cartoon9I have to remember that I’m an officer and when I give a Marine an order they will obey no matter what. When I use the tonometer and say “don’t blink” I had better remember to follow up with “blink” before they get dry eyes.

Conversation with a Navy Optometrist

I remember fondly my time being a doctor to the Marines. Wet behind the ears, eager to hone my craft, suddenly given superhuman abilities such that with only an internship I could function independently in a remote setting…oh, wait, that last part didn’t happen. Fortunately there was, on the base with me, a wizened old doc (I think his name was Wenzel) who had practiced in rural Kentucky prior to going back and studying pediatrics. His counsel was always wise and when distilled down often ended up being “When in doubt, turf it out.”

We were at a fairly busy ambulatory clinic and urgent care center in Kaneohe, Hawaii. All of us took call. I remember making multiple trips to the civilian hospitals to transport patients. The active duty dependent and military retiree patients had to pay quite a bit out-of-pocket if they used the civilian facilities without consulting us first. We used to get folks driving PAST the civilian hospital to come to our ambulatory dispensary having heart attacks (I can remember one dying on the H-3 while in the car, wife driving 80 miles an hour) and  respiratory arrests (one of the most harrowing ambulance rides of my life, ever) in addition to the assorted 21-year-old Marines who never failed to learn the lesson that alcohol renders no one invincible. The lessons I learned there about the limits of an ambulatory practice setting, the triage and transport of sick people, as well as the health risks folks will take as they try to save a buck,  have stayed with me for 25 years.

I also learned some very concrete lessons on practice organization and care delivery. First, we had a very robust quality assurance program and worked hard to create a culture of quality and safety before it was fashionable. Second, against the wishes of the base commanding officer who wanted to have “his own hospital,” any attempt to be who we were not (a small ambulatory presence designed to get folks the care they need when they need it) was resisted by folks above my pay grade. Third, the Navy was experimenting with nurses in charge of practices such as this and I was extremely fortunate to work with several very good Nurse Corps OICs and learned to work as a member of a care team.

The military is a unique practice environment. The emphasis on readiness as well as wellness provides lessons for all of us in healthcare. Unfortunately, military medicine may be in trouble. The remote locations, providers who may not be invested with tours of only 3 to 5 years, and inexperienced physicians who are moved rapidly up in rank based on medical training apparently has led to problems.  The New York Times has recently published a story highlighting the downside that is worth a read. I was most struck by the quality and safety problems highlighted in the article. Physicians are apparently being placed in small hospitals with skills ill-suited for the location and/or patient population and attempting to provide care comparable to what they learned in their training. In addition, data aggregation techniques now used in the civilian world to assess quality and improve care are not in common use in the military hospitals. Leadership positions are being given to physicians who have a high rank by virtue of their residency training but limited real world or even military experience. The military is not entirely to blame. When they try to consolidate hospitals or provide care in a different fashion they are obstructed by the community, who uses their congressperson to keep the jobs local.

Our troops and their families as well as those who have retired from active duty have the expectation of high quality and safe healthcare, as does the general public. We need to equip all physicians with the skills necessary to practice in the environment in which they find themselves. Surgeons in isolated areas need to focus on doing small procedures well and leave the complex cases for hospitals with teams to provide care, whether on a military base or in rural Alabama. We need to teach how to assess and incorporate meaningful quality and safety practices starting at day one of medical school and not assume competency by virtue of a residency training certificate. The Milestone project seems to be a good start at making sure this happens at the residency level. Lastly, we need to teach leadership. Physicians are expected to be leaders. It’s time we give them the tools to do it.

“And the illusion posted to the feds is that there is a range of options available. And it seems to me that BCBS is basically using the Obamacare turmoil as a cloak for forcing everyone into higher cost plans (and blaming it on the federal law). And, well you know all that. But still.” e-mail from Bill

The system I work for charges about $120 for an office visit to those who are uninsured (increasingly the poor in Alabama). I am an “in-network” provider for Blue Cross of Alabama as well as other insurance companies. This means that I have agreed to accept payment of less than $120 from patients (typically $60 for a routine visit)  in exchange for them referring people to me. The payment generally requires the patient to cough up about $25 up front and me submit a bill (costing my practice about $10) to collect the other $35. The difference between $60 and $120 I never see and is referred to in the office as an “adjustment.” Pre-ObamaCare, I could be fairly certain that if I submitted the bill to Blue Cross I would get the $35. In addition, as an in-network physician if I ordered x-rays or blood work it was paid for no matter where the patient went to get it. If I had a lab in my office I would get paid but, since I don’t, we have a LabCorp draw station in our building. The patient walks 50 feet and stick an arm out and I get the lab results in my electronic health record.

