Obama & healthcare part I: how to achieve "universal care"

I am a family physician who has been in primary care practice for over 14 years.  If you're a Obama supporter (like me) you're probably as pleased as I am that he is determined to extend healthcare coverage to all Americans.  But to achieve universal care, there are tougher challenges ahead than the obvious issues of enrollment.  

Based on what I'm seeing from day to day, we need to keep the adminstration focused on the following issues:

Shortage of primary care doctors.  MDs in my field are retiring faster than in previous times because of burnout from paperwork, and the constant struggle for documentation and pre-authorization.  Most medical students recognize this, and they are choosing not to enter the field.  They have large student loans, and are forced to choose more lucrative, procedure-oriented specialties.  No matter how common insurance coverage becomes under the new plan, there won't be universal care in the future if this trend continues.  

Routine use (and over-use) of specialty care.  Other countries where primary care is the main delivery system of healthcare have the same or better health in their citizens. We continue to be a country that expects specialty care, despite that this care is more expensive and may be more dangerous (because of more interventions that may lead to complications).

We have solutions, but it will probably take great political will to implement them:

Lighter loan repayment plans for students graduating in family practice would encourage more to enter the primary care fields.  Also, with a complete overhaul of the current reimbursement schedule, insurers should offer greater rewards for the health and wellness care delivered by primary care doctors. This will save the system even more money in the long run if we have a single-payer system. Current employer-based insurance coverages have no incentive to invest in the long-term, since employees switch jobs many times in their lifetime.

In case my post seems to be simply self-serving, here's a story to show the implications for the average patient.  One of my over-90 patients who is currently in care for coronary disease, has undergone cardiac catheterization TWICE in the past 6 months despite the fact that she and I have agreed on treatment with medicines, and not surgery or invasive stents.  The cardiologist has little incentive not to perform these tests since Medicare reimburses very well for them. 

In this situation, the cardiologist acted more like a highly paid plumber than a physician, in not looking at the entire situation and taking into account what is best for this elderly patient.

More examples of the over-use of specialists can be found in a recent New York Times article by Jane Brody: “More Isn’t Always Better in Coronary Care.” Surgical invasive management has been expanded without any data that these expensive interventions extend life for the majority of patients who receive them.

-- submitted by Dr. Deborah Campbell MD

spinal chord

I've been journaling about Vedic chant and its perplexing, strong effects on the health and well-being of my students (and on mine, too, of course).  Then, out of the blue comes last week's Sunday NYT article:  Composing Concertos In the Key of Rx:

"I broke vertebrae 11 and 12, missing the spinal cord by a millimeter... The doctor said I can't do much for you for a while, but you can sing if you like" says Vera Brandes, a researcher in the field of music therapy.  She was sharing her room with a Buddhist whose friends came and chanted daily.  After just two weeks at the hospital, an MRI showed her spine was completely healed.

According to the article, doctors at leading research hospitals are designing studies to learn how music therapy works for conditions such as depression.  Based on the assessments from these studies, one said:

Physiologically it's perfectly plausible that music would affect not only psychiatric conditions, but also endocrine, autonomic, and automimmune disorders.  I can't say music is a pill to abolish these diseases ... [but] so many pills have horrible side effects.  Music has no side effects, or no harmful ones.

 

bologna

Great new post on the Daily Beast about the shortage of hands-on, old-fashioned, family doctoring  ... alas this kind of thing was once performed by physicians who didn't need to feed their MRIs, and infusion centers with "customers". 

Fewer graduates today choose family medicine because PCPs are forced by insurers to sandwich patient after patient into bologna-thin slices of time, and they do it for far less reimbursement than their specialist and surgical colleagues.  Dr Abraham Verghese makes suggestions to remedy the problem (quite easily) by creating a quid pro quo between new PCPs requiring scholarship debt relief and the government, which has a pressing need for a "physician corps" to practice in rural and underserved areas.  

Question for the day: has the mechanized care model won our hearts and minds so much that we will refuse to consider Dr. Verghese 's simple, effective proposal ... only because it promotes an archaic style of care?  

Some of my friends have had unnecessary MRIs.  I wonder whether the choice was made heedlessly, because of underlying anxiety that might have been addressed by a truly "attending" physician.  

And I have had one (perhaps) unneeded and very expensive biopsy, so I have to make some adaptations, too.  If my OB-GYN had had the time to call me before the decision was made with the surgeon, my choice might have been different.  Indeed she tried, but by then it was too late, and it's nearly always impossible to reach her by phone to return calls.  The choice of tight scheduling is not hers to make.  I'm sure she'd like to be more available. 

To create change, there has to be a will to wean ourselves off the fantasies surrounding high-tech care: that these procedures provide certainty in diagnosis (not always) and cost effective care (not necessarily).  

We can all agree that regular screening is a boon for many conditions.  But being sliced and diced into films, slides, and images is not equivalent to receiving good medical attention.  As a nation, we need the political will to keep private insurers who profit from high tech as far away as possible from the design of the new system.  One economist described the market effects of insurers' competition in healthcare:  "Competition can sometimes fragment value ... and even destroy it."

