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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….

Healthcare is almost 20% of our economy. A future President Clinton or a future President Trump will, through executive action, have a lot to say about how that money is spent. Commonwealth fund (found here) has an exceptional comparison of the two candidates’ proposals and how they would effect the budget. If you care about fiscal responsibility, for the record, the balance sheet is found below:


So, the Trump plan is not, despite what he claimed in the debate, the way to fiscal solvency.

Kaiser Family Foundation has put together a specific list of issues (found here) that folks appear interested in and has evaluated each camp’s claims.  The Cliff’s notes version is as follows:

Health insurance coverage and cost – Issues include overarching reform of health system remains unpopular in a partisan manner. Affordability hampered by a glitch where family coverage became more expensive, “cost sharing” was not controlled by the law, enrollment was not implemented well, and transparency provisions not implemented. Market place competition is limited, especially in rural areas.

  • Clinton
    • supports policies to maintain and build upon the ACA.
    • increase premium subsidies in the marketplace so no participant is required to pay more than 8.5% of income for coverage.
    • fix the “family glitch” and allow people to buy coverage through the marketplace regardless of their immigration status.
    • make a public plan option available in every state and give people the option of buying into Medicare starting at age 55.
    • invest $500 million annually in outreach and in-person assistance to enroll more uninsured in coverage, and she would enforce ACA transparency provisions.
    • authorize the federal government to review and disapprove unreasonable health insurance premium increases in states that do not have such authority, repeal the Cadillac tax.
    • proposed new private plan standards to waive the annual deductible for at least three sick visits per year, limit monthly cost sharing for prescription drugs to $250, and protect against surprise medical bills when patients inadvertently receive care out of network.
    • proposed a new refundable tax credit of up to $5,000 to subsidize out-of-pocket health expenses (including premiums in marketplace plans) for all Americans with private insurance.
  • Trump
    • complete repeal of the ACA, including the individual mandate to have coverage.
    • create high risk pools for individuals who have not maintained continuous coverage.
    • provide a tax deduction for the purchase of individual health insurance.
    • promote competition between health plans by allowing insurers to sell plans across state lines; an insurer licensed under the rules of one state would be allowed to sell coverage in other states without regard to different state laws that might apply.
    • promote the use of Health Savings Accounts (HSA), and specifically would allow tax-free transfer of HSAs to all heirs.
    • would also require price transparency from all hospitals, doctors, clinics and other providers so that consumers can see and shop for the best prices for health care procedures and other services.

Medicaid – Issues include states’ concerns regarding financing and unwillingness to expand to those too poor to qualify for a tax rebate required coverage

  • Clinton
    • encourage and incentivize states to expand Medicaid by providing states with three years of full federal funding for newly eligible adults, whenever they choose to expand.
    • would also continue to make enrollment easier and launch a campaign to enroll people who are eligible but not enrolled in coverage.
  • Trump
    • supports a Medicaid block-grant and a repeal of the ACA (including the Medicaid expansion).
    • would cover the low-income uninsured through Medicaid after repealing the ACA.
      • The House Republican Plan, which is part of a larger package designed to replace the ACA and reduce federal spending for health care, would offer states a choice between a Medicaid per capita allotment or a block grant.

Medicare – Issues include prescription drug costs, fate of provisions in ACA, public option for those 55-64

  • Clinton
    • supports maintaining the current structure of the Medicare program and opposes policies to transform Medicare into a system of premium supports. On the issue of prescription drug costs
    • supports allowing safe re-importation of drugs from other countries, allowing the federal government to negotiate drug prices in Medicare, especially for high-priced drugs with limited competition, and requiring drug manufacturers to provide rebates in the Medicare Part D low-income subsidy program equivalent to the rebates provided under Medicaid.
    • does not support repealing the ACA or any of the Medicare provisions included in the law; rather, she supports expanding the law’s value-based delivery system reforms.
    • proposed to allow people ages 55 to 64 to buy into Medicare.
  • Trump
    • No position on the issue of Medicare program restructuring or whether to allow older adults ages 55 to 64 to buy in to Medicare.
    • supports repealing the ACA, which would presumably mean repealing the law’s Medicare provisions.
    • supports allowing safe re-importation of prescription drugs from other countries.

