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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. 

Signed, 

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.

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From the US Congress, 1837

Mr. L. insisted that the same reasons which had been urged by the gentleman from Louisiana (Mr. Johnson), in support of his amendment, applied with equal force to Mobile. That city was known to be increasing in population, wealth and business, with great rapidity. It was situated in a climate regarded as somewhat unhealthy at certain seasons, but its immense trade required the employment of seamen and boatmen at all seasons of the year, and if hospitals were to be provided for sick seamen and boatmen at the expense of the Government at any points, he regarded the southern cities as the places most entitled to notice. The amount he had proposed was small, and he hoped his amendment would not be rejected. The amendment prevailed without a division.

The last sentence seems sort of quaint today, doesn’t it. This was the discussion that ensued when the Marine Hospital in Mobile Alabama was funded in 1837. This bill funded hospitals in New Orleans, Mobile, Portland, Newport, and Wilmington, North Carolina, at a cost of $115,000 each.

Why were these hospitals needed? Most illness and death at the time was due to infectious disease. Most sick folks were treated in their homes;  physicians (or other healers) were in attendance, but the nursing was done by family members. In port cities, merchant seamen were necessary to transport goods  from America to Europe (here in Mobile, it was transporting cotton to Liverpool, England). To quote from the National Library of Medicine:

These seamen traveled widely, often became sick at sea, and then, away from their homes and families, could not find adequate health care in the port cities they visited or would overburden the meager public hospitals then in existence. Since they came from all the new states and former colonies, and could get sick anywhere, their health care became a national or Federal problem.

What began as a loose network of hospitals eventually became the US Public Health Service.

In the 1870s, when the Marine Hospital Service was federalized, the city of Mobile saw the need to provide these types of services for her citizens, and the Board of Health was created (by Alabama constitutional mandate). The duties included:

  • Examine all cases of malignant, pestilential, infectious, or epidemic disease
  • Exercise general supervision over sanitary regulation
  • Supervise all matters pertaining to quarantine
  • Supervise all measures of detention, disinfection, and purification of vessels from ports against which quarantine is proclaimed

The county health officer was employed by the Board to oversee the above. In addition, he was required to maintain vaccine and vaccinate all indigent people free of charge (that would be smallpox and rabies in 1873). He was also directed to maintain a dispensary where poor, sick people could receive care.

Fast forward to today. The traditional “health department” is performing roughly the same tasks as outlined in the 1870s, immunizations, control of infectious illnesses (in Mobile, mosquito control is a big part of this), and care of the  sick who happen to be poor. They are, it seems, victims of their own success. Malaria is unheard of in Mobile except when it arrives in a person who has traveled here with the parasite already incubating in his or her bloodstream. Vaccination has moved to the physician’s office with the Vaccines for Children program. Community Health Centers have taken over care of the poor sick. The public health focus needs to be on prevention and early detection of chronic illnesses. These account for 70% of American deaths and most of our disability. Many chronic illnesses are a consequence of tobacco use, poor diet, sedentary lifestyle, and risky behavior.

In Louisville, Kentucky, the “Board of Health” is now the Louisville Metro Department of Public Health and Wellness. Not only do they do they perform the traditional health department role but they

  • provide education regarding health behaviors that affect health, such as tobacco use
  • distribute condoms to prevent STIs
  • work to combat childhood obesity through physical activity
  • work to eliminate food deserts through food justice
  • sponsor a health equity speaker series

They do this in a belief that they can address the root causes of health disparities by supporting projects, policies and research working to change the correlation between health and longevity and socioeconomic status.

A far cry from running the quarantine station, is it not?

A primary contributor to Costa Rica’s success has been its focus on the well being of its people.  For Costa Rica, health and education are priorities for the success of their nation.

The attention to health has brought this middle-wealth country’s health indicators in line with those of OECD countries.[viii]  In 2001 the average life expectancy at birth in Costa Rica was 76.6 years.[ix]  In 2000, 97% of births were attended by skilled professionals, 89% of the pregnant women were given prenatal care, and 93% of children under 1 had health insurance.[x]  From 1990 to 2000 life expectancy increased by 0.8 years, the fertility rate dropped, and the population grew due to an influx of Nicaraguan immigrants.[xi]  In 2000 there were 16 physicians and 3.2 nurses per 10,000 population.[xii]  In 1999 there were 12,000 people living with HIV/AIDS, giving an adult prevalence rate of 0.54%.[xiii]  However, Costa is the only Central American country to provide antiretroviral treatment to all patients through its social security system.[xiv]  The leading causes of death were cardiovascular disease and neoplasms, which is comparable to many OECD countries.[xv]  Spending on health care has increased steadily over recent years, and in 2000 it composed 9% of the national GDP.[xvi]

(report to the Global Economic Council, 2002)

I received an e-mail today from Doctors for America. This group is a “national movement of physicians and medical students fighting for a system in which everyone has equal access to quality healthcare.” I signed up (membership is free) when the “Obamacare” debate was raging to express my core belief in access to quality healthcare publicly. Several other physicians in my group signed up as well. At one point there was a map and we accounted for a large majority of the Alabama membership.

