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Parent: My child had a fever last night to 102 degrees and isn’t taking in anything. He’s one year old tomorrow

Me (looking at what appears to be a very ill child): Does your child have any other medical problems? Are his vaccinations up to date?

Parent: We were waiting until after his first birthday. We were afraid of the vaccines.

germ theory n. The doctrine holding that infectious diseases are caused by the activity of microorganisms within the body.

The local web log decided to weigh in on the vaccination controversy last week. In an article that presented both sides equally weighted, several physicians were quoted as imploring their patients to follow the vaccination guidelines. Speaking against vaccination, Michael Bucknell, DC, BS was interviewed:

Bucknell said that many parents who choose not to vaccinate their children don’t just stop at reading one blog. “I’ve never met a parent who heard one study and said I’m not going to do it,” Bucknell explained. On his business website, Bucknell has listed numerous articles he cites in his decision not to vaccinate his sons. He also said his oldest who is 10 years old was sick for the first time in his life recently.

I really don’t want to litigate the germ theory of disease in this space though it turns out there is a long history in chiropractic thought, beginning with Palmer, of disbelief of germs as a causative agent and thus vaccination as a mechanism of prevention. Let’s concede that although not all human disease is caused by germs and not all exposure to a germ leads to disease, there is a lot of overlap between germ exposure and diseases linked to the germ. For those of you who are unwilling to concede this, you can stop reading here and move onto this article. If you have doubts but are “germ questioning,” here is a very nice article about why your personal observations (I smoke and don’t have cancer) often conflict with empiric evidence.

Now that they’re gone, let’s address the broad issue of vaccine safety and the more narrow issue of what the kids won’t catch. First, to the broad issue of vaccine safety. Turns out over half of parents have such concern with a quarter of them specifically thinking the vaccine will increase their child’s chances of being autistic. As the media clearly is unwilling to pick sides on this, let me help (thanks to the American Academy of Pediatrics):

Almost every vaccine contains an immune stimulator (antigen) in a liquid (adjuvant). If you are worried about the adjuvant having mercury – the type of mercury found in thimerosal is  ethylmercury which is broken down and leaves the body very quickly and has NEVER been shown to be harmful. Because of parental concern, however, anything that contains the word mercury has been removed from almost all vaccines given to children (some influenza preparations are the exception).

If you are worried about the adjuvant containing aluminum (used to boost the effect), there is less aluminum in the shot as there is in a weeks worth of formula or breast milk. We need it to live.

The vaccines work by exposing the body to a part of the germ, allowing the body to develop an immune response the first time it is exposed. Many people are concerned that this “revved up” immunity leads to certain disease, specifically autism. The initial autism correlation was based on a bad study where scientists lied, a study that has since been retracted from the medical literature and described as an “elaborate fraud.” There have subsequently been A LOT of studies that fail to show any correlation.

Lastly, many parents worry about “why so many shots?” Through vaccines, we protect against 14 diseases. To do that it takes a lot of shots, given that it takes about 3 shots 6 months apart to confer immunity to a specific disease. Why so young? Many of the diseases that kill children occur prior to the child turning 2. In perspective, however, we expose the child to 150 antigens over the entire schedule through the age of 2. That same child, eating doodle bugs outside, is exposed to up to 2000 antigens a day.

As a medical student, I cared for children who became seriously ill from Haemophilus Influenza B. It affected approximately one child in every 1000 and in New Orleans we would almost always have 2 or 3 children in the pediatric intensive care unit on a ventilator because of it. Of those, one in 10 would die and about 1/3rd of the survivors would be deaf or neurologically devastated. The HIb vaccine was introduced into the vaccine schedule in 1989. With vaccination, the occurrence of the disease is for all intents and purposes, 0. I haven’t seen a case in 25 years. This is why I believe in vaccines. What can I do to further convince you?

My wife: Why is Obama making people buy insurance policies that cost 8% of their take home and pay for “not much”

Me: Don’t blame me, I voted for “single payer”

My wife is involved in the enrollment process for the Affordable Care Act. Last year she enrolled many folks who were grateful for their newly found access to health care. This year she is finding a that many folks didn’t pay for health insurance previously because a) they are reasonably healthy and b) they realize that they are paying for, to coin an expression, crap.

