Wednesday, July 29, 2009

Culture Shock - Why sociologists need to have a voice in healthcare reform

Cost controls are necessary to successful health care reform. Unfortunately, it is hard to implement. As the Dartmouth study showed and Atul Gawande's article in the New Yorker
highlighted (and my previous blog explained), there are dramatic regional differences in Medicare spending. And more fascinating-the areas that spend the most have lower quality than the more pecuniary areas.

Also, neighboring cities and towns will have completely different patterns in usage (as the Atul Gawande article showed with McAllen and El Paso cities in Texas). How could towns just a few miles away be so different?

We've all experienced how "the other side of the tracks" can be wholly different in regards to race, income, real estate value, and education attainment. Clearly, cultural differences from township to township, city to city, and region to region have a huge effect on health care buying patterns.

Some of those cultural differences have to do with expectations. The more successful you are, the higher your expectations. I read a blog the other day (by a @ePatientDave) that brought to my attention a blog about the lack of good customer service in healthcare. I think we in medicine do have a long way to go to make life more convenient for patients (e.g. long waits in waiting room of offices could be twittered, emailed or texted to patients so they could do something else rather than sit and waste time). However, I had a blog about the Press-Ganey and how it is taking the decision-making away from physicians and not always for the better.

For those who don't instantly know about the Press-Ganey, it is a survey that administrators of hospitals use as gospel for who is the best hospital and is all about customer satisfaction. I do want my patients to be satisfied. However, if your definition of satisfaction is getting an x-ray for your ankle that you don't need, or an MRI you don't need, than you won't be satisfied even though I might be practicing excellent medicine.

In fact, on my Facebook account someone defriended me as a result of my comments that their MD practiced good medicine in resisting their insistence of antibiotics for bronchitis. They believed (as many do) that a Z-pack cures all, and their usage won't affect antibiotic resistance for the whole population (despite the whole micro/macro effects that each person has on public health...). The problem is, they were not uneducated demanding people. They were reasonable in wanting what they perceived as the fix to their problem, despite the fact that most evidence is to the contrary, and the negative effects are far worse than they realize. Clearly, changing their behavior will not be easy and will lead to very unsatisfied patients.

Therefore, when you talk about singlepayer and how well it works in other countries (which is debatable) realize there are extreme cultural differences in regards to expectations of care. The United States has a higher desire for personalization and as a whole will not be able to embrace reform that restricts their choice, creates longer waits, and forces their physician to refuse care that patients want but might not (statistically) need.

Thus, if we want to address cost-containment in medicine, you can't just blame the physician for over-testing and over-treating. Certainly, the current reimbursement system does allow for these abuses, and some MDs abuse this more than others (and in a previous blog, I outline my proposal to change that compensation system). However, many physicians don't have the energy, or the financial strength, to withstand the demands of their patients and give in to their demands. While tort reform could help physicians withstand their patients' insistence on unnecessary care, it won't solve the core issue: patients want what they want.

So how do you change patients' wants? Ask Frank Luntz, the master of verbal manipulation. I don't know the answer to that. My guess is that sociologists should have a large role in assessing these problems and would be better able to make suggestions as to how to modify the perceived needs of patients in a way that satisfies patients and does not enrage them.

The advertising complex is somewhat to blame for this as well, and might be the solution. It seems there is a disconnect in patient thinking: they want their doctor to practice good quality Evidence Based Medicine (EBM), but not when it conflicts with what they personally want. And it puts physicians in a bad position, "Give in to the patient, and practice expensive, less-than-ideal medicine or risk a lawsuit, patient-complaint, or administration sanction from low Press-Ganey patient satisfaction scores."

Maybe we can use the advertising complex with the help of sociologists to modify this disconnect. Maybe we can't. But if it is not done, I can predict that health care reform will to some degree make people unsatisfied bc costs will escalate out of control and need painful solutions to tamp it down, or face (on some level) the feeling of a lack of personal choice - especially in the areas of the country that have higher (and at times) unreasonable expectations of what their physician and what the healthcare system should provide.

Wednesday, July 22, 2009

The ignored elephant in the room. What's missing from the health care reform discussion.

