All posts by Dino William Ramzi, MD, MPH

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Primary care is key piece to U.S. healthcare puzzle

Another article, this one published in the Vancouver Business Journal on June 19, 2015, found here.

 

Healthcare in the U.S. is sick, bloated and ineffective. In some circles, investment in primary care infrastructure is prescribed as one of the important components in an effort to fix the U.S. healthcare system. My personal opinion is that primary care infrastructure is the single most important piece of the puzzle.

Healthcare is a $4 trillion industry that represents more than 1/6th of GDP. It is also growing at a rate that threatens to exceed the 20 percent threshold in the next few years. The Soviet Union’s economy collapsed when non-productive spending on defense exceeded 25 percent, and it has been argued that this level in healthcare expenditures would cause enormous misery for U.S. businesses. However, it is a mistake to examine healthcare as a monolith. The system is made up of various parts, each of which has varying interests to assure their survival within the system.

Hospitals, for instance, rely on flow-through of as many procedures as possible. Orthopedic, heart and urological procedures traditionally lead the way. Physicians in these specialties are especially prized by hospitals since they tend to refer the most valuable patients. Other physicians have professional and financial interests that are diametrically opposed. If primary care was enabled to do its job, it would keep interventions in community offices, where charges are at lower rates and the care, while some would argue is technically less precise, is often more personalized and therefore more prized by individual patients.

Even the insurance industry is not monolithic in the market conditions that maximize their bottom lines. Some insurers manage care very little, limiting the review of utilization and making their money from processing transactions. In some ways, these companies are aligned with the hospitals and specialty physicians. The managed care plans assume risk for their subscribers’ healthcare costs. They stand to make money if patients use fewer services and as such, are more closely aligned to the average primary physician rather than the average specialist.

Of course, this varies tremendously from person to person. A provider at Kaiser tends to think of fewer procedures, tests and consults as better care, whereas a for-profit primary care practice may gravitate to concierge care, and developing niche service lines like Botox, varicose vein treatments and selling nutraceuticals. Some of the more abusive niche products are narcotic pill mills, medical marijuana clinics and some of the new testosterone-centered men’s clinics.

Primary care has been marginalized in an overtly specializing society. The main driver of this phenomenon is that the financial incentives for a significant portion of the industry are aligned with generating more procedures, more testing and more specialty consultations. After all, that is where the best margins are.

On the other hand, managed care and primary care tend to have aligned interests in saving money for people and the health system in general. Primary care cannot stand on its own; there is no point to having preventive services and first line care if curative care and specialized care is not available. But not every person with high blood pressure or heart failure needs a cardiologist. In fact, specialists would spend more time treating and caring for conditions more suited to their degree of specialization if front line medicine was better built up than it is today.

The trend toward healthcare purchasers utilizing narrow networks of high value providers is related to effective primary care and an appropriate specialty network. Trouble is that the infrastructure for primary care has been neglected for so long that competition for primary care services is likely to raise prices to the extent that, in the near future, it will compete with current health plan offerings. For now however, high-value primary care holds the promise of reducing employer costs and putting enough money into primary care to attract medical students and resident graduates into areas of healthcare that have been spurned for so long.

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Direct Primary Care and the Working Poor

This post was written for PanZoe‘s blog on May 21, 2015, here.

 

One of the easiest vulnerabilities to spot in healthcare after the Accountable care Act are those individuals who simply cannot afford their deductibles. The insurance mandate in Obamacare leads those who work low wage jobs without benefits to buy the cheapest policies.

These policies have huge deductibles, so even with great subsidies, these individuals simply can’t afford to see a doctor. In fact, they are often exposed to the full “rack rate” for health services and have inflated out of pocket costs 2 to 3 times as high as insurance companies pay providers.

A 40 year old man sat at home with a cold, or so he thought. When his fever did not get better after three weeks and he started getting so short of breath that he couldn’t work, he finally came to see me. His cold was really a pneumonia and could have been treated weeks earlier by someone who recognized the red flags early enough. Instead, he ended up in hospital and his $8000 deductible got charged pretty fast.

Low wage workers are the productive members of society trying to transition out of multi-generational cycle of poverty, and succeeding to some extent. Such shocks can throw them back on the public rolls. One of the major advantages of Direct Primary Care for low income individuals just above the Medicaid threshold is unlimited access to high-impact primary care. They can get minor illnesses treated quickly, before suffering serious illness requiring hospitalization. In addition they have access to prevention, care coordination and chronic disease. The technology that goes with Direct Primary Care, like secure video and texting is of particular importance to people whose trips to the doctor often impact their income. In jobs without benefits, if you don’t work, you don’t get paid.

