Monday, February 27, 2017

Health insurance as a contributor to high medical costs

After writing about the coming demise of the Affordable Care Act, I began to think, again, about why it costs so much to deliver health care in this country. If it was cheaper, legislation to make health care a right, rather than the randomly distributed privilege it is now, would be so much easier.

Medical costs doubled every decade from 1960 through 2000. This happened in tandem with the rise of comprehensive health insurance. Today the vast majority of health care is paid for by some sort of health insurance. Hospitals and physicians spend a huge amount of time generating information to convince insurance companies to pay us. Patients aren't usually aware that more than half of the time doctors or nurses spend at work is used to document what we do. These days it is primarily on a computer. The documentation can be helpful to communicate our thoughts and plans to colleagues or keep a record of what happened so we can create a history that caregivers can read at some future time, but the majority of it is to prove to insurance companies that we worked hard and we did what we were supposed to do. There are also many employees of a hospital or a clinic who are employed primarily to communicate with insurance companies so we can be paid. I've heard it estimated that 50% of human hours in a hospital is devoted to billing. This rings about true, though I think that if we were to examine all of the adjustments we have made over the years that are due to our payment system, we would find the percentage to be higher.

In an attempt to make us do our jobs better, we are monitored for the quality of our care as measured by adherence to certain guidelines for serious diseases in the hospital. It is cumbersome to develop the tools we need to report on, for instance, how we treat sepsis (overwhelming infection.) The data regarding how to do this best is still actively evolving and new recommendations seem to show up in the good journals a few times a year. By the time we have our tools developed, the newest recommendations have changed and insurance companies are still judging us based on outdated guidelines.

The amount of administrative complexity associated with insurance billing is huge and requires the insurance companies to employ large numbers of people. Each of these people's salaries and the new large buildings they sit in are part of medical costs as well and are reflected in insurance premiums and become part of the cost of delivering health care.

Insurance includes not only private health insurance companies such as Blue Cross and Humana, but also federal and state administered insurance, Medicare and Medicaid. Public and private payers have very similar inefficiencies built into their systems. Public insurance providers, at least in theory, have another level of inefficiency built in since they not only are large bureaucracies using complex schemes for paying for services delivered to people who are far removed, but they also require expensive legal processes to be funded.

There are other parts of the equation that add up to high medical costs, and some of them have their very own devoted blog posts. A third party payment system, such as we have, along with fee for service payment for medical care are a recipe for rising costs.

It would be jolly to dismantle such an inefficient system, except that it would also be economically horrific on a national and possibly global scale. Nine percent of Americans are directly employed in the health care industry. This doesn't include all of the people employed because we have a large and growing health care industry. It doesn't include the postal worker who delivers health related junk mail, the construction workers who build the new health insurance building, the people who polish the Mercedes Benz of the CEO's of hospitals, the devoted teachers who educate health care workers or the many other people who thrive or survive because the health care industry is booming. Reducing costs by making a major cut in the way we do business, such as getting rid of private insurance companies, would have far reaching consequences on employment and the economy.

This is one of the reasons that changing the way we do health care is so tricky. Perhaps we want to continue to spend lots of money on health care because it is a quirky thing we Americans like to do. Even so, it seems like it should be possible to have better outcomes for all of the money we spend. We ought to be able to winnow out the parts of the system that don't add value. In order to make such changes, we should go slow, creating alternatives that prove their value and edge out present less functional systems.

Creating a national health care system, a single payer, seems almost attractive enough to make what would be a huge and potentially catastrophic change. Canada and France, both of whom have systems that provide health care for every citizen at a cost that is lower than that in the US, use single payers. In Canada, with which I am more familiar, this makes billing incredibly simple and actually possible for a doctor to do him or herself quickly and without help. Patients do not pay for anything except for most drugs, dental care and some other necessities that are specifically excluded from coverage. Instead they pay a hefty but income adjusted tax to pay for the entire system, called Medicare. There are some private health insurance companies that people sometimes use to pay for those things that are not included in Medicare coverage, but this is a small fraction of the health care industry.

It could be argued that we have tried very hard to make a health care system work with a hodge podge of public and private funding and that it clearly hasn't worked, with rising prices and far from universal coverage, even with changes wrought by Affordable Care Act. A single payer system is the cure for our ills. A single payer could negotiate with providers of health care services, setting prices and examining new technology based on its costs and benefits. There are problems, both practical and theoretical, with this answer. As far as the theoretical issues, it is usually better to allow private businesses to create solutions to needs such as health care since they can be more innovative and more flexible than large governmental agencies. If the federal government designs a health care system there will be a tendency to create “one size fits all” solutions, which don't lend themselves to the truth that every person is different and has somewhat different health care needs. Practical aspects include the fact that we presently have a federal government which is far too influenced by powerful lobbies and thus probably can't actually negotiate better prices. Other creative solutions to improve quality with innovative ideas require the ability of lawmakers to work together, listen to each other and develop compromises, which they appear unable to do. There is also a pervasive distrust in the federal government that means that the majority of constituents would likely not trust them to manage health care. It would, in fact, be a huge change in how things are done and the road would be very bumpy.

It is very difficult to think our way to a perfect and universal health care system. It will require small and sometimes courageous steps in the right direction based on a shared concept of what we want as both providers of health care and consumers. It will require leaders who thrive on working together to find new solutions. It may involve private insurers as well as public and it may even transition to a true single payer. In the end it will need to be a flexible and high quality way to provide good health to everyone at a price that we can afford without pinching the rest of the economy.

Janice Boughton, MD, ACP Member, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health Care So Expensive?, where this post originally appeared.

Things that bug me include a lack of understanding of the eGFR

Once upon a time, we had to estimate GFR from the creatinine using an app or even a calculator. Now almost all labs provide estimated GFR, but this is both a positive and a negative.

I rarely find a resident (or attending physician) who understands the principles behind eGFR, and thus too often they interpret the number incorrectly and use it wrong. Here is my quick guide for understanding eGFR.

Back in the day, before the turn of the century, we measured 24 hour urines. We would measure the volume over 1440 minutes and measure the urine creatinine level. Given these numbers and the serum creatinine level, we would plug the numbers into the classic formula UV/P.

This method had the major problem of actually collecting an accurate 24 hour urine.

Cockroft and Gault published this article in 1976: Cockcroft DW, Gault MH. Prediction of creatinine clearance from serum creatinine. Nephron. 1976;16:31-41. [PMID: 1244564]

The formula of “creatinine clearance=(140-age)*wt kg/Scr*72 for men and 85% of that number for women” was the commonly used for many years.

Two other formulas based on the same reasoning are likely familiar to many readers, the MDRD formula (used by most labs) and the CKD-EPI equation.

What are these formulas all doing? They are estimating daily creatinine production! The numerator of the creatinine clearance formula, while the creatinine is stable, represent daily creatinine production. In steady state situations, virtually all the creatinine produced each day from muscle breakdown gets excreted in the urine.

We can predict muscle mass in several ways. Muscle mass estimation allows us to estimate daily creatinine production and hence the numerator of our formula.

MDRD and CKD-EPI both estimate muscle mass from age, gender and race. They assume a reasonable estimation from those demographics.

So we have 2 constraints on the use of eGFR. Serum creatinine has not changed and is not changing, and the patient has a “normal” muscle mass.

So here are the cautions. If the serum creatinine is either increasing or decreasing then eGFR is meaningless and should not be reported or considered. Here is the thought experiment. Mr. Jones has a serum creatinine of 1. We remove both his kidneys. Tomorrow his creatinine is 2. We know that he has no GFR, yet the formula would suggest a GFR 1/2 of the previous days. So just report that the serum creatinine is increasing or decreasing, but do not report eGFR.

