Robert Kocher, Emmanuel Ezekiel and Nancy Ann Deparle have published an article in the August 24th edition of The Annals of Internal Medicine urging physicians to embrace the change in the health care system associated with the Affordable Care Act. The article describes the numerous changes to the practice of medicine. These changes include technological innovation and medical records, working in teams with a variety of non-physician providers, including payment mechanisms aimed toward such, proactively managing preventive care and incorporating patient-centered outcomes research into practice. The article emphasizes how the act removes barriers to care for our patients by improving information about the care of our patients and by providing incentives to improve care and to focus on preventive care. The article acknowledges many physicians’ disappointment in the continuation of the sustainable growth rate formula. However, despite this frustration, the Affordable Care Act provides much that we as physicians can use to improve the ability to provide quality care to our patients.

As physicians, we have taken an oath to protect our patients. This act provides a new way for physicians to focus their energies on delivery of care to populations and to improve care with this end in mind. The Affordable Care Act is just the first step in providing high quality and effective care for our patients. We encourage you to become more familiar with the ways that you can improve your patient outcomes through the Affordable Care Act.

Dr. Cheryl Bettigole, MD/MPH, President-Elect of the National Physicians Alliance, joined Congressman Joe Sestak (PA-07) and other health care advocates at a town hall hosted by Families USA to help explain the new health care benefits becoming available under the Patient Protection and Affordable Care Act. The Congressman and the others highlighted the ways that the PPACA will benefit Pennsylvanians, in particular working families and small businesses:

*By providing affordable health coverage to uninsured Pennsylvanians with pre-existing conditions;
*By expanding access to affordable coverage for Pennsylvanians who purchase their own health insurance.
*By eliminating all co-payments for preventative services (starting in September 2010).
*By providing much needed assistance to seniors by closing the Medicare prescription drug donut hole, which will be phased out by 2020. Seniors who hit the donut hole are already receiving a $250 rebate check.
*By eliminating co-pays for preventative care under Medicare starting in January 2011.
*By allowing young adults, the nation’s largest group of uninsured, to remain on their parents’ health care plan up to the age of 26 (starting in September 2010).
*By providing the largest middle class tax break in history, $464 billion in health care tax credits for working class families over 10 years.
*By encouraging small business growth due to $40 billion of small business health care tax credits over ten years and reducing small business health care costs by 18 percent.
*By eliminating discrimination against women by insurance companies.
*By reducing the federal deficit by $143 billion over ten years and as much as $1.2 trillion over the next twenty years, according to the Congressional Budget Office.

Thanks to Dr. Bettigole for helping to spread the word on the benefits of the PPACA to her fellow Pennsylvanians! These benefits apply to all states and we applaud her efforts to get the word out! See coverage of the town hall here.

In an editorial titled, “Prognosis: Debt” Fred Hiatt of the Washington Post expresses concern over the (misleading) 1.6 trillion dollar price tag placed on health care reform, but in a way makes a compelling argument for including a public health insurance option in health reform.

He writes that President Obama (and others) have defined the major problem with our health care system as being unsustainable growth in costs, while congressional Democrats have primarily focused on expanding coverage to the uninsured:

congressional Democrats and the most involved interest groups behind them are far more passionate about universal coverage than about controlling costs. Thus Obama’s political calculation: Push for health-care reform that delivers universal coverage — and insist on as many levers to control costs going forward as possible.

He explains that this disconnect between the problem and proposed solution comes from the fact that it’s easy to expand coverage but hard to control costs. He states that proposed cost saving measures, such as focusing on prevention, shifting from specialist care to primary care, and changing provider payments from fee for service, all are unproven, and he implies that expanding coverage to include all Americans would inevitably lead to more debt. He gives several suggestions to the President on how to ensure that whatever “new burden” we take on with health care reform “is really paid for”.

As a physician, I do think universal coverage and equitability in our health care system is a “moral imperative” – I see patients without health insurance or with inadequate health insurance who have put off necessary care due to costs and suffered the consequences – but for the sake of argument, let us just talk about costs.

If we expand health insurance coverage without controlling costs, as outlined by Mr. Hiatt, we would have the equivalent of the Massachusetts plan. Their health exchange (“Commonwealth Connector Authority”) and individual mandate to purchase insurance (with subsidies for lower income individuals and families), along with Medicaid expansion and other measures, has achieved more than 97% health insurance coverage. This initially improved access to care (more individuals had a usual source of care besides the ER and a preventive care visit in the preceding 12 months), and decreased the financial burden of health care costs on some families (with fewer people spending more than 10% of their income on out of pocket costs). However, without a mechanism to control costs, there have been challenges in limiting increases in premiums and some of the gains in affordability have been lost.