In policy circles Direct Primary care suffers from an image of care for the elites. But the low price point makes it most appropriate for low and middle income individuals. These are the people most likely to benefit from a close relationship with a primary care provider.

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Lawmakers Must Raise Medicaid Reimbursement

This article was published in The Columbian on March 25, 2015 during a legislative session when the WSMA and others were trying to prevent the ACA increases in primary care physician fees from sunsetting. To this day, we continue to under-fund the most important cost-containment mechanism inherent in the healthcare system.

 

 

Nearly 31,000 more people in Clark County have gained health insurance through Medicaid over the past year. When uninsured, many patients forgo basic care and can wind up in the emergency room when their health conditions can no longer be ignored — a very expensive and inefficient way to deliver health care.

Now, insurance coverage is opening doors to see a primary care doctor for preventive care and management of chronic conditions — in theory. In reality, many doors remain closed because low Medicaid rates mean many providers aren’t able to accept more Medicaid patients.

Medicaid expansion was a critical first step in covering more people in our state. But now it’s up to our state Legislature to take the necessary second step to ensure that coverage translates to access to actual health care — funding a fair reimbursement rate for Medicaid primary care providers.

Right now the reimbursement rate to care for Medicaid patients is woefully inadequate, and it is a key reason why some providers don’t take Medicaid patients. In an attempt to address this problem, the federal government temporarily raised Medicaid rates to pay primary care services at the same rate as Medicare. That temporary rate increase expired in December.

For the state, it’s a simple financial equation. Without access to quality primary care, preventable emergency room visits increase while health outcomes worsen, costing the state money, productivity and lives. Several studies in Washington state demonstrate a significant reduction in emergency department visits and hospitalizations as the result of increased primary care utilization, particularly when integrated with mental health care.

Positive effects

We also know that maintaining fair Medicaid reimbursement rates improves patients’ access to primary care. A recent study looked at the effect of enhanced Medicaid payment rates on primary care access in 10 states (not including Washington). It showed that the availability of primary care appointments for new patients increased by 7.7 percentage points in states with the enhanced rates.

A recent survey in this state showed similar impact. Just over one-third of primary care physicians in smaller practices indicated increased willingness to accept new or continue providing care for current Medicaid patients as a result of the federal government’s temporary Medicaid payment increase.

Providers with larger numbers of Medicaid patients reported the greatest impact of the payment increase, indicating that it had made them more willing to accept new Medicaid patients and to continue providing care for current Medicaid patients.

The loss of the rate increase will reverse these gains. The survey found that nearly three-quarters of primary care physicians not in large health care organizations would limit or reduce the number of Medicaid patients they see when the payment increase ends.

The plan has gotten positive feedback from local legislators. Let’s hope that translates to commitment when budget negotiations get tough. The ability for thousands in Clark County to use their Medicaid coverage and get the care they need depends on it.

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Where are the primary care providers?

This is an unpublished Op-Ed intended for The Columbian at the end of May. I got bumped by WSMA President Dale Resiner, so no hard feelings. Here is WSMA version of the Columbian editorial.

Last week, the news hit that The Vancouver Clinic was going to reduce the number of Medicaid patients they care for. This kind of patient selection is nothing new. Many county elderly already know nearly every practice is closed to Medicare. In fact, some offices that do not accept Medicare simply hand you your walking papers when you become eligible. Anyone with a background in public health will cringe at that behavior, but anyone with healthcare business experience will know that you can’t blame them.

The announcement comes at a bad time for the state as Medicaid expansion can impact health only if the new sign-ups have access to doctors, especially in primary care. There are several industry wide factors that contribute to this kind of decision: low payment rates, penalties for fraud that are so over-reaching a single billing error could potentially cost a practice over $10,000 and the extra staff time required to get approvals from Medicare Advantage plans. The same is true for Medicaid except the payments are even lower.