What do most of the health care reform bills have in common? Amongst other things, they use Medicaid as a tool for expansion of coverage. And this could be their fatal flaw, which if enacted, will cause the reformed system to come crashing down.

Don't get me wrong, I'm all for expanding coverage. Especially for the poor. Nothing frustrates me more when I have a patient in the ER who would benefit from an outpatient treatment but won't get it because they don't have money and/or insurance coverage.








Physicians decide not to see those patients, or give them 4 month waits for a limited number of "Medicaid" appointments, and those patients understandably end up in the ERs getting expensive care that is incompletely reimbursed, thus jeopardizing the solvency of hospitals like Boston Medical Center.


Since we have the example of Massachusetts to learn from (good aspects and bad aspects) we should learn those lessons - the chief being, MEDICAID MUST BE REFORMED BEFORE IT IS EXPANDED.

One possibility of reform is to increase payments to physicians and hospitals giving them a margin of profit, and encouraging better coordinated care to patients with multiple and/or chronic conditions requiring good primary care. While this increases costs on the front end, it decreases costs on the back end, since patients with expensive chronic conditions get better, less costly primary care, instead of more costly ER and inpatient hospital care. Of course, this implies there are sufficient primary care physicians available to give this increased care, which, if you read my previous blog, is likely not the case.

Another possibility of reform is to take Medicaid and rather than pay for services, just subsidize Medicaid patient's premiums with a private insurer in a group market/exchange system. This will undoubtedly cost more money, as Medicaid's expenditures per patient is less than private insurance (likely due to their lower payments to providers). If the market/exchange enacts good cost controls then this option could work. If not Medicaid will cost the country more than ever.

If we don't enact significant Medicaid reform, our whole country will face the problems Massachusetts' reform is only now revealing, and it could continue the downward spiral of healthcare in this country, rather than improve it.

Saturday, July 18, 2009

The Primary Problem with Universal Healthcare Coverage

There is a dark side to Universal Health Insurance. And if these concerns are not dealt with first Universal Coverage could lead to disaster.

More Primary Care Physicians Are Needed.
As I mentioned in previous blogs, few people pay attention to the law of unintended consequences of legislation. The example set in Massachusetts has shown that with some success (97% coverage), there can be the beginnings of failure. In other words, when you suddenly have a large group of people who are insured and ENCOURAGED to get preventative care, where do they go? To their Primary Care Physician. The result? Very long waits to see their physician, which is measured in months, not weeks. Also, more visits to the emergency department. And this leads to increased costs. And this happens in Massachusetts which has more physicians per capita than any state in the nation.

Currently, in the U.S. we have a shortage of Primary Care Doctors (PMDs). In 2005, the Council on Graduate Medical Education released a report predicting a shortage of about 85,000 physicians by 2020 (which will be worse if the older MDs wary of healthcare reform retire as they are threatening to do).

The American Academy of Family Physicians recommended that to meet the need for primary care physicians in 2020, the United States would have to train 3,725 family physicians and 714 osteopathic physicians annually. This is just the recommended Family Practitioners and does not address other PMDs that are needed such as Internists.

In 2007, only 1107 medical students matched into Primary Care residencies. It takes 3 years to train a PMD. If this year (2009) we tripled the number of Primary Care matches, the country would still be 40,000 PMDs short.

The GAO study GAO-08-472T found that preventative care, coordinated care for the chronically ill, and continuity of care can achieve better health outcomes and cost savings. The study also found that states with more primary care physicians per capita have better health outcomes than states with fewer primary care physicians, and that states with a higher generalist-to-population ration have lower per-beneficiary Medicare expenditures.


This means we need more money for physical infrastructure in medical schools to accommodate such a large increase in students. Also, more money for residency spots (it takes approximately $100,000/year to train a physician). Finally, I highly support government subsidization of medical school tuition to minimize student debt as students with large amounts of debt tend to pick higher paying specialties (in other words, NOT primary care).