This is where the public health insurance option comes in. Massachusetts does not have a true public health insurance option. The Congressional Budget Office’s $1.6 trillion estimate on the 10 year costs of the Senate Health, Education, Labor, and Pension committee’s health reform bill did not include evaluation of the public health insurance option. A proposal by the Commonwealth Fund for comprehensive health system reform including a public health insurance option, provider payment reform, and investment in public health infrastructure was estimated to have a net impact over ten years of $3 trillion in savings. While the upfront costs in expanding insurance coverage may appear daunting, as long as it is coupled with a mechanism to control costs, it will be a wise investment that improves access, quality, and slows growth in health expenditures.

And the cost savings are not just wishful thinking – lower administrative costs and the ability to negotiate lower rates from providers and pharmaceutical companies would allow a public plan to offer premiums at least 20% less than those of comparable plans in private individual or group markets. This expansion of coverage would not reduce overall health care costs, but these savings are not included in the 1.6 trillion dollar price tag for the HELP committee’s proposal. If employers or individuals previously with commercial insurance chose to buy into the public plan and its less expensive premiums, there could be significant savings overall.

A public health insurance plan would also likely reduce the costs of premiums of private health insurance through competition. 94% of health insurance markets are “highly concentrated” by FTC standards and most metro areas only have one or two options for consumers. This near monopoly is not good for costs or quality.

The effects of payment reform may be more difficult for the CBO to estimate, but a public plan would have a clear advantage over private insurers in shifting incentives toward prevention, care coordination, and evidence based medicine. Managed care was supposed achieve these goals in the private sector, but it has failed to control costs or improve quality. Medicare has begun to align payment with outcomes through pay for performance and nonpayment of care for preventable complications instead of simply reimbursing for the volume of care provided. A public plan would have the national scope to influence practice patterns across the country; a public plan would offer transparency and could be held accountable if cost or quality measures were not being reached; and a public plan would have the mission of disseminating effective payment innovations to other payers as a public good.

There are many other reasons why we need fundamental health care reform – most pressingly because it is unconscionable to deny sick patients necessary care because of inability to afford health care costs – but the realities of increasing health care expenditures do require a discussion of costs. While it is unfortunate that a misleading CBO estimate on the costs of one version of the health care bill have decreased momentum for reform, drawing on the lessons from Massachusetts, we can still use this information to promote meaningful change. Relying on the private health insurance industry to control costs would be a mistake. However, adding a public health insurance option is extremely popular, with 72% of Americans supporting a public plan in the most recent poll, and would provide several mechanisms to control costs. The American people are correct on this one, and our elected representatives better be listening.

Aaron Fox, MD
National Physicians Alliance
New York City – Local Action Network

When my wife wants to get me to exercise she says “your health is your greatest wealth”. The quote is attributed to Virgil, and hence is some 2000+ years old. One would never think many people heard that quote looking at the United States today! To me, the 1948 WHO definition of health,

“Health is a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity”,

sounds like an idealist fairytale, that nobody really cares about. We all thought that health care would feature prominently in the presidential race, that is until our other wealth, the financial one, evaporated. Quickly, billions of dollars were mobilized to help out institutions, many of which I am sure still pay handsome bonuses, and it was explained to us that we could not let too many banks and insurance companies fail, because it would have worldwide, catastrophic implications. I am not knowledgeable enough to judge what would have happened, but the fact that no one in the treasury thought it necessary to see what was being done wit the money makes me a little suspicious we were – at least partially – duped.

Health care, while still mentioned, somehow took the backseat. And now of course that our federal deficit is going sky rocket, even Obama is thinking how much money Medicare and Medicaid really need. Meanwhile, at least in Maine, hospitals have not been fully paid for their services to Medicaid patients in years, and payments are delayed. As states head towards significantly depleted coffers, this will undoubtedly get worse.

Ask a (wo)man on the angered Main Street, and they wil tell you that Universal Healthcare is a good thing. Ask them if they’d pay for it (other than their own), and they’ll probably tell you “No way!”. However after some relatively minor scoffs in congress, unbelievable amounts of money have been dedicated to “save” our financial system (and way of living). Just to visualize, 700 Billion dollars is about equivalent to the annual income of 15 Million US households. It is around one third of the annual healthcare cost.

I believe this nation has to realize that its people’s health is of one of its most valuable assets and it has to act accordingly. We are developing into a nation of people ravaged by ailments such as obesity and diabetes, that may soon make (and maybe already have made) us unable to sustain our way of life as a country. Many suggestions are out there, but to me it is clear that is has to involve strengthening primary care and prevention and making health care more accessible and yes, cheaper (brace yourselves, this will mean people in the health care field will likely make less money). If we can bail out our banks, then we can find a way to bail out our people. I am quite certain that cost in the long run will be less than the cost of a nation on disability.

