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Me: Why is your blood sugar so high?

Patient: Couldn’t afford the insulin

Me: But you have insurance and it is on your insurances formulary. I thought you told me it cost you $30 a vial

Patient: Yeah, this time it costs me $150. And ya know, I gotta eat….

A couple of years ago I was fixated for a while on the cost of insulin. Mostly, I fixated on why it was so expensive. From 2012 to 2016 the price of insulin doubled and to have Type 1 Diabetes meant someone (the patient, the insurance company, the government) had to pay on average $18,500 a year. In other words, without insurance they have to budget to buy a new car every year, with no trade-in.

Having Type 1 Diabetes is basically like having a birth defect. The prospective patient is at risk to losing the ability to manufacture insulin from birth with exposure to a certain virus being the trigger for this to actually occur. The only treatment for folks who acquire Type 1 Diabetes is insulin replacement therapy. Without it, they die. Well, we are pretty sure they do. Since insulin was discovered in the 1920s it has been unethical to withhold insulin as a medical experiment from Type 1 diabetics. Prior to that, by literally starving the patient to death, you could buy them up to a year. Since the 1920s, we have had insulin. The discoverers sold the patent for a dollar a piece so that humanity could benefit.

Type 1 diabetes is a great disease (as diseases go) for a doctor to treat. The body has a deficiency. Replacement is relatively straightforward. If the patient is cooperative with regime (checks blood sugar regularly, administers insulin to keep sugar down) he or she can expect to live into their 8th decade. The dad of my best friend growing up was a Type 1 diabetic and he survived his into his 70s with diabetes only to die in Katrina. Though special diets may help and exercise may help, what is required is insulin. Without it, ingested sugars and fats convert to ketoacids instead of energy for the body and then death happens. Almost always when someone with Type 1 diabetes has ketoacids in their blood they are either insulin deficient (“well, doc, I meant to take my insulin this morning but…”) or have another illness that has increased their insulin requirements.

Which brings us to the cost of insulin. The prices, it seems, keep going up. For us non-diabetics it would be like charging us for air. Not only that, but charging us extra after exercise for the extra oxygen we extract. Why is it going up? To find out I spent a lot of time reading about our really crappy system of pharmacy distribution and payment systems. Remember the corner pharmacist? Now he is a pharmacy benefits manager. They control the prices the pharmacies have to pay for drug prior to distribution and control what the patient pays (the money they make off of this is called “the spread.” They make drug companies give rebates to get medications on the formulary that they rarely share with patients. They overcharge patients for medications and pocket the difference. They make pharmacists sign contracts that forbid them to tell the patient that the $40 lisinopril prescription is available for $4 at Walmart. They make consumers use coupons to artificially inflate the prices even more.

As much as I wanted to blame this new middleperson arrangement for the rising prices (and it can be blamed for the fluctuating prices), PBMs are not the cause. The insurers try to convince us that it isn’t them but a lack of personal responsibility. Drug companies try to say that cutting edge medicines are expensive and Americans deserve only the best.  Neither of these are true. As was reported in Vox:

Luo, the paper’s lead author, doesn’t find the “cost of innovation” argument very convincing. In his research, he’s come across many examples of the same insulin products that have been continuously available for years without improvements, and yet their price tags have gone up at a much higher rate than inflation.

“The list price of these products are already out of reach for most Americans living with diabetes — in some cases over $300 a vial,” he said. “It is also strange to see Humulin still priced at over $150 a vial considering this product was first sold in the US in 1982.”

In other words, drug companies are flat out raising prices. Why are they are doing it? Because they can. There are only 3 companies that make insulin, the products are not generic (small improvements patented every 10 years to keep a new patent), and oddly the prices are the same across all the companies.

So what can we do to stop it? As a physician, there are a couple of things I can do. There are “human” insulins that is relatively cheap (NPH and Regular, alone and in combination) that I can write for my Type 2 diabetic patients. In theory this would, over time, drive the price down if we all did it. I can (and do) only use formulary medications whenever possible, even though it means switching several times a year at times. As a patient, consider using cheaper “human” insulin if you have Type 2 diabetes. Talk to your doctor about making the switch. Join in the protests over the cost of insulin. Let policymakers know that access to life sustaining hormones should be a right. To paraphrase Martin Niemoller, first they come for your hormones….

download“If the entire materia medica at our disposal were limited to the choice and use of only one drug, I am sure that a great many, if not the majority, of us would choose opium; and I am convinced that if we were to select, say half a dozen of the most important drugs in the Pharmacopeia, we should all place opium in the first rank.”