Prescription drugs – Issues are pricing (generally more expensive in US than in other countries despite being manufactured in the same facility) and out-of-pocket costs (many plans have gone to a cost sharing rather than a deductible strategy

  • Clinton
    • proposes prohibiting “pay-for-delay” deals whereby companies make payments to competitors for agreeing to delay market entry
    • increasing funding for the FDA Office of Generic Drugs to reduce their approval backlog
    • reducing the market exclusivity period for biologics
    • and directing the FDA to prioritize biosimilar drugs with few competitors. To address price increases for generic drugs
    • proposes to establish consumer oversight in federal agencies
    • penalize drug companies for unjustified price increases
    • allow importation of lower-cost drugs from countries with similar safety standards.
    • She also supports eliminating tax deductions for direct-to-consumer advertising
    • requiring FDA approval of advertisements
    • tying federal support for drug companies to their investment in R&D
    • increasing transparency of the additional value new drugs have over existing treatments
    • allowing Medicare to negotiate drug and biologic prices. To address OOP spending on prescriptions,
    • proposes a $250 per month cap on cost sharing for covered drugs; and a rebate program for low-income Medicare beneficiaries that mirrors those in Medicaid.
  • Trump
    • supports allowing importation of drugs from overseas that are safe and reliable but priced lower than in the U.S.
    • supports greater price transparency from all health providers, especially for medical exams and procedures performed at doctors’ offices, clinics, and hospitals, but does not specify whether this policy would also apply to retail prescription drugs, which typically are not considered services or procedures.

Opioid epidemic – Issues include increased use (1 in 20 nonelderly adults used opioids for nonmusical purposes), increased addiction ( 2 million non elderly adults with of the level of opioid use increases to the level of opioid use disorder, often referred to as abuse, dependence, or addiction), increases in overdose deaths (those involving opioids have quadrupled since 1999).

  • Clinton
    • released a $10 billion (over ten years) plan to fight drug addiction.
      • includes a federal-state partnership to support education and mentoring programs
      • development of treatment facilities and programs
      • efforts to change prescribing practices, and criminal justice reform.
      • direct federal action to increase funding for treatment programs
      • change federal rules regarding prescribing practices
      • enforce federal parity standards
      • promote best practices for insurance coverage of substance use disorder services
      • issue guidance on treatment and incarceration for nonviolent and low-level federal drug offenders.
  • Trump
    • Will build a wall on the U.S.-Mexican border
      • will help stop the flow of drugs and thus address the opioid epidemic.

Reproductive health – Issues include access to preventive services, publicly funded family planning, and abortion services

  • Clinton
    • supports policies that protect and expand women’s access to reproductive healthcare, including affordable contraception and abortion.
    • defends the ACA’s policies, including no-cost preventive care and contraceptive coverage. promised to protect Planned Parenthood from attempts to defund it and would work to increase federal funds to the organization. called for the repeal of the Hyde Amendment which she believes limits low-income women’s access to abortion care.
    • would appoint judges to the Supreme Court who support Roe v. Wade, ensuring a women’s right to choose an abortion.
  • Trump
    • called for defunding Planned Parenthood if they continue to provide abortion
    • He states he is pro-life but with exceptions when the pregnancy is a result of rape, incest, and life endangerment.
      • has promised to appoint pro-life justices to the Supreme Court that seek to overturn Roe v. Wade
    • would also work to make the Hyde Amendment permanent law
    • would sign the Pain-Capable Child Protection Act, legislation that would sharply limit access to later term abortions.
    • would also repeal the ACA, which would eliminate minimum scope of benefits standards such as maternity care in individual plans and coverage of no-cost preventive services such as contraceptives in private plans.





Resident: This is an 85 year old woman who presented in sepsis from a multilobar pneumonia. Her temperature was 103.2 and she had a blood pressure of 100/60. Her chest x-ray showed pneumonia. Two hours after the antibiotics, she is up and around and wants to go home.