There’s a great article in the last NYT of 2008 about the new “restrictions” that the pharmaceutical industry is imposing on itself. No mugs, no pens, no trinkety free goodies.

Sounds great, right? Pharma is policing itself.

Well, first of all, these restrictions are all voluntary, which means no penalty for breaking the rules. And rule-breakin’ penalties is one of the reasons we have laws.

Then if we read a little further, there’s some fine print down in grafs eleven and fourteen:

The guidelines, for example, still permit drug makers to underwrite free lunches for doctors and their staffs or to sponsor dinners for doctors at restaurants, as long as the meals are accompanied by educational presentations.

The industry code also permits drug makers to pay doctors as consultants “based on fair market value” — which critics say means that companies can continue to pay individual doctors tens of thousands of dollars or more a year.

Cutting out the pens but leaving the rest is like going on a diet where you only eat Big Macs. They’ve cut out the cheapest and least effective part of their marketing campaigns, while doing nothing about the most expensive and deviously influential elements.

Drug reps can still buy lunches for doctors in their offices; they can still take docs out to dinners, as long as there is some educational component. (I went on one of these “educational dinners” long ago… the talk lasted 5 minutes and then we ate for two hours…)

Also, the companies can still pay “consulting fees” that generally run in the tens of thousands. Some of these consultancies are real. But do you think most of the doctors who receive these consulting payments would continue to get them if those doctors banned drug reps from their offices, banned all lunches and dinners, and stopped prescribing the manufacturer’s drug?

Which leads me to my main point: drug companies should not be allowed to track in precise detail exactly which doctors are prescribing their medicines. They should be allowed to know the rough outlines — by zip code, for example — but allowing them to buy databases with the exact number of prescriptions each doctor has given out for each medicine. . . . there’s too much potential for an unspoken quid pro quo to exist between doctors and drug reps.

I am heartened by one aspect of this: the fact that Pharma is imposing these restrictions voluntarily means that they see the writing on the wall. They are trying desperately to prevent the kinds of laws that New Hampshire passed from spreading across the country. They want to give opponents of reform some ammunition, something to let them point to and say “See? The drug companies have cleaned up their act! Everything is fine now!”

Except in four or five years, when we’re paying attention to something else, the pens and mugs will come creeping back. They’ll come back slowly, a trickle at a time, without the big press release and glowing article in the New York Times.

The time has come to reject the hidden intrusion of Pharma into our lives. Prescriptions belong to doctors and patients, no one else.

(p.s. I’ve started a blog dedicated to this issue: www.prescriptionprivacy.blogspot.com)

America’s Children are too fat. You cannot deny it (just look outside). They develop diabetes at an alarming rate. There is no doubt that many of them will develop into unhealthy adults and suffer of the  consequences: premature coronary artery disease, chronic pain, disability etc.

16 months ago, the American Academy of Pediatrics endorsed a guideline developed with the AHA in 2006 on how to treat children with disorders that have been shown to put them at risk for prematrue coronary artery disease. The highest risk catergory, which would receive medicines early in the course of treatment, featured conditions fairly rare in childhood (including Diabetes Type I). As recently as July 2007, the US Preventive Services Taskforce concluded that

Several key issues about screening and treatment of dyslipidemia in children and adolescents could not be addressed because of lack of studies, including effectiveness of screening on adult coronary heart disease or lipid outcomes, optimal ages and intervals for screening children, or effects of treatment of childhood lipid levels on adult coronary heart disease outcomes (emphasis added)

Now we are reading that children as young as 8 may be candidates for medications if they have a LDL concentration (“bad cholesterol”) above 160 mg/dl. These risk factors include:

obesity, hypertension, or cigarette smoking or a positive family history of premature CVD (cardiovascular disease)

So maybe the above Task Force – and I  – have missed a recent large outcomes trial that shows that treating an overweight child with a Statin (presumably that, because as the article points out most other medicines are poorly tolerated) will prevent adult heart disease. Furthermore, this articles hopefully compared it with the standard of care… if you find it, let me know. What is the standard of care? Here are a few suggestions by the American Heart Association:

Cholesterol and Atherosclerosis in Children

AHA Scientific Position

There is compelling evidence that the atherosclerosis (…) begins in childhood and progresses slowly into adulthood. Then it often leads to coronary heart disease (…)

Elevated cholesterol levels early in life may play a role in the development of atherosclerosis in adults.

