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Resident: The patient is a 45 year old black male…

Me (interrupting): I really don’t like identifying people by the color of their skin. What else do you know about him?

Resident: The patient is a 45 year old automobile mechanic who is here for a recheck of his diabetes…

Me (interrupting): Who lives where?

Resident: I don’t know, Mobile. Can I please just finish?

Me: Not until you tell me where he lives and why it’s important

Resident (whispering to another resident): is there another attending I can talk to?

Our current mayor, when he was elected, established an outcome for his “mayorship.” He stated, unequivocally, that he wanted Mobile Alabama to be the safest, most business and family friendly city in America by 2020. Well, OK, in my objective writing classes we were taught to focus on SMART objectives. That is, they had to be specific, measurable, achievable, relevant, and time oriented. For example: We want to to be the most family friendly city based on the “family friendly poll” that is administered by the governor’s office twice a year and includes a scientific sample families in Mobile, Huntsville. Montgomery, and Birmingham. Yeah, forgot that step, I’m afraid.

What should it mean to be the most “family friendly” city in Alabama? Mobile is a geographically large city. Bordered by a river on one side, the city stretches 12 miles in one direction and almost 10 miles in another. Does “family friendly” mean parks? We got some, but not a lot. Does it mean churches? We got a lot of those. I bet it is neither one of those. I would bet, if you ask people, they want it to mean a good life for their children. I bet people would say “I want my kids to be happy, healthy, and successful.” How are we doing with that?

Turns out, the federal government keeps statistics on the “healthy” part at the neighborhood level. You can use a tool (such as this) to find out if you live in a healthy neighborhood or an unhealthy one. If you live in an unhealthy one not only are you doomed to a likely premature death but so are your children, In Alabama the healthiest neighborhood provided it’s denizens with a life expectancy of 88 years (an affluent suburb of Birmingham) to 63 years (an area of Montgomery that Martin Luther King marched through 50 years ago). Mobile’s neighborhoods range from a high of 81 to a low of 63.

The neighborhood with the lowest life expectancy in Mobile is not that far from my house. I treat several patients who live there. What sets the neighborhood apart? The people are poor. They work, just not at affluent jobs. One in four are uninsured. One in five report poor mental health and/or poor physical health. A baby born in this neighborhood can only expect to live to 65. A baby born in the mayor’s neighborhood? 82.

How can the mayor improve the health of this neighborhood? There are some simple fixes that could happen tomorrow. An effective bus route through the neighborhood, for example. A find a way to subsidize a source of fresh vegetables and fruits that is less than two miles away. Offer community support services at the neighborhood elementary school.

I believe that family friendly means that our children, who have not yet made any choices, have an equal chance at success. By that metric we have a ways to go by 2020/


Image result for Lowndes county alabama
A United Nations official arrives in Alabama this week to investigate poverty, inequality and “barriers to political participation” in the state
Alston will spend Thursday in Lowndes County, where he will be looking at issues like health care, access to clean and safe drinking water, and sanitation.
The Guardian reported in September on a study exposing the fact that a small number of people have tested positive for hookworm – a parasitic disease found in impoverished areas around the world – in Lowndes County.
What he’ll find if he looks-only 30% of the citizens of the county have functional septic tanks, 1 in 3 live in poverty and 1 on 5 will have no health insurance. That’s OK because he’ll find only 2 doctors, no dentists, no psychiatrists, He’ll find that 1 out of every 100 babies die before they reach a year old (worse than most developING countries) and one in two expectant mothers have little if any prenatal care.
Coincidentally, he’ll find that Lowndes County has one of the lowest median property tax rates in the country, Lowndes County is ranked 2682nd of the 3143 counties for property taxes as a percentage of median income..
He’ll find a county where slaves outnumbered their masters by 2 to one in 1860 and the population was 26000. He’ll find a county where blacks outnumber whites now by 3 to one but the population is now only 11,000. He’ll find a county where 1 in 5 are living off social security and one in 10 have no car. 
In other words, he’ll find the Alabama people think of when you say the word Alabama.


Me (while in the military): Well, why can’t we do it this way. This person is malingering and really needs to be “not in the Marines.”

My superior: You really don’t want to. This person might be a screw-up but he is well connected and you really don’t want to start a “congressional.”

