Monthly Archives: April 2014

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Measles and the Upcoming Outbreak

The following article was published April 2, 2014 as a guest editorial in the Oregonian and can be found on Oregon Live here. Today, we can say the North American measles epidemic is in full swing. We are just waiting for the body count, a comment the Oregonian in their wisdom elected to remove from my submitted draft. 

 

Measles is near. Last Aug.18, Texas health officials announced 12 cases of measles in that state. By Aug. 20, the number of officially reported cases was 16. The majority belonged to a single church whose pastor had been recommending that parents avoid vaccines. It wasn’t even the biggest outbreak last year. There were 58 cases in New York. So far this year, we’ve had five cases near San Francisco, 20 in Orange County and over 320 cases in Canada’s Fraser Valley to our north, which has spread to at least one resident of Whatcom County Washington. We’ve also had an outbreak of mumps at Ohio State.

It is only a matter of time before the most vulnerable start suffering the consequences of an American epidemic. Oregon is the state with highest exemption rate in the US. This makes our local area particularly vulnerable to an explosive epidemic. Just for perspective, only 3 percent of children are exempted in California, and they have had the biggest outbreak so far this year. As the ring gets tighter, it is only a matter of time before officials in the Portland metro area have to scramble to respond to a disease we thought we had eliminated from our shores in 2000.

Measles is not the flu. It is much worse. Influenza has an attack rate of about 50 percent, measles 90 percent. That means that 90 percent of non-immune people who come in contact with the measles virus will actually acquire the disease. Complications range from the trivial, like ear infections and diarrhea, to dehydration, to pneumonia, dehydration and encephalitis, a serious type of brain infection.

Traditional epidemiology reports that 20 percent of children can expect to be hospitalized, and three out of a 1,000 will die. Most recent data from Europe would suggest that the numbers are closer to 30 percent hospitalized and a 1-2 percent fatality rate.

In the 1950s and 1960s,  an average of 450 American deaths were annually attributed to measles or its complications. Following the introduction of the measles vaccine, the number of cases steadily declined until 2000, when there were no cases at all.  In 2013, the latest year for which the CDC has reported statistics, there were 189 cases of measles.  Many were imported from countries with inadequate vaccine coverage, but we are seeing more cases in vaccine refusers. There have been no recent deaths, but in a large epidemic, the odds are not promising.

After 15 years of misinformation, complacency due to the lack of domestic deaths and a series of paranoid and ignorant conspiracy theories, we are starting to see outbreaks. This is misinformation with a body count.

When the percentage of people immune to measles drops significantly, massive and sudden increases in the number of measles cases follow. In France, where the anti-vaccine movement caught fire in the middle of the last decade, cases of measles went from about 30 in 2005 to 15,000 in 2011. There were six deaths. Last year, the United Kingdom suffered 1,219 cases with one death.

Some of the cases are occurring among children who have received the vaccine. Since vaccines are never 100 percent effective in preventing any disease, the risk of failure rises proportionately to the cumulative weight of exposure. The more cases are in your neighborhood, the greater the chance that your vaccinated child may get the disease.

No vaccine is entirely safe. Balancing the risks of preventing disease with the risks of the actual vaccine is not an easy task. Informed consent is a cornerstone of any medical practice, and every parent has the responsibility of weighing the evidence for themselves. But how do parents decide when the information about vaccines is more about conspiracies and wrong data? How do responsible and critical thinking parents who chose the vaccine react when a significant proportion of their neighbors undermine collective efforts to keep a deadly disease out of their home?

 

Some goals, like eliminating measles, can only be accomplished by group action, taken with full knowledge that a few will suffer, but the majority will gain something significant. This is what it means to live in a community. This is what it means to be responsible.

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Employed Physicians

This old post is here because I have been thinking a lot lately about the impact of employed physicians on a community’s health. Since this post was written, I have worked for a large hospital-based primary care practice where I was being pressured to produce referrals and tests. When I left, the company waived any non-compete clauses. If they had elected to enforce them, my current community would have been deprived of a family physician in an area of primary care penury. So the lack of independence in primary care may lead to overuse of specialty and technological services and deprive communities of the specific function (primary care) that makes health systems more efficient. This 2008 post contains the seed of an idea to develop a sustainable business model for the independent primary care physician in the interests of the public health. But there are several steps I will have to fill in, so stay tuned. Meanwhile, enjoy…

 

I had an interesting conversation with a feller from Texas the other day. I was telling him how I had formed my impressions of docs in employed situations from my experience on the East Coast. It just seemed that the solo practitioner was almost dead, if not completely so. Even in rural Maryland, it was more likely to find groups of two or three docs in private practice fiercely holding on to their independence in the face of large single- or multi-specialty groups encroaching from the suburbs. Many of the large groups have found Stark-compliant ways of working with nearby hospitals, or, in some areas, are outright owned by the hospitals.