Eating patterns and genetics affect blood cholesterol levels and coronary heart disease risk.

Lowering levels in children and adolescents may be beneficial.

(…)

To reduce fatty buildups in arteries in children (and adults):

Cigarette smoking should be discouraged.

Regular aerobic exercise that lasts at least 30–60 minutes on most days of the week should be encouraged.

High blood pressure should be identified and treated.

Obesity should be avoided or reduced.

Diabetes mellitus should be diagnosed and treated.

Children age 2 years and older should be encouraged to eat at least five servings of fruits and vegetables daily as well as a wide variety of other foods low in saturated fat and cholesterol. Doing this will help them maintain normal blood cholesterol levels and promote cardiovascular health.

No mention of drugs…..

I do not doubt that some children, particulary those with extremely elevated LDL (above 500 or so), may benefit from Statin drugs. But every obese child with a LDL above 160? That may be hundreds of thousands if not millions of young people swallowing expensive pills, with rare but serious side effects, and no proven benefit. It may help (prove it!), but the problem of obesity among children is not one of pill deficiency. How about spending the billions of health care dollars that such a treatment program will presumably cost, and getting more education, physical ed and better nutrition to our kids!

 And then when you read that the lead author Stephen Daniels has a conflict of interest (undisclosed by the journal), you may get nauseated… hey, there is a pill for that, too!

Read more in the New York Times, or LA Times.

Cheers to the U.S. House of Representatives!!

On last evening, the House took a great step toward ending discrimination toward a group of patients with the passage of the “Paul Wellstone Mental Health and Addiction Equity Act of 2007,” named after the late Senator from Minnesota who was a passionate advocate for mental health parity. I salute Reps. Patrick Kennedy, D-R.I. and Jim Radstad, R-Minn. for their bipartisan effort to end stigma and right this severe wrong with regards to healthcare in the United States.

The Senate sponsors, Sen. Edward Kennedy, D-Mass., Sen. Pete Domenici, R-New Mexico and Sen. Mike Enzi, R-Wyoming, will work to help send it to the president for signature. This bill is so important. It pains me to have to tell patients who receive all of their care for primary care and specialty services at our hospital that I can not see them or that they have very high co-pays.

It is embarrassing and shameful that a physician in the house, Rep. Phil Gingrey, R-Ga, would not vote for this bi-partisan bill. When will the medical community remember that the brain is still an organ and is vulnerable to illness and should not be separated from the body when we think about the practice of medicine.

Write your Senators! This bill needs to be passed!

I think we have gone done the road of separate but equal once before. It did not work then and does not work now.

“We are one. If we don’t know it, we will learn it the hard way.”
– Bayard Rustin, Civil Rights Activist, Organizer of the 1963 March on Washington

Now is the time to join the National Physicians Alliance at its meeting in Houston, TX. If you have never been to an NPA event, you are truly missing out. Missing out on energy. You may arrive tired and disheartened, but you leave energized and full of momentum to make a difference. Whether you would like to join in NPA’s efforts to ensure the availability of quality health care to all in the US or to explore how big business looks to compromise your practice as a physician and the health of your patients, you can find it with this group.

Certainly, one of the best things about a National Physicians Alliance meeting is finding like minded physicians who are in the struggle to maintain the integrity of our profession, and who strive daily to put their patients first. That is what excites me. It is an exciting time in our country and everyone is talking about change. Now is the time for physicians like us to make a stand and be heard.

When I leave an NPA meeting I truly get what Bayard Rustin was saying. We are truly one!

(link to register for the NPA meeting)

In a recent opinion piece (or here), Betsy McCaughey, former lieutenant governor of New York and current adjunct senior fellow at the Hudson Institute, raves against mandatory health insurance, in fact she claims to know the “Truth About Mandatory Health Insurance”! This is accompanied by a caricature by Chad

Crowe, worthy of a feature in ‘How to Translate Polemics into Art’.

“Requiring catastrophic coverage (our parents called it major medical) probably is smart“, Betsy muses, but, in brief, comprehensive coverage would not solve overcrowded emergency rooms, and anyway many uninsured are immigrants (and – sarcasm intended – we know most of them are illegal = do not deserve health care) and healthy people should not be made to pay premiums covering the risk of sick people.

First, I doubt (and for her sake I hope) that Betsy has set foot in an ‘overcrowded’ ER in an inner city hospital recently, other maybe for a brief cameo appearance. I am not saying that giving everyone health insurance tomorrow would make this problem go away. But as someone who has trained at institutions running such ERs, I can attest to the fact that many (not all) visits are due to lack of preventive care, proper education and the availability of health care providers that actually see patients (the one’s that cannot pay beaucoup $$$).