Today’s e-mail (also found on their blog) pointed out that the Ryan health care plan was going to be voted on in the Senate and urged us to contact our elected representative to let out voices be heard. My voice often carries a message at odds with our congressional delegation and I tire of writing to them but I recommend that you read the blog post for yourself. To use their summary of the the high points, if passed (and signed by the president) the new law would:

  • Eliminate traditional Medicare and replace it with a voucher for seniors and disabled Americans to buy their own insurance. Each person would receive a fixed-amount voucher to choose a private insurance plan. The value of the voucher would increase with time, but would not rise at the same rate as insurance premium increases.
  • Cut Medicaid funding for states by turning it into a fixed-amount federal block grant program.  With the block grant program, states that are already struggling to cover Medicaid patients would have to make do with decreased federal help.  The Kaiser Family Foundation estimates that within 10 years, 44 million people who would have been on Medicaid in would not have coverage – that includes children, pregnant women, seniors in long-term care, and the disabled.

The proposed changes in the Ryan budget would:

  • Decrease access to health care.  Seniors, disabled, children, and low-income Americans would lose the safety net that currently protects the health and security of millions.
  • Decrease quality and ineffectively control costs. Vouchers and block grants will not reduce the underlying drivers of health care cost growth. Lasting cost control will come from a transformation of the ways we deliver and pay for health care. It will not come from simply shifting the responsibility for paying to America’s seniors and most vulnerable.  Many new delivery system reform projects, such as the Accountable Care Organizations and Patient Centered Medical Homes, will work to encourage quality of care (reduced waste, greater coordination, and improved efficiency), rather than the high quantity of care that is driving up health care costs and doing little to improve patient health.
  • Put patients at increased financial risk. Vouchers for insurance premium support and block grants will control federal health spending over time, but they will do so by shifting financial risk and administrative burdens onto state and local providers, families, communities and vulnerable beneficiaries.

President Obama will veto this if it passes. I remain disappointed in our elected legislators who have an opportunity provided by the Affordable Care Act to force health care providers, big pharma, and to a certain extent patients into producing and consuming more cost effective care. If this effort were undertaken, it should lead directly to better health outcomes and less spending on health care—money that could be spent on other goods and services. Instead they are participating in a thought exercise regarding whether or not health care is a commodity that will respond to market forces.

The American public is of one voice. They do not want a change in benefits, and they want someone else to pay for those benefits. If that ends up with me in a defined contribution plan for health care during the most expensive 30 years of my life, I’m moving.

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.

A year ago, the U.S. Preventive Services Task Force issued what they thought would be a relatively uncontroversial analysis of the evidence and recommended strongly that women get mammograms on a biannual basis between the ages of 50 and 74 which I discussed here.   The recommendation of delaying the start of mammograms by 10 years led to much debate among patients, advocacy groups, and physicians.  Unfortunately, it also resulted in confusion among patients.

The reason for the change is that we know that women who are at very high risk for breast cancer (more than one first degree relative such as a mother or a sister who had early breast cancer) should consider  being tested for the breast  cancer gene (BRCA-1 and BRCA-2) and should have very frequent, early testing for breast cancer directed by a specialist. We also know that women at average risk (no close relatives with breast cancer) do not live longer or otherwise benefit from mammograms before the age of 50. What we don’t know was when women at intermediate risk (several relatives with breast cancer) should begin getting mammograms.

Last week, a study by British researchers was published in the Lancet Oncology, titled “Mammographic surveillance in women younger than 50 years who have a family history of breast cancer.”  The study helps answer the question “when is the right time to start mammograms?”  The answer is – It depends on the patient’s family medical history.

This particular study was designed to determine if women who do not have the breast cancer gene (BRCA-1 or BRCA-2) but do have a strong family history (at least one first degree relatives such as a mother or  a sister with a very early cancer or multiple relatives such as sisters, aunts and cousins with cancer) benefit from annual mammograms starting at age 40. This study found that those women who are intermediate risk for breast cancer (strong family history  but negative for the cancer gene) and were offered mammograms were less likely to die of breast cancer than if they had not received a mammogram.

