How we got here, part 2

Founding Chair, University of South Alabama

In the 1970’s, health care reform was happening. Medicare and Medicaid had been established by President Johnson and expanded by President Nixon. The WWII veterans were well established in their jobs, all of which came with extensive health care benefits thanks to wage and price controls. Everyone was clamouring to use their “insurance” cards. A massive expansion of the physician workforce was going to lead to medical happiness and longevity. The “directional” medical schools were founded to facilitate this These were medical schools at such universities as East Carolina, East TTennessee State, and South Alabama. Since the “big name” schools were putting out specialists, it was assumed that these schools would put out generalists, with an emphasis on Family Medicine.

South Alabama was founded with this primary care focus. moon Mullins, our founding chair, had been in private practice in Fairhope Alabama for 19 years when he was asked to create the department as a part of the new medical school. In the case of South Alabama, Family Medicine was incorporated in the fabric of the school.

It turned out that incorporating a social movement into an establishment instution was not good for the social movement. As early as 1989, Gayle Stephens was warning that we (as a specialty) “should never become so indolent, smug, or arrogant that we take the interest of medical students in family practice for granted. That would be a fatal mistake.”

The 1990s brought about that mistake, and it has proved to be almost fatal. Between the Clinton health care reform proposals and the managed care “gatekeeper” movement, we believed that the benefits of primary care were self-apparent, and we were valued. The next decade proved to those of us in academic medicine how wrong we were.

The 2000’s were characterized by a belief in the “market”. Healthcare “consumers” (those with insurance) were given almost carte blanche access to providers, technology, and were told that any long-term damage done by poor lifestyle choices could be undone. Uninsured “consumer” were given access to heroic care through EMTALA. In fact, the President George W Bush was quoted as saying  “The immediate goal is to make sure there are more people on private insurance plans. I mean, people have access to health care in America, after all, you just go to an emergency room.” So, clearly by the end of the tenure of the last administration, “primary care” was out and consumer driven care with the Emergency Department safety net as a unfunded mandate was in. So much for controls on consumption, prevention, or any other attempt to have grown-ups in charge.

This is the system President Obama is trying to fix.

The road to health reform, Part 1

I outlined for the new residents how we got to the place we are today (in my opinion). Over the next couple of posts, I will try to put into words what was in the Powerpoint.

My history began with the story of Arthur Hertzler. Dr Hertzler (pictured above) He was known as  the “Horse and Buggy Doctor”.He attended Southwest Kansas College and then Northwestern University Medical School. Since the average country physicians was not as well educated, Dr Hertzler’s private practice in Halstead, Mo would have been unusual in its own right. The fact that he maintained this practice and taught pathology, histology, surgery and gynecology at the University Medical College in Kansas City and University of Kansas School of Medicine was amazing. his fame, though, was from his book, the Horse and Buggy Doctor, written in 1938 about his practice. In it was a personal account of his experiences and it was an instant best seller. It offers a discription of the quintessential “country doctor”.

Ward Darley was not a family physician, but was also innfluential in the speciaties founding. He had his A. B. and M.D. from University of Colorado and after a period of private practice in Denver he went on to become president of the AAMC in 1952 and president of the University of Colorado in 1953. In 1949 he wrote “The place and training of the General Practitioner”.  In it, he says “This doctor-a physicianin the fullest sense of the word-should be interested in and qualified to function as a healthCounsellor and a health coordinator for a given individual from birth to death. Personal preventive medicine, as well as community health, should claim a great deal of his effort. Ability to function effectively in the prevention, early diagnosis and treatment of emotionally and personality determined illnesses should be of the first importance. General diagnostic ability predicates that he will recognize his limitations and know when specialist consultation or referral is indicated. The need for proficiency in the therapeutics of the common medical conditions should be apparent. His need for surgical ability other than diagnostic will depend upon the locale of his practice and his proximity to surgical consultants and facilities.” In essence, he discribed the need for and the training of the prototypical family physician.