Second, the notion that healthy young people should not pay more for healthcare than they consume is exactly the problem that has been bogging down the US system. Other countries have widespread or mandatory insurance – backwards places like Western Europe, you know – many of which the WHO rates better than the US on healthcare (France is No 1, Italy No 2, Spain No 7, Austria no 9, Netherlands No 17, UK No 18, Germany No 25, Canada No 30…. the US is a distant 37th). And by the way, the US also is not top of the list when in comes to fairness of financial contribution, as stated in the same report (the front runner here is Colombia, and there are 7 European countries in the Top 10). In Germany, for example, everyone shares the cost of healthcare, insurance is mandatory – the underlying principle here is called solidarity. And no, Germany does not have socialized medicine, and if you think solidarity sounds socialist, then read its definition here and un-wash your brain! It is basically risk sharing. If only the ones with the risk end up paying for it then healthcare can never be affordable for anyone even with a decent income – unless your are young (i.e. low risk) and healthy, which is not the majority of US citizens. Thank goodness that in the US, most young people will become old people later in life and thus consumers of healthcare (it would probably help if you could take your insurance from job to job). And yes, if you make lots of money and do not buy health insurance, you are probably either extremely shortsighted or fatalistic.

However the mean household income in the US is a somewhat meager $40+ k, and provided you do not have insurance through your employer, according to the Kaiser Family Foundation, an average family plan will run at ~ $11,000 (Oh, and a few thousand on top of that may be your deductible/co-insurance). Does that sound affordable?

That is not to say that healthcare consumers should not share responsibility , i.e. live healthier lives, for which many may need incentives (not punishments).
I think if US citizens – and their leaders – are not able to think out of the box of their Suum Cuique (“to each his own”) mentality, we are heading for healthcare Armageddon. And it won’t matter if we start with 23.7 million uninsured (Betsy, how is that number any better than 43 million?) or more, it’s going to go up, fast.

Crossposted at Stupor Cordis

(photo courtesy of the Treatment Action Campaign)

World AIDS Day was yesterday, Saturday December 1st, 2007. Much thanks to the hundreds of organizations and the thousands of people who work day in and day out to garner funds, break down stereotypes, treat medically, and help prevent the spread of HIV/AIDS around the world. And thoughts and empathy to the many many people living with HIV/AIDS.

Susan McCallister at the Hesperian Foundation talks about leadership and responsibility in the movement:

Closer to the ground, we can see what real leadership on HIV and AIDS looks like:

• The people living with HIV who publicly disclose their status, especially those who were earliest to disclose in their communities, where they risked their lives to do so.
• The thousands of health workers and community organizers who have dedicated themselves to providing care for communities overwhelmed with HIV, and have strategized brilliantly to mobilize and manage scarce resources to have the greatest impact.
• The children who, having lost parents, step capably and uncomplaining into the role of raising younger children in their care.
• The determination and rage of groups like Act Up, which have forced the development and greater accessibility of ARV medicines.
• The solidarity represented by organizations like Partners In Health and Medecins Sans Frontieres, committed to providing first world health care and pharmaceuticals to poor communities around the world.

This is leadership in action.

Those agencies and individuals in control of the world’s vast streams of wealth, whose small spigots are so inadequately turned on over the giant basins of HIV need, may wear the mantle of world “leadership,” but many don’t deserve it. If the elite and powerful had anywhere near the courage, dedication, intelligence, and passion of the people directly confronting HIV in the world today, things would be different. We could restore health care systems, relieve poverty, extend public water and sanitation projects, improve nutrition, and widely distribute affordable second-line medicines. We could also generate hope, little nurtured by the timid and bureaucratic half-measures deemed realistic by the “leaders.”

If the AIDS Day slogan “Take the Lead” is to have any real meaning, we have to find ways to empower and recognize leaders who treat health as if people matter — especially people with HIV.

The National Physicians Alliance has teamed up with other organizations to work specifically on the crisis of the Health Care Workforce globally (see our work on this issue here)

A few of the other hundreds of organizations doing amazing work around the globe:

* ’08 Stop AIDS
* Medicines Sans Frontiers (Doctors without Borders)
* HealthGAP
* American Medical Student Association
* Partners in Health
* Treatment Action Campaign (South Africa)
* CHAMP: Community HIV/AIDS Mobilization Project
* Physicians for Human Rights
* CoCoSi (El Salvador) click on english version of the site

(add other inspiring organizations in the comments section, or contribute your thoughts on the NPA’s work on the healthcare worker shortage around the globe)