McAllen California

Dr. Gawande in an article published in The New Yorker in June

http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande

used the town of McAllen, Texas as a prototype of everything that is wrong in American medicine. Read the article and then the post below which will tell you how McAllen got to be the medical gold rush on the Rio Grande. You can substitute Stockton for McAllen and you will be close to te truth here



July 22, 2009
Return to McAllen: A Father-Son Interview
By IAN ROBERTSON KIBBE
By now, Dr. Atul Gawande's article on McAllen's high cost of health care has been widely read. The article spawned a number of responses and catalyzed a national discussion on cost controls and the business of medicine. It even made it's way into the President's address to the AMA.
Almost overnight, McAllen and the Rio Grande Valley were thrust into the national health care spotlight – the once sleepy border town became, not a beacon on a hill, but a balefire in the valley, representing much of what is wrong with the current medical culture.
But, McAllen wasn't always like something from an old Western, where doctors run wild and hospital CEO's compete like town bosses. I remember McAllen quite differently. I remember it, because as it turns out, it was where I was born.
It's also where my father, Dr. David Kibbe, practiced medicine from 1980 to 1990. In order to find out how McAllen earned the dubious reputation it now has, I sat down with my Dad, and asked him what he remembers about that little border town on the Rio Grande.

Ian Kibbe: So Dad, what was your first reaction to reading Atul Gawande's article?

David Kibbe: Well, Ian, it was sort of "oh-my-gosh, he nailed it." And, of course, a flood of memories, good and bad, came back to me about our time there. My medical career began there, you and your sisters were born there, small town 4th of July parades, etc. But I left after great disappointment and frustration.

IK: What were you doing in McAllen practicing medicine anyway?

DK: The National Health Service Corps sent me there to work in a clinic for migrant farm workers. The NHSC had provided me three years of medical school scholarship, and so I owed three years of service in an under-doctored area of the country. I speak Spanish, and so working as a family doctor in the Rio Grande Valley of Texas, which is the home of many of the country's Hispanic migrant farm workers, was a good fit. Hidalgo County, where McAllen is located, was the poorest county in the country, and there was a real physician shortage there in 1980.

I worked in a migrant farmworker clinic with ties to the United Farmworkers, Cesar Chavez' group, in McAllen. As a young physician from outside the Valley, and working in the one clinic in the county where the poor could receive medical care for free or almost free, I got to see an amazing diversity of medical problems that many physicians in this country never see, such as Dengue fever and leprosy. It was a great opportunity to be of service, in my opinion.

And then in 1982 we started a family practice in Mission, Texas, about 4 miles west of McAllen, where the physician shortage was even more critical. You were born in the little 67-bed hospital in Mission the next year.

IK: So, what did McAllen's health care system look like when you first got there?

DK: Well, it wasn't really a system, it was a community. And I would characterize the medical culture as primary care-oriented for at least the first half of the decade. Family physicians, internists, and pediatricians were in charge of things, ran the county medical societies, provided most of the medical care including hospitalizing sick patients and delivering babies. We had a couple of surgeons, and one cardiologist who was board certified.

But starting in the early 80's things began to change. In 1982 HCA opened Rio Grande Regional Hospital. Then in 85' Universal Health opened McAllen Medical Center. Both were large for-profit hospital chains, with new facilities, and both recruited literally dozens of sub-specialists where there had previously been only a handful. So within three years, there was a significant change towards subspecialty care, and that trend intensified over the next few years.

At first, the influx of technology and subspecialty care was welcome. We, the primary care docs, had more help locally, and didn't need to transfer patients to other parts of the state for subspecialty care or specialized surgery.

IK: Why the sudden interest in McAllen?

DK: Money, plain and simple. Most of the new subspecialists were guaranteed enormous incomes, by the hospitals. Since I was one of the first American-trained primary care physicians in the McAllen area, and I made an effort to reach out to retirees from the North, or "Snowbirds" as they were called, I guess I created sort of a beachhead as my practice grew. As a result, I was courted very heavily by the subspecialists for access to those retirees and the subspecialty care they could generate.

IK: So, in some ways it was like a medical "gold rush?"

DK: Exactly. What was initially exhilarating change and modernization turned into a "gold rush" atmosphere, as more and more subspecialty doctors came to town and competed to see who could make the most money, admit the most patients, or build the largest homes. McAllen went from having one cardiologist to having two competing cardiac surgery teams. They created a cascade of demand. The primary care docs slid to the bottom of the totem pole economically and socially. I now understand this as the disintermediation of primary care.

IK: Can you give me an example of what you're talking about?

DK: Sure. So, in 1983 I'd see a patient with intermittent chest pain, and that day refer him to the cardiologist for evaluation. He'd call me on the phone and say, "David, I've seen your patient Mr. So-and-so, examined him, listened to his heart, and have done a tread mill stress test. Everything seems ok, so I'm sending him back to you for further evaluation for his problems." Fine.

But by 1987, I'd make the referral and never hear another word. Running into the cardiologist in the hospital hallway or locker room, and asking what happened to my patient, I'd get this response: "Oh, well if I remember correctly I admitted him to the hospital and we did angiography, which was normal. But he was having a headache, so the neurologist ran some CT scans, and I asked the gastroenterologist to do endoscopy because there was a question of some GI problems. As I recall, everything was normal, but I still see him every month for his blood pressure."

So, an evaluation that used to cost a couple hundred dollars turned into many thousands of dollars worth of testing and procedures; and this happened day in day out, week after week, year after year.

Another issue was quality assurance. I was the hospital staff physician in charge of the quality assurance program at Rio Grande Regional Hospital. But we could never make any improvements. There was one cardiac surgeon who kept leaving several tiny needles inside his patients' chest cavity after heart surgery, and we couldn't figure out a way to cut that out. He was too important to the hospital, I guess, to offend. And he knew he could just blow us off. It was all about the money.

IK: What role did you see the large for-profit hospitals playing in this change?

DK: It seemed to me that the hospitals encouraged the newly arriving doctors' attitudes about making money. These were young doctors, for the most part, right out of training. The hospital would pay them large guaranteed incomes to get them to locate in McAllen, and pay the rents on their offices for a number of years, too. The hospitals were competing openly for procedures and tests, unlike in some towns where there are agreements to share high cost facilities, like heart surgery or cancer treatment centers. But in McAllen there was out-and-out financial war between the doctors on each of the hospital staffs.

IK: And you were right in the middle of this war?

A: Well, yeah! As I said, I was courted very heavily by the subspecialists for access to my patients, but at some point that dynamic changed from seeking my referrals to taking my patients.

IK: So why did you hang around for so long?

Well these changes didn't happen overnight. I was practicing medicine and taking care of patients. Also, think I didn't know any better. Eventually I got my business degree because I wanted to figure out what the hell was going on! So, I went to the University of Texas business school part-time during those last two years we were in McAllen, primarily to try to understand what was happening to health care. It was clear that one needed a business degree to understand medicine in McAllen, Texas. Also, at the time, getting an MBA seemed like a good idea because everyone was saying medicine was a business now.

IK: Who was saying that?

Many of the doctors and the hospitals, the journals and the literature.

IK: So when did you say "enough is enough?" What finally made you decide to leave McAllen?

DK: We left in 1990 to come to Chapel Hill, North Carolina. There were a number of reasons I wanted to leave the McAllen area, but the main reason professionally was that the medical culture had become so subspeciality dominated and oriented towards profiteering, that it simply was no longer rewarding to be in family practice there. I mean, in 1987 there were more MRIs in McAllen than there were in all of Canada! And most were owned by doctors or groups of physicians.

May I ask you a question?

IK: Sure.

DK: What was your best memory of living in the Rio Grande Valley during the first eight years of your life?

IK: Wow, that's tough. But I'd have to say I had the best times at those big cookout's out in the country. There was something really magical about running through the orange groves with my friends and the smell of ripening oranges mixed with the smell of charcoal, and Texas barbecue. It was a pretty care-free time for me. Oh yeah, and the fireworks. Eight year olds love fireworks.
Well, thanks Dad. This was fun.

DK: Love you, son.

Ian Kibbe is Associate Editor for The Health Care Blog. He is also a writer, actor, video producer and editor.
David C. Kibbe MD MBA is a Family Physician and Senior Advisor to the American Academy of Family Physicians who consults on health care professional and consumer technologies.

Putting patients first

Just read this

http://www.seefirstblog.com/2009/07/21/my-reaction-to-putting-patients-first/

A Time For Revolutions???

The Role of Clinicians in Health Reform
Source: New England Journal of Medicine
July 22 2009

William Beveridge, the economist whose 1942 report led to the founding of Britain's National Health Service (NHS), famously said that "a revolutionary moment in the world's history is a time for revolutions, not for patching."1 Given the combination of the global downturn and the time bomb that is health insurance costs, there is no denying that health care in the United States has reached such a moment. This matter is too important to be left to the politicians and policymakers; there is an urgent requirement for professional clinicians to step up and lead the debate.

