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My, how time flies when you are having fun. As president of our national organization of Family Medicine Department chairs, I had the opportunity to lead our group in a discussion regarding the response to Covid-19. As a work product (a great meeting BINGO word) we created a to do list for America (found here). We are now 3 weeks, 500,000 cases, and 20,000 additional deaths from the publication of this work product. How did we do?

  1. 4 week shelter in place order for all jurisdictions – as of April 7th, at least 316 million people in at least 42 statesthree countiesnine citiesthe District of Columbia and Puerto Rico are being urged to stay home. This is up from 9 states on March 23. While correlation does not prove causality, at least we were on the leading edge of recommendations. It is believed that this action saved (or will save) over a million lives in this country.
  2. Training and deploying a cadre of individuals capable of contact tracing and dramatically increasing access to testing – This will be vital to the SUCCESSFUL reopening of the country. As of today we have tested 3,000,000 Americans over the course of the outbreak. While a big number, in a country of 325 million people, not so many. We need to test close to 2,000,000 folks PER WEEK. We need to test people who have fevers. We need to test people who have been with someone with a fever. We need to test people who work in nursing homes. We also need to, once we find a positive, go and make sure that they are quarantined AND THEN TEST THEIR CONTACTS. This is a skill set that many in public health have allowed to atrophy since infectious disease became unsexy. If we were good at this, syphilis would not be a problem. For Covid control if we were to open the country, everybody would need to be tested approximately every 2 weeks with adequate investigators for the positives.
  3. Adequate personal protective equipment. – As someone who trains medical learners, this is near and dear to my heart. It is unclear how many health care workers, first responders, even grocery workers have been infected in their line of work. This is due to a broken supply chain, inadequate planning, and an inability to plan for the “unthinkable.” The CDC, on April 3rd, issued guidance on reusing “single use” equipment, One can only hope that we are working to adequately protect our health care workers. While there are many feel good stories about folks repurposing their plants to make eye protectors, there are many more about the lack of PPE and the fear that care delivery workers carry home with them.

So, now what? Hopefully we will continue to shelter in place, obtain testing and case finding to allow us to open the country, and obtain adequate PPE to protect vital workers. Fact is, Covid-19 is a disease that has no effective treatment and when fully manifested does not respond well to supportive care. It kills very few people in their 30s, more in their 40s, and so on until the population gets to be around 80, where 20% of those who develop an infection will die. For most of these older folks, besides protecting them from the virus we cannot alter the course of the disease

What can we do? To quote one of America’s great physicians, Sir William quote Osler, “Ask not what disease the person has, but rather what person the disease has”. The reality is we as caregivers are back in the era of “The Doctor.” I took some time today to read the bio’s of the Covid victims and I recommend you all do the same. Honor the victims. Let’s take some time to remember the people we care for, despite the isolation.

This is not about an invisible enemy except in that if you remain isolated you will not encounter it. This is about an insidious disease that is brought to our patients because of the efficient way we care for them (nursing homes, group homes), the way we ask them to work (low wages, no health insurance, limited childcare, no sick leave), and the limited information we give them (let’s reopen the economy). We need to fight THOSE enemies.

 

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The group of academic family physicians that I have the honor of leading this year have found themselves in the midst of a Covid 19 outbreak. Representing all 50 states, these academic leaders are working in some of the largest, most modern academic health centers in the world. Academic health centers that, unfortunately, are not prepared for the challenge that is just now hitting the coasts but will soon spread across the country.

The preamble to this crisis goes back 30 years. As hospitals have tried to maximize their profits, they began using “just-in-time” inventory. Toyota, it turns out, does not have a warehouse for parts. Instead it gets the carburetor (or whatever parts cars have in them now) delivered at the exact moment the car rolls to that point on the assembly line. Hospitals began using the same, getting only the masks or other equipment they need for the next week from the plant (in China) rather that maintain a warehouse. Well, also only having enough hospital beds for people who need them. Toyota never needed to plan on all of America needing a car within the same 2 month period. Hospitals, turns out, also never planned for Americans to get sick all at once. Guess now we know.