Me: Wow

Resident: I know, based on the CURB-65 criteria her predicted mortality is about 50%

I give away a lot of advice, that people may or may not want.  People come to me not for information regarding their disease but for a cure. They want to feel better. This is in part an residual of the miracles of the antibiotic age that I was a part of this weekend. Pneumonia, the “old man’s friend” is now, if treated efficiently and effectively, almost always curable as attested to by my patient form this weekend. The proliferation of “urgent care”s and “immediate care”s is partly because people want to feel better immediately (it isn’t Dr. Perkins I need, it is a prescription and a steroid shot) and partly they don’t want to miss a pneumonia and die (it isn’t pneumonia, is it?).

The antibiotic model is that it works great for pneumonia in old people in part because the outcome is so dramatic. The older person is still old but the pneumonia is now gone. It is a lousy model for chronic illness. Take insulin for 4 days for your diabetes and you still have to take it the 5th day. And the 365th day for that matter. Unlike the pneumonia, which if untreated will kill you quickly, the high blood sugar of diabetes rarely kills. It is the aftereffects, the sequelae, of diabetes that kills with heart disease, stroke, infection, and blindness.

The New York Times covered a science story regarding the differences in premature mortality between the rich and the poor (found here). In it they point out that the differences can be explained by smoking (the poor are much more likely to smoke, now) and prescription narcotic abuse (just because it came with a prescription doesn’t mean it is safe). The third contributor is obesity. The rich are less likely to be obese than the poor, but not that much less (31% vs 37%), so why is obesity more of a problem for them? The investigators didn’t know why, exactly.

We had another patient this weekend who was admitted for her diabetes that explains why obesity isn’t so bad for the poor but the sequelae of obesity is. Her diabetes is well controlled when she has her insulin. Her job provides her insurance. Unfortunately her job doesn’t pay enough to cover the copay for the insulin, her grocery bill, and her housing expenses. So often, she has to make a choice between food and insulin, especially if her job doesn’t give her enough hours. So it isn’t the obesity per se. It really isn’t the diabetes, per se. It is the need to choose between a warm place to stay, food for her family, or her insulin that forces her to neglect herself. The sequelae of being poor in America.



george-price-i-m-the-captain-of-this-ship-new-yorker-cartoonRick Blaine: Yes. I guess it is too far ahead. Let’s see. What about the engineer? Why can’t he marry us on the train? Why not? The captain on a ship can. It doesn’t seem fair that. Hey, what’s wrong, kid?
Ilsa Lund: I love you so much. And I hate this war so much.

Casablanca, 1942

Being a ship’s captain probably used to be so cool. Dining with the important guests. Yelling commands during exciting storms. Marrying Humphrey Bogart and Katheryn Hepburn types who were tired of that “crazy old war.”

Life onboard a ship has likely been romanticized ever since people traveled from one place to another by boat. Oh, sure, there are stories like Billy Budd and Mutiny on the Bounty but the romance of the sea was always there, at least to those who were not actually at sea.

In an old, old (1960s) Star Trek episode, a computer is placed on the Enterprise and given full command. Kirk is placed on board with a skeleton crew and the computer (remember, it could talk) is given full control. Kirk, accepting of his fate, is even called Captain Dunsel by his colleagues, a term meaning he serves no useful purpose (such as teats on a bull). Just as Kirk finds his peace with the new Star Fleet technology (and, as always, saves the Enterprise), today’s ship captains have done so as well.

The current life at sea is it is a lonely life at best. My department cares for some of the merchant marines who come through Mobile. The large container ships typically have only 12 crewmen and no passengers and are on-board a vessel over 400 yards long. There are likely over 10 different languages among the 12 crew, and so dinner time likely has limited shared conversation. They are with each other at sea for months at a time and as a rule spend less than 24 hours in port. The Captain has the responsibility for keeping this team working in an orderly fashion. Interestingly, the Captains who have come to our office for care seem to like their job. They, as a rule, smoke too much (many are Greek). Not a life I would choose for myself but one that carries responsibility, provides a challenge, offers freedom from direct oversight, and commands respect. A job that is sought after by many. Not one that I’ve met feels like a “Captain Dunsel.”