President Barack Obama has brought health care reform to the forefront of people's minds, and it is now a matter of when, not whether, change will come. Repeatedly quoted statistics — on the numbers of uninsured Americans, for example, or the high, rapidly growing expenditures on health care — leave no room for ambiguity, and groups across the political landscape recognize that the U.S. health care system is unsustainable in its current form.

Every country in the developed world confronts a similar challenge right now: finding a way to create a well-resourced but sustainable system that provides care of the highest quality to those who need it. One would be hard-pressed to find credible opponents — regardless of their political stripe — to the goal of providing "universal health care." The disagreement arises when the discussion turns to the best way to achieve this aim. Each country needs to discover the formula that suits it best.

The outcome of health care reform in the United States will no doubt be very different from that in Britain, despite what some U.S. lobbying groups would have Americans believe. Britain's NHS lies at the opposite end of the spectrum from the current U.S. system, in terms of both its structure (a tax-funded public program as opposed to mainly private, employment-based insurance) and the problems it faces (historically, a lack of resources and slow uptake of new treatments as opposed to bulging costs), but in the late 1990s Britain had to confront reform on a scale as challenging as that being contemplated in the United States today.

In 1997, Britain had a new government, which had inherited a health care system that was chronically underfunded and suffering from a lack of capacity, with average waiting times of 18 months from referral to treatment. Funding for 1997 was £35 billion; for 2010 it is £110 billion, and waiting times are now as short as they've ever been — 10 years ago, patients waited approximately 18 months for treatment, and now they wait only a few weeks. Although both the causes of and responses to reform were very different from those in the United States today, the NHS's experience can provide some valuable lessons.

A key insight to be gained from the post-1997 NHS "revolution" is that it is important for clinicians to be involved in both informing and leading change. Successive attempts at top-down regulation and reform in Britain damaged clinicians' morale and bred distrust between them and politicians. Not having been central to the decision making, clinicians subsequently didn't trust the proposals or fully understand their purpose.

Last year saw the publication of the report High Quality Care for All, of which I, as a health minister, was lead author. Based on the findings of the Next Stage Review conducted by 2000 clinicians from all fields of care, it redefined the NHS, setting out a bold 10-year vision rooted in evidence of what matters to patients, the public, and NHS staff members. It established the mission of providing high-quality care — driven by clinical leadership, best evidence, and innovation — as the organizing principle of the service and has put the NHS firmly on the path toward systemic improvement in outcomes and efficiency.

Similarly, placing professional responsibility for health outcomes in the hands of clinicians, rather than bureaucrats or insurance companies with vested interests, must be the ambition of any new structure in the United States. Such an approach will lead to a health care system that has a democratic mandate and clinical leadership.

U.S. clinicians should bear three things in mind as they consider how to approach this debate. First, politicians must be made to recognize the role of clinical leaders in shaping a transformed but effective health care system. If clinicians can redefine the debate so that it focuses first and foremost on patients and health outcomes, that will provide a strong common purpose for efforts to tackle the challenges of funding structures and access to care.

Second, clinicians need to be involved in defining the link between funding and the care provided. It is for the patients at greatest risk that the U.S. system has the greatest difficulty providing access. The United States needs to find a model that best meets its needs while also being socially acceptable. Clinicians will have to find a brave voice if funding structures are to be reviewed in a way that puts quality of care before financial gain.

Finally, clinicians must educate both policymakers and the wider public about appropriate levels of care. Health care systems all suffer from a disproportionately heavy focus on the treatment of acute illness and injury — the type of medical work glamorized on television — which consumes by far the most resources. But primary care accounts for most of the health care that is delivered: nearly a billion visits are made to physicians' offices every year in the United States, but there are fewer than 40 million hospital stays. The current system of insurance and referrals can often lead to the unintended consequence of unnecessary referrals for the most expensive tests and treatments. Health problems related to lifestyle, such as obesity, smoking, and diabetes will be solved not by high-tech robotics and bigger hospitals but rather through access to family doctors, innovations in public health, and lessons from the emerging discipline of behavioral economics.

The best outcomes can be achieved only when the system itself is healthy and built on real partnerships between patients and clinicians. Britain's experiences to date, both good and bad, have proved this to be true. Building a health care system centered on clinical professionalism and responsibility is the only way to achieve such partnerships and to ensure that all patients are well served.

Beveridge's characterization of revolutionary moments echoes in our ears today as the NHS goes through a period of radical reform. And as the United States, for its part, does what it does best — summoning up its revolutionary spirit — clinicians should step up and shape the debate, not wait to be handed a possibly misguided reform as a fait accompli.

No potential conflict of interest relevant to this article was reported.


Source Information

From the Health Ministry, U.K. Department of Health, and Imperial College — both in London.

Who are the uninsured????

Kennedy : Universal Health

‘The Cause of My Life’

Inside the fight for universal health care.
Edward M. Kennedy
NEWSWEEK
From the magazine issue dated Jul 27, 2009

In 1964, I was flying with several companions to the Massachusetts Democratic Convention when our small plane crashed and burned short of the runway. My friend and colleague in the Senate, Birch Bayh, risked his life to pull me from the wreckage. Our pilot, Edwin Zimny, and my administrative assistant, Ed Moss, didn't survive. With crushed vertebrae, broken ribs, and a collapsed lung, I spent months in New England Baptist Hospital in Boston. To prevent paralysis, I was strapped into a special bed that immobilizes a patient between two canvas slings. Nurses would regularly turn me over so my lungs didn't fill with fluid. I knew the care was expensive, but I didn't have to worry about that. I needed the care and I got it.

Now I face another medical challenge. Last year, I was diagnosed with a malignant brain tumor. Surgeons at Duke University Medical Center removed part of the tumor, and I had proton-beam radiation at Massachusetts General Hospital. I've undergone many rounds of chemotherapy and continue to receive treatment. Again, I have enjoyed the best medical care money (and a good insurance policy) can buy.

But quality care shouldn't depend on your financial resources, or the type of job you have, or the medical condition you face. Every American should be able to get the same treatment that U.S. senators are entitled to. Really ? who pays for it?

This is the cause of my life. It is a key reason that I defied my illness last summer to speak at the Democratic convention in Denver—to support Barack Obama, but also to make sure, as I said, "that we will break the old gridlock and guarantee that every American…will have decent, quality health care as a fundamental right and not just a privilege." For four decades I have carried this cause—from the floor of the United States Senate to every part of this country. It has never been merely a question of policy; it goes to the heart of my belief in a just society. Now the issue has more meaning for me—and more urgency—than ever before. But it's always been deeply personal, because the importance of health care has been a recurrent lesson throughout most of my 77 years.

Nothing I'm enduring now can compare to hearing that my children were seriously ill. In 1973, when I was first fighting in the Senate for universal coverage, we learned that my 12-year-old son Teddy had bone cancer. He had to have his right leg amputated above the knee. Even then, the pathology report showed that some of the cancer cells were very aggressive. There were only a few long-shot options to stop it from spreading further. I decided his best chance for survival was a clinical trial involving massive doses of chemotherapy. Every three weeks, at Children's Hospital Boston, he had to lie still for six hours while the fluid dripped into his arm. I remember watching and praying for him, all the while knowing how sick he would be for days afterward.

During those many hours at the hospital, I came to know other parents whose children had been stricken with the same deadly disease. We all hoped that our child's life would be saved by this experimental treatment. Because we were part of a clinical trial, none of us paid for it. Then the trial was declared a success and terminated before some patients had completed their treatments. That meant families had to have insurance to cover the rest or pay for them out of pocket. Our family had the necessary resources as well as excellent insurance coverage. But other heartbroken parents pleaded with the doctors: What chance does my child have if I can only afford half of the prescribed treatments? Or two thirds? I've sold everything. I've mortgaged as much as possible. No parent should suffer that torment. Not in this country. Not in the richest country in the world.

That experience with Teddy made it clear to me, as never before, that health care must be affordable and available for every mother or father who hears a sick child cry in the night and worries about the deductibles and copays if they go to the doctor. But that was just one medical crisis. My family, like every other, has faced many—at every stage of life. I think of my parents and the medical care they needed after their strokes. I think of my son Patrick, who suffered serious asthma as a child and sometimes had to be rushed to the hospital for treatment. (For this reason, we had no dogs in the house when Patrick was young.) I think of my daughter, Kara, diagnosed with lung cancer in 2002. Few doctors were willing to try an operation. One did—and after that surgery and arduous rounds of chemotherapy and radiation, she's alive and healthy today. My family has had the care it needed. Other families have not, simply because they could not afford it.

I have seen letters and e-mails from many of these less fortunate Americans. In their pleas, there's always dignity, but too often desperation. "Our school is closing in June of 2010, which means that I will be losing my job and my health insurance," writes Mary Dunn, a 58-year-old schoolteacher in Eden, S.D. "I am a Type I diabetic, and I had heart bypass surgery in 2005. My husband is also a teacher [here], so we will both be losing insurance. I am exploring options and have been told that I cannot stay on our group policy or transfer to another policy after our jobs cease because of my medical condition. What am I to do after 39 years of teaching to acquire adequate health coverage?" Dunn also serves as mayor of Eden, for which she is paid $45 a month with no health benefits.