In Hawaii, where I was stationed, we lived in fear of “congressionals.” Some enlisted person or another would get what he or she perceived as bad care and before you new it, a letter from a congressperson’s staffer would appear on the commanding officer’s desk.

Dear Captain (blank),

This is to inform you that one of our constituents feels that the care they received  was substandard. Please provide in writing the circumstances surrounding this incident. 


Congressman Foghorn Leghorn

This letter would initiate a chain of events that resulted in all productive activity stopping until all of the minute details could be compiled into a mountain of paperwork and sent “up the chain.” The reality was that the Congresspeople probably could care less about what actually happened but, being the representative of the people, wanted to respond (or be seen as responding) to their constituent. The actual effect was to keep us from doing what we were being paid to do, provide quality care to the troops, and instead focus on the distraction.

This past week our Congressman, Bradley Byrne, responded to what he perceived his constituents wanted. He voted aye on a blank check for congress to “investigate” Planned Parenthood’s role in, I don’t know, having a disturbing lunch conversation regarding embryonic tissue donation. (If you want an in-depth discussion on the ethics of the use of cells in scientific discovery, a good source is this book.)

The investigation, though, seems not to be investigating the use of embryonic tissue in medical advances (think rubella and varicella vaccine) but, very specifically:

Requires the Panel to investigate and report on:

  • medical procedures and business practices used by entities involved in fetal tissue procurement;
  • any other relevant matters with respect to such procurement;
  • federal funding and support for abortion providers;
  • the practices of providers of second and third trimester abortions, including partial birth abortion and procedures that may lead to a child born alive as a result of an attempted abortion;
  • medical procedures for the care of a child born alive as a result of an attempted abortion; and
  • any changes in law or regulation necessary resulting from such findings

Congressman Byrne, please don’t let them turn this into an expensive distraction. Let’s investigate how to make it REALLY difficult for these entities to procure fetal tissue by making pregnancy termination rare. I would ask that Congress use the  “any other relevant matter” clause to investigate the real causes of our abortion crisis and these should include:

  1. In states that have not expanded Medicaid, working parents are only eligible for Medicaid if their incomes are below 61 percent of the poverty line (about $11,900 for a family of three), and jobless parents must have incomes below 37 percent of the poverty line (about $7,200 a year for a family of three). In most states, Medicaid coverage is not available at all to adults without children. This large group of people does not have easy access to long-term effective contraception and thus is more likely to have an unwanted pregnancy and seek out pregnancy termination. How are these states responding to the challenge?
  2. Health coverage during the period before pregnancy allows women to receive preventive care like regular doctor visits, birth control, information about making healthy food choices, tobacco cessation programs, and substance abuse services that decreases their own health risks and makes it more likely that their babies will be born healthy if and when they become pregnant. For example, research shows that prenatal care for high-risk pregnant women reduces the incidence of costly premature births. In states that have not expanded coverage. these people only seek care after they become aware of their pregnancy and make a conscious decision to go to the doctor’s office. They are more likely to have a fetus with a problem and seek out termination. What are we doing to provide access to women prior to conception in the states that have not accepted expansion?
  3. By accepting the Medicaid expansion and eliminating gaps in coverage, the state administrative costs are reduced because the states  no longer have to process enrollment and disenrollment for women who move on and off Medicaid coverage based on pregnancy, thus reducing the size of government and saving the state needed tax revenue that could be returned to the taxpayers. In those states not accepting the expansion, how are they justifying this needless expansion of bureaucracy?

I expect my response soon.

Signed, your constituent and a taxpayer.

david-sipress-are-we-there-yet-new-yorker-cartoon (1)

When I was growing up my sisters and I would play the “Are we there yet” game. For those of you who do not indulge, this game is played by getting in the car, allowing the adults to begin the journey, then about 5 minutes into the ride begin asking “are we there yet?” in a rapid fire fashion using the most annoying voice one can muster. The adult’s role is to sit and ignore the game as long as possible and, when the time is right (generally about 5 minutes in) turn to the back and say “WE ARE HALFWAY, NOW SHUT UP.” At that point, the game is over and, in my family car, generally transitioned to the pinching game (“Allen is pinching me”).

