Primary Care

Meet Gary Bloch, a family practice doctor living and working in Toronto, Canada. Dr. Bloch takes the time with each patient he sees to remind them to fill out their tax returns, knowing that many will see a refund and be able to claim various tax credits. As he explains in this piece for The Globe and Mail, "The link between health and income is solid and consistent – almost every major health condition, including heart disease, cancer, diabetes, and mental illness, occurs more often and has worse outcomes among people who live at lower income. As people improve their income, their health improves. It follows that improving my patients’ income should improve their health."

The connection between income and health is both clear and simple: if patients collect the refunds and tax credits they are eligible for, they will boost their income and be much better able to meet their immediate health care needs and stay healthy in the long term.

As I've written about in the past, health problems compound financial ones and vice versa. I would guess that by initiating these conversations about income and tax filing with patients, Dr. Bloch is learning a great deal about possibly the largest sources of stress in his patients' lives, is better able to understand any financial limitations patients' may have in following his medical directives, and is gaining the trust of his patients.

Here's our wrap-up of last week's articles by our own Shannnon Brownlee and Joe Colucci:

Letting Big Pharma Review Its Own Drugs — What Could Go Wrong? (The Atlantic Health Channel):

Earlier this month GlaxoSmithKline agreed to pay a record breaking $3 billion fine for a slew of criminal and civil violations. But is a fine really enough? In a piece in The Atlantic, Shannon Brownlee and Joe Colucci argue that we need to stop letting drug companies track the post-market safety of their drugs and establish an external automatic review system. 

12 Ways Health Care Could Be Improved If the House Wanted to Hold More Than Symbolic Votes (The Atlantic Politics Channel):

In the wake of the House's 33rd vote to repeal/defund Obamacare, Joe and Shannon propose a list of 12 things the House could have done to make a better use of tax payers' dollars and actually improve health care. In the article in The Atlantic the proposals range from enacting a less intrusive mandate to funding after school programs to teach kids how to cook. Any of them would have worked better than another "symbolic vote."

Why The ‘Best’ Hospitals Might Also Be The Most Dangerous (TIME Ideas):

We've all seen them—the U.S. News Rankings of everything from colleges to cars. How do their hospital rankings look? In her latest article for TIME, Shannon argues that, based on new rankings by Consumer Reports, many top-name hospitals fail to measure up in terms of safety. Hospital rankings would be a lot more useful if they considered how medical care affects most patients, not whether a hospital performs some cutting-edge procedure on three patients per year.

On Wednesday, June 27th my roommate convinced me that we should give up the comfort of our intern-housing beds for the cold hard concrete of justice and the company of other "Supreme nerds," waiting in line to witness the historic ruling on the ACA.  I'm usually not that compulsive, and I resisted at first. After some powerful persuasion, I eventually consented to go.  Interning here in DC this summer has presented me with many invaluable opportunities, but none has been as amazing as what awaited me next morning.  I owe my roommate a big "Thank you" for not succumbing to my stubbornness.

You could feel the excitement in the air.  Most of us were students or recent graduates, interns or nearby residents. Many didn't sleep that night, choosing instead to stay up night sharing opinions and speculations. Some finally succumbed to exhaustion.

We woke up in a sea of cameras. At 5:00 AM there were more camera crews set up than at 10:00am on Monday, when the Arizona case was released.  

As the morning wore on, I found myself constantly mulling over what might happen inside that beautiful building later that day. This would be among the most important, far-reaching cases of my lifetime.  

Politically I have always found a bit of both sides in myself.  With conservatives, I share concerns about the growing powers of government.  I was wary of the expansion of power that upholding the mandate would grant to Congress's interpretation of the Commerce Clause. (Yes--I was concerned about the broccoli argument.)

On the other hand, as I have learned more about the Affordable Care Act, it has become more and more appealing.  As a future physician I love the patient protections and expanded access that the health care law provides.  I also believe that sometimes the spirit of the law is more important than the letter of the law.

