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Remember the song, “We’re # 37“? It came out in 2009, the beginning of the debate about the ineffectiveness of the American healthcare system and the need for change. The video went viral, more because of the catchy tune and cute visuals, I’m afraid, than for the message. Here we are 6 years later and even with the Obamazation of health care our system is still last in the industrialized world. We still do not offer access to all of our citizens (witness the 24 states that deny access to the working poor), Our system remains very inefficient with 30% of spending wasted on inefficiency and unnecessary care. We deny people access to measure proven to extend lives and do so in a manner that punishes those of color disproportionately. Worse, we do it in a manner that costs twice as much as other industrialized countries, with most of that money coming from taxpayers.  .

As a part of a class I am taking, I have been reading a lot about change management. This weekend, I read John Kotter’s book Leading Change. In this book he identifies 8 components necessary to change an entrenched system in the business world:

  1. Establishing a Sense of Urgency (people need to sense that the platform is on fire before they jump into the ocean)
  2. Forming a Powerful Guiding Coalition
  3. Creating a Vision
  4. Communicating the Vision
  5. Empowering Others to Act on the Vision
  6. Planning for and Creating Short Term Wins
  7. Consolidating Improvements and Producing Still More Change
  8. Institutionalizing New Approaches

Why are we still last? It appears that we skipped the first step. Most people never use healthcare at all. thus they are unaware that the platform is burning. Or, even if they do, it is for an urgent problem (my throat hurts, I have a cough) and our system is really good at getting folks in and out for self limited problems in a very expensive manner ($111 to tell you “It’s a cold, live with it“). For the 20% who need our system a lot, the system has moved most of the costs to the taxpayer, so the true costs are hidden. Of course, this is after the family has bankrupted themselves but the expression “blood from a turnip” comes to mind.

Turns out that part one of the Obamazation was “getting all people access” and that wasn’t even in Kotter’s book. Part two, “transform the system”, started last week. Sylvia Burwell, secretary of Health and Human Services, announced last week a series of sweeping Medicare payment changes.  In effect, the platform has been set on fire. The changes moving 50% of the money from fee-for-service to quality by 2018 with an interim goal of 30% by 2016. What does this mean?

[The adminstration] plans to tie 85 percent of all Medicare payments to outcomes by the end of 2016 — rising to 90 percent by 2018.

A subset of those payments — 30 percent in 2016 and 50 percent in 2018 — will have to be part of what the government calls “alternative payment models.” These are contracts where groups of doctors and hospitals and pharmacists — a big enough network, essentially, to cover a patients’ whole spectrum of health care needs — get a lump sum of money to take care of a set number of patients.

This, in addition to the 40% of commercial contracts that currently include a value component, means that over half of all dollars in health care will be contingent on quality. Is that smoke I smell?

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'I know I failed all the tests and never handed in any finished assignments. So what's your point?'Resident – You know that girl who just found out that she was pregnant and came to us around 26 weeks

Me: Yeah

Resident: Well she has a Hemoglobin A1C (measure of long term blood sugar control) of 11. Turns out she has undiagnosed diabetes.

Me: (Sigh) Go ahead and call high risk OB

The March of Dimes gave Alabama an F in the prevention of pre-term birth. That is not surprising in and if itself. We always get an F. In 2006, when 1 in 5 infants in Alabama were born before 37 weeks, we got a “low F.” At least this year, it was only 1 in 7. I guess that is an F+. In the United States as a whole, the number is a little over 1 in 10, putting us up there with Sierra Leone and Ghana and well below that of Cuba. Best state is California with a preterm birth occurring every 1 in 15 times. “Best practice” countries (the Scandinavian countries are the ones that do it best) have a preterm birth rate of about 1 in 20. The Alabama county with the highest (Bullock, 1 in 4, as a country would be worst in the world), through no coincidence, only has 4 primary care doctors, 2 dentists, and no obstetricians or hospitals that provide care for pregnant women.

Why does preterm birth matter? The vast majority of infants that die are delivered before 37 weeks; some die for no apparent reason. The more births beyond 37 weeks gestation, the lower the infant mortality. In addition, these infants are more likely to be admitted to a neonatal intensive care unit. March of Dimes anticipates that if Alabama were good at preventing preterm birth, we could save almost $500 million, most of it Medicaid.