The role of the physician is now changing in our health care system. The New England Journal of Medicine has posted an article this week about the changing role of physicians. They cite the current situation as untenable and point out that the alternative “usually comprising some combination of alternative sites of care or caregivers, new care processes, and enabling technologies” depends on “two local factors: effective care teams and good management of local operations (“clinical microsystems”).” We have the opportunity to be a positive force  or we can continue to perform poorly and blame others.

Just as there is no “I” in team, there is no team based care without patients. Trying telling this to a Doctor Dunsel. “Our great care,” so the conversation goes, “is wasted on crappy patients.” There has even been a discussion amongst certain academics that we may have a created a super-race of non-compliant patient so self destructive that they can overcome even the best of care.

When trying to sell the benefits of team based care, Doctor Dunsel will tell me “I would love to be a part of a team, it’s the staff/ancillary personnel who are the problem.” Non-physicians’ contribution to care quality tends to be undervalued . The belief is that the great doctoring done by the smart doctor is lost in the incompetence of others. Outcomes measures and benchmarks, therefore, will never work.

So, just like the ship’s captains don’t do a lot they used to (including perform marriage ceremonies), physicians are going to have to come to grips with our changing status and roles. Physicians in the new model will need to “focus on promoting collective action, ceding control to the team, and showing the way by asking others how to get there.” The New England Journal article points out that these changes will be difficult

This model of clinical leadership runs counter to much current practice. [It is]  contrary to mainstream medical training and culture and the current tort environment. In many places, accepting a clinical leadership role brings a loss of status and income as well as disdain from peers.

To avoid becoming “Doctor Dunsel,” we need to embrace the concept of team. Back to the New England Journal article

Without formal authority, the only tool that clinical leaders have is their behavior: what they say, how they say it, and how they model good practice. The choice of language — expressing the team’s purpose in terms of creating value, curing disease, preventing harm, and caring for patients — and even tone of voice are essential leadership tools.

Instead of questioning how we can maintain the status quo, we need to ask the following of ourselves and our peers

“What are we trying to achieve?” “What is the best way to achieve it?” “Are we getting the desired results?” “What can we do to get even better results?” And “are our systems keeping patients safe?”

In a newsletter I receive about Accountable Care Organizations (boy, they really need to come up with a better name for these things) was a list of “what patients want” from their ACO. It isn’t a bad list and since I rarely talk about the patient experience I have elected to post bits of it (with annotation) here:

1) A primary care doc who responds pretty quickly to my calls, emails, texts or Skype (or has a fabulous nurse practitioner or physician’s assistant who gets right back to me). Someone who routinely asks how I’m feeling, not just whether my body is OK. Someone who makes eye contact and can explain what’s going on with words I understand.

I taught the first year medical students about how to be a “good doctor” despite everything it still comes down to communication, both verbal and non-verbal

2) A dentist who does the same (and who shares records with my doc.)

3) Evening and weekend office and lab hours.

4) An electronic medical record I can view at home and add to as needed. The record will show the prices of the tests or treatments my doctor recommends and the ones I receive.

I have mixed feelings about “patient annotated records.” Although in my core I believe that people want to feel better, I have enough experience with patients that manipulate for secondary gain to be very wary of this concept.

5) A patient coach who will help me get a second opinion or find more information about my illness, set health improvement goals, and understand the costs of my care. Someone who will help me be an informed advocate for myself and my family.

6) An ombudsman with whom I can register problems or a complaint.

7) A great, easy-to-navigate website that includes my records and all the information my patient coach wants me to see: FAQs and videos or health explainer-type games as well as a place to chat online with patients who’ve been in a similar circumstance.

Just saw a demo by Polycom about how to do just that with tele-medicine technology. The technology is here, and the ACO concept might make it a possibility.