To meet the short term demand for increased primary care, a number of creative solutions must be enacted. I have a few suggestions:
1) Increase physician productivity by elimination of non-patient duties:
  • Documentation (have government subsidies for scribes)
  • Pre-approvals (hopefully patients in health markets/exchanges or Medicare will not need pre-approvals as this costs tons of money in physician productivity and unnecessary admnistrative costs)
2) Improved physician reimbursement for primary care (will lure back current primary care physicians that have shifted away to become medi-spas/hospitalists/concierge medicine will encourage more medical students to go into primary care)

3) Encourage US-Trained foreign residents to stay in the US.

4) Create a pathway for foreign-trained primary care doctors who speak good English (particularly Australia/UK/Canadian trained) to do a one year primary care appenticeship under a board-certified IM or FP physician, followed by an exam to allow them to obtain a license to practice.

5) Give tax breaks or other incentives to semi-retired/recently retired primary care physicians to bring them back into the workforce. (via L.Saldana MD)

Getting more PMDs won't be fast. And it won't be easy. But if we want USEABLE Universal Health Care, then it must be done.

Sunday, July 12, 2009

The truth about the controversy surrounding taxing health care benefits and related employer issues for health care reform

Whatever side you are on about the issue of leaving health care benefits alone or repealing their tax exempt status, I will attempt to clarify some of the issues.

I don't understand the vociferous criticisms of taxing health care benefits. Here's why: The average person likely does not realize that the tax incentive for employers to offer health insurance mainly benefits high income employees. That is, because the monies given as a health insurance benefit are untaxed.

Therefore, if you don't pay much tax, you don't get much benefit. You think you are getting "free" insurance from your employer, but you are actually getting paid lower wages than you would otherwise. Thus, eliminating the untaxed healthcare insurance benefit eliminates a wealthy person giveaway. For example, if you assume the average family of four insurance cost of $12,000, a high bracket employee would save approximately $4000 in taxes. A lower income earner would not pay much tax, and therefore would not get much of a benefit. Why are we subsidizing the wealthy with our 100 billion dollars in tax breaks?

However, if you eliminate this benefit, you must compensate for it or things will be worse off than the status quo.

  1. You must require that employers still give a benefit for healthcare insurance that is equal to the amount to what they did in the previous year, or increase the salary of each employee by an amount equal to what they paid in insurance benefits the previous year. Employers must not be allowed to interpret the taxing of benefits to mean that they no longer need to offer health insurance benefits.
  2. You must replace the tax benefit with a sliding scale credit that will benefit the poorest americans.
If the above protections are not put into place, the likely result will be an eroding of the employer supported healthcare insurance base. While not perfect, the employer model of distribution of health insurance insures millions of people and undermining this would be counterproductive when the goal is to have more people insured. This potential underlies the basis for the criticisms to tax healthcare benefits.

Even with the protections, the likely result of a healthcare market/exchange combined with removal of the tax-protected status of health care benefits is that employers will no longer provide health insurance to their employees. They will provide money that will go into a health care account that is used in the market/exchange. The burden of providing healthcare insurance to their employees will be lifted. This is a good thing. For healthcare. And for the economy as a whole.

Employer mandates for coverage vs. fines for not participating
I guess this comes down to a societal moral argument: "Should employers be responsible for giving healthcare to their employees?"

Back in the day, employers covered their employees not out of obligation, but out of necessity. If your employees were healthy, they'd be more productive. Productive companies made more money. It's that simple. The irony is that what was borne out of a need to improve their profit margins and recruit superior talent, now stifles profits and drives companies to foreign countries.

If employers want to recruit top talent, I think providing a health insurance benefit would be of value, and for that reason, employers will continue to do this voluntarily. However, should they be obligated? That is a whole 'nother issue.

As I said before, to prevent significant loss of insurance coverage, companies that offer benefits should continue to offer a monetary subsidy for health care coverage. So I'm going to set aside the standard argument that we should just let unfettered capitalism determine whether companies offer coverage. Whether that is superior or not can be debated by economists. I'm dealing with the reality of trying to cover all americans in a system where corporations already pay much of the freight.

Both the House and Senate have various versions of bills that will penalizes companies that don't offer coverage. The House version penalties could be upwards of $4000 per employee, whereas the Senate version charges $750. A big problem I have with the house version is that it charges based on size of the payroll. What if the company is losing money? They still have to pay a fine? IF there is such a penalty it should have some "outs" for companies making below a certain threshold (or not making money at all). Also, the threshold for small businesses is way too low. In this economy, small businesses are already struggling, and you are going to tax their payroll? The likely result is lower payroll, and thus, slower growing companies, and slower improvement of the recession.