Macht DI. (1915) The history of opium and some its preparations and alkaloids. JAMALXIV:477–481

Disabled, chronically abandoned

(Sign held by a young woman protesting in front of a pain clinic shuttered by the DEA last week)

Often in nature, a substance is found (or some believe God has placed a substance) that has serendipitous properties in humans. One of the first instance of humans discovering this was with the milky substance found in a flower now known as the poppy. Thousands of years ago, someone (we think an Arab adventurer) for whatever reason ingested that the milky substance in the “proto” poppy plant and found it relieved his pain. For the next thousand years, through cultivation and trial and error the opium poppy was born in China. Papaver somniferum. 

Pain is a funny thing in people. It is a mechanism almost all of God’s creatures have to tell them that if they stay in their current situation bad stuff might happen to them. One of the things we are taught in medical school is how to get people to describe their pain. We tell students to get people to use a 1-10 scale with “1 being a paper cut and 10 being an elephant sitting on your chest.” Did you know there are a lot of people whose paper cuts are a 10? Once the situation has resolved, we have chemicals in our body that connect with the pain receptors (there are 4 such receptors, with mu being one) to relieve the pain and give pleasure. The opium poppy, which likely could only move back and forth and doesn’t need a lot of pleasure materials, has been bred to have 12% of its latex made up of these pleasure drugs (morphine, codeine, and to a lesser extent thebaine which was used to make hydromorphine).

Having a drug that reduces pain is lucrative. Having a drug that causes pleasure is more lucrative. In the 1800s, German scientists were able to extract pure opium from the poppies. Although available for pain relief, the larger market was in euphoria production in shops (mostly in China) using water pipe technology. Ironically, it was declared illegal in China (where the poppies were grown) but was smuggled by the British into China and sold to the opium dens to offset the imbalance of trade they found themselves in from importing tea. Only fair, I suppose.

We don’t need flowers today. Thanks to the God-given ability of humans to reverse engineer, the world produces about 700 tons of narcotics. Most of this medication makes its way to the US. We have 5% of the population and account for 99% of the hydrocodone use in the world (active ingredient in Vicodan), 83% of the hydrocodone use (active ingredient of Oxycontin), and 37% of the world supply of Fentanyl. We consume twice as much per capita as the next highest nation. Within our country, even, there is much variation with Alabamians consuming 2 1/2 times (1 1/2 prescriptions per person) as much as Hawaiians. The misuse of these drugs contributes to 17,000 deaths annually, as many as ovarian cancer but without a ribbon to raise awareness. Deaths aside, there is the problem of diversion. Many people get a prescription for 90 Vicodan, take 60, and sell 30. There are willing markets of buyers and many physicians are unaware that their sweet little elderly lady patient (who has the medicine in her urine) has a side business.

It turns out opioids have a downside. They are addictive, meaning that they cause aberrant behaviors on people unable to get access to the drugs by buying pills from the guy down the street. They cause a physical dependence. People who are suddenly denied access will suffer from physical symptoms such as nausea, vomiting, and profuse sweating. Chronic use results in tolerance, meaning that it takes an increasing dose to get the same effect. If you are going to create a market, what better product to sell?

As detailed in this New Yorker article, this problem has been a long time coming, and we in the healthcare field are complicit. Beginning in the 1980s, scholarly articles encouraging the addition of narcotics to our inadequate pain treatment regimes have been published. Some very smart people believed that treatment of chronic, non-cancer pain with opioids could work  “with relatively little risk of producing the maladaptive behaviors which define opioid abuse.” In the 1990s makers of legal narcotics (Purdue in particular) began marketing their products to physicians and patients as safe for everyday ailments such as neck and back pain. With a team of 5000 sales people, a bonus system that encouraged “market growth,” and the assistance of the Joint Commission which began requiring hospitals to evaluate and treat pain, over $1 billion worth of Purdue’s Oxycontin was sold in the US in 2000.