What her clients, and everyone else in America, is painfully aware of is the following (complements of Dissent Magazine):

In America we spend a lot of money and get worse outcomes than folks who live in other countries. Some of our excess mortality is due to car accidents and gun violence but there is general agreement that even once that is accounted for, we don’t get our money’s worth. Why?

As a rule, we pay more than our peers for the same health care goods and services (especially drugs). Much “health spending” is wasted on administrative overhead, on marketing, and on the important business of figuring out who is insured and who isn’t. And that spending is starkly uneven, lavishing services on those with good insurance coverage and bypassing those without.

Here in Mobile, we finished celebrating Mardi Gras today. This is, in the words of my son, a very weird celebration. For 3 weeks, people eat, drink, and dance to excess. The streets are filled with vendors that sell such delicacies as fried Oreo cookies. The parades themselves feature folks throwing moon-pies by the thousands to the crowds. Today, tens of thousands of folks were out today cooking lots of meat over open flames and drinking lots of adult beverages.

Today was Mardi Gras day. It features a parade, the Knights of Revelry, with the lead float featuring Folly who, using pig bladders, calls attention to our excesses.

Mardi Gras 2010 096Then, at the end of the day, Folly reappears being chased by Death.

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Legend has it that, at the end of the parade, Folly wins out. However midnight invariably comes and Folly is put away for another forty some-odd weeks.

As my wife has discovered, we have been throwing the equivalent of a “carnival” diet for healthcare. We throw a lot of care at the wrong people and not enough at the people who need it. As a consequence, we are now requiring folks to spend up to 8% of their income or risk a penalty.

Here is Mobile, after today, moonpies will no longer fall from the sky. One has to fry ones own Oreo cookies if he or she has a hankering. The parade barricades go away. Perhaps people will demand more disciplined health care spending as well.

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Me: Ms G, you have atrial fibrilliation and a lot of other medical problems. That means that your heart can form blood clots that go to your brain It is REALLY important that you take the blood thinner the cardiologist put you on.

Ms G: I know but he gave me this Elliquis and I just can’t afford it. My Blue Cross charges me $140 a month for the medication and that’s just too much

Me: There are much cheaper alternatives. Warfarin, for example, can be used very safely and keep you from getting a stroke.

Ms G: He never even mentioned that to me. Can you talk to him?

When this happened this past week, I was a little irritated. Ms G is not the easiest patient to care for and now I was having to deal with a problem not of my making. After making several phone calls we switched the Elliquis ($275 a month, $140 out of pocket to my patient) to warfarin ($6.50 a month plus $24 in monitoring costs, less than $10 a month to my patient) and everybody left happy (and late). Eliquis and other expensive blood thinners offer only a marginal improvement over warfarin and they do it in a very expensive manner. They reduce of the risk of stroke over 3 years from 16 stokes per 1000 people treated with warfarin to 12 stokes for people taking the newer medications. Of those 1000 patients, an extra one (2 vs 3) on warfarin will have a major bleeding problem. While an advantage, my patient chose not to trade $1200 in food money to do this and instead made the decision on her own to triple her risk of stroke (10 strokes per 1000 annually in those untreated with atrial fibrillation and her other conditions) by not taking anything. My patient is now on warfarin and presumably much better protected from having a stroke. Why was my patient not offered the opportunity to make a choice between the new improved method OR the tried and true method?

May have had something to do with marketing. As was pointed out last night, Americans have an expensive ($330 billion) prescription drug habit. The habit not only pays for the pills (a very small part of the cost) but also the payments to doctors who do the “education” of their colleagues. In 2013 this education cost Americans $24 billion, with marketing accounting for more than research in 9 of 10 companies. In the words of John Oliver “Drug companies are like high school boyfriends: they are more interested in getting inside you than in being effective once they are there.” Bristol Meyer Squibb spent an estimated $20 million in 2013 to “educate” physicians regarding the advantages of Elliquis over warfarin in stroke prevention, with about $15 million going to physicians to extol its virtues to other physicians. I don’t know if that was the reason for the oversight. To be honest I suspect in my patient’s case it was mostly ignorance of my patient’s social situation by the cardiologist that caused my long day.