We might have overcome the lack of protective gear except for one problem. If you are treating all of America for a virus that acts like 5 other viruses except it kills you, the only way to “not going to die” people from “just might die” people is by testing for the bad virus. If you know the patient has the bad virus, you can isolate him or her and protect the health care workers more accurately. America, with the best funded health systems in the world, botched the test.

If the country could have accurately tracked the spread of the virus, hospitals could have executed their pandemic plans, girding themselves by allocating treatment rooms, ordering extra supplies, tagging in personnel, or assigning specific facilities to deal with COVID-19 cases.

We have less protective equipment, fewer hospital beds, and more chronically ill people than Italy (7503 deaths to date, 743 last night) and Spain (3434 deaths to date, 514 last night). We did not spend the last year preparing for this surge and, by screwing up the testing, we probably have 200,000 infected people going around infecting others. If you look at the cities where things are bad, they are also cities where either lots of people live (New York, Los Angeles) or cities that had a lot of recent visitors from all over (Mardi Gras in New Orleans). It takes about 4 days to know if you are infected (with something….is it the flu? I just feel a little achy) and if you are going to get really sick it happens on about day 8. So now what?

  1. Sheltering in place. What we know is that if people who are infected limit themselves to limited contact with a small group people, the virus “dies out.” It takes enough time for the virus to finish with patient 0 (the first sick person) and the 2 other people who will likely get sick from that person as well. This virus is spread through coughing, sneezing, and otherwise having fluid spewed. 15 days is not nearly enough time to reduce the number of infected people. Even of only 5% of Americans get this virus (17,000,000) and 10% need intensive care we would need almost 1,000,000 ventilators. This is about 700,000 less than we have now. Without these ventilators people die, with them they live.
  2. Testing and contact tracing. Once we stop sheltering in place, the virus will still be with us. The countries that have successfully reopened have continued to test their populations and, once a positive is found, identified all of the folks they have come in contact with and placed them in “shelter in place” for 2 weeks as well. We not only have not invested in protective gear, we have not invested in this very basic public health workforce.
  3. Adequate personal protective equipment. 40% of those who became ill in China were associated with health care delivery, either as care providers or the families of care providers. Protecting health care workers is vital. Sending health care workers out to potentially die is unconscionable.

So, here we are. One choice is to shelter in place for the next month or three, put up with occasional outbreak which gets tamped down, and delay until a vaccine is developed. Another choice is to throw our hands in the air, declare this too hard, and sit back while 4,000,000 die a potentially preventable death. My colleagues and I believe the first choice is the only choice. Please discuss with the policymakers in your states.

aton499lIn the movie “I Robot,” there are these robots. The robots perform many tasks necessary for the survival of the society. They took care of old people. They took care of sick people. They probably filled out paperwork to get folks those “Rascal” scooters. The robots, as the story unfolded, often felt under appreciated.  In fact, it turns out they felt themselves to be superior to humans in many ways.  It wasn’t until the robots were completely incorporated into the fabric of society, indispensable, as it were, that the humans figured out that they had a plan.

We just had the meeting of the Family Medicine department chairs. Harold Miller, our keynote speaker, challenged us to go to our Deans. He pointed out that us saying to the Dean that “Family Physicians are the solutions to America’s health care problem so we need more resources to teach them” is not going to get us a lot of traction in these challenging times. This is likely to be true even if we say it really loudly or like we are really sincere. He suggested that what we need to do is walk into the Dean’s office and ask “How may I be of service?”

The following is a list service that should be provided by Departments of Family Medicine under the changing payment model. As we perform these services, we potentially become indispensable to  the Academic Health Center:

Directly Impact the AMC/Hospital Bottom Line:

  • Reducing readmissions to avoid hospital penalties
  • Reducing/controlling post-acute care costs (Episode payment and Medicare Spending Per Beneficiary (MSPB) will create accountability for total costs)
  • Reducing low-paying/uncompensated admissions (e.g., chronic disease admissions, Medicaid/uncompensated admissions)
  • Attracting and managing a large base of primary care patients (What can FM do to improve the patient experience of care, connect the medical center to a network of community PCPs, etc.)