In the post-ObamaCare days, things are a little trickier.ObamaCare required  insurance companies tell tell us a little more about what we are paying for. Remember the list of essential services? When you pay your premium there are 10 things you are supposed to get. No fine print, no bull. One of the 10 things is Laboratory Services. My friend Bill, who is self-employed and purchased an individual Bronze Plan policy (low monthly, high deductible), had an illness. His policy was through Blue Cross of Alabama. He went to an in-network physician who took 50% of what the cash payment would have been (and paid $10 to get some of it from Blue Cross). In good faith he was sent down the hall to get labs (a covered service). He just got his lab bill for $200 which is the full freight, cash price. No adjustment, no Blue Cross portion. My friend Bill, we now know, is virtually uninsured for Labs (and a bunch of other stuff as well).

Here are the fun activities you get to learn about if you have a Blue Cross Bronze plan.  Your money no longer pays for someone to negotiate rates for your labs, x-rays, or surgeries. Better sharpen your negotiating skills.  For you Bronze plans holders, they’ve already negotiated an exclusive contract with Quest who will gladly schedule that stat CBC in Foley, 25 miles away, on Wednesday (true story). Want something a little more convenient, pay full freight. You need a little minor surgery or even major surgery?  My friend Bill will get to employ one of two strategies. The first is to do what he can to get the costs as low as possible. The second will be, rather than worry about the $5 aspirin,  to forfeit his $6000 deductible up front and ask for the single room and steak dinner, secure in the knowledge that they can’t hurt him more.

Turns out that Blue Cross Silver is the plan to get in Alabama, by design. For the extra $81 a  month you pay to Blue Cross, here is what you DON’T have to do. If you need an X-ray, CT, MRI or any other imaging, you DON”T have to negotiate the price yourself. You will pay only $300 a test, no matter how expensive the test is. If you need a lab, you DON’T need to drive over 25 miles to have it done. and then ask them to only process your blood in a single lab in the state. If your in-system doctor orders it, Blue Cross will negotiate for you to get the best price possible from LabCorp or whomever.  You need a little minor surgery or even major surgery? You Silver slackers DON’T need to negotiate the anesthesia fee, surgeon’s fee, or operating room costs.

This likely isn’t tomorrow’s problem. Even with the limited price pressures in the Silver plans (by far the most common), the prices in most states are less this year than they were last year. What this illuminates more than anything else is the crazy and perverse incentives that are currently incorporated in our health care system. We in health care set our prices crazy high and let Blue Cross or some other insurer reduce them arbitrarily. The bill for surgery includes $5 aspirin and $3000 MRIs, prices that no one is expected to pay. Look for the pricing structure to change dramatically in the next 5 years with many things getting bundled together and much greater transparency. Meanwhile, Bill, I understand Humana is looking to compete head to head with Blue Cross in Alabama. You may, however, want to find out which lab they use first before changing.

ÒDaddy, can I stop being worried now?ÓText from my daughter “Should I worry about Ebola”

Text back from me “Are you considering moving to west Africa?”

My first class in medical school was in our freshman auditorium. The Dean (or someone who looked old, must have been about 50) came up to the podium and said: “This is a great time to be a doctor. When I was sitting in your seat, the person at the podium had us look to our left and to our right and then said “Of the three of you, one will not be here by the end of the 4 years because of tuberculosis.” You, fortunately, do not have to worry about that.”

Tuberculosis, I thought. What the heck is that and of course I’m going to worry about it (I remain uninfected to date).

When I was a third year medical student, AIDS hit New Orleans. I remember being on an infectious disease rotation and going into the emergency room where an emaciated man with blue tumors (Kaposi’s sarcoma, I now know) all over his body was in “isolation.” The isolation, in this case, was no one placed in the bed next to him (it was an open bay ward) and yellow CAUTION tape placed across the entrance to the bay where he had been placed. My attending, who remains a role model to me, tore the tape down and said “Whatever you THINK you are doing with this tape it is accomplishing nothing except dehumanizing this person who is ill.” The patient died. None of us on the health care team became ill.