How will we, as a nation, answer her? I've heard countless such stories, including one from the family of Cassandra Wilson, a 14-year-old who once was a competitive ice skater. She's uninsured because she has petit mal seizures, often 200 times a day. Her parents have run up $30,000 on their credit cards. They've sold her skating equipment on eBay to pay for her care.

These two cases represent only those patients who lack coverage. We also need to find answers for the increasing number of Americans whose insurance costs too much, covers too little, and can be too easily revoked when they face the most serious illnesses.

Our response to these challenges will define our character as a country. But the challenges themselves—and the demands for reform—are not new. In 1912, when Theodore Roosevelt ran for a third term as president, the platform of his newly created Progressive Party called for national health insurance. Harry Truman proposed it again more than 30 years after Roosevelt was defeated. The plan was attacked, not for the last time, as "socialized medicine," and members of Truman's White House staff were branded "followers of the Moscow party line."

For the next generation, no one ventured to tread where T.R. and Truman fell short. But in the early 1960s, a new young president was determined to take a first step—to free the elderly from the threat of medical poverty. John Kennedy called Medicare "one of the most important measures I have advocated." He understood the pain of injury and illness: as a senator, he had almost died after surgery to repair a back injury sustained during World War II, an injury that would plague him all of his life. I was in college as he recuperated and learned to walk without crutches at my parents' winter home in Florida. I visited often, and we spent afternoons painting landscapes and seascapes. (It was a competition: at dinner after we finished, we would ask family members to decide whose painting was better.) I saw how the pain would periodically hit him as we were painting; he'd have to put down his brush for a while. And I saw, too, how hard he fought as president to pass Medicare. It was a battle he didn't have the opportunity to finish. But I was in the Senate to vote for the Medicare bill before Lyndon Johnson signed it into law—with Harry Truman at his side. In the Senate, I viewed Medicare as a great achievement, but only a beginning. In 1966, I visited the Columbia Point Neighborhood Health Center in Boston; it was a pilot project providing health services to low-income families in the two-floor office of an apartment building. I saw mothers in rocking chairs, tending their children in a warm and welcoming setting. They told me this was the first time they could get basic care without spending hours on public transportation and in hospital waiting rooms. I authored legislation, which passed a few months later, establishing the network of community health centers that are all around America today.

Some years later, I decided the time was right to renew the quest for universal and affordable coverage. When I first introduced the bill in 1970, I didn't expect an easy victory (although I never suspected that it would take this long). I eventually came to believe that we'd have to give up on the ideal of a government-run, single-payer system if we wanted to get universal care. Some of my allies called me a sellout because I was willing to compromise. Even so, we almost had a plan that President Richard Nixon was willing to sign in 1974—but that chance was lost as the Watergate storm swept Washington and the country, and swept Nixon out of the White House. I tried to negotiate an agreement with President Carter but became frustrated when he decided that he'd rather take a piecemeal approach. I ran against Carter, a sitting president from my own party, in large part because of this disagreement. Health reform became central to my 1980 presidential campaign: I argued then that the issue wasn't just coverage but also out-of-control costs that would ultimately break both family and federal budgets, and increasingly burden the national economy. I even predicted, optimistically, that the business community, largely opposed to reform, would come around to supporting it.

That didn't happen as soon as I thought it would. When Bill Clinton returned to the issue in the first years of his presidency, I fought the battle in Congress. We lost to a virtually united front of corporations, insurance companies, and other interest groups. The Clinton proposal never even came to a vote. But we didn't just walk away and do nothing—even though Republicans were again in control of Congress. We returned to a step-by-step approach. With Sen. Nancy Landon Kassebaum of Kansas, the daughter of the 1936 Republican presidential nominee, I crafted a law to make health insurance more portable for those who change or lose jobs. It didn't do enough to fully guarantee that, but we made progress. I worked with my friend Sen. Orrin Hatch of Utah, the Republican chair of our committee, to enact CHIP, the Children's Health Insurance Program; today it covers more than 7 million children from low-income families, although too many of them could soon lose coverage as impoverished state governments cut their contributions.

Incremental measures won't suffice anymore. We need to succeed where Teddy Roosevelt and all others since have failed. The conditions now are better than ever. In Barack Obama, we have a president who's announced that he's determined to sign a bill into law this fall. And much of the business community, which has suffered the economic cost of inaction, is helping to shape change, not lobbying against it. I know this because I've spent the past year, along with my staff, negotiating with business leaders, hospital administrators, and doctors. As soon as I left the hospital last summer, I was on the phone, and I've kept at it. Since the inauguration, the administration has been deeply involved in the process. So have my Senate colleagues—in particular Max Baucus, the chair of the Finance Committee, and my friend and partner in this mission, Chris Dodd. Even those most ardently opposed to reform in the past have been willing to make constructive gestures now.

To help finance a bill, the pharmaceutical industry has agreed to lower prices for seniors, not only saving them money for prescriptions but also saving the government tens of billions in Medicare payments over the next decade. Senator Baucus has agreed with hospitals on more than $100 billion in savings. We're working with Republicans to make this a bipartisan effort. Everyone won't be satisfied—and no one will get everything they want. But we need to come together, just as we've done in other great struggles—in World War II and the Cold War, in passing the great civil-rights laws of the 1960s, and in daring to send a man to the moon. If we don't get every provision right, we can adjust and improve the program next year or in the years to come. What we can't afford is to wait another generation.

I long ago learned that you have to be a realist as you pursue your ideals. But whatever the compromises, there are several elements that are essential to any health-reform plan worthy of the name.

First, we have to cover the uninsured. When President Clinton proposed his plan, 33 million Americans had no health insurance. Today the official number has reached 47 million, but the economic crisis will certainly push the total higher. Unless we act now, within a few years, 55 million Americans could be left without coverage even as the economy recovers.

All Americans should be required to have insurance. For those who can't afford the premiums, we can provide subsidies. We'll make it illegal to deny coverage due to preexisting conditions. We'll also prohibit the practice of charging women higher premiums than men, and the elderly far higher premiums than anyone else. The bill drafted by the Senate health committee will let children be covered by their parents' policy until the age of 26, since first jobs after high school or college often don't offer health benefits.

To accomplish all of this, we have to cut the costs of health care. For families who've seen health-insurance premiums more than double—from an average of less than $6,000 a year to nearly $13,000 since 1999—one of the most controversial features of reform is one of the most vital. It's been called the "public plan." Despite what its detractors allege, it's not "socialism." It could take a number of different forms. Our bill favors a "community health-insurance option." In short, this means that the federal government would negotiate rates—in keeping with local economic conditions—for a plan that would be offered alongside private insurance options. This will foster competition in pricing and services. It will be a safety net, giving Americans a place to go when they can't find or afford private insurance, and it's critical to holding costs down for everyone.

We also need to move from a system that rewards doctors for the sheer volume of tests and treatments they prescribe to one that rewards quality and positive outcomes. For example, in Medicare today, 18 percent of patients discharged from a hospital are readmitted within 30 days—at a cost of more than $15 billion in 2005. Most of these readmissions are unnecessary, but we don't reward hospitals and doctors for preventing them. By changing that, we'll save billions of dollars while improving the quality of care for patients.

Social justice is often the best economics. We can help disabled Americans who want to live in their homes instead of a nursing home. Simple things can make all the difference, like having the money to install handrails or have someone stop by and help every day. It's more humane and less costly—for the government and for families—than paying for institutionalized care. That's why we should give all Americans a tax deduction to set aside a small portion of their earnings each month to provide for long-term care.

Another cardinal principle of reform: we have to make certain that people can keep the coverage they already have. Millions of employers already provide health insurance for their employees. We shouldn't do anything to disturb this. On the contrary, we need to mandate employer responsibility: except for small businesses with fewer than 25 employees, every company should have to cover its workers or pay into a system that will.

We need to prevent disease and not just cure it. (Today 80 percent of health spending pays for care for the 20 percent of Americans with chronic illnesses like diabetes, cancer, or heart disease.) Too many people get to the doctor too seldom or too late—or know too little about how to stay healthy. No one knows better than I do that when it comes to advanced, highly specialized treatments, America can boast the best health care in the world—at least for those who can afford it. But we still have to modernize a system that doesn't always provide the basics.

I've heard the critics complain about the costs of change. I'm confident that at the end of the process, the change will be paid for—fairly, responsibly, and without adding to the federal deficit. It doesn't make sense to negotiate in the pages of NEWSWEEK, but I will say that I'm open to many options, including a surtax on the wealthy, as long as it meets the principle laid down by President Obama: that there will be no tax increases on anyone making less than $250,000 a year. What I haven't heard the critics discuss is the cost of inaction. If we don't reform the system, if we leave things as they are, health-care inflation will cost far more over the next decade than health-care reform. We will pay far more for far less—with millions more Americans uninsured or underinsured.