At least my patient didn’t die from an overzealous sales force. Every day, 46 people die of prescription narcotic overdoses in the US. In Alabama in 2012 there were 140 narcotic prescriptions written for every 100 people. We really don’t need folks selling doctors on selling more narcotics. However, in 2012 a potent narcotic (Fentanyl) was introduced in a sublingual spray to compete with others similar preparations (Fentora and Actiq). These medications typically have, as their very specific indication (the reason to give to a patient), cancer pain not responding to around the clock narcotics. Insys, the company that makes Subsys, spent an estimated $6 million to educate physicians about this drug in 2013. I have to admit, until I read the Propublica article, I had not heard of it. As I don’t treat many patients with intractable cancer pain, that did not particularly surprise me. They only spent $44 a meal to educate 5,000 physicians. They did pay for 775 educational events (paying a physician $2,500 to talk about the drug every time) and hired 189 consultant physicians at $2,370 each. I guess they had to get the word out. Problem is they were and are getting the word out to the wrong people. Less than 1% of the prescriptions were written by oncologists. The product was a high potency narcotic of which there were already others on the market (a “me too” drug):

The former sales employees said that while the company targeted some oncologists, it placed more focus on high prescribers of competing products like Actiq and Fentora, regardless of whether those doctors treated cancer patients. They also said they were trained to mention the restriction to cancer pain at the beginning of the sales pitch and then to move on to a more general discussion of “breakthrough pain” in the doctors’ other patients.

Not only did Insys not worry about its drug getting into the wrong hands, it kind of counted on it:

Comments from a Wall Street analyst underscore that view. “As Subsys grows more mature, we expect the number of experienced patients to grow,” Michael E. Faerm, an analyst for Wells Fargo, wrote last year in a note to investors. “As the experienced patients titrate higher, the average dose per prescription should increase.”

The company used physicians who had problems with the DEA as their speakers and unorthodox methods to motivate its sales force. A cursory review of the Opiophiile forum reveals that their product is a success, with many addicted individuals enjoying the convenience and simplicity of the medication, with some even ingeniously discovering they can use it intravenously…just like heroin. Also the boards attest to the effectiveness of the marketing strategy.

Shelley, my doctor recommended it to me pretty much as soon as it came out. He said that the company that makes them wanted him to be a representative for them or something like that.

No wonder sales have increased 400% in the most recent quarter over last year and people are bullish on Insys’s prospects. in fact, investors only got skittish when a physician in Michigan who accounted for 20% of the drug sales lost his license. Fortunately for investors, their “medical marijuana” product is about to come to market to broaden the Insys portfolio and the market cap is back up.

Don’t get me wrong, I am by no means anti-medication. In fact, only 30% of people who would benefit from warfarin or related blood thinners receive them in the correct dosage and we need to work to use this inexpensive drug more effectively. I would personally prefer to find a different way to get the Opiophile readers their fix (with entries such as “Fentenyl patch, shootable” I am concerned their might be a lot of misuse in that community). Most importantly, as a profession, let’s stop shilling for Wall Street. I’m sure they’ll do fine without us.

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Remember the song, “We’re # 37“? It came out in 2009, the beginning of the debate about the ineffectiveness of the American healthcare system and the need for change. The video went viral, more because of the catchy tune and cute visuals, I’m afraid, than for the message. Here we are 6 years later and even with the Obamazation of health care our system is still last in the industrialized world. We still do not offer access to all of our citizens (witness the 24 states that deny access to the working poor), Our system remains very inefficient with 30% of spending wasted on inefficiency and unnecessary care. We deny people access to measure proven to extend lives and do so in a manner that punishes those of color disproportionately. Worse, we do it in a manner that costs twice as much as other industrialized countries, with most of that money coming from taxpayers.  .

As a part of a class I am taking, I have been reading a lot about change management. This weekend, I read John Kotter’s book Leading Change. In this book he identifies 8 components necessary to change an entrenched system in the business world:

  1. Establishing a Sense of Urgency (people need to sense that the platform is on fire before they jump into the ocean)
  2. Forming a Powerful Guiding Coalition
  3. Creating a Vision
  4. Communicating the Vision
  5. Empowering Others to Act on the Vision
  6. Planning for and Creating Short Term Wins
  7. Consolidating Improvements and Producing Still More Change
  8. Institutionalizing New Approaches

Why are we still last? It appears that we skipped the first step. Most people never use healthcare at all. thus they are unaware that the platform is burning. Or, even if they do, it is for an urgent problem (my throat hurts, I have a cough) and our system is really good at getting folks in and out for self limited problems in a very expensive manner ($111 to tell you “It’s a cold, live with it“). For the 20% who need our system a lot, the system has moved most of the costs to the taxpayer, so the true costs are hidden. Of course, this is after the family has bankrupted themselves but the expression “blood from a turnip” comes to mind.