So, God placed this wondrous drug in the proto-poppy for what reason? If used correctly, say for the pain associated with metastatic cancer, it is truly a miracle. If used by people to mask the psychic pain of living in America and written by physicians who are just too busy to talk to their patients, it is probably not what God intended. If given by physicians to folks in exchange for sexual favors thus feeding their addiction it is almost certainly not what God intended.

Perhaps God put the proto-poppy on earth to test physicians. We can make a lot of money selling these poppy derivatives but we can also get in big trouble. The test for us is to use it correctly.

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.

toon-1079Now where were we? Oh yeah: the important thing was I had an onion on my belt, which was the style at the time. They didn’t have white onions because of the war. The only thing you could get was those big yellow ones…

Grandpa Simpson, Last Exit to Springfield

One of the persistent myths of my profession is that “we used to see whoever needed to be seen, regardless of whether or not they could pay.” Then came Guv’mint and, well, you know the rest. The slippery slope to communism. The beauty of these myths is that they are very difficult to contradict. A pure market system last existed long ago in this country. Private insurance started in 1950, and though it initially covered hospital care only, it quickly added coverage for office visits. Kerr-Mills began providing care for the poor in the 1950s and was followed by Medicare and Medicaid in the 1960s. Those who fondly recall the days of sliding physicians fees  are by now in their 70s and 80s and are mostly recalling childhood visits (remember the smell of rubbing alcohol?).

In 1950, the first year for which we have good data, the average American at birth could expect to spend 68 years on this earth (65 for guys and 71 for gals). If that person happened to be black, as about a third of Alabamians were, those numbers were a bit less (59 for men and 62 for women). These numbers mostly reflect deaths in childhood, because those that were already 65 could expect to live another 14 years (or almost to age 80) and the difference between races was non-existent.  Access to good sanitation and immunizations was the difference in getting kids to age 5. Access to physicians, not so much.

The other thing that we know is that prior to our current patchwork system, the medical problems in young, healthy 20 year-olds were, well, a problem. From a 1951 article entitled Physical Status of Men Examined Through the Selective Service in World War II we find that 40% of men over 18 examined for selective service in Alabama were disqualified. 19% of those disqualified were for dental problems. You had to have 12 (TWELVE) teeth, 6 on top and 6 on bottom, to be qualified for service. 30% didn’t have vision corrected to 20/40 or better (THEY HAD NO GLASSES). 1 in every 8 had gonorrhea or syphilis. 1 in 100 had ACTIVE tuberculosis. In the discussion, the author point out that children reared in a North Carolina orphanage who had good access to health care paid for by someone other than their parents only had 1.4% rejects. Recruits from the general North Carolina population with limited access to health care  had a 44% rejection rate. While the AMA was urging us to protect our patients from the federal government,  this physician was making an argument for improved access through government action.

Fast forward 60 years. We have provided almost all citizens access to sanitation and immunizations and most to access to care prior to birth (and now prior to conception in those states accepting the Medicaid expansion). Life expectancy at birth is now almost 79 years and those that are 65 can expect to make 84. Tuberculosis is a disease of the past. Most of us have multiples of 12 teeth. Almost all of us that can see do see. Though disparities still remain, much has improved thanks to Medicare, Medicaid, and subsidized insurance. When physicians wax nostalgically about the days before “big guv’ment” I tend to think about them with an onion on their belt.

al-ross-is-there-a-doctor-in-the-house-that-s-the-call-harold-s-been-waiting-new-yorker-cartoonMedical students no longer dissect a cadaver in most medical schools. After hours call, or working outside of regular work hours to provide care to hospitalized patients needing assistance, is rapidly becoming an anachronism as well. Teaching hospitals used to use residents and students in lieu of hiring physicians to work at night. The learners would take care of sick people at night and in exchange teaching would occur during the day. One attending I had fond memories of his call days as an intern, sitting at the nurses station playing the guitar.

When I was in medical school, call was busy. The medical student would be expected (at least at Tulane in the 1980s) to come into work at Zero dark thirty and work all day taking care of the daytime patients. When the day’s clinical duties were winding down, the student who was on call would find the resident that was on call (protocol varied from service to service) and get “sign-out,”  or in other words find out what tasks needed to be done between now and 0 dark thirty tomorrow. The time that sign-out occurred varied depending on the speed of the clinical team you were on as well as the willingness of the other team to accept sign-out. You might be finished by four but if the on-call team wasn’t ready for you, tough. The feeling was that you were responsible for your patients 24/7/365 and the privilege of sign-out could only be enjoyed if both parties were ready. I remember several nights when I was not on call but was not afforded the luxury of sign-out until 8 pm or later.