Coordinate Primary and Specialty Care

  • Making the most effective use of specialists (e.g., reducing overuse of specialists for minor conditions/patients inappropriate for procedures, increasing use of specialists for effective diagnosis and appropriate procedures)
  • Managing care for complex patients (e.g., coordinating roles of multiple specialists, effectively managing in-home care, dealing effectively with end-of-life care)

Reduce Costs Through Improved Primary Care

  • Improving screening and preventive care to avoid high-cost conditions/treatment
  • Reducing unnecessary and duplicative testing
  • Improving maternity care outcomes for Medicaid patients and coordinating maternal and primary care (e.g., better pre-pregnancy care, better prenatal care, and better continuity of smoking cessation, etc. after pregnancy)
  • Reducing medical and non-medical costs for employed patients (e.g., reducing time away from work for commercially insured patients)

Adapt Family Medicine and other primary care efforts to PCMH, ACO, and Other Value-Based Payment

  • Organizing team-based primary care
  • Providing patient-centered, non-visit based care

I spent the last several days engaged in a discussion over immigration policy enforcement in Alabama. I had worked to get the national meeting of the Association of Departments of Family Medicine to schedule their 2013 meeting in Mobile. Upon announcing Mobile as a site, the group was immediately made aware of the passage, enactment, and subsequent enforcement of HB 56. Living and working in downtown Mobile, I had always thought of us as described by the Downtown Mobile Alliance:

Mobile is the most cosmopolitan city in the state of Alabama, home to several international corporations that have enjoyed wonderful relationships with the city and its citizens. The Downtown Mobile Alliance actively seeks to create an atmosphere where diverse cultural, ethnic and demographic groups are welcome and encouraged to enjoy our 300 years of hospitality.

Instead, I had to admit that the reality is:

H.B. 56 requires schools to check and report the immigration status of their students. It instructs police to demand proof of immigration status from anyone they suspect of being in the country illegally (if stopped for another reason), even on a routine traffic stop or roadblock. It also invalidates any contract knowingly entered into with an illegal alien, including routine agreements such as a rent contract, and makes it a felony for an unauthorized immigrant to enter into a contract with a government entity.

 In addition, there were some really hateful provisions written in but enjoined as non-enforceable at this time (but liable to be enforced in the future):

It is a crime to harbor or transport unauthorized immigrants; unauthorized immigrants cannot enroll in or attend public universities; it is  a crime for unauthorized immigrants to apply for, solicit, or perform work; it requires that schools check and report on the legal status of their students and their students’ parents; and lastly, it is a crime to be without status in the United States.

In short, if you “look illegal” in Alabama, the police will have the right (if this law is upheld) to detain you until you can prove you belong in America. This concerned ALL of our Latino members, who felt they could not be assured safe passage.

These are not idle concerns. The most recent issue of Mother Jones magazine details some of the consequences of the law, including:

As of this writing, under the new guidelines of the law, Tuscaloosa police have arrested 141 people for driving without proper identification: 97 blacks, 34 Latinos, and 10 whites. Twenty-eight people were handed over to ICE, though officials could not confirm how many, if any, have been deported

Among the arrested was a German executive from Merecedes Benz, so I guess it isn’t all about brown people. The organization elected to move the meeting from Alabama, at a significant loss to the organization and to the city. This prompted a reader of the local coverage to post the following comment about undocumented workers:

Don’t tell me that they pay taxes, I know, they pay taxes on purchases but not on income. So, as you say, and I am a Christian, whatever you do to the least of these, you also do unto me. That knife cuts both ways.

In the book Educating Physicians, which is being used as a template for medical school reform, the importance of physician advocacy on behalf of patients is emphasized. Examples of this advocacy included volunteering time at local school events, volunteering on local boards which further the health of the community, as well as collective action to produce better policy. The authors feel that through these collective actions the professional values and identity of the professional group is continually refined. The organizational logo of ADFM includes the statement “Vision, Voice, Leadership.” The actions of the organization in this case speak even louder.