Ebola virus is the latest illness to capture the public’s attention. Confined to west Africa unless those ill are transported, it has claimed the lives of 1427 people, about 10% of whom are health workers. Apparently my daughter’s text was prompted by the news reports associated with the transport of the American physician to Atlanta. Spurred on by movies like “Outbreak” and breathless news reports from Dakar by Ofeibea Quist-Arcton (pronunciation found here), folks here are concerned WAY out of proportion to what they should be (unless their neighbors are west African health care workers who just got back and appear mighty sick). Americans should worry about a lot of things: their diet, their lack of physical activity, their use of tobacco and guns. “Ebola” should be appear on the list below “death from bee sting” (100 Americans annually)

Turns out that Ebola is big news because people tend to make many decisions based on feeling and belief rather than based on a calculated risk assessment.  Psychologists have coined the term “Dread Factor” for the combination of

  • perceived lack of control,
  • catastrophic potential,
  • fatal consequences, and
  • the inequitable distribution of risks and benefits.

Ebola (0 deaths in America) hits the sweet spot. We humans worry more about what we can’t control, especially if the long term consequences are unknown, the potential risk is believed to be high, and there is nothing we can do to mitigate it. In “Perception of Risk Posed by Extreme Events” Peter Slovic points out that, probably as a result of eons of programming, we worry excessively about things such as a satellite falling out of the sky and hitting us (0 human deaths so far) and worry very little about backyard swimming pools (10 Americans die A DAY). Makes setting public health policy difficult. If you don’t believe me, look at the backlash regarding Michelle Obama’s healthy children initiative to reduce obesity (1375 American deaths A DAY).

Fine, you say, I know that smoking is unhealthy. What I don’t want to do is die from Ebola.What can I do? Turns out, a lot.

As a health care consumer, make your concerns known. If not dying from Ebola is the most important thing to you, let your doctor know. He or she might suggest something simple, like avoiding travel to the remote villages of west Africa. Meanwhile, take some time to understand why worrying about other elements of your physical well-being might be more useful in the long run.

As a health care professional, don’t just dismiss your patients’ concerns. Listen to them and provide information about why these fears might be unfounded. By the same token, don’t take advantage of your patients’ irrational fears. Providing excessive testing is expensive and often is less helpful than a frank discussion on risks.

We humans react instinctively (on feelings) and intellectually (based on rules and empirical evidence). We often make decisions based on feelings (I am unsafe and need a gun) that run counter to evidence (a person with a gun is 22 times more likely to kill a family member than a bad guy).

As physicians, much of what we do (and don’t do) affects health in a limited fashion. Perhaps we need to get better at helping people to overcome their own barriers to achieving health instead of offering tests for scary things we know aren’t going to happen because “the patients want them.”

I am taking a summer away from some of my daily and weekly tasks to focus on other things. I am spending my time helping to redesign our healthcare system to prepare for the transformation of Alabama’s Medicaid into an Accountable Care Organization which is scheduled to occur in 2 years. This will take a lot of effort on the part of a lot of people to accomplish but in the end an effective Medicaid program is something that we in Alabama need.

I have written this blog, in part, so others will take up the cry for affordable, accessible health care for America. Although the ACA is not perfect, it is the law that we have. I am heartened to see others take up the mantle. In today’s newspaper, two UA-Birmingham medical students have written an essay asking the people of Alabama to see past their prejudices and support the expansion of Medicaid based on their experience volunteering in a free clinic.They use the case of Ms C, a woman who suffers from difficult to control blood pressure and no insurance, to illustrate the need and then close with:

As Alabama continues to refuse Medicaid expansion, we witness the fallout every Sunday. For all of us, it is frustrating to think about how a preventable illness such as Ms. C’s high blood pressure, can cost so much for our healthcare system and for an individual’s well-being because it went untreated.

As care providers at the free clinic, we must swallow the hard realities of the current healthcare environment and watch our patients do the same. As future physicians, we worry about practicing in a state where the most downtrodden among us are overlooked. And as your fellow Alabamians, we hope that this state will prove to be one that looks past ideology and supports our neighbors in their toughest times.