The job of the person on call was to work-up all of the new admissions as well as take care of the work that was left over from the folks who signed out. Oh yeah, there was nobody to draw blood, transport the patients to x-ray, or any other menial tasks. Oh yeah, and no radiologists, either.

Resident: Take the new admission up to CT, he’s still not right and I don’t think we can wait until morning. After you drop him off go run this blood to the lab and tell them we need it STAT! Then go find an endotracheal tube. We’re going to have to intubate.

Me: On my way

Me, to CT tech: I’m leaving this guy here and going get some stuff. He needs a CT without contrast. Yes I paged my attending (a white lie) and he says we need it. Page me if he stops breathing.

Me, to lab clerk: We need this STAT

Lab clerk: The tech is on break, feel free to run it yourself (which we actually did at Charity)

Me to central supply clerk: I need a number 7.5 ET tube

Bored clerk: It’s in the back somewhere, knock yourself out.

After a night of admitting sick people, running labs, gathering equipment, and in general feeling useful, we (after, as Doctor Eaton points out in the comments, “morning report” where the attending would grill us for not knowing what we were doing) then had to work the next day until “sign-out.” The difference being that as the off-coming team we got to sign-out first.

This was the job of residents and students because, as we used to say at Tulane, calling an attending after hours was a “sign of weakness.”

At least that is the way it seems in my 30 year old memories. In actuality, what I remember is being bone tired, being scared to death that I wasn’t doing the right thing by the patient, but living with the certainty that late in the night New Orleans in the 1980s I was the best shot for these folks to get better because the alternative was death on the streets.

Today, the trends that led to my bad call nights have accelerated. Hospitalizations are much shorter (Average length of stay 11 days for hospitalized Medicare patients in 1980, 5.7 days today) and patients are much sicker (50% of hospitalized Medicare patients are obese up from 25% in 1980, over half have over 2 chronic conditions, and almost 1 in 5 are on dialysis).  Consequently, the world of hospital call (and medicine) has changed. Medical students and residents are only allowed to work 80 hours in a week, and if they are working a 24 hour shift they must be allowed to “strategically nap.” Sign-out is now termed Check-Out and is much more formalized. The expectation is that, though the patient has a primary physician, a team will see the patient through the hospitalization. That team includes physicians, nurses, techs, and others whose job it is to get the person healthy enough to leave the hospital as soon as possible. Many times check-out is to a night float resident (and a night float attending) who only work from 7pm to 7am.

We are still working through some kinks such as how best to handle the hand-offs. Despite these challenges, I believe that teaching hospitals are almost certainly much safer today as a result of the changes.

jesusNews item:

Workers at La Bit’s Heating and AC Services (in Mobile Alabama) have been living in fear for weeks, afraid of what 35-year-old Kenneth McGee would do next.

“They were minding their own business, and then here they are the subject of a random attack by someone who lives in the neighborhood.  And they don’t deserve that,” said Mobile County District Attorney Ashley Rich.

Workers say the bizarre behavior started last month with McGee hiding in the bushes, watching the business. Investigators say he threw a brick through a windshield and punched their mail box. Rich says McGee was released from Searcy Hospital (a state mental institution) last year when it closed, and prior to that, he had been in and out the facility for more than a decade. She believes it was a mistake to shut the facility down because her office is now dealing with people who should be in a mental health facility.

“It is very frustrating, and it’s something we’re seeing more and more of,” said Rich. “We were extremely disappointed when they closed Searcy because that was the facility closest to Mobile County.”