Clark County has severe access problems for patients insured by government plans. Physician incomes in the Pacific Northwest are considerably lower than much of the nation and particularly in Vancouver that was once a rural county and historically did not justify the higher costs associated with being a suburb of Portland. In fact Clark sports one of the lowest primary care physician to population ratio that can be found in any urban county on the West Coast. According to the Graham Center, a primary care think tank in Washington DC, “a relative shortage in the physician workforce with geographic and specialty maldistribution contributes to difficulties in accessing needed services.” Clark County is a case in point.

When an area doesn’t have enough primary care but plenty of specialists, a few things will happen: 1) costs rise because seeing a specialist results in higher costs than seeing a primary care doctor, 2) primary care office fees rise because of a simple supply and demand equation, 3) where fees cannot rise because they are regulated, doctors opt out.

Opting out can take various forms: 1) a physician can decide do concierge medicine and cater to the wealthy, 2) they can become selective and refuse to take patients covered by low-paying insurers, 3) they can stop dealing with the hassle of sick patients’ ongoing needs and simply do urgent care for the easy no-headache payments or 4) they can close their doors.

All these options have been exercised by Clark County physicians in the past few years. Either way, patients lose out because they are the ones in need of lower cost access, coordination of care and the insights that can only be gained by a longitudinal long-term relationship between a patient and provider.

It’s just that this kind of work is thankless. It is high risk because of the awesome regulatory burden and exhausting because of the breathtaking scope of knowledge required. Every specialist knows more about their chosen field than the primary care physician, but every primary care doc is more competent than that one specialist at every other of the 130 specialties recognized in the US. A very few specialists become insensitive, unsupportive, preachy and intrusive. Intrusiveness is increasingly the hallmark of legislatures around the country with mandates for extra medical education on their pet subjects, like pain management, suicide prevention and AIDS, just to name a few. Some state imposed medical education requirements may be relevant and other times merely a distraction from the real work of medicine. It is ironic that this is the year of the suicide prevention mandate from Olympia, imposed on physicians, the profession with the highest suicide risk of all.

The question no longer is why you can’t find a primary care doctor, but how can any still exist. The problem with healthcare is not Obamacare, and definitely not the absence of Obamacare. What got us into this mess is under-investment in the primary care workforce. With or without Obamacare, the current path is not sustainable and will adversely affect the greater economy soon, that without draconian government efforts, it could be too late to fix. If we had an effective source of primary care, the whole system would be efficient enough to take care of everyone without some practices dropping whole groups of patients.

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Abortion

I wrote this article in 1994 for the Canadian Medical Association Journal, trying to make a point that in the heat of the abortion debate in Canada, people had staked out ideological positions that missed the point of human suffering.

I am not sure I would completely agree with myself today, given my understanding of the theological and spiritual arguments against abortion. It is fine to stand with women on choice, but the sanctity of human life is not a choice. I have no resolution and so simply suffer, in my own simple way. 

The fourth clinic

There are four clinics on the seventh floor of a downtown Montreal hospital ‘s west wing. Many of those who walk past the first three, headed for the orange door of the family planning clinic, wear an unmistakable look of grim determination of overwhelming sadness in the face of unbearable choice. Abortions are performed behind this orange door.

The suffering these people experience is not in the physical pain of the procedure, nor is it necessarily a reflection of the loss of a potential life. Loss, after all, is part of our lives, and pain can be drugged to the point of numbness. No, the suffering stems from the burden of choice.

In all the debates about abortion, there is little to be found that addresses the psychologic pain that people who choose abortion carry with them. The weight may lighten with the years, but it seems to always remain in some measure. Decades later, memories remain vivid. An abortion is nearly al­ ways an event of immense import in the lives of those who act on their decision.

In my practice, I see women who use abortion clinics repeatedly, almost as a method of contraception. They are often young, and come from unsettled back­grounds or depressed socioeconomic settings. Many others are simply irresponsible. They cannot remember to take their pill, or they forget to use a condom.

Most of the women who choose abortion, though, do so for reasons that are difficult to deny or judge. They are in a vast grey area in which moral judgments must be made as to what society can and cannot accept. It is here that the arguments are salient and eloquent, and yet they are always much too cerebral to count emotion.

The two extremes — abortion must always be available on demand and abortion must be out­lawed under all circumstances — are accompanied by every possible position in between.

Certain simple facts exist regarding the emotional experiences of women who choose abortion, and even the bravest face cannot hide the element of guilt. Even those who firmly believe that an embryo is little more than an in­ significant, nonviable collection of tissue may have to cope with disapproving families or unsupportive males. Women who have abortions must be able to grieve their loss without the usual ceremony and ritual that society provides for mothers who lose full­ term babies.