My problem with the Senate version is that all companies are fined exactly the same amount without regard for profitability. I don't love the idea of fining companies for not paying into the health insurance market. However, if we as a country decide that there needs to be a shared responsibility amongst various sectors of society to give all americans health care coverage, then corporations are part of this. And corporations that don't participate become a liability to getting this coverage. We just have to make sure we don't do this at the expense of corporate health.

Saturday, July 11, 2009

The truth about the controversy surrounding public option for health care reform

The public option has created a ton of controversy and risks becoming the hotbutton that makes the whole health care reform movement fall apart. And yet, the arguments don't meet the facts. So I will attempt to clear up the misinformation and confusion.

What is the public option?

Many health reform proposals create a health market/exchange where people could be grouped into large balanced risk pools via either state or federal groupings (I prefer federal see previous blog, #1 for details) and have numerous health insurance companies to choose from.

The problem with this model, especially with the state market/exchange solution, is that there has been such consolidation in the health insurance market, that 94% of metropolitan markets in the U.S. have only one choice. If it were on a state by state basis, that might improve to a few choices - unless there is some agreement by insurers to maintain state monopolies to reduce competition. If it were on a federal basis, like the federal insurance plan that congress uses [not saying we should duplicate this, but there are many aspects of FEHBP that are worth emulating], there would be a large number of choices (100s).

Adding a public option to the list of choices has been suggested by many.

1) Public Option will likely cost less due to lower administrative costs. (Probably true, though less so with the state exchange model, moreso with a federal model.)
2) Public Option will be able to have protections for patients e.g. pre-existing conditions, preventative care etc...
3) Public Option will increase competition and force the private insurers to become more efficient and have added value benefits that a public option doesn't have. (Maybe yes, maybe no. See my explanation below.)

1) Public Option will steal patients away from the private insurance market. (To some degree yes. See below for further explanation.)
2) Public Option will cause insurers to make less money. (Probably so. Though they will have access to a larger market with all those newly insured patients and might be able to make up for it on volume - e.g. the Walmart model.)
3) Public Option will cause bureaucrats to be in charge of healthcare ("get between you and your doctor"). (Possibly. Some models suggest an independent federal reserve type system to oversee the public option to prevent this. But right now most people have no insurance w/ER, or underinsurance with corporation "getting between you and your doctor.")
4) Public Option will pay doctors and hospitals just as poorly as Medicare and Medicaid. (Possibly. Medicare and Medicaid pay less than cost for many doctors for many conditions [and yet perversely overpay for certain procedures] and while insurers aren't exactly generous, doctors and hospitals do better with private insurers overall.)

So do we need a public option?