Turns out that part one of the Obamazation was “getting all people access” and that wasn’t even in Kotter’s book. Part two, “transform the system”, started last week. Sylvia Burwell, secretary of Health and Human Services, announced last week a series of sweeping Medicare payment changes.  In effect, the platform has been set on fire. The changes moving 50% of the money from fee-for-service to quality by 2018 with an interim goal of 30% by 2016. What does this mean?

[The adminstration] plans to tie 85 percent of all Medicare payments to outcomes by the end of 2016 — rising to 90 percent by 2018.

A subset of those payments — 30 percent in 2016 and 50 percent in 2018 — will have to be part of what the government calls “alternative payment models.” These are contracts where groups of doctors and hospitals and pharmacists — a big enough network, essentially, to cover a patients’ whole spectrum of health care needs — get a lump sum of money to take care of a set number of patients.

This, in addition to the 40% of commercial contracts that currently include a value component, means that over half of all dollars in health care will be contingent on quality. Is that smoke I smell?

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2645472-moon1“To him who devotes his life to science, nothing can give more happiness than increasing the number of discoveries, but his cup of joy is full when the results of his studies immediately find practical applications.”

—Louis Pasteur

Henry “Moon” Mullins was the founding chair of the department of which I am now the Chairman. He trained at Tulane (as did I) and was in private practice for about 20 years in Fairhope Alabama when he got a call from Fred Whiddon, the founding President of the University of South Alabama. Dr Whiddon wanted to see if he would consider leaving his practice to create a Department of Family Medicine in Mobile, which he did. When I met him, in 1991, he was in 64 and had just completed a sabbatical studying medical infomatics at the National Library of Medicine. As a resident and later as junior faculty, I would have long discussions with Moon about how to get  “docs” to practice based on best practices rather than using techniques and information obtained during training (regardless of how many years ago) or for better or worse, from pharmaceutical reps.

In that discussion, we would often mention the problem of diffusion. From an article in 2006:

Studies of dissemination of evidence-based guidelines (aka, consensus statements) suggest that awareness varies widely across medical subspecialty, with awareness ranging from as low as 20% among cardiac surgeons to 90% to 95% among obstetricians.17 The dissemination gap for clinical research also has a time component. A review suggested that it took an average of 17 years for 14% of original (i.e., discovery) research to be integrated into physician practice.

17 years seemed to me like a very long time. Why so long? Many people my age have stained teeth from tetracycline, a miracle antibiotic that was introduced in the 1960s. For that antibiotic, it wasn’t 17 years but 17 months before 90% of physicians were using it. The combination of its remarkable effectiveness and peer pressure from early adopter colleagues was enough to overcome physician inertia. Many discoveries though, such as the life saving effect of beta-blockers for a year following a heart attack, are not given to all eligible patients even today, more than 20 years after the data was definitive.

Today, appropriate beta blocker use varies regionally from 68% to 92%. What is surprising is the factor that predicts the best who will get the appropriate medication: Tractor use in 1940.

The introduction of hybrid corn in the 1930s and the introduction of tractors in farming was not via a disruptive innovation model. The first states to have over 10% of farmers planting high yield corn and using tractors? Illinois and Iowa in 1935. The last states (1948)? Alabama and Georgia. Being a “late adopter” state for these technologies correlates strongly with being a late adopter for the use of beta-blockers after a heart attack. For example, Alabama was last to adopt tractors and to adopt beta blockers.

What set apart the early adopters? One of the factors is having folks (farmers and doctors) talk to each other in informal settings. We late adopters need to pay more attention to having quality information exchange among health professionals. Another is that, educationally, a rising tide floats all boats. A better educated populace demands better care. Lastly, innovation likely didn’t occur because it was more profitable to wait. Second-mover advantage, risk aversion, and uncertainty are powerful de-motivators. We need to change the incentives such that physician are paid to do the right thing.

Moon is now 86 and calls the department every now and again to check on us. As a department, we continue to work on ways to encourage physicians in Alabama to “do the right thing”  and overcome our historic tractor disadvantage.

Thanks, Moon, for starting us on this journey.

140428_cartoon_054_a18174_p465According to new research by Emmanuel Saez of the University of California at Berkeley and Gabriel Zucman of the London School of Economics, the richest one-hundredth of one percent of Americans now hold over 11 percent of the nation’s total wealth. That’s a higher share than the top .01 percent held in 1929, before the Great Crash.

