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I posted a week ago on health care and the market for rural America (and by extension, Alabama). I wanted to share with this group a vision that some of us at the Alabama Rural Health Association have. I will share some thoughts I have on how to achieve that vision later.

An Achievable Vision for Alabama

By 2021 Alabama will have a rural health infrastructure characterized by excellence in ACCESS and QUALITY. This system will have the following characteristics:


  • Every rural Alabamian will have one or more primary care providers within 10 miles of his or her home offering acute care, chronic disease care, and preventive services for 60 hours a week
  • Every rural Alabamian will have a hospital within 30 miles offering critical need access 24/7/3
  • Every rural Alabamian will have ready access to needed specialty care within the state


  • Care provided in rural Alabama will be characterized by excellence
  • Primary care will be accessible to all residents regardless of ability to pay
  • Primary care will offer ongoing continuous care as characterized by stability of providers over time
  • Care will reflect coordination among physicians, hospitals, and other healthcare providers using electronic and other means
    • Primary care will coordinate care across all domains and facilitate access to needed services not located within the community
    • Care available within the community will be comprehensive, offering care beginning at pre-conception and ending with natural death
    • Care within the community will be characterized by use of accepted quality and safety measures, the results of which will be readily available to the members of the community
  • Care provided will reflect and enhance the culture of the community
  • Providers will understand the unique needs of the community and will provide services targeted to those needs
  • Providers will deliver services outside of the traditional office setting when needed, including at occupational sites, home and businesses, and other settings as needed


Beginning to sound like a broken record, the newly elected Alabama Republican state representatives are once again demonstrating their “market” credibility. They are quoted in the paper today as  identifying the state funded teachers health insurance as the place to insert needed market reforms. The legislators and the governor are quoted as having this as a priority:

Starting health savings accounts for teachers and state agency employees. An employee and the state could put money into a person’s account, which would belong to the employee and could be used to pay medical costs. Together with the accounts, the state would offer high-deductible health insurance, which would save the state money.

  Such a plan, which Bentley championed on the campaign trail, could cut the number of insurance claims paid by the state because people, in theory, would be less likely to seek medical care that wasn’t absolutely necessary if they had to pay more of their own money for it, said William Ashmore, chief executive of the State Employees’ Insurance Board.

As I have discussed before, HSAs are good theory but haven’t been shown to improve health or reduce risk taking behavior.  This was looked at more in-depth here and here (subscription required) with the following observations from the literature.

  • Cost savings for a care event have never been documented. For the most part the health costs seem lower because healthier people tend to use HSAs and spend their health care dollars on things such as dental work, vision care such as lasik, braces, cosmetic procedures, and maternity care.
  • Chronic illness care costs more in these types of plans and the “catastrophic” coverage often doesn’t kick in leaving people to make “hard decisions” regarding life saving treatments
  • People using these types of plans tend to disregard preventive recommendations leading to fewer immunizations, PAP smears, and mammograms and more late stage and preventable illness
  • People tended to make poor decisions about seeking care for serious symptoms (such as chest pain)

So why does this idea not die? Possibly because it is consistent with the  constant message from groups like the Heritage Foundation denying the benefit of all government oversight and extolling market solutions (regardless of the supporting evidence). For the most part I think it has traction because it seems intuitive that if people have “skin in the game” when it comes to their health purchases they will make better decisions. We would all like to believe that humans will make rational decisions, in particular when in comes to health, as no one wants to lose one’s health. Unfortunately, as my friend Josh Freeman has pointed out, most people use very little health care so have little opportunity to make decisions and influence the market. When folks need it, however, they really need it:

Seniors, because they are also more likely to have multiple chronic health problems that require multiple hospitalizations, and because they are more likely to have cancer, which costs a lot to treat, are also disproportionately represented in the high cost group. However, they are still the minority of that group. These high-cost users are the “outliers”, and also include other people with cancer, people with trauma, as from auto accidents, requiring multiple surgeries, and premature and sick babies requiring incredibly expensive care in neonatal intensive care units.

What HSAs do is encourage those people who are low utilizers to spend more on things that provide a marginal benefit, thus raising healthcare costs. A better way would be to work within the confines of the Affordable Care Act to create efficiencies within our state (as is being done in other states). If we are lucky our legislators will come to this conclusion as well before the HSA lobbyists sell them a new policy for the teachers and folks like me are left to clean up the mess.

A note for clarification: Apparently, state employees already can opt into an HSA. Someone should probably brief the Governor-elect on the existing options.

As I was poking around the AHRQ website looking at funding opportunities I ran across a state specific health “dashboard” that highlighted some different findings. I’m used to seeing Alabama not fare well when compared to other states. This set of measures hit closer to home as they are looking at measures that are more specific to primary care. While we did very poorly on some measures (48th best in colon cancer deaths, 35th best in care for congestive heart failure), we also had a notable exceptional measure (7th in communication with providers for certain Medicare beneficiaries).