Rethink coverage. Expand Medicaid.

Have a productive summer.

News item:

vcm_s_kf_repr_268x188

 

On the NPR show “Wait, Wait, Don’t Tell Me” when this item came up one of the panelist suggested that this was an evidence-based decision. Perhaps a study of homeless people had been done and they had all sung the “Crayon Song” one too many times. Big audience laugh…

As a parent, we want a lot for our children. We want them to have a good life, to work hard but not too hard, to enjoy beauty and the company of others, and to have a family of their own to torture them like they tortured us. To this end, schools function to provide content that our children need to learn but also contribute to the rest of this as well. By ignoring any outcomes but college acceptance, we diminish the other aspects of education.

The two pillars that predict community success are educational and health care infrastructure. Measuring both has been fraught with peril.  Like Justice Stewart said about pornography, we know good schools and good healthcare when we see it. Unfortunately, that metric, like pornography, is difficult to quantify. In the Mobile   public schools that my children attended, there was a metric of “total scholarship money offered.” This was a particularly weird metric that encouraged the students to apply to colleges they had no intention of attending so they could receive a reportable scholarship offer. The healthcare metric, “Providence Hospital is MY hospital” is likewise not a good metric. If you go to the government’s hospital compare website (found here) you’ll swhat are good metrics.

Commonwealth has just come out with the latest report on the state of our county’s health (found here). We as a community once again fared poorly. Out of 306 health regions, we are listed at number 270. Of the 43 metrics that are used to assess our health system’s performance, we were excellent in one and very poor in 13. We were rock bottom in 3. What are we best in? Nurse response to call lights and home health wound healing. We are rock bottom in preventable mortality (people dying early) and people who have lost 6 or more teeth.

Mostly, it turns out that good schools reflect a critical mass of motivated parents who are willing to pay extra to attract good teachers and work harder to help their children achieve. When that happens, the halo effect tends to help others to achieve as well. Health care quality, it turns out, also is dependent on insurance status, educational attainment, regional income, and engagement of people in their own health. To improve education or health care delivery, it takes a village.

People want to live in areas with quality education and healthcare. I can only hope we can find a metric other than early ABCs to measure kindergarten quality with.  I also hope that our doctor governor accepts the health care metrics and charges us to work together to improve them, rather than force us to live in denial and in a broken system.

 

Libertarian-LifeguardsWhen I was a child there were only 3 channels on the television (and yet, folks found something to watch, go figure). One of the commercials that it turned out was foreshadowing for the loss of our textile industry to Chinese sweatshops was included a catchy song that went “Look to, the union label, when you are buying that coat, dress, or blouse.” We as kids would sing it as our mothers took us to the discount store to purchase knock-off tee-shirts for half the price of those high-falootin Jockey ones. Although they were clearly of poorer quality (and the tags itched) they did cost a lot less.

In America today, goods have become fungible. The source of origin is unclear, in part because Egyptian cotton might go to Bangladesh to create a tee that has an American rapper’s face on it. Since I work in a service industry with access limited by licensure, I don’t worry about outsourcing. Here in Alabama, though, there are a group of economists who want to change that.

Troy University’s Manuel H. Johnson Center for Political Economy, which I have written about before, has decided to take on Alabama’s licensing laws. Daniel Smith, professor of Economics, has published a “study” where he determined that 25% of Alabama workforce being required to have an occupational license is too many. Health professionals are one of the groups he singles out for his bureaucratic reduction act. In doing so, he cites a position paper from the libertarian leaning Cato Institute that argues 1) Defensive medicine is what protects you from incompetent physicians, not licensing; 2) Defense lawyers  are actually quality control monitors; 3) Specialty boards provide more quality control; and 4) People would pick quality over price if given enough information.

What bought the study to my attention was “Koch Brothers endowed professor” Scott Beaulier’s, editorial at al.com. It includes the circuitous argument that licensing limits the supply which limits access so more people get sick, and if only we could expand access by allowing unlicensed health workers there would be fewer sick people. Huh? He claims that once one person’s house wired by Bubba the shade tree electrician burns, others will shun Bubba and he’ll go out of business. Same thing for doctors, I guess.