This would threaten not just the health of Americans but also the strength of the American economy. Health-care spending already accounts for 17 percent of our entire domestic product. In other advanced nations, where the figure is around 10 percent, everyone has insurance and health outcomes that are equal or better than ours. This disparity undermines our ability to compete and succeed in the global economy. General Motors spends more per vehicle on health care than on steel.

We will bring health-care reform to the Senate and House floors soon, and there will be a vote. A century-long struggle will reach its climax. We're almost there. In the meantime, I will continue what I've been doing—making calls, urging progress. I've had dinner twice recently at my home in Hyannis Port with Senator Dodd, and when President Obama called me during his Rome trip after meeting with the Pope, much of our discussion was about health care. I believe the bill will pass, and we will end the disgrace of America as the only major industrialized nation in the world that doesn't guarantee health care for all of its people.

At another Democratic convention, in arguing for this cause, I spoke of the insurance coverage senators and members of Congress provide for themselves. That was 1980. In the last year, I've often relied on that Congressional insurance. My wife, Vicki, and I have worried about many things, but not whether we could afford my care and treatment. Each time I've made a phone call or held a meeting about the health bill—or even when I've had the opportunity to get out for a sail along the Massachusetts coast—I've thought in an even more powerful way than before about what this will mean to others. And I am resolved to see to it this year that we create a system to ensure that someday, when there is a cure for the disease I now have, no American who needs it will be denied it.

This story was written with Robert Shrum, Senator Kennedy’s friend and longtime speechwriter.

Why Did all the Doctors Go???

The Uncertain Future of Primary Medical Care
David Mechanic, PhD
Annals Of Internal Medicine
7 July 2009 | Volume 151 Issue 1 | Pages 66-67

The United States needs a strong primary medical care capacity as we engage the challenges of health care reform, expand insurance coverage, and constrain medical costs without sacrificing quality. Research over decades has repeatedly demonstrated that primary care services that provide continuing access to care are associated with superior population health outcomes . Nonetheless, the future of U.S. primary care is uncertain, many clinicians report high levels of frustration and dissatisfaction, and careers in primary care are increasingly unattractive to new medical graduates.
Linzer and colleagues studied 422 family practitioners and general internists in 119 ambulatory clinics. They report high levels of unhappiness about time pressure and practice pace, little sense of control over work conditions, and deficient organizational culture. Other data indicate substantial deficiencies on measures of quality outcomes and neglect of care processes.

Three themes persist across time, place, and practice arrangements . First, primary care physicians persistently report time pressures and insufficient time for patients, but practice disorganization substantially limits their ability to cope . Second, primary care physicians dislike intrusions on their clinical autonomy by managers and are particularly dissatisfied when their remuneration depends on successfully constraining the clinical choices they can offer their patients . Finally, physicians want remuneration to meet their expectations and reflect the intensity of their efforts . Each of these themes will be important as we consider different ways of restructuring medical care and improving standards of care and cost-effectiveness.

Average encounter time has increased substantially over the decades (8). The data do not support the claim that primary care visits are shorter , with an average time of around 15 minutes . However, the perception of time pressure is realistic because more competing treatments have become available; more preventive interventions are demanded; patients have become better informed, more assertive, and more insistent on explanations; and demands for documentation and other bureaucratic requirements have increased. Direct-to-consumer advertising has also increased physician stress because patients ask for advertised drugs, which requires physicians to either spend more time on explanation to divert demands or to prescribe drugs unnecessarily .

Studies consistently find that primary care physicians are more satisfied when they have fewer patients and can maintain a less hurried practice pace, but physicians who adopt this practice style usually don't achieve their target income. Some find lower income an acceptable trade-off for a more enjoyable practice style, whereas others seek to have their cake and eat it too by organizing concierge practices that achieve higher incomes through enrollment fees. Such personal solutions exacerbate health care disparities and increase the challenge of achieving universal access.

Maintaining the fast pace needed to achieve target incomes contributes to physician dissatisfaction and difficulties in providing comprehensive, integrated care. Cost constraints make increased remuneration for primary care unlikely unless income is redistributed from specialists to generalists, which the advantaged class understandably resists. Nevertheless, many clinicians, managers, and policy makers are becoming more interested in moving away from payment for each billable unit and toward coverage of episodes of illness or partial capitation that combines a base payment for managing care for each enrolled patient with fee-for-service and other performance and productivity incentives. Whether these changes will reduce income disparities between segments of the profession is ultimately a political issue.

Linzer and colleagues' findings indicate that, whatever the conditions of remuneration, reduction of chaos in the practice environment and development of more supportive organizational cultures are required to make primary care careers more manageable and satisfactory. Physicians need to be provided with the technical and professional team support that facilitates high-quality care and provides a greater sense of control over one's work.

When quality initiatives, such as evidence-based decision making, implementation of clinical effectiveness research, pay for performance, and electronic health records, are taken in isolation, some perceive them as exacerbating workload and reducing discretionary judgment. But taken together and integrated into effective practice arrangements, they facilitate higher-quality care and greater physician control. Evidence-based standards are essential guides, but health systems must protect physician discretion in decision making when patient circumstances justify it, as in Kaiser Permanente group practices . The key is not rigid adherence, but accountability to colleagues for the reasonableness of one's decisions.

Because physicians have different preferences for how they practice, different models will coexist. Kaiser Permanente and the U.S. Department of Veterans Affairs provide successful models for reorganization of patient care functions. In these systems, primary care physicians have a more defined role, working in teams with hospitalists, nurse practitioners, and other relevant personnel. Care coordination within the team takes time, but sharing workload and responsibilities facilitates high-quality care and often leads to increased physician satisfaction. The patient-centered medical home is popular in part because the conceptual model includes a management fee for the coordination and integration of care, an incentive that is so often lacking. Although many advocate the patient-centered medical home model, its implementation, effectiveness, and capacity to control costs remain uncertain .

Most primary care practices are small and will probably remain so for the foreseeable future . Some primary care physicians, using electronic health records and new forms of communication with patients (including e-mail and group visits), practice to their satisfaction in small or even solitary practices . Many more primary care physicians are likely to join with nurse practitioners and physician assistants to seek ways to manage workload more comfortably.

Electronic health records and an interoperable information technology framework are critical for implementing the coordination, integration, and continuity central to primary care. Although the start-up effort and learning curve may initially slow practice pace and increase workload, electronic health records help physicians manage care and workload effectively and contribute to professional satisfaction. They make possible virtual integration, even in small practices, and address many of the strains of contemporary care, including monitoring and coordinating (19), avoiding duplication and error, and facilitating transparency and accountability. Effective information technology is a core feature that helps build a constructive practice culture and a renewal of medical professionalism .

The future of primary care remains uncertain, and much depends on payment policies and incentives for developing workable frameworks for team efforts and professional responsibility. Primary care as an indispensable set of functions will persist in some form, because most patients want a primary care physician. The challenge is to organize 1-on-1 care as part of an integrated system that serves the needs of both patients and physicians, enhances quality, and keeps costs within reason.


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David Mechanic, PhD, Institute for Health, Health Care Policy and Aging Research, Rutgers, The State University of New Jersey, 30 College Avenue, New Brunswick, NJ 08901; e-mail, mechanic@rci.rutgers.edu.

Healthcare Fever

Sonia Sotamayor will be he soap opera du jour this week and will displace he health care debate.
This "time out" should allow up to reconsider some of the isssues and proposed solutions.
In a series of Op Ed presentations in the New York Times this morning the debate concerning some of the issues is played out.
Taxes for health care benefits is a contentious topic. Liberals believe that it is a God given salary increase that must be given by an employer as long as it is not taxed to the employee.
The origins of our health insurance system exist from World War II wage price controls. Unions unable to get wage increases accepted health benefits in lieu of them.
The conservative view point allows for taxation of these benefits, arguing that the individual taxed would then become a more discrimminating purchaser of health care and more appropriate in the use of expensive interventions.
Both points are presented below

July 12, 2009
Op-Ed Contributor
Don't Tax Health Benefits.
By ROGER HICKEY

AMERICANS are demanding health care reform that guarantees them quality, affordable insurance, reduces the burden of health costs on employers and individuals and provides backup coverage through a public health insurance option.

But the suggestion that we pay for these needed reforms by taxing the health benefits that millions of us get through our employers is very unpopular — Americans fear that it could undo the one part of our health care system that now works (sort of). And we worry about new tax burdens on people who have worked hard to get and keep decent health coverage. If Democrats want to avoid a serious reaction against their important reform efforts, they should heed these concerns.

America’s health insurance system has evolved over the decades since World War II, when companies began offering health insurance — untaxed as income by government policy. Today, around 160 million of us get our health insurance from employers. And in these difficult times, millions of workers have repeatedly given up wage increases in order to keep their health benefits.
John McCain, when he was running for president last year, proposed taxing all employer-provided health benefits. Were we to do that, some 20 million Americans would lose employment-based health insurance, according to some estimates. And many employers would stop contributing to group health insurance — forcing their workers into the more expensive individual insurance market.

