Category Archives: Uncategorized

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Reflections on Health Care Past, and Future

The Portland Business Journal recently sponsored a forum entitled Health Care of the Future, providing a glimpse into what Portland companies are doing to disrupt the healthcare system. Panelists discussed new models for healthcare, new technologies that extend the reach of physicians and financing methods. It was a hugely attended event, with a great buzz, fantastic networking opportunities and a lot of great information. But close to the end of the conference, a couple of comments were made by panelists that I found incredibly frustrating reflections of an old, broken, sick health care system that were oddly out of place.

 

First, Jared Short, the head of Cambia’s Insurance group (Regence BCBS) who recounted diagnostic failure in the primary care setting as one reason for high cost to the system. He brought up a personal experience with his son’s diagnosis of a chronic rheumatic condition that took over two years to diagnose, despite elaborate investigations. Of course we don’t know the clinical details, but that’s why it’s an unfair characterization of primary care.

 

As an intern, I was responsible for the diagnosis of a case of lupus in a man who had been searching for a cause over ten years. I was not smarter than my colleagues or professors, but rather, the unique evolution of his disease made it impossible to diagnose earlier. Doctors knew that waiting and watching was the best possible strategy and in this patient’s specific case, there was sufficient trust that the patient was content to wait rather than pursue useless investigations. This is always necessary in a market where distortions are introduced by the fact that advanced investigations are essentially subsidized by payers. If patients understood what little value they added at time, they would decline. It is frightening that the head of one of the largest and most powerful payers in the Northwest has such a distorted view of the diagnostic process and value within the system.

 

If primary care is inadequate, then we should invest in supporting primary care and attracting the smartest minds. You do not get to underinvest in a key health system function for decades and then complain that it doesn’t do its job.

 

The other inexplicable comment is one I used to hear frequently in healthcare business circles in the past. Martie Ross, a principal in a consulting firm out east, made the point that insurers needed to find mechanisms of transferring risk to health providers with new value-based payment methodologies.

 

My point is that healthcare providers are not risk bearing entities and should generally be discouraged from doing so. It is not clear which features of ACOs predict their success, but some of the most successful ones have been where the risk was transferred to the ACO, but not necessarily to the providers. Providers should be in the business of taking care of people and doing the right thing, irrespective of the cost. As far as insurers go, their business is the management of risk, not the transfer of risk. To a lifelong family physician, insurance companies transferring risk seems like cheating.

 

Moreover, the only entities large enough to absorb this kind of risk are large integrated health systems which is the birthplace of perverse incentives for high volume, excessive and sometimes unnecessary care. Small practices arguably do better at quality where large systems are better at collecting data and generating revenue.

 

The disdain for primary care and the industry’s tone-deaf dehumanization of health to “risk transfer” are part of the reason our old system is broken and we are experiencing this generational opportunity for disruption. This is the health care of the past, not the Health Care of the Future.

 

 

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Fire Fighting for a Beleaguered Community

This is a story that appeared in The Camas Post-Record, our local weekly, about my EverMed DPC partner, Scott Jonason. It was written by Dawn Feldhaus.

 

 

 

Three people with ties to the Camas-Washougal area recently spent a few days in north-central Washington, to help individuals affected by the Okanogan complex fires.

Scott Jonason, a physician assistant, certified and owner of Lacamas Medical Group, in Camas and Vancouver; Jennifer Kaufmann, a Lacamas medical assistant for 12 years; and George Ryland, a former Camas resident, provided medical support to fire crews and residents of the Tunk Valley area — 20 miles north of Omak.

They were there from Aug. 30 to Sept. 3.

“We were equipped to provide advanced first aide, for wound care, insect bites, dehydration and respiratory illnesses like asthma or COPD flares,” Jonason said.

They also delivered supplies that had been donated from the Camas-Washougal community.

Supplies from this area included water and sport drinks, as well as snacks, such as protein and granola bars for firefighters.

School supplies were also donated.