We have 2 situations in which patients clear do not have “normal” muscle mass. The first occurs in athletes with increased muscle mass: body builders, many football players, etc. Our formulas underestimate the numerator. The denominator has increased because they do make more creatinine each day. Thus, we will underestimate their creatinine clearance with the eGFR formula. Sometimes this would label these individuals as having CKD. In this situation you will need to measure a 24-hour urine creatinine collection.

The second occurs in patients with decreased muscle mass. Some such situations include spinal cord injury patients, major amputations, muscle diseases, and severe cachexia. We recently had a patient with a spinal cord injury and a serum creatinine of 0.4. The formula suggested that his eGFR was approximately 200. The formula was wrong. His numerator was actually much lower than the formula would predict.

Before you use the serum creatinine and the eGFR to make clinical decisions, you should understand these issues. As clinician educators we must remain vigilant and make certain that our learners understand the reasoning behind eGFR. It really bugs me that all our students and residents do not know this. This speaks to inadequate education.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.
Friday, February 24, 2017

Will big data replace your doctor?

It's a common complaint among doctors: “Who is making these health care policies? It couldn't be real doctors, could it?” As a doctor “in the trenches” I wonder who these people are who influence our lawmakers. I'm sure they care, but the ideas they come up with are so insane to those of us in the office and in the hospital, we sometimes wonder if they're just messing with us.

For example (indulge me for a minute; I'll get to the point), Blue Cross requires us to enter data about our patients into their system. One question we often have to answer is, “Does the patient have depression or a history of depression?” If I answer, “Yes” but the patient isn't depressed right now the computer will not let me complete the form. Blue Cross's answer to this? “Just say they don't have a history of depression.” (I did not follow this advice, as it seemed dishonest.)

Which brings me to the point. I was reading a piece in the Wall Street Journal the other day, a piece about healthcare, written by “a former hedge-fund manager.” His disjointed piece makes for painful reading, but his central argument seems to be that if we just had access to enough data, we could have “cheaper and higher-quality health care.”

I'm a big fan of science-based medicine, something that requires lots of good data, but the article seems to imply something more emergent, a “SkyNet“ of medicine, if you will. The author, Andy Kessler, says that, “The key is data. With more of it, accuracy gets better over time.” If we could only improve the interoperability of our electronic health records, we could save lives and money. What kind of data is he talking about?

Tons of data come with medical records. Then there are digital scales, Fitbit steps, WellnessFX blood tests, Apple iWatch data and 23andMe genetic test results. Eventually there will be daily commode sensors measuring blood sugar and prostate-specific antigen levels, among other things.

Leaving aside how disturbing this sounds, examples would be laughable if they weren't published in a paper widely read by policy makers.

Imagine all that data being crunched, in real time, by machines looking for patterns—which then put out a simple text message. “Your hemoglobin A1c (HbA1C) has spiked again. I thought we agreed to cut back on the linguine.”

This is not how it works. The practice of medicine relies on data on both large and small scales. On the large scale are things like clinical trials that use sophisticated statistics to help us make rational decisions. On the small scale are data points like our diabetic patients' HbA1C's , a number which estimates how well they are controlling their disease.

Large-scale data, the stuff we get from the medical literature, can tell us, for example, that most diabetics should keep their HbA1C below 7.0 to avoid the complications of their disease. What it cannot tell us is how to get Mrs. Smith to that number, or even if that number is right for her. And the number is only useful if checked at least three months apart. It's not a real-time thing.

But for the sake of argument, let's pretend that Kessler picked a better example. Sticking with diabetes, let's say Mrs. Smith is wearing a continuous glucose monitor, and that those numbers, along with her grocery receipts and her “sitting time” as measured by a fitness wearable, are being sent to SkyNet. And let's say this clever computer sends her a text saying, “Get moving and lay off the linguine.”

To be useful, this model assumes that Mrs. Smith doesn't realize that her diet choices are unwise, or that that if she does realize it, she's too stupid to change. Real people, it turns out, don't work this way. Diabetics work hard to control their disease, and it's not easy for medical, social, economic and dozens of other reasons.

Big data is unlikely to make a “real-time” difference in patients' lives. Where it can help us is in designing rational healthcare policy. But we already have much of the data we need to do that. We know we spend too much and have worse outcomes than other countries. We simply choose not to change. No amount of data will help us make better decisions if we don't really want to change.

Peter A. Lipson, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. After graduating from Rush Medical College in Chicago, he completed his internal medicine residency at Northwestern Memorial Hospital. This post first appeared at his blog at Forbes. His blog, which has been around in various forms since 2007, offers "musings on the intersection of science, medicine, and culture." His writing focuses on the difference between science-based medicine and "everything else," but also speaks to the day-to-day practice of medicine, fatherhood, and whatever else migrates from his head to his keyboard.

The drive to dismantle 'Obamacare'

I find it difficult to divert my attention from started on Inauguration Day and all that is ending, or at risk of it. Since it's generally ill advised to write about one thing while thinking about another, I feel compelled to choose a topic in that domain. The assault on the Affordable Care Act, or “Obamacare,” is the obvious choice.

The one problem for me and you alike in this area is the volume of ink (or number of electrons) already directed at it. Are there novel things left to say?

I believe there are, and surprisingly perhaps, at a very fundamental level. The contingent particulars—the number of lives affected, the dollars in play—have certainly had ample attention. It's the first principle issue that has received the least. Namely: is it at all true that some version of “American values” and our free-market inclinations in any way justify the Republican opposition to the ACA?

The answer is a surprisingly easy and obvious “no,” and there's a good chance the decisive evidence of that is no further away than your garage. The evidence is your car.

Most of us drive. To do so on public roads requires that we have auto insurance. It's not optional. If you drive on public roads without auto insurance, you face fines and penalties, and the potential loss of your license. Auto insurance is mandated by every state government.

Where's the hue and cry? Isn't this government intrusion un-American? Shouldn't we be scrambling to dismantle the auto insurance bureaucracy, rather than accepting the unending parade of commercials for Geico, and Liberty Mutual, and eSurance, and the rest?

We all seem to accept that unless use of our cars is limited to the driveway on Sundays, insurance for all makes good sense. Why? Because your use of a car on a public roadway might affect me. If you are both poor and a bad driver, does that mean I should get stuck with the costs of a crash you cause? We all seem inclined to say: no. You should have insurance to cover the costs of any mayhem you might impose on the rest of us- and vice versa, of course.

In other words, in the area of auto insurance we seem inclined to accept the fundamental role of government in creating fairness, a level playing field, and common rules. We also accept that in this context, free market forces may yet prevail. That they do is just what those competing advertisements for this insurance company versus that tell us. Government establishes the floor for us all, free market forces compete to raise the ceiling.

Health insurance is, or at least should be, viewed in exactly the same way. For one thing, until or unless we develop cars that are both driver-less and passenger-less, the movement of cars along public roads will involve the movement of human bodies, too. How bizarre to require insurance only for the less expensive and eminently more replaceable of the two.

Some form of universal health insurance is the norm throughout the developed countries of the world for good reason. Any alternative is a demonstrably bad idea. We pay for that bad idea in the U.S. in every currency that matters: the needless loss of life from years, the needless loss of years from life, and an absurd number of dollars allocated to medical care producing relatively bad outcomes.

That the ACA is imperfect obviates none of this, nor in fact are its limitations accidental. The ACA was encumbered with flaws from the start by those opposed to it for reasons of ideology they forgot to apply to auto insurance. Consider, for instance, the chaos if some states required auto insurance and others did not. What would happen when an uninsured driver from, say, Rhode Island, hit my car on a Connecticut highway? Gaps and inequities would stress the system, and just such stresses were introduced on purpose into the copious particulars of Obamacare.

I am reluctant to say what I think this rush to repeal the ACA, whatever the consequences, is really about. I suspect there's no real need. In the context of an orchestrated effort to erase the Obama legacy, it's rather self-evident. But I can say what it certainly isn't about.

