a better explanation can be found in the answer to one of the questions in “Steven Pinker’s Mind Games”, a psychology quiz on the NY Times website: “the best liar is the one who believes his own lies”. But it is hard to look at, not to mention listen to or read, the hard-core right-wing justices on the Supreme Court (who, unlike the GOP’s many presidential candidates are not even running for office) without thinking that they are, essentially, mean. They are not only against helping people when it will cost them, not altruists (another Pinker question), but even when it will save them money (again, see graphic).

I do not claim to be a legal scholar of the status of any of the Supreme Court Justices, or indeed the President. I gained some understanding from “The elusive right to health care under US law”, by Prah Ruger, Ruger, and Annas in the June 25, 2015 issue of the New England Journal of Medicine, published before any of these SCOTUS decisions were announced.[2] It’s a good and readable article which helps medical people like me understand some of the logic of court decisions. One line I found of particular interest was “American constitutionalism has championed negative liberties more than positive rights.” The idea is that the Constitution says government should not be allowed to take away our individual liberties (e.g., our guns) but not so much that we have a right to things (e.g., health care).

And yet, as pointed out by Gail Collins in “Supremes hit a high note”, this Court has “…destroyed the nation’s campaign finance laws, limited workers’ rights to challenge wage discrimination and women’s rights to control their bodies. And basically disemboweled a 50-year-old Voting Rights Act that Congress had renewed by increasingly large margins on four different occasions.” These decisions, almost all of which came out differently from those of the last 2 days only by the “swing vote” of Justice Kennedy (Chief Justice Roberts did join the majority in the decision on ACA), do not always follow this logic. It is quite an extension of the idea of liberty to say that corporations are people (the founders certainly didn’t think so) or money is speech. It is quite opposite protecting individual liberty to have laws limiting the ability of women to obtain contraception or abortion (although they can sure have guns!). Whether put forward by ignorant bigots, self-serving politicians, or sanctimonious Supreme Court Justices, the concept is most consistently “people should be allowed to do whatever they want, as long as they want the same things I do, but not what I disapprove of”. Sometimes, particularly when describing the actions of the powerful, this is described as political. But I think Dr. Cohen is right; it is essentially mean.

A phrase we commonly hear is that “mean people suck”. They do, but more important, when they have positions of power, they can do a lot of damage to others.
  





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

Sunday, June 21, 2015

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

The title of the press release from the World Bank, “New WHO and World Bank Group Report Shows that 400 Million Do Not Have Access to Essential Health Services and 6% of Population Tipped into or Pushed Further into Extreme Poverty because of Health Spending”, about says it all. Or does it? Certainly, it summarizes the core information provided by that study, and that is pretty bad. Even in a world whose population this year reached 7 billion that is a big number (nearly 6%), and remember that it is talking about “…essential health services—including family planning, antenatal care, skilled birth attendance, child immunization, antiretroviral therapy, tuberculosis treatment, and access to clean water and sanitation.” This is not coronary artery bypass surgery (as essential as that seems to those of us who need it), or knee replacement (which may make it possible for us to walk with less pain), or even tight control of our diabetes (possibly less prevalent in populations that are chronically malnourished), still less entirely elective care.

We are talking about access to clean water and sanitation. We are talking about the fact that the greatest cause of death in the world is water and that most of those deaths are in children. We are talking about the absence of the most fundamental aspects of access to health, not to mention health care and medical care.  While not a focus of the World Bank report, in many places war makes it worse, adding to the lack of basic services an extraordinary need for major medical care. In his New York Times Op-Ed piece of June 21, 2015, Nicholas Kristof describes the chilling war being waged by the government of Sudan against its own people in the Nuba Mountains, with daily bombings of civilians. He describes the deaths and maiming of children, and the inadequacy of even the most committed physicians to help in the atrocious conditions that exist there. An 8-year old boy, who had just lost several siblings to the bombing, showed extraordinary courage,” the lone doctor at the hospital remembers, “but he would scream every day from pain as his dressings were changed.” While he “persevered for weeks”, “flies were laying eggs in his wounds, and soon the burns were crawling with maggots. Dr. Catena says that he would cut out the maggots, and the next day more would return.”