While many health experts acknowledge that taxing all benefits would cause chaos, some share the conservative view that a lot of people are getting “too much” insurance coverage from their employers and are pushing to get new revenues by taxing plans that are more expensive than average. But several recent studies find that it is almost impossible to design a tax that doesn’t overburden workers in firms with older or low-income employees or companies in regions with higher-than-average insurance premiums.

The Communications Workers of America looked at one proposal (to tax all employer-paid health benefits worth over $13,000 for a family) and found a typical member of its union in Pennsylvania with a working spouse and one child would pay $3,165 more in taxes in the first year, and $27,949 more over eight years. The issue is heating up. The Senate majority leader, Harry Reid, has told colleagues that they should not tax health benefits. But the debate continues.

It is dangerous for politicians to focus the government’s taxing power on the hard-won benefits of middle-class families. Fair and progressive income and wealth taxes are a better way to pay for health reform — and keep workers feeling as though they have a positive stake in achieving good health care for all.

Roger Hickey is a co-director of the Institute for America’s Future and a member of the steering committee of the Health Care for America Now coalition.





July 12, 2009
Op-Ed Contributor
A Loophole Worth Closing
By JONATHAN GRUBER

POLLS show most Americans are in favor of universal health care. But how will we pay for it? There is an obvious place to look for the money: the tax exclusion for employer-sponsored insurance.

When my employer pays me in cash wages, I am taxed. Not taxed is the $10,000 per year that my employer spends on my health insurance, and this leaves me with an effective tax break of about $4,000. Over all, this break costs the federal government $250 billion per year in forgone revenue.
This is more than we would need to cover every American who now lacks health insurance. Ending the exclusion would provide a progressive source of financing for universal coverage, since higher-income taxpayers would contribute most of the revenues. It would stop discrimination against those who can’t obtain insurance through their employers and therefore have to pay with after-tax dollars. And it would end a policy of providing a bigger tax break the more one spends on health insurance, which drives overspending on medical care.

Some worry that without this “tax bribe,” employers would no longer offer health insurance, and sicker and older people would not be treated as fairly on their own as they are in employer groups. This is not an issue for medium and large employers, which have continued to offer health insurance as the value of this tax bribe has gone up and down through the years. Small employers might reduce coverage, but this blow would be softened if the policy helped finance a universal plan in which all Americans would get group rates.
Removing the exclusion need not mean an across-the-board tax increase. We might consider merely capping the dollar amount of employer-sponsored health insurance that is excluded from income taxation. Individuals would include in their income taxes the amount of premiums over and above, say, the average cost of employer-sponsored insurance. A typical middle-class employee with premiums of $1,000 a year higher than the average would pay only about $150 in extra taxes, yet such a policy would raise $500 billion in federal revenues over the next decade. This policy would provide strong incentives to purchase insurance more efficiently, since the highest-cost plans would be taxed but lower-cost plans would not. To ensure that the cap was not unfair to employees with relatively high insurance costs, employers could be allowed to compute an adjustment in the cap based on their location or their workers’ ages.

Closing this tax loophole would fix a fundamental flaw in our health care system. Even just capping it would provide the revenues to take us much of the way to universal coverage, without raising taxes on those who purchase average cost insurance.

Jonathan Gruber is a professor of economics at the Massachusetts Institute of Technology.

Medical malpractice is a topic that rapidly arouses physician passions. Most find that such actions are frivolous and the cause of excessive testing breeding a cover your ass culture.
The articles below both written by lawyers argue that medical malpractice has in fact had salutory benefits.
Mr. Baker argues that some of the safety practices adopted in medical institutions are in fact fall outs from a malpractice explosion.
Michelle Mello was one of the authors of the original Harvard Liability Study which purported that malpractice was more prevalent that liability action and injuries due to medical error more prevalent than believed.
Thoufh she does not suggest a cap on payments she does suggest defense by the practice of evidence based medicine. Mr. Baker also supports this though less vigorously.
The sixty four million dollar question who creates the evidence? After all evidence is based on the opinions of experts and every palintiff and defense malpractice lawyer knows such experts are not exactly an endangered species



July 12, 2009
Op-Ed Contributor
Liability = Responsibility
By TOM BAKER

OUR medical liability system needs reform. But anyone who thinks that limiting liability would reduce health care costs is fooling himself. Preventable medical injuries, not patient compensation, are what ring up extra costs for additional treatment. This means taxpayers, employers and everyone else who buys health insurance — all of us — have a big stake in patient safety.

Eighty percent of malpractice claims involve significant disability or death, a 2006 analysis of medical malpractice claims conducted by the Harvard School of Public Health shows, and the amount of compensation patients receive strongly depends on the merits of their claims. Most people injured by medical malpractice do not bring legal claims, earlier studies by the same researchers have found.

On the other hand, medical liability has improved patient safety — by leading hospitals to hire risk managers, for example, and spurring anesthesiologists to improve their safety standards and practices. Even medical societies’ efforts to attack the liability system have helped, by inspiring the research that has documented the surprising extent of preventable injuries in hospitals. That research helped start the patient safety movement.

When it comes to rising medical costs, liability is a symptom, not the disease. Getting rid of liability might save money for hospitals and some high-risk specialists, but it would cost society more by taking away one of the few hard-wired patient safety incentives.

Besides, there’s a better answer for doctors worried about high malpractice insurance premiums.

Critics point to defensive medicine as the hidden burden that liability imposes on health care. Yet research shows that while the fear of liability changes doctors’ behavior, that isn’t necessarily a burden. Some defensive medicine is, like defensive driving, good practice. Too often, we can’t distinguish between treatments that are necessary and those that are wasteful. Better research on what works and what doesn’t — evidence-based medicine — will help. And it will address the more general challenge of avoiding costly but unnecessary care.

Just as we need evidence-based medicine, we also need evidence-based medical liability reform. The research shows, overwhelmingly, that the real problem is too much malpractice, not too many malpractice lawsuits. So medical providers should be required to disclose injuries, provide quicker compensation to deserving patients and — here’s the answer for doctors worried about their premiums — shift the responsibility for buying malpractice insurance to hospitals and other large medical institutions. Evidence-based liability reform would give these institutions the incentive they need to cut back on the most wasteful aspect of American health care: preventable medical injuries.

Tom Baker, a professor at the University of Pennsylvania Law School, is the author of “The Medical Malpractice Myth.”





July 12, 2009
Op-Ed Contributors
The Cap Doesn’t Fit
By MICHELLE MELLO and AMITABH CHANDRA

DOCTORS are battered by the medical malpractice system. They complain, with reason, about unpredictable jury awards, escalating insurance premiums, the emotional toll of litigation and the cost to their reputations of being labeled “negligent” because of outcomes beyond their control.

Patients, too, often feel victimized by the system, enduring an average wait of five years for compensation for their injuries, and suffering the same emotional exhaustion from the drawn-out legal battle. The public gets stuck with a large part of the bill. When doctors practice “defensive medicine” to minimize their legal risk, we all pay for it.

Doctors tend to believe capping damages on malpractice awards would solve their troubles. But the best evidence shows that although caps modestly constrain the growth of insurance premiums, they don’t reduce the number of claims or address any of the fundamental pathologies of the system.
Two kinds of reforms are especially promising. First, in areas where we have reliable scientific evidence about what constitutes optimal clinical care, we should enable doctors to defend themselves against malpractice claims by simply showing that they adhered to evidence-based practice guidelines. An emergency room doctor, for example, could invoke well-accepted guidelines to explain his decision to refuse to order a stress test for a patient with chest pain that appeared not to be due to coronary disease.

This would address doctors’ complaints that malpractice suits often succeed even when care was not negligent, and also reduce incentives to practice defensive medicine and encourage doctors to adopt evidence-based practices.

Second, certain medical injuries should be pulled out of the court system and be handled by an alternative process in which the patient needn’t prove negligence. Severe birth injuries are a good place to start, for they can occur even with exceptional care. We should route these claims into a birth injury fund administered by the Department of Health and Human Services or a state-level counterpart, which would assign fair compensation on a no-fault basis.

Florida and Virginia have operated birth injury funds for nearly a quarter-century, and though not perfect, they have done a commendable job of balancing the needs of health care providers and patients. Doctors can buy into the program, avoiding lawsuits for severe neurological birth injuries, for under $6,000 per year (hospitals for about $50 per birth).

Our proposal would not do away with that hobgoblin of the malpractice system, the negligence standard, but it would curb its worst mischief.

Michelle Mello is a professor of public health and Amitabh Chandra is a professor of public policy at Harvard.