I hoped for a ruling that satisfied my views on both ends of the spectrum.  

While we waited inside I talked with a political science major from Johns Hopkins University.  When I asked her how she would respond to someone who believes that the ACA violates the Constitution she told me about her "Comparating Constitutions" class.  

"Under the United States Constitution, the government would not be violating its duty if it just sat back and did nothing," she said.  "Other countries' constitutions  have specific provisions written in them that forbid the government from doing nothing.  They have to provide certain services. Because of this, they are much more welcoming of big social changes like health care reform." When I asked if she advocates amending the constitution to have such duties she said, "Well, that's so long and difficult."

Her attitude surprised me.  In effect, she was saying, "Yeah, I realize there are limits in our Constitution, but they shouldn't get in the way of doing what society believes is right." 

Eventually we were shown upstairs to a room with small lockers where we were told to leave all electronic devices and other personal items.  From there we were directed to the courtroom where we waited and whispered for half an hour. Despite my profound lack of sleep, as soon as the Justices walked in a surge of adrenaline flooded my body.  No one but this relatively small group of people I was sitting with would ever witness these words uttered out of Justice Roberts's, Ginsburg's and Kennedy's mouths.  It was amazing to think that I was watching history before anyone else.  

The mandate was found unconstitutional under the Commerce Clause, but constitutional under the taxing power, and the rest of the law stood with it. (The Court did overturn the expansion of Medicaid as coercive, but the only part that was actually removed was the threat of removing all Medicaid funding for states that choose to opt out of the expansion.) I don't think there was a soul there who saw what was coming. As for me, I was elated! Upholding most of the ACA meant that meaningful health care reform would continue, and the check on the Commerce Clause abated my fears of growing Congressional power. Both of my concerns had been addressed.

I was surprised, however, by the "strike-the-whole-thing-down" position taken by the four justices who wrote the dissent.  As I see it, there are many parts of the ACA that are completely constitutional. The opinion of the dissenters seemed to be the mirror opposite of the opinion I had heard from the political science student just an hour earlier. According to the dissent's view of Congress's taxing and spending power, "the Court has long since expanded that beyond ... taxing and spending for those aspects of the general welfare that were within the Federal Government's enumerated powers." They cited "the Department of Education, the Department of Health and Human Services, [and] the Department of Housing and Urban Development" as "sizeable federal Departments devoted to subjects not mentioned among Congress' enumerated powers, and only marginally related to commerce."

In other words, they were saying, "Yeah, these agencies are solving pressing problems, but they extend beyond Congress's constitutional powers." Under similar logic, they argued that the whole Affordable Care Act should be struck down.

Picture:  Associated Press

After the Court finished the rulings, and the term, we were quickly ushered outside.  

Michelle Bachman was on a loudspeaker in the middle of the Tea Party crowd, insisting that since the justices had failed it now falls to the voters to repeal Obamacare.  She was drowned out, at times, by boos and chants of "Four more years" by people holding "we love Obamacare" and "stand up for women's health" signs.

 I stopped to ask a woman holding a "Protecting Our Care" sign what she thought about the ruling.  She was happy, of course, that the law had been upheld.  I followed up by asking her what she thought about Justice Roberts' ruling that the mandate doesn't stand under the Commerce Clause yet does stand under the taxing power.  She gave me a confused look and said, "I don't know what you're talking about."  Caught off guard, I awkwardly ended the conversation as I came to a profound realization:  most of these people here don't care about the specifics.  They're not here to find out how all the details play out.  

I would venture a guess that nearly everyone there that day would very comfortably identify themselves with one of two groups: those for limited government or for social justice.  In each group, as long as their ends are met, the details aren't important.  The limited government crowd wanted the law overturned--despite the fact that our health care system is on life support and millions don't have access to care.  The social justice crowd was elated by the ruling--regardless of its implications for the federal government's power.