Yes, most of these 400 million are not in the US, are in developing (a euphemism, perhaps) countries. But in the US there is great need also; every day in our cities we see people who have not had access to TB or HIV treatment, who have delayed care because they are uninsured and cannot afford the cost, until they are so sick that their treatment costs far more than it otherwise would have. We see women who do not come for antenatal care until very late in their pregnancies if at all, missing the chance to discover and treat relatively minor problems until they become major. Fortunately, it is uncommon in the US for them to not receive “skilled birth attendance” since the law requires hospitals to provide care when women come in in labor, but they often appear with no records of whatever prenatal care they may have had. An excellent post on the blog of Medical Care Section of the American Public Health Association (unfortunately, access is limited to APHA members), “For Medicaid enrollees, a choice: PCP or emergency department?”, by Sandhya V. Shimoga, describes the problems that Medicaid patients, particularly those newly covered by Medicaid expansion in those states that have done so, in finding primary care providers; they continue to have to use the ED instead, often (again) with conditions far worse than they would have otherwise had. This, of course, does not count the largely insured people in the US who elect not to immunize their own children, secure in the knowledge that most other people are and that they will have access to care if anything does go wrong. Which it often, by the way, does.

And then there are states like mine, Kansas, that have chosen not to expand Medicaid, so that people similar to those Shimoga describes in Oregon and California do not even have a choice. The people of this state, once proud of its education and health care, have seen their rate of uninsurance increase relative to the states which have expanded Medicaid (Kansas only state to increase number of uninsured: A how NOT to do it strategy, August 9, 2014). The “solution” backed by the Republican Party and state governors such as Kansas’ Governor Brownback, is to further decrease the number of insured people by suing on a wording issue in the Affordable Care Act (ACA, “Obamacare”) that might invalidate the federally-run insurance exchanges which have allowed low-income-but-not-desperately-poor people in states like Kansas to gain insurance coverage.

This is a bold strategy, likely to work as well as Governor Brownback’s experiment in reducing taxes on the wealthy and businesses in 2012, which left the state with an $800 million budget deficit this year (on a budget of only about $8 billion). Half was replaced with one-time funds (eg, raiding the state highway fund) and the other half, after a marathon legislative session that ended a month late, with the largest tax increase in state history. However, these were all regressive taxes, mainly a sales tax increase, that hurts the poor and middle class; the 2012 cuts stayed in place for the wealthy, so I guess in that sense it did work. Business pays less tax, and if you own your business (say, self-employed lawyers or doctors) you pay no state income tax although your employees do. Kansas spends less now than neighboring Nebraska, which has 2/3 as many people. Now if we can only get rid of those federally-sponsored exchange so even more people will be uninsured…

The World Bank report calls for universal health coverage. “The world's most disadvantaged people are missing out on even the most basic services," says one official, who adds that a “... commitment to equity is at the heart of universal health coverage.” The report said that 17% of people were pushed into poverty (<$2/day) and 6% into “extreme poverty” (<$1.25/day) by the cost of emergency health care. Few Americans make anywhere near that little, but the cost of living, and of health care, is much higher and the same trend exists here; medical expenses are the largest cause of personal bankruptcy (see Fox Business’ 2014 report).

As more countries make commitments to universal health coverage, one of the major challenges they face is how to track progress,” says another World Bank official, commenting on the study. Of course, if a country, such as the US, does NOT make a commitment to universal health coverage, this is not a problem.

Except, of course, for the people without health care.

Sunday, May 24, 2015

Health, Medicine and Justice published: available on Amazon


NOW
Available from Amazon, Barnes and Noble, and independent booksellers.