Our Governor’s journey through the changing healthcare landscape has been evolving. In 2010, while campaigning for Governor, he had some deeply held beliefs regarding the newly passed Obamacare:

I started laying the groundwork for Alabama’s rejection of Obamacare by pre-filing a Constitutional Amendment to prohibit any person, employer, or health care provider from being compelled to participate in any health care system. It also codifies Alabama’s 10th Amendment rights over this issue. I have real-world solutions that will result in affordable and accessible health care for all without bankrupting our nation or pushing us closer toward a government-controlled, single-payer system.

The Supreme Court decreed the Medicaid expansion part of ObamaCare to be coercive in 2013 (As an aside, for it not to have been coercive it would have had to meet the following criteria (1) related to the general welfare, (2) stated unambiguously, (3) clearly related to the program’s purpose, and (4) not otherwise unconstitutional.) 26 states elected not to take the expansion, preferring to stick with the (poorly funded, focused on wasteful inefficient care delivery) old program. Our Governor announced that we would be one of the states refusing the Medicaid expansion:

The Affordable Care Act–or ObamaCare–and Medicaid expansion is taking our nation deeper into the abyss of debt, and threatens to dismantle what I believe is one of the most trusted relationships, that of doctors and their patients. Essential to ObamaCare is Medicaid expansion–a federal government dependency program for the uninsured. …

Now they are telling us we’ll get free money to expand Medicaid. Those are your hard-earned tax dollars. Our great nation is $17.2 trillion in debt and it increases by $2 billion every single day. That is why I cannot expand Medicaid in Alabama. We will not bring hundreds of thousands into a system that is broken and buckling.

The good news is that his view continues to evolve. Over the objection of our state senators, he is now ready to accept Medicaid expansion IF there is a work requirement, along with a few other conditions:

“It would have to be in the private sector and there would have to be some requirements on it,” Bentley told reporters in December. One specific requirement he mentioned was that he’d like to see the system tied to employment. “(Recipients) need to be working on getting a job, or having a job.”

A couple of things, Governor, to consider before you start playing the pinching game with Senator Pittman. 72 percent of uninsured adults who are eligible for Medicaid coverage live in a family with at least one full-time or part-time worker. More than half (57 percent) of these adults are working full- or part-time themselves. The overwhelming majority of workers earning less than 138 percent of poverty—81 percent—don’t have coverage through their employer because their employer either doesn’t offer it or it is unaffordable to them.The Kaiser Family Foundation recently looked at the main reasons for not working among unemployed, uninsured adults likely to gain Medicaid coverage if their state adopted the Medicaid expansion. It found that 29 percent were taking care of a family member, 20 percent were looking for work, 18 percent were in school, 17 percent were ill or disabled, and 10 percent were retired.

Maybe we really are halfway there.


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

Question posed to my students in a health policy course

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

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

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

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

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

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

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

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

I 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.

The state of Alabama has a generous retirement system for teachers and other public employees. After working for 25 years (regardless of age), you can retire. This has been a boon for teachers (by far the largest employee group in the state). The legislature was successful this past session  in putting into place an increase in the employee match over the strong objections of the teachers. The problem was not the cost of the pension itself, which has been relatively secure as a result of investments on the behalf of the System. What will bankrupt us is the cost of health insurance. If a teacher retires at 47 (possible under the current system), he or she will be retired for 15 years longer than his or her working life. The health insurance product that is offered (PEEHIP) is a PPO. This means that the beneficiary pays a fixed amount and if he or she goes to a preferred provider there is little or no “skin in the game” for either one. As health care costs have risen, the premium paid by the retiree (about $4,000 annually for family coverage if not Medicare eligible) is only 30% of the total premium ($12,000 annually) with the rest paid by the state. Back when high health care costs were economic multipliers that were  GOOD, a report identified that

…healthcare payments surpassed $1.4 billion and over $1.3 billion went to Alabama providers and facilities.

Now that health care costs (for PUBLIC EMPLOYEES) are bad

Alabama’s PEEHIP program needs an immediate comprehensive strategy for cost containment and pre-funding of PEEHIP benefits for future retirees. Of the three options available—raising taxes, reducing government spending, and reforming PEEHIP—only the latter two have the potential to both save the state money and keep the state’s economy from further harm.