We, as are other states, are in a bit of a budget bind. It seems that “No new taxes” often conflicts with “services needed for the good of the citizens.” Nowhere is that more apparent than in the field of major mental illness such as schizophrenia. Most people with a major mental illnesses have done nothing to bring it on themselves, are disabled from a young age so have no money saved to pay for treatment, and may be alienated from their support system as a consequence of, well, the difficulty of coping with someone who has a major mental illness.This is compounded by the fact that folks with this disease are often stigmatized by their behaviors, so much so that the name of an asylum in England became synonymous with “uproar and confusion.”(bedlam)

The state of Alabama plays its own part in the dynamic tension between the needs of the state and the desire of the people not to pay for needed services. A suit filed in 1970 (Wyatt vs Stickney) became a landmark ruling that created a mandate to actually provide treatment for folks with mental illness who are held for treatment. The attorney for Ricky Wyatt, the 1970s plaintiff, alleged the following:

that patients received inadequate treatment and that the hospital was understaffed and underfunded. Of its 5,000 patients, 1,600 were geriatric patients and more than 1,000 were mentally retarded, both groups receiving custodial care but no psychiatric treatment. In terms of staffing, the hospital employed 17 physicians, 12 psychologists with varying academic qualifications and levels of experience, 21 registered nurses, 13 social service workers, 12 patient-activity workers, and approximately 900 psychiatric aides to treat the 5,000 patients. The employees whose duties involved direct patient care in the therapeutic programs, however, included only one clinical psychologist, three medical doctors with some psychiatric training, and two social workers. Alabama’s daily expenditure per patient was $6.00, with a daily food allowance of less than $0.50, compared to the national average of $15.00 a day

The case lasted 15 years with appeals and resulted in the Department of Mental Health operating under an injunction which lasted until 2003. At that time Alabama was found to be in compliance with the “constitutional right of civilly committed mental patients to receive adequate treatment” and the case was closed.

In 2009 (6 years after federal oversight ceased), the budget cuts started.

From 2009 to 2012, Alabama cut its total general fund mental health budget from $100.3 million to $64.2 million, according to NAMI. Only South Carolina (39 percent) experienced a deeper percentage of cuts. Medicaid is the largest source of financing public mental health services, accounting for nearly 50 percent of all public sector spending. NAMI argues that although using Medicaid is a laudable strategy, there are millions of individuals with serious mental illness who do not have access to Medicaid.

When the cuts began, it was clear that indiscriminate cuts would lead to problems:

Switching mental health care to community programs is a good idea “as long as enough funding comes to the community to support the lack of having institutional beds,” Tuerk Schlesinger, CEO of AltaPointe Health Systems in the Mobile area, told last February. Without that support, the community won’t be able to care for patients previously staying in state hospitals, Schlesinger said.

Although the Mental Health Commissioner could not be reached for comment regarding Mr McGee’s case, he was quoted in 2012

The future of mental health emphasizes greater independence for the consumer, then-Alabama Department of Mental Health Commissioner Zelia Baugh said at a November 2011 town hall meeting in Mobile.

“People can always eat,” Baugh said, “but if you teach them to fish, that’s a life lesson.”

Isn’t that from the book of Hezekiah in the Bible? No, wait, I’m thinking about the story about the loaves and the fishes…Jesus FED people fish!

There are a group of bloggers who are family physicians or friends of family physicians and WE are trying something a bit different. Laurence Bauer, who is the Chief Executive Officer of the Family Medicine Education Consortium is coordination this effort. We are trying to educate ourselves on the effect of social media as well as trying to determine what the effect of social media actually is. Larry is offering a guest column today which several of us are cross posting.

The Dreams of the Founders of Family Medicine

Laurence Bauer, MSW, MEd

It is important to realize that many in and out of medicine told the founders they would not succeed. The cynics believed that the dominant forces in medicine were too entrenched and there were too many societal forces working against the idea of a generalist renaissance in medicine. After all real medicine involved care of hospitalized patients; anyone could care for the people “out there”. But the founders dreamed big, bold dreams; they were a determined and visionary group.

They dreamed of a cadre of talented and competent Family Physicians that would serve the people in all the communities of our nation. The rich, the poor and all in between in rural, urban and suburban communities all needed access to a Family Physician. They believed that the practitioners in this specialty would focus on the needs of their patients and communities and would protect people from the medical industrial complex as much as possible

They dreamed that a new academic specialty would emerge whose core would focus on issues surrounding patient management and the care of the whole person in their community.  They believed that medical education was moribund and harmful and in need of a compassionate and thoughtful revitalization.

For the founders, the biomedical model was inadequate. They believed that it is not possible to be effective as a physician without understanding the contextual issues that influence a person’s life. The biopsychosocial model, the power inherent in relationships and the abilities and skills involved in creating facilitative relationships needed to be integrated into medical education, practice and scholarship.