Health care delivery in the U.S. is a mess. We lead the world by far
in spending, but trail other developed countries in most health outcomes.
Our health care is disjointed, not coordinated, and seems
to be designed to maximize profits for insurers and health care
providers. These two groups usually seem to be in conflict about
which should get most of the money. While individual patients may
receive outstanding care, especially when it can be delivered profitably,
the population as a whole does not. Is the system not working,
or is it working too well to do the wrong thing? After all, “every
system is perfectly designed to get the results that it gets”.
In this book, Dr. Freeman argues that the problem is that our
healthcare system is not designed primarily to improve health. He
presents extensive evidence about the design of our health care
system and the results that it gets. He examines the imbalance
of high-tech care with primary care, the way our doctors are educated,
how new discoveries are presented to the public, and the
role of profit in distorting the design of U.S. healthcare. He suggests
how a new system could be designed based on the values
of achieving the best health for all of our people.

-----------------------------
“Health, Medicine and Justice is not your typical health care book. It challenges the very goals underlying the U.S. health care system: “We are getting what our system is designed to get—profit and wealth for those who control it, rather than health for the people of the nation.” If you think this idea is too controversial, this book is full of facts that make the case.” —Thomas Bodenheimer, M.D., University of California – San Francisco 


Uncommon sense on health care - a book review, The Kansas City Star, March 29, 2015
“Joshua Freeman is chief of family medicine at the University of Kansas Hospital and an inveterate blogger. He started his “Medicine and Social Justice” blog in 2008 calling for universal health care coverage and has returned repeatedly to the subject. That’s because even though the Affordable Care Act makes coverage available to many people, Freeman doesn’t think it goes far enough. And while politicians dare not speak its name, Freeman isn’t shy about what he thinks we need: A single-payer, Canadian-style system covering everyone.

Freeman recently gave me an advance copy of his new book, “Health, Medicine and Justice: Designing a Fair and Equitable Healthcare System,” laying out his arguments. It’s a fine primer on the tangled web of special interests and ultimately futile regulation that passes for a health care system in this country. (Truth in punditry: Freeman cites my reporting in his chapter on the role of profit in health care.)

Freeman provides telling anecdotes: His experience treating uninsured patients whose chronic illnesses were out of control because they couldn’t afford care. His discovery in New Orleans of a safety-net clinic sponsored by Qatar — which means America, the richest nation on Earth, accepts foreign aid to care for its poor. He’s also good at taking points often made by others and making connections. Yes, we know we spend more on health care than other wealthy
nations and despite that, our people aren’t particularly healthy. But the U.S. also spends less on social services, he observes, the kinds of things
that elevate people from the poverty that degraded their health in the first place.

But the poor don’t have political clout. Health care providers and insurers do. So that’s where the money goes. “We have a health care system that is designed to make profit rather than health,” Freeman says.

According to Freeman, a single-payer system — basically, Medicare for all — would go a long way toward putting the focus back on patients. It would eliminate the crazy quilt of insurance plans that drive up administrative costs. And it would set more equal and rational payments for medical
services. Providers could still compete, Freeman says, but it would be on the basis of quality or personal style.

Perhaps Freeman’s most compelling argument is that a system covering everyone would unite us all, rich and poor. We would all have an equal
stake in making sure providers were adequately paid and delivered high-quality care, and that everyone had access to that care.

But Freeman sees health care as a basic human right. That’s still a subject for debate in the United States.” — by Alan Bavley


“The US health care system is broken,” Joshua Freemen tells us in the opening line of his powerful critique, Health, Medicine and Justice: Designing a Fair and Equitable Healthcare System. He spends the next 300 pages masterfully and persuasively documenting this charge. His voice is disappointed more than it is angry or shrill. Freeman is a practicing family physician and the chairman of the Department of Family Medicine at the University of Kansas School of Medicine. It is his system and he wants to see it perform as it should, to work in a more equitable fashion, and to produce results that the country is paying for but not getting. His command of fact is impressive and his tone caring and therapeutic. He tells us about everything from comparative health systems in Europe to profit motives in the Board Room. Dr. Freeman concludes that a single
payer health system is the solution to better and more equitable healthcare in America. It is “political will,” he tells us, “that will fix the broken system.”
—Fitzhugh Mullan, M.D., Murdock Head Professor of Medicine and Health Policy, Professor of Pediatrics The George Washington University


