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peter-steiner-i-m-sorry-sir-but-dostoyevsky-is-not-considered-summer-reading-i-ll-h-new-yorker-cartoonTime once again for the summer hiatus, where I spend some quality time with my family, work on other projects, and in general try to stay out of trouble and on the beach as much as possible. For those of you who are looking for a way to become more informed on health policy from a primary care perspective, I have put together several suggested areas of focus.

  1. Population health: The buzzword for the next year is population health. As those of you who read my stuff know, traditional medical care is necessary but not sufficient. America’s “best health care in the world” system will continue to be expensive (#1) and not very effective (#37) until we acknowledge that a whole lot more than doctoring goes into health. For a primer, RAND (link here) has published a synopsis on what works and what doesn’t in this arena. This paper is a good start. Once you get your feet wet, my friend and fellow blogger Josh Freeman has published his book Health, Medicine and Justice: Designing a Fair and Equitable Healthcare System (available on Amazon) which, though focused on our broken system, has a lot of insight about how an emphasis on population health could take us in a better direction.
  2. Palliative care: Death comes to us all. As I watched the movie “The Judge” all I could think about while watching the Robert Duvall character was how movie Frank Burns was old now,which meant I was old, too. In the movie, Robert Duvall’s character has colon cancer (“Stage IV, the worst”) and is suffering from “chemo brain.” His chemo is administered by his GP in his lake house and, aside from hitting the dude on the bicycle and not remembering, it is a pretty idyllic cancer life. He apparently stops chemo and goes on to live for another year, dying  while fishing with his son after they have dealt with old baggage. While health care delivery wasn’t an integral part of the movie, patient choice and shared decision making was. We as Americans say we want that kind of life and death. We seldom get it. Atul Gawande lost his father several years back and has written an exceptional book entitled Being Mortal. It is an excellent read and provides insight into the mismanaged way we deal with chronic illness and terminal care as the inevitable happens.
  3. Obamacare: The Affordable Care act is 5 years old. When all is said and done, this act has begun the process of retooling our care delivery system. For the latest update on what is or is not happening, RAND has provided a summary of where we are after 5 years to get you up to speed (link here). You say you need to walk before you can run? Though I haven’t read is, Ezekiel Emmanuel is one of the architects of the law and has a book out detailing what the law was supposed to do and is doing (link here).  Emmanuel is an ethicist and a very good writer, and I suspect his book will offer some keen insights into why the law has been shaped in this way. From the observer perspective, Steve Brill’s book offers an exceptional synopsis of where we have been and where we are going. If the Supreme Court rules rules in favor of King (in King v Burwell) and dismantles the law, you can read what the conservative response may be for under $4 here. Hurry, though, if the law is struck down prices might go up.

Y’all have a safe and fun summer.



I discussed the slowing of health care delivery inflation here. The New York Times published an op-ed by Zeke Emanuel and Jeffery Leibman that further illustrates how maintaining the  Affordable Care Act is necessary to continue bending the cost curve. Using several examples of expensive, marginally effective therapy, they point out that much of the cost of Medicare is based on income maximization on the part of care providers as they function in this fee-for-service world. Their critique of the anti-ACA alternatives as a method of cost control are as follows:

  • Meat-cleaver cuts hack spending indiscriminately. Cuts that fail to distinguish between high-value and low-value medical care would do more harm than good.
  • Cost-shifting cuts don’t actually reduce health care spending; they just shift costs from the government to the private sector. … raising the eligibility age [for Medicare] would reduce government spending on Medicare, it would shift the costs to individuals and businesses. It would also increase the number of uninsured 65- and 66-year-olds, leading to worse health outcomes and making it harder for older Americans to find work.
  • Penny-wise, pound-foolish cuts reduce current spending by a little but raise future costs by a lot. Raising co-payments for office visits and medications is a good example. Research shows that when older adults are charged higher co-payments, they reduce their primary care visits and use of prescription drugs. But the research also shows that forgoing this outpatient care leads to an increase in expensive hospitalizations.

They point out that already in place in the ACA are provisions that incentivize improved care delivery at reduced cost. They close with the following

The seeds of a solution lie in the accountable care organizations, medical homes and bundled payment reforms that were authorized by last year’s Affordable Care Act. Accountable care organizations are groups of health care providers and hospitals that work together to treat patients. Medical homes coordinate primary care services. And bundled payments consolidate the many costs of an episode of care, like a hospitalization, into a single payment, incentivizing efficient delivery of tests and treatments. All of these reforms allow payments to be based primarily on the number of patients cared for and the quality of that care rather than on the volume of services provided.

01carey600It was my hope that by this time we would have help from the feds to enhance primary care training, changes in residency funding to direct money to primary care departments, and management fees which would help us to pay for the care we deliver to our 750 diabetic patients among other things. Instead, we are in the middle of what appears to be a rather mean-spirited discussion regarding the age-old question of just who is my brother’s keeper.This has gotten me to thinking about the problem of the commons

Garret Hardin described a scene in an English common pasture “Picture a pasture open to all. It is to be expected that each herdsman will try to keep as many cattle as possible on the commons.” He then describes his vision of what will happen if all are allowed access unchecked.  “Adding together the component partial utilities, the rational herdsman concludes that the only sensible course for him to pursue is to add another animal to his herd. And another; and another…. But this is the conclusion reached by each and every rational herdsman sharing a commons. Therein is the tragedy. Each man is locked into a system that compels him to increase his herd without limit–in a world that is limited. Ruin is the destination toward which all men rush, each pursuing his own best interest in a society that believes in the freedom of the commons. Freedom in a commons brings ruin to all.”

Garrett has since been somewhat discredited. It is not clear that the resources as they appeared limited were so in actuality. This seems to be, however, the fear of the Republicans with healthcare. They seem convinced (and I have to admit that there is some evidence to support this) that those who are now uninsured (and have no current access to the commons) once given access will consume unlimited resources. Interestingly, they feel like those who now receive Medicare are entitled to unlimited access to the health care commons…an interesting stance.

What is really interesting is that Ezekiel Emanuel has been accused of formulating “death panels” as a solution to the problem of the healthcare commons. What has articulated is a way out of this problem of the commons. He clearly believes (as do I) that a certain amount of the “health care commons”  should belong to all of us. To solve the problem of overuse, he suggests that we would have to select what is included in our “commons”. If we don’t want to be in a group that funds terminations for example, we don’t select that group. I would like to see this further articulated as it seems preferable over people who have no money for health care dying in the street to me.