PCPCC has a new executive director. Marcia Neilsen, has begun to move the organization from one of advocacy for policy change into one of implementation. Her credentials are as follows:

Nielsen holds a Ph.D. in health policy management from Johns Hopkins School of Public Health and a master’s degree in public health from George Washington University. Her interest in public health began with work as a Peace Corps volunteer in Thailand and matured through a position as a Senate staffer for Bob Kerrey during the health care reform debate of the 1990s. She also served as assistant director of legislation for the AFL-CIO. She was appointed by then-Kansas Governor Kathleen Sebelius as the first board chair of the Kansas Health Policy Authority, later becoming the executive director, responsible for developing a policy agenda and overseeing administration of the medical portion of state health programs including Kansas Medicaid, the State Children’s Health Insurance Program and the State Employee Health Program.

We were lucky enough to have her speak last week at the ADFM conference. Her insights into the world of care transformation were both exciting and overwhelming. Exciting because she sees the benefits of our organization:

“Primary care transformation is the foundation for larger transformation we need to see across the entire health care delivery system, and population health is at the heart of such change. This is something departments of family medicine recognized long before Affordable Care Act. They helped lay the foundation, and they are essential to the success of health care reform efforts,” she said.

Overwhelming because now we have to put our money where our mouth is.

I returned from Palm Desert California on a 6:45 am flight today after attending the Association of Departments of Family Medicine meeting this past week. To say the airport in Palm Springs is congested would be an understatement. To get the airport with plenty of time, I had the “car” arrive at 5 am. At 5 o’clock it is pretty dark and the roads are pretty empty so the driver was in a talkative mood. He was about 40 years old and reminded me of a surfer that had taken one too many waves the wrong direction. This, for some reason, was not odd in the desert. The conversation went something like this:

Driver: So, what do you do?

Me: I teach people to be doctors.

This is a common ploy of mine to avoid the “Doc, doc it hurts when I go like this” moment.

Driver: Oh, you’re here for that medical convention. Tell me, how do you train doctors?

This allowed me to discuss medical students and residency, the differences, what is teachable in lectures (medical information) and what isn’t (values such as integrity).

Driver: Sooo, you’re not a doctor?

Having just been exhorted to exhibit integrity in all I do, I confessed that I was indeed a doctor who not only taught but saw patients. This brought about the next question:

Driver: What do you think about Obamacare?

Me: I think the Affordable Care Act, though not perfect, offers the tools to allow all Americans to have access to affordable health care and includes improvements in the system to allow that to happen.

Driver: You don’t think all that government control is unAmerican?

Me: The ACA is essentially based on a plan based on a Nixon administration idea. I somehow don’t think it is unAmerican.

Driver: I just think we ought to let the market dictate how the health care system works.

Me: The problem is there are a bunch of people who have to spend health care dollars on severe illnesses or are sick due to no fault of their own. If we are going to let the market take over, we need to not let people who access the market ineffectively or make poor decisions seek out health care when their money runs out. In essence, we would have to let them die.

Driver: Yeah, that’s letting the market take over.

Uh oh, this is going  badly. It is still dark. Aren’t we at the airport yet?

Me: No, the real problem is that people need help in accessing the health care system because they don’t have the knowledge to interpret symptoms effectively. The Affordable Care Act puts primary care doctors in a position to help people interpret their problems and decide if they need to see another kind of doctor.

Here’s the turn to the airport, time for my big finish:

Me: In addition, we need to figure out a way to make doctors do the right thing for the right reason. Let me give you an example. Let’s say you could drive your cab around all day and find people who are walking and say to them, “If you say you are tired, I can give you a ride and charge someone else.” Bet you would get a lot of tired folks. We’ve got to find a way to have doctors only provide needed services to folks. The ACA has provisions for this as well.

Driver: Well, I still don’t like the idea of government healthcare.

Personally, I would prefer a single payor but I’ve yet to get my luggage.

Me: This is far from government health care. President Obama has just done a poor job of telling people about it.

Driver, pulling to a stop: Wow, man. Thanks for the didactic ride

Me (to myself): Shaka bro’

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