In 1965, the Millis commission further discribed the need for generalist training and outlined the barriers to care. As a result of these and other great men and women, the American Board of Family Practice was founded in 1969 with 15 pilot training programs. The training was notable in its ininclusion of behavioral sciences and its requirement for recertification.

In upcoming posts I will describe the formation of USA Family Medicine, and the path to health reform and the role that our programs have played.

Concern and Hope

As healthcare reform moves into the sausage factory phase, I remain convinced that healthcare reform is imperative for the health of Alabamians almost more so than most Americans and that Alabamians are the least likely to appreciate the urgency and the effort.

I don’t know how many of our citizens are aware that government pays for 45% of healthcare costs (through Medicare, Medicaid and other programs). If they were, they would perhaps appreciate that President Obama rightly feels that we as taxpayers should be getting value for our tax dollar. That is why his principles (outlined at www.healthreform.gov) focus on universal coverage, coverage portability, prevention of illness, and reduction in medical errors and waste.

 Our Senator, appearing on Fox News Sunday, bemoaned the efforts of the Democrats to dismantle the “the best healthcare system the worls has ever know”. I wonder if he is aware that the average age of primary care physicians in Alabama (overwhelmingly the type of physician practicing in rural areas) is 50, and some counties have fewer than 3 physicians for the entire county. Eight counties have no hospital at all.

Delays in care are common throughout our state. Trauma deaths, the best predictor of care availability, are twice as high in rural Alabama than in the US as a whole. Obstetrical care is unavailable in 33 of the 55 rural counties. Life expectancy in rural Alabama is 3 years below that of the United States overall, a difference that can be directly attributed to lack of access to health care. See the Alabama Department of Public Health website for further details on the state of medical care in rural Alabama.

On the hope side, we graduated 4 new Family Physicians at the Admiral Semmes last night. Unlike previous years, where the graduates were going to practice Emergency Medicine or Urgent Care, this year the graduates were entering the practice of Family Medicine. In addition, we had 6 “Interns” complete their first year of training, at least one of whom will practice in rural Alabama. Maybe the glass is half full.

Govment in Medicine

As we continue on a path towards healthcare reform, one of the ongoing concerns is “Govment control” of healthcare. For whatever reason, major capitalists on CNBC tonight have a mortal fear of this. At this point in time, 40% of healthcare costs are directly paid for by either the federal or state governments. Up until now, the public has been given access to this money, accounting for about 7% of the GDP with little to no accountability. The public purchased $3.1 billion dollars of pills to combat erectile dysfunction in 2006 but 15% of women did not get screened for cervical cancer. 40% of Medicare expenditures were incurred in the last month of life. I think the grown-ups should at least work on bringing some rational thought to what we are spending OUR money on.

Targetted training

Kaplan GA. Ann NY Acad Sci 1999, 896:117-199

Most residency training is paid for by Medicare through the sponsoring hospital. HRSA Title VII provides money specifically to support programs who train physicians that leave training and practice among underserved populations. The previous administration had eliminated the program despite evidence of great success. There is $400,000,000 in the stimulus package for this year for this program. Additionally, the renewal will be put before Congress this year as well. Below are the key aspects of “Health Professions and Primary Care Reinvestment Act” which were H.R. 7302 and S. 3708 but will be renumbered in the 111^th Congress.

In addition to the traditional emphasis in Family Medicine training, the following is included in the language of the bill for the “pre-doc” (programs that offer training to medical students) and residency grants:

·        to plan, develop, and operate an interdisciplinary training program that includes at least 1 of the following which demonstrates a team approach to care and may demonstrate a patient-centered medical home model:

o   A program designed to teach trainees the skills to provide interdisciplinary patient care through collaboration among various professionals, including those trained in geriatrics, physician assistants, nurse practitioners, pharmacists, or social workers.

o   A program developed in collaboration with dental students or residency training programs to improve integration and access to dental care.

o   A program developed in collaboration with psychologists and other behavioral and mental health professionals to integrate mental and behavioral health and primary health care

 

For the programs to develop primary care departments, the emphasis will be on: 

 

·     innovative approaches to clinical teaching using models of primary care, such as the patient centered medical home, team management of chronic disease, and interdisciplinary integrated models of health care that incorporate transitions in health care settings and integration physical and mental health provision.