In the 45 years since the commercial, unions have lost almost all of their sway. Americans demand clothes made so cheaply and with so little regard for those involved that when we find out 800 Bangladeshis are injured annually while making $7 tees we shrug and continue to seek out even cheaper options. I look forward to the Libertarian state of Alabama where we all get to be quality monitors. As they say on the Simpsons, “Hi Dr Nick…”

 

children-claw-claw_machines-arcades-arcade_games-little_boy-awhn203lWhat passes for news these days is tough to judge. Newsprint on a national basis is a dying (or dead) medium for transmitting information. Our local newspaper has move to a hybrid online-print format where now we can read LOST TODDLER FOUND IN CLAW MACHINE both 3 days after the event when posted on-line after a slow news day and again in print 5 days after the event. Scanning various content sites seems to be the way to get information in an organized fashion, but that is time consuming. My 20-something daughter goes to Reddit, where readers post content and then other readers vote it up or down. In a way simplifying the process (if 2000 other people think it is important it must be) but in a way limiting you to what other 20-somethings think is important (is the fact that a TWENTY-TWO-year-old crew member saved people on the Korean ferry disaster REALLY the most important story of the day?).

Older people tend to watch the news networks. People of a certain age interested in food stamp fraud watch Fox, and folks interested in airplane abductions are going to CNN these days. Big stories tend to get on-site coverage. But a lot of the “little stories,” ones that are of the human interest variety, often contain incomplete information and are simply put out there to reverberate over the internet with no context and no analysis of what happened. Such is the case, I suspect, with the rogue mammogram tech (688 Reddit votes). The story in the CNN/Fox/news.google world is that this mammogram tech (Rachael Rapraeger) got “behind in her work” and took it upon herself to enter “normal” into 1200 mammogram reports rather than walk the mammograms down the hall to the waiting radiologist. Two women died of their diagnosed-too-late breast cancer. For this Ms. Rapraeger took a plea and will do jail time. Another bad cog in the best health care system in the world machine, thankfully caught before she could do even more harm.

The Macon news offers a little more in-depth coverage today and suggests the story might not be as cut and dried:

  • The tech’s job consisted of performing the mammogram and then either creating a file jacket for a new patient or updating an old file jacket. She was then expected to walk the file with the mammogram film down the hall and give it a radiologist to read
  • The process of creating or updating the file jackets was apparently extremely time consuming for Rapraeger, who chose instead to enter the negative results over a period of months using the radiologist PIN numbers given to her by hospital staff rather than provide the radiologist with the films
  • Immediately after she was terminated, the suite was converted to digital and the machine, hard drive of the computer, and in many cases the films themselves were destroyed.

As a physician with an interest in health system design, neither of these articles answered my questions. If I were the journalist these are the questions I would want the answer to:

  1. Didn’t the radiologist think something was up when day after day he sat in that dark room waiting for mammograms to be delivered to him and none ever came, despite the fact that 15 people a day were walking in and out of the mammogram suite? Did anyone submit the bills for these?
  2. Did the tech really have EVERY radiologist’s PIN/electronic signature (there are about 8 that went to that hospital) and if so, how did she get it? Did these radiologists then bill for the reading? Who else at the hospital has the ability to enter physician specific information over their signature? Did the hospital think this might be a problem?
  3. Didn’t the hospital find it fishy when no positives were being reported out of their system over a period of several years? The positive rate is normally as high as 25% over several years. Are other tests besides mammography showing normal results, but actually not being done at all?
  4. Whose idea was it to destroy the records (and apparently many of the old mammograms) during the renovation?

I suspect folks with an interest in claw machines could ask the same kind of questions (and based on the comments, many would like answers to their claw related questions as well). I just have to wonder if the person who puts the toys in the claw machine is ready to do jail time, because the lowest person in the pecking order at Perry Hospital is about to.

 

So last week I talked about how physicians make money not just off of seeing patients but also off of the “mark-up” for medications given in the office. I was asked by the editorial writer at al.com what I really thought and here is what I said:

1) This is only one payer although these are the most expensive patients for the most part. In Alabama, physicians make most of their money form BC/BS so this is only a part of the picture

2) The number is not the take home pay. Think of it as an inventory that they sold. Having said that, physicians take home a lot of money. Orthopedists took home over $400,000 on average in 2012. Even he lowest paid took home $175,000. To do that, though, they shave a little off of everything on that list.