It's not about saving lives, or money. It's not about evidence, or sense. It's certainly not about the lessons of epidemiology. The one potential surprise in the mix is that it's not about ideology, either, at least not any ideology applied consistently. If mandating insurance for human bodies is in any way un-American, how can mandating insurance for auto bodies be universally accepted without resistance?

This tendency, by the way, to invoke values or principles or ideology to justify a cause, while overlooking monumental internal inconsistencies, is more norm than exception and redounds accordingly to the deficiencies of our public discourse, and our collective shame. The fuss over medical use of marijuana is a good example. Most of those in the opposition presumably have no clue that medical cocaine has been legal all along; it is used to treat epistaxis, or severe nosebleeds. Many legal drugs are incomparably more dangerous and addictive than marijuana. Opposition is a hollow and inconsistent ideology, signifying no real understanding.

So, too, is the rush to repeal the ACA despite the good it has done, and the far greater good it could do if the sabotage imposed on it at the start were systematically expunged. The drive to dismantle anything like universal health care coverage in America is blithely inattentive to the realities of driving in America, and the government mandated requirements that pertain along the highways and byways of every state, from sea to shining sea.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.
Thursday, February 23, 2017

Probiotics promote digestive health--is there a germ of truth

Several times each week, I am asked about the value of probiotics. Many of my patients are already on them, based on a personal recommendation or an advertisement. As a gastroenterologist, I routinely treat patients with all varieties of diarrhea conditions, such as irritable bowel disease, ulcerative colitis, Crohn's disease, lactose intolerance, celiac disease, and the highly feared gluten sensitivity. Many of them arrive in the office with a probiotic in hand waiting for me to pass judgment. These patients look to me as a Digestive Supreme Court Justice as they sit on the edge of their chairs waiting for my ruling in the case of Probiotics vs. Disease.

First, let's all be clear on what a probiotic is. Probiotics are bacteria that provide health benefits when consumed. Stop a moment and consider how bizarre this concept is. Physicians have been fighting germs since the days of Louis Pasteur. We have taught the public for generations how important personal hygiene is. We are counseled not to eat under-cooked food from fear of contracting a food borne illness. Every hospital in the country is stressing hand washing to all personnel to protect patients from infection. Many of us won't leave the house without a hand sanitizer bottle.

In other words, germs are bad, unless they are probiotics! In the latter case, billions of germs are deliberately ingested in order to relieve symptoms and treat diseases, an ironic shift in classic germ-fighting medical practice.

Hardly. Our intestines are filled with zillions of bacteria. Miraculously, during health these germs are not able to penetrate through the walls of intestines to reach internal organs which would cause a severe infection. These strains of bacteria within the bowel all live together in balance providing health benefits to us. They aid in digestion and immunity. Some of these germs create vitamin K, which we use to maintain a healthy clotting system.

When this bacterial neighborhood, which is called the intestinal biome, is disrupted, then disease can set in. For example, when we take antibiotics to attack “bad germs,” such as for a pneumonia or a urinary tract infection, the antibiotic also upsets the “good bacteria” within our intestines. In addition, many digestive diseases have an intestinal biome that is out of balance. When the biome isn't balanced, then the whole body is under a strain.

Here's the theory in simplified form. When the community of beneficial germs within our bowels is disrupted from antibiotics or disease, probiotics can get the biome back into balance. Scientists are not entirely sure how this happens, but probiotic research is in high gear to understand how they work and who should receive them. The theory is that bringing the biome back to its normal state restores health and relieves symptoms.

What do I tell my patients with digestive conditions regarding probiotics? I tell them the truth. The supportive science is rather thin, but many of my patients feel better on a probiotic program. We don't know precisely which probiotic works best for a specific patient or disease, or how often to dose them. Importantly, we believe that they are safe, but I would be very reluctant to recommend them to someone with compromised immunity.

If you have digestive symptoms and are contemplating a probiotic, here are 3 steps to consider:
• Open the jar.
• Open your mouth.
• Open your mind to the belief that these germs can heal you.

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

3 pretty awesome things about the UK's National Health Service

Recently, I've been writing a lot about health care systems around the world and thinking about what an ideal system for America would look like. I've enjoyed reading the online responses—healthy debate is indeed a wonderful thing. I've said previously how out of all the systems I've experienced, the ideal probably resides somewhere in-between a completely socialized system and a private, free-market-insurance-based one. Australia comes pretty close to doing this, by encouraging people to buy their own insurance, but also having a public backup for those who need it. Despite growing up with the UK's National Health Service, and admiring it on many different levels, the fact remains that no other country in the world has copied this heavily centralized system. Yet, I can't say by any stretch of the imagination that it's not a hugely noble and fair concept with humanistic ideals. Lots of my closest family and friends rely on it and are very happy with their service. Here are 3 amazing things about the NHS:
1. No bills and no stress over expenses
No British citizen has to worry about ever seeing a medical bill or dealing with out-of-pocket costs. Emergency care is excellent and most urgent matters are dealt with in a timely manner. Those things that do incur charges, such as certain prescriptions, are capped at a very low level with plenty of exemptions. The majority of UK citizens would gladly sacrifice choice and put up with some waiting for non-urgent care, to keep this system in place.
2. Great selfless doctors
Doctors in the United Kingdom are among the most hard-working in the world and rarely choose a medical specialty because of how much they will earn (there's not much variation between what medical specialists are paid anyway). Granted, they have relatively low student debt (although that is changing), but are generally much more conservative and inclined to only do what's absolutely necessary. As a patient, you will never have the thought in your mind that your doctor is ordering a test or recommending a procedure because they want to make more money.
3. Fosters a sense of society
The fact that most of the British public sees their NHS as a national treasure, also reflects something else that is very different on both sides of the pond. In the UK, there is more of a concept of “society”, which naturally comes about in socialized systems. People in Britain generally have a feeling of “we are all in it together”, especially when it comes to the health service. Since its founding, America has generally been a more individualistic society which encourages freedom, choice and personal responsibility. The collective consumerist psyche in the United States would unlikely endear itself to socialized medicine anyway (and I'm not saying there's anything wrong with that, but merely stating an observation).

Every health care system in the world is currently facing its share of challenges due to a combination of expensive new treatments and aging populations. The NHS also has huge problems with physician and nurse shortages, low physician morale due to contractual disputes, and excessively long wait times for certain illnesses. But it would be disingenuous to suggest that it's all bad and anything other than the reality that many socialized health care systems are respected and loved by millions of their citizens. Can we really say the same here in the United States?

Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care. This post originally appeared at his blog.
Wednesday, February 22, 2017

The Affordable Care Act (aka Obamacare) on the chopping block

The Patient Protection and Affordable Care Act (ACA for short, or Obamacare as it has come to be known) was passed on March 23, 2010 after intense wrangling and many compromises. It is a huge and complex bill which changed health insurance costs and availability significantly, resulting in over 20 million Americans getting health insurance who were previously uninsured. Many people can now get health care without impoverishing themselves, but the bill is also not without significant and possibly fatal flaws.

What does it do?

The link here is to a blog I wrote in early 2010 after a grueling 5 hours of reading the bill that was eventually passed. The things people like about it include:
• Health insurance can be bought through “exchanges” which make it easy to compare plans and purchase insurance.
• The wording of policies has to be understandable for regular people.
• An insurance company can't refuse to cover a patient because of a pre-existing condition and insurance rates can't be hiked due to being in poor health.
• Adult children can remain on their parents' insurance until age 26.
• Insurance companies can't stop paying medical costs after a certain ceiling amount and can't kick someone off due to medical problems.
• Procedures considered to be effective prevention need to be covered 100%, without a deductible owed by the patient.
• Private health insurance is subsidized for people with low income and free insurance is available for people at even lower income through the Medicaid program in those states that have chosen that option. Nineteen of the fifty states, however, have opted out of expanded Medicaid.
• For most people buying health insurance through the exchanges, health insurance premiums will be affordable due to subsidies.
• There have been innovations designed to improve both cost and quality.