  • The biggest fear amongst individuals against the public plan is that it will steal patients from private insurers and cause them to go out of business, and thereby creating a single payer model that is increasingly showing itself to be insufficient in the many countries that have one. However, I asked a number of my well-insured friends if they would choose to keep their insurer versus going to a public plan and all said they would shy away from using a public plan. Not scientific I know, but it backs up a PNHP study from FEHBP experience: that more people choose a higher out-of-pocket plan if it gives them more choice. In other words, people won't necessarily choose the cheapest one. It is possible that the public plan might even have trouble finding people to choose it in the beginning, until it proves itself to be at least equal in quality to a private insurance plan.
  • If we don't have a public option that causes insurance companies to change their practices by competition, the alternative is not having one, but increasing regulations of the insurance companies who participate in the market/exchange. I'm not a fan of increased regulations due to the law of unintended consequences. But expect this if the public plan option is not enacted.
  • The public option will allow for competition in markets where there is a monopoly. True, in our current state, but with a well-functioning market/exchange system there should be plenty of competition already, making that a less viable reason for enacting one.
  • Insurance companies will have trouble with growth and maintaining value for their shareholders. Initially, there will be plenty of growth with the many new people entering the healthcare insurance market. However, it may be that health insurance companies will have to move into a high dividend model for shareholder value, rather than a growth model. Personally, I think this is the only ethical way to run health care businesses. Insurance companies do provide a valuable service in the creation of risk pooling and redistribution of funds to allow for people to be covered for illness, and therefore do have a right to get a margin of profit on that. However, growth of profits at the expense of health care is abhorrent (as the only way to grow profits is by decreasing what you pay to providers/hospitals, decreasing coverage/denying care for patients, increasing rates, and consolidating with other companies to create monopolies).
  • The public option will force insurance companies to be more efficient/competitive and create added value. Maybe. The insurance companies might provide more services to attract new customers. Unfortunately, it is not in their best interest to do so, in that the more services you offer, you then select for people who need more services, and thus you get a sicker group of people as clients and less profits. More than likely, they won't offer more services, they'll try to compete on price and simply make less money and/or cut reimbursement rates to providers/hospitals to compensate.
The answer is No. We don't NEED a public option. We can accomplish the same goals through regulation. However the public option provides a method of getting the desired changes we need through competition, not regulation, in a more efficient manner. So while we don't need a public option, I think it is the best way to get what we want, and I don't think it will lead to a single payer system. That is, unless the public option is so superior that private insurers fail to compete on any level. Which I find highly unlikely. UPS and FedEx have found ways to compete with the USPS. Private corporations can compete successfully with government programs allowing both to healthily coexist. Thus the public option can be beneficial without being disruptive.

Monday, July 6, 2009

If the sun cancer doesn't kill you the sunscreen will (AKA The back from the beach blog)

Before heading down to florida for the July 4th weekend at the beach, I prepared. My skin tone is somewhere between my mother's olive skin and my father's pale-as-a-ghost untannable skin. Unfortunately, it is not an even split and I lean far closer to my dad than my mom.

That being said, I can tan, but I can burn even easier, so to keep my youthful appearance I make sure to have plenty of sunscreen. Or is that sunblock? Think there isn't a difference? Can you navigate the UVA/UVB alphabet soup? After reading articles similar to the this I got educated about the difference.

UVA causes cancer and aging, UVB causes sunburn. Sunscreen absorbs, Sunblock reflects. Did you know that SPF (sun protection factor) numbers are only for UVB? There is no scale for UVA. The definition of SPF is the length of time a product protects against skin reddening from UVB. 15 SPF protects 15 times longer - about 5 hours, 93% protection. SPF 30 =30 times longer, blocks 96.7% of UVB. The improvement is minimal at higher SPFs: 50 = 98% blockage and 100 is 99%.

Just because a sunscreen blocks both UVA and UVB does not mean it blocks ALL UVA frequencies. To be sure you block all cancer causing rays, you need these three ingredients: Avobenzone, Zinc or Titanium. And you need approximately 10% of one of these materials to get full blockage. Plus, you need to reapply every 2 hours, or the effects of sweating will diminish the effectiveness.

I've read a number of websites that are concerned about the stability of Avobenzone (also seen on labels as Parsol 1789 or butyl methoxydibenzoylmethane), but a number of studies declare it stable-that is, if by itself. Avobenzone degrades nearly completely if used in combination with Zinc or Titanium. In the U.S. you can't combine these ingredients, but so many people use makeup with mineral sunblocks, you can unintentionally negate the effect of your Avobenzone sunblock. So be careful with layering of sunblocks. More is not always better.

Okay, back to my story. After stocking up on my UVA/UVB sunblocks: Aveeno for the face (has Avobenzone) and Neutrogena fresh cooling mist (I love the cooling in the heat!) [has Avobenzone], I headed to the beach. I thought I was prepared. Until I read this by the Environmental Work Group (EWG).

I looked up the Neutrogena first, since I use it on most of my body. And I noticed in the top right it had a toxicity rating of 6/10. Curious, I paged down, and found one of the active ingredients was a 9/10 toxic rating! And when I did more research on this page I discovered that two ingredients in MOST sunblocks (including mine) are highly toxic especially if absorbed into the skin - and they are highly absorbed - Octinoxate and Oxybenzone. These two sunscreens can cause allergic reactions, lead to hormone-driven uterine damage, and can act like estrogen in the body.