You ask, why not just do what it takes? Saving half a billion dollars, improving the lives of almost 10,000 children in Alabama. Who could be against it?

Funny story, that. It was during the 1980s in the Bush 41 administration when we as a country identified infant mortality as a problem. Nationally, about 4 in every 1000 newborns were dying in the period of time between birth and 1 month of age. Some great thinkers and law makers got together and suggested that a lack of access to healthcare was a reason that these women were having early and unhealthy babies. In 1986, Congress passed, George HW Bush signed and Alabama Republican Governor Guy Hunt accepted a Medicaid expansion to provide care to pregnant mother because, well, “Won’t somebody please think of the children?” Today, almost 80% of pregnant Alabamians get prenatal care in the first trimester and 49 in 50 receive some type of prenatal care.

Fast forward 30 years later. We now know that, as I told my resident who presented this patient, by the time the woman presents for prenatal care, the horse is out of the barn. About half of all pregnancies are unplanned. Many women suffer from poorly controlled chronic illness that, should they become pregnant, can worsen pregnancy outcomes. Many woman are making lifestyle choices that can cause unintentional harm to their yet-to-be conceived infant but can be changed in a positive manner. To reduce preterm births we need to focus on pregnancy spacing, pre-conception counseling, addressing lifestyle choices that lead to poor outcomes, and planning pregnancy for those with chronic illnesses such as diabetes. There is a term “strong for surgery” that is gaining traction. Women also need to be “strong for pregnancy.”

This is a problem of primary care. We should provide preconception counseling to all women of child bearing age when given the opportunity. We as a society should provide access to primary care for all women of reproductive age (especially those with chronic conditions), and provide outreach to those with conditions related to poor behaviors to correct the behaviors before pregnancy. Our current President, a Democrat, gave us one of the tools (Medicaid expansion to women prior to conception) that is necessary if we want an A. It would still take a lot of work to get that A, as it almost always does. Just by accepting the expansion, we could easily get a gentleperson’s “C.” I suspect instead we’ll take the “F” in hopes that the next test will be on something easier, like football.

I have been paying attention to the national political scene for the last several weeks as you might imagine. I watched the last debate and, though it was entertaining, I was left with the odd feeling that the President of the United States probably is given too much credit for the price of gasoline. Health care, being 21% of the national budget, is something the President ought to try to get a handle on. Federal and state government, accounting for 40% of the total health care dollars spent, ought to demand value and accountability for its money. The Affordable Care Act attempts to do just that. As it is one of the signature (and most controversial) pieces of legislation enacted by this administration, it was odd that it was only mentioned indirectly during the debate:

The issue first arose, in fact, from a question about how the candidates would rectify the women’s pay inequality problem.

“You know a major difference in this campaign is that Governor Romney feels comfortable having politicians in Washington decide the healthcare choices that women are making,” Obama said. “I think that’s a mistake. In my healthcare bill, I said insurance companies need to provide contraceptive coverage to everybody who is insured. Because this is not just a health issue, it’s an economic issue for women.”

Obama continued that “Governor Romney not only opposed it, he suggested that in fact employers should be able to make the decision as to whether or not a woman gets contraception through her insurance coverage.”

Continuing his attack on the broader matter of healthcare, Obama said that when Republicans wanted to repeal Obamacare, Romney indicated it was the first thing he would do, “Despite the fact that it’s the same healthcare plan that he passed in Massachusetts and is working well.”

Governor Romney countered when asked to compare and contrast himself to George W Bush:

“The thing I find the most troubling about Obamacare – well, it’s a long list, but one of the things I find most troubling is that when you go out and talk to small businesses and ask them what they think about it, they tell you it keeps them from hiring more people,” Romney said. “My priority is jobs. I know how to make that happen.”

As the law closely resembles the Massachusetts health care law enacted while a Republican Governor (Mitt Romney) was in office, is based on principals first put forth by the conservative Heritage Foundation, and incorporates many elements related to consumer choice, I am convinced it is as close to universal coverage as we will get in my practice lifetime. I am also convinced, like the President, that reliable access to healthcare is more than just emergency treatment but must include access for preventive and chronic illness care. I am disappointed that none of the eighty-two undecided voters at the second debate wanted to make it an issue.