They believed that medicine was a profession that involved more than a technical set of skills and a high income. They accepted the responsibility to care for the whole person; mind, body and soul.

They believed that the practice of medicine required team work among the medical and helping professionals and that the patient was to be an active partner in the care process. In fact, it is the patient’s goals and agendas that drive the healing process.

They believed that life-long learning and the need to continuously upgrade one’s knowledge and skills was critical to the practice of medicine.

They dreamed of generations of leaders who would rise to take their places and extend their efforts.

They believed that Family Medicine was more than another group of medical practitioners. Family Medicine should serve a transformative agenda that changed the academic medical centers and health systems so that they would better serve the people and communities.

They were willing to bring other generalist colleagues to their ranks. They respected the pediatricians especially who wanted to contribute to Family Medicine’s early development. They sought a relationship with psychiatry and mental health professionals. They had a comfortable relationship with the general surgeons and all their colleagues who respected the value of a generalist practitioner.

I’m giving a talk tomorrow to the first year medical students about financing health care. This is a talk I give every year, takes about an hour and a half, and it will be all of the information they get on this topic from our medical school for the next 3 1/2 years. The talk tracks health care financing from no insurance to the development of private “insurance,” public payment,and proceeds to the system as it is evolving as a consequence of the Affordable Care Act.

If you’re interested in why things are as crazy as they are, I refer you to The Social Transformation of American Medicine. This book, written in the 1980’s, is still the best resource for this subject matter. Written with attention to context, Paul Starr discusses the transition from a cottage industry which relied on patients paying cash (or other medium of exchange) into, well,  a cottage industry where large swaths of the population did not have access to care. For those who were not independently wealthy, it became clear early on that they would need to pool their money so that when the odd really bad thing happened, there was sufficient money from those to whom bad things had not happened to cover the costs. This was how private insurance came about. For some reason, major population groups were given access to alternative types of care (veterans, railroad employees).

The elderly were a special case. It was clear that every elderly person would need the service (at the time of Medicare’s passage 1 in 6 elderly went into the hospital on an annual basis) and they voted. Congress reported more mail on the subject of elderly access to health care than any other subject. The AMA, according to Mr Starr, was loath to give up the cottage industry aspect for this population. As a consequence, the law accommodated the needs of the elderly (access) and the desires of organized medicine (maintenance of the status quo) for this group. I refer you to the CMS website if you want to see the convoluted consequences of these compromises.

The poor were also a special case. Under the cottage industry model, the poor were the responsibility of the community. Care was delivered in public hospitals, by religious orders, by physicians delivering charity care, or more likely not delivered at all. Congress felt that the care was needed but was unwilling to take total control away from the states. As a consequence, Medicaid developed with a minimum level of services but allowed states to provide more services. Payment was a state-federal partnership. Medicaid thus has no long-term constituency (no one sees themselves as poor forever although many see themselves as old forever) and tends to be targeted for cuts by every governor, regardless of political affiliation.

All of these programs were tweaked over the intervening half century. Medicaid began to focus more on children and mothers-to-be in most states. As more illness moved outside of the hospital and the elderly couldn’t afford the medications, prescription drug coverage was added to Medicare. Cost containment has been a problem from the start, both in government programs as well as the private programs.

The New Republic has an amazing series about how the sausage was made to put together the Affordable Care Act, found here (subscription required). It turns out it was no different from the passage of Medicare or Medicaid—with one notable exception. When Medicare was being considered, the elderly were mobilized to assure its passage. The Affordable Care Act, by contrast, is focused on those who currently have no coverage and are unlikely to vote. It is disliked by seniors, possibly due to deliberate mis-information, and they vote. Interestingly, despite a rough start 45 years later Medicare is very popular and performs very well (although somewhat more expensively than it needs to). It may be that once the smell and taste of sausage is in the air the Affordable Care Act will be popular as well.

When I give the talk to the students, they politely listen. Although I am not old enough to have cared for sick elderly folks that were hidden in the attic for fear of exposing the family to medical bankruptcy, I am old enough to have cared for elderly  folks who were hospitalized because they could not afford life-saving medication. I still care for folks who have no insurance, and I have to game the system to get them needed care. I don’t know that the students appreciate how much easier Robert Kennedy and Lyndon Johnson (Medicare, Medicaid), George W. Bush (Medicare prescription coverage, expansion of the Community Health Centers) and Barack Obama (Affordable Care Act) have made their lives.