The third debate is one over Medicare costs. I found his one especially interesting.
Background:Mr. Obama has exerted his "regulatory authority" to allow the Medicare Payment Commission (MedPAC) to dictate payment policy rather than suggest it and leave its enactment to the regulatory whims of a fractitious Congress.
Nancy Kane is a member of the MedPAC and she publically argues that Medicare payments to hospitals not be cut. She believes that such cost constraints would result in higher out patient costs, an area that is rising far more rapidly than the costs of hospitals.
Interestingly, she argues that a solution is a bundling of payments for hospitals and physicians for episodes of care. There is some validity to her arguments. Though hospital costs are largely opaque to patients and physicians, the latter are responsible for generating them. The most expensive medical instrument is the physician's pen and the illegibility of the product makes an understanding of costs difficult.
It would be interesting to determine who will control the purse strings the physician or the hospital.
Paul Ginsburg a noted health economist argues that cutting hospital costs is necessary. He buttresses his arguments with references to high quality hospitals which have lower costs than those with higher costs and worse outcomes.
As the debate proceeds August will be a warm month in Washington.



July 12, 2009
Op-Ed Contributor
Keep Hospitals Whole
By NANCY KANE

ONE way that the Obama administration proposes to pay for universal coverage is by cutting Medicare payments to hospitals. True, at 35 percent of 2007 Medicare spending, hospitals represent the largest provider group, but they are not necessarily the most rational target for draconian payment cuts. Cutting payments to specific provider types is not the answer. When payments go down in one area, they end up increasing elsewhere. For instance, Medicare has more constraints for inpatient payments than for outpatient, home health care or skilled nursing care.

As a result, per beneficiary inpatient costs grew only 18 percent from 2002 to 2007, while outpatient costs increased 47 percent and skilled nursing and home health costs each rose more than 50 percent. These differences partly reflect the trend of hospitals discharging Medicare patients “quicker and sicker” so that they go from a tightly controlled inpatient payment system to a less constrained one. Another problem is that the more Medicare restricts payments to hospitals, the more hospitals ask of their privately insured patients.
Real, sustainable containment of medical costs will require an approach in which one government agency at the state or federal level sets uniform rates for all payers, public and private. Also, units of payment like doctor visits and lab tests need to be packaged into a single amount that covers all services related to that spell of illness, so that constraints on one part of the system do not create explosive cost growth in another. An all-payer feature would limit the ability of providers to raise private sector rates to make up for public sector constraints on rates. An integrated payment unit across all providers involved with treating an illness or medical condition would also encourage better coordination of care for patients with multiple chronic diseases.

Integrated payment units might start as bundled payments for services by all providers delivered during a hospitalization and a post-acute stay. Such payment units would encourage individual provider types like hospitals, skilled nursing facilities and primary-care doctors to come together in “accountable care organizations” that take responsibility for the cost and quality of all medical services.
The Medicare program’s long-term viability, as well as hopes for universal coverage, rest on our ability to get payment reform right.

Nancy Kane is a professor of management at the Harvard School of Public Health and a commissioner on the Medicare Payment Advisory Commission.



July 12, 2009
Op-Ed Contributor
Cut Medicare With a Scalpel
By PAUL B. GINSBURG

THE deal struck by the Obama administration and the hospital industry to reduce the growth of annual Medicare payment increases by about $100 billion over 10 years deserves scrutiny. In the weeks before the deal, the hospital industry predictably screamed foul at proposals to rein in the growth of those payments, pointing out that 58 percent of hospitals lost money treating Medicare patients in 2007.

But what about the 42 percent of hospitals that didn’t lose money? Is the problem that Medicare is a stingy payer? Or that too many hospitals have grown cavalier about controlling costs and have the market power to demand higher payment rates from private insurers to stay in the black regardless of Medicare rates?
A report in March by the Medicare Payment Advisory Commission makes a good case for the latter, suggesting there is room to trim the fat from Medicare payments without hitting bone in many hospitals.

According to the commission, high payments by private insurers — which exceeded hospitals’ actual costs by 32 percent in 2007 — resulted in overall hospital profit/surplus margins of 6 percent in 2007, the highest since 1997. The commission points to hospital consolidation and consumer and employer pressure on insurers to offer a broad choice of hospitals as tilting the balance of power toward hospitals in price negotiations.

But not all hospitals can increase fees for private insurers, especially not hospitals that treat a relatively large number of Medicaid patients. Not surprisingly, many of these hospitals did a much better job of holding their costs down.

The commission found that nonprofit hospitals facing the least financial pressure, those with high non-Medicare profits, spent more per unit of service. Nonprofit hospitals facing the most financial pressure, those with little income outside Medicare, controlled their costs better.

Worried that financial pressures might lead to lower quality of care, the Medicare commission also examined how hospitals that did a good job of controlling costs compared on measures like mortality rates and readmissions. These hospitals typically had higher quality and lower costs, and will likely be the ones hit hardest by across-the board reductions.
The recent deal between Mr. Obama and the hospital industry can hardly be called “health reform.” What is clear, however, is that hospital market power, left unchecked, will pose a formidable obstacle to the president’s promise to make health care more affordable.

Paul B. Ginburg is the president of the Center for Studying Health System Change, a policy research organization

Primary Care (Physician)???????

The ACP Advocate Blog by Bob Doherty

Are doctors and non-physicians speaking the same language when they define primary care?
I know I am showing my age, but the White House roundtable on primary care that ACP President-elect, Fred Ralston, and I attended last week reminded me of the "What's my line?" quiz show from my childhood. The show featured a contestant in an unusual occupation that was kept secret from a panel of celebrities. Each of the celebrities would try to guess the contestant's occupation, by asking "yes or no" questions that the contestant was required to answer truthfully.

The White House's primary care roundtable included community pharmacists, nurse-midwives, nurse-practitioners, physician assistants, psychologists, an oral hygienist, and two physicians, Dr. Ralston and a pediatrician working in a community health center. Each described themselves as primary care providers. But had they been subjected to "What's my line?" style questioning, I think it would be become evident that their lines (roles) were very different from each other.

The optometrist said that he was the "primary care provider" for patients with eye disease. The community pharmacists said they are the first contact for patients filling their prescriptions and uniquely qualified to provide medication management. The psychologist said she provided primary care mental health services to children and adolescents. The nurse-midwives said they were primary care providers for many women, not only during childbirth but throughout their lives. The PAs said that they were primary care clinicians in a physician-led team. The nurse-practitioners said that they were primary care providers for patients of all ages and conditions, and in some communities, they were the only primary care providers. The oral hygienist said she provided primary care for the mouth! Dr. Ralston described his role as a primary care (general) internist caring for a patient population, principally made up of elderly patients with multiple chronic diseases.

As the conversation continued, it struck me that the language that each of the non-physician professions used to describe primary care was quite different. The pharmacists and optometrists placed the emphasis on being "first contact" providers and the specialized skill they can bring to those contacts. The physician assistants made it clear that they believe that they play an increasingly important role in primary care, but not outside of a physician-led team. The psychologist had a regular relationship with her patients, but on mental health issues, not the entire range of her patient's health care needs. Only the NPs and nurse-midwives stated that they provide comprehensive primary and preventive care to their patients.

The Institute of Medicine describes primary care as "the provision of integrated, accessible healthservices by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community." [Emphasis added] ACP also notes that the hallmarks of primary care are "first contact care, continuity of care, comprehensive care, and coordinated care" of the whole person.

Many of the professions represented at the White House's primary care roundtable have important supporting roles within their areas of expertise, but they are not trained to address "a large majority of personal health care needs" or provide comprehensive and coordinated care of the whole person. That is, they simply are not primary care clinicians as the IOM (and ACP) would define it. Advanced practice nurses in some states might meet the IOM's definition, but their skills and training are complimentary--not equivalent--to those of primary care physicians, a topic that ACP discussed at length in our position paper on NPs and primary care. PAs meet the definition, but only when teamed with a physician.

I don't think there was anything wrong with the White House reaching out to different professions. Much of the discussion focused on common ground issues, like the need for coordinated teams that recognized the different skills that each profession can contribute, and for workforce policies to ensure we have enough professionals--physicians, nurses, PAs, and others--with the necessary skills.

But it is important that policymakers not lose sight that primary care is not something anyone can do. It requires an internist or other highly trained clinician who accepts personal responsibility and accountability for addressing a large majority of personal health care needs and developing a sustained partnership with patients, with an emphasis on coordinated, comprehensive and continuous care.

Today's question: Do you think primary care means the same thing to the different health professions?

Looking up North?

The posting below is proof that a public funded health care entity can exist and be complemented by private enterprise

The Changing Face of Canadian Health Care

By Evan Falchuk

Many Americans look to Canada, as an example of a government-run health care system that works.

But is that really what it is?

Health care in Canada is funded mostly publicly, but is provided mostly privately. That is, most care is delivered by privately run hospitals and medical clinics, with fees paid for by the various provincial governments.

Americans often call this system “single payer,” but it’s really not true. There are many other payers.

For example, if you’re injured on the job, your care is paid by a workers compensation insurance plan funded by employer premiums. Millions of Canadians also have supplementary health insurance policies, typically called “extended health care” coverage, which cover things not paid for by the government, like prescription drugs and other medical services. There is also a growing market for full medical insurance plans, and critical illness plans to provide cash to offset the out of pocket burdens of medical cost. As much as 30% of Canadian health care expenses are funded through these non-government payers.