What's wrong with it?
• Although health insurance is more affordable for most people and now covers preventative services, it is also required. If the insurance companies have to agree to insure patients who are going to cost them lots of money, they also need to insure patients who won't cost lots of money or their costs will go up and they will no longer be able to make a profit. The requirement to buy health insurance is called the individual mandate and is enforced by a penalty charged on income tax of up to $695 for an individual who has not paid for insurance for a year. The amount of the fine is capped at the cost of the cheapest insurance available. The idea is that you can either pay and get insurance or pay and not get insurance. People don't like being told they have to buy health insurance, especially if they are well. Unfortunately for many of the insurance companies, healthy people did not purchase insurance despite penalties, so many of these insurance companies had to opt out of the exchanges because they lost money.
• The ACA was supposed to reduce costs overall. Obviously it wasn't going to cost less to get health care for many more people, but the overall trend was supposed to go in the right direction. This document from the Center for Medicare Services is interesting. Health care expenses as a percentage of our gross domestic product went up, from 17.4% in 2014 to 17.8% or $9,990 per person in 2015. The Congressional Budget Office predicted an overall reduction in costs. Perhaps it just needed more time.
• The government assured the insurance companies that it would pay them for any losses under the new plan. The total cost of this was expected to be minimal since insurance companies that did well would pay a portion of their profits to the program. There were more losses than expected, and the Republican dominated congress refused to fund the difference, leading to what was essentially a breach of contract. The stiffed insurance companies are now suing the federal government for billions of dollars. It turned out that health care cooperatives, which were a great idea, had the biggest trouble staying afloat and so the vast majority of those have folded.
• More patients can now receive health care, 20 million or more, but out of pocket expenses and the price of insurance is rising. Before subsidies, health insurance premiums will rise 25% in 2017. Premiums reached over $18,000 for an average family in 2016, though most families still were able to buy affordable policies through the exchanges because of subsidies.
• People receiving health insurance through their employers are spending increasing portions of their salaries for their share of health insurance premiums, now over 10%. Employers pay the majority of these premiums, leading to lower profits and lower worker salaries. This is a continuation of a trend that was present before the ACA passed, but the situation has not improved.
• Twenty-nine million people are still uninsured. Nineteen states have refused to expand Medicaid. This leaves patients who are too poor to afford health insurance but not poor enough to qualify for regular Medicaid with no health insurance. These people get medical care only in extreme circumstances or pay for expensive care themselves, leading to financial destitution and unpaid bills which hospitals or clinics have to absorb.
• Some of the experiments to improve quality and reduce costs have introduced layers of complexity to doctors' already complex jobs and this leaves them with less time to spend with patients and with more job dissatisfaction. Physician burnout is increasing, now at over 50%, primarily attributed to administrative duties.

Could the ACA be better?

Yes, for sure. There were many compromises leading up to passage of the bill, despite the fact that in the end it passed without any Republican support. Progressives pushed for a single payer system which would make the federal government the major provider of health care coverage. (Actually, in terms of dollars spent, the federal government is the major provider of health care coverage.) This could have been done as an expansion of Medicare which is already an established and relatively frugal insurance plan. The government would then have been in competition with the health insurance industry which did not make their very powerful lobby happy, and some physicians balked, expecting a heavy handed approach to what they were allowed to do for their patients. A “public option” was also put forward, which could have provided an optional government funded insurance, but that, too was seen as competing with private insurers and might have become yet another very expensive and possibly budget busting entitlement program. The ACA legislated the creation of the Center for Medicare and Medicaid Innovation to help come up with creative ways to provide and pay for health care, but prevented them from using cost-effectiveness analysis to decide what to recommend. This was because of concerns about “rationing” health care. The ACA in its original form required the states to expand Medicaid, with the federal government footing all of that cost for 2 years and then gradually reducing that subsidy to 90% by 2020. The Supreme Court found that requirement to be unconstitutional, leaving 19 states to make a short sighted decision to forego a significant subsidy from the federal government and leave a proportion of their poorer citizens without health care coverage.

So the ACA could be better by being bigger. It could have entirely revamped how health care was paid for by introducing a single payer or provided a good public option. This would not have passed congress and certainly won't now. It might have been great eventually, but would have been very expensive and might have destabilized the economy. The ACA could have explicitly recommended we reduce costs by looking at value and eliminating services with low value. It could have offered expanded Medicaid without state support, leading to more nearly universal health coverage.

It could have been better by having bipartisan support, but, having watched the whole process go down, it's not clear how that could have happened. The idea of universal coverage with an individual mandate was taken straight from various Republican proposals over the last 15 years, and looked very much like the Massachusetts health plan sponsored by Mitt Romney. The ACA did not fund abortion and did not extend Medicaid to illegal immigrants. It provided a waiver for patients based on religious beliefs. There was no funding for talking about end of life wishes with patients due to concern that this might mean we had created “death panels” to decide who would live or die. Still, there was no Republican support for what was very appeasing legislation.

It could have been better by being smaller. Many of the exclusions and exciting new programs which were introduced to make it attractive to legislators also made it hard to understand. Patients to this day have very little idea what the ACA is or even that it is the same thing as what they call Obamacare. Physicians are unclear about its provisions and blame various woes on the ACA that belong to different legislation or to developments not related to law at all.

What will happen to it?

Members of the present administration have vowed to repeal it, but want to hold on to some of the most popular provisions. I have gleaned from many reliable sources that:
• They would like to make health insurance companies continue to insure people regardless of pre-existing conditions so long as they maintain continuous health care coverage. They also want to allow children to stay on their parents' health plans until age 26.
• They do not want to continue to subsidize the expansion of Medicaid or subsidize insurance for people based on income. They would consider a refundable tax credit to help pay for insurance.
• They would like to limit the federal government's funding of Medicaid. Presently the federal government pays a percentage of each state's costs for Medicaid and has significant control over how that money is spent. The Republicans in power favor “block grants” for Medicaid which would provide a fixed amount of money for the program to each state, to be spent as the state decides. This could lead to appropriate economies, but could also lead to states running out of money for programs and cutting funding to vulnerable people.
• There has been a proposal to reform malpractice at the federal level, primarily capping what a plaintiff can receive for non-economic damages. This would save money, in theory, by encouraging physicians not to order excessive tests just to avoid being sued. Thirty states have already passed such legislation and some evidence does point to a reduction in health care costs.
• Health Savings Accounts (HSA) would play a part in paying for care, allowing patients to use pre-tax dollars for health expenses. Unfortunately most of the people who have bought insurance through the exchanges are not wealthy and have been subsidized, and so don't have money to put into HSAs.
• It is unclear what the administration intends to do with regulations on the insurance industry. If they require that insurance companies insure patients with pre-existing conditions who will likely be more expensive, but repeal the individual mandate as they have promised to do, insurance companies might well fail. Patients have become used to getting preventative care without having to pay a deductible, but it is unclear that this is cost saving, so without legislation to require coverage insurance companies may do away with this provision. This is likely to make constituents very unhappy. I have not heard anything about caps on out of pocket expenses or lifetime expenditures.
• There is an intention to allow insurance companies to sell their products across state lines, improving competition and therefore reducing costs. This may help, but patients may find that their cheaper out of state insurance doesn't pay for their local doctor or pharmacy or that it lacks protections they had come to rely on.

Bottom line

There is a good chance that the “Obamacare” that we are just getting used to will go away. This will be “the beginning of an uncertain and tumultuous chapter in U.S. health policy” per Jonathan Oberlander, a professor at University of North Carolina and the author of The Political Life of Medicare, in an article in a recent issue of the New England Journal of Medicine. The ACA has been divisive and irksome to Republicans for years and they would have repealed it already if they had had the political muscle they do now. It will be tremendously difficult to deal with the aftermath of that, especially the 20 million people whose access to health care will be endangered or lost. None of the ideas that have been mentioned so far come close to managing this. In order to provide access to care that constituents demand at a price that taxpayers can tolerate, compromises will need to be made. The work of improving cost efficiency in medical care, pharmaceuticals and in payment models will need to become a non-partisan issue.