8) Cool incentives and rewards for staying healthy, exercising more, losing weight or quitting a bad habit.

9) Easy parking or valet service or a shuttle from the closest train station or golf carts that drop me at the front door (can we make going to the doctor more fun?)

Folks need to walk (My daughter tried to get us to buy her a “Barbie Car” to use to go to the park instead of walking and I was against that as well).

10) Really nice front office staff who know my name and remember something about me and offer to help with the next step in my care and maybe even get me water or tea as I wait.

11) Basic tests in the same building as my primary care doc that don’t require more than a 30-minute wait.

12) Quality measures I can understand and evidence of improvement

Trying to get folks to look for quality is going to be the answer to many of our problems. Trying to package information in a manner that the lay person will intuitively understand what quality is will be vital to the success of this massive system change.

She has a wish list which is very interesting as well, so check it out.

When my son was young, I used to read him a Dr Seuss Book entitled Oh, the Places You’ll Go! In this book, the protagonist, who is clearly going places except when he is not, is warned about the trap of waiting:
You can get so confused
that you'll start in to race
down long wiggled roads at a break-necking pace
and grind on for miles across weirdish wild space,
headed, I fear, toward a most useless place.
The Waiting Place...
...for people just waiting.
Waiting for a train to go
or a bus to come, or a plane to go
or the mail to come, or the rain to go
or the phone to ring, or the snow to snow
or waiting around for a Yes or a No
or waiting for their hair to grow.
Everyone is just waiting.
Waiting for the fish to bite
or waiting for wind to fly a kite
or waiting around for Friday night
or waiting, perhaps, for their Uncle Jake
or a pot to boil, or a Better Break
or a string of pearls, or a pair of pants
or a wig with curls, or Another Chance.
Everyone is just waiting.
We in Alabama now sit and wait and see whether or not our Governor will choose to provide health care coverage for our poorest citizens at little to no cost to the state for the next 5 years through the expansion of Medicaid (thanks to the Obama-supported PPACA). I have some questions for those of us in Alabama stuck in the Waiting Game:
1)We have an opportunity as a consequence of the expansion of Medicaid as provided by the ACA to provide coverage to 60% of our current uninsured and coverage for preventive services and chronic disease care to a large number of underinsured. Shouldn’t every organization interested in the health of Alabamians support this? For those of us who feel a sense of responsibility to our fellow Alabamians,  whose job is it to go to the Governor and  the key legislators? For those who can’t support it,  how do we as a state provide the care to these poor folks when the DSH money goes away and hospitals are no longer given federal money “just for being open to poor people.”
2) Opportunities (i.e., grant $$) to improve community health markers are found throughout the ACA. Shouldn’t every agency interested in the health of Alabama be applying for these grants? That part of the law is not in question and is THE LAW.
3) The movement towards Patient Centered Medical Homes and ACOs  has likely reached a tipping point. States like Alabama are very dependent on the legacy of Hill Burton hospitals in rural communities that are likely not going to survive the transition. How do communities plan for this and who helps them to do this if the state chooses to ignore the existence of the new law?

My wife (and editor) is a columnist for a hyper-local start-up trying to compete with our local newspaper. She wrote a column, published today, on the trials of one of our (now deceased) “urban chickens.” The story takes the reader from the designer chicken coop to the vet who specializes in urban chickens, through the diagnostic testing (mostly physical exam), and the outcome (the chicken had to be “euthanized”). We have had several conversations about this event in our household, mostly around how a vet can charge so much money to diagnose a bird that one can get pre-cut up at Food World for 69 cents a pound with a coupon. Mostly, I filed this under people with extra money do odd stuff for their animals and vets are willing to work with us to facilitate this behavior. I couldn’t help but reflect that in the old days, the county agent would have provided the diagnosis (“That’s bad”) and offered a free solution (wringin’ its neck). Or so I learned from watching reruns of Green Acres while I was growing up.