“In his book, Health, Medicine and Justice, Joshua Freeman not only explains the unique features of the U.S. health care system that result in significantly higher costs but only mediocrity in performance, he also discusses the issues against a background of health care justice. This leads to the compelling conclusion that, being all in this together, we can apply principles of health care justice to ensure higher quality health care for everyone, at a level of spending that the nation can afford.”
—Don McCanne, M.D., Senior Health Policy Fellow, Physicians For a National Health Program (PNHP)


“This is an informative and entertaining overview of the current status and deficiencies of the US healthcare system. It will serve as a useful text for anyone just beginning their inquiry into how the system works, or for someone wanting a refresher course on the influences of social policy and values on the outcomes of the unique approaches to providing healthcare prevalent in the  US.”
—Robert Graham, M.D., former CEO, American Academy of Family Physicians


“Whether simplifying the arcane methods of financing graduate medical education, or clarifying the inaccuracies and conflicts of interest in the way that medical schools report their production of primary care doctors, Dr Freeman provides insight into the bases for our out-of-balance health care workforce. In an engaging and understandable style, he not only identifies the underlying issues but also points to some opportunities for righting the health care system’s deficiencies; and makes a strong argument for why we should do so. If you don’t care about social justice and don’t want to risk caring more, don’t read this book.”
—Christine C. Matson M.D., Glenn Mitchell Chair in Generalist Medicine Chair, Department of Family and Community Medicine, Eastern Virginia Medical School

------------------
Contact: Joshua Freeman, M.D.
Cell Phone:
Email: jfreeman3@gmail.com
Health, Medicine and Justice
Designing a Fair and Equitable Healthcare System
By Joshua Freeman, M.D.
Published in 2015 by Copernicus Healthcare • 315
pages • ISBN PB: 978-0-9887996-8-4 • $18.95

Tuesday, May 19, 2015

Medical testing: is it about quality?

In her New York Times “Well” blog of April 13, 2015, physician Abigail Zuger comments upon “Quantifying Tests, Instead of Good Care”. She discusses a variety of factors that lead to physicians ordering more and more tests. In part, this is the simply the result of the advance of technology and thus the profusion of tests that can be done --  laboratory tests, imaging (like x-rays and their ever more complex cousins), and even parts of the physical examination (“Yes, little blood pressure cuff over there in the corner, that means you”) --  which sometimes can be seen as meaning they should be done. Other factors are about money. The tests cost money, a negative for patients and insurers, but they make money for the laboratories and imaging facilities and the hospitals which often own them, and frequently employ the physicians doing the ordering. Dr. Zuger notes that “Ordering tests, chasing down and interpreting results, and dealing with the endless cycle of repeat testing to confirm and clarify problems absorb pretty much all our time.”

Another impetus is our desire – patients and physicians alike – to find out what is wrong when there is something wrong. Or, when there is nothing really wrong, to perhaps prevent later disease by finding something hidden lurking inside. There are all these tests we can get! The patient may have had many of them before, ordered by another provider, or know people who have had them. They hope that something will give them an answer. The doctor may feel that there may be an answer out there that s/he might miss if a test is not ordered, or if s/he is a primary care physician that a specialist might order these tests so maybe we should do it first; after all, it sometimes seems as if one thing specialists do when we refer patients to them is order a bunch of tests that we could have. Or, and this is a big focus of Dr. Zuger, that their “quality ratings” may suffer if s/he doesn’t order these tests.

Quality ratings are measures of things that doctors should do (or, sometimes but more rarely, should not do) for patients with certain conditions or complaints; increasingly, insurers, employers, and third-party groups are assessing the quality of care that a physician delivers in this way. Are these recommendations not based on evidence? In many cases, they are. For prevention, the US Preventive Services Task Force assesses the degree to which tests may be indicated or not for different people, often based upon their age and sex. It gives them ratings: ‘A’ is strongly recommended based on good evidence, ‘B’ means there is some, but weaker, evidence to support doing it, ’C’ means there is conflicting evidence and patient preference should be taken into account, ‘D’ means not recommended (might even be harmful), and ‘I’ means insufficient evidence to assess. A smart phone app, ePSS, can be downloaded by anyone; put in age and sex and it tells you which preventive tests are recommended.