I would argue that health care costs are what they are, they are very expensive for certain people in Alabama, and they are possibly most expensive for retired teachers. There are many things that we can do to reduce the cost of health care, but the first rule of change is that people have to want change for it to happen. In an editorial on the Kaiser Family Foundation website, Drew Altman talks about the realm of the possible. The regulations surrounding the Affordable Care Act are being written and put forward for public comment at a fairly rapid pace. As he points out

The regulations give states substantial flexibility in structuring exchanges, should they choose to set them up. (If a state doesn’t establish an exchange, then the Federal Government will operate one in the state.) In crafting the draft regulations, federal policymakers had to weigh how prescriptive to be. For example, they had to decide whether to prohibit insurance company representatives from serving on the boards of exchanges, or require exchanges to aggressively negotiate with insurers. In general, they erred on the side of less, rather than more, requirements.

My dream is that Alabama Medicaid, Alabama Blue Cross (the folks that manage PEEHIP) and our Republican physician governor will get in a room and petition CMS to allow a grand experiment on how we can do better. We should be able to provide adequate care for our poor, cost effective care for our retirees, and allow choices such that if you want to pay for excessive care, you can (at the risk of hastening your own death). If only Richard Nixon had gotten this law passed the first time around.

I have a neighbor who is riding his bike from Mobile Alabama to Springfield Missouri to call attention to the need for better mental illness care. They happen to have a son who suffers from mental illness and thus (as many of us do) got involved because of their own son and then become involved with an organization that has a much larger purpose. Not only is D. G. riding his bike across country but his wife, Connie, is an officer in the local chapter of NAMI. Part of D.G.’s reason for taking this on, he says, is that

Even if we don’t raise money, if I can change the attitude of just one person relative to mental illness, it’s worth it. We talk about every other disease but we won’t talk about mental illness. There’s just such a terrible stigma associated with it.

Mental illness has been stigmatized since Biblical times. with Descartes being the most recent scapegoat. Part of the stigma was, I suspect, due to the nature of the affliction. Unlike pneumonia with its fever and coughing, those afflicted with mental illness have no outward manifestation, so the common belief seems to be that if they would only try hard enough, they could control their behaviors. In modern times we have devised treatments but the situation has not improved as much as we would hope. Some people don’t respond to the medications. Others may respond partially but feel so fuzzy headed that they want to stop the medication. Others respond so well that they feel normal, so figure they are cured and quit taking the medication for that reason. All in all, not a good illness to have and very difficult to treat, but an illness just like many other chronic illnesses. Because of the need to keep people taking medicine that makes them feel bad even when they are feeling better, mental health professionals developed “Assertive Community Treatment” options that include (from Wikipedia)

  • a clear focus on those participants (clients) who require the most help from the service delivery system;
  • an explicit mission to promote the participants’ independence, rehabilitation, and recovery, and in so doing to prevent homelessness and unnecessary hospitalization;
  • an emphasis on home visits and other in vivo (out-of-the-office) interventions, eliminating the need to transfer learned behaviors from an artificial rehabilitation or treatment setting to the “real world”;
  • a participant-to-staff ratio that is low enough to allow the ACT “core services team” to perform virtually all of the necessary rehabilitation, treatment, and community support tasks themselves in a coordinated and efficient manner—unlike traditional case managers, who broker or “farm out” most of the work to other professionals;
  • a “total team approach” in which all of the staff work with all of the participants, under the supervision of a qualified mental health professional who serves as the team’s leader;
  • an interdisciplinary assessment and service planning process that typically involves a psychiatrist and one or more nurses, occupational therapists, social workers, substance abuse specialists, vocational rehabilitation specialists, and certified peer specialists (individuals who have had personal, successful experience with the recovery process);
  • a willingness on the part of the team to take ultimate professional responsibility for the participants’ well-being in all areas of community functioning, including most especially the “nitty-gritty” aspects of everyday life;
  • a conscious effort to help people avoid crisis situations in the first place or, if that proves impossible, to intervene at any time of the day or night to keep crises from turning into unnecessary hospitalizations; and
  • a promise to work with people on a time-unlimited basis, as long as they demonstrate a continuing need for this highly intensive and integrated form of professional help.

The goal is to maintain the client’s ability to function in society, despite a high cost and potential loss of freedom. If done right, it is expensive. Unfortunately, it is often easier to allow people with mental illness to wander about with no access to care and walk on the other side of the street as we seem to do commonly here in Alabama.