Because everyone participating in the study received screenings, there was no control group.  This makes the findings not as strong as one designed with control group, but still the results are relevant and important.

In case it’s not readily apparent, the reason not to just offer mammograms to everyone is that  women who are screened when it is not needed are placed at risk of unnecessary surgery and increased anxiety. If a patient would receive no benefit from the screening, then it should not be recommended. From this study we can deduce that in addition to all women over 50 benefitting from mammograms, women over 40 with a strong family history are better off if they get a mammogram  as well.

Based on this study, a woman younger than 50 should know her family medical history and be willing to discuss it with her primary care physician. Based on this study there are some women that clearly benefit from being enrolled in a screening program before the age of 50. If she has one or more close relatives who are  afflicted with breast cancer she should  discuss early screening with her physician.

The holiday season is a great time to talk with family members about health and learn more about one’s family history. A great tool to use for this is found here. After using this tool to determine a complete family history, the  primary care physician can help to ascertain risk status and lay out a plan for early detection and treatment or prevention of diseases. By using this tool a person could find a type of medical screening such as a mammogram that might be of benefit or maybe they’ll just find out interesting information about their family.

The New England Journal of Medicine published a nice article on the constitutuionality of the Affordable Care Act. In it, there is a lot of information regarding the rhetoric versus the reality.

On the possibility of repeal

However, legislation that overturns the ACA has no chance of becoming law during the next 2 years; in the short term, congressional repeal is a symbolic cause, rather than a realistic possibility

On the politics of repeal

Pushing for repeal nonetheless allows Republican congressional leaders to assuage their conservative base. But it also represents a risky political strategy. Overturning the law would effectively deinsure 32 million Americans, deregulate the insurance industry, strip insured persons of coverage protections and enhanced benefits, and worsen the projected federal budget deficit – all while the number of people without insurance gallops upward, along with premium prices. A campaign to repeal health care reform could enable Democrats to paint Republicans as doing the bidding of the insurance industry.

Where things stand now

Moreover, parts of the ACA have already gone into effect. Repealing the entire bill would mean that some Americans would lose benefits – including insurance reforms that allow parents to keep children on their plans until the age of 26 and that prohibit insurers from imposing lifetime limits on coverage.

On the mandate

Most legal scholars believe that the mandate is constitutional, and another federal judge in Michigan agreed in a recent ruling.

Why the law seems unpopular

The dilemma for reformers is that too many Americans believe in controversial provisions of the law that don’t exist, such as the imaginary “death panels,” whereas not enough Americans are familiar with or identify as part of the law popular provisions that are real, such as enhanced Medicare coverage of preventive services and new consumer protections for Americans with private insurance.

Why it will likely succeed

Government health insurance programs, once they are in place, often prove enormously popular regardless of the controversy surrounding their enactment; Medicare is an important case in point. The ACA may yet overcome partisan polarization, its amorphous structure, and public skepticism and thereby follow a similar course. But for that to happen, the law’s key provisions must first be fully implemented.

So what is going to happen? As I told a group this past week, the real problem is trying to provide seamless coverage so that folks who develop an illness are not left dying in the street because everyone tries to dodge responsibility for paying for the care required.  Senators from Massachusetts and Oregon have proposed a revision to the Act that would allow states to opt out if they can demonstrate their plan offers equivalent coverage to that required by the  Affordable  Care Act. As a person living in a state that continued building schools intended for a single race for at least 15 years following “Brown vs the Board of Education of Topeka,” I would like to see how they will determine equivalency before I feel good about revision. Let’s move ahead.

Earlier this week I posted about Blue Cross of North Carolina and how instead of trying to incent physicians to provide better care they have elected to pay more for the same old care and hope doctors do better. I also mentioned Community Care of North Carolina and they have facilitated change in North Carolina which may make the North Carolina Blue Cross “experiment” appear to be more effective than it should be. It is worth looking more closely at Community Care, especially when compared to a more traditional Medicaid “managed care” model.

I’ll use Alabama’s plan as an example. Alabama has a traditional Medicaid Patient Management program started in 2004. Called Alabama Patient 1st, it offers every Medicaid recipient in Alabama an opportunity to designate a primary care physician. All of the doctors get paid “fee-for-service” (they get money for seeing patients in the office) but this designated physician gets a small amount of “capitation” (approximately $3 per month per enrollee) and in return is expected to provide some coordination function (the most apparent one is to provide referral requests for patients who need specialty care). In addition, the primary care provider has an opportunity to collect “shared savings.” The shared savings is calculated annually and is based on

  • Efficiency – the amount Medicaid spent on behalf of a PMP’s panel compared to expected
  • Performance – Utilization of generic drugs, non-emergency services, and office visits as compared to expected.