Of course, not all doctors do all the recommended screening tests, and frequently they do tests that are not recommended (e.g., PSA to screen for prostate cancer) or more frequently than recommended (Pap smears to screen for cervical cancer), or in people for whom the test is not recommended (mammograms in younger women). When it comes to diagnostic testing rather than screening, looking for the cause of something when the patient is actually ill, there is even less consensus, and often a prevailing attitude of “more (testing) is better”. One effort to combat this is the Choosing Wisely campaign begun by the American Board of Internal Medicine Foundation. This campaign asked specialty societies to identify 5 or more commonly-done tests or interventions in their specialty that should not be done. However, the same recommendations are not always endorsed by every relevant organization. For example, the American Academy of Family Physicians recommends “Don’t do imaging for low back pain within the first six weeks, unless red flags are present.” Great, but neither the American College of Radiology nor the American Academy of Orthopaedic Surgeons, arguably the groups that could make money from this, has such a recommendation.

And then there is the risk. Some of the tests receiving USPSTF ‘D’ recommendations are more than not helpful; they can lead to harm, and this is even more true of the many potential tests that can be done looking for disease. Discussing the work of a collaboration at the Dartmouth Medical School that looks at the utility of tests, Dr. Zuger notes that such iconic treatments as controlling blood pressure can lead to bad outcomes in many older people where the benefits (avoiding stroke and other complications) begin to be outweighed by the risks:  “One study found that nursing home residents taking two or more effective blood pressure drugs did remarkably badly, with death rates more than twice that of their peers. In another, dementia patients taking blood pressure medication with optimal results nonetheless deteriorated mentally considerably faster. Yet no quality control system that I know of gives a doctor an approving pat on the head for taking a fragile older patient off meds.”

This is just the tip of the iceberg. Tests cost money, and often show results that lead to more tests, and then maybe to procedures (biopsies, for example) that maybe show abnormalities that lead to bigger interventions. And, sometimes these interventions are life-saving, but not always. Or maybe, even, not often.  And they do often have side effects, some of which are not insignificant. The person in whom a series of tests identifies cancer and is then treated and then survives is almost always grateful for the testing and the treatment, although in many cases they would have survived just the same with no treatment, and without the costs both in dollars and in side effects. The classic example is prostate cancer, where the evidence of any treatment making a difference in survival is weak at best; it is either a devastating disease from which one dies, painfully, or more commonly a benign condition that one dies with but not from but which treatment seems to have little influence on. Except for the cost, and the non-trivial side effects of impotence, incontinence, and the effects of radiation on the rectum.

Increasingly, data is showing that much breast cancer is similar. As discussed in my December 2012 blog post “More on mammography: just because you don't like the results doesn't make research junk science”, a large study by Bleyer and Welch showed that, with new and more sensitive mammographic screening, many more women are being diagnosed with early-stage breast cancer. However, despite treatment, we are not seeing anything like that reduction in late-stage breast cancer, which means most of those early stage cancers would not have progressed at all. And yet every woman diagnosed and treated sees herself as a survivor who has been cured, even in those cases where progression would not have occurred. In his wonderful recent New Yorker article “Overkill” (May 11, 2015), Atul Gawande notes that we treat all “cancer” as if it were rabbits in a pen who have to be chased down before they escape, when in fact many cancers are “birds” that have flown away and are gone before we can do anything and many others are “turtles” who are not going anywhere whatever we do.

The goal of medical care is now to achieve the “Triple Aim” of high quality, patient satisfaction, and lower cost. As with many things that come in threes, it is not that hard to achieve two but very challenging to achieve all three. Patients satisfaction is important, but not at any cost. Cost control is good, but not if it seriously limits quality. One place to start, then, is with quality, and specifically not doing what is useless or even harmful as assertively as we do what is likely to be of value.


And, of course, to make sure that it is the disease or risk of disease that determines what tests are done, not people’s insurance or socioeconomic status, ethnicity, gender or personality.