3) There’s a lot on that list that physicians sell that doesn’t make the patients healthier. Next time you as a patient are offered a steroid shot for your cold, question whether or not it is necessary or might it contribute to the chance you will get diabetes. Doctors are doing a lot of stuff to people because people expect it and because insurance pays for it. Under the new insurance plans a lot more little stuff that doesn’t work like steroids for colds will be paid for out of the patient’s pocket. Having a doctor you trust might allow you to ask “is this really necessary?” In fact, you might even be able to ask it via e-mail.

THEN I was asked to put it into layman’s terms and (with A LOT of help from others) we came up with “The tomato version of Medicare spending.” I  will suggest that you go here to read it if you want a neat explanation or ever went to the store hungry for a tomato sandwich and ended up with heirloom tomatoes, foccacia, Maytag blue cheese, and a bill for $200 and wondered “why did I do that?”

crime_writing_comic-scaled500Wayne Tarrance: How about you get down on your knees and kiss my ass for not indicting you as a co-conspirator right now, you chickenshit little Harvard cocksucker?

Mitch McDeere: I haven’t done anything, and you know it!

Wayne Tarrance: Who gives a f**k? I’m a federal agent! You know what that means, you lowlife motherf**ker? It means you’ve got no rights, your life is mine! I could kick your teeth down your throat and yank ‘em out your a**hole, and I’m not even violating your civil rights!

From The Firm, a novel by John Grisham. In it Mitch McDeere graduates from law school and takes a job for a lot of money with a prestigious law firm, then discovers that they (and by extension he) are working for the mob. The discovery is courtesy of Federal Agent Tarrance.

We have 77 students in our medical school class. They chose their “senior advisors” this week. These are the people who will guide our students through the complex career choicces leading to a  a residency. There are specialties to chose, audition rotations to plan, and interviews to schedule. We had 3 select family medicine as their potential specialty. This is as opposed to 13 choosing surgery, 9 choosing psychiatry and 9 choosing medicine-pediatrics. Not what we want to see out of our class and, as only 4 chose family medicine from last year’s class, we have been doing some departmental soul searching.

As opposed to the other clinical rotations at our school, we send our students out with physicians in practice. We tell ourselves that this pulls them out of our safety-net hospital environment and teaches them what the real world is like. We also interview our students after their clinical rotation in family medicine. What we are discovering is that this exposure to the “real world” is turning them away from primary care in general and family medicine in particular. The most painful was the student who said “I can see myself doing Family, but I think I am going to do psychiatry. Family doctors don’t know their patients.” On the psychiatry rotation, we have found out, they see 3 patients a day, Monday through Friday. As students they really get to know these patients. It seems that the life of a psychiatrist seeing 3 patients a day has a certain appeal.

The federal government has released the payment information on physicians who took Medicare in 2012 (found in a searchable database here). Turns out, the Internal Medicine faculty member in our institution most engaged in teaching medical students took care of 32 Medicare patients in the hospital in 2012 and oversaw 100 outpatient visits. The psychiatry attending admitted 16 inpatients who stayed about 4 days apiece. Although they take care of other types of patients (these are only the ones over 65), they probably both had a lot of time to interact with students.

One of the community family physicians we send our students to had about $100,000 in Medicare payments in 2012 and the following numbers:

  • 815 office visits at $39.33
  • 179 less intensive office visits at $26
  • 89 more intensive office visits at $56
  • 66 hospitalized patients who were in the hospital an average of 4 days. He (or she) made $143 for the initial visit, $52 for the other hospital days.
  • Gave 264 steroid shots at 18 cents apiece.

These numbers are what goes to the practice, not home with the physician at the end of the day. Half of that, as our students are no doubt told, goes into paying the people required to generate the bill to get paid by Medicare.

Had the students spent time with the busiest community psychiatrist in town (based on $157,000 in Medicare payments), they would have seen a doctor with almost 660 hospital visits, over 200 nursing home patient visits and who supervised 300 medication visits with the medication given by a therapist. With the busiest community oncologist ($1.7 million)? Over 40,000 injections of levoleukovorin.