This is calculated on a point basis with each point being worth $0.2190 from the efficiency pool and $0.0660 from the performance pool.

I feel like I understand this pretty well and yet have trouble translating my practices action into dollars in our pocket.

North Carolina had a very similar  program to Alabama’s, called North Carolina Access. In 1999 North Carolina looked at their Access program and determined that although they had accomplished a key goal (an identified primary care provider for every Medicaid recipient) they were not achieving the desired results of better care for less money. They then began work on the North Carolina Care model, discussed in detail here. This program was based on 4 principles:

  • local control and physician leadership
  • primary focus on improving quality
  • the need for public/private partnerships
  • shared responsibility at a state and local level to develop management tolls needed to provide actionable information

Currently, the plan is throughout the state. A series of local networks take responsibility for the enrolled recipients as a group (population medicine). Each network has a physician leader who serves as a medical director and focuses activities as they relate to quality improvement, cost containment, and care management.

In addition to providing traditional physician services on a fee-for-services basis, physicians are expected to follow recommended guidelines, participate in patient education activities, provide information back to the network, and provide 24/7 coverage. They get $2.50 per patient for providing these services, another $2.50 to hire non-physician case managers, and additional money will follow for providing quality care.

Easy for the docs to understand and budget for.

In short, as the Patient Centered Primary Care Collaborative has pointed out, doctors need to be paid differently:

  • The most effective way to re-align payment incentives to support the PCMH would be to combine traditional fee-for-service for office visits with a three part model that includes:
  • A monthly care coordination payment (“bundled care coordination fee”) for the physician work that falls outside of a face-to-face visit and for the heath information technologies needed to achieve better outcomes. Bundling of services into a monthly fee removes volume- based incentives and promotes efficiency. The prospective nature of the payment recognizes the up-front costs to maintain the required level of care. Care coordination payments should be risk-adjusted to ensure that there are no inherent incentives to avoid the treatment of the more complex, costly patients.
    • A visit-based fee-for-service component that recognizes visit-based services that are currently paid under the present fee-for-service payment system and maintains an incentive for the physician to see the patient in an office-visit when appropriate.
    • A performance-based component that recognizes achievement of quality and efficiency goals.

Or, put another way, when we paid people like the HMOs did, the patient didn’t get enough care. When we pay them fee-for-service like we do now in Alabama the patient gets too much care. We need a more creative system of payment.

I was in a meeting yesterday and overheard this statement regarding the need to plan for changes in the care delivery system. It got me to thinking about how much we don’t know about the implementation. It turns out the once a law is passed, the devil is in the details and the Patient Protection and Affordability Act is no different.

I figured a good place to look is a textbook entitled “Government in America” and what they say is that

Once Congress, the president, or the Supreme Court makes a policy decision, it is most likely that bureaucrats must step in to implement those decisions. Since bureaucrats are typically less visible and are not elected to their positions, their actions and power are often subjects of considerable debate.

They also point out that

Much depends on whether bureaucracies are effectively controlled by the policymakers that citizens do elect-the president and Congress.

So how does the president exert control?

  • Appointing the right people to head the agency.
  • Issuing executive orders.
  • Tinkering with an agency’s budget.
  • Reorganizing an agency.

In the case of health care reform, here is what those agency heads are saying:

Quote from Anthony Rodgers, M.S.P.H., deputy administrator for the Center for Strategic Planning and Initiatives at CMS:
“The basic medical home model offers better coordination of care and patient care management,” said Rodgers. “But we quickly have to move to more advanced medical homes that have the ability to manage acute and chronic care across the continuum of care.”
Quote from  Mary Wakefield, R.N., Ph.D., administrator of the Health Resources and Services Administration:
Access to health care “is very much about access to health insurance coverage,” said Wakefield. However, she added, access to health care also depends on the availability of a team of highly qualified health care professionals.

She called for a primary care workforce that is “adequate in number, adequate in distribution and adequate in competencies in order to deliver on this (medical home) care model.”

“I want to be clear that President (Obama) going forward and everyone at HRSA understands the importance of addressing this deferred issue — that is a focus on primary care and a focus on building a platform of health care providers,” she said.”