Monday, April 27, 2015

Beyond Flexner: It is time to stop shoring up the bridge and figure out how to cross the river!

I recently attended the “Beyond Flexner 2015” conference in Albuquerque, NM. Originally titled “Beyond Flexner II”, it was a followup to the 2012 “Beyond Flexner” conference in Tulsa, OK, which I discussed in my June 16, 2012 post “Beyond Flexner: Taking the Social Mission of Medical Schools to the next level”. The first conference was itself in part stimulated by the 2010 publication of “The Social Mission of Medical Education: Ranking the Schools” by Mullan, Chen, et al. in the Annals of Internal Medicine.[i]  Fitzhugh Mullan, head of the Medical Education Futures group at George Washington University, was co-director of this recent conference along with Arthur Kaufman, Vice Chancellor for Community Affairs at the University of New Mexico Health Science Center. The organizing committee was a “Who’s Who” of leaders in the movement to make medical schools more accountable for meeting the actual health needs of the people of the United States, including Gerry Clancy, host of the 2012 conference in Tulsa, and several of the other authors of 2010 paper.

The attendees at the 2012 conference in Tulsa were captured in a posed photograph, crowded but with  recognizable faces. This would not be true of the nearly 400 people in Albuquerque, who also represented a much wider group. In addition to more university sponsors (including Florida International University, which will host the next conference in 2017), several other foundations have joined the Josiah Macy, Jr. Foundation, which helped sponsor the first conference as well. The bulk of the attendees were medical school faculty, with some residents and students, but others from a wide swath of those with an interest in the impact of medical school output on health were in attendance. Notably, this included people from the cooperative extension services based at our nation’s land grant universities, who have been collaborating with health sciences centers to create “health extension” programs in a number of states (The Primary Care Extension Service, July 12, 2009);  New Mexico’s HEROs (Health Extension Rural Offices) program is one of the national leaders.

There were a number of stimulating and provocative speakers, including Camara Jones, about whom I have already written, who spoke about racism and the Social Determinants of Equity. Don Berwick, founder and senior fellow at the Institute for Healthcare Improvement, and former interim Administrator of the Center for Medicare and Medicaid Services (CMS), gave a powerful talk about the direction of healthcare in the US. His most powerful metaphor was of the Choluteca Bridge in Honduras, which was so well built that it withstood Hurricane Mitch in 1995. Unfortunately, the hurricane relocated the river, so that now it no longer functions for its intended purpose! Dr. Berwick also noted that if the US spent 15% of its GDP on health care, instead of the current 18%, it will still be higher than #2, Switzerland. If the US had spent at the per capita rate of Switzerland over the last 25 years, it would have spent $15.5 TRILLION less. That is real money, and could have been used to address many of the social determinants we are always told there is not enough money to do.


Perhaps the most stirring talk was given by H. Jack Geiger, former Dean of the Sophie Davis (now City University) School of Medicine in New York. Accurately described as a “living legend”, Dr. Geiger founded the first two community health centers in the US, in Charlestown, MA near Boston and in Mound Bayou, MS. He was a founding member of the group Physicians for Social Responsibility (PSR), the US affiliate of the International Physicians for the Prevention of Nuclear War (IPPNW), and Physicians for Human Rights (PHR). In his introduction we were reminded that Dr. Geiger was once chastised by a federal bureaucrat for writing prescriptions for food for his patients in Mississippi, and told that the federal funds supporting his program were to be for treatments. His now-classic response was that “the last time I checked my medical textbooks, the treatment for malnutrition was FOOD!” He noted that the last decade might be called that of raising consciousness of the Social Determinants of Health, but that because many of these are determined by (and are currently being eroded by) the political process, called for the next decade to be that of the Political Determinants of Health. He did not mention, but I note, that while IPPNW won the Nobel Peace Prize (1985), the Nobel Prize for “Medicine” in fact goes exclusively to researchers in the basic sciences. How wonderful, fitting, and appropriate would it be to go to someone like Jack Geiger, whose life’s work had really made a difference in the health of people!