“Immediate needs have been answered, but they will have ongoing needs,” Jonason said. “There are more humanitarian needs and livestock needs, for those who lost everything.

“The future needs include more sheltering and clothing, as well as food,” he added. “Most of the people are back in their houses and are self-sufficient.”

Additional undergarments, such a T-shirts, underwear and socks, are needed for firefighters, according to Jonason.

“Some of them have been in tents up there for a couple of weeks,” he said. “They could be there for another month.”

The Okanogan complex fires have grown into the largest wildfire in Washington history at more than 256,567 acres.

In addition to addressing medical needs, Jonason said he, Kaufmann and Ryland unloaded trucks of supplies and provided security checks in homes.

There had been some problems with looters, Jonason said.

“We stomped out a couple of hot spots,” he said. “We had shovels and picks in our trucks. We buried it or snuffed it out.”

Jonason grew up in Wenatchee, located approximately 120 miles from Tunk Valley.

His 22 years in the military included service in the Army, the Oregon Army National Guard and the Oregon Air National Guard.

“My feeling was, ‘if I can help, I should,” Jonason said, regarding his recent trip to the areas affected by fires.

Ryland has retired from the Oregon Army National Guard. He was an Army medic with Jonason 25 years ago.

The two friends have previously assisted victims of Hurricane Katrina, in New Orleans.

Kaufmann and Jonason have provided post-earthquake assistance, in Haiti.

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Media Mentions for EverMed and DPC, Another Grant Request for PanZoe

We got a couple of media mentions a couple of weeks ago for EverMed’s DPC efforts. They were brief, one more or less accurate and the other word-for-word the way we would have like the issues framed.

From Elizabeth Hayes of The Portland Business Journal comes the following:

A Vancouver-area company is launching a new model of delivering primary care services in the Portland area, one designed to give patients direct access, regardless of their insurance plan.

EverMed Direct Primary Care of Camas isn’t itself insurance, but layers on top of a patient’s existing plan. A member pays a set monthly fee and receives comprehensive primary care services.

While most Director Primary Care companies employ doctors directly, EverMed is seeking established, independent primary care clinics. About 30 clinicians at eight clinics have signed up in Clark County and about half a dozen clinics are in various stages of the contracting process in Portland, said Seth Sjostrom, director of business development.

EverMed charges patients $45 to $85 a month for unlimited access to a primary care doctor for wellness exams, basic diagnostics and other non-emergency needs.

“The principle of DPC is that you don’t need insurance for day-to-day care. It’s for catastrophic illnesses,” said Dr. Dino Ramzi, EverMed’s chief medical officer and a physician with Lacamas Medical Group in Camas.

Members can enroll directly, though many have come through self-funded employer medical plans. Ultimately, EverMed would like to partner with an insurer who would devise a plan that doesn’t include primary care, Ramzi said.
So far, EverMed has signed up 75 members and five corporate clients. Sjostrom said the company is now promoting itself with insurance brokers in hopes of attracting more business during the 2015-16 enrollment season this fall.

More and more patients have gravitated to “bronze” plans, with high deductibles. Faced with copays or an unmet deductible, these patients may defer care, which ends up costing more in the long run when a patient ends up at an urgent care clinic or the ER. Highly effective primary care could save the health system a third of its costs, Ramzi said.

This upset Seth, as noted above, our Director of Business Development. It turns out I misrepresented our pricing structure, essentially because it has undergone several changes. My momoery is not what it used to be. In fact, as we prepare to enter the employer market more profoundly, there are signals we may have to make further changes. Pricing is an important component. We want to make sure providers get good value, but it is telling that employers are falling over themselves, given the price of assured primary care is remarkably low from tehir perspective.

The Direct Primary Care Journal did a perfect job representing our efforts. (Duh, it was a press release.)

Direct Primary Care clinics have been popping up all over the country, it was only a matter of time before the Portland marketplace became a part of the revolution in healthcare.

Born from the concierge clinic concept, Direct Primary Care (DPC) is the iteration for the masses. As one of EverMed DPC’s marketing tag lines states, DPC is “genuinely affordable health care”.