As we fight to destigmatize mental illness and offer appropriate treatment to those who have it, society seems to be moving to stigmatize other folks with certain types of chronic illness. The most recent example is that of diabetes mellitus. I went to a presentation about health coaching at the National Rural Health Association meeting. This presentation discussed a model of care that, although less intensive, offers many elements of Assertive Community Treatment. The goal of the therapy is to move folks with diabetes to a disease-free  state by working with them to encourage lifestyle changes, medication compliance, and disease self-management. It is surprising how rapidly the conversation turns to “disincentives” such as more money in insurance premiums, encouraging “self control” through shame and stigmatization, and “if only they would stay out of McDonald’s.”

As we come to understand how much of our healthcare costs can be reduced through positive lifestyle modifications, I hope that we can celebrate the triumph of modern medicine over the frailty of the human condition. Instead we seem to be moving to punishing those who are less than perfect. A trend I will continue to fight.

Earlier I spoke of nine things we can do in Alabama as consumers to strengthen rural health care. Having spent a couple of days in Austin at the National Rural Health Association conference, Dale Quinney and I brainstormed and came up with four things the state of Alabama can do to improve the health care delivery system in rural Alabama right now:

The pipeline for rural primary care providers needs to be strengthened rapidly and effectively. There are opportunities to strongly encourage (pressure) Academic Health Centers in Alabama to produce sufficient primary care providers of the right background who are committed to practice in rural Alabama. These providers should include not only physicians who will go into Family Medicine, RURAL pediatrics or RURAL Internal Medicine but should also include mid level providers to be a part of the health care team. Alabama programs are leaders in selective admissions, pipeline programs, and rural tracks in both UAB and USA, wiht examples found here and here. Considerable expansion coupled with measurable outcomes (entrance into primary care specific post-graduate training, entrance into practice in rural Alabama, continued practice at 5 and 10 years) should lead to more providers very quickly.

Enhancing primary care delivery quickly will result in an improvement in health outcomes. The Office of Rural Health/Office of Primary Care or another agency in the Alabama Department of Public Health needs to become a leader in facilitating practice transformation. Physicians in rural Alabama will need more than just computers in their offices to practice in the new age of accountability and quality improvement. The Office should have sufficient staff and resources to functionally coordinate efforts by a myriad of agencies including AQAF, BC/BS, Al-REC and other HIE entities. The goal should be that every primary care practice in rural Alabama has the opportunity to participate in practice improvement activities and deliver measurably enhanced primary care. The goal should be that every primary care practice should be able to qualify for NCQA Patient Centered Medical Home Level 3 status within 5 years

The rules for licensure and practice protocols need to be scrutinized.  There are numerous instances where professional organizations or trade organizations have been allowed to make rules that while making sense on the face, serve to reduce the efficiency of rural practice. This is more true as technology changes.  An example is the Board of Dental Examiners which only tests once a year and does not grant reciprocity such that should a dentist consider relocating to Alabama he or she would have only one opportunity to do so annually. Given the ease of giving a test at a testing center, this seems antiquated. Another is the Alabama Board of Pharmacy’s rules limiting or preventing  telepharmacy, which would be a boon to rural hospitals. A third example is one of Psychiatry. There are acute mental illness needs in every state. In Alabama, these are exacerbated by a chronic shortage of mental health professionals. Several times over the past 10 years we have had natural or man made disasters where voluntary mental  health professionals have desired to come and assist with the acute crisis only to be thwarted by the Board of Medical Examiners. There are many  such instances that need to be addressed. There needs to be attention paid to this rapidly as technological advances have already outpaced many of these rules.

Technology such as telehealth offers tremendous opportunity to transform care delivery but there needs to be a local infrastructure in place. There are many examples of telehealth  and other technologies reducing disparities, eliminating costly transportation, and improving care. For the most part, these technologies are coupled with robust primary care and community hospital resources. It is vital to leverage technology to improve care. It is clear, however,  and supported by data that without the “high touch” component best exemplified in primary care practices outcomes will remain below that of the country and the rest of rural America. There needs to be an office whose responsibility is to assure that technology is leveraged to its fullest but that the outcome is always improved health for the citizens of Alabama.