But looking on the Neutrogena page, and clicking on Oxybenzone reveals it does much more damage: neurotoxicity, endocrine disruptions, and hematologic and renal abnormalities. Of course, all my lip balms with SPF have one or both of these toxic compounds. I'm sure none of that ends up in my mouth and gets into my system.

While zinc and titanium are potentially carcinogenic and disruptive to bodily functions, they are do not seem to be absorbed through the skin, even if in the nano form. So I'm less worried about those. Avobenzone has low absorption also, and its toxicity seems to be less defined as with the other common toxic ingredients.

By the time I read all this, it was too late. I have enough sunblock to last for a year. But I do have several lip balms, and I will use the non-protective but also non-toxic ones since I use them for dryness primarily. In the future, I will buy sunblocks listed as approved on the EWG web page and feel (somewhat) confident that I will protect myself from skin cancer and also not toxify my body.


After posting this blog I had a reader suggest another chemical that seems superior in its UVA coverage that is approved for use in U.S. but is not in wide use: Mexoryl. A nice review of it is here - best UVA coverage, doesn't break down, negligible absorption, water soluble so if absorbed (e.g. swallowed) leaves the body quickly, low toxicity, but misses some of the UVB spectrum (that causes sunburn).

Likely Mexoryl (SX) will need to be packaged with another component to get more UVB protection, but it seems like a great ingredient to prevent cancer and aging with low toxicity. There is a version of Mexoryl (XL) that is not approved in U.S. yet, but available in Canada that has FULL UVA and UVB protection. The article I linked to has a link for where to buy sunscreens with Mexoryl - Loreal makes a bunch. For Mexoryl XL do a froogle search-there are many in canada (Ombrelle was recommended to me) [though I don't recommended anything not approved by F.D.A. You buy anything like this at your own risk...]

Wednesday, July 1, 2009

A Few (Rare) Good Things About The Current Healthcare System

Subtitle "Make sure to keep these things intact when enacting healthcare reform."

In my previous post on healthcare reform, I stated what is probably controversial but I believe true - Do not fear socialized medicine in the future as we have that NOW. Most of our healthcare system is in shambles. But there are a few bright spots.



What began as a convenient, low cost marketing method for insurance companies trying to sign up customers for health insurance way back when, has become a cornerstone of today's insured population.

Currently, there is a well-developed infrastructure using employers to disseminate healthcare plans to their employees. I don't want to add to the employer's burden. In this economy, we don't want to further burden our industry with mandates or increased responsibility. I do, however, want to take advantage of this method of health insurance distribution.

Many people are afraid that the healthcare markets/exchanges will cause a leeching of people out of employer coverage and into the market/exchange coverage. If done right, the Market will have more competition, more choice and will be attractive for those wanting more than what their employer can offer them. Once enough people switch away from their employer's plan, it will diminish their group buying power and effectively destroy the employer market for insurance coverage.

I would not focus on this as it is not necessarily a bad thing. I do think that ANY HEALTHCARE REFORM BILL THAT INCLUDES A MARKET/EXCHANGE MUST HAVE A PROVISION THAT EMPLOYERS WHO PAID FOR HEALTHCARE WILL CONTINUE TO SPEND THE SAME MONEY AS THE PREVIOUS YEAR FOR THE EMPLOYEE. In other words, employers will not be supplying healthcare insurance, they will provide the $ for insurance - just like before.

Think about how much money each company will save in not having to offer health insurance. They'll still pay for coverage, but the payments will be predictable.



Technology is expensive, and according to the Robert Wood Johnson Foundation study is THE major driver of the high cost of medicine. America is the leader in the creation of new, better technologies like CT, MRI, Angiopasty...the list goes on for miles...that have improved the diagnosis and treatment of many illnesses.

The problem we face is the skyrocketing costs that have made paying for these expensive new technologies untenable for the average person. Insurance coverage is a must in order to take advantage of this healthcare progress. However, the cost of insurance is going up as a result. there must be a way to maintain American Innovation, while allowing people access to these high cost tests and procedures at reasonable cost to society.

There is. See my next blog for my thoughts on how to manage this tightrope walk between low costs, efficiency, and innovation.