In catching up on a backlog of New England Journal articles, I came across an article that points out the cost-effectiveness of environmental prevention (either through creating opportunities such as walking and bike paths or prohibiting bad behaviors such as driving without seat belts) when compared to individual focused efforts such as screening for colon cancer. I also read the review of the Insitute of Medicine report on childhood obesity in a subsequent issue. Disturbing was the breakdown of attribution of cause by political ideology, with “conservatives” more likely to blame children for their own obesity. Another Bloomberg article points out that physicians are at times willing accomplices in subverting any requirement for personal responsibility. The writer documents physicians self-referring into a surgery center that gives them a tremendous profit in exchange for only referring folks with the “right” insurance and looking the other way as the insurance companies were milked (or bilked, depending on the outcome of the lawsuit) for excess payments.

In short, to improve the health of the country we are going to have to make societal changes that lead to prevention, convince 30% of the population that this is not socialism, and find ways to keep physicians and others from gaming any new system. Paul Grundy, my friend with the Patient Centered Primary Care Collaborative, would see the chicken story as a metaphor for a broken system but would understand the need for a county agent approach. He sent me an advanced copy of  their newest report (to be released September 6) entitled “Benefits of Implementing the PCMH: A review of cost and quality results, 2012.” The Patient Centered Medical Home is a way to organize care delivery that combines the best of high value physician interaction, rewards for population health, and identification and elimination of waste. The new assessment of this method of care delivery is:

The PCMH improves health outcomes, enhances the patient experience of care and reduces expensive, unnecessary hospital and ED care.

It is being implemented across the country with the following consequences:

  • As medical home implementation increases, the Triple Aim outcomes of better health, better care and lower costs are being achieved.
  • Medical home expansion has reached the tipping point with broad private and public sector support.
  • Investment in the medical home offers both short- and long-term savings for patients, employers, health plans and policymakers.

Note that the outcome for human patients (better health) is different than the outcome for chickens (stewpot). I hope for the sake of all of us that we achieve these outcomes (for people). Now if only we can bring a County Agent to Mobile who knows about chickens.

The [Medicaid] expansion could help extend insurance in some of the state’s poorer counties, such as Greene and Wilcox counties, where median household income runs between $22,000 and $23,000 a year. However, Williamson said, 60 of the state’s 67 counties lack health care providers. “The problem is if you’re expanding by 40 percent the Medicaid population, you are not expanding by 40 percent the provider population,” he said. “I don’t think you can say giving 400,000 people a Medicaid card is going to be equivalent of giving them access.”

Dr Don Williamson, State Health Officer and interim Alabama Medicaid Commisioner, on whether or not to accept the Medicaid expansion included in ObamaCare.

Hillsdale Middle School,which was in a rough, somewhat working class neighborhood, was torn down in Mobile this past year. It was built in the mid-1960s. I used to take the 1st year medical students to  the school in the spring to deliver health information to the students and faculty. It was their first contact with real people as a health professional and they tended to be very excited. They would put together information and use games and other means of interacting with the students. For the most part it offered the medical students a window into care delivery and offered the middle school students an opportunity to obtain free, unbiased health information.

After the second or third time, the principal took me to the flag area to show me a plaque. It read “Hillsdale High School, built to serve colored Mobile students, 1965.” He explained to me that the school, built without the bells and whistles which usually accompany high school construction, was built to try to provide a solution to the “separate but equal” problem. Of course, 1965 is ten years after the “Brown vs the Board of Education” ruling that separate but equal was ineffective.  Four years later, when Phidippides arrived in Mobile with the news that segregated education was against the law, it was converted into an integrated middle school.

The evidence for a primary care solution to the health care access problem has been known for many years. The commercial insurance market has felt the pressure since the founding of the Patient Centered Primary Care Collaborative by large employers in 2006. We had evidence in Mobile for the need for better, more improved Medicaid delivery in 2000 with the failure of the Bay Health Medicaid HMO. North Carolina has shown how to do it right with CCNC.

Unfortunately, rather than thoughtfully working through how to best deliver the best care (which is primary care) to the citizens of Alabama, we have this response instead, from Alabama State Senator Paul Bussman, R Cullman:

Bussman said he hopes voters will defeat President Obama in his reelection bid and pressure Congress to strike down the health care plan.