This is the healthcareometer from the site for Alabama. You can see that unfortunately we are doing measurably worse than we were at baseline. I hope our physician governor will challenge those of us involved in care delivery to shoot for “strong” or “very strong” when the next snapshot is taken.

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

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

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

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

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

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

I was at a meeting of Family Medicine Department Chairs in Tuscon Arizona this past week. This is an exceptional meeting for hearing what other departments are doing regarding educating medical students, developing research activities around primary care, and learning about topics of importance to primary care (the Patient Centered Medical Home was the featured topic of the meeting). The reason to go to these meetings is to 1) confirm that you are doing stuff that others are doing and doing it better than they  2) confirm that you were correct in not doing stuff that seemed important at the time but you were convinced it would lead to disaster or 3) figure out how to make up for lost time when starting a task that should have been initiated several years ago.

This particular meeting featured a panel of exceptional students from the University of Arizona College of Medicine in Tuscon talking about what we (as educators) can do to foster interest in primary care. They were all committed to primary care and it was refreshing to hear from these idealistic students. Many of them were from rural Arizona or had life experiences that led them to enter medicine to make a difference in their patient’s lives. They did confess to being an exception in their class, with the majority of their fellow students focusing on materials needed for the test (the here and now) as opposed to the big picture.

 I confess to having a pang of regret. Our students did not to me seem so idealistic when our department faculty attempt to offer instruction in social issues as a part of the Fundamentals of Doctoring course here in Mobile. I wondered if perhaps our school is not as effective as other schools in fostering an attitude of social justice. I wondered if our students were too focused on the high stakes exam (NBME Step I) to get the big picture we were trying to draw for them. That was why I was pleased to receive a very nice e-mail today thanking my department for the perspective we bring to the 1st and 2nd year of medical school. It made me feel that maybe our efforts are worthwhile.

A long way of asking you to thank one of your teachers today…it’ll make them feel better.

As I alluded to previously, I was in the nation’s capitol as a part of the National Rural Health Association’s Policy Institute. Many advocacy organizations have such activities, bringing members in from throughout the country to discuss common issues with their members as a group. All 50 states were represented. We had three of us from the Alabama Rural Health Association and visited with the staffs of both of our Senators and 6 of 8 Representatives.

Although the political landscape is still uncertain, primary care (and more specifically family medicine) is on everyone’s mind. From the speakers to the staffers, there is an appreciation for what we do as a specialty and a concern that we will not accomplish sufficient change to enable family physicians to do their job as well as they should. Everyone expressed appreciation for “Family Docs”

The other striking thing is that all of the staffers were aware of the Patient Centered Medical Home and (although some were more convinced than others) were convinced of its potential value. It has been amazing to see how fast this concept has made its way into conversations about health care delivery.

I’ll have more later but if you still are unconvinced about the value of Family Docs, their commitment, and their abilities here’s something for you to look at…

University of Alabama, Birmingham is in the process of selecting a new Dean for its medical school. I have worked in academic medicine for almost 20 years and my father was in academics throughout the period that I was growing up so I understand the ebb and flow of the academic setting. In fact, Wallace Sayre summed up the problems very succinctly by saying “Academic politics is the most vicious and bitter form of politics, because the stakes are so low.”

This is never more apparent when it is time to hire a high-ranking executive in an academic setting. Universities typically use a “Search Committee”  to develop a list of candidates that the Provost (in this case) might choose from. Here is a quote from the University of New Mexico policy on hiring such people:

An effective search committee strategy will do much to facilitate, rather than undermine, an effective search. Keep in mind that the goal when using a search committee is to optimize the effectiveness of the search process from the perspective of all parties concerned-the hiring authority, members of the search committee, colleagues, and in particular, the applicants. Since the search process sets the stage for the future employment relationship, careful attention should be paid in effectively managing this very important phase of the staffing process.” (emphasis mine)

Imagine if  all HR departments had to run potential executives in front of a group of disgruntled folks with their own axes to grind. It would be a wonder if anybody got hired.

The reason this came up is that the Search Committee for the Dean at UAB does not contain a Family Physician, General Internist, or a General Pediatrician. The leadership in Family Medicine asked whether a differently constituted search committee might select a Dean that would place more emphasis on primary care and rural medicine.