*As a person in need of health care, it may be wise to sign up for health insurance through the marketplace before the Jan. 31 deadline, if you are not already insured. The future of these insurance policies is unclear, but it is unlikely that any change in the ACA will affect insurance that a person has already purchased, at least in the short term.

Janice Boughton, MD, ACP Member, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health Care So Expensive?, where this post originally appeared.
Tuesday, February 21, 2017

A new textbook on health systems science

Many aspects of academic medicine, from the structure of the medical school curriculum to the organization of departments in schools of medicine, are neatly segregated into two buckets: basic science and clinical science. In the jargon of medical schools and education, basic science refers to the basic biomedical sciences that have traditionally been taught in the first two years of medical school, such as anatomy, physiology, biochemistry, and pharmacology. While plenty of clinical material has migrated into the first two years of medical school over the years, such as learning to interact professionally with patients and perform a physical examination, the main focus of the first half of medical school has historically been on basic science, culminating in the U.S. Medical Education Licensure Examination (USMLE) Step 1 exam.

Once students finish their basic science years, they move on to the clinical sciences, where they begin rotations, also called clerkships or clinical experiences. They usually first rotate through the core medical specialties, i.e., internal medicine, surgery, pediatrics, obstetrics/gynecology, and psychiatry. This is then followed by rotations in other specialties and subspecialties, ultimately leading to graduation and the start of their residency training.

This division of medical education goes beyond just the medical school curriculum. The organizational structure in most medical schools is to group academic departments into basic science and clinical departments. These two types of departments usually have different funding models. Basic science departments are usually funded by base budgets for teaching and grants for research, with an expectation that just about all faculty have research grant funding. Clinical departments have base budgets and research programs as well, but they perform another activity, which is clinical care that provides practice opportunities (and revenues) for faculty and learning experiences for students, residents, and fellows. In many clinical departments in medical schools, research activity is modest and may be partially subsidized by the margins from clinical revenues.

The focus on these two groups of sciences takes the perspective of the physician taking care of a single patient, i.e., applying the best biomedical science through the lens of a specific clinical specialty. However, despite its primacy, there is more to the practice of medicine than taking care of single patients. Physicians and other clinicians work in a healthcare system that has other concerns, such as continually increasing costs, worries about patient safety, and questions about the quality of care delivered. As such, 21st century clinicians must be competent in more than the diagnosis and treatment of disease in individual patients. This has led to emergence of the notion of a “third science” of medicine, which focuses on how to optimally provide healthcare for patients and populations. While some describe this as “healthcare delivery science” (my preference) or “implementation science,” the emerging name, as given to a textbook in this area, is now “health systems science.”

The textbook is published by the American Medical Association (AMA), which has been supporting innovation in medical education through its Accelerating Change in Education (ACE) consortium, funded by grants to medical schools [1]. OHSU was one of the original grantees in this program to establish “medical schools of the future.” I have been pleased that one outcome of this program has been the expansion of instruction in clinical informatics for medical students, which I consider to be an essential competency for 21st century physicians [2].

The titles of the chapters of the new textbook describe the important topics covered by health systems science:
1. Health Systems Science in Medical Education
2. What Is Health Systems Science? Building an Integrated Vision
3. The Health Care Delivery System
4. Value in Health Care
5. Patient Safety
6. Quality Improvement
7. Principles of Teamwork and Team Science
8. Leadership in Health Care
9. Clinical Informatics
10. Population Health
11. Socio-Ecologic Determinants of Health
12. Health Care Policy and Economics
13. Application of Foundational Skills to Health Systems Science
14. The Use of Assessment to Support Learning and Improvement in Health Systems Science
15. The Future of Health Systems Science

I am delighted myself to be the lead author of one of the chapters, not surprisingly the one on clinical informatics [3]. I hope this chapter will introduce many new generations of medical and other health professions students to the informatics field and its role in healthcare delivery. Of course, informatics plays many roles beyond healthcare delivery, such as informing the care of individual patients and facilitating all types of research, but the effective use of data and informatics is a key aspect of health systems science.

I hope that this new textbook will lead the way in emphasizing the importance of health systems science in the work of physicians and other healthcare professionals. Clinicians have long known that diagnosing and treating disease, while the centerpiece of medical practice, cannot be carried out in a vacuum outside the realm of the patient's and larger health system's context. The care delivered to those individual patients will be better if the clinician has the perspective of that larger system.

1. Skochelak, SE, Hawkins, RE, et al., Eds. (2017). Health Systems Science. New York, NY, Elsevier.
2. Hersh, WR, Gorman, PN, et al. (2014). Beyond information retrieval and EHR use: competencies in clinical informatics for medical education. Advances in Medical Education and Practice. 5: 205-212.
3. Hersh, W and Ehrenfeld, J (2017). Clinical Informatics. in Health Systems Science. S. Skochelak, R. Hawkins, L. Lawson et al. New York, NY, Elsevier: 105-116.

This post by William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, appeared on his blog Informatics Professor, where he posts his thoughts on various topics related to biomedical and health informatics.

Is direct primary care the answer or the problem?

Long time readers know of my fascination with the affect heuristic. Simple stated, we overvalue the benefits of a concept that we like, and underestimate the problems or vice versa.

This article about direct primary care induces conflicting analyses, “Here is the PCP crisis solution and it's simple.”

I like the idea based on this reasoning. Primary care in 2017 has several problems. Both physicians and patients have dissatisfaction with direct face time. Primary care physicians suffer high levels of burnout because the financial model requires them to see patients to quickly to do their job properly. These quick visits likely induce physicians to order more tests and consultations than they would if they could spend more time on history and physical examination.

Direct primary care allows physicians to spend more time with patients, because they decrease their “panel size” from greater than 2,000 to 800 or less. These physicians have more time to communicate with their patients using telephone and email.

But the panel size decrease waves a red flag for opponents of this movement. They always ask, “Who will care for the patients?”

When primary care physicians burnout they often totally leave their practice, often becoming hospitalists or urgent care physicians or subspecialists or retirees. If direct primary care keeps them practicing, even with fewer patients, at least they are providing important primary care.

Currently, medical students and residents often find primary care unappealing because of the work conditions. I often argue that direct primary care may induce students and residents to choose primary care and work with a reasonable number of patients.

This debate has no solution. My arguments are not based on data, but rather on anecdotal observation. I worry about primary care, because the current model often leads to more expensive substandard care. You cannot rush visits and provide the highest quality primary care. You must take shortcuts to shrink your visit times.

This debate is philosophically interesting and, in my opinion, a great example of that affect heuristic. We cannot resolve this question with data, because the factors are multiple and too often you really do not understand the underlying motivations for doing primary care, or leaving primary care or moving to direct primary care. So we will likely continue debating this issue to no clear conclusion.

But of course, I am correct.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.
Monday, February 20, 2017

Why should we care about conflicts of interest in medicine?

A recent issue if the JAMA, The Journal of the American Medical Association reads like an exposé. At least 3 of the research articles do. So exciting. I don't want medicine, my field, to be ethically unsavory, but it is sometimes. It makes me proud to see that it sometimes polices itself and that such information is published in a high profile journal.

The first article is entitled “Patient Advocacy Organizations, Industry Funding and Conflict of Interest” by Susanna Rose of the Cleveland Clinic along with colleagues of hers from the University of Chicago. It turns out that 67% of patient advocacy organizations such as the American Diabetic Association, the Multiple Sclerosis Foundation and March of Dimes, organizations that support patients with various diseases, receive support from industry. Specifically, “industry” means organizations that make money by selling products related to health. More than one in 10 of these organizations received over half of their support from industry. Nearly 8% of the leaders of advocacy groups surveyed admitted to feeling pressure to conform to the wishes of their corporate donors. Since this is a hard thing to admit, that number probably vastly underestimates the true impact.