My previous post has generated a bit of interest among folks smarter and more knowledgeable than I about the health care workforce. I refer you to the post for the full comments. I thought Bob Bowman’s comments were important (and long) enough to warrant a separate post which follows. The one thing I think everyone agrees on is that quality is as important as access and we need to find a delivery system that delivers both:

To understand this situation, one must understand that for near poor, poor, lower income, middle income, rural, underserved, less educated, CHC, lowest health literacy, elderly, oldest of the elderly, and all populations in most need of basic health access that are most complex in evaluation and treatment…(Ferrer, Mold, Rosenblatt, Bowman) Are most likely to see family practice physicians

And are seen in locations with the least health spending, resources, support staff, facilities A few years back the Hartford Currant, the oldest newspaper in the US, singled out doctors from certain medical schools as lower quality using questionable measures. Not surprisingly these were front line doctors serving the most challenging populations that other US docs were less likely to care for.Social determinants shape most outcomes for lower and middle income Americans – decisions by patients, access to care, response to treatment, etc. This is also why pay for performance is a bad idea.Osteopathic information and my own research helped me in this area. In the 1960s the AMA became alarmed about the osteopathic patient care influence much higher than osteopathic numbers. The reason was that over 70% were in family practice or general practice with the longest medical careers (over 35 yrs), the most active, the most volume, and the highest primary care retention (over 90%). This resulted in the most patients seen in the least time. With osteopathic down to 35% FPGP by the 1990s and 18% now, this impact has diminished and the truth is that this was a family practice impact all along

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My wife and I were invited to dinner at the home of one of my daughter’s friends. My daughter is a graduate of the International Baccalaureate program of Murphy High and her friends tend to be interesting (if not a little nerdy). This particular friend is majoring in pre-med and has parents who immigrated from Vietnam following the fall of Saigon. As is usual when one has a physician dinner guest (and perhaps when one doesn’t) the conversation turned to mutual acquaintances and the interactions they have had with the health care system. One particular discussion, although I have changed  the circumstances a bit, illustrates one of the concerns that I have with health care reform.

The story was about a mutual acquaintance who happened to be Vietnamese and had an untimely death. He was not cared for by me or any of my close colleagues so the circumstances always remained a little unclear to me. The word in the community was that he had been feeling poorly for a bit before his death. My host reported that he went to seek medical care (“all he saw was his family doctor”), was placed on some medications, and later died. As the conversation progressed, other speculation was that he may not have taken the medication (Vietnamese don’t like to take medication if they don’t feel badly) and he otherwise may not have been a full participant in his care (western medicine is too strong). My hosts, who speculated that cardiac disease was the cause of his death, implied that if he had only seen a cardiologist things might have ended differently. I have to admit that part of me had a pang of regret as well…

The problem is communication. The pre-patient attempting to interpret his or her own symptoms (are they bad enough to seek care, who should I seek care from, if I don’t feel better) is often discouraged from easily communicating with a live human being who could assist with this interpretation. As it turns out, up to 58% of all Americans use the Internet to determine how and when to access other health care resources. This resource, while offering the world’s information, does not facilitate personalized interpretation. This particular person’s health symptoms were made more difficult to interpret because of the circumstances (when you survive near starvation in Vietnam living on cassava you don’t complain about a little chest pain) and residual health beliefs brought in from a previous culture (well documented by Anne Fadiman in “The Spirit Catches You and You Fall Down”)

How could this have ended differently? Maybe not at all, as people die of heart attacks all the time. If it were to have ended differently, it would have been as the result of an improved interface between the person who might be sick and the health care system. The Advanced Primary Care model offers one such model. The patient would be in a relationship with a TRUSTED Family Doctor (or his or her staff) who could help with personalized symptom interpretation prior to becoming ill. Second, this TRUSTED Family Doctor will be able (by virtue of a changed payment structure) to take sufficient time to determine if there are special needs (communication, residual illness beliefs, etc) that would need to be dealt with at the time of a visit or while engaged in other types of communication. Thirdly, this TRUSTED Family Doctor will be willing to work with the patient to overcome these barriers and facilitate optimum care NO MATTER HOW LONG IT TAKES.

Obviously, I feel strongly that we can and should be practicing in this manner. Why do we not? First, I believe that we as a country have a love affair with technology and feel more comfortable relying on specialist-controlled technology for symptom interpretation in the same manner that we like the mechanic to “hook the car up to the computer.” Trying to convince the average person that a “Level 1 Diagnostic Scan” is worse than worthless is going to take  a lot more than me saying so. Second, spending time with the patient is not why doctors currently get paid. Insurance companies have been quick to reward doctors for using technology (under the mistaken belief that it would make the system more efficient) and have been slow to develop ways to reward extended interviewing and risk analysis based on multiple methods of information gathering. Third, I suspect we admit students into medical school who prefer interacting with technology to people interaction. Insurance reform has happened. Now lets discuss real health care reform

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