·     Generating the capacity to do Community Health Needs Assessment-

 

Lastly, they will create a new entity, the Primary Care Training Institutes, whose purpose is

 

·      To prepare and train primary care providers by enhancing and coordinating multiple aims within academic health centers in order to lead to improving patient care delivered to health disparity populations and reduce health disparities;

·      To enhance the status of primary care within undergraduate and graduate medical education through influencing priorities in practice, education, and research;

·     To develop innovative approaches to primary care education and scholarship by transforming and integrating health care systems through interdisciplinary, team-based, and collaborative models that may demonstrate improved quality or lower costs;

·     To create economies of scale through academic and community collaborations by enabling academic infrastructure support for multiple community programs.

 

This money is needed to improve our training and make it more targeted towards what will imporve health, not just attack illness. Let’s all work to put this program back on track.

 

Reforming healthcare

 

My neighbor does not use our practice for her “medical home“. In fact, although she has a pediatrician for her children and an internist for herself she keeps her own “primary care” counsel. We have lived next door to them for several years and I often find myself being asked to comment on the quality of care received by her or her family across the porch rail. I don’t know whether to be amazed at her resourcefulness (she keeps several orthopedics groups on speed dial for her active son) or chagrined for our profession’s lack of “hominess”(she showed me a “lesion” on her daughters foot which was clearly a wart but she was searching for a dermatologist to give her the definitive diagnosis and treatment not available from her pediatrician). I hope that adequalte payment for the activities associated with being good primary health care such as coordination of care and delivery of competent first contact care will be a part of the reforms that are projected to arrive. I also hope that primary care physicians are up to the challenge.

Healthcare 2015: The Impact of the Obama Presidency

Funny if not true

IBM has sponsored a discussion about health care reform that is a very interesting and informative. The discussion is a part of the IBM Healthcare 2015 series. The most recent webcast is available on demand and offers commentary by Peter Budetti on why reform will happen this time as opposed to 1993 and Len Nichols on what are the potential obstacles. More imprtantly, is the discussion by Paul Grundy MD, chair of the Patient Centered Primary Care Collaborative on the patient centered home. This is not a new concept but one that has not been implemented because of funding. It looks good for a change in how healthcare is paid for and delivered.

The Post-Modern Physician

In a book review on Trusting Doctors: The Decline of Moral Authority in American Medicine By Jonathan B. Imber in the New Republic Sherwin Nuland makes an eloquent case for the inherent morality that comes with the profession. He points out that this morality is not a product of our modern Judeo-Christian mindset but has been infused into the profession through an unbroken chain of healers leading from then Hippocratic tradition into the Jewish and Arabic physician tradition first before becoming a western medical principle.  The books thesis is that the ethical construct of modern medical care is at risk due to an increased emphasis on technology and a decreased societal emphasis on religious (Catholic and main line Protestant) ethical principles. Dr Nuland points out that the risk to the profession and the public’s skepticism dates back much further than one might think and is grounded in findings of fact (the Tuskeegee Syphilis experiment is one such ethical lapse). He feels that physicians need to eschew religious justification for their actions and instead be guided by higher moral priciples as befits our profession.

Nuland states “For more than two thousand years, that interaction, and its setting of medical morality, was the primary basis of the trust and the authority placed in the members of the medical profession and the profession as a whole by those who depend on them for healing. Now the uniqueness and intimacy of the interaction has been allowed to fray. That is the moral crisis. It behooves the profession and the laity to recognize its gravity and to seek measures to restore as much of the old relationship between patient and physician as is reparable.”