It is my opinion that it would not and here’s why. Academic medicine sees Family Medicine as one of a number of competing clinical concerns that they need to balance as they provide education for undifferentiated students.  Traditional academic deans are concerned with maintaining or building revenue streams (typically family medicine is not helpful in this regard), maintaining the educational programs (in which case they need Family Medicine as well as Surgery, Medicine, OB, Peds, and Psych and Pathology  known collectively as the educational “six-pack plus one”), and growing research programs (typically not a Family Medicine function except at the Dukes of the world). Academic medicine in my opinion, does not seen themselves as producers of the physician workforce anymore than Colleges of Arts and Sciences see themselves as producers of the Chaucer scholar workforce. Colleges of Education tend to understand this workforce issue better than most (probably due to the initial charters under which they were founded and state mandates) but now with the charter school movement that might change.

Those of us in academic Family Medicine might see ourselves as producing tomorrow’ s healers but Deans and Provosts see us as  most equal to the others in the “six-pack.”

Medical schools typically don’t care about shortages, workforce needs, unless required to by external pressure. The reason is multi-factorial. One is that there is a lot of give in the system. We graduate 17600 allopathic physicians in this country. There are another couple of thousand osteopathic graduates. We allow almost 10,000 folks from other countries or from Caribbean schools into this country EVERY YEAR to fill the remaining slots. That’s one reason that medical schools don’t worry because this allows US schools to say that the “market” will fix things. We have been unsuccessful in the last 10 years in trying to develop a primary care workforce using a majority non-US grads.

The other reason is that the pipeline following medical school graduation is in the training hospitals and this portion of the pipeline is divorced from the medical schools. Medical schools point to the residencies and claim protection from these types of issues. The residencies point to success in the match as proof that their clinical care is vital and necessary. The way the payment structure is set up all of the grads get jobs, so why should the residencies worry? Of course, when we all get leukemia from CT exposure it’ll be a problem but more business for Oncologists as well.

What makes Deans worry about students attitudes towards a career in primary care? Mandates work for state schools. If the governor or key legislatures say “you gotta make primary care docs”, it happens. As it stands now, some in the Alabama legislature are securing funding fo an osteopathic pipeline as a response to the “shortage” but there are still no mandates in place so it’ll likely fail in this regard as well. This pipeline may have more success because folks educated in rural areas are more likely to go into primary care, all other things being equal.

What else works? Selecting the right students, educating them in a nurturing environment, and paying them (or at least not making them take out and pay loans) for doing the right thing. Paying primary care docs for doing the right thing makes students want to go into primary care. Lastly, making the communities conducive to quality care delivery works (which is why I would like to see collaboration between Schools of Public Health and Colleges of Medicine).

In summary, I suspect that UAB will select a Dean based on the weight of his or her CV and the perceived possibility of extramural funding and/or prestige regardless of the search committee composition. If Alabama wants primary care docs, the Dean will probably not matter one way or another. In fact, one Dean would argue that the Dean’s job is more of a mediator than anything else.  The Governor, on the other hand, will be a different story.

I recently gave a “State of the Department”  report to the Executive Committee of the College of Medicine. I took over as Chair in 2005 and have attempted to create a training environment that would facilitate entry of students into a primary care practice with a focus on rural and underserved Alabama.  The template we are working off of is above.
We’ve not done very well in the 4 years since I became Chair.  Only 5% of the students have gone into Family Mediicne and those going into Internal Medicine and Pediatrics have mostly left the state. In the course of the discussion, the non-Family Physician faculty became very defensive and felt that they should not be asked to take responsibility for an outcome that they were unable to influence. In addition, they felt that test scores were an outcome that they should be able to influence and rural students would have trouble keeping up with our current students.
Fortunately, the National Rural Health Association is working on a position paper to counter this argument. In it, they point out that “Medical education programs that include a focus on attracting practitioners to rural settings offer both recruiting and retention benefits to rural communities. In one study, six medical schools that made an explicit commitment to increasing the rural physician supply, that had a defined cohort of students, and that offered a focused rural admissions process or an extended rural clinical curriculum placed an average of 57% of their graduates in rural areas (compared to a 3% of medical students who report intending to practice in rural areas and the 9% of physicians who currently work in rural areas) and, of the two schools for which statistics were available, 79% and 87% of these physicians were still practicing in rural communities from 1 to 20 years after graduation. Implementing similar strategies for 10 students a year in the 125 United States allopathic medical schools would conservatively create an estimated 1139 physicians in rural practice, more than double the numbers expected without these strategies in place.”
This study does not mention test scores but it has been my experience that the NBME exams measure one clinical competency (medical knowledge) and do it on a threshold basis (can you make the minimum on the exam). Maybe we need to assess medical schools differently…

I am training for the marathon here in Mobile and this is the end of my first 60 mile week. Although I don’t define myself as a runner, I guess running 60 miles in a week would be dumb for a non-runner. Here in Mobile,we  runners can pursue our avocation outside almost every day of the year. I am further blessed by living just north of a large, antebellum cemetary (Magnolia Cemetary) where a circuit is about 1.8 miles or, put another way, it takes 2 1/2 laps over 45 minutes to run 5 miles

Running for several hours gives one a lot of reflecting time. While running today I reflected on being called a socialist by our medical students for pointing out that the Democrats had won the election and would probably dictate changes in health care policy (being right doesn’t make one especially popular) and the results of the cloture vote which proved my point. After that my thoughts turned to the cemetary and the monuments contained within. Many of the private graves have clustered dates which coincide with outbreaks of yellow fever or influenza but my attention today was drawn to the monuments  with labels such as Woodmen of the World, Watermen’s Association, and Fire Department Association among others .These were put up by benevolent societies.