Last week I spoke of a goal for care delivery in Alabama that I believe is achievable.  This goal is not Alabama specific although given some of our health markers I suspect we have more “opportunities” than most. This goal was long on vision but short on specifics. Today I want to offer nine specific challenges to us all (targeted to consumers because we are all health care consumers) that I believe will help push the health care delivery system in Alabama towards that goal. If we as patients and/or a provider demand care in this manner, it will happen (maybe).

1) If quality care exists in your community, use it

This is the most important point of them all. We all know that people choose a physician based on affability, availability, and ability is assumed. Unfortunately in rural America ability is not assumed. The phenomena of bypass is a testament to this fact. Patients need to be educated regarding certification by accrediting bodies and the implication regarding “ability. This means the JC for hospitals and NCQA for ambulatory sites.  Physicians need to demand transparency. Post practice data and encourage others to make practice data available. Hospitals are now making hospital data available  Patients need to be educated to be vocal if demands are not met and most importantly, not to just vote with their feet

2) Demand improved  primary care (and be willing to pay for it)

Communities need to be taught how to recruit and retain a primary care physician. There is a lot of work that has been done on this. The academic work can be found here and a resource can be found here.

3) Seek out and use “Medical Homes” for health care

The American Academy of Family Physicians has been working for the past 5 years on creating a type of primary care practice for the future. They refer to their model as the Patient Centered Medical Home (PCMH) and more information can be found here. Family physicians have been called America’s best kept secret. The majority of them are changing over their practices to Patient Centered Medical Homes.  In a PCMH quality care is documented, measured and improved. The patient experience is enjoyable and patients are encouraged to communicate and self-manage problems. Technology is used to improve the care experience. The care experience is continuously improved. There will be a certification process that will probably be through NCQA.

4) Find physicians who have conquered the digital divide

Without electronic health records, it is almost impossible to accomplish chronic disease management. With an electronic health record, however, a VA in rural West Virginia showed a significantly improving 12 of 13 care processes and 3 of 6 clinical outcomes (HbA1c, LDL, cholesterol).  There are now Health Information Exchanges being developed that will facilitate E-prescribing, receipt of structured lab results, and sharing patient care summaries across unaffiliated organizations. In addition, congress has directed the development of Regional Extension Centers to help physicians “get connected.” Alabama’s Center is Al-Rec. These centers are charged with providing education and outreach to providers, assist with vendor selection and purchasing for electronic health records, and provide workflow design consultation. In addition, these centers are tasked with promoting interoperability.

5) Find a doctor comfortable with telehealth/telemedicine

Telemedicine is effective but expensive, We have very  good evidence for improved outcomes in toxicology (Poison Control) where Every $1 spent on manning phones saves more than $7 in avoided health care charges. We also have evidence for ophthalmology, orthopedics and fracture care,  telemetry, stroke treatment, and dermatology. Unfortunately, the expense is difficult for many practicing physicians to cope with but if patients were to demand remote access there are effective solutions.

6) Demand a focus on quality

Rural hospitals that use established guidelines, such as the American Heart Association’s  GWTG-CAD performance measurements,  mortality is same as in urban settings. The performance measures mentioned above include recommendations such as early aspirin use, smoking cessation counseling, and use of certain drugs at discharge that are very easy to follow. Better systems, not more expensive equipment, save lives and are easily achievable in rural America.

7) Demand provides in your community to collaborate, collaborate, collaborate

If there is a community health center (CHC), a rural health clinic, and a critical access (or small rural hospital) in your community, encourage collaboration. Only 19% of critical access hospitals  report  a collaborative relationship with CHCs. Barriers include a lack of knowledge about the other and competition for patients. In communities where this collaboration happens, there are improved primary and preventive health services, improved Inpatient care, better 24 hour emergency care and  better access to specialty care.

8 ) Encourage mental health and primary care to work together

Primary care is already used 50% of the time for those seeking care for mental illness. Persons with mental illness are more likely to make a visit to their primary care doctor to receive care than they are to go purposefully to a mental health professional.  Primary care doctors do have a lack of recognition of mental health issues based on billing data but this may be an artifact of the billing system. Although there is currently a lack of integration of general medical and mental health services, there is a groing trend for physicians in private practice as well as rural health clinics to offer mental health services on site. This needs to be encouraged.

9) Work to build a healthy community

Health care delivery can only go so far. A healthy community is needed to move a community to being full on chronically ill individuals to one full of individuals who are chronically well.