As we find ourselves learning of such large conflicts as Frederick Goodwin’s $1.3 check from pharmaceutical companies not reported to his audience on the Infinite Mind  until pointed out by Senator Grassely  we need to consider much smaller conflicts. Are we able to make recommendations to our patients without conflicts arising? One hopes that physician payment re4form will emphasize only needed care and not excessive procedures and prescribing that forces us to check our ethics at the office door.

Health care delivery and urgent care in Mobile Alabama

There in an article in today’s Press Register touting the opening of several “Urgent Care” centers in the Mobile area. The writer presented this as a huge plus for the healthcare consumers as they could have their “deep cuts” or “sinus infections” cared for in a more timely fashion than in the traditional emergency room. Aside from the more mundane concerns of whether we need a center for this type of suturing (realistically you can do this in between patients in an efficient emergency department as you wait for MVAs to roll in) or sinus infections (think antibiotic resistance), the real issue is one of efficient and effective care delivery. These “centers” are part of the problem. The New England Journal of Medicine has had a series of “Perspectives” about the health-care system in this country. Last week, the essayist compared our countires experience with that of others. As we are all now familiar, we spend twice as much per capita and have much poorer outcomes than all other industrialized countries. In this weeks NEJM, Victor Fuchs points out three “inconvenient truths” about health-care. The first is that the annual growth will lead to healthcare consuming 30% of the GDP within 30 years, an unsustainable expenditure of public dollars for what is mostly (in the case of the American health-care system) a private good. The reason for this growth (Truth 2) is increased access to technology and healthcare infrastructure regardless of incremental cost/benefit to the individual patient or society. Truth 3 is that sick people tend to be poor and well people have to pay for sick people. To quote Dr Fuchs “No country achieves universal coverage without subsidization and compulsion, but U.S. politicians tie themselves and the health care system in knots by proposing reforms designed to conceal these realities. Politically, the most appealing plans are those that mislead people into thinking that someone else is paying for their insurance. Currently more than half of insured Americans obtain their coverage through employment, and workers have been led to believe that their employer bears most of the cost of their care — a belief that labor-market experts have concluded is invalid. When a firm pays $3,000 to $7,000 per worker per year for health care, it can get that money in only three ways: reducing potential wage increases, increasing prices for what the firm sells (which means lower real wages for workers everywhere), or lowering profits.”

The illustration at the top of this post identifies 15  necessary interventions to get control of our health care costs. Many of them involve reinvigorating the primary care infrastructure in this country. None of them identify “increased urgent care access” as the answer. Even though our newspaper doesn’t get it, I hope that the policymakers do.

Will the last Family Doc turn out the lights?

I was given an article posted in Salon entitled “Where have you gone, Marcus Welby”. The writer identifies a strong primary care base as being integral to  health care delivery. Additionally, the writer points out that we have a current shortage and because of the age of our workforce, it will get even worse. Additionally, the pull of foreign born individuals into our healthcare workforce creates a drain within their home countries. Bob Wachter also discusses this in detail on his blog. What to do?

The quote in the title is a reference to a famous billboard from Seattle in the 1971’s. It was a response to rampant pessimism about the future of Seattle, a city of now of 500,000 with a metro of 3,000,000. Seattle came back, through a combination of supporting their existing infrastructure (those of us in Alabama know how powerful Boeing is), allowing new opportunities to flourish (who’d heard of StarBucks in 1971), and in general continuing to slog away every day trying to make something good happen. In Family Medicine, we continue to focus on our old tactics (delivery of excellent patient care), while looking to practice redesign to move us into a more stable environment. Even in Boston, high end primary care is getting some press. We hope that those folks that pay the bills will take note of our efforts and reward us with improved payments for our efforts. This is the only way that we will turn the tide and begin increasing the primary care workforce.

 The Commonwealth Fund sponsored a seminar on such innovations and how to pay for them on Monday. It does appear that someone is paying attention.