The Institute of Medicine has written extensively on conflicts of interest and how to manage them. Financial conflict of interest occurs when the primary aim of an organization, in this case to advocate for patients' best interests, is in competition with a secondary goal such as promoting a product for a company that pays your bills. It is hard to quantify just how these conflicts of interest play out. Big drug and device companies have tremendous amounts of money, expertise and resources to strengthen an organization, but they also are primarily motivated by making money. If they wish to sell a product that is of questionable benefit to patients, an advocacy organization could be a powerful ally in marketing. Patients think of their advocacy organizations as representing their interests, sometimes in opposition to the medical establishments. There are no disclaimers for them to read such as “this organization supported by the makers of patented titanium bone screwdrivers or magic diabetes-be-gone pills.”

The next article by Dora Lin and colleagues from The Johns Hopkins School of Public Health looked at the organizations and individuals who argued with the U.S. Centers for Disease Control's (CDC) guidelines for prescribing opioid pain medication for chronic pain. Unless you have lived under a rock, you have probably observed that prescriptions for pain medication in the opiate class increased dramatically for several years, followed by all of us noticing that there was increasing numbers of patients addicted and also dying of overdose. In response to this problem health care advisory groups have recommended prescribing these drugs less often, at lower doses and discontinuing them sooner along with offering non-opiate options for pain control that are less dangerous and probably more effective. When the CDC's recommendations came out there were criticisms and so there was a period of invited comment before the final release. It turns out that the majority of criticisms came from organizations with ties to opiate manufacturers and none of them mentioned this in their comments. There are many reasons for the U.S. opiate epidemic, but misinformation propagated by the pharmaceutical industry was definitely an important one.

The third article was even more concerning from a financial standpoint. In the last few years we have seen major changes in the way we treat hepatitis C and elevated cholesterol levels. Guidelines released in 2013 by the American Heart Association recommended that we extend the number of people who will be treated with cholesterol lowering “statin” drugs to anyone with a 10 year risk of atherosclerotic cardiovascular disease (heart attacks and the like) of over 7.5%. Guidelines released in 2015 for the treatment of hepatitis C, a chronic liver disease caused by a blood borne virus, suggested that we treat everyone with hepatitis C with extremely expensive drugs which, kudos to pharmaceutical researchers, can cure the disease.

The price tag is the reason that this last article (by Akilah Jefferson and Steven Pearson of the National Institute of Health and the Institute for Clinical and Economic Review) is of greatest concern. Statin drugs, which are definitely good for some people, especially those with known heart disease, are set to reach over $1 trillion in worldwide sales by 2020. The new hepatitis C drugs can run over $1,000 a pill, or $80,000 and up for a treatment course and will account for about 10 billion dollars of health care spending in 2015. It turns out that a significant number of physicians in both of the groups who were responsible for developing these guidelines had support from the manufacturers of the drugs they directed to be used so extensively. The Institute of Medicine made some pretty clear recommendations about conflicts of interest in 2009 and neither of the organizations responsible for producing these very influential guidelines followed these recommendations.

So it's good that we are talking about this but not good that it is happening. The problem with conflicts of interest isn't that they necessarily lead to bad decisions, but that they probably do and that we don't know. We as physicians try to do good, and we've been told in the last many years that we can do the best for our patients by following guidelines. These guidelines, we are led to believe, are based on the best of scientific evidence and, lacking the time to read all of the literature and keep up with the astounding amount of new data that comes out every year, we would do well to follow them. But if the people who create the guidelines work for the companies that stand to benefit financially from the outcomes of those guidelines, we would do better to question them. At the level of populations, the decision to recommend that all patients receive a treatment rather than a smaller group of patients who would more clearly benefit makes a huge difference. Our individual budgets as well as our nation's budget for health care are limited. A choice to use an expensive medication is also a choice not to do something else that might benefit us more.

Conflicts of interest are common and part of the human condition. It is not possible to entirely eliminate them in any situation. In cases such as guideline development and patient advocacy groups in which patients are vulnerable to influences which do not have their best interests as a guiding force, we should be especially sensitive. Physicians should try hard to recuse themselves from making important decisions in which they have a conflict of interest. We should honestly recognize that bias in the form of industry connections may make it impossible to be truly objective.

Janice Boughton, MD, ACP Member, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health Care So Expensive?, where this post originally appeared.
Friday, February 17, 2017

Why health care information technology may never improve

One of the topics I write most about and have also done a considerable amount of consulting work on, is improving and optimizing health care information technology. I hate to say this, but after a few years of doing this, I'm starting to despair a little by what I'm seeing. It's a question I never thought I'd ask: But will health care IT ever really get to where it should be? Improvement is desperately needed—even small tweaks can be made to our electronic medical record (EMR) systems to help improve workflow for doctors. Information technology in its current format is the number one frustration for doctors (and nurses) across the United States—and responsible for much misery at the frontlines of medicine, as an unacceptably large amount of time is spent navigating them. Here are 3 reasons why improvement is uniquely difficult:

1. Wrong customer: administrator not end-user
Watch this post as a video

Attending many events and networking meetings in health care IT, one thing has become abundantly clear to me. We (meaning doctors) are not the people that health care IT folk are catering to. It's the hospital administrations. Can you imagine if great companies like Apple totally disregarded the end-user experience like that? This is one of the prime reasons we find ourselves in this preposterous situation. As an example, I recently used the latest version of Siri on an Apple device. And how brilliant it was. Far, far superior to any voice recognition software I've used in health care, and designed with the user in mind

2. It's a monopoly once installed

Once health care organizations have spent millions of dollars on a particular EMR, the IT vendor is truly “in”. The organization is stuck with it no matter what—and can't just switch to another one if they don't like it. Therefore, what incentive is there for the IT system to really get better?

3. Lack of strong voice

I was talking to a very intelligent doctor recently who was bemoaning how he was spending the vast majority of his day at a computer screen. Certainly not why he went to medical school. He said something very thought-provoking: “I'm surprised that the medical profession has allowed themselves to be so quickly turned into data-entry clerks without making a fuss.” So true. What happened to the public perception of a doctor—the fierce patient advocate who always stood up for good medicine? Why is there not a strong national movement to improve health care IT?

Even the most hardened technophobe doctor would acknowledge that technology represents the future in all aspects of our lives. But we want good technology that is fast, efficient and seamless—enabling us to be doctors. We don't want reams of garbled data that transforms our patients' stories into tick boxes. We want rapid mobile order entry systems. We also want an acknowledgement that the medical profession has to remain a social and personable profession—not one where the frontline heroes are turned into “type and click bots”.

It frequently feels when I meet health care IT folk that we are in two separate worlds. I'm quite an optimist by nature, and hope I'm proved wrong about this never improving.

If you feel as strongly as I do, please consider signing the online petition here: care-improve-health care-information-technology-at-the-frontlines-of-medicine?recruiter=448220882&utm_source=share_petition&utm_medium=copylink

Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care. This post originally appeared at his blog.

Combating the terror of chronic disease, and vice versa

Many of us listened to President Obama say his official goodbye. In light of the political turbulence in which we find ourselves, there is both abundant and diverse opportunity for attendant reflection. I choose to focus mine here on a simile that populates the space where my professional purview, and my anxieties as a citizen in the modern world converge. Terrorism is like chronic disease, and vice versa.

The relevance of President Obama's farewell to this rumination is the obvious: the POTUS who took office twice in the post-911 world began, and ended his two-term stay in the White House at war with global terrorist organizations. We have seen triumphs, and we have seen disasters, but we certainly see no end in sight.