In The Firm, Mitch realizes, too late, that “the law” he learns in law school is not the law he signed a contract to practice at his new law firm. I’m afraid that in our Family Medicine clinical rotation we are providing a dose of unwanted reality to the students. They are seeing that the business of medicine is a lot about running people through as fast as you can in hopes of getting the insurance company’s $20 (or, in the case of triamcinalone, $0.18). As a consequence, the students are voting with their feet into other specialties only to find, once out, that to make the big money you have to sell a lot of antibiotic and steroid injections no matter the specialty.

I’m afraid that unless the payment structure changes, chasing $20 bills is what the real practice of medicine is about. Maybe to increase interest in family medicine we just need to do a better job of hiding this inconvenient truth from our students until they go into practice. As Mitch McDeere found out, it’s not like you can leave.

 

Price Conscious 512My wife is reading (or listening to, I can never tell which) a book about “private life” (called At Home).  One of the vignettes is about the development of safe drinking water. The central character in this story was John Snow, a physician living in London in the time of cholera (temporally in the 1850s). The legend is that using a map (this was the first documented use of a map to determine the source of an outbreak, very cool stuff) he plotted the cholera deaths and placed them proximate to a fresh water concern on Broad Street. He attempted to get the local government to act on his theory that the water pump was contaminated and the cause of the outbreak. Convincing the authorities (the local Board of Guardians) to remove the handle, he is credited with stopping the outbreak (or at least preventing a resurgence in the neighborhood).

A couple of things about this story. First, Doctor Snow had lived through a previous outbreak of cholera several years earlier, and as a consequence he was unconvinced of the prevailing theory that miasma (bad air) caused the disease. His theory, that the disease was limited to the gastrointestinal tract and death was caused exclusively by dehydration, was consider not a little kooky. He was working on very little evidence as the existence of a cholera organism, though described in Florence roughly at the same time, was unknown to physicians in London. Robert Koch, the man who really put germs on the map as causative agents of disease, would not develop his postulates until 30 years later.  Doctor Snow, it turns out, was looking for an opportunity to test his theory, and the St James Parish outbreak happened to have everything he needed (water contaminated with sewage with little competition from clean water and so delicious that people knew of pump by name, people who were dying of cholera at a fast clip, and a Board that was willing to try new things out of a sense of responsibility to their parishioners). As luck would have it, the water was VERY contaminated (wash water from an infected baby’s diapers and fresh water kinda mingled right where the pump intake was) and so the intervention was successful. John Snow lives on as a medical hero.

Not everyone bought into the “drinking water causes disease” meme for a couple of reasons. First, miasma as a cause of disease had a lot going for it. If God made things smell bad, it must be for a reason, amirite? Second, because bad smells and disease tended to intersect where poor people lived, bad things must be happening to “bad people.” The slums were filled with people moving from the countryside during the Industrial Revolution, people who “were not nice people.” Therefore, in the Victorian age “the miasmas that seemed so prevalent among the poor slums were seen as God’s punishment for immoral lifestyle.” Over time, the sanitarian won and, by first building sanitary sewers and providing drinking water and later providing vaccinations, outbreaks of diseases like cholera and polio were conquered.

So, in this country we are heading into our own Broad Street Pump moment. 26 states have elected to take full advantage of the Affordable Care Act, including expanding Medicaid to those who make below 138% of poverty as a sole qualifying criteria. In these states, Medicaid rolls have grown by 8%. This means that more than 3 million adults will have the security afforded by knowing they are not one illness away from bankruptcy. They will have access to care for complaints such as “blood in my stool” which would have gotten them triaged out of an emergency room before but now, under the right circumstances, a colonoscopy to find and cure their colon cancer. They will get treatment for bladder infections, pneumonias, and cellulitises without needed to get so sick as to require hospitalization.

24 states, including Alabama, have not expanded.Their rolls have expanded by 1%. These folks are mostly working, some at several jobs. They are using their common sense to tell them when to seek expensive care. I f they guess right, bankruptcy and an opportunity continue to work and pay off medical bills. If they guess wrong, death from a preventable illness. Meanwhile many, including public officials, are convinced that they are uninsured because they are undeserving.

So, who will be our John Snow? Who will look at those dying from a lack of access in states like Alabama and say enough? How many deaths from preventable conditions will it take? Anyone know how to use Google Maps?

 

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