In contrast to these groups, Court's job is only to determine whether the law in question is Constitutional--nothing more, nothing less.  As Justice Roberts put it, "we possess neither the expertise nor the prerogative to make policy judgments. Those decisions are entrusted to our Nation’s elected leaders, who can be thrown out of office if the people disagree with them." 

In that sense, it seems like this discussion--between two parties who care more about the ends than the means--is sort of out of place in front of the institution that is primarily concerned with the means. It was precisely the means, the details, that allowed me to feel like the day had been a win-win. By knowing the specifics of the law and the case against it, I felt like I was the only one reveling in a two-sided victory!

If the limited government crowd would have paid a little more attention to the details they may have found a silver lining in their defeat--the ruling on the Medicaid provision could end up being a major limit on federal power over the states, and some liberal bloggers have been complaining that the Court's ruling has "gutted the commerce clause."

Instead of examining the ruling, the groups were too busy volleying taglines. When this type of one way discussion takes place and people disregard the details, they tend to talk past each other.  The result is conflicting, often embarrasing, messages...

...like this:    

...or polls like this (CBS News/NY Times):  

And yet, while it might not always make sense, we have a long tradition of protesting in front of the Supreme Court.  I'm not suggesting that should end. Nor am I suggesting that we need to avoid the use of hyperbole to get one's point across.  Sometimes it can be entertaining.

But, are the two positions really irreconcilable? Can we fix the health care system and still keep limits on governmental power?  I believe we can, and I believe that is what we saw last Thursday.

Politics will continue to play on, speculations about Justice Roberts's reasoning will continue, but if we want to get things done we need to stop talking past each other, care enough to see what the other side has to offer, and build off our common ground.  

In the coming months and years, health care reform must continue. The ACA, though a good step forward, is far from a complete solution to the health care crisis. We have some tough questions ahead of us involving the quality and cost of care. Solving these problems will require our meaningful dialogue and thoughtful consideration of the details.

And by considering the details we may just discover, like I did, that solving problems doesn't have to be one-sided. We can find a middle-of-the-road solution that covers everyone's needs. That way, no one has to feel like they are "left out in the open."

The number of the day is 222—the international dialing code for Mauritania.  More interestingly, 222 is the number of nationwide ER visits per minute in 2011, according to the 2007 Emergency Department Summary from the National Hospital Ambulatory Medical Care Survey (NHAMCS). Across the year that amounts to “116.8 million ER visits or 39.4 visits per 100 persons.”

Last Monday the Alliance for Health Reform held a Briefing addressing this topic: "The Right Care at the Right Time:  Are Retail Clinics Meeting a Need?" The briefing was sponsored by the Alliance and WellPoint, Inc. to examine the question of whether urgent care clinics and retail care clinics (together called convenient care clinics) are meeting a need in the health care system. The panelists at the event included physicians from WellPoint, RAND Health, and the American Academy of Family Physicians (AAFP). The president of the trade association for retail clinics, the Convenient Care Association, was also on the panel. The conclusion of everyone present was that convenient care clinics are meeting a need. In a broader sense, their findings also presented a strong case for a reinvestment in and retooling of the primary care system, as a whole.

The use of emergency departments has been on the rise for many years. Contrary to popular belief, a Senate hearing reported that the main increase in traffic is not due to increased utilization by uninsured patients. Instead, the largest increase has been seen in those with private insurance.  The report also listed that "physician office visits have increased at an even higher rate than emergency department visits." They suggest that the concurrent increase in ER visits reflects a growing increase in demands for ambulatory care services, and that some of that demand is spilling over into the ER.