I reflected to my acquaintance how different it was out here in the Western desert regions, where it seemed the employed docs sometimes felt they could act like it was their own shop and close up with less than a day’s notice to stay home with the kids or go duck hunting or take whatever break is justified by a hard-working, highly-valued provider of a needed service by a grateful community.

You can’t do that when there are 50 physicians and 300 employees whose work schedules are dependent on physicians providing billable services on razor-thin margins.

Well, maybe you can. It’s all about the supply and demand equation, isn’t it? If there aren’t enough primary care physicians to go ’round, the tolerance for behavior inconsistent with a larger organization’s overall well-being is better tolerated. And certainly the local physicians’ culture has an important role to play. Texas docs, I was told were nearly never in large groups and they never tolerated overbearing administrative intrusions to their clinical or vocational independence.

I walked away from my conversation with a tall and lanky Texan (sorry for the cliche, but he was tall and nearly lanky), with an understanding of how different the situation is for physicians across the country and how my approach to change management and performance management is colored by my East Coast experience.

In areas where managed care penetration is high, employed physicians predominate by choice, and a high regard for academic analysis output exists, there is an atmosphere of understanding and willingness to work within a corporate environment. Evidence-based medicine, quality and performance improvement are all perceived as methods to improve health care delivery systems for the betterment of the community. Physicians understand the choice to enter employed positions and accept the trade-offs, giving up some independence for the sake of fewer administrative headaches, better benefits and perhaps, a reasonable lifestyle.

In areas where one or more of these conditions do not hold, physicians resent encroachment on their judgment, style or authority and mistrust the motives of administrators of all stripes. EBM, QI, and PI are bridles of control to be avoided at all costs and administrative entities are regarded to exist for their personal betterment and not the benefit of communities nor the doctors, Such physicians enter into an employed arrangement begrudgingly and only if they feel that their work is not subject to the kind of oversight that will reduce their independence.

OK, I’m dumb. I didn’t realize the obvious until now. I have grown up in academic environments which are so dominated by various stakeholders that the independence of the community physician a distant recollection from the stories of William Carlos Williams; the vague memory of a historical work of fiction read in childhood. The East coast and its large cities are places where independent practitioners are aberrations or mavericks worthy of awe, disbelief and admiration.

Elsewhere in the country, in smaller cities and younger landscapes, the independent practitioner has thrived and the battle for physicians’ independence is much more vigorous.

It is possible to engage physicians any number of ways in future improvements to health care. The lessons of the East tell me that the best way is not confrontational. Without physicians, no meaningful reform is possible, despite the best efforts of other stakeholders. On the East Coast, docs have been beaten into submission. It took a long time, created a lot of ill feelings and did not accomplish much. The rest can do it faster, more collaboratively and with greater focus. The first step is to get a clear understanding of the situation and adapt to local environments.

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Revolution or Evolution

I resurrected this old blog post because it reflects some of the most basic and fundamental issues that were not addressed by the ACA. It is as current today as in 2008. Changes in health technology, consumer-facing health tools, payment reform and Meaningful Use have not moved the needle on establishing a unified view on the the nature and purpose of health care systems in general.

 

Call me a skeptic, but this health care system (which does not serve the majority of its stakeholders) is not likely to change overnight, even (especially) if Obama wins the election. What we have in the US is an undesigned, organic, chaotic system which accomplishes exactly what it is designed to accomplish. Problem is, everybody thinks it is designed to do something different and the result is incoherent.

Some treat health care as an entitlement. It is the right thing to do because nobody should ever go without access to care in the face of illness. Illness is frightening, as are many other things in the world. But fear of getting sick is about as good a justification for universal health care as universal access to… say, attorneys. It may be a good thing to do, but I would rather push for universal access to information.

Many physicians see the health care system as a vehicle for the intellectual challenges and exercises in skill required of the practice of medicine. As an exercise in meritocracy, health care should be more available to those best able to pay for it. There has always been and will always be value in having uncommon skill or knowledge. I firmly believe that this drive, rather than the profit motive, is what pushes most physicians to specialize, sub-specialize and constantly and marvelously push back the limits of what can be done with the human body.

Health systems are also an opportunity to find a margin. Yes, health care is a business and in America, profit is not a dirty word.

Health care is also as “issue” for politicians, and to the extent that it affects voters, it influences the government agenda. It represents a way to get a vote.

Health care can be seen as a public health measure, which I tend to do. This suggests that those interventions that are most likely to help the health of populations (as distinct from the health of individuals) should get the most resources. With all due apologies to my sub-specialty colleagues,who are critical to our health care infrastructure from many perspective, it is here that primary care wins out hands down.

In fact, the broader the definition of health, the less medical it becomes. Securing water, adequate shelter, safe employment, reliable food sources, traffic safety and basic literacy are health issues that hardly fit into our usual conception of health care or the current reform debate. Immunizations, prenatal care and primary care are the most cost-effective things the medical world has to offer. PAHO and WHO publish guides for policy makers.