However paid for, supply (and funding) for health care has not been able to keep up with increasing demand. The result has been well-documented: long waits for health care services. Waiting is a normal part of the Canadian health care experience, with provincial governments publishing information on wait times and working to fix them. The Canadian Supreme Court admonished the provincial governments in 2005, saying “access to a wait list is not access to health care.”

And so an interesting dynamic has emerged.

Canadians are justifiably proud of their extraordinary health care system, and care deeply about preserving its core principles. But they also care deeply about looking after each other, and are as creative and innovative as any people on the planet. As wait times have grown, so has a burgeoning private market.

Hospitals running diagnostic imaging equipment like MRIs are only paid by the government to run during certain hours of the day. So creative hospitals decided to run the same machines during the overnight hours, charging patients (rather than the government) a fee for the service, which could be provided on an expedited basis. While politically controversial, it made it possible to serve more patients without the need for additional government funding.

These types of ideas have grown, extending now to stand-alone diagnostic centers. A couple of days ago, I visited one, Mayfair Diagnostics, in Calgary. This center was created by a group of physicians, who, like others I have met, knew they couldn’t change the system, but could improve the part in which they work. So they bought leading imaging equipment and opened up centers that cater to self-pay patients, as well as those funded through other sources. They actively promote themselves as a way to get needed medical insight only a couple of days – as opposed to the 6-8 week average wait patients would otherwise face. Doctors working in this center also work in hospitals serving government-sponsored patients, making the Mayfair center and others like it a supplement to the government system. And at a price of $650 for an MRI, it’s inexpensive by U.S. standards.

Other kinds of private centers have opened up as well. Some operate almost as membership-only medical practices, offering much of what might be considered primary care. Others provide even more comprehensive services, making most aspects of ambulatory care available on a privately-paid basis. For certain specialties like orthopedics, some even offer complete hospital surgical services.

The Canadian system remains very different from the American one. Canadians do not want their system transformed into anything that reflects American “rugged individualism.” And yet the natural human desire to look after oneself and ones family poses dilemmas. When a loved one is sick, all the abstract ideas melt away, and you think – how can I do everything I can to get help, now.

We’re all entitled to that kind of help — Americans, Canadians, whatever.

The ways Canadians are trying to make sure everyone gets that help are slowly changing the face of Canadian health care.

The Physician may be a Patient

July 9, 2009
Doctor and Patient
When Doctors Make Mistakes
By PAULINE W. CHEN, M.D.

I met Ed (not his real name) during internship, the year after we both graduated from medical school. Built like a competitive wrestler, Ed was an Ivy League college graduate and one of his medical school’s top students, a 27-year-old who wanted nothing more than to become a general surgeon. Like me, he was enamored with the fearlessness that seemed to characterize the specialty. At a dinner during our first month on the job, Ed told the rest of us, “I love that nothing scares a general surgeon.” A dreamy look passed over his well-chiseled face as he continued, “They can take care of it all.”

Ed was determined to be that kind of surgeon and applied his intelligence and good nature to the huge workload we always had at hand. One night when I was on call I found Ed, who was supposed to have gone home for the night, in a patient’s room. A small mound of discarded alcohol swabs, blood-stained gauze pads and used test tubes stood by his side as the patient, an older woman, laughed and encouraged him on. When Ed saw me, he smiled sheepishly. “I never learned to draw blood in medical school,” he said. “It takes me a few tries.” The patient patted Ed’s hand and nodded as he continued, “If I can’t draw blood, how am I ever going to be able to operate?”

But several months later, I learned that Ed had gotten in trouble one night for not responding to a nurse’s page about a critically ill patient. “He must have been overwhelmed,” I thought, remembering that only a few nights earlier I had likewise forgotten a nurse’s request after several trauma patients rolled into the emergency room and I never returned to the wards as promised. I silently vowed to do better the next time and now hoped that Ed would do the same.

But a couple of weeks later, I heard that Ed overslept and missed morning rounds. A month later he was publicly reprimanded for examining and placing undue pressure on a patient’s freshly sewn incision. And a month after that, he was placed on probation because he had pulled a surgical tube out of a patient when it should have stayed put.

Suddenly it seemed as if Ed, the promising young surgeon, had disappeared into a vicious cycle of errors and mishaps and couldn’t pull himself out.

But Ed, the friend, had gone missing, too. He stopped smiling when we passed one another in the halls and refused to meet up with the rest of us for meals. “I’ve got to read,” he would say, his face stony. “I’ve got to study.” He still roamed the wards at all hours, but now he was like a man possessed. With his list of patients crumpled in one hand and a pen in the other, Ed studied patient charts and reports for hours, furiously jotting notes down on his list.

Despite his efforts, Ed continued to stumble. He soon developed a reputation for being testy, not only with other doctors and nurses but with patients. He argued, lost his temper and was too rough during procedures. One afternoon I heard Ed’s voice bellowing from a patient’s room: “But I never said that to you! Why did you have to tell the senior doctor that? You got me into trouble!”

Ed finally gave up on becoming a surgeon. In trying to understand what had happened to our once aspiring colleague, the other young doctors and I talked about how stress is inevitable and surmised that those who collapsed under the pressure were probably better suited to other lines of work. We speculated that Ed lacked a certain sense of humility.

But all of our ruminations finally boiled down to this: each of us was only one misstep away from that lonely and vicious cycle of errors that could unexpectedly and irrevocably spiral out of control.

In the years since, I have worked with other doctors who have had similar experiences. And while the discussions at disciplinary meetings and at morbidity and mortality conferences tend to focus (and rightly so) on the effects of these physicians’ errors on patients, there is rarely any time devoted to how such errors affect doctors and their subsequent interactions with patients.

I called Dr. Colin P. West recently, a practicing general internist and the associate director of the internal medicine residency training program at the Mayo Clinic in Rochester, Minn. About three years ago, Dr. West and his colleagues published an article in The Journal of the American Medical Association on the effect of errors on physicians-in-training and on the outcomes of their future patients. The researchers found that self-perceived errors not only increased the risk of burnout and depression but also adversely affected subsequent patient care. Over time, young doctors who believed they had made errors in the past felt less and less empathy toward their patients, which then led to an even greater risk of subsequent errors.

“What we are learning is that there’s clearly a cost for doctors and patients,” Dr. West said. “There’s probably a certain amount of stress that’s constructive, but when you deal with it for too long and take it too far, that’s when work suffers.”

While doctors should strive for as few errors as possible, “you can’t go through training without making an error unless you are not taking care of patients,” Dr. West said. “And if you are really invested in the care of patients, there’s a personal cost when things don’t go well.”

That cost can extend to patients. Doctors who are depressed are as much as two times more likely to make subsequent errors than doctors who are not. “From the point of view of the patient,” Dr. West observed, “it’s important whether the doctor treating you is experiencing symptoms of depression or burnout.”

And while Dr. West’s research focuses on doctors-in-training, he added, “I don’t think that as a practicing physician you ever stop thinking about how you could have done better, even sometimes with those events you probably couldn’t have prevented.”

Greater support for doctors from both the training process and patients could help to improve patient outcomes and strengthen the patient-doctor relationship. “In 21st century medicine, there’s no reason for a patient to accept suboptimal care,” Dr. West said. “At the same time, patients need to balance their expectations against the reality of the physician experience. And the medical establishment needs to do a better job of helping patients understand what physician lives are really like.”

“This doesn’t mean that physicians need to be coddled,” Dr. West continued, “but they need to be supported from within and by patients. They need to be supported in developing those relationships that help them to flourish. The reward is a stronger physician-patient bond. And that leads to more effective health care for everybody.”

Join the discussion on the Well blog: "For Doctors, the Personal Toll of Mistakes"

Brilliant

This is an op ed from the New York Times and is critical for health care reform
July 6, 2009
Op-Ed Contributor
Health Care’s Infectious Losses
By PAUL O’NEILL

Pittsburgh

HEALTH care reform seems to be on the way, whether we want it or not. So I have been asking questions about the various proposals. Here is a sampling.

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Which of the reform proposals will eliminate the millions of infections acquired at hospitals every year?

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Which of the proposals will eliminate the annual toll of 300 million medication errors?

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Which of the proposals will eliminate pneumonia caused by ventilators?

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Which of the proposals will eliminate falls that injure hospital patients?

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Which of the proposals will capture even a fraction of the roughly $1 trillion of annual “waste” that is associated with the kinds of process failures that these questions imply?

So far, the answer to each question is “none.”

Let’s consider that $1 trillion of waste. If we could capture all of it, the savings over 10 years would be five times what President Obama has said he will extract from insurance companies over the same period. The president’s vision of bringing down health care inflation by 1.5 percent a year over the next decade would not be a victory, but a capitulation to the enormous waste in the delivery of medical care.