Urgent care clinics, like NextCare Urgent Care, and retail care clinics, like CVS’s “Minute Clinic,” are perfectly poised to benefit from this spillover (and the numbers show that they have).  They are open more hours than primary care offices, and cost less than the emergency rooms.  Granted, if you suddenly lose feeling on the left side of your body and start to slur your speech you are not going to stop to consider this dilemma, but ERs across the country already see a steady stream of people who are not in such life or death situations (ask any ER doc).  In fact, one of the panelists pointed out that nearly 25% of ER visits could be safely seen at other sites.  For the working single mom, whose daughter developed a fever of 101 on Saturday night, a quick Sunday morning visit to the nearest urgent care clinic will no doubt be preferred over an expensive 4 hour long ordeal at the ER.  And their transparent prices make it a feasible option for the cost conscious patient.

Rick Kellerman, former president of the American Academy of Family Physicians (AAFP), was the panelist representing traditional family physicians. As one might expect, family physicians initially felt threatened by the convenient care movement—especially by retail clinics, which are usually staffed with physician assistants or nurse practitioners. While many of their concerns (fragmentation of medical care, decreased care coordination, “medicalization of symptoms”) persist to this day, Kellerman said that the AAFP eventually told their members that they needed to wake up to the demands of their patients: “If you don’t like retail clinics, change the way you practice.” Subsequently, many physicians responded by offering changes such as extended hours, open appointments for call-ins, “quick clinics” for walk-ins with minor problems, and group appointments for chronic disease management. Many of these doctors have embraced the movement by partnering with clinics in order to get referrals or becoming supervisors of clinics. In forming such partnerships, these physicians are offering their patients a way to get setting of care that hopefully will combine the cost-consciousness and convenience of an urgent care clinic with the benefits of a long-term doctor-patient relationship and better-coordinated care.

While disagreements remain, the facts show that convenient care clinics are increasingly common, while the number of medical students going into family medicine is decreasing.  The convenient care movement has flourished in part because the status quo in health care is failing.  Regardless of what happens to the Affordable Care Act in the upcoming days, policy makers need to work toward a solution to the primary care problem—a solution that includes both convenient care clinics and traditional primary care. Everyone--primary care docs, retail and urgent care clinics, ER docs, and patients can benefit from making sure people are treated in the right place at the right time

If you want to find out more, here’s a link to the materials from the briefing.

Earlier this year I was sitting in the student lounge of UT Southwestern Medical School searching for health policy internships in DC.  I was stunned by how many opportunities I came across, but few seemed like such a perfect match as the opportunity here at the New America Foundation.  Part of the reason for this has to do with my own experience with "avoidable care”—an experience that sparked my interest in health policy and preventive medicine.

The Robert Wood Johnson Foundation’s Vulnerable Populations Portfolio hosted a webinar on Thursday entitled HealthCare’s Blind Side: Exploring Solutions to Address Social Needs. You can read more about RWFJ’s work on addressing the social and economic determinants of health here. This webinar focused on developing ways to bridge the gap between traditional medical care and meeting social needs.

We don't often post raw links or pictures without commentary, but the last few weeks have involved a few great ones that we couldn't pass up.

First: via the new Washington Post Wonkblog (congrats on the new site, guys!), Dr Seuss explains the medical arms race in the video to the right! (Watch it fullscreen--it's worth it!)

Welcome to the first installment of our “Health By The Numbers” daily feature! Each day, we’ll be presenting a surprising number with some significance to health care, whether it be the implementation of the Affordable Care Act implementation, federal health spending, or the storage capacity of the human brain (4 Terabytes!) Let us know what you think of this feature or suggest a Number of the Day via email or Twitter!

All too often, patients facing elective surgeries are not given the chance to learn about the full range of options available to them.  Many go into the operating room unaware of the unique risks and benefits of the procedure they're about to undergo.  Some even fail to understand the elective nature of the treatment, that the decision to go under the knife is actually theirs -- and not their doctor's -- to make. The result? Patients often don’t get the treatment they would have preferred had they been if fully empowered and informed.

Today marks the unveiling of a new report from the Dartmouth Atlas Project and the Foundation for Informed Medical Decision Making that illuminates this enormous problem.  And it is enormous. As many as 70 percent of patients undergoing certain surgical procedures would have chosen a different option had they had a chance to be fully informed, and to share the decision with their provider.