As we now have a law, should I be worried about the election? In a discussion orchestrated by the Kaiser Foundation between Tom Daschle (taking the Democratic side) and Avik Roy (taking the Republican side), Daschle pointed out how the act could be undone with a change in President and 50 Republicans in the Senate:

I would say that the bulk of it can be dismantled.  If a president is determined to do it, he can do three things.  First of all, he can pass legislation.  As you say, he can use reconciliation for certain amounts affecting the budget of the federal government.  And that’s calculated to be somewhere in the 40 to 60 percent range, depending on how parliamentarians ultimately rule on some of these budgetary questions.  So that’s number one.  Number two: through rule making.  He can really do a lot to change the course of the legislation because – especially with the Affordable Care Act – the secretary and the president were given wide latitude.  And third, he can defund it.  He can just simply not dedicate resources within the budget.  That will be his prerogative as he sets his own budget.  So he could have a profound effect on the outcome of the ACA in a very short period of time.

Should the election bring a change in the Senate and Presidency, would we restart the conversation under a President Romney? Or once again would the Emergency Department represent sufficient access for poor people before they succumb to death inconveniently in their apartment?

The Affordable Care Act has been the law for 2 years now. Judging from the discussion last night on health care, the analysis of which is found here, the leaders of the two political parties disagree on the impact and the intent of the law. Of course, some of that disagreement is not based on fact:

On how the new law delivers coverage:

Mr. Romney sharply criticized Mr. Obama’s health care law, falsely suggesting that it would allow the federal government to “take over health care.” Mr. Obama noted the similarities between his health care law and the one Mr. Romney signed as governor of Massachusetts, saying: “It wasn’t a government takeover of health care. It was the largest expansion of private insurance.”

On keeping the popular aspects of the new law:

[Mr Romney also] said, “I’m not getting rid of all of health care reform. Of course, there are a number of things that I like in health care reform that I’m going to put in place. One is to make sure that those with pre-existing conditions can get coverage.”

But Mr. Romney’s aides later clarified that he would only explicitly guarantee insurance for people with pre-existing conditions if they have maintained coverage with no significant lapses. That could exclude millions of Americans with conditions like cancer, heart disease and asthma.

Breaks in coverage are common. A recent report by the Commonwealth Fund found that 89 million Americans went without health insurance for at least one month in the period from 2004 to 2007, perhaps because they had lost jobs, been divorced or lost eligibility for a public insurance program.

My question is not how do we teach the intricacies of the new law to politicians (I’m not sure I have the skill set for that) but how to teach the law to medical students. The pipeline from a pre-med student contemplating admission into medical school to entering into practice is roughly 10 years. When I entered my premed program in 1978, for example, Medicare for end stage renal disease was just 6 years old and policy makers were just beginning to realize how expensive an open invitation to use dialysis might become. I, as an 18 year old, was clueless.

There is a study published last month in the Archives of Internal Medicine (found here) that illustrates just how little attention medical students pay to things such as this. In this study. Minnesota medical  students were asked questions regarding their knowledge of the new law and their assessment of the impact it might have on their practice. I will acknowledge that Minnesota medical students (55% liberal with more than half anticipated a primary care specialty) are a little different than the ones I teach. That being said, less than half felt they understood a law that would rearrange their professional life and 41% had no opinion. The students views on the law were colored by their political leanings.

As was stated last night, this election is about choices regarding many things, including health care. The Commonwealth Fund has analyzed both candidates position on health care delivery (found here) and has this to say:

President Obama supports the goal of near-universal health insurance coverage, by maintaining existing private insurance markets but also instituting tighter and more standardized regulations across the country to ensure a broad choice of comprehensive health plans to all who seek coverage.

Governor Romney, on the other hand, has not identified universal coverage as a goal. While also supporting a health insurance system based on existing markets, he believes that more limited regulation will ensure a broad choice of health plans for consumers.

Our department teaches medical students about the Affordable Care Act.  We point out that the intent and effect of the law (as articulated by the President’s statement above) is consistent with the core values that they need to support as physicians. regardless of party affiliation.

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