In an article about benevolent societies at the turn of the last century, C. A. Spencer identifies these as “any local voluntary or incorporated non-profit association organized with or without capital stock providing mutual assistance for its members in the form of services or payments.” These organizations were designed to offer protection to their members at cost with the organizations constitution specifying the benefits to be provided such as sickness, disability, burial, and occasionally survivor. The as many (if not all of the members) belonged to the labor class, services usually provided by family members and servants to upper class folks were provided by the society which was an incentive for membership. These services included “watching” the sick and providing a physician who was kept on retainer. The members when not sick got to (and still get to) wear some great costumes and have a lot of fun. For example, the Mobile (Alabama) Turner’s Association celebrated the thirtieth anniversary of its founding in 1868, according to the Mobile Daily Register, with a parade, an address, and a song and dance exercise followed by fireworks.  As white workers became more prosperous, their societies tended to become less important to the provision of services (they were able to pay cash or their workplace provided doctors) but because of the economic precariousness of blacks in the early 20th century (most men were laborers), their societies were more likely to have survived. Interestingly, some of these societies have evolved into insurance companies.

Benevolent Societies were an important way to aggregate resources among African-Americans, recent immigrants, and members of common crafts (particularly if there was an element of physical risk). They became less important to the provision of healthcare in the 1950’s with the rise of employer based insurance and government-funded coverage to the poor and the elderly in the 1960’s. Perhaps if we all still had a vested interest in our own health as well as that of our immediate neighbor-in-the-funnny-hat then the debate over paying for health care reform would be a little more civil.


In our (soon-to-be-paperless-but-not-soon-enough) office, we have boxes where messages from patients, abnormal labs, and such are placed by the staff for action by the provider. Because it is not possible for everyone to know where everyone else is at any given time, we have taken to placing paper over the cubby-holes notifying the staff that we will be out until a certain day. If one is going someplace fun, a picture or something else fun is placed on the message as well. As Chairman, my cubby is covered more that most and this past week I used my “Out Reforming Healthcare” message for 3 of the 5 days.

On Tuesday I traveled to Birmingham to meet with the folks from the Patient Centered Primary Care Collaborative and hear Paul Grundy speak to primary care physician leadership as well as Alabama business leadership. His message is always strong and consistent and it is getting more focused.  As a physician who is involved in direct patient care as well as population based care for IBM employees, he is encouraging all employers to stop paying for garbage (his words). From a recent interview:

“40% of the care that’s delivered, according to some folks, is unnecessary and I see it every single day.  I know parts of the country where it costs $17,000 for the last six months of life and others where it’s $127,000 and by the way the patients in the $17,000 category, this particular case in Iowa live longer and are happier with the care than the ones that are in a scenario that is over $150,000.”

He sees transformational change coming and being lead by an empowered primary care workforce. Denmark is being looked at as a model with the number of hospitals reduced by 80%, for example.

On Wednesday I traveled to Montgomery to preside over the Alabama Rural Health Association board of directors meeting. As I have detailed previously, Alabama has an impending crisis regarding the healthcare workforce in rural Alabama. Although this meeting will not make a difference as a stand-alone activity, it is refreshing to get people in a room who are able to agree on a problem, potential solutions, and set in place a strategic planning activity focused in addressing the shortage. In that meeting we committed to focusing resources on FaceBook to recruit young folks interested in rural Alabama (search on FaceBook to find the page yourself), creating a strategic plan to better direct our resources, and finalizing issue briefs on the manpower crisis in rural Alabama health care prior to January 2010. We also committed to doing rather than talking.

Lastly, we went to New Orleans on Thursday to recruit Tulane students into our Family Medicine Residency program. The refreshing thing about this trip (aside from the soft shell crab) was that we spent a lovely evening with students who clearly entered medicine for the “right reasons” and they were committed to Family Medicine. We had a very pleasant visit and hopefully will see them in Mobile during the interview process.

In summary, like Paul Grundy I believe transformational change is coming. I believe it can happen in rural Alabama. The attitude of the students on Thursday confirmed my optimism. It was, however, a long week…