“We already have an issue in Alabama with a shortage of physicians. This will overrun those that we have,” Bussman said. “I personally hope this becomes like a Pearl Harbor and the American people say they’ve had enough. The only way to repeal this is to get (President Obama) out of office.”

So…a little advice. Black folks and white folks are together in school and the world did not end. Fight all you want, the Affordable Care Act is the law of the land. If I were you, Alabama Legislature, I would direct Dr Williamson to figure out creative ways to provide care to all of your constituents as access will no longer be limited by income.

  • A video from Kaiser Family Foundation, found here or here, explains the ACA in lay persons terms. The only caveat is that since the ruling, states may elect to allow their poor citizens to not be covered through the Medicaid expansion (to prove a point as the feds pick up the entire tab for the next several years and it’s not like they weren’t getting care anyway)
  • A video that explains how we are trying to deliver better care within our practice using a template called “The Patient Centered Medical Home.”
  • A video that takes a humorous poke at the second video

I recently ran across health policy researcher and physician Allan Detsky’s article entitled “What Patients Really Want from Health Care.” I found it very disheartening, since if Dr Detsky is correct our society will soon go the way of the Mayans. As David Nash summarized (using the Affordable Care Act as a point of reference):

  • Dr. Detsky reports that what a majority of us want is a healthcare system that relieves our symptoms when we’re sick and restores us to “good health” by our own definitions. He observes that we understand, but are less interested in, healthcare services aimed at preventing future illness. The implication is that wellness programs and population health initiatives may be a hard sell without sweetening the pot.
  • He found that a majority of us want to be given “hope” and to be offered options that “might” help even when our health is unlikely to improve. In essence, we are likely to demand more tests and treatments even when these are unlikely to be effective.
  • Most of us want private rooms without paying anything out of pocket.
  • We want clinicians who are judged “the best” by other patients or our doctors rather than by objective information (e.g., quality data contained in HHS’ Physician Compare website). In other words, we are less likely to use the tools that are available to make better healthcare decisions.
  • We prefer treatments that require little or no effort on our part (e.g., medications and/or surgery) rather than strategies that require us to change our behavior (e.g., dieting, exercising). Because our clinicians will be judged, in part, on their ability to influence our behavior, we are likely to impede their success.
  • On the bright side, most of us agree with the Act’s recommendations concerning continuity, choice, and coordination. We want to build better relationships with our clinicians and we expect them to communicate with one another.

Dr Detsky goes on to point out that Americans do not care how much we spend in aggregate nor do they care what the real cost of their own care is when presented with the information. The current debate regarding the federal deficit is clear proof of this.

In an attempt to put a better spin on American’s apparent irrationality about health, physician and medical informatics expert Joseph Kvedar looked at the information using  a  different lens. His take on American’s desires can be read here. He feels that focus on “patient satisfaction” was flawed, well, because it focused on patients. If we were instead to focus on folks who are not yet sick and are interacting with the health system on a limited basis, he believes we will find a different set of goals. He believes that folks want to have meaningful interactions involving interpretation of their own data in light of a desire to live long, full, and rich lives. He believes that folks that suffer from chronic ailments want to be gently guided back to full health in as painless a manner as possible. He believes that in general, people want respect and control of their own situation.

I would like to believe Dr Kvedar. I precept Family Medicine residents, however, who present patient after patient whose diabetes is poorly controlled and who are asking the resident to give them yet another stab at a pharmacological fix (maybe if we add Byetta) to what is a behavioral problem (did you know that if you lost 30 pounds I wouldn’t have to add this medicine and could probably remove one?). My experience tells me that Dr Detsky has his finger on the pulse of our patients and future patients. A colleague sent me a recent paper entitled “The Cost of Satisfaction.” Patients were followed over time and those who were more satisfied in this study spent more on drugs and were more likely to die. How do you empower folks, change attitudes, and make people feel responsible for their own health? It will likely take something different than giving people what they want.