In writing about the 2012 conference I suggested that certain goals be the focus of the “Beyond Flexner” movement:
·         Diversity: How does the school produce a health workforce that looks more like American by enrolling, and supporting, a group of students that is truly diverse in ethnicity, gender, socioeconomic status, and geographic origin?
·         Social Determinants of Health: How does the school teach about and train students in, and carry out programs aimed at addressing, the social determinants of health? How does its curriculum and work invert that of the traditional medical school, which focused most on tertiary hospital-care, and emphasize instead ambulatory  care, community based interventions, and interventions on the most important health determinants including housing, safety, education, food, and warmth?
·         Disparities: How does the school, through its programs of education and community intervention, and its research agenda and practices, work to reduce disparities in health care and health among populations?
·         Community Engagement: How does the school identify the community(ies) it serves and how does it involve them in determining the location of training, kinds of programs it carries out, and in identifying the questions that need to be answered by research?
I believe they are still valid. The Social Determinants of Health (SDOH) were discussed everywhere in the conference, and Health Disparities are the central focus of addressing them, or in Dr. Jones’ phrase, the Social Determinants of Equity. Community Engagement was emphasized through the broader participation in the conference (such as the people from Extension services) and one of its highlights was an afternoon of tours of such community-engaged programs in Albuquerque. I went on a visit to the city’s International District, and the East Central Ministries, which operates an innovative clinic driven by community health workers, an Urban Farm, and a small factory manufacturing ollas, unglazed clay jugs used for low-water-use irrigation.

Diversity was certainly addressed by many of the conference speakers, including Dr. Jones and Marc Nivet, Chief Diversity Officer for the Association of American Medical Colleges (AAMC), who pointed out how poorly our schools have done. In the 1990s The AAMC had a goal for minorities of “3000 by 2000”, but in the last 35 years African-American applicants have increased by 1000 and admissions by only 250. Jose Rodriguez and his colleagues writing in Family Medicine note that African-Americans peaked at 8.1% of medical students in 1994, and was down to 7.23% in 2010, Hispanics are up to 8.25% despite a much higher % of the population, and underrepresented minority (URM) faculty in medicine has increased from 7% to 8% from 1993 to 2010 despite an increase in those same groups in the general population from 23.1% to 31.4% in the same period.[ii] In the accompanying editorial, which I wrote, I call for an immediate, dramatic, and comprehensive effort to change both the socioeconomic and racial makeup of our medical school classes.[iii]

If anything was a little disappointing to me at the conference, it was the degree to which the audience was less willing to pick up on the issue of lack of diversity. While there was applause for the comments of Drs. Jones, Nivet, and others, most of the questions and comments focused on the SDOH. These are extraordinarily important, and emphasizing the need to teach them in medical school is as well, but poverty will not be solved quickly. Diversity, on the other hand, could be; our medical school class next year could look dramatically different if we changed the criteria by which we admit so that half the class came from the lower 50% of income and we had double the percent of minorities.

Many of the conference attendees were from newer medical schools, whose goals are more tied to SDOH, Community Engagement and Diversity, and they were celebrated from the podium. But while they may deserve this celebration, the older medical schools need to be held responsible as well; unless they change their admissions practices and their goals to serve the communities, the impact of the newer schools will be only at the margins.

There is a lot to do, and to accomplish it will take a movement. Hopefully a movement growing from “Beyond Flexner” can start the process.





[i] Fitzhugh Mullan, MD; Candice Chen, MD, MPH; Stephen Petterson, PhD; Gretchen Kolsky, MPH, CHES; and Michael Spagnola, BA. The Social Mission of Medical Education: Ranking the Schools. Ann Intern Med. 2010;152(12):804-811. doi:10.7326/0003-4819-152-12-201006150-00009
[ii] Rodriguez JE, Campbell KM, Adelson WJ, Poor representation of Blacks, Latinos, and Native Americans in Medicine, Fam Med 2015;47(4):259-63.)
[iii] Freeman J, Diversity goals in medicine: it’s time to stop talking and start walking, Fam Med 2015;47(4):257-8.

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