Direct Primary Care is a healthcare benefit option where members pay a set, low monthly fee to receive comprehensive primary care services. DPC is not itself insurance, it is an affordable option to access primary care needs for the member and their family.

EverMed DPC is a new spin on the growing Direct Primary Care marketplace. While most DPC offerings are staff model enterprises (the physicians work for the DPC business), EverMed DPC seeks out independent primary care clinics that are already established in the communities they serve.

“One of our key objectives as EverMed DPC is preserving the viability of the independent primary care practice. We see Direct Primary Care as a way for clinics to not only survive, but thrive,” says founder and clinician Scott Jonason, PA-C.

EverMed DPC makes accepting direct primary care patients a turn-key proposition for clinics. “We handle nearly everything for clinics – marketing, contracting, payroll and bank withdrawals, enrollments – all the clinics we serve really have to do, is see their patients,” Director of Business Development, Seth Sjostrom states.

With their network in southwest Washington established, growing northward into Seattle and across the river into Oregon were natural next steps. “If anything, we were overwhelmed by the positive response we received. We quickly realized growing slowly was not an option,” Sjostrom says.

EverMed DPC’s plan? Having enough clinics spread throughout the Portland metro in time to have homes for primary care patients opting for DPC membership during the 2015-2016 healthcare enrollment season.

“Our second objective is to truly remove finances as a barrier to primary care,” Jonason explains, “Working with the healthcare broker community and employers, we provide an affordable way to provide quality care while at the same time, driving down costs.”

EverMed DPC aims to add value to employers and individuals by minimizing the number of urgent care and emergency room visits, thereby reducing the overall total healthcare spend. “When patients are concerned about paying copays or worried about unknown costs of seeking care, they tend to avoid seeking treatment until it is too late and then they end up in the ER. With DPC, if they have a concern or even unsure if they need to come in, they can call, visit or even use secure email or text depending on the clinic,” Jonason adds.

“We believe when physicians have genuine relationships with their patients, quality of care improves. Timely care that values the relationship and is focused on the whole patient means that doctors are in the position to respond quickly and guide the patient to the right diagnosis, coordination or medical management as efficiently as possible. The hallmark of quality primary care is taking care of the individual, not the visit,” Dr. Dino Ramzi, EverMed DPC’s Chief Medical Officer states.

With healthcare reform, many individuals and even businesses opted for plans with higher deductibles in order to secure lower premiums. Direct primary care serves those with high deductible plans to manage their day to day health, knowing their insurance is in place should they require more extensive care. The trend across the country is to increase individual out-of-pocket expenses. This trend is unlikely to reverse, but DPC makes those expenses more budget-friendly.

“We have had a number of members who purchased a Bronze plan through the exchange but signed up for DPC to take care of their more common needs, assuming they wouldn’t hit their deductible. We have had several taking part in Christian medical share programs that also saw DPC as a way to bridge the gap,” Sjostrom shares.

“Our most common membership, though, has been through employers with self-funded medical plans. They see DPC as a fixed variable in their annual medical cost plan while serving as a way to manage costly medical interactions by avoiding unnecessary Urgent Care an Emergency Department visits.”

How do businesses and individuals enroll in EverMed DPC? “Members can enroll directly through our website or 800 number, but we strongly encourage prospective members to learn more about DPC through their licensed insurance broker. Healthcare can be complex, we want to be part of a package that really meets our members’ needs,” Sjostrom says.

Direct primary care programs on their own do not meet the obligations required in the Affordable Care Act, though they can be a complement that makes sense for a lot of people and companies seeking for a solution that provides real healthcare value.

“No copays, no deductibles, the smallest administrative burden…with EverMed DPC, we return the focus of healthcare to the patient,” Sjostrom adds.

Meanwhile PanZoe‘s efforts to raise funds for a national giving effort for DPC is going strong as we apply again to the Community Foundation of Southwest Washington.

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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.