Final word today from the good doctor:

"Health reform must take away the incentives to do to and replace them with incentives to do for the patient and to be with the patient.  As the debate heats up and the lobbyists warm to their tasks, let's listen to the patients, because they can tell us what's wrong.  Yes they can."

"Hello Health" (can this be serious?)

Imagine an electronic medical system that's physician-friendly and patient-friendly ... and it comes with neighborhood doctors who "care about the whole you."  

That's the promise offered by Hello Health, a new, concierge-model, primary care service in Brooklyn, with a new branch in the West Village.  It uses email communication between MDs and patients to break the artificial standard of a 15-25 minute office visit, a stricture commonly imposed by private insurers.  The goal, according to the site, is to renew the personal attention and old-fashioned relationship we patients once enjoyed with our family doctors.

Emails could reduce unneeded office visits in this new model.  By using graduated units of care (beginning with a simple patient query by email as the minimum unit), their approach can increase office visit length when required, and without long waits.  It would permit the docs to appropriately price and offer many levels of service, even house calls.  The cost to the patient rises with the time and the level of individual attention involved in a single consult.  The EMS software that allows for emails and access to patient records will also link MDs to colleagues and their own community of providers.   (Maybe a few yoga teachers too?)

Oh, by the way, other physicians can purchase the Hello Health system. That makes me wonder -- is the software the real news here or is it actually a workable clinical model?  And why do they have a name that reminds me of the ubiquitous Hello Kitty?  How serious are they?

 Hello Health also means goodbye to security because it's strictly pay as you go: there's no insurance billing.  But when you consider that almost 20% of Americans under age 65  lack insurance at the moment, that's not a bad market share.  Here's the article about it on Health Affairs.

What's missing?  Maybe some realism about how to maintain clear boundaries with patients.  What happens when the patient's credit card runs out?  Will the "personal attention" and the doctor-patient relationship they touted on the site terminate (like shutting off the tap when you haven't paid your water bill)?  That's the troubling scenario that insurance often helps us to avoid with our PCPs.  Imagine having the "relationship" ... and then when funds run out, your emails bounce back.  That's ugly.  

Hello Health is a new model worth exploring, but it may be another way to sell clinical software.  I'm not sure that they've solved the underlying problem: how to determine the amount and type of services offered to a patient according to need AND capacity to pay.  In an ethical system there has to be a good way to balance out this equation, and I'm not sure the heuristics are there yet! 

Still if emails can help doctors avoid unnecessary visits and patient backlogs .... it's not a bad start after all.

integrated vs. integrative health: which comes first?

A source at NIH told me that their share of the stimulus has been allocated within days of the President's announcement.  Basically every approved project in the pipeline will receive funding.  And as I type, staffers at NIH and on the Hill are completing final touches on the design of the much-ballyhooed, national, electronic medical records system.

So much for the yoga principle of reflection before action.

Evaluated  in the context of 2009 medical information technology, the "new" records system will be B.C.  Of course this stone-age system has some advantages.  It will reduce medication error and it will probably be coming soon to a medical center near you.  So let us rejoice in small blessings.

  If you want to get a glimpse of where we need to eventually take the system, that is,  if we are to have uniform, research-based standards of care in the U.S., visit the Harvard Catalyst site.  Catalyst is the portal to an extraordinary bioinformatics system being honed and refined around the ethical practice of computational information gathering [ie: bioinformatics, with a focus on genomic research and clinical records, and collaboration from the Divinity School on ethical guidelines].  Furthermore Catalyst assembles "information from every scientific core into an indexed, searchable data base."  When we realize that Harvard's "scientific core" includes the Medical School, the Dana Farber Cancer Institute,  and 16 leading facilities surrounding Cambridge, we have Harvard's permission to gasp in awe.  And they Twitter!

One question rages on, for me at least.  Can there be integrative (mind-body) care as part of a treatment plan unless we have integrated care (records sharing with patient privacy protection)?  And how can my services be incorporated into the primitive national system that's now in the works?

Patients don't like talking about their alternative care with their PCPs, and until they do, and until we all share and measure outcomes within the same electronic records system, there will be an unconscionable amount of waste in CAM (complementary alternative medicine).  I don't see why Medicare or private insurers should pay for yet another failed, disease-management approach.  CAM has not reduced costs in California where it is widely reimbursed.  Shared information and timely case management would have saved money.  

If you want to read about more CAM practitioners engaging in salutary self-criticism visit one of my favorite stops online The Health Care Blog, and Matthew Holt on the recent meeting on integrative health at the Institutes of Medicine.  Also check out the recent blog entry on employers masochistically funding market inefficiencies.  Because employers have no database to find an insurance program with the best fit, the "invisible hand" of the market fails to operate in medicine (once again!).

In the meantime, let's say a little prayer for all the possibilities that were wasted in this week's panicky rush to approve some -- any -- electronic medical system.  Perhaps it's another sign of lost trust in this society.  Advocates for quality healthcare feel they must sprint headlong to endorse an inadequate information system.  Otherwise the media howl their jeremiads and destroy public goodwill toward a more rational, comprehensive, and thoughtful approach that can't be summarized in a soundbite.

Breathe in, breathe out and say "whatever".