A health system like ours is at cross-purposes. Many advocate a total overhaul but that’s not how change happens. Incremental change is more likely. Even if we were to reach some sort of tipping point in technology, or delivery, or insurance we will not likely see a complete change in a high resource service sector. Despite the complexity of the health system, care is still delivered one-on-one. All other discussions remain MBA-speak appropriate for the Harvard Business Review and little else.

Don’t get me wrong, I like what I see in the health reform world. I like Dr. Val. I like Steve Case for that matter. I think what they are doing in consumer-driven health care is valuable. Jay Parkinson sounds like a smart guy and I might even ask him what he thinks about spreading his model to rural areas. I believe that the Future of Family Medicine project has enormous potential for change as evidenced by the TransforMED project and the rising popularity of the medical homes concept. PHR‘s have potential. RHIO‘s even more.

But none of these ideas are sufficiently transformative to represent the answer to a broken health system. Together, they represent a significant change in direction that incrementally may have an outsize impact.

The single notion that could have the greatest effect is the one that says we cannot and should not provide for every possible health benefit under the sun.

Rationing by cost (a barrier to access) is more acceptable than rationing by mandate, regulation, insurance company ruling or queuing. No rationing does not exist in any industry.

This means we must prioritize the things we cover. We make decisions all the time about what is covered and what is not covered, but we currently decide based on politics; that is to say the sum total of influence exerted by stakeholders and lobbies.

Frankly, it’s not a bad way to do it; I don’t believe in central planning. Look at Canada. But a better way to do it is follow the data. Otherwise every right wing crackpot and left wing entitlement-creator will have outsize say according to the way the political winds blow. Right now, we have two nutty ideas floating around: one way is expanding health care coverage under government tutelage and the other is giving tax credits to poor people to buy health insurance (source: Pikalaina). As far as I’m concerned, government should only guide and create an environment for market forces to accomplish common goals (in this case, health.) Expanding government programs is not the way to do it. Tax credits for poor people are ridiculous; I can’t get my poor patients to spend on bus fare if there is no IMMEDIATE benefit.

McCain is also promoting an idea to allow insurance companies to compete across state lines. Bob Vineyard at Insureblog seems to feel it won’t work because of differing state mandates (the analogy is with credit card companies). In other words, states are already making choices about which benefits are to be covered. This may be viewed as rationing, or alternatively, choosing which parts of health care to subsidize. In fact, I prefer the subsidy position, because it puts us on more firm moral ground. If we chose to subsidize any industry, we should do it on the basis of data and a specific goal in mind. A utilitarian like me will view government’s responsibility as creating the greatest common good i.e. the most wellbeing. This merges nicely with the broader definitions of health.

What I like about the McCain idea is that it represents incremental change. To address Vineyard’s correctly pointing out that state mandates represent a serious obstacle, they are not insurmountable. A federal rule for companies selling insurance across state lines could be that they meet or exceed the benefits coverage of most states. These policies will be more expensive than policies sold in low-mandate states, but provide useful alternatives for those willing to pay. They will represent real competition in high mandate states, which are sufficiently populous to get people asking questions. There are other legislative and regulatory hurdles to get over, but ideas should not be discarded before a full and public airing.

Transparency in the insurance industry and in hospital pricing, expanding coverage for the uninsured and under-insured, a more flexible tax code to allow for the purchase of alternative insurance products, increasing adoption of IT and maximization of its potential in measuring and affecting quality, aggressive changes in models of care delivery and defining different levels of coverage according to health impact analysis are all a small part of the solution. Overall, there is a tremendous amount of value yet to be unlocked in the US medical system, but tearing a system apart to rebuild it from the ground is not a good option. Revolutions tend to be more destructive than creative.

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Cost effectiveness of well child visits

We published this back in 2008 on the old blog. It remains germane to the economics of primary care and I updated it with a link to The Incidental Economist.

 

Immunizations are simply the best and most cost-effective intervention ever conceived by the science of medicine. They are so important that health care providers have toyed with various techniques to improve immunization rates. For example, my current facility has a full-time immunization nurse who can give missing vaccines to children following a sick visit (as long as they don’t have a fever.)

The principle of vaccinating when you got ’em in the clinic is common in many developing countries and under-served areas, since you never know when you will see these children again.

Now the practice is being questioned. According to an article in Pediatrics, some parents don’t bring their children back for well visits. The well-child visit includes a brief developmental assessment, physical examination and anticipatory guidance. These aspects of the visit have great value, especially for the young, low-income mothers who are the most likely to conflate a well visit with a shot.

As a clinician, I understand the value of well child visits, but my public health degree must question the data. There is insufficient evidence to support annual adult examinations. Studies with children are naturally more likely to yield a benefit, but I just haven’t seen them. After all the well-child visit schedule is tied to… you guessed it, immunizations.

It’s good to know that there is documentation of the downside of opportunistic immunization (which has been our experience). I am not sure it matters in the big picture. After all, one of the few things on which health economists agree is that prevention usually doesn’t pay off.