We’re talking about 16,000 people, each worth at least $110 million. Robert Reich

None of my patients, that I am aware of, has $110,000,000. No one I know has a private jet.

My patients are more likely to have cars that are unreliable. They get rides from strangers to get to their appointments. They catch a bus  that is so unreliable they ride all morning for a 2:30 appointment and then spend the rest of the evening getting back home. I saw a patient last week who had kept her child home from school for a week with asthma in part because she couldn’t get a ride from her house and there is no bus that goes out that far. Perhaps a jet would have helped but I doubt it.

What does help my patients is Medicaid. About half of the folks that we see have Medicaid. In Alabama, as I have said before, one needs to be VERY poor to qualify for Medicaid, so these are folks that have a lot of other problems associated with poverty as well. My residents and I spend a lot of effort working around transportation issues, dysfunctional family issues, and other “social” issues. At times, the task seems overwhelming.

Referred to as the social determinants of health, this term describe “the array of complex forces that shape and influence the public’s health, often out of clinician sight. These include poverty, income inequality, lack of access to affordable and nutritious food, lack of educational and employment opportunities, violence and racism.” In a recently completed well designed study, investigators showed that access for poor people via Medicaid leads to higher wages, fewer arrests, and a greater likelihood of college graduation. These things in turn lead to better health. Other studies are showing that permanent supportive housing for folks suffering from mental illness goes a long way to reducing the cost to the public of these individuals. People who live in food deserts are more likely to be poor, obese, pay more for healthy food, and make unhealthy choices.

We do as much as we can in our exam room but me, my residents, and my patients
need your help. First, Medicaid is increasingly shown not to be a “broken system”  but life saving to those in need. Support expansion, especially here in Alabama where many are one illness away from bankruptcy. Secondly, while many things contribute to poverty, substandard housing and expensive, unreliable transportation contribute the most. Support policies that mitigate the effect of these such as housing subsidies and transportation alternatives. Third, obesity and related diseases (heart disease, diabetes, arthritis) are clearly related to food policies that benefit agri-business. Buy local and support those who do as well as supporting policies that increase access to healthy food. Lastly, educational attainment predicts economic success with college graduates earning double that of non-college graduates. Support policies that lead to better access to education.

Also, if you are in the top 0.01%, you could give up your private jet and give the money to our residency. Please contact me off-line for this one.

leo-cullum-expert-witness-new-yorker-cartoon1“Childbirth is something that is primitive, ugly, nasty, inconvenient,” Simone Diniz, associate professor in the department of maternal and child health at the University of São Paulo, said. “It takes long, and the idea is we have to make it fast. It’s impolite for doctors to leave cases for the doctors on the next shift–there’s a sense that you need to either accelerate it or do a C-section.”

From an article about C-section rates in Brazil

The World Health Organization has decided that about 6 out of 7 babies should be born “naturally.” How do they know this? Mostly, by making educated (and some less than straightforward) guesses. Fact is that as we doctors have medicalized childbirth, we have complicated the choices women have to make, made childbirth less convenient, and not really improved outcomes all that much. Witness Brazil, where the c-section rate is almost 50% and the maternal mortality rate is 69/100,000 births,  The best country for mothers surviving childbirth is Belarus, where only 1 mother dies per 100,000 births and where 4 out of 5 mothers have a vaginal delivery. Here in the United States, by comparison, 1 in 3 mothers get a c-section, maternal mortality is 28/100,000  and for all we spend we are still #62 in maternal mortality, between Korea and Malaysia.

One school of thought is that all of these c-sections are at least resulting in healthier babies. If only that were true. Although the statistics for infant mortality are a little confusing (some countries don’t count babies below a certain weight and others do), Brazil should have a really low rate with so many of their mothers going to section. By their count, about 12 out of every 1000 neonates die, twice that of America (best is Luxembourg at 1/1000, 3 out of 4 delivered vaginally).

If a high number of c-sections are not particularly good for the mother or the baby, why do so many get done? The National Partnership for Women and Families has debunked some myths and identified some real problems. First the myths:

1) “I want my baby on Tuesday” – Although we would like to believe that consumer choice has something to do with it, only 1% of women who have primary c-sections (a first baby born via c-section) requested that it be done that way.