Jonathan Cohn has a very nice piece in the New Republic about Blue Cross, the transition from community rating to risk rating, and the transition from not-for-profit to ginormous profits. I recommend reading it as it explains better than I can why we’re in this mess. In sum, this is a very skewed market. A market based overhaul, while possible, would require a rethinking of our national sense of “goodness” (would we really be willing to let people die on the streets for the sin of being sicker?).

The question for those of us in Alabama is why, when Alabama Blue Cross is a not-for-profit, are our costs not lower. It would seem that not paying attention to the stock prices would make it a kinder, gentler company. After reading this article, I feel I gained a little insight into our unique problems.

First, apparently it may be that competition from the other insurers might be bad. When BC/BS of Alabama was the only game in town, it could afford to offer community ratings because it was a sole source provider. With other insurance companies bidding on insurance for businesses, Blue Cross claims (and they are probably correct) that they must offer rates and packages competitive with these insurers otherwise the HR folks won’t choose BC/BS. This was explained to me by the medical director of a HMO I used to work with when I was pushing him to offer more comprehensive care. he said he could push quality for an entire presentation and then the CEO would point out that the competitors rates were $1.00 per employee lower and what was he going to do about that? Without a benefits floor, it’s all about price.

Secondly, BC/BS is competing with itself. Every year or so, it goes to the client and discusses the new cost of care based on what happened in the company last year. The companies, for the most part, pay for all of their own costs and BC/BS takes a cut off the top (called a third-party adminstration fee). Don’t think the CEOs aren’t aware of which employees have cost them health care dollars and aren’t asking what can be done to alter benefits and render health care less expensive. Again the answer may be “nothing” but my bet is that if BC/BS offers that answer, United Health gives a different answer that may be more than a little draconian.

Lastly, we (Americans and Alabamians) are already paying for the most expensive health care utilizers. Almost 50% of the health care dollar is funded through our taxes and much of that goes to Medicare and Medicaid. Everyone (well 96%) of folks over 65 are Medicare eligible and consume quit a bit of health care in their last 20 – 30 years. Medicaid in Alabama covers the vast majority of premature infants. The goal of all good companies is to reduce risk. The best way to reduce health care risk is to move people who will consume health care completely out of the risk pool. Again, done potentially through manipulating copays and other means.

It looks like some of the tools to reform this system may make it to the President’s desk for signature. If not, the current system is still far from market based despite what some people  claim.

In my previous post, I sited a research project that found the average amount of journal reading in 2000 for a practicing internist was around 4 hours per month. This is not an awful lot of reading, given that there are 17,000,000 articles currently available in MedLine. Our field is especially prone to information overload, given the breadth of patients and illnesses we come in contact with. When I graduated from medical school, I did as I was told others did, browsed the medical literature, pulled out articles and put then in a “journal file”, and felt guilty about not doing enough to “keep up”. No wonder the average physicians’ medical knowledge base was directly related to when he or she graduated from residency.

Fast forward 20 years. The Internet was invented by Mr Gore and the personal computer by Mr Gates. Mark Ebell outlines how physicians should use the medical literature. He points out theat the most useful information is relevent, valid and takes little time to access. Computer accessable information is more useful that textbooks (many of which are outdated prior to hitting the shelf). Many physicians now use decision rules to help sort out complex clinical situations. These rules are typically evidence based and often have been validated in “real world” situations. Examples of such rules include the Framingham Cardiac Risk Assessment and the Wells Criteria for suspected pulmonary embolism. Services are now available which aggregate literature and offer clinical “answers to questions” that have been developed using a standardized process. Up-to-date is one such service popular with our residents. If a single journal article is used, it is important to look for those journals that have started to include an assessment of the evidence which supports the recommendations. Then there is searching the 17, 000,000 articles to find the needle in the haystack. What used to be time consuming and complex is now available to anyone on PubMed or Google Scholar.

In short, where previously 15 to 20 clinical questions went unanswered in a typical day, now access to clinical information at the point of service has never been easier. The most important thing is that it’s only going to get easier.