The president says he likes audacious goals. Here is one: ask medical providers to eliminate all hospital-acquired infections within two years. This is hardly pie in the sky: doctors and administrators already know how to do it. It requires scrupulous adherence to simple but profoundly important practices like hand-washing, proper preparation of surgical sites and assiduous care and maintenance of central lines and urinary catheters. With these small steps, we would no longer have the suffering and death associated with infections acquired in hospitals and we would save tens of billions of dollars every year — money we should have in hand before new health-care entitlements are enacted.

What policymakers tend to forget is that only the people who do the work can make this happen. Legislation can’t do it, regulation can’t do it, infection-control committees can’t do it, financial incentives and disincentives can’t do it. But excellence is possible, and it has been demonstrated.

Where it works, the common denominators are strong leadership and a committed work force. Among those doctors showing the way are Brent James at Intermountain Health in Utah, Gary Kaplan at Virginia Mason Clinic in Seattle and Richard Shannon at the University of Pennsylvania, who have helped bring infection rates down drastically at their own hospitals and at others.

Hospitals and medical schools have great impetus to increase the ranks of such doctors: these improvements in patient care don’t cost money, they save money. And they represent only the tip of the iceberg in opportunities for improving outcomes and reducing costs at the same time.

A next step would be for the government to finance a prompt, detailed and hard-headed study of every example of error, infection and other waste in five major medical centers. Such data would give policymakers and caregivers a clearer picture of the possibilities for cost-saving improvements.

It would also help if reporters and pundits became more informed about the opportunities for improvement, so they could help educate the public and improve the level of the reform debates. As for members of Congress, perhaps it would help them to understand the problem if we assembled the data, by House district, on hospital-acquired infections, medication errors and other waste indicators. They are more likely to push for the right sort of change when they realize that people they know and represent are being hurt or killed by practices we know how to stop.

In the end, any health care reform that does not address the pervasive waste and the associated burden of needless suffering for patients and staff alike will give us little to celebrate.

Paul O’Neill was the secretary of the Treasury from 2001 to 2002

Is Reduction in Physician Fees Rationing of Care?

President Obama is prepared to cut spending for Medicare and Medicaid. Doctors and hospitals will be paid less for services provided under Medicare.
Is that an example of rationing in action?

A radiologist, may argue:

"The proposed fee schedule for 2010 for radiologists and cardiologists is 21% less than this year! Instead of being reimbursed 36.00 per RVU, CMS proposes to reimburse at 28.00 per RVU. These reductions are the first signs of removing economic incentives for medical practice.
Please give us your thoughts about capping the number of work units and how this will put RATIONING on steroids?
There will be few radiologists and cardiologists working after they hit the magical cap number."

Let us be clear about who is rationing what here.

When Medicare reduces its payments to doctors, it rations money to them. It does not directly ration the health care the doctors might render patients.

If physicians refuse to treat patients at the lower fees, it is they who ration health care, even if the incentive to do so came from Medicare.

While I doubt that the payments to radiologists and cardiologists actually will be cut by 21 percent soon — more on that next time — let us suppose it were so. Would there then be “few radiologists and cardiologists working” after such a fee cut?

Presumably, the afflicted physicians would withhold their services only from Medicare and Medicaid patients, assuming that private insurers pay more. But could most radiologists and cardiologists actually earn an adequate livelihood only from privately insured patients? I have my doubts.

Like everyone else, radiologists and cardiologists certainly can claim to be sorely underpaid relative to the extraordinarily high compensation of bankers and corporate executives, which appears to have little correlation with contributions to society. But relative to their colleagues in internal medicine, pediatrics and family practice, radiologists and cardiologists actually are very well paid.

There are a number of sources on physician income (see, for example, this). All of them suggest that the median annual net income of radiologists and of cardiologists (around $400,000) is more than twice that of family practitioners, internists and pediatricians (less than $200,000). The median is a statistic such that half of physicians earn as much as the median or more, and the other half as much or less.

So even if Medicare cut fees of radiologists and cardiologists by 21 percent, the income of these specialists would still exceed that of their colleagues in primary care by 60 percent or more.

Would that be a reason to quit medical practice? After all, doctors are not bankers. They do not work merely for pecuniary gain, but derive non monetary, psychic rewards from their jobs.

Cold hearted as it may seem, economists judge a profession’s income as adequate if it attracts enough young people into the profession. For the last half-century that has been so in American medicine. The constraint on the number of American-trained physicians has never been an inadequate supply of eager and qualified American applicants to American medical schools. Instead, it has been a deliberate constraint on the number of American medical-school slots.

For reasons that elude me, United States policy makers and the medical establishment have for decades preferred to deny thousands of eager and qualified American youngsters the opportunity to study medicine and have then met the resulting shortage of physicians by importing foreign-trained physicians from other countries.

But while there is no overall shortage of qualified young Americans eager to study medicine, there is now a nationwide lament over a shortage of American medical-school graduates willing to enter the primary-care specialties. For that reason Medicare may soon substantially increase the fees for primary-care physicians, assuming private insurers will swiftly follow suit, as usual.

The only question then is whether such fee increases will come at the expense of taxpayers or from other parts of the health care sector, perhaps even the more highly paid medical specialties, including radiology and cardiology. That is a political call.
United States taxpayers have been too stingy vis à vis the medical profession.

I shall also describe a highly ritualistic and entertaining form of Kabuki theater staged annually in Washington in conjunction with the year’s Medicare fee update.

Act I in the play is always the announcement of a 20-percent cut in the fees Medicare pays physicians.

That “cut” actually ends up as a increase of 1 to 2 percent and an annual increase in Medicare spending per Medicare beneficiary on physician services of 5 to 6 percent.

It will be so again this year.

Canadian healthcare

Canada is often praised or panned (based on ones political leanings) for its healthcare system. here is a model of how it works
Canadians can be of two minds about their public health care system.

Tommy Douglas, a former premier of Saskatchewan, was voted “The Greatest Canadian” by the Canadian Broadcasting Corporation viewers for setting up what became the model for the country’s health system. And a survey last year partly sponsored by the federal government found that Canadians ranked “universal health care” among the 10 defining factors of their country (along with Niagara Falls, beavers, hockey and a robotic space arm).

At the same time, Canadians can be quick to complain about that very system. Their chief complaints include wait times, access to doctors, unusual treatments and specialized imaging equipment as well as its overall cost.

Given that, it’s not surprising that Canada’s experience is being used to support the arguments of people on both sides of the American debate about health care.

But before judging Canada’s system, and its suitability as a model for the United States, let’s look at how the system’s financing developed.

The biggest problem in assessing Canada is that there are, in fact, 15 different systems rather than a single, national program like Britain’s. Each of the 10 provincial and 3 territorial governments administers and delivers health care to most residents. On top of that, the federal government is responsible for native people who live on reserves, as reservations are known in Canada, as well as members of the military and their families.

While broad pieces of federal legislation provide overall guidance for each provincial system, they have nevertheless developed largely on a piecemeal basis since the 1960s. Adding to the complexity is the tendency of provincial governments to bicker amongst themselves while vigorously opposing any federal efforts to usurp their constitutional powers over health care.

So when thinking about health care in Canada, bear in mind that for every general rule there can be a multitude of exceptions.

C. David Naylor, a physician and health policy analyst who is president of the University of Toronto, succinctly summed up the system in the title of a book in 1986: “Private Practice, Public Payment.”

Mr. Douglas’s socialist government in Saskatchewan introduced Canada’s first province-wide, government-financed health care system in 1962, immediately provoking a strike by doctors. But it was a Royal Commission established at roughly the same time that ultimately provided the framework for the rest of the country.

Canada’s health care insurance industry, which was growing quickly in the early 1960s, joined with the country’s medical association to campaign against publicly funded medical care for all but the poorest Canadians.

The Royal Commission ultimately rebuffed them. Dr. Naylor’s analysis is that mixing public coverage with private insurance would be a bureaucratic mess that could cause public monies to subsidize for-profit medicine and insurance.

But the doctors did get some of their demands. Canadian physicians are not government employees. They retain a great deal of control over when, how and where they work. Instead of being paid salaries, most of them bill provincial governments on a fee-for-service basis. Canadian hospitals are also autonomous institutions that are generally, but not necessarily, governed by local health authorities.

The details of how that operates become complicated very quickly. But for patients, it’s all invisible.

They never see a bill for hospital treatments or services provided by their doctor. Some hospitals and physicians once imposed surcharges and service fees on patients, but the federal government shut down the practice in 1984 by cutting off health financing to provinces that allowed it. Similarly doctors cannot moonlight and provide basic medical services to patients who are willing to pay for faster or more attentive service.

That doesn’t mean, however, that Canadians do not have health care costs that they have to pay out of pocket or through private insurance. Most dental work, prescription drugs for people not at retirement age, and eyeglasses are among the many costs not covered. The Canadian Institute for Health Information estimates that governments covered about 70 percent of the 171.9 billion Canadian dollars (roughly $148 billion) spent on health care last year.

The challenge for governments to come up with that money, and how effectively the system uses it