2) “My doctor says I’m not made for a baby to come out down there” – Though we believe that  women are getting older and more likely to have other medical problems, this is not the case. The evidence is that those women who before 1990 would have had a trial of labor, all things being equal are now being encouraged to go to c-section.

3) “If I do a c-section the patient won’t sue me, especially if things go horribly wrong” – Turns out that the medical system screws up about 1 in every 100 deliveries but only 2% of those lead to lawsuits. Turns out docs are much more influenced by who they chat with in the doctor’s lounge than by actual risk of malpractice claims.

Why so many c-sections? First, women are not encouraged to get in shape for childbirth. We are discovering that the human body deals much better with changes associated with surgery if its owner has it in good shape. This is true for childbirth as well. Women need to be encouraged to be in good physical shape at all times but especially as childbirth approaches. Second, it is important not to rush mother nature. We are finding out that waiting until after the due date to do anything is very important. Obstetrics means “to stand by” and that is what doctors (and patients) need to do. Third is that we are afraid to agree that anything but “once a c-section, always a c-section” is okay. A problem when the primary c-section rate is so high. Fourth, we tend to have a blase attitude towards surgery. We do a lot of surgery in this country and tend to think nothing of it. Obstetricians make a living at it. Along with that  is a belief that nothing bad happens in surgery. Although  c-sections are much safer than they once were, the human womb is not made to be cut open several times and have a baby forcibly removed. Lastly, doctors get paid more for doing a c-section. Less so now in terms of money (it used to be different) but much more so in terms of time (one hour for a c-section as opposed to sitting up with a woman for 12 hours) and increased opportunity cost (ability to do something else with that 12 hours). In the words of one Brazilian who was rushed into a c-section after laboring for 6 hours (less than the average labor takes by half): “He was saying, ‘I was at a birthday party, and I want this done fast because I want to go back and finish my whiskey,’” she said.

To change the c-section rate, then, women will need to take back their bodies from doctors (again). They need to be aware of what the c-section rate is at the hospital they are planning to deliver at and select a doctor and a hospital with a rate below 25%. They need to demand an opportunity to go into labor naturally if at all possible. Mostly, though, they need to prepare for labor physically and mentally. Turns out that only mothers can prevent needless c-sections.

'Not cremated exactly, but barbecued would be okay.'The critical question is how soon that sort of quality and cost control will be available to patients everywhere across the country. We’ve let health-care systems provide us with the equivalent of greasy-spoon fare at four-star prices, and the results have been ruinous. The Cheesecake Factory model represents our best prospect for change. Some will see danger in this. Many will see hope. And that’s probably the way it should be.

Atul Gawande “Big Med”

There is an article from the New Yorker that made the rounds a couple of years ago about the coming revolution in medical care. The author, Atul Gawande, uses the Cheesecake Factory restaurants as an example of a business that delivers a high quality product in every location in a predictable fashion. He then identifies several examples in medicine where these sorts of things are beginning to happen, one around orthopedic procedures and one involving care of the intensive care patient. The orthopedic procedure is much more personalized, in part because Gawande’s mother is the “case” with her knee replacement being the example. As a wise health care consumer, he identifies the surgeon with the best outcomes for his mother’s  particular need. What he finds is that standardization, team-based care, and attention to consistency trump individual skills in healthcare. The article was not without its critics. Mostly, not about how dare Dr Gawande criticize the-best-healthcare-system-in-the-world but more about how taking bad systems and superimposing incremental change was a recipe for disaster. Might make for a delicious sandwich brought out quickly but not great hip replacements and diabetes care. Instead, it was suggested, medicine as an organization should look at “new methods of managing [that] have been developed that build on self-organizing teams working in an iterative fashion and closely linked to what customers might want.” Less putting a delicious sandwich on the table, more giving people the equivalent of an  “Angry Birds” app when they need it. People do love Angry Birds… In the last 2 years we at South Alabama have been struggling how we are going to practice and teach in our Academic Health Center. We need to train the next generation of physicians. The next generation of family doctors will need to be able to move quickly from caring for people who have a minor complaint to working with non-physicians doing the same to helping folks manage their own chronic illness to helping those whose illness has progressed manage their symptoms. We have decided, as a system, to get good by focusing on the following:

  • Create and sustain culture of constant improvement throughout care delivery cycle
  • Create and sustain highly accessible primary care medical homes
  • Coordination of services between primary and specialty care
  • Coordination of services across hospital, ambulatory, and rehabilitative settings
  • Reward interdisciplinary team-care approaches as defined by coordination, communication, and shared responsibility
  • Create and sustain infrastructure to provide real-time data to inform care decisions
  • Partner with sister institutions and community agencies who share common patients/clients to facilitate care across continuum

South Alabama is about to begin redesigning our care delivery and, presumably, educational offerings to meet these goals. I suspect we will need more and better recipes. I also think some Angry Birds might help as well.