This somber conclusion took me back to my impressions as a medical resident, training in Internal Medicine, in the late 1980s and early 1990s. For those who don't know, residency is the crucible of medical indoctrination, the harsh gauntlet of transformation. The hours and duress of it all have been attenuated over time, although they remain impressive by most standards.

In my day, the typical workweek spanned 100 hours, and sometimes more, running through night as well as day. Almost all of that time was spent tending to hospitalized patients who were inevitably, in this age of ever more outpatient care, very sick. Our mission was a combat mission; we were combating the ever-present threat of decompensation and death.

We were pretty good at it, and the never-ending advances in medicine make us better at it all the time. We can treat astonishingly complex and grave diseases effectively. In the ICU, technology can take over for almost every failed organ system, albeit much less well than the native article. Death, more often than not, can be forestalled.

But we ourselves are forestalled, now as then, in moving past combat to the solace of success. The hospital was all about people who mostly had serious chronic diseases that never needed to happen, and were never going away. We care providers and our technical wherewithal were and remain all the King's Horses and all the King's Men; and our patients, alas, were Humpty Dumpty. What we could not put together for them was genuine vitality, long gone, and gone for good. Famously, you can't unscramble an egg.

But Humpty Dumpty conveys another message, more important: why is that fall off the wall necessary in the first place? Let's put a seat belt up there; or cushions at the base of the wall. Or lower the wall. Or replace it with a bench; who needs to sit on a wall, anyway?

The simple fact is that most of what lands people in hospital beds is preventable. We have known how to prevent roughly 80% of all chronic disease and premature deaths for decades.

For me, the lesson in knowing that 8 out of 10 hospital beds never needed to be populated in the first place if people would only make better use of their feet (more physical activity), their forks (better diets), and their fingers (no tobacco products held there)- along with attention to a short list of other modifiable hazards- was that combating the consequences of established disease simply wasn't good enough. I wanted to go back to a time when vitality was still intact, and try to keep it that way. It was obviously already too late for those patients I was treating in the hospital; but not for their children.

So, I followed my residency in Internal Medicine with another, in Preventive Medicine, and the rest, as they say, is history. For the better part of the past 30 years, I have done both to the best of my ability: combating established disease by treating patients, and working to promote lifestyle as preemptive medicine. Treated disease is better than untreated disease, but not nearly as good as untrammeled vitality.

Which brings us back to the end of the Obama era, with the terrorism war ongoing, our troops still in harm's way, seemingly never able to leave Afghanistan. These troops are combating terrorism like medical personnel combat disease in the hospital; the situation is already bad in both cases, and the job is to contain the threat.

There is no real victory in either case. The killing of terrorists inevitably begets more terrorists; the war is self-perpetuating. So, too, is a medical model far more devoted to combating chronic diseases it knows how to prevent, than preventing them.

The remedy is a far greater emphasis on prevention. That view requires patience, because we cannot prevent what has already happened. If the already sick inspire better attention to prevention and health promotion, it is the next generation that will benefit fully. The current cohort gets treatment; the next gets vitality.

If that view pertains to terrorism, too, as seems likely- questions about preventing terrorism a generation from now should be at least as salient as saber rattling. But of course, they are not. Our leaders are all but obligated to talk tough, and tell of our strength in bombs and bullets and walls. These are needed for the already hostile, just as scalpels, and dialysis, and coronary bypass are needed for the already sick. But far kinder, gentler treatments suffice to keep the healthy well. Shouldn't we be assessing, discussing, and investing in whatever it would require for our children to need bombs and bullets less?

The ultimate remedy to terrorism is likely as slow as preventive medicine; desired effects span decades, and generations. Populations stewed in the hate of echo chambers need to die out in time and be replaced by progeny who can find their way to a common humanity through the advent of understanding. Education and opportunity are anti-terrorism vaccines.

Saying so does not make administering them easy, and I don't mean to imply anything of the sort. But not saying so, renouncing global connections, and hunkering behind walls- all but guarantee we will simply keep getting, and treating, the same disease indefinitely. Vaccinating the world against smallpox wasn't easy either, but had we not done so- we would still be treating it.

No trauma response at the base of a wall will ever be as good as preventing a fall from it in the first place. No border wall will ever be hard enough to get over to rival the protective power of genuine understanding. More focus on prevention could give our children a world mostly free of chronic disease and terrorism alike. For now, both wars rage on- in part because we seem inclined to accept that's the best we can do. It's not. We can do better.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.

Pan-resistant NDM-containing K. pneumoniae lacking MCR-1

I wanted to let you know about a new case report in MMWR while simultaneously raising the MMWR Altmetric Score. Seriously, how can such a case only have one blog mention in 24 hours—Jon Otter must be just getting back from holiday.

The Centers for disease Control and Prevention has reported a case of New Delhi metallo-beta-lactamase (NDM-1)–containing carbapenem-resistant Enterobacteriaceae (CRE) and Klebsiella pneumoniae isolated from a wound specimen of a woman in her 70s who had returned to the U.S. after a log visit to India. She also reported prior visits with multiple hospitalizations in India. The isolate was resistant to the 26 antibiotics tested, including all aminoglycosides and polymyxins (despite being MCR-1 negative), while it was intermediately resistant to tigecycline. The fosfomycin MIC was 16 μg/mL. Unfortunately, the patient developed sepsis and died. Fortunately, the patient had been isolated and screening revealed no evidence of transmission.

CDC offered three take home points:

Most CRE remains susceptible to at least one aminoglycoside or tigecycline,

When patients with this highly resistant organisms are identified, they should be placed under contact precautions*, and

Facilities should obtain travel histories and consider screening for CRE if patients are from high-risk areas.

*Note: nice to see that somebody still loves contact precautions.

Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands). This post originally appeared at the blog Controversies in Hospital Infection Prevention.
Thursday, February 16, 2017

Repeal and replace Obamacare--STAT!

Am I referring to Obamacare here or Obama himself?

I am glad that we have a new president. Like most of the country, I was ripe for a change of direction and a new approach to foreign and domestic affairs, and we are certainly getting that. New readers here might erroneously suspect that I voted for Trump. I didn't. For the first time in my presidential voting history, I wrote in my choice for our top two office holders.

I have written multiple posts on my unfavorable views of Obamacare since it was jammed through congress without a single Republican vote. (Do I sound slightly partisan here?) Interested readers are invited to peruse posts on this blog within the Health Care Reform Quality category, if you dare.

There are two kinds of people who oppose Obamacare:
• folks who believe it is wrong on policy grounds
• folks who wield it as a political cudgel to bash Obama.

Some opponents are a hybrid of both of the above.

I was also suspicious that the Affordable Care Act (ACA) was always an interim step preceding a full nationalization of our health care system. Obama is on the record favoring such a policy during his 2008 campaign. If Obama could have achieved this politically in one step, he would have. The ACA represented the political upper limit that he could achieve, hoping that this would make a full would bring us within reach of a government takeover. Some conspiratorial skeptics believe that the ACA was designed deliberately to fail so that private insurance companies would have to abandon it, as they have. Then, the beneficent government would have to step in to rescue Americans who needed medical coverage STAT! While I offer no opinion on this wild charge, there were many smart people who averred when the ACA was delivered to us, that the numbers would never add up. And they didn't.

It is my belief that government is simply not equipped to assume control of the entire health care system and operate it at the highest level of quality possible, while controlling costs. Remember how smoothly the web site release was? Do you think this would have happened if Google or Facebook was in charge? Which company do you have a higher opinion of in terms of quality and efficiency, the Bureau of Motor Vehicles or Amazon? If folks want to have a government insurance plan like Medicare, I am fine with this. But, give us access also to the free market. I like choice because competition breeds excellence. When FedEx came onto the scene, it forced the U.S. Postal Service to really step up, which they have.

And, we all know that the plan's proponents were somewhat less than truthful. Feel free to Google Jonathan Gruber to become reacquainted with his 2014 comments which make reference to stupid American voters and other niceties. How long did it take the Obamians to admit that the statement, “If you like your doctor, you can keep your doctor,” was known to be false from the outset?