Perhaps relieving the burden of suffering is one of the missions of medicine. Of course, suffering can mean different things to different people. On one level, there can be no comparison with the       suffering that is survived daily on a global scale: the suffering of war, hunger and needless disease in the developing world. The poorest of Canada’s poor are wealthy when compared with the homeless of Somalia, yet suffering knows no economic barriers. It merely changes character.

The peasants of Delhi know no other life, and neither do the children of affluence. They each suffer in their own way. There seems to be no need to punish someone for the bravura of youth or the failure of contraception.

Moreover, the importance of a woman’s ability to control her own fertility is but the first step in a long process that empowers and emancipates women. There are lessons to be learned from the women of countries where contraception is outlawed and women suffer the pain of inequality or domestic violence.

The easy availability and growing acceptability of abortion alters the dynamics of reproductive choice. The balance of power shifts toward women, as does the burden of responsibility, but our family laws have failed to keep up with the reality of our technologically determined choices. We all have our own attitudes and opinions regarding abortion, culled from our individual and shared upbringing and values, but these matter little in the physician’s office.

The issues concerning abortion are not technical. They are not about numbers of weeks, the method chosen, the setting, or even who pays. They have nothing to do with the individual doctor or even those of the patient. They are about the face of suffering, the face of the human condition.

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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.

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Health Risk and Pleasure

I thought I would post this one from The Physician Executive because Val was once my favorite internet buddy. My Canadian ex-compatriate is now remarried and has moved to South Carolina. But one thing has not changed: the timeless notion that people somehow view healthcare as a way to dodge the consequences of overindulging their little pleasures. In this case we are talking about something relatively innocent: unpasteurized dairy consumption. Our health officer in Clark County gets upset every time he hears about another place selling raw milk in Clark County. The latest I found was Camas Produce selling raw goat’s milk.

It’s easy to condemn the practice of consuming raw dairy on its scientific basis. Trouble is I love artisanal French cheeses. Many are raw and were outlawed int he US at the time this post was written in 2007. I am a happy camper now that I can get unpasteurized cheese. I hope Dr. Melnick will forgive me this one indulgence.

 

Dr. Val at the Voice of Reason posted an article on the hazards of raw milk. She grew up on a dairy farm, so her observations are particularly cogent. The article raised two questions in my mind.

First, our clinic’s practice is heavily Latino, dominated by Salvadoreans who have a tradition of consuming raw milk products. In fact, Salvadoreans consider yogurt made from raw milk one of the healthiest foods for young infants. My patients tell me it is usually introduced at around two or three months of age.

Of course, this goes against the usual recommendations for baby feeding in the US, which appears to me to be based on bowel maturity and propensity for allergies, as much as on healthy nutrition. There have been sporadic cases of bovine mycobacteria amongst Hispanic infants in our area, which is a stone’s throw and a ferry ride across the Potomac from Dr. Val’s stomping grounds (so much for anonymous blogs, eh?)

My classic and rigorous medical training causes me to carefully counsel my patients against the consumption of anything other than breast milk and formula for the first four months and to avoid raw milk products until they are old enough to choose for themselves. My cultural sensitivity makes me wonder if this is truly appropriate.

Yogurt, perhaps reserved for later infancy, is probably a great source of nutrition to have become an important staple in El Salvador. Culture is important to everyone who has one, and food and child-rearing are important aspects of culture. The documented number of infections in our County was 4 in 2005. Is that enough to intrude on culture and tradition, or can we just remain sensitive to the fact that these children are at risk an intervene early? I’ve never had to treat an infant with cow tuberculosis in their gut, but I wonder… I just wonder…

The second thought that came to my mind is about the French! No I’m not getting political… I just like French cheese. One of my favorites is Camembert from Normandy made from raw milk. Perhaps there is something in the process of making cheese that I am missing, but raw milk cheeses taste better and have been really hard to find because of the Department of Agriculture’s import restrictions. I just found a really smelly cheese store nearby and I’m in heaven. The first thing I asked is if they had raw cow’s milk cheese and the guy behind the counter smiled and nodded knowingly. He probably figures me for a connoisseur for asking!

Raw milk products have inherent hazards, but this isn’t like eating a puffer fish prepared by a novice sushi chef.

Just wondering…