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Is it society’s duty to ensure equitable access in healthcare?

Question posed to my students in a health policy course

In his book “The Healing of America,” T.R. Reid identifies four distinct methods of (paying people who are) providing healthcare to the citizens of a country. Some countries follow the model of England and collect money form all citizens, mostly via taxes, and use that money to pay for needed care. It is also referred to as  the Beveridge model, after Lord Beveridge, who wrote a report in the war years identifying disease as one of the five “Giant Evils” and recommended state action to combat this and other evils. In this model everyone is entitled. The second was the German model which mandates participation in private insurance. This is also referred to as the Bismark model, after Otto von Bismark, the Prussian chancellor who determined that universal healthcare could be a force in the fight for a unified Germany.  In this model, everyone is mandated to participate. The third is the Canadian model, which taxes citizens to pay for care but allows health care entities to be private contractors. In this model, budgets are set at a regional level and as a consequence some artificial shortages are created. In this model, everyone is treated equitably within the system.  Lastly is the “out-of-pocket” model. In this model, prevalent in developing countries, care is rationed based on ability to pay. In this model, no money=no access.

As T.R. Reid explained in his book and my class identified as America’s unifying model, we use an “all of the above” approach. For those over 65, active duty military, eligible veterans, and native Americans we apply the Beveridge model. Once Americans are in one of these groups, it IS society’s responsibility to provide equitable access in healthcare (well, sort of. Physicians can “opt-out” but for the most part, this is true). For those who work at jobs in larger businesses, we tend to apply the Bismark model (and Obamacare reinforces this). The employers are given a significant subsidy to provide health insurance and most Americans (before 2010, 66%) pay through healthcare via this mechanism. For some of the poor (mostly children and pregnant women but some with chronic illness) and military dependents we apply the Canadian model (how Medicaid and Tricare work, for the most part). For everyone else, we apply the pay- out-of-pocket-or-die-or-go-to-jail model. Obamacare attempted to move the last three groups into an amalgam of Beveridge (poor) and Bismark (everyone else) model.

Turns out the sticking point is the question I asked my students. Unlike my students, who had about a 70-30 split that it was a society and thus government problem, the American public thinks differently. Only 42% of Americans feel a responsibility for their fellow American’s access to healthcare. This increases as people get older peaking with of those who are 65 and older. 53% of these  believe that government should not be providing their health care. The majority of folks opposing the law, in all fairness, despite this believe it is the responsibility of our elected officials to make the existing law (be it via Bismark, Beveridge, Canada, or other) work.

The New England Journal of Medicine has published two essays on this topic this week. The first, out of Kentucky, discusses the benefits to patients living in a poor state that has elected to avail itself of the improvements in access offered by the Affordable Care Act. The author, who had previously written of access problems, says it this way:

But during the past year, many of my lowest-income patients have, for the first time as adults, been able to seek nonurgent medical attention. I recently evaluated a 54-year-old man with hyperlipidemia and a systolic blood pressure of 190 mm Hg whose last physician visit had been with a pediatrician. Before he enrolled in Medicaid, he would have been unable to pay for his appointment and laboratory work, and I wouldn’t have considered offering him a screening colonoscopy since he would surely have been billed for it. Newly insured, however, he was able to afford the tests and medications that most Americans would expect to receive, and he told me he felt proud to have witnessed a sea change in health care delivery in Kentucky and that recent reforms seemed “just.”

On the other side of the discussion is South Carolina, an equally poor state that has elected not to avail itself of the benefits afforded via implementation of  Obama-care. The author speaks of the many attempts to influence policy makers into accepting access for South Carolina’s poorest citizens. This culminated in a series of arrests following peaceful protests on the capitol steps. In his words, he had to act because

When I graduated from medical school in 1979, we did not take an oath, but I have since striven to adopt the words of Moses Maimonides as my guiding philosophy: “The eternal providence has appointed me to watch over the life and health of Thy creatures” and “Preserve the strength of my body and of my soul that they ever be ready to cheerfully help and support rich and poor, good and bad, enemy as well as friend.” My interpretation of this prayer is that I need not only be a good clinician in the hospital or clinic but also attend to the effects on my patients’ lives of the wider world, whether my own hospital or the state government. [W]e must pay attention to the whole patient. Similarly, I now believe that our concern for our patients should encompass the effects of public policies that result in direct harm.