Let's face it. The ACA promised us quality and cost control and in my view it has failed on both counts. I do congratulate the president here, as I have previously, for taking on the challenge of health care reform. Republicans over several presidential administrations failed to seriously confront this challenge. And the plan does cover more Americans, which we all agree is a necessary goal. But, the collateral damage of this achievement warrants a new direction, admitting that it may not be possible to uproot the entire tree.

The replace part is going to be tougher than the repeal part. Will the GOP take a lesson from their adversaries and jam it through without a single Democrat vote?

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Health is more than health care

When we think about achieving good health, it's natural to think of visits to the doctor for “checkups” and age-appropriate interventions like vaccinations or cancer screening.

But here's something you might not know: The “health care system” as we know it, an American industry on which we collectively spend $3 trillion annually, only accounts for one-fifth of our overall health.

Twenty percent? How can so much spending impact so relatively little of our well-being?

Well, it turns out other factors collectively have a much greater impact:

Genetics: To whom we are born impacts our health profoundly. If our parents are blessed with long, healthy lives, then we are much more likely to be, too.

Education: The better our education, individually and collectively, the more we can achieve in life. Education is tied to income (something we all know), but it also correlates directly to health outcomes in aggregate. Cutting investments in common and higher education is sabotaging our children's future—not just in earning potential, but in real health: more suffering and earlier death.

Employment: The ability to earn a living wage means that people can be financially solvent and participate in the consumer economy. Given a choice, almost no one would choose handouts. People want meaningful work—work that employs our skills and engages our minds.

A diverse economy that grows new businesses means more job opportunities that not only pay the bills but allow us to invest in our families, homes, and communities.

Environment: It's well known that those residing in certain Tulsa ZIP codes have life spans on average 11 years less than those in more affluent parts of the city (This difference has actually lessened from 14 years over the last decade.) Mayor G.T. Bynum has made reducing this disparity one of his administration's central goals, as celebrated in a recent editorial in this newspaper.

We also know that when our neighborhoods are safer, we increase the likelihood that we will move our bodies more—which along with nutrition is the single greatest predictor of good health.

And of course: Nutrition! Access to healthy food and safe water is something that most of us take for granted. But many areas north, east and west of downtown Tulsa are literal food deserts—places with greater than two-mile gaps between locations where fresh fruits and vegetables can be purchased. And our Tulsa public transportation options barely ease this burden.

Nutrition and exercise are the two health determinants over which we have the most direct individual control. (How are you doing with those New Year's resolutions so far?)

We can't choose our parents, or therefore our genetics. But collectively, if we are in agreement that we want Tulsa to be a place of improving health, we do have a lot of say in how we manage our neighborhoods, our food supplies and our educational attainment.

At the University of Oklahoma-University of Tulsa School of Community Medicine the curriculum emphasizes study and advocacy of these so-called social determinants of health—beyond the “traditional” organ-based pathologies. We believe that interdisciplinary understanding of these factors—which can lead to exorbitant stress—will help to reduce the burden of ill health in our population as we age.

Tulsa has an opportunity to become a “Blue Zones” city like Shawnee and Fort Worth, Texas, recent cities that have contracted with Healthways to make structural changes to spur better health. The Blue Zones idea comes from the discovery of the five places in the world where citizens live the healthiest and longest lives because of exercise (walking most places), nutrition (more plant-based diets), and social connectedness.

We have the ingredients here in Tulsa to take on such a challenge, and working through the updated Community Health Improvement Plan that will soon be released by the Tulsa Health Department, we can all choose to live healthier lives—both individually and as a community.

Amazingly, we can do all of this regardless of our need to interact with our “health care system.”

Note: This essay appeared as an op-ed in today's Tulsa World

This post by John H. Schumann, MD, FACP, originally appeared at GlassHospital. Dr. Schumann is a general internist. His blog, GlassHospital, seeks to bring transparency to medical practice and to improve the patient experience.
Monday, February 13, 2017

The 21st Century Cures Act allows drug companies to speed up development of drugs that may not work

Early in December Congress came together in bipartisan support of HR 6, the “20th Century Cures Act.” So unusual, these days, for a “landmark bill” to pass into law without major objections by Democrats or Republicans. Perhaps something fishy was going on. Perhaps this was a chance to please special interests while making the average voter feel that, at last, congress was going to accomplish something good.

The bill was hailed as supporting the development of new drugs and devices to cure dread diseases by reducing unnecessary regulation by the Food and Drug Administration. I found the text. It is amazingly difficult to read. The legal terminology is nearly impenetrable and the actual content is pretty hard to discern. It is also full of barely related measures, some of them excellent and some of them likely to have nasty consequences. I am particularly wary of the provision that encourages use of digital medical imaging by paying less and less for tests done with older X-ray machines, the one that allows pharmaceutical companies to pay for doctors' continuing medical education and the one that excludes approved generics from calculations of average manufacturers' price for drugs. I am perplexed by the creation of a 14-person working group specifically to address Lyme disease and other tick-borne diseases.

An excellent commentary by Aaron Kesselheim MD, a primary care physician with a law degree and special expertise in the ethics of pharmaceutical research and sales, discussed the many problems with this legislation. He is particularly concerned that the shift toward haste in approving new drugs will lead to new and expensive drugs that will enter the marketplace without convincing proof that they actually work. The FDA, at its inception, was instrumental in reducing the number of quack medicines on the market and inspiring trust in newly invented products. The bill will encourage the use of data which may be less accurate than what is presently required.

We do need more and better drugs to treat the conditions that make us miserable and shorten our lives. The U.S. has been at the forefront of the world as an inventor of innovative products that save lives, though often at astronomical prices. The U.S. was responsible for developing anti-viral medication that has allowed us to actually cure hepatitis C, a disease that often leads to end-stage liver disease. The drug manufacturers charge $40,000 for a course of these medications, and many of those who have the disease are either uninsured or underinsured. We have come up with cancer chemotherapies that are less toxic and make metastatic cancer, which was once a death sentence, into a treatable disease, but they are oh so expensive. We have also made some terrible drugs. We have produced drugs for high blood pressure that don't reduce the risks associated with it, drugs for pain that have been pushed to the extent that huge numbers of Americans have become addicted, medication for bladder urgency that makes the mouth dry, but barely changes a person's urgency or incontinence. We have produced injectable medication for cholesterol which does reduce serum levels, but is not yet known to save lives or improve health. This can cost over $10,000 per year. I don't think we want to allow pharmaceutical companies to enforce their own ethical standards.

The bill was also roundly praised for a provision that was supposed to fight the opiate epidemic. Again, I find the text of the bill to be difficult to understand, but it appears to be pretty anemic. From what I can glean, it allows insurance companies to cut off payment for drugs of addiction to patients who are felt to be at high risk of prescription drug abuse. In addition these people must receive information on drug and mental health treatment programs which are federally funded. It does not have to actually provide this treatment. Dr. Kesselheim says there is money for grants to the states to reduce opioid abuse and to reorganize mental health care delivery, but I found nothing like that in the text of the bill.

The bill does provide better funding for the FDA, which is good, because with sequesters and budget cuts, the financial support for funding research through this agency actually went down 22% from 2004 through 2015, according to Dr. Kesselheim. The costs of this program will be paid for by selling off some of the US petroleum reserves and from cuts in the prevention and public health fund of the Affordable Care act. That doesn't sound like a good choice.

Overall, it is not clear that the Cures act actually cures anything. It will increase funding to the FDA and may streamline approval for innovations, but we will be less sure that those innovations are really useful. Congress may have passed legislation that gives drug and device manufacturers a pass to make products that are painfully expensive and may not work.

Janice Boughton, MD, ACP Member, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health Care So Expensive?, where this post originally appeared.