For Medicare patients with conditions that can be treated with surgery, whether or not they undergo elective surgeries depends largely on where they live and the clinicians they see. According to the report:

Researchers found Medicare patients living in Casper, Wyoming are nearly six times more likely to undergo back surgery than patients living in the Bronx.  Medicare patients with heart disease in Elyria, Ohio, were 10 times more likely to have a procedure such as angioplasty or stents than those in Honolulu. And women over 65 living in Victoria, Texas were seven times more likely to undergo mastectomy for early-stage breast cancer than women in Muncie, Indiana.

(Full report available here)

To highlight the dramatic findings of this study, the New America Foundation will host a roll-out event at 3:00pm on Friday, February 25^th.  (Register here) Shannon Brownlee, the lead author of the study and Acting Director of New America’s Health Policy Program will open with a short presentation of the Atlas’ findings, followed by remarks from Len Nichols, the Director of the Center for Health Policy Research and Ethics at George Mason and Christine Bechtel, Vice President of the National Partnership for Women and Families.

The report used Minnesota as a case study to highlight that even in a state widely known as a leader in patient-doctor collaboration, there remains room for significant improvement.

(Pioneer Press)

Variations of this magnitude are the byproduct of a system in which physicians and patients are often unequal partners in the decision making process. What patients truly want may not be taken into account when medical decisions are made.  In addition to analyzing data on practice patterns, the report advocates for shared decision making, a process by which a patient is fully informed about the potential risks and benefits of available procedures before choosing a treatment plan with their doctor. 

In the absence of clear, evidence-based guidelines for care, rates of surgery can vary wildly based on non-medical criteria. Rates in small communities, for example, can swing based on the opinions of one practice or a small number of doctors. Some prefer surgery, while others might be motivated by lucrative reimbursements for the procedures. "The goal really is to get patients and others to see the extraordinary range of the variation," said Shannon Brownlee to the Star Tribune. "While some differences are to be expected, she said, "those differences are swamped in many cases by the variation that is driven by [a doctor's] opinion."

The release of this newest Atlas will advance the conversation about appropriate rates of medical care and about truly patient centered care. We've been making the case that overtreatment is rampant in our health system, from implanted defibrillators to early induced delivery to mammography.  We simply don't know what the "right" rates are, but we know that when patients are fully informed, they may want less care, or less invasive care.  According to Dr. Michael Barry, President of the Foundation for Informed Medical Decision Making, a patient engaged in shared decision making chooses a more conservative course of treatment for a variety of conditions on average 20 percent more often. With the health system's current cost crisis, supporting conservative -- often less expensive-- treatment is an essential tool to lowering utilization and controlling runaway health expenditures. Doing so with shared decision making can tackle this problem WHILE improving patient outcomes and satisfaction. It beats the alternative of waiting until impending fiscal catastrophe forces more draconian decisions.

But the more important reason to advance shared decision making is that it's the right thing to do for patients.  We hope you can join us in bringing attention to this critical issue.

Like many American patients, the American health care delivery system suffers not only from acute crises, but also from a chronic, poorly managed and debilitating disease. Primary care is in trouble. Not only are primary care physicians (PCPs) fleeing the profession in droves, but fewer and fewer medical students express an interest in pursuing a primary care career. Those entering the profession don't last long - 1 in 5 general internists become specialists by their tenth year in practice. The workforce pyramid needed to support effective health care reform – with a broad base of primary care providers – is being steadily eroded.

The coming crisis was the topic of a recent conference hosted by the American Board of Family Medicine and the Robert Graham Center. Dr. Robert Phillips, director of the Graham Center, emphasized that while the average ratio of individuals in the U.S. to PCPs is 1500:1, that ratio ranges from 500:1 to 5000:1 depending upon the region you’re talking about. While we don’t know the “right” ratio, we do know that rural communities are particularly barren of PCPs.