I do believe it is society’s responsibility to provide equitable access and believe Obamacare is the mechanism through which to accomplish this. Living in Alabama, a state that has not accepted the Medicaid expansion, how do we as educators look those we teach in the eye and say “We did all we could” to ensure access for those who are poor, who have mental illness, who are unable to speak for themselves? Anyone else ready to march on Montgomery?

'I know I failed all the tests and never handed in any finished assignments. So what's your point?'Resident – You know that girl who just found out that she was pregnant and came to us around 26 weeks

Me: Yeah

Resident: Well she has a Hemoglobin A1C (measure of long term blood sugar control) of 11. Turns out she has undiagnosed diabetes.

Me: (Sigh) Go ahead and call high risk OB

The March of Dimes gave Alabama an F in the prevention of pre-term birth. That is not surprising in and if itself. We always get an F. In 2006, when 1 in 5 infants in Alabama were born before 37 weeks, we got a “low F.” At least this year, it was only 1 in 7. I guess that is an F+. In the United States as a whole, the number is a little over 1 in 10, putting us up there with Sierra Leone and Ghana and well below that of Cuba. Best state is California with a preterm birth occurring every 1 in 15 times. “Best practice” countries (the Scandinavian countries are the ones that do it best) have a preterm birth rate of about 1 in 20. The Alabama county with the highest (Bullock, 1 in 4, as a country would be worst in the world), through no coincidence, only has 4 primary care doctors, 2 dentists, and no obstetricians or hospitals that provide care for pregnant women.

Why does preterm birth matter? The vast majority of infants that die are delivered before 37 weeks; some die for no apparent reason. The more births beyond 37 weeks gestation, the lower the infant mortality. In addition, these infants are more likely to be admitted to a neonatal intensive care unit. March of Dimes anticipates that if Alabama were good at preventing preterm birth, we could save almost $500 million, most of it Medicaid.

You ask, why not just do what it takes? Saving half a billion dollars, improving the lives of almost 10,000 children in Alabama. Who could be against it?

Funny story, that. It was during the 1980s in the Bush 41 administration when we as a country identified infant mortality as a problem. Nationally, about 4 in every 1000 newborns were dying in the period of time between birth and 1 month of age. Some great thinkers and law makers got together and suggested that a lack of access to healthcare was a reason that these women were having early and unhealthy babies. In 1986, Congress passed, George HW Bush signed and Alabama Republican Governor Guy Hunt accepted a Medicaid expansion to provide care to pregnant mother because, well, “Won’t somebody please think of the children?” Today, almost 80% of pregnant Alabamians get prenatal care in the first trimester and 49 in 50 receive some type of prenatal care.

Fast forward 30 years later. We now know that, as I told my resident who presented this patient, by the time the woman presents for prenatal care, the horse is out of the barn. About half of all pregnancies are unplanned. Many women suffer from poorly controlled chronic illness that, should they become pregnant, can worsen pregnancy outcomes. Many woman are making lifestyle choices that can cause unintentional harm to their yet-to-be conceived infant but can be changed in a positive manner. To reduce preterm births we need to focus on pregnancy spacing, pre-conception counseling, addressing lifestyle choices that lead to poor outcomes, and planning pregnancy for those with chronic illnesses such as diabetes. There is a term “strong for surgery” that is gaining traction. Women also need to be “strong for pregnancy.”

This is a problem of primary care. We should provide preconception counseling to all women of child bearing age when given the opportunity. We as a society should provide access to primary care for all women of reproductive age (especially those with chronic conditions), and provide outreach to those with conditions related to poor behaviors to correct the behaviors before pregnancy. Our current President, a Democrat, gave us one of the tools (Medicaid expansion to women prior to conception) that is necessary if we want an A. It would still take a lot of work to get that A, as it almost always does. Just by accepting the expansion, we could easily get a gentleperson’s “C.” I suspect instead we’ll take the “F” in hopes that the next test will be on something easier, like football.

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